Extensive Ulceration Research Articles

Skin grafting in the treatment of hard-to-heal leg ulcers

Some risk factors or comorbidities may make Chronic Leg Ulcers (CLU) very difficult to heal. These ulcers are usually defined refractory ulcers and may require an in-hospital intensive care to increase the healing rate. Aim of this retrospective study was to assess if our clinical routine in hospitalized patients, made up with surgical debridement followed by donor skin grafting (allografts), may favor the ulcer healing. The records of 120 patients (55 males and 65 females; mean age 73.9±11.3 years) with ulcers greater than 100 cm2 and lasting for more than 1 year were analyzed. The median ulcer size was 165 cm2 (IQR 130-250 cm2; range 100-1000 cm2). The median ulcer duration was 24 months (IQR 16-32 months; range 12-300 months). The ulcer pathophysiology was venous in 74 patients, arterial in 21, mixed in 12, vasculitis in 5 and post-traumatic in 8 patients. After debridement the patients were submitted to allograft procedures (single or multiple) up to the ulcer healing. When allograft was able to create an effective granulation tissue and reduce the ulcer size an autograft was performed to get the ulcer closure. 109 patients healed and 11 were lost at follow-up. 65 patients healed just with one allograft in 16 weeks (IQR 13-21 weeks). 42 patients healed with 2 procedures in 20 weeks (IQR 18-23 weeks). 31 of them received a final autograft while 11 healed with two allografts. 2 patients with an ulcer surface of 200 cm2, both affected by CLI, healed with 3 allografts procedures in 40 and 33 weeks, respectively. Pain and exudate amount were significantly decreased and even disappeared after the first allograft. Allografts alone or followed by an autograft are able to get the ulcer healing also in case of extensive and long lasting ulcers refractory to all previous treatments.

Childhood pyoderma gangrenosum: diagnosis often missed

We present a 10-year-old male child who presented with 2 months history of fever and extensive ulceration over both lower limbs and buttocks. The new lesions were bullous and pustular, so working diagnosis of bullous impetigo was considered. WBC count showed mild anemia and neutrophilic leucocytosis. Peripheral smear showed neutrophilia, adequate platelets and normal lymphocytes. Blood culture and pus culture were sterile. Stool for occult blood was negative, liver function tests were normal. Mantoux test was negative. Serum immunoglobulins were normal and HIV, HBsAg tested negative. Skin biopsy showed foci of granulomatous inflammation with neutrophilic infiltration. With persistent neutrophilia and neutrophilic infiltration of ulcers, pyoderma gangrenosum was kept as diagnosis. The child was started on local steroid application and oral prednisolone 1 mg/kg/day. Wthin 2 days of oral steroids child became afebrile. Ulcers started healing and neutrophila also normalized. In view of reappearance of fever, immunosuppressive, closporin was started, after which child responded well and ulcers healed completely. So, in conclusion, we report a paediatric case of pyoderma gangrenosum which poses diagnostic difficulty, particularly to non-dermatologists. The dramatic response to steroid and cyclosporine helped cure the ulcers and remit the disease and sufferings.

Gastric Metastasis of an Ovarian Granulosa Cell Tumor Diagnosed in a Patient with Worsening Reflux

