Non-healing Lesions Research Articles

A Non-Healing Lesion on the Anterior Chest of a Patient Receiving Hemodialysis: A Case Study

Basal cell carcinoma is the most common type of skin cancer, and patients receiving hemodialysis are at increased risk of developing them. This article describes a case of a patient with a basal cell carcinoma in which the diagnosis was delayed due to the lesion masquerading as granulation tissue at the site of a previous tunnelled hemodialysis catheter. Early detection of basal cell carcinomas is important because delayed detection increases the risk of local invasion and the requirement for more complex surgical management.

Early Referral for Non-healing Lesions

Early Referral for Non-healing Lesions

Variation in Leishmania chemokine suppression driven by diversification of the GP63 virulence factor.

Leishmaniasis is a neglected tropical disease with diverse outcomes ranging from self-healing lesions, to progressive non-healing lesions, to metastatic spread and destruction of mucous membranes. Although resolution of cutaneous leishmaniasis is a classic example of type-1 immunity leading to self-healing lesions, an excess of type-1 related inflammation can contribute to immunopathology and metastatic spread. Leishmania genetic diversity can contribute to variation in polarization and robustness of the immune response through differences in both pathogen sensing by the host and immune evasion by the parasite. In this study, we observed a difference in parasite chemokine suppression between the Leishmania (L.) subgenus and the Viannia (V.) subgenus, which is associated with severe immune-mediated pathology such as mucocutaneous leishmaniasis. While Leishmania (L.) subgenus parasites utilize the virulence factor and metalloprotease glycoprotein-63 (gp63) to suppress the type-1 associated host chemokine CXCL10, L. (V.) panamensis did not suppress CXCL10. To understand the molecular basis for the inter-species variation in chemokine suppression, we used in silico modeling to identify a putative CXCL10-binding site on GP63. The putative CXCL10 binding site is in a region of gp63 under significant positive selection, and it varies from the L. major wild-type sequence in all gp63 alleles identified in the L. (V.) panamensis reference genome. Mutating wild-type L. (L.) major gp63 to the L. (V.) panamensis sequence at the putative binding site impaired cleavage of CXCL10 but not a non-specific protease substrate. Notably, Viannia clinical isolates confirmed that L. (V.) panamensis primarily encodes non-CXCL10-cleaving gp63 alleles. In contrast, L. (V.) braziliensis has an intermediate level of activity, consistent with this species having more equal proportions of both alleles. Our results demonstrate how parasite genetic diversity can contribute to variation in immune responses to Leishmania spp. infection that may play critical roles in the outcome of infection.

Pink plaque on the hypogastrium

Bowen’s disease is a type of intraepidermal squamous cell carcinoma usually affecting the elderly and occurring on sun-exposed areas, such as the face, scalp, and limbs. The development of Bowen’s disease in other locations such as the abdomen is rare. In these cases, dermoscopy proves to be a helpful tool in making the diagnosis [1]. A 65-year-old male with no previous medical history presented himself with a nonhealing asymptomatic lesion on the abdomen slowly growing for the last ten years. A dermatological examination revealed a 6-cm well-limited erythematous plaque on the hypogastrium with peripheral pigmentation (Fig. 1). Dermoscopy found central keratin as well as white shiny structures, including white shiny lines, white shiny areas, and rosettes (Fig. 2) as well as brown linear globules and dots on the periphery and looped vessels (Fig. 3). Bowen’s disease was the most likely diagnosis, which was confirmed by histopathology. The patient underwent surgery for excision of the lesion with 5-mm margins.

Painful facial abscess.

Any case of a chronic nonhealing lesion of the face should include this condition in the differential.

