Case for Diagnosis
Poorly Circumscribed, Long-Standing Tumor on the Foot of an Immigrant
Tumoración mal delimitada de larga evolución en el pie de un inmigrante
P. Giavedoni
, A. Barreiro-Capurro, J. Ferrando
Corresponding author
Servicio de Dermatología, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
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The circles indicate the size of the surgical defects after excision with adequate margins.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L.M. Valladares-Narganes, A. Pérez-Bustillo, G. Pérez-Paredes, M.Á. Rodríguez-Prieto" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L.M." "apellidos" => "Valladares-Narganes" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez-Bustillo" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Pérez-Paredes" ] 3 => array:2 [ "nombre" => "M.Á." 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Giavedoni, A. Barreiro-Capurro, J. Ferrando" "autores" => array:3 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Giavedoni" "email" => array:1 [ 0 => "giavedonip@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Barreiro-Capurro" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Ferrando" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumoración mal delimitada de larga evolución en el pie de un inmigrante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1058 "Ancho" => 1417 "Tamanyo" => 387694 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. B, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>100. C and D, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>200.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 39-year-old Moroccan man with no relevant past history consulted for assessment of diffuse, painful swelling of the right foot, accompanied by redness and small ulcers with secretion. The symptoms had first appeared 1 year earlier. The patient reported no trauma to the area and presented no other symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination of the right foot revealed indurated, poorly defined nodules with purulent secretion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging revealed soft tissue involvement, fungoid masses, nodular lesions, and a lytic lesion in the first metatarsal.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Histologic examination with hematoxylin-eosin staining revealed dermal abscesses surrounded by fibrous tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). At higher magnification, structures formed by basophilic granulations surrounded by an eosinophilic hyaline material were observed inside the abscesses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Abundant polymorphonuclear neutrophils, plasma cells, histiocytes, and necrotic material were observed in the periphery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). These structures were stained with the periodic acid–Schiff (PAS) technique.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><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" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Actinomycetoma of the foot.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Filamentous gram-positive bacteria consistent with <span class="elsevierStyleItalic">Actinomyces</span> species were observed in culture (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient received 3 cycles of treatment, each administered 2 months apart, with intramuscular amikacin at a dose of 500<span class="elsevierStyleHsp" style=""></span>mg/d for 21 days and treatment with trimethoprim/sulfamethoxazole at a dose of 2<span class="elsevierStyleHsp" style=""></span>g/d for 6 months.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The symptoms recurred 6 months and 1 year later, and the patient received treatment with amikacin at the same dose as before. Clinical and microbiologic cure was achieved 1 year after treatment ended.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0050" class="elsevierStylePara elsevierViewall">Mycetoma is a chronic suppurative infection caused by <span class="elsevierStyleItalic">Actinomyces</span> bacteria or eumycetes. Actinomycosis of the foot is caused by inoculation following trauma; it is most common in men between the ages of 30 and 50 years in barefoot-walking populations, agricultural workers, immunodeficient patients, and homeless persons.