CASE REPORT A 60-year-old woman with a 2-year history of T1a NX M0 ovarian granulosa cell tumor (GCT) status post total abdominal hysterectomy with bilateral salpingo-oophorectomy presented with worsening reflux, abdominal pain, nausea, and loss of appetite. Esophagogastroduodenoscopy showed multiple gastric polyps with white tops and patches of necrotic appearing mucosa (Figure 1). Biopsy of the gastric polyps showed extensive surface ulceration and necrosis with associated atypical epithelioid and spindle cell proliferation (Figure 2). Although the immunohistochemical markers for sex cord-stromal tumors are negative, the histomorphology is similar to the patient's prior ovarian GCT (Figure 3). An extensive immunohistochemical marker panel performed to exclude the other common entities was negative. Thus, this most likely represents a metastasis from the ovarian GCT. Metastatic workup revealed bilateral metastatic pulmonary nodules, enlarged paraesophageal and paraaortic lymph nodes, and a brain metastasis. Patient was a poor surgical candidate and did not tolerate chemotherapy. Repeat imaging showed disease progression; she refused palliative chemoradiation and chose comfort measures.Figure 1.: Esophagogastroduodenoscopy shows multiple gastric polyps with white tops and patches of necrotic appearing mucosa.Figure 2.: Gastric polyp biopsy showing atypical epithelioid and spindle cell population.Figure 3.: Histomorphology of the gastric polyp showing (A) negative calretinin immunostain of prior tumor and (B) immunostain of present tumor.GCT is a rare sex cord-stromal tumor associated with low malignant potential.1 This tumor has a strong tendency for late recurrences, with an incidence of 25-30%, and is associated with a poor prognosis.1 Once the tumor recurs, it is fatal in 80% of cases. Most recurrences occur within 10 years after the initial diagnosis (median 4-5 years).1-4 Prognostic factors that affect the 5-year survival rate include tumor rupture, tumor stage, tumor mitotic rate, and residual disease. Common sites of metastasis are within the pelvis and the lower abdomen, with rare cases in the lung, liver, brain, bone, diaphragm, abdominal wall, and adrenal gland.1-3 Patients should be kept on a long-term follow-up protocol even if the primary tumor is occult.2 Patients with advanced metastatic GCTs are treated with aggressive surgical debulking and postoperative chemotherapy (platinum-based), especially in cases of widespread metastasis.4,5 DISCLOSURES Author contributions: J.S. Klair and K. Soota wrote the manuscript and reviewed the literature. A. Vidholia provided the pathology images and reviewed the literature. C.M. Berkowitz revised the manuscript. JS Klair is the article guarantor.

Gastric Metastasis of an Ovarian Granulosa Cell Tumor Diagnosed in a Patient with Worsening Reflux

CASE REPORT A 60-year-old woman with a 2-year history of T1a NX M0 ovarian granulosa cell tumor (GCT) status post total abdominal hysterectomy with bilateral salpingo-oophorectomy presented with worsening reflux, abdominal pain, nausea, and loss of appetite. Esophagogastroduodenoscopy showed multiple gastric polyps with white tops and patches of necrotic appearing mucosa (Figure 1). Biopsy of the gastric polyps showed extensive surface ulceration and necrosis with associated atypical epithelioid and spindle cell proliferation (Figure 2). Although the immunohistochemical markers for sex cord-stromal tumors are negative, the histomorphology is similar to the patient's prior ovarian GCT (Figure 3). An extensive immunohistochemical marker panel performed to exclude the other common entities was negative. Thus, this most likely represents a metastasis from the ovarian GCT. Metastatic workup revealed bilateral metastatic pulmonary nodules, enlarged paraesophageal and paraaortic lymph nodes, and a brain metastasis. Patient was a poor surgical candidate and did not tolerate chemotherapy. Repeat imaging showed disease progression; she refused palliative chemoradiation and chose comfort measures.Figure 1.: Esophagogastroduodenoscopy shows multiple gastric polyps with white tops and patches of necrotic appearing mucosa.Figure 2.: Gastric polyp biopsy showing atypical epithelioid and spindle cell population.Figure 3.: Histomorphology of the gastric polyp showing (A) negative calretinin immunostain of prior tumor and (B) immunostain of present tumor.GCT is a rare sex cord-stromal tumor associated with low malignant potential.1 This tumor has a strong tendency for late recurrences, with an incidence of 25-30%, and is associated with a poor prognosis.1 Once the tumor recurs, it is fatal in 80% of cases. Most recurrences occur within 10 years after the initial diagnosis (median 4-5 years).1-4 Prognostic factors that affect the 5-year survival rate include tumor rupture, tumor stage, tumor mitotic rate, and residual disease. Common sites of metastasis are within the pelvis and the lower abdomen, with rare cases in the lung, liver, brain, bone, diaphragm, abdominal wall, and adrenal gland.1-3 Patients should be kept on a long-term follow-up protocol even if the primary tumor is occult.2 Patients with advanced metastatic GCTs are treated with aggressive surgical debulking and postoperative chemotherapy (platinum-based), especially in cases of widespread metastasis.4,5 DISCLOSURES Author contributions: J.S. Klair and K. Soota wrote the manuscript and reviewed the literature. A. Vidholia provided the pathology images and reviewed the literature. C.M. Berkowitz revised the manuscript. JS Klair is the article guarantor.

