Acral Malignant Melanoma of the Lower Limb in an Elderly Patient With Diabetes Mellitus and Hypertension: A Case Report From Uganda.

Acral Malignant Melanoma of the Lower Limb in an Elderly Patient With Diabetes Mellitus and Hypertension: A Case Report From Uganda. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Acral Malignant Melanoma of the Lower Limb in an Elderly Patient With Diabetes Mellitus and Hypertension: A Case Report From Uganda. Nakatudde Mariam.S. This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9619137/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Malignant melanoma is an aggressive malignant tumor arising from melanocytes and is associated with high mortality when diagnosis is delayed. Although relatively uncommon in African populations, it is frequently diagnosed at advanced stages due to low clinical suspicion and misinterpretation as benign or chronic skin conditions. Elderly patients with comorbidities such as diabetes mellitus and hypertension are particularly vulnerable to delayed diagnosis, as lower limb lesions may be mistaken for diabetic ulcers, vascular disease, or chronic infections. Case presentation We report the case of an 82-year-old male with known hypertension and type 2 diabetes mellitus who was admitted to the Internal Medicine ward with a progressively enlarging pigmented lesion on the left lower limb. The lesion initially began as a small, painless black macule and slowly enlarged over several months, later developing irregular borders, nodularity, and focal ulceration with occasional bleeding. The patient also experienced generalized weakness, reduced appetite, and unintentional weight loss. Clinical examination revealed a large asymmetrical pigmented ulcer nodular lesion with surrounding induration and ipsilateral inguinal lymphadenopathy. Laboratory investigations demonstrated mild normocytic anemia and poor glycemic control. Imaging showed no evidence of distant metastasis. Histopathological examination confirmed invasive cutaneous malignant melanoma. The patient was managed with inpatient metabolic stabilization, wound care, and multidisciplinary oncologic evaluation. Conclusion This case emphasizes that malignant melanoma should always be considered in the differential diagnosis of any persistent, evolving, or atypical pigmented lesion, particularly in elderly patients with chronic comorbidities. Early recognition, timely biopsy, and coordinated multidisciplinary management are critical in preventing delayed diagnosis and improving survival outcomes. Internal Medicine Malignant melanoma elderly patient diabetes mellitus hypertension lower limb lesion Uganda case report INTRODUCTION Malignant melanoma is a serious malignant tumor that develops from melanocytes, the cells responsible for producing melanin pigment in the skin. Although it is less common than other skin cancers, it is considered the most dangerous because of its rapid ability to invade surrounding tissues and metastasize to distant organs if not diagnosed early. In most patients, melanoma begins as a slowly enlarging pigmented lesion that may later develop irregular borders, color changes, nodularity, ulceration, or bleeding. Because the lesion is often painless in the early stages, many patients delay seeking medical attention until the disease has become advanced [ 1 ]. Elderly patients are particularly at risk of late diagnosis because skin changes are frequently mistaken for normal aging, chronic wounds, or other benign dermatological conditions. Malignant melanoma is increasingly becoming a global public health problem. According to the International Agency for Research on Cancer, about 332,000 new cases of melanoma and nearly 60,000 deaths were reported worldwide in 2022, and these numbers are expected to continue rising over the coming years ([IARC][ 1 ]). Studies have shown that the global incidence of melanoma may increase by more than half by the year 2040 due to aging populations, environmental exposure, and delayed recognition in some regions [ 2 ]. Although many melanoma cases are linked to ultraviolet radiation exposure, the disease can also occur in darker-skinned populations, especially as acral lentiginous melanoma affecting the feet, palms, and lower limbs [ 3 ]. This form is important because it is not usually associated with sun exposure and may therefore be overlooked. In Africa, melanoma is reported less frequently than in Western countries, with many nations recording incidence rates below 1 per 100,000 population. However, the lower reported incidence does not mean the disease is unimportant. African patients commonly present with late-stage disease characterized by large ulcerated lesions, deep tissue invasion, and metastasis. This is mainly due to poor public awareness, low suspicion among healthcare workers, delayed referral, and limited access to histopathological diagnosis. In addition, many pigmented lesions on the lower limbs are often mistaken for traumatic wounds, diabetic ulcers, or chronic infections, leading to prolonged delay before biopsy is done [ 2 ]. Recent African reports continue to emphasize that melanoma in black populations is usually detected only after significant progression, which greatly worsens the prognosis [ 4 ]. In Uganda, malignant melanoma remains a rare but under recognized surgical and oncological problem. Very few cases have been documented in published Ugandan literature, and the available reports show that many patients seek care only when the lesion has become very large, fungating, or non-healing. A recent Ugandan case report described a patient who presented after three years with an advanced giant melanoma of the foot, highlighting the severe delay in diagnosis and treatment that still exists in the country ([PubMed ][ 2 ]). Factors such as poor health-seeking behavior, financial limitations, inadequate cancer screening services, and low awareness among both patients and healthcare providers contribute greatly to this challenge. In elderly patients with chronic diseases such as hypertension and diabetes mellitus, lower limb lesions may also be wrongly