Case Presentation: A 56-year-old man with paraplegia due to a motor vehicle accident 30 years prior and a long-standing stage IV sacral pressure ulcer was admitted with severe sepsis, anemia, hypercalcemia, subacute weight loss of 60 pounds, and acute encephalopathy. A prior attempt to biopsy the sacral bone due to concern for osteomyelitis led to severe bleeding. Imaging showed destruction of the pelvic bones by a large mass, new hepatic and pulmonary lesions, and bulky pelvic lymphadenopathy. Repeat biopsy showed poorly differentiated squamous cell carcinoma (SCC) with necrosis. After further clinical decline, the patient and his family chose a transition to comfort care, and he died. Autopsy confirmed findings characteristic of a Marjolin ulcer, with extensive metastatic SCC arising from the chronic wound with spread to peri-spinal tissues, lungs, liver, and spleen. This spread of tumor was more extensive than imaging had shown just a few weeks prior.
Discussion: A Marjolin ulcer is a rare but highly aggressive cutaneous malignancy that arises in chronically injured, inflamed, or scarred skin such as burn scars, long-standing pressure ulcers, venous stasis ulcers, traumatic wounds, and areas of chronic osteomyelitis (1–3). Lesions often present as squamous cell carcinoma, but can also manifest as basal cell carcinoma, melanoma, or sarcoma. Malignant transformation of these wounds is thought to stem from genetic mutations that lead to uncontrolled cellular proliferation in scar tissue (4). Although it can develop rapidly in rare “acute” cases within one year, malignant transformation typically occurs after a long latency period averaging 25–35 years (1). Clinical features that should prompt biopsy include new ulceration within a wound, exophytic or nodular growth, persistent pain, bleeding, or rapid increase in size of a chronic wound or scar (5). Marjolin ulcers behave far more aggressively than conventional cutaneous SCC, with higher rates of regional metastasis and worse prognosis. Diagnosis requires biopsy and histopathologic confirmation. Management centers on early recognition and wide surgical excision (2,6). This clinical entity is important for hospitalists to be aware of and to maintain a high index of suspicion for, as they frequently care for patients with longstanding wounds—and early detection can significantly influence outcomes.
Conclusions: This case highlights the critical importance of hospitalists recognizing the clinical syndrome of Marjolin ulcers. Maintaining a high index of suspicion for changes in chronic wounds enables early diagnosis and timely oncologic evaluation. Proactive wound surveillance – particularly in high-risk patients with immobility, chronic inflammation, or recurrent infections – remains essential, as early identification offers the best opportunity for effective treatment.