Malodorous Discharge Research Articles

Management strategy of a periodontist in treating a patient with bisphosphonate-related jaw osteonecrosis: a clinical case

Relevance. Drug-related osteonecrosis of the jaws is a serious complication of antiresorptive therapy in patients with cancer, systemic osteoporosis, and Paget's disease, significantly impacting the patients' quality of life.Clinical case description. This article analyzes the progressive oral manifestations of a complication of antiresorptive therapy—drug-related osteonecrosis of the jaws—in a patient with breast cancer. The osteonecrosis was characterized by an exposed bone area in the upper jaw, periodontal inflammation, and a malodorous discharge from the mouth. The paper details the appropriate management strategy by the periodontist, tailored to the patient's individual characteristics.Conclusion. Early initiation of a conservative, comprehensive, and gentle treatment regimen can reduce inflammation in periodontal tissues, including the necrotic area, thus avoiding the need for high-risk surgical procedures.

Hidradenitis Suppurativa Is Associated with Severe Sexual Impairment

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory disorder of the pilosebaceous unit, often affecting and deforming intimate regions. HS is associated with severe pain, pruritus, and constant, purulent, malodorous discharge expected to impair sexual health of patients. Methods: We performed a cross-sectional, multicentric study involving 199 German patients from the health services research project “Epidemiology and Care in Acne inversa (EpiCAi).” The sexual health, HS severity, and quality of life of the studied group were evaluated using a specially designed questionnaire. Results: Regardless of gender, HS has an enormous impact on patients’ sexual health. The patients scored, on average, 28.8 ± 5.3 points on the Relation and Sexuality Scale (RSS). Multiple linear regression revealed that females and patients with Hurley III stage had higher sexual dysfunction (p = 0.012). Sexual dysfunction is associated with pain (β = 0.25), the number of active lesions, the affected areas (β = 0.14), and psychosocial aspects, including low quality of life (β = 0.404), stigmatization (β = 0.411), depression (β = 0.413), and anxiety (β = 0.300). Patients already see a substantial decrease in sexual frequency in the early stages of HS, while functional impairment and fear increase with the severity of the disease. Conclusion: Sexual health and management of its dysfunctions should be part of a holistic approach to HS patients.

Evaluation of Various Diagnostic Strategies for Bacterial Vaginosis, Including a New Approach Based on MALDI-TOF Mass Spectrometry.

Bacterial vaginosis (BV) is a common dysbiosis of unclear etiology but with potential consequences representing a public health problem. The diagnostic strategies vary widely. The Amsel criteria and Nugent score have obvious limitations, while molecular biology techniques are expensive and not yet widespread. We set out to evaluate different diagnostic strategies from vaginal samples using (1) a combination of abnormal vaginal discharge and vaginal pH > 4.5; (2) the Amsel-like criteria (replacing the "whiff test" with "malodorous discharge"); (3) the Nugent score; (4) the molecular quantification of Fannyhessea vaginae and Gardnerella vaginalis (qPCR); (5) and MALDI-TOF mass spectrometry (we also refer to it as "VAGI-TOF"). Overall, 54/129 patients (42%) were diagnosed with BV using the combination of vaginal discharge and pH, 46/118 (39%) using the Amsel-like criteria, 31/130 (24%) using qPCR, 32/130 (25%) using "VAGI-TOF", and 23/84 (27%) using the Nugent score (not including the 26 (31%) with intermediate flora). Of the 84 women for whom the five diagnostic strategies were performed, the diagnosis of BV was considered for 38% using the combination of vaginal discharge and pH, 34.5% using the Amsel-like criteria, 27% using the Nugent score, 25% using qPCR, and 25% using "VAGI-TOF". When qPCR was considered as the reference, the sensitivity rate for BV was 76.2% for the combination of vaginal discharge and pH, 90.5% for the Amsel-like criteria, 95.2% for the Nugent score, and 90.5% for "VAGI-TOF", while the specificity rates were 74.6%, 84.1%, 95.3%, and 95.3%, respectively. When the Nugent score was considered as the reference, the sensitivity for BV was 69.6% for the combination of vaginal discharge and pH, 82.6% for the Amsel-like criteria, 87% for qPCR, and 78.7% for "VAGI-TOF", while the specificity rates were 80%, 94.3%, 100%, and 97.1%, respectively. Overall, the use of qPCR and "VAGI-TOF" provided a consistent diagnosis of BV, followed by the Nugent score. If qPCR seems tedious and for some costly, "VAGI-TOF" could be an inexpensive, practical, and less time-consuming alternative.

