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.