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3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">No spirochetes were identified with immunohistochemistry&#44; nor mycobacteria with Ziehl-Neelsen&#44; and PCR for <span class="elsevierStyleItalic">Chlamydia trachomatis &#40;C&#46; trachomatis&#41;</span> and <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> in tissue tested negative&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Genital pyoderma gangrenosum&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient returned for a follow-up visit with worsening of his left leg ulcer&#44; whose biopsy also turned out to be consistent with pyoderma gangrenosum&#46; This diagnosis was followed by the infiltration of 40mg of triamcinolone acetonide on both lesions and oral cyclosporine A &#40;3&#46;5mg&#47;kg&#41;&#44; leading to the complete resolution of the lesions within 2 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>c&#41;&#46; The patient remains stable on 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day of oral cyclosporine and deflazacort 6<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; During follow-up in internal medicine&#44; the abdominal ultrasound revealed the presence of splenomegaly&#46; After ruling out hematological disease as responsible for the neutropenia and considering the patient&#39;s rheumatoid arthritis&#44; he was diagnosed with Felty&#39;s syndrome&#46; The patient is currently awaiting evaluation to start anti-TNF treatment for disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pyoderma gangrenosum is a non-infectious neutrophilic inflammatory dermatosis clinically characterized by the appearance of erythematous nodules or pustules that progress to ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Approximately 50&#37; of patients have an associated systemic disease&#44; with rheumatoid arthritis being one of the most common ones&#44; especially in aggressive forms of the disease&#44; as in our patient who had accompanying Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This syndrome is a severe form of rheumatoid arthritis characterized by the simultaneous occurrence of splenomegaly and neutropenia&#46; Pyoderma gangrenosum does not have a specific histological pattern&#44; but a mixed dermal infiltrate along with ulceration&#44; epidermal necrosis&#44; and edema<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> in the absence of other detectable infectious agents&#46; Leukocytoclastic or lymphocytic vasculitis phenomena are a common finding&#46; The treatment of choice is corticosteroids and cyclosporine A&#46; Other therapeutic alternatives include mycophenolate mofetil&#44; infliximab&#44; and IV immunoglobulins&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lesions of pyoderma gangrenosum are often found on the lower extremities&#44; with genital involvement being an exceptionally rare finding&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> as it can be mistaken for Fournier&#39;s gangrene&#46; In this entity&#44; debridement is the treatment of choice to prevent progression&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Conversely&#44; aggressive surgical measures to treat pyoderma&#44; such as circumcision&#8212;as in our case&#8212;are contraindicated as they tend to worsen the lesions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">When pyoderma is found in the oral or genital region&#44; differential diagnosis with ulcerative sexually transmitted diseases is mandatory&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Syphilis is characterized by a single painless ulcer&#46; Chancroid &#40;<span class="elsevierStyleItalic">Haemophilus ducreyi</span>&#41; causes painful ulcers and suppurative inguinal lymphadenopathies&#46; Lymphogranuloma venereum &#40;<span class="elsevierStyleItalic">C&#46; trachomatis</span>&#41; obstructs lymphatic flow&#44; causing chronic genital tissue edema and accompanying lymphadenopathy&#46; The diagnosis of these entities can be confirmed through specific serological tests and PCR&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The dermatologist&#39;s intervention is of paramount importance in the diagnosis of ano-genital disease&#44; as seen in this case of atypical location pyoderma gangrenosum&#46; A thorough patient&#39;s history and complete skin examination are essential to achieve diagnosis&#46; Our participation is key to avoid aggressive surgical measures&#44; which can condition the patient&#39;s progression and final prognosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Cases for Diagnosis
Genital Ulcers of Torpid Evolution
Úlceras genitales de tórpida evolución
M. Colmeneroa,
Corresponding author
sendracolmenero@gmail.com

Corresponding author.
