International Journal of Medical Science and Public Health Research
6
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TYPE
Original Research
PAGE NO.
6-11
10.37547/ijmsphr/Volume06Issue03-02
OPEN ACCESS
SUBMITED
04 January 2025
ACCEPTED
06 February 2025
PUBLISHED
11 March 2025
VOLUME
Vol.06 Issue03 2025
CITATION
Shokhista Bobokulova. (2025). A clinical case of chronic ulcer complicated
by generalization of infection. International Journal of Medical Science and
Public Health Research, 6(03), 6
–
11.
https://doi.org/10.37547/ijmsphr/Volume06Issue03-02
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
A clinical case of chronic
ulcer complicated by
generalization of infection
Shokhista Bobokulova
PhD, Senior Lecturer, Department of General and Pediatric Surgery,
Tashkent Medical Academy, Uzbekistan
Achilova Ozoda
PhD, Hematologist of the transplantation department of the Republic
Scientific Research Medical Center of Hematology, Uzbekistan
Abstract:
According to the ICD-10 definition, chronic
ulcers are wounds that do not heal within the usual
healing period of this type of injury or location. Chronic
ulcers most often develop in patients with a burdened
morbid background in the form of diabetes mellitus
complicated
by
angio-
and/or
neuropathy,
decompensated form of venous insufficiency, in
bedridden patients for a long period of severe patients.
The urgency of the problem of treating a chronic ulcer
or wound is due not only to its medical significance but
also to its social and economic importance. Chronic
wounds are a heavy burden for both patients and their
family members. Due to the presence of pain, infection,
loss of function in the affected area, as well as constant
financial costs, not only does the quality of life decrease
and the number of disabled people increases, but
conditions are created for the generalization of
infection, the development of surgical sepsis and the
death of the patient. In this manuscript, we present a
clinical case description of the features of the course of
a chronic wound that was complicated by the
generalization of the infection of the type of chronic
sepsis.
Keywords:
Long-term nonhealing wounds, complicated
course of chronic inflammation, clinical case.
Introduction:
Unresolved problems in the treatment of
long-term nonhealing soft tissue wounds still account
for the share of a negative impact on the economy in
any country in the world, regardless of its level of
development. In the literature, there is statistical
information according to which more than a billion
people around the world suffer from chronic soft tissue
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wounds [1].
This colossal number of patients requires long-term
and close attention from medical personnel, and
periodic shifts of outpatient and inpatient treatment
naturally cause substantial financial costs. For
example, in a study by a group of specialists from the
United States led by S.R. Nussbaum [2], it was revealed
that almost 15% of Medicare holders (8.2 million) had
at least one type of chronic wound.
Surgical infection was the most common category
(4.0%), followed by diabetic infections (3.4%). Total
Medicare cost estimates for all types of wounds ranged
from $28.1 billion to $96.8 billion, including the cost of
treating the infection, with the most expensive costs
being for surgical wounds ($11.7, $13.1 and $38.3
billion), followed by diabetic foot ulcers ($6.2, $6.9 and
$18.7 billion).
It should be noted that the highest costs in the
treatment of chronic wounds were outpatient settings
($9.9-$35.8 billion), followed only by the costs of
patients who received treatment in an inpatient
setting ($5.0-$24.3 billion).
In order to identify the real scale of the impact of
chronic wounds on health, we analyzed systematic
literature published over the past 10
–
15 years in the
most popular databases. The results showed that
health-related quality of life was lowest among
patients with physical abnormalities, including chronic
wounds. The same number of patients was noted after
limb amputation as a result of the progression of
chronic wounds [3].
According to M. Olsson et al. [4] The burden of costs
was mainly related to amputations in patients with
concomitant type 2 diabetes mellitus, where the cost
of hospitalization ranged from $12,851 to $16,267 for
this patient population.
Patients with chronic wounds have a poor quality of
life-related to overall health. Accordingly, the costs
associated with the treatment of chronic wounds
remain significant [5]. This dictates the need to
develop and implement chronic wound management
strategies aimed at improving health-related quality of
life and effectively reducing costs for this group of
patients.
In this regard, clinical cases will be helpful for
practitioners.
MATERIAL AND METHODS OF RESEARCH
The results of the clinical examination of 84 patients
with chronic wounds who were treated and examined
in the multidisciplinary clinic of the Tashkent Medical
Academy are analyzed. All patients were represented
by bedsores in 29 (34.5%) patients, ulcerative
formations in patients with diabetic foot syndrome in 28
(33.3%) patients, and trophic ulcers due to
complications of chronic venous insufficiency of the
lower extremities in 27 (32.1%) patients. Male (68.7%)
at average age 63.8 9.6 years
The research methods were complex. Clinical methods
of research included the collection of complaints, the
identification of the history of the disease with the
peculiarities of the course of the wound process
throughout the entire period of its development. The
obligatory stages of the examination of patients were
the identification of both the etiological cause of chronic
wounds and the presence and severity of concomitant
diseases.
