Martorell Hypertensive Ischemic Leg Ulcer and Digital Auto-Amputation in an Obese Young Male with Systolic Heart Failure: Case Report.

Introduction: Martorell hypertensive ischemic leg ulcers (HYTILUs) is a rare, painful, and rapidly progressive lower extremity ulcer associated with long-standing, poorly controlled systemic hypertension. It most commonly affects obese women between the fifth and seventh decades of life and is characterized by microvascular arteriolosclerosis with preserved distal pulses. Diagnostic delay is frequent due to clinical overlap with venous ulceration, calciphylaxis, vasculitis, and pyoderma gangrenosum. Case Presentation: A 27-year-old obese African American man with uncontrolled hypertension presented with a 2-year history of bilateral, painful, non-healing lower extremity ulcers. The lesions began as erythematous indurated plaques that progressively ulcerated despite compression therapy, debridement, and enzymatic wound care. On examination, he had deep, punched-out necrotic ulcers on the dorsal feet and toes, marked non-pitting edema, intact pedal pulses, and severe hypertension (210/104 mm Hg). Extensive laboratory, microbiologic, and vascular investigations were unremarkable, and Doppler studies excluded significant arterial or venous occlusive disease. Histopathology was nondiagnostic but did not support vasculitis or infection. Further evaluation revealed decompensated systolic heart failure with a left ventricular ejection fraction of 27% due to idiopathic cardiomyopathy. Following aggressive cardiovascular optimization and diuresis resulting in substantial fluid loss, the patient's edema and ulcerations improved markedly with conservative wound care alone. Notably, he developed spontaneous auto-amputation of the distal phalanx of the right second toe, a complication not previously described in association with HYTILU. Conclusion: This case highlights an unusual demographic presentation of HYTILU in a young male with severe systolic heart failure and documents digital auto-amputation as a novel complication. The patient's clinical course underscores the central role of uncontrolled hypertension and microvascular compromise in disease pathogenesis, as well as the importance of addressing systemic cardiovascular pathology to achieve wound healing. Early recognition of HYTILU and differentiation from mimickers such as calciphylaxis and pyoderma gangrenosum are essential as management strategies differ substantially. Maintaining a high index of suspicion in atypical populations may prevent misdiagnosis, inappropriate interventions, and irreversible tissue loss.