, J.B. Repiso-Jiméneza, M.D. Bautista de Ojedab
a Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain
b Servicio de Anatomía Patológica, Hospital Costa del Sol, Marbella, Málaga, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 53-year-old man with a 15-year history of poorly controlled rheumatoid arthritis was undergoing treatment in general surgery for a 2-month-old ulcer of torpid course on his left leg developed after trauma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; The patient was referred to the Dermatology Unit following the appearance of new ulcers in the genital area&#46; Upon examination&#44; a necrotic plaque was observed on the glans and foreskin with edematous penile shaft &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>a&#41;&#46; In the groin&#44; large&#44; soft&#44; and movable lymphadenopathies were palpated&#46; The empirical diagnosis of primary syphilis was followed by the intramuscular injection of 2&#44;400&#44;000 IU of penicillin&#46; Additionally&#44; a blood sample was drawn for a complete blood count including serology for HIV&#44; hepatotropic viruses&#44; and syphilis&#46; In urology&#44; a circumcision was performed to remove the necrotic eschar&#44; adding prednisone 30<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#46; However&#44; the patient returned to the hospital 1 week later with suture dehiscence and increased necrosis size &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>b&#41;&#46; The serology test was negative&#44; and the blood count showed leukopenia &#40;1200&#47;&#956;L&#41;&#44; neutropenia &#40;150&#47;&#956;L&#41;&#44; and anemia &#40;hemoglobin 11&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#46; The histopathological examination of the surgical specimen revealed the presence of ulceration&#44; chronic inflammation&#44; vasculitis with thrombosis&#44; and ischemic necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">No spirochetes were identified with immunohistochemistry&#44; nor mycobacteria with Ziehl-Neelsen&#44; and PCR for <span class="elsevierStyleItalic">Chlamydia trachomatis &#40;C&#46; trachomatis&#41;</span> and <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> in tissue tested negative&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Genital pyoderma gangrenosum&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient returned for a follow-up visit with worsening of his left leg ulcer&#44; whose biopsy also turned out to be consistent with pyoderma gangrenosum&#46; This diagnosis was followed by the infiltration of 40mg of triamcinolone acetonide on both lesions and oral cyclosporine A &#40;3&#46;5mg&#47;kg&#41;&#44; leading to the complete resolution of the lesions within 2 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>c&#41;&#46; The patient remains stable on 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day of oral cyclosporine and deflazacort 6<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; During follow-up in internal medicine&#44; the abdominal ultrasound revealed the presence of splenomegaly&#46; After ruling out hematological disease as responsible for the neutropenia and considering the patient&#39;s rheumatoid arthritis&#44; he was diagnosed with Felty&#39;s syndrome&#46; The patient is currently awaiting evaluation to start anti-TNF treatment for disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pyoderma gangrenosum is a non-infectious neutrophilic inflammatory dermatosis clinically characterized by the appearance of erythematous nodules or pustules that progress to ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Approximately 50&#37; of patients have an associated systemic disease&#44; with rheumatoid arthritis being one of the most common ones&#44; especially in aggressive forms of the disease&#44; as in our patient who had accompanying Felty&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This syndrome is a severe form of rheumatoid arthritis characterized by the simultaneous occurrence of splenomegaly and neutropenia&#46; Pyoderma gangrenosum does not have a specific histological pattern&#44; but a mixed dermal infiltrate along with ulceration&#44; epidermal necrosis&#44; and edema<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> in the absence of other detectable infectious agents&#46; Leukocytoclastic or lymphocytic vasculitis phenomena are a common finding&#46; The treatment of choice is corticosteroids and cyclosporine A&#46; Other therapeutic alternatives include mycophenolate mofetil&#44; infliximab&#44; and IV immunoglobulins&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lesions of pyoderma gangrenosum are often found on the lower extremities&#44; with genital involvement being an exceptionally rare finding&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> as it can be mistaken for Fournier&#39;s gangrene&#46; In this entity&#44; debridement is the treatment of choice to prevent progression&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Conversely&#44; aggressive surgical measures to treat pyoderma&#44; such as circumcision&#8212;as in our case&#8212;are contraindicated as they tend to worsen the lesions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">When pyoderma is found in the oral or genital region&#44; differential diagnosis with ulcerative sexually transmitted diseases is mandatory&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Syphilis is characterized by a single painless ulcer&#46; Chancroid &#40;<span class="elsevierStyleItalic">Haemophilus ducreyi</span>&#41; causes painful ulcers and suppurative inguinal lymphadenopathies&#46; Lymphogranuloma venereum &#40;<span class="elsevierStyleItalic">C&#46; trachomatis</span>&#41; obstructs lymphatic flow&#44; causing chronic genital tissue edema and accompanying lymphadenopathy&#46; The diagnosis of these entities can be confirmed through specific serological tests and PCR&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The dermatologist&#39;s intervention is of paramount importance in the diagnosis of ano-genital disease&#44; as seen in this case of atypical location pyoderma gangrenosum&#46; A thorough patient&#39;s history and complete skin examination are essential to achieve diagnosis&#46; Our participation is key to avoid aggressive surgical measures&#44; which can condition the patient&#39;s progression and final prognosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Original language: English
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