A parieto-occipital scalp tumor, noted in a Nigerian boy during the first month of his life, gradually increased in size, and after two attempts at partial removal there was a rapid increase in its size. When he was 17 years old, it measured 21 X 17 X 16 cm. There was no underlying skull defect. Complete excision of the tumor was achieved, and on histological examination it was found to be a fibrosarcoma. The patient was given a course of radiotherapy following wound healing. He remained well for 5 1/2 months but then had manifestations of small local recurrence and distant metastases that responded only minimally to another course of radiotherapy combined with cancer chemotherapy.
The resolution of skin and soft tissue infections following a single course of treatment with flucloxacillin was assessed in 235 patients recruited by nineteen physicians. In all, 88.5% of patients were completely cured or showed a highly satisfactory improvement after 3 to 12 days' treatment. Only three patients failed to show any improvement at all. Side-effects were limited to twelve patients (5.1%) all of whom were able to complete their course of treatment.
We present the case of 53 year old Caucasian male smoker with remote history of left lower extremity deep venous thrombosis (DVT) and a strong family history of thrombosis, who presented to the Center for Wound Healing at MedStar Georgetown University Hospital with spontaneous left leg ulceration. Prothrombotic evaluation revealed homozygosity for the Factor V Leiden (FVL) mutation.
Therapeutic anticoagulation was commenced with warfarin (Coumadin) and the patient underwent successful debridement and apligraf followed by split-thickness skin graft (STSG) of two wounds. He had an uneventful post-operative course and on the 27th postoperative day the grafts were 95% intact. However, by post-operative day 41 there was 10% graft loss, and over the subsequent 2 weeks both grafts necrosed. On further questioning, it transpired that the patient had discontinued his warfarin on post-operative day 37 because he thought it was no longer necessary.
The patient is enrolled in the WE-HEAL study, and at the time of the original graft, residual skin fragments from the STSG were transplanted onto a nude mouse for development of an animal model of wound healing. The mouse graft was successful and was harvested at post-operative day 87 for pathological examination.
We review the mechanisms by which prothrombotic states, particularly FVL mutation can contribute to skin graft failure and delayed wound healing. This case highlights the importance of considering prothrombotic conditions in patients with spontaneous leg ulcerations and the impact of therapeutic anticoagulation on healing. It further allows us to demonstrate efficacy of our animal model in which we are utilizing residual fragments of STSG tissue for transplant onto nude mice for manipulation in the laboratory.
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