Lymphoepithelioma-like carcinoma: a rare case of rectal cancer.

Lymphoepithelioma-like carcinoma (LELC) is a histological variant that resembles nasopharyngeal lymphoepithelioma and occurs in various locations such as the salivary glands and lung. LELCs in the digestive tract are rare, accounting for only 2% of cases, being exceptional in the rectum. We present the case of an 84-year-old man with rectorrhagia, whitish malodorous discharge and constipation of one month's duration. Rectal examination identified a tumour. Colonoscopy revealed a rectal lesion that was confirmed by biopsy as malignant, and MRI showed an extensive rectal tumour. Histopathology revealed undifferentiated carcinoma with acute inflammatory infiltrate, consistent with LELC. Immunohistochemistry was positive for keratins 5/6, 18, 20, CEA and BER.EP4, while in situ hybridisation for Epstein-Barr virus (EBV) RNA was negative. The multidisciplinary decision included neoadjuvant radiotherapy and anterior rectal resection. The patient remains in complete response two years after treatment. Histologically, LELC is characterised by an acute inflammatory infiltrate interspersed with poorly differentiated neoplastic cells. The stomach is the most commonly affected region in the gastrointestinal tract, with more than 80% of gastric LELCs associated with EBV. To date, only four cases of rectal LELC have been reported, and its association with EBV was demonstrated in only one case. There are no standard treatments for rectal LELC, underscoring the need to gather more cases to understand its pathogenesis and develop effective treatment strategies.

Effect of a combination of pea protein, grape seed extract and lactic acid in an in vivo model of bacterial vaginosis

Bacterial vaginosis (BV) is a common vaginal dysbiosis characterized by a malodorous discharge and irritation. The imbalance of the vaginal microbiota plays a key role in the development of BV. It has been demonstrated that Gardnerella vaginalis (GV), a facultative anaerobic bacillus, is involved in BV. Due to the rising number of antimicrobial-resistant species, recurrence of BV is becoming more frequent in women; thus, alternative treatments to antibiotics are needed. Natural substances have recently shown a great efficacy for the treatment of vaginal dysbiosis. Thus, this study aimed to investigate the beneficial effect of a product containing pea protein (PP), grape seed extract (GS) and lactic acid (LA) in an in vivo model of Gardnerella vaginalis-induced vaginosis by intravaginal administration of GV suspension (1 × 106 CFU/20 µL saline). Our results demonstrated that the product containing PP, GS and LA significantly reduced GV proliferation. More specifically, it significantly preserved tissue architecture and reduced neutrophil infiltration, inflammatory markers and sialidase activity when used both as a pre- or a post-treatment. Moreover, the product displayed strong bioadhesive properties. Therefore, our data suggested that the product containing PP, GS and LA could be used as alternative preventive or curative treatment for the management of BV.

Palliative Radiotherapy for Symptomatic Locally Advanced Breast Cancer.

Objective: Women with locally advanced breast cancer (LABC) or inoperable local recurrence often suffer from a significantly reduced quality of life (QOL) due to local tumor-associated pain, bleeding, exulceration, or malodorous discharge. We aimed to further investigate the benefit of radiotherapy (RT) for symptom relief while weighing the side-effects. Materials and methods: Patients who received symptom-oriented RT for palliative therapy of their LABC or local recurrence in the Department of Radiation Oncology at Heidelberg University Hospital between 2012 and 2021 were recorded. Clinical, pathological, and therapeutic data were collected and the oncological and symptomatic responses as well as therapy-associated toxicities were analyzed. Results: We retrospectively identified 26 consecutive women who received palliative RT with a median total dose of 39 Gy or single dose of 3 Gy in 13 fractions due to (impending) exulceration, pain, local hemorrhage, and/or vascular or plexus compression. With a median follow-up of 6.5 months after initiation of RT, overall survival at 6 and 12 months was 60.0% and 31.7%, and local control was 75.0% and 47.6%, respectively. Radiation had to be discontinued in 4 patients due to oncological clinical deterioration or death. When completed as initially planned, symptom improvement was achieved in 95% and WHO level reduction of analgesics in 28.6% of patients. In 36% (16%) of patients, local RT had already been indicated >3 months (>6 months) before the actual start of RT, but was delayed or not initiated among others in favor of drug alternatives or systemic therapies. RT-associated toxicities included only low-grade side-effects (CTCAE I°-II°) with predominantly skin erythema and fatigue even in the context of re-RT. Conclusion: Palliative RT in symptomatic LABC or locoregional recurrence is an effective treatment option for controlling local symptoms with only mild toxicity. It may thus improve QOL and should be considered early in palliative patient care management.

