MKSAP: 79-year-old man with a sacral ulcer

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 79-year-old man is evaluated for pain in the buttocks region. He was diagnosed with non-Hodgkin large B-cell lymphoma 6 months ago. Although his lymphoma has responded well to therapy and he is without evidence of active disease, he required hospitalization three times for chemotherapy-associated complications during his treatment course. He has been bedbound at home during his lymphoma treatment. He describes the pain as severe when sitting and has difficulty finding a comfortable position lying down as well. He has the least pain when standing, but he is unable to stand for very long. He has had no fever. Medical history is otherwise remarkable for hypertension, hyperlipidemia, type 2 diabetes mellitus, and advanced chronic kidney disease being treated with in-center hemodialysis. Medications are felodipine, insulin, calcium carbonate, calcitriol, and erythropoietin.

On physical examination, the patient is afebrile, blood pressure is 104/58 mm Hg, and pulse rate is 64/min supine. BMI is 18. Weight is 58 kg (128 lb), decreased from 77 kg (170 lb) 5 months ago. He appears cachectic with temporal wasting. Examination of his back shows no vertebral tenderness to palpation. There is wasting of the gluteal muscles. Examination of the sacrum reveals a shallow ulcer that is 5 cm in diameter with a hard black eschar covering the base. There is no wound drainage and no surrounding erythema.

Which of the following is the most appropriate management of this patient’s lesion?

A. Biopsy of the lesion
B. Intravenous antibiotics
C. Leave the wound open to air
D. Surgical debridement

MKSAP Answer and Critique

The correct answer is D. Surgical debridement.

This patient has a sacral decubitus pressure ulcer that is unstageable, and the most appropriate treatment is surgical debridement. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar. The black eschar at the base of the wound prevents adequate evaluation of wound depth and further impairs wound healing. Therefore, this patient should undergo debridement of the eschar to expose healthy, viable tissue in order to assess the depth of the wound, allow for wound staging, and promote healing. Debridement can be accomplished either surgically or with specialized dressings, such as saline wet-to-dry dressings or autolytic dressings.

Lymphomatous invasion of the skin is highly unlikely in this patient without other evidence of active disease following recent treatment; therefore, biopsy is not indicated.

Antibiotics would be indicated in the case of an infected pressure ulcer; however, there is no evidence that this patient’s wound is infected at this time. There is no visible drainage or pus, and there is no surrounding erythema to suggest cellulitis. Additionally, he has no systemic signs or symptoms of infection.

The goal environment for ideal wound healing is a moist wound bed that controls excess exudate. The wound bed should be neither too moist (macerated) nor too dry. Leaving a wound open to air to dry is rarely, if ever, appropriate management.

Key Point

  • Debridement of eschar is necessary in patients with unstageable pressure ulcers to assess the depth of the wound and promote wound healing.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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