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of the disease has increased in Europe and the United States as a result of immigration and travel from endemic areas.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Clinically, it is characterized by swelling, abscesses, fistulization, and secretion of discharge containing colored granules. The color of these granules can be the key to diagnosis. The techniques used to diagnose the disease also include imaging, cytology, histology, immunodiagnosis, and, most importantly, culture. DNA sequencing is useful in cases in which the culture is negative.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The incubation period ranges from weeks to months. Initially asymptomatic, the disease progresses by infecting deep tissues, forming abscesses, fistulas, and pseudotumors.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The disease is usually diagnosed at advanced stages of progression. Actinomycetoma can progress rapidly and lead to risk of amputation, and it can even lead to death by means of systemic dissemination. However, actinomycetoma responds better to antibiotic treatment than eumycetoma does. Local complications can lead to extensive, disfiguring scars.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Diagnosis requires a detailed medical history and physical examination. The color of the granules should raise the suspicion of actinomycetoma or eumycetoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The differential diagnosis should include other local infectious processes such as botryomycosis as well as various tumors.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment is based on expert opinion—no evidence-based studies have been carried out—and lasts between 3 and 18 months. Surgery is necessary in many cases of eumycetoma.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Histopathology" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "xack75382" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Giavedoni P, Barreiro-Capurro A, Ferrando J. Tumoración mal delimitada de larga evolución en el pie de un inmigrante. Actas Dermosifiliogr. 2014;105:191–192.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1058 "Ancho" => 1386 "Tamanyo" => 150902 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1058 "Ancho" => 1417 "Tamanyo" => 387694 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. B, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>100. C and D, Hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>200.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mycetoma in children: Experience with 15 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Bonifaz" 1 => "G. Ibarra" 2 => "A. Saúl" 3 => "V. Paredes-Solis" 4 => "E. Carrasco-Gerard" 5 => "L. 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Muntané" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2012.04.013" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2013" "volumen" => "104" "paginaInicial" => "77" "paginaFinal" => "78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22925228" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of Actinomycotic mycetoma involving the right foot" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Tilak" 1 => "S. Singh" 2 => "A. Garg" 3 => "J. Bassi" 4 => "V. Tilak" 5 => "A.K. Gulati" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Infec Dev Ctries" "fecha" => "2009" "volumen" => "3" "paginaInicial" => "71" "paginaFinal" => "73" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atypical presentation of Madurella mycetomatis mycetoma in a renal transplant patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.F. Meis" 1 => "R.A. Schouten" 2 => "P.E. Verweij" 3 => "W. Dolmans" 4 => "J.F. Wetzels" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Transpl Infect Dis" "fecha" => "2000" "volumen" => "2" "paginaInicial" => "96" "paginaFinal" => "98" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11429018" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Úlcera plantar crónica en inmigrante africano" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Molina-Ruiza" 1 => "E. Pérez-Vegab" 2 => "T. Zulueta-Doradoc" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2012.02.004" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2012" "volumen" => "103" "paginaInicial" => "733" "paginaFinal" => "734" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22652504" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack75382" "titulo" => "Acknowledgments" "texto" => "<p id="par0085" class="elsevierStylePara elsevierViewall">We would like to thank Dr. Josep Arimany for allowing us to study and treat his patient.