Case for Diagnosis
Ulcer on the Scrotum
Úlcera en el escroto
L.C. Arango-Duque
, S. Blanco-Barrios, E. Fernández-López
Corresponding author
Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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"apellidos" => "Fernández-López" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Úlcera en el escroto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 1669 "Tamanyo" => 319596 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was an 81-year-old man with a history of stage A chronic lymphocytic leukemia, ischemic heart disease, and rheumatoid arthritis for which he was taking methotrexate (7.5<span class="elsevierStyleHsp" style=""></span>mg per week), prednisone, and diclofenac.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He consulted because of a painful ulcer on the scrotum that had first appeared a few weeks previously and was treated with topical silver sulfadiazine. One month later, the lesion had worsened, as had the patient's general status, with fever, dyspnea, mucocutaneous pallor, and enlarged axillary and inguinal lymph nodes.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed an ulcer on the scrotum. It measured 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm and had slightly infiltrated borders and a fibrin-covered base (<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">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Histopathology of the skin biopsy specimen revealed minimal hyperkeratosis in the epidermis and, at a deeper level, an area of geographic necrosis surrounded by an intense mixed inflammatory component comprising mainly lymphocytes and monocytes with plasma cells, histiocytes, and eosinophils. No granulomatous infiltrations were observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory analysis revealed pancytopenia, impaired renal function, and increased lactate dehydrogenase and C-reactive protein levels. Culture of exudates from the ulcer and tissue were negative.</p><p id="par0030" 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="par0035" class="elsevierStylePara elsevierViewall">Cutaneous ulcer secondary to methotrexate.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Methotrexate was suspended, and intravenous folic acid was administered.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The complete blood count values gradually returned to normal, with progressive resolution of the ulcer. One month later, the ulcer had re-epithelialized completely (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0050" class="elsevierStylePara elsevierViewall">Methotrexate is a synthetic analog of folic acid that is used as a chemotherapy agent and for the treatment of inflammatory diseases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The most common adverse reactions include gastrointestinal discomfort, joint and muscle pain, and general malaise, which are usually dose-dependent and can be attenuated with folic acid. More severe side effects, such as liver and blood disorders, can also be observed.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Relatively common cutaneous adverse effects include stomatitis and mouth ulcers, which are usually early markers of toxicity. Other skin disorders, such as photosensitivity, exanthema, vasculitis, erythema, scaling, and toxic epidermic necrolysis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> are rare and appear at high doses of methotrexate.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Skin ulcers, unlike mucosal ulcers, are an uncommon side effect<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> that has been reported mainly in patients with psoriasis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> They are exceptional in patients with no history of this psoriasis, and few cases have been reported in the literature.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Cutaneous ulcer with pancytopenia is considered a sign of drug toxicity.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">A literature review by Pearce and Wilson<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> between 1967-1996 revealed that only 17 patients had experienced this side effect.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Lawrence et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> divided these skin ulcers into 2 types: type I ulcers, which present as necrosis of the psoriatic plaques, and type II ulcers, which are found on skin not affected by psoriasis but by previous disorders or concurrent conditions such as stasis dermatitis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Direct toxicity seemed to be the underlying mechanism in both types.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The results of the histopathology study are usually nonspecific, although there have been reports of changes resulting from epidermal dysmaturation and eccrine squamous syringometaplasia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The main risk factors associated with methotrexate-induced ulcers include changes in dose, concomitant therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), renal failure, concomitant infections, outbreaks of pustular psoriasis, and advanced age.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The occurrence of this and other adverse effects stresses the need for long-term follow-up in patients receiving methotrexate, even at low, stable doses. Medication, especially NSAIDs, and renal failure can boost the toxicity of methotrexate.