A Treatment Approach in a Toxic Hepatitis Patient Having Chronic Lymphedema and Stasis

Chronic lymphedema hold an important place among the reasons of leg ulcers other than venous disorders, and leg ulcers in patients with lymphedema are seen frequently. Primarily wound maintenance, pneumatic compression and vacuum assisted wound closure systems should be used in stasis ulcers developing due to lymphedema. When systematic antibiotic treatments are used irregularly and without function, it can harm the patient rather than benefit. In this article we present a chronic lymphedema patient in whom toxic hepatitis developed due to irregular antibiotic and analgesic usage in order to treat leg ulcers.


INTRODUCTION
Lymphedema is a chronic disorder of the lymphatic system that is formed by an accumulation of protein rich fluid in the interstitial space.Lymphedema is mostly seen in upper and lower extremities but it may also be seen in other body regions like face and external genital organs.There are two types of lymphedema; primary and secondary.Secondary lymphedema is the most common cause of the disease.Infections, neoplasms, prior surgery, trauma or radiation can be counted as etiologic factors of the secondary lymphedema (1).According to World Health Organization (WHO) data, there is total of more than 120 million filarial lymphedema patients especially in tropical climates and in India (2).Chronic lymphoedema and venous insufficiency with leg ulcerations are distinctly separate cases.Leg ulcers are mostly (70%) originated from venous insufficiency (2).Among the other reasons of leg ulcers, chronic lymphedema takes an important place in lymphedema patients.Leg ulcers are seen as 10% in lymphedema patients (2).In this article we present a chronic lymphedema patient in whom toxic hepatitis developed due to irregular antibiotic and analgesic usage in order to treat leg ulcers.

CASE REPORT
Seventy-year old male patient was admitted to our clinic with a complaint of chronic lymphedema in both lower limbs with non-healing ulcers for oneyear duration.Physical examination on admission reveals a massive edema on lower limbs.On both two feet dorsum, there were ichtyosis, skin thickening and hyperkeratotic outlook.Distal arterial pulses were pulsatile.Near to medial malleolus of left lower extremity there was an ulcerous lesion of about 20 cm diameter, and there was another ulcerous lesion of 10 cm diameter on foot dorsum.There were serous fluid and fibrinous exudation on wounds.According to venous color doppler ultrasonography imaging, there was no venous insufficiency.From the medical history of the patient it was learnt that the lymphedema had been diagnosed approximately 20 years earlier.There were also repetitive lymphangitis attacks and non-healing leg wounds for a year.The patient was using antibiotics irregularly for a year, and recently had serious nausea, vomiting and inappetence complaints.During his follow up, laboratory findings showed 40 times highness in transaminase levels and the patient was diagnosed with toxic hepatitis.199 Case Report / Olgu Sunumu Any responsible factor was not obtained except medicines.Antibiotic and analgesic treatments were ceased because of toxic hepatitis.The patient was then given a course of intravenous liquid treatment which consisted of amino acid solution.There weren't any pathogens recovered from the wound cultures which were repeated in every 3-4 days.The patient was dressed with physiological saline solution and betadine.
Granulation tissue development was provided by draining the exudation in wounds with negative pressure by using vacuum assisted wound closure systems (VAC).In addition, leg elevation and pneumatic compression were done with support bandage compression.Approximately after 3 weeks of treatment, apparent granulation in wounds and reduction in ulcer diameters were seen, regression in leg diameter was observed and inflammation in peripheral tissues recovered.The oral intake and general condition of patient got better and his liver functions returned to normal (Figure 1).

DISCUSSION
Stasis ulcers can be defined as tissue and skin changes that develop as a consequence of venous deficiency.Venous hypertension develops that increases due to valve deficiency mostly (3).They are mostly seen in around medial malleolar as a location and are responsible for 70-90% of all extremity ulcer reasons (4-5).In anamnesis past thrombophlebitis, varicosity operations and saphenectomy should be questioned.Facts in which chronic venous deficiency is thought, color doppler ultrasonography takes an important place in diagnosis (6).Venous ulcer history in family, the presence of ischemic heart disease, smoking, vasculitis, connective tissue diseases, local traumas, diabetes and the usage of oral contraceptive are among the risk factors for ulcers.In leg ulcer etiology lymphedema can be seen more rarely.Leg ulcers due to lymphedema can be seen in 4 different types (2).The mildest type is defined as Type 1.It is a type that goes along lymphorrhea and eczematous leg ulcers.These patients are recommended wound maintenance, rest cure, and VAC treatment and compression therapy (2).
Limb ulcers can be rarely seen in lymphedema patients who do not have venous insufficiency.In our case we addressed the treatment of a patient having stasis ulcer with lymphedema.The patient had a history of irregular usage of antibiotics and a result of this usage toxic hepatitis was occurred.Since venous insufficiency was not obtained, the patient was not considered as stasis ulcer patient.The patient didn't have any signs of systematic infection, that's why topical treatments and wound maintenance were primarily applied.
In recent years toxic hepatitis rose up to first ranks among reasons of acute liver deficiency due to increased medication (8).Again subclinical increase in liver lysis tests known as transaminases (SGOT/SGPT) takes an important place among those reasons.As a result of the long term usage of analgesic and antibiotics that metabolize in liver, toxic hepatitis can be developed.Serum levels of SGOT and SGPT enzymes can reach to 1000u/l.The benefits of hypertonic solutions that contain branched amino acids in liver deficiencies and hepatic encephalopathy are known (8).Intravenous administration of Hypertonic Hepatamine 8% ®(Eczacıbaşı-Baxter Medical Products Corp., Istanbul) solution which contains crystallized amino acids was performed.During the treatment we did not apply any antibiotics regimen.However, especially in the first days of treatment, during dressing of stasis ulcer, short term effective local anesthetic and rarely low dosage of narcotic analgesic usage were needed.
In many previous research studies related to compression treatments, it was suggested that the usage of elastic bandaging with occasional pneumatic compression treatment can be beneficial in stasis ulcer recovery (9).For this reason, we combined both compression treatments.In a day 3x2 hours of 50mmHg pneumatic compression was applied, for the rest of the time elastic bandaging on both lower extremities as well as leg elevation were continued.The importance of negative pressure wound systems are well known in recovery of wounds and in the reduction of secondary edema in venous ulcers (10).So we also applied vacuum supported closing systems to our patient for 6 sessions in order to aim for the negative pressure wound treatment.
As it is seen in this case, primary wound maintenance, pneumatic compression and vacuum supported wound maintenance equipments should be used in stasis ulcers developing due to lymphedema.When systematic antibiotic treatments are used irregularly and without function, it can harm rather than benefit the patient.