Painful Nodules Research Articles

Multiple glomus tumours: Clinical, ultrasonographic and histopathologic findings of a rare disease.

Glomus tumour is a rare benign neoplasm originating from the glomus body, clinically presenting as a violet-coloured, painful nodule more sensitive when exposed to cold or hot. This hamartoma is typically solitary and predominantly affects the limbs, extremities and nail beds. Theappearance of multiple tumours and lesions not placed in the extremities is rare and frequently misdiagnosed. At dermoscopy, it appears as ahomogeneous, structureless, purplish area surrounded by a whitish region. Skin ultrasound shows a well-defined, round, hypoechoic mass. We report a case of numerous blue-purplish painful nodules distributed inthe trunk and arms while sparing the extremities, with typical dermoscopy and ultrasound findings. A biopsy was performed, confirming thediagnosis of glomangioma. We call attention to this rare condition to help dermatologists make this diagnosis when facing multiple painful nodules.

Co-occurrence of posterior chest wall pilonidal sinus with melanocytic nevus: a challenging presentation: a case report

IntroductionTo date, only a limited number of case reports have documented the co-occurrence of PNS and melanocytic nevus in the medical literature. This study aims to report an exceptionally rare case of posterior chest wall PNS in conjunction with a melanocytic nevus.Case presentationA 46-year-old female presented with a long-standing black lesion on her left upper posterior chest wall, that had become painful in the two months prior to presentation. There was a painful, dark blue, non-erythematous, and non-tender nodule on the left upper posterior chest wall. Based on the patient’s desire for cosmetic purposes, the lesion was excised totally with primary closure under local anaesthesia. Histopathological examination revealed intradermal melanocytic nevus with inflamed pilonidal sinus.DiscussionThe rarity of posterior chest wall PNS associated with nevi poses unique diagnostic and therapeutic challenges for clinicians. The distinct anatomical location, different from the conventional region, and the rare association between the two conditions may delay accurate diagnosis and result in mismanagement or inappropriate interventions.ConclusionThe posterior chest wall PNS is another type of atypical PNS that is extremely rare. The association between PNS and blue nevus is a fascinating medical finding that deserves further investigation.

Glomus tumor of the great toe: An uncommon case report

Introduction: Masson’s glomus tumor is a neuromyoarterial hamartomatous proliferation that develops from corpuscules located at the dermal-hypodermal junction, it is a rare but not exceptional benign tumor and it is less frequently reported in the foot. Case presentation: We present a unique case based on its unusual location, clinical presentation (pain being the primary symptom) and its misleading appearance on MRI. Treatment involved surgical excision of the tumor, resulting in a favorable outcome. Histopathological examination of the excised specimen remains crucial for definitive diagnosis, highlighting the importance of considering this unusual location in the differential diagnosis. Discussion: Pathogenesis remains poorly understood, and diagnosis can be difficult. It preferentially affects the hands (75%) and it is subungual in 50% of cases. Diagnosis is based on the clinical triad of sensitivity, pain and intolerance. Advances in high-resolution MRI have improved false negatives, with lesions showing hypo-signal in T1 and hypersignal in T2, with clear contrast between normal tissue and tumor. Diagnostic certainty is provided by histology. After complete removal of the tumor, results are generally considered excellent. In most cases, pain disappears rapidly, and the affected finger or limb returns to normal within three months. Conclusion: Glomus tumors are certainly rare, but not exceptional, and a high degree of suspicion is required when faced with a painful purplish nodule. Usually distal, periungual in location, they can occur anywhere, with sometimes unusual and puzzling localizations.

Dilip's Transmucosal Internal Sphincterotomy: A Simplified Approach to Lateral Internal Sphincterotomy for Fissure in Ano.