To determine the incidence of sepsis and organ failure
associated with its presence, we used the classification
of sepsis according to R.C. Bone [6], adopted as a basis
at the consensus conference of pulmonologists and
intensive care physicians in the USA (Chicago) in 1991
[7]. A verified diagnosis of sepsis as a complication of
chronic wounds was made by us on the basis of clinical
and pathogenetic signs proposed by the conciliation
conference.
Blood was inoculated in two vials with media to detect
bacteremia and to study aerobic and anaerobic
microorganisms. A microaerostat and dishes with 5%
blood agar were placed in a thermostat and incubated
at a temperature of +37 °C for 48
–
72 hours. Smears
were stained by Gram. Colonies grown under aerobic
and anaerobic conditions were compared according to
their morphology and microscopy results. [8] and Gould
[9]. The content of microorganisms in 1 ml of
pathological material (exudate) was expressed in
decimal logarithms of absolute numbers.
Local clinical methods of wound examination were
based on the assessment of the nature of the
necrobiotic
process
in
the
wound.
The
presence/absence of a local inflammatory process and
the type of tissue necrosis (dry, wet or mixed) were
visually assessed.
The type of tissue in the chronic wound bed was
determined, which could be in the form of dense and
red granulation, brittle and pale granulation, fibrous
film or tissue, as well as in the form of eschar formation.
The nature of wound exudate (serous, hemorrhagic,
purulent), its colour (colourless, pink to red, white,
creamy and green), consistency (transparent, watery,
bloody, and thick) and the smell of exudate (present/not
present) were assessed.
RESULTS AND DISCUSSION
In the presence of brittle and pale granulation tissue, as
our studies have shown, the nature of wound exudate
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was mainly watery, serous-hemorrhagic, odourless,
scanty, and pink to light red in colour.
In cases where the surface of a long-term nonhealing
wound was covered with fibrous tissue, the character
of the wound exudate was hemorrhagic (blood
consistency)
with
moderate
formation
and
odourlessness. In contrast to it, the fibrous film was
mainly characterized by the presence of serous-
purulent, watery, and moderately discharged.
Covering the wound with a scab led to the formation
and production of purulent exudate, which often had a
thick consistency, from white to green, and had an
unpleasant odour.
The study of microbial wound contamination in
patients with long-term nonhealing wounds revealed
the absence of any significant characteristics with the
etiological form of the lesion (bedsores, diabetic foot
syndrome or trophic leg ulcers). At the same time, the
total content of aerobic microorganisms in long-term
nonhealing wounds was equal to 106-107 CFU/ml (on
average 6.5±0.08 lg CFU/ml). The prominent
representatives of the identified microorganisms were
facultative cocci, enterobacteriaceae, Pseudomonas
aeruginosa and other associations. Staphylococci
(25.6%),
representatives
of
Proteus
(16.5%),
Pseudomonas aeruginosa (15.5%) and Enterobacteria
(12.2%) were most often sown. Escherichia coli was
sown in small quantities and accounted for only 6-7%.
Among the anaerobic pathogens, B. melaninogenicus
(22.0±0.8 lg CFU/ml), B. Fragilis (17.0±0.4 lg CFU/ml),
F.
nucleatum
(10.0±0.2
lg
CFU/ml),
Peptostreptococcus (9.0±0.31 lg CFU/ml), Peptococcus
(8.0±0.2 lg CFU/ml) and Eubacterium (3.0±0.1 lg
CFU/ml) were seeded to a greater extent.
When assessing the degree of generalization of
infection, it was revealed that signs of systemic
inflammatory response syndrome were not noted in all
patients.
Thus, in 33.3% of cases (28 patients) they did not have
any general signs indicating generalization of the
infection at all. Among them, the main part were
patients with trophic ulcers of venous etiology (46.4%).
In other cases, the variance in the frequency of
recording the number of patients without signs of
systemic inflammatory response syndrome turned out
to be almost identical between patients with bedsores
(28.6%) and patients with diabetic foot syndrome
(25%).
According to one clinical or laboratory sign of the
syndrome of systemic inflammatory reaction, 28
(33.3%) patients had it. Among them, patients with
diabetic foot syndrome (39.3%) and bedsores (32.1%)
prevailed. Patients with trophic ulcers of venous
aetiology turned out to be only 28.6%.
The most common signs were tachycardia (35.7% of
cases) and general hyperthermia/hypothermia (28.6%
of cases). Leukocytosis was noted in 7 (25%) patients,
and 3 (10.7%) patients also had dyspnea at rest.