LANGERHANS CELL HISTIOCYTOSIS IN A CHILD WITH ALBINISM AND INVASIVE SKULL LESIONS

<h3>Introduction</h3> Langerhans cell histiocytosis (LCH) is a rare disorder that involves excess production of dendritic cells, a form of histiocyte. LCH is heterogeneous in its presentation, varying from single bone lesions to multi-organ failure and considerable mortality. Here, we present a child with LCH who has albinism and persistent skull and orbital lesions. <h3>Case Description</h3> Patient from rural Guatemala was seen at the National Public Hospital of Escuintla during a medical mission trip. He was a 2-year-old boy with congenital albinism and a 6-month history of ulcerative lesions of the right periorbital, frontal, and retroauricular areas with purulent and malodorous discharge (Figure 1A,B). Lesions continued to worsen despite two courses of unknown oral antibiotics and chlorine dioxide rinses. Birth history was unremarkable; he received routine vaccinations including BCG. Skull x-ray showed a large area of decreased lucency in the right frontal and parietal lobe (Figure 1C). MRI of brain and orbits revealed a necrotic mass in the same area (Figure 1D). Wound cultures grew <i>Pseudomonas aeruginosa</i> and intravenous cefepime was initiated. Patient was transferred to the main cancer institute in Guatemala where biopsy of the skull lesion confirmed LCH. <h3>Discussion</h3> The diagnosis of LCH in our case was delayed primarily due to the limited resources and access to medical care. LCH can be invasive, and patients often need a multidisciplinary team approach in a tertiary care center. Additional immunologic studies and genetic evaluation, if available, can provide further insights. To our knowledge, this is the first report of LCH in a patient with albinism.

Definitive Radiation Therapy for Locally Advanced Skin Cancer in a Developing Country

<h3>Purpose/Objective(s)</h3> Skin cancers in less developed countries often present at advanced stages, and often with symptoms and in the elderly. Imaging resources are limited, advanced surgical techniques and plastic repair is often not available, and patients must bear much of the cost of treatment. Many patients are referred for radiation therapy (RT) for symptoms such as malodorous discharge, bleeding, or pain. This study is done to evaluate the results of evaluation and treatment in a country with limited resources, but with sophisticated radiation techniques. <h3>Materials/Methods</h3> 100 patients who completed definitive radiation therapy (96) or adjuvant RT for positive margins (4) between 2015 and 2022 were identified in the RT database. All were planned with a CT simulation. Lymph nodes (L/N) were evaluated by the sim CT +/- ultrasound and FNA, and treated if suspicious. RT doses ranged from 52-70 Gy with variable fraction sizes and schedules, with a planned EQD2 dose of 55-70 Gy. RT techniques included electrons or VMAT. For follow-up, patients or their family were contacted regarding medical status, symptom response, tumor status, and satisfaction. <h3>Results</h3> The median age was 74 (range 60-95). 60% of tumors were squamous cell (SCC) and 40% basal cell (BCC). Tumor grade was rarely reported. Location of tumor was face and scalp (98%), and limb and torso (2%). On physical exam, 23% of tumors were >5 cm and sizes ranged to 9.5 cm. 31% presented with discharge or bleeding and 31% with pain. Tumors were staged as T2-4. CT or ultrasound detected suspicious nodes in 17%. 30% of patients died of any cause in the follow-up period, most from cardiovascular disease. 12 patients died of cancer; 9 pts had SCC and 3 had BCC. All 12 had tumors presenting on the face or scalp and 2 had suspicious L/N at presentation. 70% of patients are alive and disease free, including 58% of patients with SCC and 87.5% of patients with BCC. Patient satisfaction was high with only 2% unhappy with the palliation they received, including those patients who died of other causes. <h3>Conclusion</h3> RT is an effective modality to palliate symptomatic, locally advanced, skin cancers. CT and ultrasound are effective methods of evaluating nodes. When advanced surgical techniques are unavailable, RT may be a reasonable option for treatment. This data will be further mined to assess the effect of treatment fields, RT dose, and fraction size. This study is limited by the lack of physician follow-up, a problem in developing countries.