Exclusive Expression of MyD88 on Dendritic Cells Is Sufficient to Induce Protection against Experimental Leishmaniasis

Leishmania parasites, endemic in (sub)tropical regions, cause a neglected tropical disease affecting ∼12 million cases worldwide. The spectrum of pathologies ranges from cutaneous leishmaniasis to progressive fatal visceral disease. Both in humans and mice, healing is associated with successful development of IFN-γ‒producing T helper type (Th)1/Tc1 cells, whereas Th2-, Th17-, and regulatory T-cell‒predominant responses are associated with progression and/or nonhealing lesions ( Kautz-Neu et al., 2011 Kautz-Neu K. Noordegraaf M. Dinges S. Bennett C.L. John D. Clausen B.E. et al. Langerhans cells are negative regulators of the anti-Leishmania response. J Exp Med. 2011; 208: 885-891 Google Scholar ; Sacks and Noben-Trauth, 2002 Sacks D. Noben-Trauth N. The immunology of susceptibility and resistance to Leishmania major in mice. Nat Rev Immunol. 2002; 2: 845-858 Google Scholar ). After transmission, Leishmania major primarily resides in skin-resident macrophages. Lesion infiltrating IFN-γ+ T cells activate macrophages to eliminate parasites through nitric oxide ( Sacks and Noben-Trauth, 2002 Sacks D. Noben-Trauth N. The immunology of susceptibility and resistance to Leishmania major in mice. Nat Rev Immunol. 2002; 2: 845-858 Google Scholar ). In contrast to the silent invasion of macrophages, parasite internalization by dendritic cells (DCs) triggers DC activation ( Woelbing et al., 2006 Woelbing F. Susanna L.K. Moelle K. Belkaid Y. Sunderkoetter C. Verbeek S. et al. Uptake of Leishmania major by dendritic cells is mediated by Fcgamma receptors and facilitates acquisition of protective immunity. J Exp Med. 2006; 203: 177-188 Google Scholar ), and infected DCs are considered to induce protection by IL-12 ( von Stebut et al., 1998 von Stebut E. Belkaid Y. Jakob T. Sacks D.L. Udey M.C. Uptake of Leishmania major amastigotes results in activation and interleukin 12 release from murine skin-derived dendritic cells: implications for the initiation of anti-Leishmania immunity. J Exp Med. 1998; 188: 1547-1552 Google Scholar ) and by priming T cells against L. major antigens. These early events after parasite inoculation are critical for disease outcome.

Cell Therapy of Pathological Gastrointestinal Lesions in Modeled NSAID-Induced Enterocolitis

Wistar rats with NSAID-induced (dexketoprofen) chronic enterocolitis of the gastrointestinal tract were treated with a cultured allogeneic cell suspension consisting of mononuclear cells (40 millions) and multipotent mesenchymal stromal cells (10 millions). The suspension was transplanted intraperitoneally, 2 times with an interval of 30 days. Cultured allogeneic fractions of bone marrow cells accelerate the regeneration of long-term non-healing gastrointestinal lesions by reducing the duration and severity of the inflammatory phase and activating the regenerative phase of the ulcerative process. It was found that the simultaneous administration of the studied cultured stem cells can be used for the treatment of chronic, long-term non-healing, poorly-scarring ulcerative necrotic gastrointestinal pathologies.

Risk of Neurodegeneration in Patients with Morgellons Disease: A Focus on the Potential Risk of Developing Alzheimer’s

Morgellons disease is a distressing dermatologic condition that typically presents with multiple, non-healing skin lesions with filamentous protrusions. Initial presentation of the condition can often include various neurological symptoms with dermatologic symptoms. Common neurological symptoms include neuropathy, cognitive impairment, and dementia. Recent studies reveal that spirochetes are a causative agent of Morgellons disease. Chronic spirochete infection is strongly associated with neurodegeneration seen in dementia and Alzheimer’s disease. This paper will provide a brief overview of Morgellons and Alzheimer’s disease and will explore the possible risk of developing Alzheimer’s in Morgellons patients.

