Case for Diagnosis
Progressive skin ulcers in extremities
Úlceras progresivas localizadas en las extremidades
S. Castillo-Loaiza
, C.J. Díaz, L.F. Cardenas
Corresponding author
Sección de Dermatología y Cirugía Dermatológica, Facultad de Dermatología y Cirugía Dermatológica, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
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Castillo-Loaiza, C.J. Díaz, L.F. Cardenas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Castillo-Loaiza" "email" => array:1 [ 0 => "silvana_castillo_l@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C.J." "apellidos" => "Díaz" ] 2 => array:2 [ "nombre" => "L.F." "apellidos" => "Cardenas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Dermatología y Cirugía Dermatológica, Facultad de Dermatología y Cirugía Dermatológica, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Úlceras progresivas localizadas en las extremidades" ] ] "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" => 520 "Ancho" => 500 "Tamanyo" => 41737 ] ] ] ] "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 71-year-old Colombian man presented to our dermatology service, in Cali, Colombia, with a history of 3-weeks of intermittent fever and painful progressive skin ulcers located on upper and lower limbs. Without any other relevant clinical information.</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 “saddle” nose, madarosis, pinna edema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and extensive ulcers withnecrotic aspect and reticular pattern in all extremities (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Neurologic exam revealed a left foot drop, with polyneuritis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histophatology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Skin biopsy showed granulomas with small-vessel vasculitis and Fite-Faraco stain revealed in the nerve fillets and vessels the presence of numerous acid-fast bacilli (AFB) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>)</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Slit-skin smear examination (earlobe, elbows and nose) was positive for AFB, bacterial index (BI): 2.5.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What Is Your Diagnosis?</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lucio's phenomenon</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Course And Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated with multibacillary multidrug therapy (MDT/MB: Rifampicin, Clofazimine, Dapsone), and corticosteroids 8-week with improvement of the lesions</p><p id="par0035" class="elsevierStylePara elsevierViewall">with persistent neurological deficit.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Leprosy or Hansen's disease is a chronic and debilitating infectious disease caused by <span class="elsevierStyleItalic">Mycobacterium leprae</span>; In the world the prevalence of leprosy has declined considerably since the introduction of multidrug therapy in 1982, in Colombia there are reported about 400 new cases per year.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The clinical expression of the disease depends on the host's immune response.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">LP is a rare and severe leprosy reactional episode in patients with diffuse lepromatous leprosy. Is characterized by the presence of painful erythematous macules that evolve to ulcers which heal leaving pearly scars, may be accompanied by polyneuritis, arthralgia and systemic compromise, constituting an medical emergency.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In our patient, the histopathologic findings showed mainly vasodilatation and thickening of the wall vessels of the superficial and deep plexus of the dermis, proliferation of endothelial cells and occasionally intraluminal clots leading to dermoepidermal necrosis. The Fite-Faroco stain was positive for the present of bacilli inside the vessels and around and in the endothelium of the wall vessels.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Other fidings that had been described are small and medium-sized arteries vasculitis, with their walls involved by clusters of globi, distortion of the structure of the vessel wall, narrowing, and obliteration of their lumen.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> LP is a distinctive type of granulomatous and necrotizing panvasculitis; the involved vessels are mostly medium- sized arteries, their occlusion leads to ischemic necrosis of the whole skin, with detachment of the epidermis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Micobacterium leprae</span> was considered the only infectious agent causing leprosy, however a report of two cases of Mexican patients with LP in which the etiological agent was sequenced, revealed a variability of approximately 7.4% in comparison with <span class="elsevierStyleItalic">M. Leprae</span> reference genome, informing a new species, <span class="elsevierStyleItalic">M. lepromatosis</span> This finding have been confirmed in later genetic studies.