Cases for Diagnosis
Chronic Plantar Ulcer in an Immigrant from Africa
Úlcera plantar crónica en inmigrante africano
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The patient reported a lesion that had developed 7 years earlier and made walking painful. Multiple treatments with antimicrobial agents in Senegal had led to no improvement. He reported no history of trauma, insect bite, or foreign body penetration and there was no significant medical history.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">A lesion, measuring 6<span class="elsevierStyleHsp" style=""></span>cm in diameter and covered by a hemorrhagic crust, was present on the sole of the patient's right foot. Removal of the crust revealed a suppurating surface with multiple fistulous tracts that produced a white-yellowish granular material (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Systemic examination showed signs of malnutrition (extreme thinness and diffuse alopecia).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathologic examination revealed orthokeratotic hyperkeratosis with underlying epidermal hyperplasia. The dermis showed a mixed, predominantly lymphoplasmacytic inflammatory infiltrate, vascular proliferation, and signs of chronic bleeding (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Clusters of gram-positive bacteria, forming structures with a basophilic granular center and peripheral eosinophilic collarette (Splendore–Hoeppli phenomenon), were observed using standard histochemical staining techniques (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Culture of the exudate revealed <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Streptococcus equisimilis</span>. Radiographs of the chest, foot, and ankle were normal. Serology showed evidence of past infection with hepatitis B virus but was negative for human immunodeficiency virus. Other laboratory tests, including complete blood count, coagulation studies, biochemistry, liver and kidney function tests, and serology, were normal or negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Primary cutaneous botryomycosis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was started with oral amoxicillin (1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h) and clindamycin (300<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h) for 4 weeks, resulting in a significant reduction in the size of the lesion. Given the considerable clinical improvement with antibiotic treatment alone and in order to avoid surgery, the patient received oral cefadroxil (500<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h) for a further 4 weeks, with complete remission of the lesion.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Botryomycosis is a chronic, granulomatous, suppurative bacterial infection that affects the skin and viscera. It is also known as staphylococcic actinophytosis, granular bacteriosis, and bacterial pseudomycosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1884, Rivolta proposed the term <span class="elsevierStyleItalic">botryomycosis</span> to reflect the presumed fungal origin of the infection, and in 1914 Magrou identified <span class="elsevierStyleItalic">S aureus</span> as one of the causes of this disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Botryomycosis represents a diagnostic challenge for many clinicians because fewer than 100 cases are described in the literature<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and it appears at different anatomical sites. The differential diagnosis should essentially include other granulomatous diseases such as actinomycosis, mycetoma, sporotrichosis, tuberculosis, leishmaniasis, and cutaneous carcinomas.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4-8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical course of botryomycosis, similar to that of chronic pyoderma, takes the form of a single lesion, which commonly affects exposed areas.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-3</span></a> The skin is the most frequently affected organ.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2-4</span></a> The main causative agent is <span class="elsevierStyleItalic">S aureus</span>, followed by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, but the infection is polymicrobial in up to 50% of cases.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The pathogenesis of the disease remains a subject of debate. It has been suggested that a balance between the number of microorganisms and the host's defences is necessary, as high concentrations of bacterial inoculum would cause extensive and rapid tissue necrosis, whereas low concentrations would cause the organisms to be phagocytized.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Definitive diagnosis is based on histologic and microbiological criteria<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-8</span></a> and is considerably aided by the study of the shape and characteristics of the granule for differentiation from actinomycosis and mycetoma (where granules are filamentous and change color rapidly with fungal stains). These studies also show the Splendore-Hoeppli phenomenon, when present. This phenomenon is highly characteristic of the disease and consists of periodic acid-Schiff–positive basophilic granules (clusters of bacteria), surrounded by eosinophilic material (immunoglobulin deposits), a reflection of the host's immune response.