Chronic Ulcers and Malnutrition in an African Patient\

Authors

Timothy G Singer
Monica A Bray
Audrey Chan
Saki Ikeda
Brittany Walters
Maren Y Fuller
Carla Falco

Publication Date

11-1-2020

Journal

Pediatrics

DOI

10.1542/peds.2020-1717

PMID

33115794

PMCID

PMC8061712

PubMedCentral® Posted Date

11-1-2021

PubMedCentral® Full Text Version

Author MSS

Published Open-Access

yes

Keywords

Child, Chronic Disease, Female, Humans, Malnutrition, Pyoderma Gangrenosum, Skin Ulcer, Zambia

Abstract

An 11-year-old female with a congenitally malformed left hand, sickle-cell trait, asthma, and history of appendicitis was transferred from Zambia for evaluation and treatment of widespread suppurative and ulcerative skin lesions that typically appeared following trauma to her skin. The ulcers first presented 3 years earlier but had markedly worsened in the 9 months prior to transfer, spreading circumferentially on her extremities and abdomen at the site of an appendectomy. They were painful and did not resolve with multiple courses of intravenous (IV) antibiotics and close management by a Pediatric Infectious Disease specialist working for a non-governmental organization (NGO) in her home country. The child had participated annually in health screenings at the NGO and previously had been average weight-for-age. The NGO arranged for international transfer to our pediatric academic medical center. Upon presentation she was severely malnourished with lesions covering approximately 35% of her body. Initial workup found leukocytosis of 21 × 103 cells/μL (79% neutrophils), hemoglobin 6.1g/dL, and MCV 66 fl. Iron studies showed iron 18μg/dL, ferritin 55ng/mL, total iron binding capacity 222μg/dL, and transferrin saturation 8%. Inflammatory markers were elevated, CRP 20.1mg/dL, ESR 131mm/hr. A chest CT demonstrated bilateral pulmonary nodules, the largest in her left upper lobe measuring 2.4 × 2.0 × 1.9 cm. Our panel of experts reviews the evaluation and treatment of this patient with extensive suppurative and ulcerative skin lesions, severe malnutrition, hematological abnormalities and pulmonary nodules and the factors considered in offering charity care to international patients.