文献简介

出版社:JAMA

作  者:

编  号:

关键字:前臂慢性溃疡;纤维化

年  份:2015   点击量:151

文献摘要

A white man in his 30s with a 7-year history of severe, mechanical, low back pain and longstanding mental depression was referred to the dermatology department for evaluation of an asymptomatic cutaneous ulcer that had developed over the past year. Physical examination disclosed a large and deep, irregularly shaped, cutaneous ulcer on the dorsum of his right forearm. Necrotic tissue and muscle exposure was seen at the base of the ulcer (Figure, A).Woody induration of skin on both forearms and on the abdominal region was also observed. Bilateral contracture of deltoid, triceps, and biceps muscles was noted. Active and passive range of motion was restricted at the shoulders and elbows. No signs of joint inflammation were seen. At the time of consultation, the patient was taking oral treatment with duloxetine hydrochloride, clonazepam, oxcarbazepine, fentanyl, sulpiride, zopiclone, omeprazole magnesium, and baclofen. He also admitted to self-administering subcutaneous injections of meperidine, 100mg 4 times per day, for the past 3 years, at different sites, including the deltoid areas and abdomen. Growth from culture specimens taken from the ulcer was negative for bacteria, mycobacteria, and fungal organisms. His serum creatinine kinase level was raised (192 U/L; reference range, 0-174 U/L), but test results for complete blood cell count; erythrocyte sedimentation rate; antinuclear antibody, rheumatoid factor, aspartate aminotransferase, alanine aminotransaminase, and aldolase levels; and serum electrophoresis were all within normal limits. A wedge biopsy from the indurated skin of the abdominal region was performed (Figure, B and C).

患者白人男性,30余岁,有7年严重、机械性、下背部疼痛病史和长期抑郁症病史,为评估一年前出现的无症状皮肤溃疡而就诊皮肤科。体格检查发现右前臂背部有一大而深的,形状不规则的皮肤溃疡。溃疡部可见坏死组织和肌肉组织(图A),且前臂和腹部区域均观察到皮肤木质硬结。双侧三角肌、三头肌和二头肌挛缩。肩部和肘部活动受限。未有关节炎症迹象。咨询时,患者正接受盐酸度洛西汀、氯硝西泮、奥卡西平、芬太尼、舒必利、佐匹克隆、奥美拉唑镁和巴氯芬口服治疗。患者自诉,过去三年,在包括三角肌区和腹部等不同部位,进行了每天4次100mg哌替啶皮下注射治疗。取溃疡处标本进行培养显示细菌、分枝杆菌和真菌培养均阴性。患者血清肌酐激酶水平升高(192 U/L;参考范围是0-174 U/L),但全血细胞计数检测结果显示:红细胞沉降率、抗核抗体、类风湿因子、天冬氨酸转氨酶、丙氨酸转氨酶、醛缩酶水平和血清电泳均在正常范围内。对腹部硬化皮肤行钻孔活检(图B和C)。