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Administration of specific antibiotics for long periods forms the basis of treatment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Surgery is recommended when faster healing is required or there is only partial response to antibiotic treatment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Most cases in the literature describe patients with an abnormal immune function or significant comorbidities,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but this was not true for our patient. Our patient had regularly walked barefoot in Senegal, a fact that, coupled with chronic malnutrition and irregular antibiotic treatment, could have contributed to the development and perpetuation of the disease.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Molina-Ruiz A, Pérez-Vega E, Zulueta-Dorado T. Úlcera plantar crónica en inmigrante africano. Actas Dermosifiliogr.2012;103:733-734.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 425 "Ancho" => 639 "Tamanyo" => 87991 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 525 "Ancho" => 402 "Tamanyo" => 103784 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 500 "Ancho" => 660 "Tamanyo" => 108665 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×400.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Botriomicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 12 | 20 |
| 2024 October | 62 | 33 | 95 |
| 2024 September | 71 | 19 | 90 |
| 2024 August | 99 | 51 | 150 |
| 2024 July | 81 | 35 | 116 |
| 2024 June | 96 | 24 | 120 |
| 2024 May | 88 | 32 | 120 |
| 2024 April | 70 | 27 | 97 |
| 2024 March | 66 | 20 | 86 |
| 2024 February | 51 | 32 | 83 |
| 2024 January | 52 | 31 | 83 |
| 2023 December | 51 | 19 | 70 |
| 2023 November | 49 | 19 | 68 |
| 2023 October | 50 | 20 | 70 |
| 2023 September | 57 | 30 | 87 |
| 2023 August | 27 | 18 | 45 |
| 2023 July | 58 | 33 | 91 |
| 2023 June | 70 | 21 | 91 |
| 2023 May | 37 | 25 | 62 |
| 2023 April | 27 | 16 | 43 |
| 2023 March | 41 | 29 | 70 |
| 2023 February | 46 | 15 | 61 |
| 2023 January | 24 | 22 | 46 |
| 2022 December | 46 | 29 | 75 |
| 2022 November | 26 | 20 | 46 |
| 2022 October | 17 | 21 | 38 |
| 2022 September | 27 | 52 | 79 |
| 2022 August | 19 | 63 | 82 |
| 2022 July | 19 | 42 | 61 |
| 2022 June | 17 | 59 | 76 |
| 2022 May | 27 | 32 | 59 |
| 2022 April | 31 | 34 | 65 |
| 2022 March | 35 | 49 | 84 |
| 2022 February | 35 | 27 | 62 |
| 2022 January | 26 | 32 | 58 |
| 2021 December | 24 | 36 | 60 |
| 2021 November | 38 | 34 | 72 |
| 2021 October | 39 | 47 | 86 |
| 2021 September | 30 | 41 | 71 |
| 2021 August | 28 | 25 | 53 |
| 2021 July | 24 | 30 | 54 |
| 2021 June | 37 | 28 | 65 |
| 2021 May | 36 | 28 | 64 |
| 2021 April | 71 | 70 | 141 |
| 2021 March | 46 | 20 | 66 |
| 2021 February | 52 | 28 | 80 |
| 2021 January | 34 | 14 | 48 |
| 2020 December | 33 | 16 | 49 |
| 2020 November | 19 | 14 | 33 |
| 2020 October | 17 | 9 | 26 |
| 2020 September | 28 | 15 | 43 |
| 2020 August | 13 | 22 | 35 |
| 2020 July | 21 | 12 | 33 |
| 2020 June | 37 | 28 | 65 |
| 2020 May | 18 | 18 | 36 |
| 2020 April | 24 | 22 | 46 |
| 2020 March | 30 | 15 | 45 |
| 2020 February | 4 | 0 | 4 |
| 2020 January | 6 | 1 | 7 |
| 2019 December | 4 | 1 | 5 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 0 | 1 | 1 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 9 | 13 |
| 2019 June | 4 | 6 | 10 |
| 2019 May | 4 | 23 | 27 |
| 2019 April | 2 | 1 | 3 |
| 2019 March | 2 | 12 | 14 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 0 | 3 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 33 | 1 | 34 |
| 2018 January | 85 | 7 | 92 |
| 2017 December | 39 | 5 | 44 |
| 2017 November | 27 | 2 | 29 |
| 2017 October | 21 | 4 | 25 |
| 2017 September | 36 | 1 | 37 |
| 2017 August | 57 | 10 | 67 |
| 2017 July | 37 | 9 | 46 |
| 2017 June | 62 | 13 | 75 |
| 2017 May | 56 | 4 | 60 |
| 2017 April | 42 | 5 | 47 |
| 2017 March | 36 | 11 | 47 |
| 2017 February | 47 | 5 | 52 |
| 2017 January | 18 | 6 | 24 |
| 2016 December | 37 | 4 | 41 |
| 2016 November | 40 | 6 | 46 |
| 2016 October | 58 | 7 | 65 |
| 2016 September | 48 | 4 | 52 |
| 2016 August | 42 | 7 | 49 |
| 2016 July | 37 | 11 | 48 |
| 2016 June | 13 | 7 | 20 |
| 2016 May | 5 | 12 | 17 |
| 2016 April | 5 | 1 | 6 |
| 2016 March | 5 | 1 | 6 |
| 2016 February | 10 | 4 | 14 |
| 2016 January | 5 | 1 | 6 |
| 2015 December | 8 | 4 | 12 |
| 2015 November | 21 | 4 | 25 |
| 2015 October | 13 | 5 | 18 |
| 2015 September | 12 | 40 | 52 |
| 2015 August | 14 | 5 | 19 |
| 2015 July | 78 | 12 | 90 |
| 2015 June | 46 | 6 | 52 |
| 2015 May | 76 | 7 | 83 |
| 2015 April | 82 | 11 | 93 |
| 2015 March | 54 | 6 | 60 |
| 2015 February | 45 | 15 | 60 |
| 2015 January | 37 | 23 | 60 |
| 2014 December | 51 | 8 | 59 |
| 2014 November | 38 | 8 | 46 |
| 2014 October | 78 | 17 | 95 |
| 2014 September | 20 | 2 | 22 |
| 2014 August | 26 | 6 | 32 |
| 2014 July | 18 | 4 | 22 |
| 2014 June | 46 | 1 | 47 |
| 2014 May | 44 | 5 | 49 |
| 2014 April | 28 | 2 | 30 |
| 2014 March | 42 | 6 | 48 |
| 2014 February | 41 | 10 | 51 |
| 2014 January | 43 | 4 | 47 |
| 2013 December | 36 | 5 | 41 |
| 2013 November | 28 | 7 | 35 |
| 2013 October | 22 | 3 | 25 |
| 2013 September | 18 | 1 | 19 |
| 2013 August | 16 | 5 | 21 |
| 2013 July | 6 | 11 | 17 |
| 2013 June | 12 | 8 | 20 |
| 2013 May | 19 | 6 | 25 |
| 2013 April | 12 | 14 | 26 |
| 2013 March | 16 | 4 | 20 |
| 2013 February | 30 | 5 | 35 |
| 2013 January | 30 | 2 | 32 |
| 2012 December | 19 | 7 | 26 |
| 2012 November | 5 | 0 | 5 |
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