Knowledge and practices of health practitioners on treatment of Buruli ulcer in the Mbonge, Ekondo Titi and Muyuka Health Districts, South West Region, Cameroon.

IntroductionAfter tuberculosis and leprosy, Buruli ulcer (BU) is the third most common mycobacterial infection. Buruli ulcer begins as a localized skin lesion that progresses to extensive ulceration thus leading to functional disability, loss of economic productivity and social stigma. This study is aimed at assessing the knowledge and practices among health practitioners on the treatment of BU in the Mbonge, Ekondo Titi and Muyuka Health Districts of the South West Region of Cameroon.MethodsThis is a cross-sectional study that investigates participants' knowledge and practices on the treatment of BU. The study uses a qualitative method of structured questionnaires in the process of data collection.ResultsSeventy percent (70%) of the participants acknowledged they encounter cases of BU in their respective Hospitals or Health centers. Among these, 48% agreed they managed BU in their facilities and up to 91.7% noted that their community members are aware that BU is managed in their facility while seventy percent of the medical practitioners indicated they cannot identify the various stages of BU. Eighty-one percent of the practitioners from Muyuka HD indicated they could not identify the various stages of BU. More than 63% of the practitioners regarded BU patients as normal people in their communities however, practitioners that practiced for less than 5 years were likely not to admit BU patients in the same room with other patients. Beliefs such as being cursed (47.06%) and being possessed (29.41%) were reported by practitioners that acknowledged the existence of traditional beliefs in the community.ConclusionDespite the fact that a majority of the health practitioners knew what BU is, most of them demonstrated lack of knowledge on the identification of the various stages and management of the illness. Practitioners demonstrated positive attitude towards patients although they would not admit them in the same room with other patients. Considering the poor knowledge on identification and management demonstrated by most of the practitioners, management of the disease would be inadequate and may even aggravate the patient's situation. Training and onsite mentorship on screening, identification and management of BU is therefore highly recommended amongst health personnel practicing in endemic areas.

The application of L-PRP in AIDS patients with crural chronic ulcers: A pilot study

PurposeNonhealing wounds or skin ulcerations are the result of insufficient repair and destruction of a local healing potential. Opportunistic infections which cause a lot of ulcer complications influence the worsening general condition of patients with AIDS, ultimately leading to death. The chronicity of the condition and poor results of conventional therapy have prompted the search for new methods of treatment. Materials and methodsWe have examined venous or arteriovenous insufficiency-related extensive crural ulcers in AIDS patients. Crural ulcer healing processes were evaluated with clinical observations and histopathological, immunohistochemical and molecular examinations of tissue samples harvested from the wound edges before and on day 10 after L-PRP cover dressing. ResultsClinical observations showed positive effects of L-PRP in all patients. However, complete wound closure was noted in 60% of cases. Statistical analysis of histological examination showed increased epidermal processes between samples, but the difference was nonsignificant. However, immunohistochemical investigations showed an increased healing process with strong statistical significance. The mean VEGF level before L-PRP usage was 114.3 vessels/mm2 and on day 10 118.9 (p=0.001523). The mean FLK level was 103.2 and 109.9 respectively (p=0.008241). The biggest differences were observed for CD34, with values of 68.2 on day 0 and 100.8 on day 10 (p=0.006982). Molecular analysis generally showed decreased gene expression and confirmed vascular formation and reepithelialization processes. ConclusionsIn our opinion, L-PRP may be used to eradicate microorganisms from wounds, to induce neovascularization, and in unhealed cases prepare the base and edge of the ulcer for skin grafting and tissue expansion procedures.