35007 An unusual clinical presentation of a squamous cell carcinoma mimicking mycetoma

Mycetoma is a chronic granulomatous infection of subcutaneous tissue caused by bacteria or fungi. It is endemic to tropical areas and leads to tissue swelling, ulcerated nodules, and draining sinus tracts. We present the case of a patient with an atypical squamous cell carcinoma (SCC), whose clinical presentation was consistent with mycetoma. Our patient is a 39-year-old Guatemalan male without past medical history who presented with a 20-year history of nonresolving swollen and ulcerated lesions on his left buttock. Upon examination, he had a large, edematous, and indurated mass with multiple circular ulcers and sinus tracts draining yellowish, malodorous discharge. Punch biopsies were performed for histology and tissue cultures. Tissue cultures for bacteria, atypical mycobacteria, nocardia, actinomyces, and fungi only grew polymicrobial bacterial organisms for which he was treated with antibiotics and had minimal improvement. Unexpectedly, histology revealed a well-differentiated SCC, and a left inguinal lymph node biopsy was positive for SCC. A wide excision was performed and hematology/oncology and surgery departments are currently following the patient for further management. This case demonstrates the importance of including SCC in the differential diagnosis when there is clinical suspicion of a long-standing infectious process such as mycetoma, especially when dealing with areas of chronic inflammation. The development of SCC has long been associated with non-healing wound ulcers. Even when solely an infectious process is suspected, clinicians should perform biopsies for both tissue cultures and histopathology to ensure prompt diagnosis, since malignancies such as SCC have the potential to masquerade as an infection.

935 Case of Bad Breath in a Child

Abstract 4-year-old girl with a two-year history of speech and language delay was referred to the Speech and Language Therapy Service by her health visitor. Additionally, she had a history of asthma, recurrent glue ears, head lice, poor dentition, a persistent malodorous nasal discharge, and halitosis. Her hyper-nasal speech sounds indicated soft palate dysfunction. Subsequent assessment in the cleft clinic resulted in a diagnosis of non-cleft velopharyngeal insufficiency. At the time of her elective pharyngoplasty, the anaesthetist and surgeon were overwhelmed by the foul smell emanating from her nose and mouth. As such, an intraoperative nasal endoscopy was undertaken to examine her vestibules. A calcified cigarette filter (Figure 1) was found impacted deep within the patient's right nostril and was removed prior to the pharyngoplasty. It was later discovered that the malodorous nasal discharge and halitosis had plagued the child since the age of 18 months. Moreover, she had undergone a number of clinical assessments within the primary care setting. However, the combination of head lice, foul smell, and her uncooperative demeanour made examination difficult, and her symptoms were inappropriately attributed to tooth decay and periodontal disease.

Evaluating the effectiveness of a single application of 7% iodine tincture umbilical dip as a prevention of infection of the external umbilical structures in dairy calves

The objective of this randomized clinical trial was to evaluate the effectiveness of a single application of 7% iodine tincture-based umbilical dip for preventing infection of the external umbilical structures in dairy calves. Five dairy farms in southern Ontario were visited twice weekly from September 2020 through June 2021. Female (n = 244) and male (n = 40) Holstein calves were randomly assigned at birth to receive either a 7% iodine tincture-based umbilical dip (n = 140) or no treatment (n = 144). Calves in the 7% iodine tincture umbilical dip group had the product administered once by the producer shortly after birth. For each newborn calf, the experimental group, calving difficulty, volume and timing of colostrum administration, time of birth, calving pen cleanliness, and the dam ID were recorded. Calf body weight was recorded during the first visit after birth, and a blood sample was collected for measurement of serum IgG concentration. Calves were health scored twice weekly from enrollment until approximately 30 d of age for assessment of external umbilical infection, joint inflammation, respiratory disease, and diarrhea. The primary outcome of the study was external umbilical infection, which was defined as an enlarged umbilicus with pain, heat, or a malodorous discharge. Calves were also weighed at 30 and 60 d to determine average daily gain. Serum IgG concentration and birth weight did not differ significantly between groups. Twenty-nine calves (20%) in the umbilical dip group developed an external umbilical infections, compared with 31 calves (22%) in the control group. A mixed logistic regression model, accounting for farm as a random effect, showed no effect of treatment on the incidence of an external umbilical infection. However, for every additional hour that calves received colostrum after birth, the odds of developing an external umbilical infection increased during the first month of life (odds ratio = 1.15; 95% confidence interval: 1.04-1.26). Additionally, treatment had no effect on respiratory disease, joint inflammation, diarrhea, average daily gain, or mortality, compared with the untreated control. These findings suggest that administering a single application of 7% iodine tincture dip to the umbilicus around the time of birth may not be effective for preventing external umbilical infections. Farm-level management factors, including colostrum management, appear to have more influence on risk of this disease.