Scrofuloderma: A Rare Case Report of Sequelae of Intestinal Tuberculosis

Abstract Introduction: Scrofuloderma is caused by Mycobacterium tuberculosis and is the most common form of cutaneous tuberculosis. It remains a significant medical challenge because its clinical manifestations mimic those of various other conditions, making diagnosis difficult. Here, we report a 28-year-old man who had been diagnosed with intestinal tuberculosis but discontinued treatment. Case presentation: He subsequently presented with a 5-month history of multiple non-healing ulcerative lesions on the abdomen with no other significant clinical findings. Ziehl-Neelsen staining of an impression smear taken from the lesions was performed as the preliminary investigation and confirmed the presence of acid-fast bacilli. Histopathologic examination of a skin biopsy specimen, PCR, and the Mantoux test also confirmed the presence of Mycobacterium tuberculosis. The patient began treatment with anti-tubercular drugs and his lesions gradually regressed. Discussion: The most common finding of scrofuloderma is a chronic, painless ulcerative lesion with purulent discharge. Cervical lymph nodes are frequently involved. These clinical features mimic several other bacterial and fungal conditions. However, Ziehl-Neelsen staining of the discharging ulcers can be used as a preliminary test to demonstrate acid fast bacilli in most of the cases. Histopathologic examination of skin biopsy specimen, culture on Lowenstein-Jensen media and PCR can confirm the diagnosis. Conclusion: Although Scrofuloderma is a rare cutaneous manifestation, it is curable with early diagnosis and prompt intervention of antitubercular drugs.

Extranodal natural killer T cell lymphoma of the oropharyx: case report

BackgroundT cell lymphoma of the upper aerodigestive tract is a rare entity usually presenting as midfacial ulcerative lesion. It is extremely rare to present as non-healing erosive lesion of the oropharynx.Case presentationA 29-year-old female patient presented with odynophagia and trismus for several months. An “inflammatory” oropharyngeal ulcer was diagnosed and she was treated with repeated courses of antibiotics and corticosteroids without response. Recently, she had some blood stained saliva and vomited fresh blood. When seen, she had extensive painful ulcer eroding the right side of the soft palate and right tonsillar area. The ulcer had a whitish floor and ragged border without any tendency to heal. A second biopsy was taken and proved the lesion to be extranodal natural killer T cell lymphoma (ENKTL). The patient was treated with a modified SMILE (steroid, methotrexate, ifosfamide, l-asparaginase, and etoposide) protocol.ConclusionsExtranodal natural killer T cell lymphoma can manifest first in the oropharynx. If left untreated it may lead to deep erosive lesion and major oral bleeding. SMILE chemotherapy protocol was used in our patient with good early response.

Highly resistant Mycobacterium abscessus subsp. abscessus infection in a Swiss cat

AbstractA 2‐year‐old European shorthair cat was presented with a nonhealing skin lesion on the right abdominal wall. Repeated surgical excision and antimicrobial treatment with cefovecin, clindamycin, and trimethoprim‐sulfamethoxazole did not lead to clinical improvement. Histopathology of the skin lesion showed pyogranulomatous dermatitis and panniculitis. Definitive diagnosis was made by mycobacterial culture and rpoB sequencing, revealing Mycobacterium abscessus subsp. abscessus. To the authors’ knowledge, this is the first report of Mycobacterium abscessus subsp. abscessus infection in a cat in Switzerland and the second case in Europe. The isolated strain carried a functional erm(41) gene that confers inducible macrolide resistance. Further phenotypic resistances to doxycycline, minocycline, and imipenem were detected, resulting in little chance of successful antimicrobial treatment. Mycobacterium abscessus subsp. abscessus is an emerging pathogen in human medicine and poses a non‐negligible zoonotic risk for the owners of the cat.

COMPLICATIONS OF ARTHROSCOPIC DRILLING IN THE TREATMENT OF OSTEOCHONDRITIS DISSECANS OF THE KNEE IN CHILDREN AND ADOLESCENTS