Extensive Skin Necrosis Ulcers and Systemic Vascular Insufficiency Syndrome with Calciphylaxis: A Case Report

Extensive Skin Necrosis Ulcers and Systemic Vascular Insufficiency Syndrome with Calciphylaxis: A Case Report

A Unique Case of Rituximab-Induced Crohnʼs Disease: A Case Report and Review of Literature

Rituximab is a humanized monoclonal antibody against CD20 which is a mainstay of therapy for a wide variety of B cell malignancies. There are only two reported cases of Crohn's disease following treatment with Rituximab in the literature. We present a very unique case of a 58 year old female who was treated with Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP) regimen for initial diagnosis of follicular cell lymphoma of the tonsils. She was treated with prolonged maintenance Rituximab treatment for a recurrence of the lymphoma two years later and the treatment was continued for two and a half years. Three years later she was noted to have increased activity in the terminal ilium and mesenteric lymph nodes on a routine positron emission tomography (PET) scan. At that time, she was asymptomatic and refused any further workup or treatment. Another PET scan done two years later showed enlarged mesenteric lymph nodes with increased activity in the terminal ileum and the spleen. A colonoscopy performed at that time revealed inflammation with extensive ulceration in the terminal ileum. Biopsy demonstrated severely active chronic nonspecific ileitis with ulceration and a small granulomatous lesion. She was then re-treated again with 4 cycles of rituximab for a presumed recurrence. Two months after the treatment, she developed severe abdominal pain leading to an emergency room visit. A computerized tomography (CT) scan showed thickening in the distal descending colon as well as the entire sigmoid colon with surrounding fat stranding. She was treated with oral ciprofloxacin and metronidazole for 10 days with improvement in the symptoms. In a follow-up PET scan done a month later, the mesenteric adenopathy resolved but the activity in the terminal ileum was unchanged and there was new activity in the sigmoid colon. The patient refused further endoscopic examination, however the PET scan findings of worsening of the bowel inflammation and resolution of the adenopathy strongly suggests Rituximab induced Crohn's disease. This case portrays the importance of being alert to the possibility of Crohn's disease occurring as complication of Rituximab treatment. This case is unique as the Crohn's disease occurred almost three years after the initial Rituximab treatment. Management of Crohn's disease in patients with a history of lymphoma can be challenging due to the risk of lymphoma from Anti-TNF and immunomodulatory treatments.Figure: PET Scan showing increased uptake in the mesenteric lymph nodes and terminal ileum.Figure: Colonoscopy image of the terminal ileum.

A Colonic Mass, Abdominal Pain and Gastrointestinal Bleeding: A Presentation of Gastrointestinal Involvement in Disseminated Histoplasmosis

A Colonic Mass, Abdominal Pain and Gastrointestinal Bleeding: A Presentation of Gastrointestinal Involvement in Disseminated Histoplasmosis

