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Table II. Laboratory investigations required before treating a wound 3. Medical history and findings from the physical examination dictate the selection of additional investigations. Due to the many possible causes of leg ulcers, the number of potentially useful diagnostic tests is also large.

Depending on the situation, microbiological tests, skin biopsy, radiologic imaging, and epicutaneous patch tests may be indicated. A correct sample must incorporate both the margin and base of the ulcer. The decision on when to take a leg ulcer biopsy is dependent on a number of criteria, but should be considered with: typical ulcers that do not respond to standard treatment or even worsen with treatment, atypical ulcers where the cause is not venous, arterial or neuropathic ulcers vasculitis, systemic and other dermatologic diseases , ulcers highly suspicious for malignancy unusual localization, nodular changes, rolled borders, multiple coalescing ulcers, presence of regional lymphadenopathy , or recent travel to tropical countries.

Table III. The most useful approach to diagnose CVI is with Doppler and duplex sonography. Other procedures such as light reflection rheography LRR , digital photoplethysmography DPPG , and venous plethysmography resting and dynamic can be used as indicated.


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When deciding on the possibility of surgery for postthrombotic syndrome with secondary varicosities, invasive phlebodynametry measurement of venous pressure with intravascular needle is often required. Measurement of the ankle-brachial index ABI is a simple and reliable test for the assessment of arterial blood flow in the leg. Servier — Phlebolymphology Phlebolymphology is an international scientific journal entirely devoted to venous and lymphatic diseases. Differential diagnosis of chronic leg ulcers. Nelzen O. Epidemiology of venous ulcers. Venous ulcers. Lautenschlager S, Eichmann A.

Differential diagnosis of leg ulcers.

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Management of leg ulcers. Current Problems in Dermatology, vol.

Basel, Switzerland: S. Karger AG; Wound assessment. ABC of Wound Healing. Accurate diagnosis and effective treatment of leg ulcers reduce prevalence, care time and costs.

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J Wound Care. Vowden KR, Vowden P. The prevalence, management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district. J Tissue Viability. Clinical practice. Chronic venous insufficiency and varicose veins.

Christopher Brookmyre

N Engl J Med. Keen D. Critical evaluation of the reliability and validity of ABPI measurement in leg ulcer assessment. Healing chronic wounds. Cutaneous wound healing. Her parents rushed her to the emergency room where doctors took a culture of a pimplelike bump on her ankle, then sent her home with some antibiotics. Days later, a surgeon was cutting out dead tissue from her foot. Over the course of several weeks, tissue had to be removed two more times. What her doctors initially believed was a spider bite rapidly progressed into a severe skin infection caused by a rare but deadly form of Vibrio , a group of bacteria naturally found in warm, brackish, and ocean waters all over the world.

In the US, the number of reported cases of Vibrio illness has more than tripled since , from to 1, in , according to the Centers for Disease Control and Prevention. Now experts say climate change is helping drive the increase, allowing the bacteria to thrive in areas that were previously too cold, and illustrating one of the many unforeseen threats rising temperatures and sea levels pose to human health. This summer, hundreds of cases of Vibrio have been reported up and down the Atlantic Coast, across the Gulf states, and in the Pacific Northwest, according to CDC data.

Several people have died from the infections in Texas and Florida. The increase in illnesses comes as climate change and coastal urbanization create a perfect storm for waterborne bacteria, said Geoff Scott, clinical professor and chair of the department of environmental health sciences in the Arnold School of Public Health at the University of South Carolina. The CDC estimates that the bacteria cause 80, illnesses and deaths each year, with the majority occurring between May and October when water temperatures are warmer. About a dozen species of Vibrio can cause human illness, but the most common in the US are Vibrio parahaemolyticus , Vibrio vulnificus , and Vibrio alginolyticus.

Vibrio bacteria can cause a range of illnesses from gastroenteritis — a disease marked by diarrhea, abdominal cramping, nausea, vomiting, fever, and chills — to septicemia, a life-threatening bloodstream infection. Vibrio vulnificus , the species most commonly associated with wound infections, can also cause necrotizing fasciitis, commonly referred to as flesh-eating disease, and lead to amputations and even death.

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Anyone can get sick from Vibrio , but people with existing health conditions, like diabetes, liver disease, or cancer, are more likely to become ill and develop severe complications. An oyster company employee sorts and counts fresh oysters in the Chesapeake Bay, where Vibrio is known to grow.

Historically, Vibrio illnesses from seafood consumption in the US have been linked to shellfish from the Gulf of Mexico, where water temperatures are regularly warm, but in the last 20 years, outbreaks have been connected to shellfish harvested in the Pacific Northwest, Alaska , and parts of the Northeast. And while the majority of illnesses — about 52, — are the result of eating contaminated food, skin infection cases are also occurring in areas where the bacteria were not previously endemic.

Between and , the hospital saw five patients with flesh-eating Vibrio vulnificus infections, one of whom died as a result.


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  • Wounds and ulcers.

In the previous eight years, the hospital had only seen one case of a Vibrio wound infection. Katherine Doktor, one of the authors of the report, told BuzzFeed News. Average August sea surface temperatures from , left, compared to August , when the northeastern US coast experienced an outbreak of Vibrio bacteria—contaminated shellfish. Pinks and reds show warmer water that promotes Vibrio growth.

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Doktor, an infectious disease physician and assistant professor at Cooper Medical School of Rowan University, said while infections are common in the Chesapeake Bay farther to the south, it was unusual to see cases from the Delaware Bay, which is sandwiched between Delaware and New Jersey. Rising sea surface temperatures in the Delaware Bay, they concluded, must have been a factor in the sharp increase in infections.


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  8. Data from the National Oceanic Atmospheric Administration shows water temperatures at two sites in the estuary hovered in the mids during the summers of and , when the five patients were infected. Though rare in comparison to other bacterial infections like staph, Vibrio vulnificus infections can progress rapidly and become fatal.

    About 1 in 5 people infected with the bacteria die, sometimes within a day or two of becoming ill, according to the CDC. Other types of bacteria can also cause flesh-eating disease. Public health officials believe the bacteria that causes strep throat is the most common cause of the infection, according to the CDC.