Fissure in ano is a prevalent and painful condition, typically treated by lateral internal sphincterotomy after conservative measures fail. Dilip's transmucosal internal sphincterotomy introduces a simplified approach that reduces the risk of damaging the external sphincter, making it particularly suitable for less experienced surgeons. This innovation offers a less invasive method with minimal risk of incontinence, providing a safer, more accessible option. Transmucosal internal sphincterotomy simplifies the internal sphincterotomy process, offering a tailored approach that eliminates the need for extensive dissection. This method allows surgeons complete control over the internal sphincter bundle, facilitating a precise, customizable cut without the risks associated with traditional internal sphincterotomy, especially in obese patients where the intersphincteric groove is not visible, leading to potentially harmful blind incisions. The procedure is performed under saddle block anesthesia with the patient in the lithotomy position. A distinctive approach involving the use of retractors and stay sutures allows the internal sphincter to be made prominent and secured without extensive dissection. The division of the internal sphincter is achieved through a minimal mucosal incision, requiring no closure and significantly reducing postoperative pain and complications. Between December 2020 and February 2022, 124 patients received transmucosal internal sphincterotomy, showing significant benefits with a median operative time of 7 minutes and low postoperative pain. With a 2.5% infection rate effectively managed and a 3% transient incontinence rate, the majority healed within 9 weeks. Recurrence was rare at 1.6%. Transmucosal internal sphincterotomy presents significant advantages over traditional internal sphincterotomy, including reduced pain, lower risk of complications, such as hematoma, abscess, or fistula formation, and the absence of painful postoperative nodules. The success of transmucosal internal sphincterotomy suggests that it should be incorporated into surgical education, offering a less daunting and more reproducible method for treating fissure in ano that is especially beneficial for junior surgeons and improving patient outcomes.

Painful Yellow-White Nodules Over Feet in an Alcoholic Male.

Painful Yellow-White Nodules Over Feet in an Alcoholic Male.

Topical and Systemic Retinoids in the Management of Hidradenitis Suppurativa: A Comprehensive Literature Review.

Hidradenitis suppurativa (HS) is a debilitating chronic skin disorder characterized by painful inflammatory nodules, abscesses and sinus tracts involving intertriginous areas and has an adverse impact on patient quality of life. Over the past decade, the therapeutic options of HS have increased significantly to comprise multiple modalities, including topical medication, systemic therapies (mainly antibiotics, retinoids, and biologics), surgical approaches, and lifestyle modifications. Biologics alone or in combination with surgery remain the treatment of choice for moderate to severe disease. However, non-biologic therapies (including retinoids) may be used as monotherapy for mild disease and in combination with biologics and surgical treatment in moderate to severe disease. Retinoids, specifically isotretinoin, acitretin, and alitretinoin, are historically used in the management of HS, supported by anecdotal evidence and with variable treatment response. Although the current American and European guidelines offer different recommendations on the use of retinoids in HS, retinoids remain a valuable ally in HS management. This review provides a comprehensive analysis of the current scientific literature on retinoid therapy (topical and systemic) in HS, highlighting disparities in mechanisms of action, efficacy, and safety to clarify their role in HS treatment.

Whole blood transcriptomics reveals the enrichment of neutrophil activation pathways during erythema nodosum leprosum reaction.

Patients with the multibacillary form of leprosy can develop reactional episodes of acute inflammation, known as erythema nodosum leprosum (ENL), which are characterized by the appearance of painful cutaneous nodules and systemic symptoms. Neutrophils have been recognized to play a role in the pathogenesis of ENL, and recent global transcriptomic analysis revealed neutrophil-related processes as a signature of ENL skin lesions. In this study, we expanded this analysis to the blood compartment, comparing whole blood transcriptomics of patients with non-reactional lepromatous leprosy at diagnosis (LL, n=7) and patients with ENL before administration of anti-reactional treatment (ENL, n=15). Furthermore, a follow-up study was performed with patients experiencing an ENL episode at the time of diagnosis and after 7 days of thalidomide treatment (THAL, n=10). Validation in an independent cohort (ENL=8; LL=7) was performed by RT-qPCR. An enrichment of neutrophil activation and degranulation-related genes was observed in the ENL group, with the gene for the neutrophil activation marker CD177 being the most enriched gene of ENL episode when compared to its expression in the LL group. A more pro-inflammatory transcriptome was also observed, with increased expression of genes related to innate immunity. Validation in an independent cohort indicated that S100A8 expression could discriminate ENL from LL. Supernatants of blood cells stimulated in vitro with Mycobacterium leprae sonicate showed higher levels of CD177 compared to the level of untreated cells, indicating that the leprosy bacillus can activate neutrophils expressing CD177. Of note, suggestive higher CD177 protein levels were found in the sera of patients with severe/moderate ENL episodes when compared with patients with mild episodes and LL patients, highlighting CD177 as a potential systemic marker of ENL severity that deserves future confirmation. Furthermore, a follow-up study was performed with patients at the time of ENL diagnosis and after 7 days of thalidomide treatment (THAL, n=10). Enrichment of neutrophil pathways was sustained in the transcriptomic profile of patients undergoing treatment; however, important immune targets that might be relevant to the effect of thalidomide at a systemic level, particularly NLRP6 and IL5RA, were revealed. In conclusion, our study reinforces the key role played by neutrophils in ENL pathogenesis and shed lights on potential diagnostic candidates and novel therapeutic targets that could benefit patients with leprosy.