Black Esophagus From Non-dissected Thoracic Aorta Aneurysm

Acute esophageal necrosis (AEN) also known as black esophagus due to its appearance on endoscopy classically involves the distal esophagus. AEN affecting the mid esophagus with sparing of the distal esophagus is rare and usually occurs in patients with thoracic aortic aneurysmal rupture or aortic dissection. Here we report a case of AEN in a patient with an unruptured and undissected thoracic aorta aneurysm (TAA). A 79-year-old female presented to ER with near syncope. She denied chest pain or gastrointestinal symptoms. She had a history of HTN and TAA, 5.5 cm in size, previously diagnosed and scheduled for repair. Her vital signs were stable with BP of 122/62 mmHg and pulse 81 bpm. Her initial laboratory studies were stable, and only d-dimer was elevated to 2049. Chest CT angiogram revealed an acute bilateral pulmonary embolism (PE) with stable TAA and mural thrombus in descending thoracic aorta. Right heart strain was revealed by echocardiogram and she was started on heparin. On day 2, patient went into acute hypoxemic respiratory failure requiring intubation. As she subsequently developed shock, pressors were initiated. On day 5, melena and bloody gastric residue was found, and hemoglobin declined from 12.2 g/dL to 7.7 g/dL. Heparin was stopped, 2 units of blood were transfused and an IVC filter was placed. Upper endoscopy revealed extensive, circumferential deep ulceration in mid-esophagus with wall irregularity and black discoloration likely esophageal necrosis (figure 1 & 2). Distal esophagus, GE junction, stomach and duodenum appeared normal. Patient was managed supportively with NPO, PPI, fluids and pressors. While her hemoglobin stabilized, patient went into pulseless electrical activity on day 23 and died after unsuccessful resuscitation. We postulate that extrinsic compression of the esophageal wall by the thoracic aortic aneurysm and the intramural thrombus resulted in obstruction of the esophageal blood vessels arising from the descending aorta which supply the mid-esophagus leading to ischemia which was worsened by the hypotension caused by PE.AEN in the setting of a thoracic aortic aneurysm can occur without rupture or dissection.Figure: Endoscopic Images showing extensive circumferential esophageal ulcerations with blackish discoloration.Figure: Endoscopic Image showing friable esophageal mucosa, mucosal separation with out active bleeding.Figure: Sagittal section of CT Angiogram of chest showing thoracic aorta aneurysm of approx. 5.5 cm size causing extrinsic compression at mid esophageal level (green arrow) along with intramural thrombus in thoracic aorta (red arrow head).

Emergence of the Epizootic Ulcerative Syndrome in Pond Reared Carp Fish (Cyprinids) and It's Control Measure in Chitwan, Central Nepal

A survey on epizootic ulcerative syndrome (EUS) was carried in carp fish (cyprinids) reared in ponds during January 2016 to January 2017 at six locations of Chitwan, Nepal. Outbreaks of EUS were observed in 39.6% of the carp during winter. EUS infection was the most for Cirrhinus mrigala (47.3% of the 170 samples) and the least for Labeo rohita (12.3% of the 65 samples). EUS infected fish weighing range between 15g-300g were characterized as extensive deep ulceration on head, dorsal and lateral part of body and at caudal peduncle region. Histopathology examination of affected tissue of skin with adjacent muscles showed mycotic granulomas indicated a positive diagnosis for EUS. Survey results indicate that poor water quality in undrained ponds, uncontrolled entry of flooded water into the pond, runoff water from adjacent paddy field and use of contaminated equipment and seine nets were found to trigger risk for EUS infection in carp pond. Impact assessment of EUS showed that average economic loss due to EUS fish disease was 2257.92 kg/ha/year (33.01%) of the expected production. The highest economic loss of 1432.14 kg/ ha/year (53.53%) was estimated for large farm and lowest loss of 950 kg/ha/year (5%) for medium size farm. The simultaneous application of Ciphalexin in feed at 80mg.kg-1 biomass of fish for 15 consecutive days and two applications of Kohrsolin-TH at 900 ml/ha (1 m pond depth water) at weekly interval was found effective to control EUS infection in carps. The combined efficacy of these two drugs was estimated to be 97.7% control of EUS infection in carp fish. Int. J. Appl. Sci. Biotechnol. Vol 5(3): 313-320

Two different protein expression profiles of oral squamous cell carcinoma analyzed by immunoprecipitation high-performance liquid chromatography