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Within the differential diagnosis, it is important to take into account the catastrophic manifestations of autoimmune diseases such as the antiphospholipid syndrome and systemic vasculitis, which can occur with cutaneous ulcers.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> There is no standard treatment for LP, and a therapy based-on corticosteroids to modulate the immune response was used, as in other immunologic reactions leprosy: type 1 reaction (reversal reaction) and ocasionally in type 2 reaction (erythema nodosum leprosum).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</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" => "Histophatology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:3 [ "identificador" => "sec0025" "titulo" => "What Is Your Diagnosis?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical Course And Treatment" ] ] ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "Bibliografía" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castillo-Loaiza S, Díaz CJ, Cardenas LF. Úlceras progresivas localizadas en las extremidades. Actas Dermosifiliogr. 2019;110:495–496.</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" => 520 "Ancho" => 500 "Tamanyo" => 41737 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 343 "Ancho" => 500 "Tamanyo" => 36340 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 376 "Ancho" => 500 "Tamanyo" => 96939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(Fite Faraco stain x 40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministerio de Salud y Protección Social de Colombia. Día mundial de la lucha contra la Lepra! Un mundo libre de Lepra¡. minsalud; 2017 [consultado 16 Abr 2017]. Disponible en: http://www.paho.org/coL/index.php?option=com_docman&view=download&category_slug=documentos_2017-826&alias=2029-dossier-lepra-2017-9&Itemid=688" ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leprosy. An update: Definition, pathogenesis, classification, diagnosis, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Eichelmann" 1 => "S.E. González González" 2 => "J.C. Salas-Alanis" 3 => "J. Ocampo-Candiani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2013" "volumen" => "104" "paginaInicial" => "554" "paginaFinal" => "563" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lucio's phenomenon: Report of five cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.F. Curi" 1 => "J.S. Villaroel" 2 => "N. Migliore" 3 => "A. Albertengo" 4 => "M.L. Aquino" 5 => "F. Ceccato" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "1397" "paginaFinal" => "1401" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lucio's phenomenon is a necrotizing panvasculitis: Mostly a medium-sized granulomatous arteritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Magaña" 1 => "J. Fernández-Díez" 2 => "M.L. Magaña" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Dermatopathol" "fecha" => "2008" "volumen" => "30" "paginaInicial" => "555" "paginaFinal" => "560" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The leprosy agents <span class="elsevierStyleItalic">Mycobacterium lepromatosis</span> and <span class="elsevierStyleItalic">Mycobacterium leprae</span> in Mexico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "X.Y. Han" 1 => "K.C. Sizer" 2 => "J.S. Velarde-Félix" 3 => "L.O. Frias-Castro" 4 => "F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 12 | 25 |
| 2024 October | 66 | 44 | 110 |
| 2024 September | 77 | 39 | 116 |
| 2024 August | 109 | 75 | 184 |
| 2024 July | 113 | 36 | 149 |
| 2024 June | 90 | 28 | 118 |
| 2024 May | 97 | 34 | 131 |
| 2024 April | 81 | 27 | 108 |
| 2024 March | 68 | 35 | 103 |
| 2024 February | 61 | 38 | 99 |
| 2024 January | 59 | 39 | 98 |
| 2023 December | 48 | 23 | 71 |
| 2023 November | 80 | 37 | 117 |
| 2023 October | 70 | 19 | 89 |
| 2023 September | 47 | 28 | 75 |
| 2023 August | 37 | 17 | 54 |
| 2023 July | 69 | 33 | 102 |
| 2023 June | 58 | 24 | 82 |
| 2023 May | 39 | 29 | 68 |
| 2023 April | 53 | 19 | 72 |
| 2023 March | 42 | 22 | 64 |
| 2023 February | 53 | 21 | 74 |
| 2023 January | 27 | 29 | 56 |
| 2022 December | 45 | 29 | 74 |
| 2022 November | 34 | 22 | 56 |
| 2022 October | 25 | 23 | 48 |
| 2022 September | 17 | 35 | 52 |
| 2022 August | 16 | 31 | 47 |
| 2022 July | 23 | 36 | 59 |
| 2022 June | 25 | 26 | 51 |
| 2022 May | 24 | 39 | 63 |
| 2022 April | 28 | 32 | 60 |
| 2022 March | 36 | 45 | 81 |
| 2022 February | 20 | 24 | 44 |
| 2022 January | 30 | 34 | 64 |
| 2021 December | 23 | 47 | 70 |
| 2021 November | 27 | 42 | 69 |
| 2021 October | 30 | 59 | 89 |
| 2021 September | 26 | 36 | 62 |
| 2021 August | 28 | 23 | 51 |
| 2021 July | 19 | 21 | 40 |
| 2021 June | 22 | 22 | 44 |
| 2021 May | 20 | 42 | 62 |
| 2021 April | 50 | 51 | 101 |
| 2021 March | 49 | 18 | 67 |
| 2021 February | 55 | 23 | 78 |
| 2021 January | 27 | 16 | 43 |
| 2020 December | 20 | 13 | 33 |
| 2020 November | 14 | 20 | 34 |
| 2020 October | 21 | 14 | 35 |
| 2020 September | 15 | 12 | 27 |
| 2020 August | 18 | 13 | 31 |
| 2020 July | 11 | 13 | 24 |
| 2020 June | 17 | 17 | 34 |
| 2020 May | 16 | 6 | 22 |
| 2020 April | 14 | 10 | 24 |
| 2020 March | 16 | 5 | 21 |
| 2020 February | 2 | 4 | 6 |
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