Interprofessional cooperation with a dermatovenerologist - specifics of hidradenitis suppurativa management in gynaecological practice.

Hidradenitis suppurativa is a chronic immune-mediated inflammatory disease that is manifested by formation of painful nodules, abscesses and suppurating fistulas, primarily in the intertriginous spaces. This painful, often under-diagnosed disease affects much more women. They are also exposed to certain specific challenges in the management of this disease, especially during menstruation or pregnancy. The treatment requires the interdisciplinary cooperation of a dermatologist, gynaecologist, obstetrician and last but not least an algesiologist and psychotherapist. Above all, early and correct diagnosis, initiation of therapy in the early stages of the disease, is a key, which also plays a fundamental role in controlling inflammatory activity, preventing complications and further prognosis.

Clozapine-induced pyoderma gangrenosum. A case report

IntroductionClozapine is an atypical antipsychotic medication which is mainly used in cases of treatment-resistant schizophrenia. Although it has several advantages over other typical and atypical antipsychotic medication, such as fewer relapses and lowering the risk of tardive dyskinesia and suicide it also has a range of adverse effects which makes compliance an issue for many patients.Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis clinically characterized by painful pustules or nodules that rapidly evolve in ulcers with violaceous, undermined borders and raised periphery. The etiopathogenesis of the disease remains unclear, however PG is usually manifested in the setting of an underlying immune-mediated disease, more commonly inflammatory bowel disease, rheumatoid arthritis and haematological malignancies.ObjectivesNevertheless, in the literature there are scarce reports of drug-induced PG.MethodsWe present the case of a 56-year-old woman with a diagnosis of refractory schizophrenia on clozapine treatment for 4 months, who was admitted to the emergency department for a skin eruption localized on the trunk, genital area and extremities. The clinical examination revealed numerous, discrete erythematous macules, papules and plaques with central necrosis, and multiple, sharply marginated ulcers with undermined, red to purple border. Further physical examination disclosed no systemic findings and laboratory analyses and skin biopsy were performed.ResultsOn work-up, white blood cell count and C-reactive protein (CRP) were elevated, while blood and pustule cultures were negative. Histologic examination revealed dermal necrosis and inflammation, features consistent with the diagnosis of PG. The pathergy test was positive.Image:Image 2:Image 3:ConclusionsPyoderma gangrenosum is a rare autoinflammatory skin disorder of unknown etiology. The pathogenesis of the disease is not well understood, but drug-induced PG is considered to result from neutrophil dysfunction and dysregulation of the inflammatory response. Cases of drug-induced PG are rare and attributed to certain drugs. Clozapine is an antipsychotic medication for the treatment of refractory schizophrenia. It is suggested that clozapine alters plasma TNF-α levels and thus can modulate the inflammatory response. To date, a variety of adverse skin reactions (Stevens- Johnson syndrome, DRESS syndrome etc) have been previously described in the literature. However, to the best of our knowledge, this is the first case which strongly indicates the likely association between clozapine and drug-induced PG.Disclosure of InterestNone Declared

More Than Meets the Eye: Localized Bullous Eruption After Transfusion

Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a neutrophilic dermatosis characterized by the presence of painful erythematous plaques and nodules with a sterile neutrophilic infiltrate on histology. However, the clinical manifestations of sweet syndrome can vary widely. Additionally, Sweet syndrome is often associated with underlying systemic diseases. In this case report, we present the case of a 72-year-old female who developed bullous sweet syndrome with oral involvement following a blood transfusion. Serology revealed an elevated pANCA level and systemic manifestations consistent with granulomatosis with polyangiitis. There have been approximately 50 reported cases of concurrent neutrophilic dermatoses occurring with ANCA-associated vasculitis. Relapse is common in these patients, with all reported cases involving the ears, nose, and throat (ENT) region. Ultimately, the concomitant presentation of ANCA-associated vasculitis and neutrophilic dermatoses is rare. Dermatologists should be aware that testing for ANCA in cases of neutrophilic dermatoses is appropriate, and if positive, close monitoring for signs of systemic vasculitis is warranted.