BackgroundOral squamous cell carcinoma (OSCC) is one of the most dangerous cancers in the body, producing serious complications with individual behaviors. Many different pathogenetic factors are involved in the carcinogenesis of OSCC. Cancer cells derived from oral keratinocytes can produce different carcinogenic signaling pathways through differences in protein expression, but their protein expression profiles cannot be easily explored with ordinary detection methods.MethodsThe present study compared the protein expression profiles between two different types of OSCCs, which were analyzed through immunoprecipitation high-performance liquid chromatography (IP-HPLC).ResultsTwo types of squamous cell carcinoma (SCC) occurred in a mandibular (SCC-1) and maxillary gingiva (SCC-2), but their clinical features and progression were quite different from each other. SCC-1 showed a large gingival ulceration with severe halitosis and extensive bony destruction, while SCC-2 showed a relatively small papillary gingival swelling but rapidly grew to form a large submucosal mass, followed by early cervical lymph node metastasis. In the histological observation, SCC-1 was relatively well differentiated with a severe inflammatory reaction, while SCC-2 showed severely infiltrative growth of each cancer islets accompanied with a mild inflammatory reaction. IP-HPLC analysis revealed contrary protein expression profiles analyzed by 72 different oncogenic proteins. SCC-1 showed more cellular apoptosis and invasive growth than SCC-2 through increased expression of caspases, MMPs, p53 signaling, FAS signaling, TGF-β1 signaling, and angiogenesis factors, while SCC-2 showed more cellular growth and survival than SCC-1 through the increased expression of proliferating factors, RAS signaling, eIF5A signaling, WNT signaling, and survivin.ConclusionsThe increased trends of cellular apoptosis and invasiveness in the protein expression profiles of SCC-1 were implicative of its extensive gingival ulceration and bony destruction, while the increased trends of cellular proliferation and survival in the protein profile of SCC-2 were implicative of its rapid growing tumor mass and early lymph node metastasis. These analyses of the essential oncogenic protein expression profiles in OSCC provide important information for genetic counseling or customized gene therapy in cancer treatment. Therefore, protein expression profile analysis through IP-HPLC is helpful not only for the molecular genetic diagnosis of cancer but also in identifying target molecules for customized gene therapy in near future.

Carcinome épidermoïde associé à une dépigmentation volontaire

Women widely use skin-lightening products for cosmetic purposes in sub-Saharan Africa despite numerous reported cutaneous and systemic complications. The occurrence of epidermoid carcinoma has long been reported, but only three cases have been published so far. We report the first case in Mali. A 30-year old woman with no noteworthy medical history was seen at our outpatient center for cervical ulceration that had been present for the last 5 years. She had used cosmetic bleaching cream over a period of around ten years. Physical examination revealed extensive ulceration on the left side of her neck. Blood tests for viral hepatitis and human immunodeficiency virus were negative. The pathological examination of the skin biopsy confirmed the diagnosis of squamous cell carcinoma. After failure of the initial excision with early relapse, multiple surgical ablations were performed 3 months later. The high prevalence of skin-lightening cosmetic use contrasts with the rarity of epidermoid carcinoma in depigmented skin. However, a large chronic ulcer on uncovered parts of the upper body, particularly the neck, should prompt physicians to consider skin cancer. Appropriate preventive measures include the promotion of educational messages for the general population, the use of sun-protection devices, and routine skin biopsy for all women presenting chronic cervical ulceration after long-term use of skin-lightening products.

ATYPICAL FACIAL INVOLVEMENT OF WEGENER'S GRANULOMATOSIS

Wegener's granulomatosis is an uncommon vasculitis of small- and medium-sized vessels. A 23-year-old female patient was referred with a diffuse gingival swelling and extensive facial ulcers. She reported a 5-month lasting non-responsive retro-auricular pustule-nodular lesion, initially diagnosed as acne. The injury progressed to numerous sharp-demarcated deep facial ulcerations. Skin biopsy was suggestive of pyoderma gangrenosum. The patient also presented with fever, diffuse pulmonary inflammation with cavitation, and gingival hyperplasia. Both p-ANCA and c-ANCA, as well as tuberculosis tests, were negative. A gingival biopsy was performed and microscopic analysis showed plenty of multinucleated cells and vascular structures with areas of clutter and infiltration of inflammatory cells, suggestive of Wegner's granulomatosis. Based on the oral biopsy report, the patient was started on corticosteroid/cyclophosphamide pulse therapy and an adequate clinical response was noted. c-ANCA was tested again 1 month later and the result was positive. The patient is now on close follow-up with adequate clinical control.