attributed to vascular insufficiency, diabetic skin changes, or pressure sores, thereby masking the possibility of malignancy. Despite progress in the diagnosis and treatment of melanoma worldwide, delayed recognition of slowly progressive pigmented lesions remains a major clinical problem in low-resource settings. This delay often results in patients presenting with advanced lesions that require extensive surgery and have poorer survival outcomes. The problem becomes more significant in elderly diabetic patients because chronic lower limb skin lesions are common and can easily mimic benign conditions. Therefore, suspicious pigmented lesions may not receive the urgent biopsy needed for early confirmation. This case was reported to highlight the occurrence of malignant melanoma in an elderly Ugandan male with hypertension and diabetes mellitus who presented with a slowly progressive lesion on the left lower limb. The report is important because it adds to the limited Ugandan literature on melanoma, demonstrates the difficulty of early diagnosis in patients with multiple comorbidities, and emphasizes the need for clinicians to maintain a high index of suspicion for melanoma in any persistent or enlarging pigmented lower limb lesion. Early biopsy, prompt histopathological diagnosis, and timely surgical management are essential in improving patient outcomes [ 1 , 4 ] CASE PRESENTATION An 82-year-old Ugandan male was admitted to the Internal Medicine ward with complaints of a progressively enlarging dark lesion on the left lower limb associated with generalized body weakness and poor appetite. The patient reported that the lesion had started insidiously several months prior to admission as a small painless blackish spot on the distal part of the left leg. At onset, the lesion was flat and insignificant in size, and because it caused no pain or functional limitation, he did not seek formal medical care. Over time, however, the lesion gradually increased in diameter, became darker in pigmentation, and developed an irregular raised surface. In the weeks preceding admission, the lesion became nodular with focal areas of skin breakdown and occasional slight bleeding after minor friction. There was also intermittent serosanguinous discharge. Despite these changes, the lesion remained largely painless. The progressive skin lesion was accompanied by generalized fatigue, reduced oral intake, and subjective weight loss. The patient also complained of reduced mobility due to fear of traumatizing the affected limb during walking. There was no history of fever, night sweats, chronic cough, hemoptysis, chest pain, abdominal pain, or change in bowel habits. He denied any prior trauma, insect bite, burn, or chronic ulceration at the affected site. There was no known history of previous skin tumors or similar lesions elsewhere on the body. The patient was a known hypertensive for the last three years and had been on nifedipine and atenolol, though adherence was occasionally inconsistent. He was also a known patient with type 2 diabetes mellitus on oral hypoglycemic therapy. Glycemic monitoring had been irregular prior to admission. There was no previous history of hospitalization for diabetic foot disease, peripheral vascular disease, or malignancy. He had no known drug allergies and no significant family history of cancer. On admission, the patient appeared elderly and chronically ill-looking with reduced physical strength. He was conscious, alert, and oriented. He was mildly pale and clinically dehydrated. His blood pressure was 150/90 mmHg, pulse rate 82 beats per minute, respiratory rate 18 cycles per minute, and temperature was within normal range. Random blood sugar was elevated at admission. Because of his advanced age, known hypertension, diabetes mellitus, constitutional symptoms, and chronic lower limb lesion, he was admitted under Internal Medicine for comprehensive evaluation, metabolic stabilization, and determination of the etiology of the progressive skin lesion. Local examination of the left lower limb revealed a solitary irregular hyper pigmented lesion located on the anterolateral distal aspect of the leg measuring approximately 6 cm by 5 cm. The lesion was asymmetrical with irregular poorly demarcated edges and variegated black-brown discoloration. The surface was nodular with focal ulceration and minimal serosanguinous ooze. Small contact bleeding points were present. The surrounding skin was mildly indurated with patchy hyperpigmentation. On palpation, the lesion was firm, non-tender, and attached to the overlying skin. Mild pitting edema of the distal limb was noted. Left inguinal lymph nodes were palpable, firm, mobile, and non-tender. Given the patient’s age and diabetic status, the initial differential diagnoses considered included chronic diabetic ulcerative skin change, malignant transformation in a chronic skin lesion, Kaposi-like pigmented lesion, chronic infective ulcer, and cutaneous melanoma. Systemic examination showed no major abnormalities in the respiratory, cardiovascular, abdominal, or central nervous systems apart from generalized weakness. Laboratory investigations demonstrated mild normocytic normochromic anemia, persistent hyperglycemia, and mildly elevated inflammatory markers. Renal function tests and serum electrolytes were within acceptable range. Glycemic control was optimized using inpatient diabetic management, and antihypertensive medications were continued with close monitoring. Chest radiography did not reveal obvious pulmonary metastatic lesions, while abdominal ultrasonography showed no clear intra-abdominal masses or organomegaly. Because of the suspicious appearance and progressive nature of the lesion, dermatologic and surgical consultations were requested, and an incisional biopsy was performed. Histopathological examination of the biopsy specimen revealed malignant proliferation of atypical melanocytes with pleomorphic hyper chromatic nuclei, prominent nucleoli, melanin pigment accumulation, increased mitotic figures, and invasion into the dermis, consistent with invasive cutaneous malignant melanoma.This