Rethinking Hidradenitis Suppurativa Management: Insights into Bacterial Interactions and Treatment Evolution.

Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory dermatological condition characterized by painful and recurrent nodules and purulent abscesses. HS can have a devastating impact on the quality of life of patients. This condition is commonly localized to the axilla, groin, perineal, and inframammary regions, and can develop fistulas and sinus tracts over time. Its pathogenesis remains elusive and is best characterized at the moment as multi-factorial. Additionally, questions remain about the role of cutaneous dysbiosis as a primary HS trigger or as a secondary perturbation due to HS inflammation. This article features works in relation to HS and its interplay with bacterial microflora. We address current treatment approaches and their impact on HS-related bacteria, as well as areas of therapeutic innovation. In the future, disease-modifying or remittive therapy will likely combine an advanced/targeted anti-inflammatory approach with one that effectively modulates cutaneous and deep tissue dysbiosis.

Hidradenitis suppurativa, intestinal microbiome and SIBO – a comprehensive overview of the issue

Hidradenitis suppurativa, intestinal microbiome and SIBO – a comprehensive overview of the issue

Hidradenitis Suppurativa in Association with Ulcerative Proctitis: Surgical Management in a Refractory Case to Topical and Systemic Treatment

Hidradenitis suppurativa (HS), a challenging dermatological condition, can be described as a chronic, painful, follicular, occlusive disease that is characterized by painful nodules, abscesses, and sinus tracts generally located in the intertriginous skin areas. This disorder places a considerable burden on affected individuals and often leads to significant impairment in quality of life for those grappling with its persistent and recurrent nature. We present the case of a 20-year-old male patient known to have ulcerative proctitis and diagnosed with hidradenitis suppurativa in 2020, for which he underwent various topical and systemic treatments, with periods of remission and recurrent flares without managing to obtain complete remission of HS. In our dermatology service, the patient underwent two surgical unroofing procedures combined with punch debridement, with the wounds being allowed to heal by secondary intention. This choice of treatment delivered great results with favorable outcomes, without recurrence of the lesions, proving to be an effective method for managing HS. By presenting this case, we underline the role of surgical procedures in managing HS, and our desire is to emphasize the importance of comprehensive understanding of this enigmatic and complex condition for more effective management strategies in patients with refractory disease.

Traumatic neuroma on the tongue tip: A case report and review of the literature

Introduction: Traumatic neuroma is a non-neoplastic proliferation of a nerve occurring in response to an injury or surgery. Traumatic neuroma on the tongue tip is a very rare proliferating lesion in the oral cavity. We present a case of traumatic neuroma on the tongue tip. This case may be valuable for understanding the pathogenesis of the neuroma. Case Report: A 79-year-old man developed a painful nodule on the tongue tip. Histologically, the nodule consisted of a tortuous proliferation of nerve fascicles, and diagnosed as a traumatic neuroma. The bundles of the neuroma expressed a strong activity of the neural marker S-100. Expression of alpha smooth muscle actin (α-SMA) being a phenotypic marker of myoblast activity was also positive in the surrounding connective tissues of the nodule suggesting a relation to the painful natures of the neuroma. Cross-sectioned nerve bundles of the neuromas seemed to be 5–7 times larger than of the normal bundles suggesting intensity of proliferation the nerve bundles. The neuroma was considered to occur by repeated stimuli of the tongue tip to the front teeth. Conclusion: Traumatic neuroma on the tongue tip is quite rare. Onset of the neuroma was suggested repeated stimuli of the tongue tip to the front teeth. Expression of α-SMA of the bundles of the neuroma seemed to accord with the painful natures of the neuroma.

Differences in hidradenitis suppurativa patterns of cutaneous involvement between sexes: Insights from a cross-sectional study

Hidradenitis suppurativa is a chronic, inflammatory condition of the pilosebaceous unit in which patients manifest multiple, painful cutaneous nodules, abscesses and tunnels. These lesions are described to affect the intertriginous zones, however, the condition exhibits significant phenotypic variability. Such variability is influenced by the patients lifestyle, genetic predisposition and sex. In this cross-sectional study, we investigate sex differences in patterns of hidradenitis suppurativa skin involvement, specifically at site of first involvement and most bothersome cutaneous site of involvement.

