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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 12 | 19 |
| 2024 Octubre | 62 | 33 | 95 |
| 2024 Septiembre | 71 | 19 | 90 |
| 2024 Agosto | 99 | 51 | 150 |
| 2024 Julio | 81 | 35 | 116 |
| 2024 Junio | 96 | 24 | 120 |
| 2024 Mayo | 88 | 32 | 120 |
| 2024 Abril | 70 | 27 | 97 |
| 2024 Marzo | 66 | 20 | 86 |
| 2024 Febrero | 51 | 32 | 83 |
| 2024 Enero | 52 | 31 | 83 |
| 2023 Diciembre | 51 | 19 | 70 |
| 2023 Noviembre | 49 | 19 | 68 |
| 2023 Octubre | 50 | 20 | 70 |
| 2023 Septiembre | 57 | 30 | 87 |
| 2023 Agosto | 27 | 18 | 45 |
| 2023 Julio | 58 | 33 | 91 |
| 2023 Junio | 70 | 21 | 91 |
| 2023 Mayo | 37 | 25 | 62 |
| 2023 Abril | 27 | 16 | 43 |
| 2023 Marzo | 41 | 29 | 70 |
| 2023 Febrero | 46 | 15 | 61 |
| 2023 Enero | 24 | 22 | 46 |
| 2022 Diciembre | 46 | 29 | 75 |
| 2022 Noviembre | 26 | 20 | 46 |
| 2022 Octubre | 17 | 21 | 38 |
| 2022 Septiembre | 27 | 52 | 79 |
| 2022 Agosto | 19 | 63 | 82 |
| 2022 Julio | 19 | 42 | 61 |
| 2022 Junio | 17 | 59 | 76 |
| 2022 Mayo | 27 | 32 | 59 |
| 2022 Abril | 31 | 34 | 65 |
| 2022 Marzo | 35 | 49 | 84 |
| 2022 Febrero | 35 | 27 | 62 |
| 2022 Enero | 26 | 32 | 58 |
| 2021 Diciembre | 24 | 36 | 60 |
| 2021 Noviembre | 38 | 34 | 72 |
| 2021 Octubre | 39 | 47 | 86 |
| 2021 Septiembre | 30 | 41 | 71 |
| 2021 Agosto | 28 | 25 | 53 |
| 2021 Julio | 24 | 30 | 54 |
| 2021 Junio | 37 | 28 | 65 |
| 2021 Mayo | 36 | 28 | 64 |
| 2021 Abril | 71 | 70 | 141 |
| 2021 Marzo | 46 | 20 | 66 |
| 2021 Febrero | 52 | 28 | 80 |
| 2021 Enero | 34 | 14 | 48 |
| 2020 Diciembre | 33 | 16 | 49 |
| 2020 Noviembre | 19 | 14 | 33 |
| 2020 Octubre | 17 | 9 | 26 |
| 2020 Septiembre | 28 | 15 | 43 |
| 2020 Agosto | 13 | 22 | 35 |
| 2020 Julio | 21 | 12 | 33 |
| 2020 Junio | 37 | 28 | 65 |
| 2020 Mayo | 18 | 18 | 36 |
| 2020 Abril | 24 | 22 | 46 |
| 2020 Marzo | 30 | 15 | 45 |
| 2020 Febrero | 4 | 0 | 4 |
| 2020 Enero | 6 | 1 | 7 |
| 2019 Diciembre | 4 | 1 | 5 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 0 | 3 | 3 |
| 2019 Septiembre | 0 | 1 | 1 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 9 | 13 |
| 2019 Junio | 4 | 6 | 10 |
| 2019 Mayo | 4 | 23 | 27 |
| 2019 Abril | 2 | 1 | 3 |
| 2019 Marzo | 2 | 12 | 14 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Marzo | 2 | 0 | 2 |
| 2018 Febrero | 33 | 1 | 34 |
| 2018 Enero | 85 | 7 | 92 |
| 2017 Diciembre | 39 | 5 | 44 |
| 2017 Noviembre | 27 | 2 | 29 |
| 2017 Octubre | 21 | 4 | 25 |
| 2017 Septiembre | 36 | 1 | 37 |
| 2017 Agosto | 57 | 10 | 67 |
| 2017 Julio | 37 | 9 | 46 |
| 2017 Junio | 62 | 13 | 75 |
| 2017 Mayo | 56 | 4 | 60 |
| 2017 Abril | 42 | 5 | 47 |
| 2017 Marzo | 36 | 11 | 47 |
| 2017 Febrero | 47 | 5 | 52 |
| 2017 Enero | 18 | 6 | 24 |
| 2016 Diciembre | 37 | 4 | 41 |
| 2016 Noviembre | 40 | 6 | 46 |
| 2016 Octubre | 58 | 7 | 65 |
| 2016 Septiembre | 48 | 4 | 52 |
| 2016 Agosto | 42 | 7 | 49 |
| 2016 Julio | 37 | 11 | 48 |
| 2016 Junio | 13 | 7 | 20 |
| 2016 Mayo | 5 | 12 | 17 |
| 2016 Abril | 5 | 1 | 6 |
| 2016 Marzo | 5 | 1 | 6 |
| 2016 Febrero | 10 | 4 | 14 |
| 2016 Enero | 5 | 1 | 6 |
| 2015 Diciembre | 8 | 4 | 12 |
| 2015 Noviembre | 21 | 4 | 25 |
| 2015 Octubre | 13 | 5 | 18 |
| 2015 Septiembre | 12 | 40 | 52 |
| 2015 Agosto | 14 | 5 | 19 |
| 2015 Julio | 78 | 12 | 90 |
| 2015 Junio | 46 | 6 | 52 |
| 2015 Mayo | 76 | 7 | 83 |
| 2015 Abril | 82 | 11 | 93 |
| 2015 Marzo | 54 | 6 | 60 |
| 2015 Febrero | 45 | 15 | 60 |
| 2015 Enero | 37 | 23 | 60 |
| 2014 Diciembre | 51 | 8 | 59 |
| 2014 Noviembre | 38 | 8 | 46 |
| 2014 Octubre | 78 | 17 | 95 |
| 2014 Septiembre | 20 | 2 | 22 |
| 2014 Agosto | 26 | 6 | 32 |
| 2014 Julio | 18 | 4 | 22 |
| 2014 Junio | 46 | 1 | 47 |
| 2014 Mayo | 44 | 5 | 49 |
| 2014 Abril | 28 | 2 | 30 |
| 2014 Marzo | 42 | 6 | 48 |
| 2014 Febrero | 41 | 10 | 51 |
| 2014 Enero | 43 | 4 | 47 |
| 2013 Diciembre | 36 | 5 | 41 |
| 2013 Noviembre | 28 | 7 | 35 |
| 2013 Octubre | 22 | 3 | 25 |
| 2013 Septiembre | 18 | 1 | 19 |
| 2013 Agosto | 16 | 5 | 21 |
| 2013 Julio | 6 | 11 | 17 |
| 2013 Junio | 12 | 8 | 20 |
| 2013 Mayo | 19 | 6 | 25 |
| 2013 Abril | 12 | 14 | 26 |
| 2013 Marzo | 16 | 4 | 20 |
| 2013 Febrero | 30 | 5 | 35 |
| 2013 Enero | 30 | 2 | 32 |
| 2012 Diciembre | 19 | 7 | 26 |
| 2012 Noviembre | 5 | 0 | 5 |
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