confirmed that the chronic progressive lesion was malignant rather than a benign diabetic or vascular skin complication. During admission, the patient continued to receive daily wound care, nutritional support, diabetic optimization, blood pressure monitoring, correction of dehydration, and treatment of anemia. A multidisciplinary approach involving Internal Medicine, Surgery, Dermatology, and Oncology was adopted for further staging and long-term management planning. The patient and family were counseled regarding the diagnosis, the aggressive nature of melanoma, and the need for definitive oncologic intervention and close follow-up, especially given the delayed presentation and presence of multiple chronic comorbidities which are known to worsen overall prognosis in elderly melanoma patients. DISCUSSION In this case, we report an 82-year-old male with hypertension and type 2 diabetes mellitus who presented with a slowly progressive pigmented lesion on the left lower limb that was later confirmed histologically as invasive cutaneous malignant melanoma. The major findings in our patient were delayed presentation, advanced age, coexistence of chronic medical illnesses, constitutional decline, ulceronodular transformation of the lesion, and probable regional lymph node involvement. These findings are in agreement with current evidence that melanoma in elderly patients is frequently diagnosed at a more advanced stage because early lesions are often painless, slowly enlarging, and clinically underestimated by both patients and primary healthcare providers [ 5 ].Our patient delayed seeking medical care for several months because the lesion initially appeared as a small painless black patch with no significant discomfort. This pattern has been widely described in melanoma progression, where the absence of pain leads to low perceived severity and delayed consultation until ulceration, bleeding, or rapid enlargement occurs [ 5 ]. Kuitunen et al. also reported that older adults commonly present late because age-related skin changes and frailty reduce early recognition of suspicious lesions, thereby increasing the likelihood of thicker tumors and nodal disease at diagnosis [ 6 ]. The prolonged asymptomatic progression seen in our patient therefore closely mirrors these observations. Another important finding was the presence of type 2 diabetes mellitus in our patient. Chronic diabetes may complicate the clinical interpretation of lower limb skin lesions because physicians often initially suspect diabetic ulcers, trophic skin changes, or vascular insufficiency rather than malignancy. Recent evidence by Tønder et al. demonstrated that although diabetes does not markedly increase melanoma incidence, diabetic individuals tend to present with significantly thicker lesions, more frequent ulceration, and more advanced local disease than non-diabetic patients [ 7 ]. This is comparable to our patient, whose lesion had already progressed to a large ulcerated nodular mass at the time of admission. Poor peripheral tissue healing, delayed symptom interpretation, and frequent overlap with diabetic skin complications may partly explain this similarity [ 7 ]. The advanced age of the patient is another clinically relevant feature. Age has consistently been identified as an adverse prognostic factor in melanoma because elderly patients are more likely to have delayed diagnosis, impaired immunity, multiple comorbidities, and limited physiologic reserve for aggressive treatment [ 6 ]. Schadendorf et al. reported that melanomas in older adults are often characterized by increased Breslow thickness, ulceration, and reduced disease-specific survival compared to younger populations [ 5 ]. Similarly, our patient presented not only with a locally advanced lesion but also with generalized weakness, poor appetite, mild anemia, dehydration, and suboptimal glycemic control, all of which required Internal Medicine stabilization before further oncologic intervention could be planned. This demonstrates that in elderly patients, melanoma should be viewed as a systemic medical challenge rather than a localized skin lesion alone. The location of the lesion on the lower limb also corresponds with patterns reported in black populations. Unlike Caucasian patients, in whom melanomas are commonly associated with sun-exposed skin, African patients more frequently develop acral and lower extremity melanomas [ 8 ]. These lesions are often hidden, mistaken for traumatic wounds, chronic ulcers, fungal lesions, or diabetic foot complications, and therefore diagnosis is frequently delayed [ 8 ]. A Ugandan case report by Wekha et al. described a similarly delayed presentation of giant malignant melanoma involving the foot, where the patient only sought care after the lesion had become massive and disabling [ 9 ]. Our case shows the same trend of late recognition in the Ugandan setting, suggesting that melanoma remains under-suspected despite its severe consequences. An equally important issue demonstrated by this case is the diagnostic value of Internal Medicine admission. Because the patient was admitted primarily with constitutional symptoms, chronic comorbid illnesses, metabolic derangement, and a progressive lower limb lesion, the medical team was able to approach the problem broadly rather than as an isolated surgical wound. Elderly diabetic patients with chronic skin lesions are frequently managed repeatedly as infectious or vascular cases before tissue diagnosis is pursued. Literature emphasizes that any persistent pigmented lesion with progressive enlargement, irregularity, or ulceration should undergo early biopsy to exclude melanoma, regardless of pre-existing diabetic status [ 5 , 7 ]. The eventual histopathological confirmation in our patient reinforces this recommendation. Overall, our findings are similar to both international and regional literature showing that malignant melanoma in elderly individuals commonly presents late, especially in the presence of diabetes mellitus and other chronic diseases that can obscure early diagnosis [ 6 , 7 ]. The case also supports African