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010500000002/v1_201403090058/S1578219014000080/v1_201403090058/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010500000002/v1_201403090058/S1578219014000080/v1_201403090058/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219014000080?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 11 | 26 |
| 2024 October | 138 | 38 | 176 |
| 2024 September | 95 | 18 | 113 |
| 2024 August | 122 | 50 | 172 |
| 2024 July | 129 | 33 | 162 |
| 2024 June | 114 | 31 | 145 |
| 2024 May | 93 | 36 | 129 |
| 2024 April | 91 | 16 | 107 |
| 2024 March | 89 | 36 | 125 |
| 2024 February | 94 | 25 | 119 |
| 2024 January | 87 | 30 | 117 |
| 2023 December | 84 | 16 | 100 |
| 2023 November | 91 | 22 | 113 |
| 2023 October | 75 | 15 | 90 |
| 2023 September | 68 | 24 | 92 |
| 2023 August | 48 | 11 | 59 |
| 2023 July | 51 | 33 | 84 |
| 2023 June | 51 | 20 | 71 |
| 2023 May | 56 | 17 | 73 |
| 2023 April | 43 | 22 | 65 |
| 2023 March | 27 | 20 | 47 |
| 2023 February | 37 | 20 | 57 |
| 2023 January | 46 | 37 | 83 |
| 2022 December | 51 | 49 | 100 |
| 2022 November | 28 | 25 | 53 |
| 2022 October | 23 | 22 | 45 |
| 2022 September | 27 | 40 | 67 |
| 2022 August | 18 | 35 | 53 |
| 2022 July | 25 | 31 | 56 |
| 2022 June | 25 | 31 | 56 |
| 2022 May | 36 | 45 | 81 |
| 2022 April | 53 | 42 | 95 |
| 2022 March | 52 | 58 | 110 |
| 2022 February | 34 | 23 | 57 |
| 2022 January | 27 | 33 | 60 |
| 2021 December | 23 | 36 | 59 |
| 2021 November | 48 | 52 | 100 |
| 2021 October | 29 | 46 | 75 |
| 2021 September | 29 | 41 | 70 |
| 2021 August | 23 | 36 | 59 |
| 2021 July | 24 | 31 | 55 |
| 2021 June | 32 | 28 | 60 |
| 2021 May | 31 | 40 | 71 |
| 2021 April | 33 | 66 | 99 |
| 2021 March | 38 | 20 | 58 |
| 2021 February | 37 | 27 | 64 |
| 2021 January | 38 | 20 | 58 |
| 2020 December | 21 | 14 | 35 |
| 2020 November | 27 | 11 | 38 |
| 2020 October | 25 | 8 | 33 |
| 2020 September | 32 | 9 | 41 |
| 2020 August | 27 | 9 | 36 |
| 2020 July | 23 | 17 | 40 |
| 2020 June | 43 | 19 | 62 |
| 2020 May | 27 | 12 | 39 |
| 2020 April | 42 | 11 | 53 |
| 2020 March | 23 | 15 | 38 |
| 2020 February | 6 | 0 | 6 |
| 2019 December | 4 | 2 | 6 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 2 | 14 | 16 |
| 2019 May | 1 | 1 | 2 |
| 2019 April | 0 | 1 | 1 |
| 2019 March | 2 | 9 | 11 |
| 2019 February | 0 | 2 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 0 | 3 | 3 |
| 2018 November | 0 | 2 | 2 |
| 2018 October | 2 | 1 | 3 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 70 | 5 | 75 |
| 2018 January | 41 | 5 | 46 |
| 2017 December | 97 | 7 | 104 |
| 2017 November | 26 | 4 | 30 |
| 2017 October | 43 | 4 | 47 |
| 2017 September | 28 | 3 | 31 |
| 2017 August | 57 | 6 | 63 |
| 2017 July | 46 | 8 | 54 |
| 2017 June | 45 | 7 | 52 |
| 2017 May | 38 | 9 | 47 |
| 2017 April | 27 | 7 | 34 |
| 2017 March | 25 | 8 | 33 |
| 2017 February | 25 | 6 | 31 |
| 2017 January | 27 | 12 | 39 |
| 2016 December | 46 | 13 | 59 |
| 2016 November | 47 | 13 | 60 |
| 2016 October | 47 | 12 | 59 |
| 2016 September | 39 | 14 | 53 |
| 2016 August | 54 | 5 | 59 |
| 2016 July | 32 | 6 | 38 |
| 2016 June | 11 | 0 | 11 |
| 2016 May | 13 | 5 | 18 |
| 2016 April | 4 | 1 | 5 |
| 2016 March | 6 | 1 | 7 |
| 2016 February | 12 | 4 | 16 |
| 2016 January | 9 | 2 | 11 |
| 2015 December | 6 | 1 | 7 |
| 2015 November | 3 | 0 | 3 |
| 2015 October | 6 | 1 | 7 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 4 | 1 | 5 |
| 2015 July | 29 | 6 | 35 |
| 2015 June | 29 | 3 | 32 |
| 2015 May | 35 | 13 | 48 |
| 2015 April | 37 | 14 | 51 |
| 2015 March | 30 | 11 | 41 |
| 2015 February | 25 | 8 | 33 |
| 2015 January | 26 | 2 | 28 |
| 2014 December | 23 | 4 | 27 |
| 2014 November | 18 | 6 | 24 |
| 2014 October | 23 | 8 | 31 |
| 2014 September | 12 | 3 | 15 |
| 2014 August | 12 | 5 | 17 |
| 2014 July | 16 | 6 | 22 |
| 2014 June | 15 | 6 | 21 |
| 2014 May | 18 | 6 | 24 |
| 2014 April | 23 | 5 | 28 |
| 2014 March | 12 | 3 | 15 |
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