Metastatic cornual melanoma in a Valesian copperneck goat

AbstractA 10‐year‐old, neutered, male Valesian copperneck goat was presented to the Clinic for Ruminants, Vetsuisse Faculty, University of Bern for a chronic wound at the base of the right horn first noticed 3 weeks before presentation. Clinical examination revealed a firm mass with ulcerations and malodorous discharge at the base of the right horn, and a duller sound on percussion of the right frontal sinus. Radiography revealed a soft tissue opacity filling the right cornual diverticulum of the frontal sinus. Upon wound debridement, tissue of grey to black discoloration was noticed and sent in for histopathological examination, which confirmed the presence of a melanoma. Subsequent ultrasonography of the liver and radiography of the thorax revealed no sign of metastatic disease. Given the poor prognosis, the goat was euthanased, and postmortem examination revealed the presence of multiple metastatic lesions in the regional lymph nodes.

Hidradenitis suppurativa: Disease pathophysiology and sex hormones.

Hidradenitis suppurativa is a cutaneous chronic inflammatory disease that is estimated to affect about 1% of the population and caused pain, malodorous discharge, disfigurement, and poor quality of life with psychosocial problems. The typical features are recurrent painful nodules, abscesses, and sinus tracts on the axillae, groins, gluteal areas, and anogenital regions since postpuberty. Smoking and obesity are two major triggering factors of hidradenitis suppurativa. Women are prone to have hidradenitis suppurativa than men in Western countries, but the male-to-female ratio is reversed in oriental countries. The disease severity can be affected by menstruation, pregnancy, and menopause. Furthermore, the phenotypes are different among men and women with hidradenitis suppurativa. Men are prone to have buttock involvement while women are prone to have axillary, groins, and submammary lesions. This review introduces the skin appendages and pathophysiology of hidradenitis suppurativa and then focuses on the sex difference and the effects of sex hormones on hidradenitis suppurativa and current hormone-associated treatments.

The facultative human oral pathogen Prevotella histicola in equine cheek tooth apical/ periapical infection: a case report

BackgroundPrevotella histicola is a facultative oral pathogen that under certain conditions causes pathologies such as caries and periodontitis in humans. Prevotella spp. also colonize the oral cavity of horses and can cause disease, but P. histicola has not yet been identified.Case presentationA 12-year-old Tinker mare was referred to the clinic for persistent, malodorous purulent nasal discharge and quidding. Conservative antibiotic (penicillin), antiphlogistic (meloxicam), and mucolytic (dembrexine-hydrochloride) treatment prior to referral was unsuccessful and symptoms worsened. Oral examination, radiography, sino-/ rhinoscopy, and standing computed tomography revealed severe apical/ periapical infection of the upper cheek tooth 209 with accompanying unilateral sinonasal inflammation and conchal necrosis. The tooth exhibited extensive subocclusal mesial infundibular cemental hypoplasia and caries, and an occlusal fissure fracture. After mechanical debridement and thermoplastic resin filling of the spacious subocclusal carious infundibular lesion, the tooth was extracted intraorally. The sinusitis and conchal necrosis were treated transendoscopically. Selective bacteriological swab cultures of affected tooth roots and subsequent matrix-assisted laser desorption ionization-time of flight mass spectrometry showed an infection with the obligate anaerobic, Gram-negative bacterium P. histicola. Surgical intervention and adapted antibiotic therapy led to normal healing without complications.ConclusionsThis study provides the first documented case of dental infection in a horse caused by P. histicola at once indicating necessity of more sufficient microbiological diagnostics and targeted antibiotic treatment in equine dental practice. This finding is also conducive to understand species-specific Prevotella diversity and cross-species distribution.