reports that lower limb melanomas in black patients are often advanced by the time of presentation because of low awareness and limited access to early histopathological assessment [ 8 , 9 ]. This report therefore highlights the need for physicians in Internal Medicine to maintain a high index of suspicion for cutaneous malignancy in any persistent or atypical pigmented lower limb lesion in elderly patients. Early recognition and prompt biopsy may significantly reduce disease progression, metastatic spread, and poor survival outcomes [ 5 ]. CONCLUSION In conclusion, malignant melanoma can present as a slowly progressive pigmented lesion that may easily be overlooked, especially in elderly patients with chronic conditions such as diabetes mellitus and hypertension. This case highlights that delayed presentation is common and can lead to advanced disease at the time of diagnosis, with possible regional lymph node involvement. It also emphasizes the importance of maintaining a high index of suspicion for malignancy in any persistent, changing, or atypical pigmented lesion of the lower limb, even in patients where diabetic or vascular skin disease is initially suspected. Early recognition, prompt biopsy, and timely multidisciplinary management are essential in improving outcomes and preventing progression to advanced melanoma. Declarations Ethical Approval and Consent to Participate: Ethical approval for this case report was obtained from Kayunga Regional Referral Hospital with approval number (KRRH/2026/777J). Written informed consent was obtained from the patient for participation in this case report. Consent for Publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying clinical information. All reasonable efforts have been made to ensure that patient identity and confidentiality are fully protected. Competing Interests : The author declares that there are no competing interests. Funding : This study received no external funding. Authors’ Contributions : Nakatudde Mariam.S, Fiona Aloyo, Abaho Robert, Mohammed Fatma Khamis, Kisombo Michael Peter .W, Mungi Belinda Mary,Namuyanjah Annah Veronica,Araba Peace,Wakhooli Joshua, Antonio Ramirez Bernis Samuel was responsible for the conception of the study, data collection, analysis, and writing of the manuscript. The author has read and approved the final version of the manuscript. Acknowledgements : The author sincerely acknowledges the clinical staff involved in the management of the patient and thanks the patient for consenting to share his case for educational and academic purposes. References Schadendorf D, van Akkooi ACJ, Berking C, Griewank KG, Gutzmer R, Hauschild A et al (2018) Melanoma Lancet 392(10151):971–984 Arnold M, Singh D, Laversanne M, Vignat J, Vaccarella S, Meheus F et al (2022) Global burden of cutaneous melanoma in 2020 and projections to 2040. JAMA Dermatol 158(5):495–503 Langselius O, Rumgay H, de Vries E, Whiteman DC, Jemal A, Parkin DM et al (2025) Global burden of cutaneous melanoma incidence attributable to ultraviolet radiation in 2022. Int J Cancer 157(6):1110–1119 Wekha G, Ebiju I, Ayesiga I, Kiyimba B, Muhumuza J (2023) A rare presentation of a giant malignant melanoma in a 67 year old female Ugandan: A case report. Int J Surg Case Rep 109:108569 Schadendorf D, van Akkooi ACJ, Berking C, Griewank KG, Gutzmer R, Hauschild A et al (2018) Melanoma Lancet 392(10151):971–984 Kuitunen I, Tolonen T, Luukkaala T, Böhling T, Koljonen V (2024) The impact of prognostic factors and comorbidities on survival in older adults with stage I–III cutaneous melanoma. J Geriatr Oncol 15(2):101701 Tønder JE, Bønnelykke-Behrndtz ML, Laurberg T, Røssell EL, Sollie M (2024) Melanoma risk, tumor stage, and melanoma-specific mortality in individuals with diabetes: a systematic review and meta-analysis. BMC Cancer 24:812 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M et al (2024) Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer, Lyon Wekha G, Ebiju I, Ayesiga I, Kiyimba B, Muhumuza J (2023) A rare presentation of a giant malignant melanoma in a 67 year old female Ugandan: A case report. Int J Surg Case Rep 109:108569 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9619137","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":634845802,"identity":"f195537b-c47d-475b-96a7-25d65f185c82","order_by":0,"name":"Nakatudde Mariam.S.","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYFACNhDBzNgAohKALH4wo4CAlgNIWtglQawEA2K1AAG/wQEQhUeLOfuxxM8f26xl+8UOP/vwoGabtPH51YkfHhgwyPOLHcCqxbIn7bDEwbZ045mz04xnJBy7bWx24+1mCaDDDGfOTsCqxeBAegNQy+HEDbcTjBkS2G4nm904uwGkJcHgNg4t5583/wBp2X87/TNDwr/b9ZtnnN38A6+WG2nHILZI5xgzJLbdZjbg792G35Ybz9IszpxLN55xO6eYIbHvNrPEDd5tFgkGErj9cj7N+EZFGTDEZqdvZvzx7TYzf//ZzTd/VNjI80tj14IFSIBVShCrHAT4D5CiehSMglEwCkYAAAA9U2qTY/hNYQAAAABJRU5ErkJggg==","orcid":"","institution":"Kampala International University","correspondingAuthor":true,"prefix":"","firstName":"Nakatudde","middleName":"","lastName":"Mariam.S.","suffix":""}],"badges":[],"createdAt":"2026-05-05 13:24:17","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9619137/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9619137/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805515,"identity":"c58df033-3e03-4380-86fa-7c322281cd9d","added_by":"auto","created_at":"2026-05-08 15:26:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":137697,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9619137/v1/4a5a0ccd-6f01-4414-93a3-998706dd8363.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAcral Malignant Melanoma of the Lower Limb in an Elderly Patient With Diabetes Mellitus and Hypertension: A Case Report From Uganda.\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMalignant melanoma is a serious malignant tumor that develops from melanocytes, the cells responsible for producing melanin pigment in the skin. Although it is less common than other skin cancers, it is considered the most dangerous because of its rapid ability to invade surrounding tissues and metastasize to distant organs if not diagnosed early. In most patients, melanoma begins as a slowly enlarging pigmented lesion that may later develop irregular borders, color changes, nodularity, ulceration, or bleeding. Because the lesion is often painless in the early stages, many patients delay seeking medical attention until the disease has become advanced [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Elderly patients are particularly at risk of late diagnosis because skin changes are frequently mistaken for normal aging, chronic wounds, or other benign dermatological conditions.