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Disease Flares
Left heel ulcer
Pearl seemed to be stable and management was becoming routine. I took this occasion to initiate a change from the FPP to an Internist – this took place during 2000. I was disappointed in the FPP for several reasons – failure to diagnose GCA/PMR initially, his micromanagement of non-essentials (limiting Pearl on size of triamcinolone container in prescription; balking at writing mail order prescriptions), and lack of aggressiveness in coordinating activities of the many specialists involved in her care. I felt that I was the coordinator informing him of what he should have been doing for us. We needed a stronger medical professional on the team. I would go through several internists before finding one several years later who could make a significant contribution to Pearl’s care.
An ominous sign of impaired circulation began in both legs and feet four months after the right heel ulcer episode concluded favorably. Both Pletal and Trental had been in use since that time. Trental was stopped because circulation had improved but Pearl restarted it when circulation appeared to diminish once again. An ulcer began to form on her left heel, mirroring that on her right heel seven months before. A doppler scan confirmed degradation in the leg arteries. Sed rate increased from 15 to 19. We wanted to increase prednisone, which had been at 10 mg/day, as did the Vascular Surgeon who now suspected inflammation rather than atherosclerosis, but the Rheumatologist said no. Pearl increased the prednisone to 12 ½ mg on her own. The Dermatologist recommended the prednisone be increased to 15 mg – the Rheumatologist relented and accepted the Dermatologist’s recommendation. Pearl felt circulation increase in her legs during the night she started 15 mg.
We proposed visiting a remote reputable Clinic for a second opinion about Arteritis therapy, Vasculitis cause, and Sinusitis therapy. The report of an MRI of a swollen eye socket performed during this period mentioned chronic sinusitis. Her specialists welcomed this potential new input. The visit will be discussed later in the section on Expanding Management Tools.
The Rheumatologist continued to insist that Pearl’s leg problems were due to atherosclerosis – he added that arteritis only affects temporal arteries. He wanted Pearl to have angioplasty on an urgent basis to avoid the need for shunt surgery in her legs. Increasing prednisone up to 20 mg corrected the left heel ulcer problem. Wound Care found that the skin area around the ulcer was getting good oxygenation so it would heal without HBO. It was almost completely healed at the last visit to Wound Care in mid-June. Again, the evidence for an arteritic problem in her legs rather than atherosclerosis was demonstrated by a favorable reaction to increased prednisone.
One day in June, 2000, Pearl spent several hours walking and standing while shopping, climbed stairs in two model homes and had no unusual pain in her legs or leg muscles. But that would change as prednisone was tapered too low repeatedly during on-going treatment of her illness.