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We report a new case of skin ulcer secondary to treatment with methotrexate accompanied by pancytopenia in a patient not diagnosed with psoriasis. The pathogenic mechanism seemed to be multifactorial, and age, lack of folic acid, NSAIDs, and renal impairment all seemed to play a role.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 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 and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Arango-Duque LC, Blanco-Barrios S, Fernández-López E. Úlcera en el escroto. Actas Dermosifiliogr. 2014;105:515–516.</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" => 1287 "Ancho" => 1669 "Tamanyo" => 319596 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1230 "Ancho" => 1669 "Tamanyo" => 364765 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin. A, original magnification ×<span class="elsevierStyleHsp" style=""></span>20. B, original magnification ×<span class="elsevierStyleHsp" style=""></span>40. C, original magnification ×<span class="elsevierStyleHsp" style=""></span>200.</p>" ] ] 2 => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1316 "Ancho" => 1669 "Tamanyo" => 379691 ] ] ] ] "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" => "The use of methotrexate in dermatology: A review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Shen" 1 => "T. O’Brien" 2 => "L. Mee Yap" 3 => "H. Miles Prince" 4 => "C.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 8 | 23 |
| 2024 October | 120 | 63 | 183 |
| 2024 September | 149 | 40 | 189 |
| 2024 August | 180 | 53 | 233 |
| 2024 July | 185 | 47 | 232 |
| 2024 June | 154 | 36 | 190 |
| 2024 May | 99 | 36 | 135 |
| 2024 April | 104 | 30 | 134 |
| 2024 March | 85 | 31 | 116 |
| 2024 February | 82 | 27 | 109 |
| 2024 January | 77 | 40 | 117 |
| 2023 December | 48 | 23 | 71 |
| 2023 November | 67 | 39 | 106 |
| 2023 October | 55 | 31 | 86 |
| 2023 September | 55 | 31 | 86 |
| 2023 August | 39 | 23 | 62 |
| 2023 July | 50 | 51 | 101 |
| 2023 June | 63 | 37 | 100 |
| 2023 May | 58 | 38 | 96 |
| 2023 April | 50 | 29 | 79 |
| 2023 March | 36 | 36 | 72 |
| 2023 February | 45 | 43 | 88 |
| 2023 January | 45 | 25 | 70 |
| 2022 December | 53 | 44 | 97 |
| 2022 November | 45 | 45 | 90 |
| 2022 October | 38 | 27 | 65 |
| 2022 September | 25 | 55 | 80 |
| 2022 August | 24 | 52 | 76 |
| 2022 July | 27 | 51 | 78 |
| 2022 June | 28 | 38 | 66 |
| 2022 May | 51 | 45 | 96 |
| 2022 April | 48 | 40 | 88 |
| 2022 March | 50 | 66 | 116 |
| 2022 February | 48 | 37 | 85 |
| 2022 January | 61 | 68 | 129 |
| 2021 December | 41 | 74 | 115 |
| 2021 November | 58 | 61 | 119 |
| 2021 October | 43 | 96 | 139 |
| 2021 September | 27 | 61 | 88 |
| 2021 August | 47 | 69 | 116 |
| 2021 July | 36 | 58 | 94 |
| 2021 June | 34 | 43 | 77 |
| 2021 May | 30 | 91 | 121 |
| 2021 April | 67 | 173 | 240 |
| 2021 March | 66 | 86 | 152 |
| 2021 February | 76 | 109 | 185 |
| 2021 January | 40 | 108 | 148 |
| 2020 December | 42 | 75 | 117 |
| 2020 November | 29 | 73 | 102 |
| 2020 October | 29 | 41 | 70 |
| 2020 September | 20 | 56 | 76 |
| 2020 August | 25 | 61 | 86 |
| 2020 July | 20 | 49 | 69 |
| 2020 June | 40 | 64 | 104 |
| 2020 May | 35 | 63 | 98 |
| 2020 April | 33 | 112 | 145 |
| 2020 March | 34 | 100 | 134 |
| 2020 February | 5 | 76 | 81 |
| 2020 January | 4 | 48 | 52 |
| 2019 December | 8 | 45 | 53 |
| 2019 November | 4 | 15 | 19 |
| 2019 October | 0 | 10 | 10 |
| 2019 September | 12 | 8 | 20 |
| 2019 August | 4 | 7 | 11 |
| 2019 July | 2 | 22 | 24 |
| 2019 June | 7 | 23 | 30 |
| 2019 May | 2 | 63 | 65 |
| 2019 April | 0 | 48 | 48 |
| 2019 March | 2 | 15 | 17 |
| 2019 February | 0 | 11 | 11 |
| 2019 January | 1 | 8 | 9 |
| 2018 December | 0 | 8 | 8 |
| 2018 November | 3 | 8 | 11 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 1 | 8 | 9 |
| 2018 August | 0 | 12 | 12 |
| 2018 July | 0 | 16 | 16 |
| 2018 June | 0 | 12 | 12 |
| 2018 May | 0 | 5 | 5 |
| 2018 April | 0 | 4 | 4 |
| 2018 March | 2 | 4 | 6 |
| 2018 February | 18 | 6 | 24 |
| 2018 January | 27 | 20 | 47 |
| 2017 December | 38 | 6 | 44 |
| 2017 November | 27 | 15 | 42 |
| 2017 October | 24 | 29 | 53 |
| 2017 September | 28 | 9 | 37 |
| 2017 August | 43 | 11 | 54 |
| 2017 July | 29 | 20 | 49 |
| 2017 June | 47 | 35 | 82 |
| 2017 May | 37 | 28 | 65 |
| 2017 April | 43 | 13 | 56 |
| 2017 March | 30 | 18 | 48 |
| 2017 February | 28 | 20 | 48 |
| 2017 January | 21 | 16 | 37 |
| 2016 December | 47 | 16 | 63 |
| 2016 November | 57 | 19 | 76 |
| 2016 October | 57 | 26 | 83 |
| 2016 September | 61 | 18 | 79 |
| 2016 August | 59 | 18 | 77 |
| 2016 July | 41 | 14 | 55 |
| 2016 June | 9 | 5 | 14 |
| 2016 May | 5 | 2 | 7 |
| 2016 April | 10 | 1 | 11 |
| 2016 March | 6 | 1 | 7 |
| 2016 February | 14 | 3 | 17 |
| 2016 January | 13 | 2 | 15 |
| 2015 December | 16 | 2 | 18 |
| 2015 November | 10 | 4 | 14 |
| 2015 October | 15 | 18 | 33 |
| 2015 September | 7 | 2 | 9 |
| 2015 August | 16 | 6 | 22 |
| 2015 July | 54 | 12 | 66 |
| 2015 June | 39 | 6 | 45 |
| 2015 May | 30 | 9 | 39 |
| 2015 April | 18 | 4 | 22 |
| 2015 March | 26 | 2 | 28 |
| 2015 February | 18 | 1 | 19 |
| 2015 January | 20 | 7 | 27 |
| 2014 December | 29 | 1 | 30 |
| 2014 November | 22 | 10 | 32 |
| 2014 October | 23 | 10 | 33 |
| 2014 September | 16 | 3 | 19 |
| 2014 August | 21 | 12 | 33 |
| 2014 July | 18 | 8 | 26 |
| 2014 June | 28 | 5 | 33 |
| 2014 May | 4 | 3 | 7 |
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