\u003c/p\u003e \u003cp\u003eMalignant melanoma is increasingly becoming a global public health problem. According to the International Agency for Research on Cancer, about 332,000 new cases of melanoma and nearly 60,000 deaths were reported worldwide in 2022, and these numbers are expected to continue rising over the coming years ([IARC][\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]). Studies have shown that the global incidence of melanoma may increase by more than half by the year 2040 due to aging populations, environmental exposure, and delayed recognition in some regions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although many melanoma cases are linked to ultraviolet radiation exposure, the disease can also occur in darker-skinned populations, especially as acral lentiginous melanoma affecting the feet, palms, and lower limbs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This form is important because it is not usually associated with sun exposure and may therefore be overlooked.\u003c/p\u003e \u003cp\u003eIn Africa, melanoma is reported less frequently than in Western countries, with many nations recording incidence rates below 1 per 100,000 population. However, the lower reported incidence does not mean the disease is unimportant. African patients commonly present with late-stage disease characterized by large ulcerated lesions, deep tissue invasion, and metastasis. This is mainly due to poor public awareness, low suspicion among healthcare workers, delayed referral, and limited access to histopathological diagnosis. In addition, many pigmented lesions on the lower limbs are often mistaken for traumatic wounds, diabetic ulcers, or chronic infections, leading to prolonged delay before biopsy is done [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recent African reports continue to emphasize that melanoma in black populations is usually detected only after significant progression, which greatly worsens the prognosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Uganda, malignant melanoma remains a rare but under recognized surgical and oncological problem. Very few cases have been documented in published Ugandan literature, and the available reports show that many patients seek care only when the lesion has become very large, fungating, or non-healing. A recent Ugandan case report described a patient who presented after three years with an advanced giant melanoma of the foot, highlighting the severe delay in diagnosis and treatment that still exists in the country ([PubMed ][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]). Factors such as poor health-seeking behavior, financial limitations, inadequate cancer screening services, and low awareness among both patients and healthcare providers contribute greatly to this challenge. In elderly patients with chronic diseases such as hypertension and diabetes mellitus, lower limb lesions may also be wrongly attributed to vascular insufficiency, diabetic skin changes, or pressure sores, thereby masking the possibility of malignancy.\u003c/p\u003e \u003cp\u003eDespite progress in the diagnosis and treatment of melanoma worldwide, delayed recognition of slowly progressive pigmented lesions remains a major clinical problem in low-resource settings. This delay often results in patients presenting with advanced lesions that require extensive surgery and have poorer survival outcomes. The problem becomes more significant in elderly diabetic patients because chronic lower limb skin lesions are common and can easily mimic benign conditions. Therefore, suspicious pigmented lesions may not receive the urgent biopsy needed for early confirmation.\u003c/p\u003e \u003cp\u003eThis case was reported to highlight the occurrence of malignant melanoma in an elderly Ugandan male with hypertension and diabetes mellitus who presented with a slowly progressive lesion on the left lower limb. The report is important because it adds to the limited Ugandan literature on melanoma, demonstrates the difficulty of early diagnosis in patients with multiple comorbidities, and emphasizes the need for clinicians to maintain a high index of suspicion for melanoma in any persistent or enlarging pigmented lower limb lesion. Early biopsy, prompt histopathological diagnosis, and timely surgical management are essential in improving patient outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eAn 82-year-old Ugandan male was admitted to the Internal Medicine ward with complaints of a progressively enlarging dark lesion on the left lower limb associated with generalized body weakness and poor appetite. The patient reported that the lesion had started insidiously several months prior to admission as a small painless blackish spot on the distal part of the left leg. At onset, the lesion was flat and insignificant in size, and because it caused no pain or functional limitation, he did not seek formal medical care. Over time, however, the lesion gradually increased in diameter, became darker in pigmentation, and developed an irregular raised surface. In the weeks preceding admission, the lesion became nodular with focal areas of skin breakdown and occasional slight bleeding after minor friction. There was also intermittent serosanguinous discharge. Despite these changes, the lesion remained largely painless.\u003c/p\u003e \u003cp\u003eThe progressive skin lesion was accompanied by generalized fatigue, reduced oral intake, and subjective weight loss. The patient also complained of reduced mobility due to fear of traumatizing the affected limb during walking. There was no history of fever, night sweats, chronic cough, hemoptysis, chest pain, abdominal pain, or change in bowel habits. He denied any prior trauma, insect bite, burn, or chronic ulceration at the affected site. There was no known history of previous skin tumors or similar lesions elsewhere on the body.