Case for Diagnosis
Painful Ulcer in a Black Man
Úlcera dolorosa en paciente de raza negra
I. Latour-Álvarez
, M. Arteaga-Henriquez, A. de Andrés-del Rosario
Corresponding author
Departamento de Dermatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain
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"apellidos" => "de Andrés-del Rosario" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Úlcera dolorosa en paciente de raza negra" ] ] "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" => 632 "Ancho" => 850 "Tamanyo" => 156651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</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">The patient was a 58-year-old black man from Senegal who was living in Tenerife and had no personal or family history of interest. During his most recent trip to Senegal 1 month earlier, the patient had manipulated a wound with a wooden stick.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a painful papule on the right knee with a whitish bloody exudate, measuring 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm. An ulcer measuring 7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm, with an indurated border and a central zone containing granulation tissue, was observed on the left thigh (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was afebrile, normotensive, with palpable peripheral pulses, and was in good general condition except for a visual analogue scale score of 7/10.</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">Complete blood count and biochemistry showed no abnormalities. Bacterial culture of the purulent exudate and a skin biopsy specimen taken from the center of the ulcer were positive for <span class="elsevierStyleItalic">Staphylococcus aureus</span>. Mycobacteria and fungal cultures and polymerase chain reaction for <span class="elsevierStyleItalic">Leishmania</span> species were negative. Serology for syphilis, human immunodeficiency virus, and hepatitis C and B viruses were negative. A tuberculin skin test was positive (11<span class="elsevierStyleHsp" style=""></span>mm). An interferon-gamma release assay (QuantiFERON) was negative and a chest radiograph was within normal limits.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Histologic examination of a biopsy specimen taken from the edge of the ulcer revealed a granulomatous reaction and granulation tissue with abscess formation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Periodic acid–Schiff and Ziehl-Neelsen staining of the cutaneous sample did not detect any biologic agents.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tropical phagedenic ulcer.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment was started with amoxicillin–clavulanic acid at a dose of 875/125<span class="elsevierStyleHsp" style=""></span>mg every 78<span class="elsevierStyleHsp" style=""></span>h for 14 days. Topical fusidic acid was applied to the wound on a daily basis. After 3 weeks the lesion had reduced in size by 50%, and after 3 months only the scar was visible.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tropical (or tropical phagedenic) ulcers are skin lesions caused by a synergistic bacterial infection. Most cases that have been reported are associated with <span class="elsevierStyleItalic">Fusobacterium</span> species, <span class="elsevierStyleItalic">Staphylococcus aureus</span>, spirochetes, and other bacteria. The infection tends to be caused by trauma or contact with stagnant water in endemic countries such as Equatorial Guinea and Senegal.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> In the past, malnutrition was considered an important risk factor, but recent studies appear to show that there is no relationship between nutrition levels and tropical ulcers.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A tropical ulcer is a synergistic anaerobic bacterial infection that, during its clinical course, can be colonized by aerobic microorganisms such as <span class="elsevierStyleItalic">Staphylococcus aureus.</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> In many cases, it is difficult to isolate the causative microorganism.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4–6</span></a> The infection does not confer immunity and recurrence is therefore possible. The pathogenesis is unknown. It is now accepted that tropical ulcers are secondary to inoculation with microorganisms caused by trauma or contact with stagnant water.