Leukocytosis in more than half of cases (57.1%) was
noted among patients with neurotrophic ulcers of
diabetic foot syndrome. A similar trend was noted in the
variance of such a clinical sign as tachycardia (50%). As
for
the
frequency
of
dyspnea
and
hyperthermia/hypothermia, in this category, variances
prevailed in patients with bedsores (66.7% and 50%,
respectively).
Systemic inflammatory response syndrome in the form
of two clinical and laboratory signs was diagnosed
among 11 (13.1%) patients. They were evenly
distributed (5 patients each) between patients with
neuropathic ulcers due to diabetic foot syndrome and
trophic ulcers of post-thrombophlebitic syndrome
(45.5% each, respectively). Among patients with
bedsores, there were only 1 clinical cases (9.1%).
The most common clinical and laboratory signs were
leukocytosis/leukopenia (40.9%) and tachycardia
(31.8%). Hyperthermia/hypothermia was diagnosed in
18.2% of cases, and dyspnea in 9.1% of cases.
Among patients with leukocytosis, patients with trophic
ulcers due to venous insufficiency of the lower
extremities prevailed (55.6%) and neutrophilic ulcers of
diabetic foot syndrome (33.3%). At the same time,
tachycardia was equally distributed among patients of
these etiological categories (42.9% each, respectively).
The same variation was found in relation to
hyperthermia/hypothermia (50% each, respectively).
As for patients with bedsores, it should be noted that 1
patient had 2 clinical and laboratory signs of a systemic
inflammatory response syndrome in the form of
leukocytosis and tachycardia.
We identified three clinical and laboratory signs of
systemic inflammatory response syndrome among 14
(16.7%) patients with long-term nonhealing wounds.
More than half (64.3%) of them were patients with
bedsores. In 28.6% of cases (4 patients) these were
patients with neutrotrophic foot ulcers due to diabetes
mellitus and in 7.1% of cases (1 patient) with trophic
ulcers due to the presence of chronic venous
insufficiency of the lower extremities.
The analysis of clinical and laboratory signs of variance
was mainly manifested by a combination of
hyperthermia/hypothermia (33.3%) and tachycardia
(31%) with the presence of leukocytosis/leukopenia
(26.2%) or dyspnea (9.5%). They were mainly diagnosed
among patients with pressure ulcers. For example,
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leukocytosis/leukopenia among patients with long-
term nonhealing wounds was noted in 72.7% of cases
among patients with bedsores. Such a situation was
also noted in relation to the presence of dyspnea
(75%),
hyperthermia/hypothermia (64.3%)
and
tachycardia (53.8%), which was apparently due to the
initially combined damage to soft tissues.
Only in 3 (3.6%) patients with long-term nonhealing
wounds, we identified four clinical and laboratory signs
of systemic inflammatory response syndrome, which
were among patients with bedsores (2 patients) and
diabetic foot syndrome (1 patient).
Thus, the analysis of the distribution of patients
depending on the number of clinical and laboratory
signs of the systemic inflammatory response
syndrome, based on the criteria for diagnosis, allowed
us to identify the presence of generalization of
infection in 28 (33.3%) patients. At the same time,
among patients with bedsores and neurotrophic ulcers
of diabetic foot syndrome, they turned out to be the
most numerous (41.4% and 36.7%, respectively).
Often, the generalization of the infection manifested
itself in the form of chronic sepsis with organ
dysfunction, which could occur under the mask of the
pathology of the affected organ. An example is the
following clinical case:
Patient S.S., born in 1973, applied to the nephrology
department of the multidisciplinary clinic of the
Tashkent Medical Academy after a long period of
examination and treatment in other hospitals with a
diagnosis of chronic pyelonephritis in the acute stage.
The main complaints were pain in the lumbar region,
frequent urination, periodic hyperthermia, palpitations,
and pronounced general weakness.
The patient has been suffering from long-healing ulcers
of the right tibia for 2 years, which appeared after
thrombophlebitis of the deep veins of the lower
extremities (figure). He received treatment on an
outpatient and inpatient basis.
Over the past month, the patient has developed
swelling of the lower extremities and free fluid in the
abdominal and pleural cavities, weight loss.
Ultrasound showed diffuse changes in the kidneys,
moderate splenomegaly, and hydracalcinosis.
Figure. Trophic ulcers of the lower extremities in the patient presented in the description of this clinical
example
On the radiography of the chest cavity organ, left-sided
exudative pleurisy was noted.
Over the past two weeks, the patient's cervical and
submandibular lymph nodes have enlarged.
Blood tests revealed hypoproteinemia (39 g/l),
dysproteinemia, an increase in alkaline phosphatase
up to 143 U/l, urea up to 18.3 mmol/l, creatinine up to
82 μmol/l, leukocytosis up to 16x109/l, thrombocytosis
- 488x109/l, erythrocytes 4.7x1012/l, haemoglobin - 78
g/l.