\u003c/p\u003e \u003cp\u003eThe patient was a known hypertensive for the last three years and had been on nifedipine and atenolol, though adherence was occasionally inconsistent. He was also a known patient with type 2 diabetes mellitus on oral hypoglycemic therapy. Glycemic monitoring had been irregular prior to admission. There was no previous history of hospitalization for diabetic foot disease, peripheral vascular disease, or malignancy. He had no known drug allergies and no significant family history of cancer.\u003c/p\u003e \u003cp\u003eOn admission, the patient appeared elderly and chronically ill-looking with reduced physical strength. He was conscious, alert, and oriented. He was mildly pale and clinically dehydrated. His blood pressure was 150/90 mmHg, pulse rate 82 beats per minute, respiratory rate 18 cycles per minute, and temperature was within normal range. Random blood sugar was elevated at admission. Because of his advanced age, known hypertension, diabetes mellitus, constitutional symptoms, and chronic lower limb lesion, he was admitted under Internal Medicine for comprehensive evaluation, metabolic stabilization, and determination of the etiology of the progressive skin lesion.\u003c/p\u003e \u003cp\u003eLocal examination of the left lower limb revealed a solitary irregular hyper pigmented lesion located on the anterolateral distal aspect of the leg measuring approximately 6 cm by 5 cm. The lesion was asymmetrical with irregular poorly demarcated edges and variegated black-brown discoloration. The surface was nodular with focal ulceration and minimal serosanguinous ooze. Small contact bleeding points were present. The surrounding skin was mildly indurated with patchy hyperpigmentation. On palpation, the lesion was firm, non-tender, and attached to the overlying skin. Mild pitting edema of the distal limb was noted. Left inguinal lymph nodes were palpable, firm, mobile, and non-tender.\u003c/p\u003e \u003cp\u003eGiven the patient\u0026rsquo;s age and diabetic status, the initial differential diagnoses considered included chronic diabetic ulcerative skin change, malignant transformation in a chronic skin lesion, Kaposi-like pigmented lesion, chronic infective ulcer, and cutaneous melanoma. Systemic examination showed no major abnormalities in the respiratory, cardiovascular, abdominal, or central nervous systems apart from generalized weakness.\u003c/p\u003e \u003cp\u003eLaboratory investigations demonstrated mild normocytic normochromic anemia, persistent hyperglycemia, and mildly elevated inflammatory markers. Renal function tests and serum electrolytes were within acceptable range. Glycemic control was optimized using inpatient diabetic management, and antihypertensive medications were continued with close monitoring. Chest radiography did not reveal obvious pulmonary metastatic lesions, while abdominal ultrasonography showed no clear intra-abdominal masses or organomegaly. Because of the suspicious appearance and progressive nature of the lesion, dermatologic and surgical consultations were requested, and an incisional biopsy was performed.\u003c/p\u003e \u003cp\u003eHistopathological examination of the biopsy specimen revealed malignant proliferation of atypical melanocytes with pleomorphic hyper chromatic nuclei, prominent nucleoli, melanin pigment accumulation, increased mitotic figures, and invasion into the dermis, consistent with invasive cutaneous malignant melanoma.This confirmed that the chronic progressive lesion was malignant rather than a benign diabetic or vascular skin complication.\u003c/p\u003e \u003cp\u003eDuring admission, the patient continued to receive daily wound care, nutritional support, diabetic optimization, blood pressure monitoring, correction of dehydration, and treatment of anemia. A multidisciplinary approach involving Internal Medicine, Surgery, Dermatology, and Oncology was adopted for further staging and long-term management planning. The patient and family were counseled regarding the diagnosis, the aggressive nature of melanoma, and the need for definitive oncologic intervention and close follow-up, especially given the delayed presentation and presence of multiple chronic comorbidities which are known to worsen overall prognosis in elderly melanoma patients.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this case, we report an 82-year-old male with hypertension and type 2 diabetes mellitus who presented with a slowly progressive pigmented lesion on the left lower limb that was later confirmed histologically as invasive cutaneous malignant melanoma. The major findings in our patient were delayed presentation, advanced age, coexistence of chronic medical illnesses, constitutional decline, ulceronodular transformation of the lesion, and probable regional lymph node involvement. These findings are in agreement with current evidence that melanoma in elderly patients is frequently diagnosed at a more advanced stage because early lesions are often painless, slowly enlarging, and clinically underestimated by both patients and primary healthcare providers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].Our patient delayed seeking medical care for several months because the lesion initially appeared as a small painless black patch with no significant discomfort. This pattern has been widely described in melanoma progression, where the absence of pain leads to low perceived severity and delayed consultation until ulceration, bleeding, or rapid enlargement occurs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Kuitunen et al. also reported that older adults commonly present late because age-related skin changes and frailty reduce early recognition of suspicious lesions, thereby increasing the likelihood of thicker tumors and nodal disease at diagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The prolonged asymptomatic progression seen in our patient therefore closely mirrors these observations.