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> Diagnosis is made clinically by exclusion.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Systemic antibiotics are curative. Penicillin is the antibiotic used most frequently and metronidazole is used in patients allergic to penicillin.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4,6</span></a> Tropical ulcers that are not treated appropriately can progress to chronic ulcers or malignant processes such as squamous cell carcinoma.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Given the increase in immigration and tourism to endemic countries, it is important to include tropical ulcer in the differential diagnosis for infectious ulcers, since this entity may be underdiagnosed due to its unfamiliarity. According to our review of the specialized literature, this is the third case reported in Europe to date.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,6</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0050" 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" => "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: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: Latour-Álvarez I, Arteaga-Henriquez M, Rosario AdA-d. Úlcera dolorosa en paciente de raza negra. Actas Dermosifiliogr. 2018;109:351–352.</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" => 674 "Ancho" => 850 "Tamanyo" => 112202 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 632 "Ancho" => 850 "Tamanyo" => 156651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×10.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The infectious aetiology of tropical ulcer a study of the role of anaerobic bacteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. 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Yesudian" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Dermatol" "fecha" => "1988" "volumen" => "26" "paginaInicial" => "49" "paginaFinal" => "53" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000004/v1_201805040442/S1578219018300453/v1_201805040442/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/15782190/0000010900000004/v1_201805040442/S1578219018300453/v1_201805040442/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018300453?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 5 | 19 |
| 2024 October | 81 | 48 | 129 |
| 2024 September | 73 | 25 | 98 |
| 2024 August | 115 | 58 | 173 |
| 2024 July | 73 | 31 | 104 |
| 2024 June | 86 | 28 | 114 |
| 2024 May | 43 | 32 | 75 |
| 2024 April | 60 | 22 | 82 |
| 2024 March | 66 | 32 | 98 |
| 2024 February | 50 | 37 | 87 |
| 2024 January | 48 | 27 | 75 |
| 2023 December | 41 | 21 | 62 |
| 2023 November | 53 | 26 | 79 |
| 2023 October | 49 | 20 | 69 |
| 2023 September | 45 | 27 | 72 |
| 2023 August | 39 | 20 | 59 |
| 2023 July | 61 | 36 | 97 |
| 2023 June | 52 | 22 | 74 |
| 2023 May | 44 | 21 | 65 |
| 2023 April | 40 | 22 | 62 |
| 2023 March | 53 | 32 | 85 |
| 2023 February | 43 | 28 | 71 |
| 2023 January | 37 | 35 | 72 |
| 2022 December | 49 | 42 | 91 |
| 2022 November | 27 | 31 | 58 |
| 2022 October | 28 | 30 | 58 |
| 2022 September | 23 | 50 | 73 |
| 2022 August | 16 | 42 | 58 |
| 2022 July | 26 | 38 | 64 |
| 2022 June | 22 | 28 | 50 |
| 2022 May | 33 | 39 | 72 |
| 2022 April | 46 | 36 | 82 |
| 2022 March | 38 | 39 | 77 |
| 2022 February | 32 | 29 | 61 |
| 2022 January | 34 | 45 | 79 |
| 2021 December | 43 | 44 | 87 |
| 2021 November | 51 | 49 | 100 |
| 2021 October | 45 | 48 | 93 |
| 2021 September | 27 | 48 | 75 |
| 2021 August | 37 | 49 | 86 |
| 2021 July | 36 | 39 | 75 |
| 2021 June | 44 | 44 | 88 |
| 2021 May | 50 | 50 | 100 |
| 2021 April | 91 | 85 | 176 |
| 2021 March | 71 | 37 | 108 |
| 2021 February | 77 | 53 | 130 |
| 2021 January | 43 | 40 | 83 |
| 2020 December | 45 | 38 | 83 |
| 2020 November | 37 | 50 | 87 |
| 2020 October | 31 | 18 | 49 |
| 2020 September | 41 | 26 | 67 |
| 2020 August | 34 | 30 | 64 |
| 2020 July | 31 | 20 | 51 |
| 2020 June | 42 | 34 | 76 |
| 2020 May | 14 | 17 | 31 |
| 2020 April | 34 | 16 | 50 |
| 2020 March | 19 | 16 | 35 |
| 2020 February | 5 | 0 | 5 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 1 | 8 |
| 2019 April | 6 | 0 | 6 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 4 | 0 | 4 |
| 2018 September | 2 | 0 | 2 |
| 2018 May | 1 | 0 | 1 |
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