Background:Arthroscopic drilling is a well-established treatment for stable intact OCDs of the knee in children when non-operative treatment fails. The decision to proceed to operative treatment requires a discussion regarding the risks and benefits of surgical intervention. While there is abundant data suggesting that OCD drilling is a highly effective treatment strategy, there is little data specifically evaluating the risks and complications of this procedure.Purpose:The goal of this study was to assess the complications of drilling of stable OCDs of the knee, and the risk factors for developing complications.Methods:In a retrospective chart review from 2009-2017, data from patients <18 years old who underwent arthroscopic drilling for stable intact OCD lesions of knee were collected. Lesions treated with other techniques (fixation, chondroplasty, OATS), and those with <3 months of follow-up were excluded. Characteristics of the lesions, treatment approach, and post-operative course were recorded. For bilateral surgeries, each knee was considered a separate record.Results:139 knees in 131 patients were evaluated, of which 102 (73%) were male. The mean age was 12.7years. 108 knees (77%) had an open physis at the time of operation. Patients were managed conservatively for a mean of 6.76 months pre-operatively (SD=6.6). Average follow-up was 14.8 months after the initial surgery (SD=13.25). 53 patients (38%) were obese or overweight at the time of surgery. All patients regained full ROM within 5° of the contralateral knee at a mean 12.9 weeks post-op (SD=3.2), with all but 7 (5 %) returning to activities of daily living at the 3-month visit. No cases of infection, stiffness, arthrofibrosis, or other procedure-related complications were recorded. 6 knees (4.3%) underwent 7 additional surgeries during the follow-up period, all of which were for treatment failure in non-healing lesions (loose body removals, chondroplasty, or repeat drilling). In a multiple logistic regression model, age, gender, status of the physis at the time of surgery, BMI percentile, and OCD size were not predictive of the need for additional surgeries.Discussion:Our findings suggest that arthroscopic drilling for OCDs of the knee is a safe procedure with minimal risk of complications. The majority of patients return to their pre-operative daily activity level with full ROM by 3 months after surgery. Complications, including reoperation, were related to the progression of the OCD, rather than the surgical procedure.

Non-Healing Leg Lesion

Non-Healing Leg Lesion

Race Predicts Unsuccessful Healing of Osteochondritis Dissecans in the Pediatric Knee.

The purpose of this study was to evaluate the effect of race, insurance status, and socioeconomic status on successful or unsuccessful healing of osteochondritis dissecans (OCD) lesions in the pediatric knee. The authors retrospectively reviewed patients younger than 18 years who were treated for a knee OCD lesion between 2006 and 2017. Patients were required to have at least 6 months of clinical and radiographic follow-up to be included, unless complete healing was achieved sooner. The primary outcome of interest was healing of the OCD lesion based on radiographic and clinical examination. A total of 204 OCD lesions in 196 patients with a mean follow-up of 15.8±6.4 months were included. The mean age at initial presentation was 12.4±2.8 years. At most recent follow-up, 28 (13.7%) lesions did not show radiographic or clinical evidence of healing. Nonhealing lesions were found in 25.0% of Black children compared with 9.4% of White children (P=.02). After controlling for age, sex, sports participation, lesion size and stability, skeletal maturity, and operative vs nonoperative treatment in a multivariate model, Black children had 6.7 times higher odds of unsuccessful healing compared with their White counterparts (95% CI, 1.1-41.7; P=.04). In this study, Black children with OCD of the knee were significantly less likely to heal than were White patients, even when controlling for numerous other factors in a multivariate model. Although the exact etiology of this finding is unclear, future work should focus on the social, economic, and cultural factors that may lead to disparate outcomes. [Orthopedics. 2021;44(3):e378-e384.].

Ulcer in the Disguise-A Rare Case Report

Tuberculosis (Tb) is an infectious disease which usually affects the pulmonary system and sometimes occursin other body organs including the oral cavity. The present article is on a case study of a 25-year femalediagnosed with TB osteomyelitis which presented a non-healing and non-painful ulcer both intra and extraorally. The diagnosis was confirmed based on histopathology. The patient underwent anti-TB therapy andher oral and systemic conditions improved rapidly. Although oral manifestations of tuberculosis are rare,clinicians should include them in the differential diagnosis of various types of oral ulcers. An early diagnosiswith prompt treatment can prevent complications and potential contaminations. Tuberculosis of the oralcavity is rare and have become a forgotten diagnosis of oral lesions. Dental practitioners need to be awarethat TB may occur in the oral cavity and should be considered in the differential diagnosis of any ulcerated,indurated non-healing lesion of the oral cavity, especially in lower socioeconomic groups. Besides, effortsshould be made to control oral TB by early detection and referral of the patient to a physician for propermanagement. Clinicians are to be careful about ulcers in disguise.