English

Aim: The aim of this study was to assess the potency of the anti-ulcer drug, Idogun on the stomach of ulcer induced albino rats. Method: Six groups of locally bred albino rats were used. Each group containing five rats of either sex were orally treated respectively with distilled water (ulcer control group), omeprazole 20mg/kg (reference group) and 100, 200, 400 and 800mg/kg extract of Idogun anti –ulcer mixture (experimental group). Rats were sacrificed one hour after oral administration of 1ml absolute ethanol to induce injury in the gastric mucosa. Results: Tissue sections from ulcer induced rats contained haemorrhage, dense infiltration by mixed inflammatory cells and extensive ulceration. These features were absent in the ulcer induced rats that were subsequently treated with the Idogun mixture. Mild tissue edema and presence of inflammatory cells were observed in the omeprazole treated section. Conclusion: Idogun anti-ulcer herbal mixture is a potent anti-ulcer drug. Key words: Idogun mixture, Stomach ulcer, Herbal

Vasculitic Ulcers in a Young Female with Dermatomyositis: An Unusual Case

Background: Vasculitic ulcers are one of the rarer cutaneous manifestations of dermatomyositis. They are considered to be a predictor of underlying malignancy. Case Report: We describe a case of extensive cutaneous vasculitic ulcers in a young female patient of dermatomyositis without a background of systemic connective tissue disorder or malignancy. Therapy with steroids and methotrexate resulted in swift remission in the patient. Conclusion: Cutaneous leukocytoclastic vasculitis in a patient of dermatomyositis shows good response to steroids complemented by steroid sparing agents.

P565 Assessments of clinical efficacy and mucosal healing in ulcerative colitis patients undergoing granulomonocytapheresis at different treatment frequencies

Background: Patients with active ulcerative colitis (UC) are known to have elevated myeloid lineage leucocytes including the CD14+CD16+ monocyte phenotype known to release tumour necrosis factor-α. Accordingly granulomonocytapheresis (GMA) with an Adacolumn has been applied to deplete inflammatory cytokine releasing leucocytes as a remission induction therapy. In general, patients who respond well continue responding and favour GMA over pharmacologics. However, published data indicate that patients with extensive deep ulcers and loss of the mucosal tissue at the affected sites may not respond well to GMA, while steroid naïve patients respond well. We have focused on GMA frequency and long term efficacy as supported by endoscopic findings. Methods: In a retrospective setting, and with interest on long term mucosal healing, we assessed the efficacy of the Adacolumn GMA in patients with active UC treated at different GMA frequencies in the past 10 years. In our data base, we found 99 corticosteroid naive patients who had received GMA at one session per week (n=18, group 1), at 2 to 4 sessions per week (n=31, group 2) or daily (intensive) GMA (n=50, group 3). Each patient could have received up to 11 GMA sessions. Initial efficacy evaluations were undertaken within 10 days following the last GMA session. Clinical activity index (CAI) ≤4 meant remission, while Mayo 0 or 1 meant mucosal healing. The included patients had been followed for ≥12 months on maintenance mesalamine. Results: The average baseline CAI in groups 1 to 3 were 7.9, 7.8, and 8.4, respectively; the number of GMA sessions were 9.1, 9.7 and 10.1 sessions, respectively; the GMA treatment periods were 55.1, 26.5 and 15.5 days, respectively. The mean CAI after the conclusion of GMA treatment courses were 2.5±2.7, 3.4±3.1 and 3.5±2.7, respectively. The rates of mucosal healing were 76.9%, 60.% and 61.8%, respectively. At 12 months, 40.0% in group 1, 57.1% in group 2 and 61.9% in group 3 had maintained mucosal healing. No GMA related serious adverse event was observed. Conclusions: This efficacy evaluation undertaking in steroid naïve patients with active UC showed that for an equal number of GMA sessions, the clinical efficacy was not significantly affected by the frequency of GMA sessions, but the time to remission and the rate of mucosal healing at 12 months were significantly better for intensive GMA. However, the efficacy outcomes in our 99 patients are higher than reported for GMA in patients with severe UC refractory to the current pharmacologicals, reflecting the fact that GMA is more effective in steroid naïve patients who have mild or moderately active UC, but not so effective in patients with severe UC in whom drug therapy has failed.