Pancreatic panniculitis associated with periampullary duodenal diverticulum

Introduction. Pancreatic panniculitis (PP) is a rare type of lobular panniculitis that manifests as painful erythematous nodules on the skin of the lower extremities. Subcutaneous fat necrosis caused by the release of pancreatic enzymes is the underlying cause of the disease, affecting around 2?3% of patients with pancreatic diseases. Case report. We present a case of a 58-year-old male patient who was admitted to our clinic due to the appearance of painful erythematous nodules on the lower extremities and trunk. Laboratory results revealed increased levels of pancreatic enzymes, amylase, and lipase, as well as heightened levels of glucose and inflammation markers. The histological analysis of the skin lesion biopsy revealed the presence of predominantly lobular panniculitis in the hypodermis, with areas of fatty tissue necrosis/saponification and remnants of adipocytes (?ghost cells?). Abdominal computed tomography scan demonstrated peri-ampullary diverticulum (PD) of the duodenum, with no signs of pancreatitis or other pancreatic abnormalities. Esophagogastroduodenoscopy showed a wide opening of PD in the D2 segment of the duodenum. The patient was successfully treated with pancreatin therapy, resulting in a significant reduction of skin lesions and decreased levels of pancreatic enzymes. Conclusion. Duodenal PDs can be the cause of PP, most likely due to the pressure they exert on the pancreatic duct, which can lead to elevated values of pancreatic enzymes. Depending on the individual characteristics of the patient, symptomatic duodenal PD may be treated with operative or non-operative measures. Treatment of PP primarily involves addressing any underlying medical condition.

A rare case of oral sporotrichosis: painful nodule in the buccal mucosa

A rare case of oral sporotrichosis: painful nodule in the buccal mucosa

Hidradenitis suppurativa: a new therapeutic approach for an old disease.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterised by recurrent painful nodules, abscesses, fistulas and scarring. The primary distinguishing factor in the complex, yet still not fully understood, pathogenesis is an inflammation occurring within the hair follicle, followed by an immune response leading to further development of the skin lesions seen in HS. The treatment of patients with HS is very difficult due to the complexity of the lesions and the frequent tendency to recurrence, which also has a negative impact on the psychological state of patients and directly translates into a reduced quality of life. This review article addresses the pathogenesis, clinical presentation of HS and, in particular, explores the new therapeutic options available.

The Role of Weight Loss and Nutrition in the Management of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is an inflammatory skin condition affecting the pilosebaceous unit. It is characterized by the formation of painful nodules, abscesses, and sinus tracts in intertriginous regions. HS has numerous, well documented risk factors including obesity, metabolic syndrome, and diabetes mellitus. Weight loss is frequently recommended as a lifestyle change for patients diagnosed with HS. There is evidence that shows weight loss improves disease severity in most cases. However, there are reports of patients who have experienced stable, worsening, or de novo disease development after undergoing bariatric surgery. Nutrition is proving to be an increasingly important aspect in the management of HS. Deficiencies in micronutrients, such as Vitamin D and zinc, as well as the consumption of triggering foods including dairy and brewer’s yeast, are implicated in HS. Encouraging patients to consume a healthy diet with supplementation of micronutrients and avoidance of dairy and brewer’s yeast has been linked to decreased HS severity. Physical activity is commonly recommended to aid in weight loss, but has been understudied in HS patients. There are reports of increased levels of physical activity decreasing disease severity, but more research is needed on this topic.

Nocardiosis ‘great imitator’: unusual disease with usual presentations at unusual site

Nocardia, an aerobic actinomycete, typically affects immunosuppressed individuals, commonly manifesting in the lungs. Cutaneous infections, particularly by N. pseudobrasiliensis, can occur, presenting as lympho-cutaneous, superficial, or mycetoma subtypes. Nocardia farcinica, resistant to third-generation cephalosporins, is particularly virulent. A 50-year-old female with type 2 diabetes presented with painful nodules, bullae, and recurrent discharge over the left wrist, mimicking cellulitis. Culture-sensitivity revealed Nocardia farcinica. Treatment involved debridement, De quervain release and prolonged Linezolid therapy for a complete cure. Cutaneous Nocardiosis can mimic cellulitis, posing diagnostic challenges due to slow growth and microbiological detection. N. farcinica demonstrated resistance to conventional antibiotics. This case emphasizes the importance of considering Nocardia infections in diverse clinical presentations, highlighting the need for a comprehensive diagnostic approach, especially in immunocompromised individuals.