5 Discussion:
In this communication, we reported on a 50- year-old female patient with a history of recurrent right lower leg swelling, dilated veins and multiple ulcers. This case highlights the challenges in diagnosing and managing chronic venous insufficiency and its complication. Deep vein thrombosis was the initial diagnosis, but the persistence and progression of symptoms suggested an underlying venous pathology.
Diagnosing venous ulcers in regions like Sudan, where endemic diseases—both infectious and non-infectious—are prevalent [9 - 20], poses significant challenges. The complexity arises from the fact that leg ulcers can result from a variety of underlying causes, including systemic health issues (Table 1), poor access to healthcare, and the impact of prolonged conflict and instability [2,7,21 – 24]. It is essential to determine the specific etiology when a patient presents with an ulcer involving the leg because the appropriate treatment may vary depending on the cause.
For ulcers on the leg, excluding the foot, the most common cause is chronic venous disease, either alone or in conjunction with other factors that impair healing, such as arterial disease, diabetes, or rheumatoid arthritis [25]. In this particular case, the patient was initially misdiagnosed as having cutaneous leishmaniasis. The endemic nature of cutaneous leishmaniasis in the region, combined with a lack of awareness among general practitioners about other clinical mimics of the condition and limited access to Doppler imaging, likely contributed to this misdiagnosis. As a result, the physician heavily relied on clinical findings alone, without the benefit of additional investigations.
Interestingly, in the presented case, it is commendable that the healthcare team took proactive steps to rule out infectious diseases, such as cutaneous leishmaniasis, mycetoma, and tuberculosis. Molecular testing of the scraping and aspirating materials played a crucial role in excluding these infectious etiologies [26,27,28]. This highlights the importance of considering and investigating various possible causes before reaching a final diagnosis.
Furthermore, the use of Doppler scan in this case was instrumental in confirming the diagnosis of chronic venous disease and its associated complications [29]. The Doppler scan likely provided valuable information about the blood flow patterns, venous insufficiency, and potential anatomical abnormalities within the venous system of the affected limb [26]. This imaging modality is particularly helpful in assessing the venous system and its role in the development of leg ulcers.
By utilizing molecular testing and Doppler scan, the healthcare team was able to arrive at a conclusive diagnosis of chronic varicose veins with multiple venous ulcers and cellulitis. This integrated approach incorporating clinical, laboratory, and imaging findings ensures a more accurate diagnosis and guides the appropriate management plan for the patient.