Bacteriological culture of the wound made it possible to
identify Staphylococcus aureus in titer 109, and urine
culture revealed Staphylococcus aureus in titer 107.
The results of hemaculture are negative. The diagnosis
was established: post-thrombophlebitic syndrome
complicated by trophic ulcers of the right tibia.
Chronisepsis with kidney damage. Pyelonephritis.
The nature of the necrobiotic process in chronic wounds
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can be diverse [10]. Thus, according to our data, in
23.8% of patients, the inflammatory process in a long-
term nonhealing wound was present, but it proceeded
without the presence of tissue necrosis. At the same
time, this variant of the course of the inflammatory
process in a long-term nonhealing wound was
presented in 65% of patients with trophic ulcers of the
lower extremities, in 25% of cases with bedsores, and
in 10% of cases with neurotrophic ulcers of diabetic
foot syndrome. In contrast, in 72.6% of cases, the
wound was characterized not only by the presence of
an inflammatory process but also by tissue necrosis.
Thus, in 36.9% of cases, the tissues of long-term
nonhealing wounds were subjected to dry necrosis; in
11.9% of cases
–
wet necrosis and in 23.8% of cases
–
mixed necrosis.
Patients with dry necrosis in long-term nonhealing
wounds can mainly be represented by cases of
ulcerative-necrotic ulcers in diabetic foot syndrome
[11].
According to the literature, damage to long-term
nonhealing wounds by wet necrosis is noted among
10
–
11.9% of patients. They can often be represented
by bedsores [12].
The development of wet necrosis in long-term
nonhealing wounds against the background of non-
rejected dry necrosis, i.e. mixed necrosis, can occur
both among patients with bedsores and among
patients with neurotrophic ulcers of diabetic foot
syndrome [13].
As our studies have shown, among patients with
trophic ulcers of the lower extremities due to
complications of chronic venous insufficiency, cases of
the course of the inflammatory process without tissue
necrosis prevailed (48.1%), and the inflammatory
process occurred least of all (3.7%) against the
background of wet necrosis of tissues of long-term
nonhealing wounds.
Dense and red granulation tissue was found among 16
(18.6%) patients. At the same time, in 68.8% of cases,
the exudate was serous, in 18.8% of cases
–
serous-
hemorrhagic, and in 12.5% of cases
–
hemorrhagic in
nature. At the same time, in 21 (24.4%) patients, we
diagnosed the presence of fragile and pale granulation
tissue, which in 19% of cases had serous exudate, in
47.6% of cases
–
serous-hemorrhagic, in 14.3% of cases
–
hemorrhagic and serous-purulent, and in 1 (4.8%)
patient, fragile and pale granulation tissue had
purulent exudate.
Fibrous tissue covered long-term nonhealing wounds
in 20 (23.3%) patients. In all cases, the exudate was
discharged. In 8 (40%) patients, the exudate was
hemorrhagic, and in 4 (20%) patients, it was serous-
hemorrhagic. In 3 cases (15% each), there was serous-
purulent and purulent exudate, and only in 2 (10%)
patients, the wound discharge was severe.
A fibrous film covered long-term nonhealing wounds in
14 (16.3%) patients, and in 15 (17.4%) patients, the
wound surface was covered with a scab. In both cases,
the discharge from the wound was either serous-
purulent (42.9%) or purulent (46.7%) in nature.
The type of tissue in the bed of long-term nonhealing
wounds was clinically manifested by the presence of
granulation tissue covered with a fibrin eschar or film
and was closely related to the nature of wound exudate
[14].
As our studies have shown, in the presence of dense and
red granulation tissue, the discharge from the wound
had a scanty serous character without odor, watery
consistency, transparent color with a yellow tint.
CONCLUSION
Analysis of the distribution of patients depending on the
number of clinical and laboratory signs of the systemic
inflammatory response syndrome, based on the criteria
for diagnosis, allowed us to identify the presence of
generalization of infection in 28 (33.3%) patients. At the
same time, among patients with bedsores and
neurotrophic ulcers of diabetic foot syndrome, they
turned out to be the most numerous (41.4% and 36.7%,
respectively). As this clinical example has shown, a long-
term disease, which was accompanied by a non-specific
clinical picture, required the mandatory exclusion of the
bacteriological factor in the development of this type of
complication. In this case, the sluggish inflammatory
process of a long-term nonhealing wound led to kidney
damage in the form of sluggish urological diseases. In
fact, we were dealing with chronic sepsis, which
manifested itself not only with signs of systemic
inflammatory response syndrome but also with organ
dysfunction.
Ethics approval and consent to participate - All patients
gave written informed consent to participate in the
study.
Consent for publication - The study is valid, and
recognition by the organization is not required. The
author agrees to open the publication.
Availability of data and material - Available
Competing interests - No
Financing
–
No financial support has been provided for
this work
Conflict of interest- The authors declare that there is no
conflict of interest.
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