\u003c/p\u003e \u003cp\u003eAnother important finding was the presence of type 2 diabetes mellitus in our patient. Chronic diabetes may complicate the clinical interpretation of lower limb skin lesions because physicians often initially suspect diabetic ulcers, trophic skin changes, or vascular insufficiency rather than malignancy. Recent evidence by T\u0026oslash;nder et al. demonstrated that although diabetes does not markedly increase melanoma incidence, diabetic individuals tend to present with significantly thicker lesions, more frequent ulceration, and more advanced local disease than non-diabetic patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This is comparable to our patient, whose lesion had already progressed to a large ulcerated nodular mass at the time of admission. Poor peripheral tissue healing, delayed symptom interpretation, and frequent overlap with diabetic skin complications may partly explain this similarity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe advanced age of the patient is another clinically relevant feature. Age has consistently been identified as an adverse prognostic factor in melanoma because elderly patients are more likely to have delayed diagnosis, impaired immunity, multiple comorbidities, and limited physiologic reserve for aggressive treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Schadendorf et al. reported that melanomas in older adults are often characterized by increased Breslow thickness, ulceration, and reduced disease-specific survival compared to younger populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, our patient presented not only with a locally advanced lesion but also with generalized weakness, poor appetite, mild anemia, dehydration, and suboptimal glycemic control, all of which required Internal Medicine stabilization before further oncologic intervention could be planned. This demonstrates that in elderly patients, melanoma should be viewed as a systemic medical challenge rather than a localized skin lesion alone.\u003c/p\u003e \u003cp\u003eThe location of the lesion on the lower limb also corresponds with patterns reported in black populations. Unlike Caucasian patients, in whom melanomas are commonly associated with sun-exposed skin, African patients more frequently develop acral and lower extremity melanomas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These lesions are often hidden, mistaken for traumatic wounds, chronic ulcers, fungal lesions, or diabetic foot complications, and therefore diagnosis is frequently delayed [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A Ugandan case report by Wekha et al. described a similarly delayed presentation of giant malignant melanoma involving the foot, where the patient only sought care after the lesion had become massive and disabling [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our case shows the same trend of late recognition in the Ugandan setting, suggesting that melanoma remains under-suspected despite its severe consequences.\u003c/p\u003e \u003cp\u003eAn equally important issue demonstrated by this case is the diagnostic value of Internal Medicine admission. Because the patient was admitted primarily with constitutional symptoms, chronic comorbid illnesses, metabolic derangement, and a progressive lower limb lesion, the medical team was able to approach the problem broadly rather than as an isolated surgical wound. Elderly diabetic patients with chronic skin lesions are frequently managed repeatedly as infectious or vascular cases before tissue diagnosis is pursued. Literature emphasizes that any persistent pigmented lesion with progressive enlargement, irregularity, or ulceration should undergo early biopsy to exclude melanoma, regardless of pre-existing diabetic status [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The eventual histopathological confirmation in our patient reinforces this recommendation.\u003c/p\u003e \u003cp\u003eOverall, our findings are similar to both international and regional literature showing that malignant melanoma in elderly individuals commonly presents late, especially in the presence of diabetes mellitus and other chronic diseases that can obscure early diagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The case also supports African reports that lower limb melanomas in black patients are often advanced by the time of presentation because of low awareness and limited access to early histopathological assessment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This report therefore highlights the need for physicians in Internal Medicine to maintain a high index of suspicion for cutaneous malignancy in any persistent or atypical pigmented lower limb lesion in elderly patients. Early recognition and prompt biopsy may significantly reduce disease progression, metastatic spread, and poor survival outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, malignant melanoma can present as a slowly progressive pigmented lesion that may easily be overlooked, especially in elderly patients with chronic conditions such as diabetes mellitus and hypertension. This case highlights that delayed presentation is common and can lead to advanced disease at the time of diagnosis, with possible regional lymph node involvement. It also emphasizes the importance of maintaining a high index of suspicion for malignancy in any persistent, changing, or atypical pigmented lesion of the lower limb, even in patients where diabetic or vascular skin disease is initially suspected. Early recognition, prompt biopsy, and timely multidisciplinary management are essential in improving outcomes and preventing progression to advanced melanoma.