A Chronic Non-Healing Oral Lesion in a Breast Cancer Patient

This case report takes readers through our journey to a diagnosis of a breast cancer metastasis superimposed on a stage II MRONJ lesion. It highlights the importance of sending all bone sequestra excised intraoperatively for histopathological examination.

Basal cell carcinoma secondary to trauma: A 3-year experience of the single center.

Basal cell carcinoma (BCC) is the most frequent cancer worldwide in humans. The risk factors reported in the literature encompass excessive sun exposure, genetic predisposition, irradiation, exposure to arsenic, and trauma. The exact role of trauma in the etiology of BCC remains unexplained. To analyze patients with BCC treated surgically in the Dermatosurgery Unit, looking for possible cases of BCC secondary to trauma. We performed a retrospective review all of treated BCCs in the Dermatosurgery Unit between January 2017 and June 2020. Among 1,832 patients with BCC, 5 (0.27%) tumors had a positive history of previous trauma. Many different types of injuries have been associated with oncogenesis in the area of the scar. The clinical presentations of lesions varied between the patients. It is worth to underline that BCC may be located in the area of post-traumatic scar; however, the incidence seems to be lower comparing to reported previously (7.3-13%). This article illustrates the importance of exclusion malignancy in every non-healing lesion. A neoplasm may be difficult to differentiate from infection or local ischemia in the area of the scar. Prudent management of all clinically unclear lesions should include a biopsy.

The curious case of an erythematous plaque on penis

Penile psoriasis is a rare entity comprising of only 3% of all the psoriatic cases. However, it is one of the most common non-venereal diseases of the genitalia. Due to the location, sexually transmitted diseases are often suspected as the first diagnosis leading to delay in diagnosis and therapy. This causes quality of life impairment of patients along with severe psychosocial disturbances. We hereby present the case of a young immunocompetent male patient with a non-healing lesion on the glans penis of 4 month duration with raised anti-herpes simplex virus 2 immunoglobulin G (IgG) and IgM titres who was previously misdiagnosed as herpes genitalis owing to the location and serology. A biopsy leads to the correct diagnosis of psoriasis. He was then treated with calcipotriol and clobetasol combination with which the lesions healed in a week. We are presenting this case to raise the index of suspicion of psoriasis in patients with isolated penile lesions, as the presentation here is different with the lesions being non-scaly, compared to the other areas of the body. Another aspect is that maybe this case represents Wolf’s isotopic response in relation with “Zoster Sine Herpete” and psoriasis. This is to our knowledge the first time this phenomenon is being reported with psoriasis..

3D skin bioprinting: future potential for skin regeneration

Skin provides protection against external agents and plays an essential role in maintaining the body homeostasis. Bioprinting as a novel strategy involves computer-controlled deposition of cells and scaffolds into a three-dimensional (3D) construction of skin. 3D bioprinting gives an opportunity to generate multi-layered vascularized skin grafts that can overcome the limitations of current skin substitutes. The main indication is treatment of troublesome wounds, especially severe burns and non-healing chronic lesions. Bioprinted skin equivalents offer a promising approach in the field of regenerative medicine. This review presents and discusses 3D skin construct formation, its limitations and modifications, and its usefulness.

Coexistence of tuberculous chancre on a chronic nonhealing wound and bilateral submandibular scrofuloderma

Cutaneous tuberculosis is caused by Mycobacterium tuberculosis with varied clinical features depending on the dissemination route and host immune status. Scrofuloderma is a type of cutaneous tuberculosis that often occurs in locations where there is an infected lymph node or bone underneath, whereas tuberculous chancre often appears in sites that are prone to trauma. Although several cases have been reported, the coexistence of more than one type of cutaneous tuberculosis is very rare. We report a 21-year-old immunocompetent male with a chronic nonhealing lesion on the left tibia followed by bilateral purulent ulcers on the submandibular area. Acid-fast bacilli examination was positive for M. tuberculosis, and the patient was diagnosed with tuberculous chancre and scrofuloderma, respectively. This case showed the importance of high clinical suspicion of cutaneous tuberculosis and the possibility of the coexistence of more than one type of cutaneous tuberculosis in order to avoid misdiagnosis and delay in treatment.