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
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Servicio de Dermatología, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
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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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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" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 14 | 11 | 25 |
| 2024 Octubre | 138 | 38 | 176 |
| 2024 Septiembre | 95 | 18 | 113 |
| 2024 Agosto | 122 | 50 | 172 |
| 2024 Julio | 129 | 33 | 162 |
| 2024 Junio | 114 | 31 | 145 |
| 2024 Mayo | 93 | 36 | 129 |
| 2024 Abril | 91 | 16 | 107 |
| 2024 Marzo | 89 | 36 | 125 |
| 2024 Febrero | 94 | 25 | 119 |
| 2024 Enero | 87 | 30 | 117 |
| 2023 Diciembre | 84 | 16 | 100 |
| 2023 Noviembre | 91 | 22 | 113 |
| 2023 Octubre | 75 | 15 | 90 |
| 2023 Septiembre | 68 | 24 | 92 |
| 2023 Agosto | 48 | 11 | 59 |
| 2023 Julio | 51 | 33 | 84 |
| 2023 Junio | 51 | 20 | 71 |
| 2023 Mayo | 56 | 17 | 73 |
| 2023 Abril | 43 | 22 | 65 |
| 2023 Marzo | 27 | 20 | 47 |
| 2023 Febrero | 37 | 20 | 57 |
| 2023 Enero | 46 | 37 | 83 |
| 2022 Diciembre | 51 | 49 | 100 |
| 2022 Noviembre | 28 | 25 | 53 |
| 2022 Octubre | 23 | 22 | 45 |
| 2022 Septiembre | 27 | 40 | 67 |
| 2022 Agosto | 18 | 35 | 53 |
| 2022 Julio | 25 | 31 | 56 |
| 2022 Junio | 25 | 31 | 56 |
| 2022 Mayo | 36 | 45 | 81 |
| 2022 Abril | 53 | 42 | 95 |
| 2022 Marzo | 52 | 58 | 110 |
| 2022 Febrero | 34 | 23 | 57 |
| 2022 Enero | 27 | 33 | 60 |
| 2021 Diciembre | 23 | 36 | 59 |
| 2021 Noviembre | 48 | 52 | 100 |
| 2021 Octubre | 29 | 46 | 75 |
| 2021 Septiembre | 29 | 41 | 70 |
| 2021 Agosto | 23 | 36 | 59 |
| 2021 Julio | 24 | 31 | 55 |
| 2021 Junio | 32 | 28 | 60 |
| 2021 Mayo | 31 | 40 | 71 |
| 2021 Abril | 33 | 66 | 99 |
| 2021 Marzo | 38 | 20 | 58 |
| 2021 Febrero | 37 | 27 | 64 |
| 2021 Enero | 38 | 20 | 58 |
| 2020 Diciembre | 21 | 14 | 35 |
| 2020 Noviembre | 27 | 11 | 38 |
| 2020 Octubre | 25 | 8 | 33 |
| 2020 Septiembre | 32 | 9 | 41 |
| 2020 Agosto | 27 | 9 | 36 |
| 2020 Julio | 23 | 17 | 40 |
| 2020 Junio | 43 | 19 | 62 |
| 2020 Mayo | 27 | 12 | 39 |
| 2020 Abril | 42 | 11 | 53 |
| 2020 Marzo | 23 | 15 | 38 |
| 2020 Febrero | 6 | 0 | 6 |
| 2019 Diciembre | 4 | 2 | 6 |
| 2019 Noviembre | 0 | 1 | 1 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Junio | 2 | 14 | 16 |
| 2019 Mayo | 1 | 1 | 2 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 2 | 9 | 11 |
| 2019 Febrero | 0 | 2 | 2 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 0 | 3 | 3 |
| 2018 Noviembre | 0 | 2 | 2 |
| 2018 Octubre | 2 | 1 | 3 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Marzo | 2 | 0 | 2 |
| 2018 Febrero | 70 | 5 | 75 |
| 2018 Enero | 41 | 5 | 46 |
| 2017 Diciembre | 97 | 7 | 104 |
| 2017 Noviembre | 26 | 4 | 30 |
| 2017 Octubre | 43 | 4 | 47 |
| 2017 Septiembre | 28 | 3 | 31 |
| 2017 Agosto | 57 | 6 | 63 |
| 2017 Julio | 46 | 8 | 54 |
| 2017 Junio | 45 | 7 | 52 |
| 2017 Mayo | 38 | 9 | 47 |
| 2017 Abril | 27 | 7 | 34 |
| 2017 Marzo | 25 | 8 | 33 |
| 2017 Febrero | 25 | 6 | 31 |
| 2017 Enero | 27 | 12 | 39 |
| 2016 Diciembre | 46 | 13 | 59 |
| 2016 Noviembre | 47 | 13 | 60 |
| 2016 Octubre | 47 | 12 | 59 |
| 2016 Septiembre | 39 | 14 | 53 |
| 2016 Agosto | 54 | 5 | 59 |
| 2016 Julio | 32 | 6 | 38 |
| 2016 Junio | 11 | 0 | 11 |
| 2016 Mayo | 13 | 5 | 18 |
| 2016 Abril | 4 | 1 | 5 |
| 2016 Marzo | 6 | 1 | 7 |
| 2016 Febrero | 12 | 4 | 16 |
| 2016 Enero | 9 | 2 | 11 |
| 2015 Diciembre | 6 | 1 | 7 |
| 2015 Noviembre | 3 | 0 | 3 |
| 2015 Octubre | 6 | 1 | 7 |
| 2015 Septiembre | 2 | 0 | 2 |
| 2015 Agosto | 4 | 1 | 5 |
| 2015 Julio | 29 | 6 | 35 |
| 2015 Junio | 29 | 3 | 32 |
| 2015 Mayo | 35 | 13 | 48 |
| 2015 Abril | 37 | 14 | 51 |
| 2015 Marzo | 30 | 11 | 41 |
| 2015 Febrero | 25 | 8 | 33 |
| 2015 Enero | 26 | 2 | 28 |
| 2014 Diciembre | 23 | 4 | 27 |
| 2014 Noviembre | 18 | 6 | 24 |
| 2014 Octubre | 23 | 8 | 31 |
| 2014 Septiembre | 12 | 3 | 15 |
| 2014 Agosto | 12 | 5 | 17 |
| 2014 Julio | 16 | 6 | 22 |
| 2014 Junio | 15 | 6 | 21 |
| 2014 Mayo | 18 | 6 | 24 |
| 2014 Abril | 23 | 5 | 28 |
| 2014 Marzo | 12 | 3 | 15 |
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