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this case report was obtained from Kayunga Regional Referral Hospital with approval number (KRRH/2026/777J). Written informed consent was obtained from the patient for participation in this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying clinical information. All reasonable efforts have been made to ensure that patient identity and confidentiality are fully protected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e \u003cstrong\u003eInterests\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe author declares that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u003c/strong\u003e \u003cstrong\u003eContributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNakatudde Mariam.S, Fiona Aloyo, Abaho Robert, Mohammed Fatma Khamis, Kisombo Michael Peter .W, Mungi Belinda Mary,Namuyanjah Annah Veronica,Araba Peace,Wakhooli Joshua, Antonio Ramirez Bernis Samuel was responsible for the conception of the study, data collection, analysis, and writing of the manuscript. The author has read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe author sincerely acknowledges the clinical staff involved in the management of the patient and thanks the patient for consenting to share his case for educational and academic purposes.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchadendorf D, van Akkooi ACJ, Berking C, Griewank KG, Gutzmer R, Hauschild A et al (2018) Melanoma Lancet 392(10151):971\u0026ndash;984\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnold M, Singh D, Laversanne M, Vignat J, Vaccarella S, Meheus F et al (2022) Global burden of cutaneous melanoma in 2020 and projections to 2040. JAMA Dermatol 158(5):495\u0026ndash;503\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLangselius O, Rumgay H, de Vries E, Whiteman DC, Jemal A, Parkin DM et al (2025) Global burden of cutaneous melanoma incidence attributable to ultraviolet radiation in 2022. Int J Cancer 157(6):1110\u0026ndash;1119\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWekha G, Ebiju I, Ayesiga I, Kiyimba B, Muhumuza J (2023) A rare presentation of a giant malignant melanoma in a 67 year old female Ugandan: A case report. Int J Surg Case Rep 109:108569\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchadendorf D, van Akkooi ACJ, Berking C, Griewank KG, Gutzmer R, Hauschild A et al (2018) Melanoma Lancet 392(10151):971\u0026ndash;984\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuitunen I, Tolonen T, Luukkaala T, B\u0026ouml;hling T, Koljonen V (2024) The impact of prognostic factors and comorbidities on survival in older adults with stage I\u0026ndash;III cutaneous melanoma. J Geriatr Oncol 15(2):101701\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026oslash;nder JE, B\u0026oslash;nnelykke-Behrndtz ML, Laurberg T, R\u0026oslash;ssell EL, Sollie M (2024) Melanoma risk, tumor stage, and melanoma-specific mortality in individuals with diabetes: a systematic review and meta-analysis. BMC Cancer 24:812\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerlay J, Ervik M, Lam F, Colombet M, Mery L, Pi\u0026ntilde;eros M et al (2024) Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer, Lyon\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWekha G, Ebiju I, Ayesiga I, Kiyimba B, Muhumuza J (2023) A rare presentation of a giant malignant melanoma in a 67 year old female Ugandan: A case report. Int J Surg Case Rep 109:108569\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Malignant melanoma, elderly patient, diabetes mellitus, hypertension, lower limb lesion, Uganda, case report","lastPublishedDoi":"10.21203/rs.3.rs-9619137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9619137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMalignant melanoma is an aggressive malignant tumor arising from melanocytes and is associated with high mortality when diagnosis is delayed. Although relatively uncommon in African populations, it is frequently diagnosed at advanced stages due to low clinical suspicion and misinterpretation as benign or chronic skin conditions. Elderly patients with comorbidities such as diabetes mellitus and hypertension are particularly vulnerable to delayed diagnosis, as lower limb lesions may be mistaken for diabetic ulcers, vascular disease, or chronic infections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report the case of an 82-year-old male with known hypertension and type 2 diabetes mellitus who was admitted to the Internal Medicine ward with a progressively enlarging pigmented lesion on the left lower limb. The lesion initially began as a small, painless black macule and slowly enlarged over several months, later developing irregular borders, nodularity, and focal ulceration with occasional bleeding. The patient also experienced generalized weakness, reduced appetite, and unintentional weight loss. Clinical examination revealed a large asymmetrical pigmented ulcer nodular lesion with surrounding induration and ipsilateral inguinal lymphadenopathy. Laboratory investigations demonstrated mild normocytic anemia and poor glycemic control. Imaging showed no evidence of distant metastasis. Histopathological examination confirmed invasive cutaneous malignant melanoma. The patient was managed with inpatient metabolic stabilization, wound care, and multidisciplinary oncologic evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case emphasizes that malignant melanoma should always be considered in the differential diagnosis of any persistent, evolving, or atypical pigmented lesion, particularly in elderly patients with chronic comorbidities. Early recognition, timely biopsy, and coordinated multidisciplinary management are critical in preventing delayed diagnosis and improving survival outcomes.\u003c/p\u003e","manuscriptTitle":"Acral Malignant Melanoma of the Lower Limb in an Elderly Patient With Diabetes Mellitus and Hypertension: A Case Report From Uganda.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 04:04:25","doi":"10.21203/rs.3.rs-9619137/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9abdb530-ca41-46ec-8e38-606d3bc53f37","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67596990,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2026-05-06T04:04:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 04:04:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9619137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9619137","identity":"rs-9619137","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}