A case study on diabetic foot ulcer and its management

Diabetic foot ulcers are a common complication of poorly controlled diabetes, forming as a result of skin tissue breaking down and exposing the layers underneath. They are most common under the big toes and the balls of the feet, and they can affect the feet down to the bones. All people with Diabetes can develop foot ulcers and foot pain, but good foot care can help prevent them. One of the first signs of a foot ulcer is drainage from the foot that might stain the socks or leak out into the shoes. Unusual swelling, irritation, redness and disagreeable odour from one or both feet are also commonly early symptoms of a foot ulcer. The most visible sign of a serious foot ulcer is black tissue (called Eschar) surrounding the Ulcer. This forms because of an absence of healthy blood flow to the areas around the area around the Ulcer. Partial or complete gangrene, which refers to tissue death due to infections, can appear around the Ulcer. In this case, a malodorous discharge, pain, and numbness can occur. Case summary: This is a case of a patient suffering from Diabetic foot ulcer as a complication of unremittent diabetes. The patient was prescribed indicated Homoeopathic remedies. Individualized homoeopathic remedy Arsenicum album was prescribed in centesimal potency which gave a positive result in the treatment of diabetes. In about 2 months the affected R. foot was entirely cured off the symptoms.

Disease surveillance in England and Wales, April 2021

Disease surveillance in England and Wales, April 2021

29. Resealing of a Spontaneously Draining Imperforate Hymen

<h3>Background</h3> Microperforate and imperforate hymen are ostensibly separate diagnoses on a spectrum of hymenal anomalies. The incidence of imperforate hymen is 1 in 1000 births, while the rate for microperforate hymen is unknown, with few case reports (1). A patient with an imperforate hymen is often symptomatic with obstructive features of the genitourinary tract, whereas a patient with a microperforate hymen may be asymptomatic, have recurrent infections, or report obstructive symptoms (1, 2, 3). We present a unique case of an imperforate hymen with spontaneous rupture, that resealed and then ruptured spontaneously again. <h3>Case</h3> A 12-year-old premenarchal female, with a history of imperforate hymen, diagnosed on specialist exam at age 3, presented to the emergency department (ED) with back pain and urinary retention. Following an abdominal exam, she passed many clots vaginally, saturating adult-sized diapers. She was diagnosed with menarche and discharged. She was referred to a pediatric gynecologist for follow-up. Following her ED visit she had continued bleeding with malodorous discharge, and stated she had been using tampons. An exam limited by patient tolerance was remarkable for no patent hymenal opening, no vaginal bleeding or discharge. She did not tolerate a q-tip test. A pelvic ultrasound was ordered for her puzzling presentation and uncertain anatomy and revealed a normal uterus, bilateral ovaries, and no evidence of hematocolpos. An exam under anesthesia (EUA) and vaginoscopy was planned. She subsequently reported a second presentation to an outside ED. She again reported back pain, constipation and inability to void. Similar to her first presentation, her symptoms were relieved by an episode of profuse vaginal bleeding with strong foul odor that resolved after a few days. EUA findings included normal clitoris with smegma, normal labia majora and minora, urethra, and no obvious hymenal patency with labial traction. With a recto-abdominal exam, a microperforation was identified. Bloody discharge was expressed, and a hysteroscope was gently passed. Vaginoscopy confirmed a normal vaginal canal and cervix. An uncomplicated hymenectomy was performed. At her postoperative visit, she had no complaints. Her exam was unremarkable and the tissue was healing normally; no follow-up was indicated. <h3>Comments</h3> This case sheds light on an atypical case where the lines between a microperforate hymen and an imperforate hymen were blurred. There are few case reports in the literature of resealing of the hymen after hymenectomy, but no other cases reporting resealing after spontaneous perforation (4, 5).

Squamous cell carcinoma of the Bartholin Gland: A rare genital cancer managed at the JFK Liberian-Japanese Friendship Maternity Hospital Monrovia, Liberia

Bartholin gland carcinoma is a rare tumor that constitutes 2-7% of all vulvar cancers. We presented a 40-years-old multipara who presented to the outpatient Gynecologic clinic of the JFK Maternity Hospital with a complaint of painful vulvar swelling of 3 years duration. The swelling began as a small lump on the left labium majus and grew overtime becoming increasingly painful, ulcerated with associated bleeding and malodorous discharge. Her last sexual activity was 2 years ago, of which she experienced dyspareunia but no post coital bleeding. Vulva examination revealed an ulcerated fungating lesion involving the left labium majus and minus, firm, tender, extending 2 cm into left vaginal wall and lower aspect of the right labium minus. The diagnosis of Bartholin gland carcinoma was made with Bartholin gland abscess and Vulvar cancer as differentials. Preoperative Fine Needle biopsy (FNA) showed acute on chronic inflammation of the Bartholin gland. A left hemivulvectomy was done and specimen was sent for histology, which revealed locally invasive squamous cell carcinoma of the Bartholin gland. Patient recovery was uneventful and she was discharged home 2 weeks post operatively on supplements and advised to follow up for chemotherapy.

