Case for Diagnosis
Progressive skin ulcers in extremities
Úlceras progresivas localizadas en las extremidades
S. Castillo-Loaiza
, C.J. Díaz, L.F. Cardenas
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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. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 13 | 12 | 25 |
| 2024 Octubre | 66 | 44 | 110 |
| 2024 Septiembre | 77 | 39 | 116 |
| 2024 Agosto | 109 | 75 | 184 |
| 2024 Julio | 113 | 36 | 149 |
| 2024 Junio | 90 | 28 | 118 |
| 2024 Mayo | 97 | 34 | 131 |
| 2024 Abril | 81 | 27 | 108 |
| 2024 Marzo | 68 | 35 | 103 |
| 2024 Febrero | 61 | 38 | 99 |
| 2024 Enero | 59 | 39 | 98 |
| 2023 Diciembre | 48 | 23 | 71 |
| 2023 Noviembre | 80 | 37 | 117 |
| 2023 Octubre | 70 | 19 | 89 |
| 2023 Septiembre | 47 | 28 | 75 |
| 2023 Agosto | 37 | 17 | 54 |
| 2023 Julio | 69 | 33 | 102 |
| 2023 Junio | 58 | 24 | 82 |
| 2023 Mayo | 39 | 29 | 68 |
| 2023 Abril | 53 | 19 | 72 |
| 2023 Marzo | 42 | 22 | 64 |
| 2023 Febrero | 53 | 21 | 74 |
| 2023 Enero | 27 | 29 | 56 |
| 2022 Diciembre | 45 | 29 | 74 |
| 2022 Noviembre | 34 | 22 | 56 |
| 2022 Octubre | 25 | 23 | 48 |
| 2022 Septiembre | 17 | 35 | 52 |
| 2022 Agosto | 16 | 31 | 47 |
| 2022 Julio | 23 | 36 | 59 |
| 2022 Junio | 25 | 26 | 51 |
| 2022 Mayo | 24 | 39 | 63 |
| 2022 Abril | 28 | 32 | 60 |
| 2022 Marzo | 36 | 45 | 81 |
| 2022 Febrero | 20 | 24 | 44 |
| 2022 Enero | 30 | 34 | 64 |
| 2021 Diciembre | 23 | 47 | 70 |
| 2021 Noviembre | 27 | 42 | 69 |
| 2021 Octubre | 30 | 59 | 89 |
| 2021 Septiembre | 26 | 36 | 62 |
| 2021 Agosto | 28 | 23 | 51 |
| 2021 Julio | 19 | 21 | 40 |
| 2021 Junio | 22 | 22 | 44 |
| 2021 Mayo | 20 | 42 | 62 |
| 2021 Abril | 50 | 51 | 101 |
| 2021 Marzo | 49 | 18 | 67 |
| 2021 Febrero | 55 | 23 | 78 |
| 2021 Enero | 27 | 16 | 43 |
| 2020 Diciembre | 20 | 13 | 33 |
| 2020 Noviembre | 14 | 20 | 34 |
| 2020 Octubre | 21 | 14 | 35 |
| 2020 Septiembre | 15 | 12 | 27 |
| 2020 Agosto | 18 | 13 | 31 |
| 2020 Julio | 11 | 13 | 24 |
| 2020 Junio | 17 | 17 | 34 |
| 2020 Mayo | 16 | 6 | 22 |
| 2020 Abril | 14 | 10 | 24 |
| 2020 Marzo | 16 | 5 | 21 |
| 2020 Febrero | 2 | 4 | 6 |
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