Outbreaks of ulcerative disease associated with ranavirus infection in barcoo grunter, Scortum barcoo (McCulloch & Waite).

In 2013, an outbreak of ulcerative disease associated with ranavirus infection occurred in barcoo grunter, Scortum barcoo (McCulloch & Waite), farms in Thailand. Affected fish exhibited extensive haemorrhage and ulceration on skin and muscle. Microscopically, the widespread haemorrhagic ulceration and necrosis were noted in gill, spleen and kidney with the presence of intracytoplasmic eosinophilic inclusion bodies. When healthy barcoo grunter were experimentally challenged via intraperitoneal and oral modes with homogenized tissue of naturally infected fish, gross and microscopic lesions occurred with a cumulative mortality of 70-90%. Both naturally and experimentally infected fish yielded positive results to the ranavirus-specific PCR. The full-length nucleotide sequences of major capsid protein gene of ranaviral isolates were similar to largemouth bass virus (LMBV) and identical to largemouth bass ulcerative syndrome virus (LBUSV), previously reported in farmed largemouth bass (Micropterus salmoides L.), which also produced lethal ulcerative skin lesions. To the best of our knowledge, this is the first report of a LMBV-like infection associated with skin lesions in barcoo grunter, adding to the known examples of ranavirus infection associated with skin ulceration in fish.

Pyoderma gangrenosum following breast reconstruction: successful treatment with steroids

Introduction: Pyoderma gangrenosum is arare cause of skin necrosis after surgery. It often appears with extensive ulcerations and scaring with significant aesthetic aftermaths. The pathogenesis is poorly understood but often associated with inflammatory diseases, however post-surgical idiopathic pyoderma gangrenosum can occur. Case Report: We report a case of pyoderma gangrenosum following a bilateral breast reconstruction in a 33-year-old woman, successfully treated with steroids. A week after the surgery wounds started to break down and extensive necrotic ulceration appeared quickly covering both breasts. After dermatopathology evaluation she received antibiotics and prednisone and three months later wounds were completely healed and surgery was not necessary.

Post-Partum Pyoderma Gangenosum Following a Cesarean Section

The occurrence of Pyoderma gangrenosum (PG) during pregnancy or postpartum has rarely been reported. These forms can also occur on a recent scar facilitated by the pathergy phenomenon. A 25-year-old woman showed an abruptly worsening of a post-caesarean wound that evolved rapidly into a painful, purulent, extensive ulcer with breakdown of sutures, along with fever and leukocytosis despite antibiotic therapy. The diagnosis of postoperative PG was evoked on the unusual course of the surgical wound, the existence of old cribriform scars on the legs, the clinical appearance of the ulceration around the surgical incision and confirmed by histology, as well as the favourable outcome under systemic corticosteroid. This case raises once again the issue of the possible relationship between pregnancy and PG. In our case, pregnancy could have triggered the PG, and the Caesarean section facilitated its clinical expression by the pathergy phenomenon. Thus, pregnancy could be in the same way as chronic inflammatory diseases, such as arthritis, inflammatory bowel disease and haematological disorders, a triggering or exacerbating factor of PG.