Ulcerated Arm Lesion in a 10-day-old Girl

1. Brittany Lehrer, MD* 2. Kyle Pronko, MD*,† 3. Alina G. Burek, MD*,† 1. *Medical College of Wisconsin, Milwaukee, WI 2. †Children’s Wisconsin, Milwaukee, WI 1. Address correspondence to Brittany Lehrer, MD, Children’s Corporate Center, Suite 730, 999 N 92nd St, Milwaukee, WI 53226. E-mail: blehrer{at}mcw.edu A 10-day-old girl presents with a progressive right upper extremity skin lesion. She was born large for gestational age at term via cesarean delivery for fetal distress. Pregnancy was complicated by diet-controlled gestational diabetes and a maternal history of genital herpes. The mother received prophylactic valacyclovir and no active herpes lesions developed during pregnancy. Immediately after birth, the infant was noted to have a 2-cm, tender, well-circumscribed area of erythema and induration over the right antecubital fossa. The extremity also had decreased movement, diminished radial pulse, and weak grasp reflex. Otherwise, she was well-appearing and her examination was normal. Radiographs of the forearm and clavicle were negative for fracture. She was diagnosed with hematoma and possible brachial plexus injury and discharged from the nursery on postnatal day 3 with the arm immobilized in a sling and acetaminophen as needed for pain. Since discharge from the nursery, the lesion has spread, ulcerated, and started draining malodorous white discharge, so the patient returns for evaluation on postnatal day 10. On physical examination, she has a poorly demarcated, erythematous, tender, indurated, circumferential plaque that extends from the mid-upper arm through the antecubital fossa to the mid-forearm. The center of the lesion is violaceous and ulcerated with white discharge (Fig 1). The affected extremity has decreased spontaneous movement, weak radial pulse, nearly absent grasp reflex, and she has pain with passive manipulation of the affected elbow. Her vital signs and the remainder of her physical examination are normal. Complete blood cell count with differential, procalcitonin, and c-reactive protein are within normal limits for age. Blood culture and herpes simplex virus polymerase chain reaction …

Palliative Toilet Mastectomy for Advanced Breast Cancer in a University Hospital of Nepal

Introduction: In Nepal, half of the breast cancer patients presented in advanced stage III (IIIA 18%, IIIB 22%), and stage IV (10%). Delayed presentations are due to lack of awareness, reluctancy and poor accessibility to health care services often leads to local complications like sloughing of fungating breast lesions, secondary infection and bleeding. The aim of this study was to analyze the advanced breast cancer (ABC) patients who underwent palliative toilet mastectomy. Methods: Retrospective review of all patients presenting with ABC who underwent palliative toilet mastectomy in the breast unit of Tribhuvan University Teaching Hospital Kathmandu, Nepal from January 2016 to December 2018, was done. The data included were demographic profile, histopathological and immunohistochemistry report, indication of surgery, adjuvant therapy, timing of surgery, and quality of life after surgery. Results: Total number of breast carcinoma patients was 155 within the duration of 3 years. There were 7 (4.5%) cases of breast cancer treated with palliative toilet mastectomy with mean age of 57.9±12.7 years. The mean tumor size was 4.3±1.3cm. The indications of palliative mastectomy were fungation-2 (28.5%), bleeding-2 (28.5%), ulceration-1 (14.3%), malodorous discharge with secondary infection-1 (14.3%) and hemiplegic patient with infection in 1 (14.3%). Luminal A molecular subtype was seen in 1 out of 7 patients (14.3%) with basal like subtype in 6 out of 7 patients (85.7%). Lympho-vascular invasion were seen in 4 out of 7 (57.14%). One patient underwent bilateral palliative mastectomy for progressive disease and margins were positive for tumor and remaining six patients had tumor free margins. Conclusion: Advanced breast cancers are treated with neoadjuvant therapy prior surgery but the delayed presentation of these with fungating, ulcerative, infective and bleeding lesions make the initial palliative toilet mastectomy a useful option.