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
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Departamento de Dermatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Islas Canarias, Spain
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Latour-Álvarez, M. Arteaga-Henriquez, A. de Andrés-del Rosario" "autores" => array:3 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Latour-Álvarez" "email" => array:1 [ 0 => "irenelatouralvarez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Arteaga-Henriquez" ] 2 => array:2 [ "nombre" => "A." "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" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 6 | 21 |
| 2024 Octubre | 81 | 48 | 129 |
| 2024 Septiembre | 73 | 25 | 98 |
| 2024 Agosto | 115 | 58 | 173 |
| 2024 Julio | 73 | 31 | 104 |
| 2024 Junio | 86 | 28 | 114 |
| 2024 Mayo | 43 | 32 | 75 |
| 2024 Abril | 60 | 22 | 82 |
| 2024 Marzo | 66 | 32 | 98 |
| 2024 Febrero | 50 | 37 | 87 |
| 2024 Enero | 48 | 27 | 75 |
| 2023 Diciembre | 41 | 21 | 62 |
| 2023 Noviembre | 53 | 26 | 79 |
| 2023 Octubre | 49 | 20 | 69 |
| 2023 Septiembre | 45 | 27 | 72 |
| 2023 Agosto | 39 | 20 | 59 |
| 2023 Julio | 61 | 36 | 97 |
| 2023 Junio | 52 | 22 | 74 |
| 2023 Mayo | 44 | 21 | 65 |
| 2023 Abril | 40 | 22 | 62 |
| 2023 Marzo | 53 | 32 | 85 |
| 2023 Febrero | 43 | 28 | 71 |
| 2023 Enero | 37 | 35 | 72 |
| 2022 Diciembre | 49 | 42 | 91 |
| 2022 Noviembre | 27 | 31 | 58 |
| 2022 Octubre | 28 | 30 | 58 |
| 2022 Septiembre | 23 | 50 | 73 |
| 2022 Agosto | 16 | 42 | 58 |
| 2022 Julio | 26 | 38 | 64 |
| 2022 Junio | 22 | 28 | 50 |
| 2022 Mayo | 33 | 39 | 72 |
| 2022 Abril | 46 | 36 | 82 |
| 2022 Marzo | 38 | 39 | 77 |
| 2022 Febrero | 32 | 29 | 61 |
| 2022 Enero | 34 | 45 | 79 |
| 2021 Diciembre | 43 | 44 | 87 |
| 2021 Noviembre | 51 | 49 | 100 |
| 2021 Octubre | 45 | 48 | 93 |
| 2021 Septiembre | 27 | 48 | 75 |
| 2021 Agosto | 37 | 49 | 86 |
| 2021 Julio | 36 | 39 | 75 |
| 2021 Junio | 44 | 44 | 88 |
| 2021 Mayo | 50 | 50 | 100 |
| 2021 Abril | 91 | 85 | 176 |
| 2021 Marzo | 71 | 37 | 108 |
| 2021 Febrero | 77 | 53 | 130 |
| 2021 Enero | 43 | 40 | 83 |
| 2020 Diciembre | 45 | 38 | 83 |
| 2020 Noviembre | 37 | 50 | 87 |
| 2020 Octubre | 31 | 18 | 49 |
| 2020 Septiembre | 41 | 26 | 67 |
| 2020 Agosto | 34 | 30 | 64 |
| 2020 Julio | 31 | 20 | 51 |
| 2020 Junio | 42 | 34 | 76 |
| 2020 Mayo | 14 | 17 | 31 |
| 2020 Abril | 34 | 16 | 50 |
| 2020 Marzo | 19 | 16 | 35 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 10 | 0 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 7 | 1 | 8 |
| 2019 Abril | 6 | 0 | 6 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Mayo | 1 | 0 | 1 |
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