March 2006






History: A 64 year-old Caucasian female presented to the emergency room with a 10-year history of a progressively enlarging ulcer on the right arm. The lesion had never been biopsied or treated. She had not seen a physician for any complaint for 20 years. The patient had hidden the lesion from her family until it was noticed 2 days prior to her presentation by her son, who brought her to the hospital. She denied pain or decreased range of motion of the right arm. She denied systemic symptoms.
Past Medical History: Patient denied any medical conditions.
Medications: None.

Physical Examination: A large ulcer was present on the right arm, ulcerated to muscle, with rolled, infiltrated borders (Figures 1). There was palpable 2 cm right axillary lymphadenopathy. A 2.5 x 1 cm slightly brown, telangiectatic, irregularly shaped plaque was present on the right back.

Admission Laboratory Data:
CBC: WBC: 6.0 (3.8-9.8); Hgb: 2.9 (12.1-15.1); Hct: 10.6 (36.1-44.3); Plt: 445K (140-440K);
MCV 52.7 (74-115)
CMP: Sodium: 137 (135-145); Potassium: 3.9 (3.3-4.9); Chloride: 106 (97-110); Bicarbonate: 21 (20-28); Creatinine: 0.8 (0.6-1.4); BUN: 10 (8-25); Glucose: 124 (65-199)
Plasma protein: 7.8 (6.5-8.5); Albumin: 3.1 (3.6-5.0); Bili: 0.4 (0.3-1.1); Alk Phos: 82 (38-126); AST: 13 (11-47); ALT: 25 (7-53); INR: 1.31 (0.8-1.2): PTT: 32.8 (23-35)

Admission Radiography: Admission chest and right humerus radiographs (Figure 2) revealed multiple poorly defined nodules over the right lung field, slightly enlarged right hilar shadow, with normal left lung field and cardiac silhouette, and no effusion. A large soft tissue defect was present over the proximal humerus.

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