Painful Ulcers Research Articles

A RARE CASE OF SYSTEMIC LUPUS ERYTHEMATOSUS IN A 20-YEAR-OLD MALE PATIENT

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease characterized by a series of exacerbations and remissions. The disease involves antibody formation against DNAand nuclear proteins, which attack tissues of multiple-organ systems. SLE is 8 to 15 times more common in women of reproductive age compared with age-matched men. Being rarer in males, it can result in delayed diagnosis leading to poorer outcomes. When compared to women, men have a more aggressive clinical course and rapid development of organ damage, which leads to a worse prognosis. Studies have shown that male patients have an increased prevalence of cytopenia, hemolytic anaemia, nephritis, thrombotic events and seizures. This is why prompt diagnosis and treatment are important to prevent the progression of the disease. We report a case of SLE in a young male patient who presented with fever, joint pain, easy fatigability and oral ulcers. Prompt diagnosis and comprehensive laboratory workup can help an alert primary care physician be instrumental in ensuring better outcomes.

ORAL LICHENOID DRUG ERUPTION SECONDARY TO RITUXIMAB ADMINISTRATION

<h3>Introduction</h3> Oral lichenoid drug eruption (OLDR) is an uncommon type of fixed drug eruption (FDE) rarely described following administration of rituximab. This case illustrates the importance of developing a broad differential diagnosis, encompassing delayed drug reactions, in immunocompromised patients presenting with oral lesions. <h3>Case Description</h3> A 64-year-old male with a past medical history of marginal zone lymphoma presented with fixed oral lesions following rituximab monotherapy. Two weeks following his second rituximab dose, he developed painful oral ulcers. Infectious workup was negative. Systemic lupus erythematosus (SLE) was considered given positive anti-nuclear antibody, double-stranded DNA, and low complement levels, as was paraneoplastic pemphigus, but antibody screen was negative. Given concern for oral lymphoma, a biopsy was performed and showed reactive squamous mucosa with ulcerative mucositis without evidence of lymphoma. Morphologic features suggested rituximab-induced ulcerative lichenoid drug reaction. He was started on oral and topical corticosteroids for 2 weeks, and his symptoms fully resolved. He was advised to avoid rituximab. <h3>Discussion</h3> FDE has rarely been described with rituximab, even rarer still is OLDR. Biopsy of the oral lesions was needed to suggest an OLRD secondary to rituximab. FDE can occur up to 2 weeks following drug administration, aligning with this patient's time course. Classically, symptoms resolve within 7-10 days following drug discontinuation. Oral lesions can be more persistent and last for months. Treatment involves a combination of drug discontinuation, oral, topical, and intralesional corticosteroids, depending on severity. This case highlights the importance of considering delayed drug reaction in patients with oral ulcers.

ODP107 Oral Ulcerations, A Rare Side Effect of Intravenous Zoledronic Acid

Abstract Introduction Zoledronic acid is an intravenous bisphosphonate known for its anti-resorptive effects and osteoporotic fracture risk reduction. A common adverse reaction with this medication is mild to moderate flu-like symptoms, which are transient and attributed to an acute phase reaction post treatment. A less common side effect, of oral ulcers is associated with oral bisphosphonates, attributed to incorrect oral intake but the real mechanism is still not well understood. We present a patient that developed oral ulcers after use of both oral and intravenous bisphosphonates, leading to suspicion of other underlying mechanisms other than incorrect oral intake of bisphosphonates. Case Report We present a 73 year old male with history of mild primary hyperparathyroidism and osteoporosis. Patient opted for medical management of his mild primary hyperparathyroidism in addition to having non-localizing studies. Treatment for osteoporosis was recommended due to femoral neck T score -2.4, FRAX score of 3.3% risk for hip fractures and history of low impact right foot fracture. The primary care team started treatment with alendronate 70 mg once a week, but patient developed oral blisters within a week of starting the treatment. Stopping alendronate led to resolution of the oral symptoms without any additional supportive treatment. Patient was later started on intravenous zoledronic acid, attributing the previous history of oral ulcers to a local effect of the oral bisphosphonates. Two days after the zoledronic acid infusion patient developed fatigue, fever, and oral ulcers. The oral ulcers were described as painful, located at the base and lateral aspects of the tongue. The ulcers later progressed to the buccal mucosa. No gingival ulcers were reported. Development of the oral blisters led to significant discomfort in eating and talking. Patient was treated with liquid nystatin 10,000 units/mL and lidocaine 2% viscous liquid. Patient had resolution of the painful ulcers approximately 2 weeks after the initial appearance. No recurrence of the oral ulcers has been reported, 4 months post treatment with zoledronic acid. Discussion Intuitively oral bisphosphonate induced mucosal injury is thought to be related to direct contact of the tablet with the oral mucosa or inappropriate ingestion of the medication and is not thought to be a systemic reaction. Our patient developed oral ulcers from both oral and intravenous bisphosphonates suggesting a possible systemic mechanism involved. Understanding potential side effects such as mucosal injury from intravenous bisphosphonates will be helpful for patient education and timely care. Presentation: No date and time listed

MANAGEMENT OF ULCERATIVE ORAL LICHEN PLANUS PREDISPOSED BY PSYCHOLOGICAL STRESS

Background: Oral lichen planus (OLP) is a chronic inflammatory autoimmune oral mucosa disease. The ulcerative type of OLP presents as erythematous ulceration with mucosal erosions surrounding whitish striae. The aetiology of OLP is unknown, but can be predisposed by psychological factors. Purpose: Reporting ulcerative oral lichen planus predisposed by psychological stress. Case: A 36 years old woman complained very painful ulcer in the right buccal mucosa and a grey-purple lower lip lesion for a year. It had been treated with topical corticosteroids, antibiotics, tretinoin, and vitamins but did not heal. Extraoral examination on the lower vermillion showed bluish-purple macules, diffuse and irregular borders, rough and painful. Intraoral examination in the right buccal mucosa showed an irregular yellowish-white ulcer with an erythematous area and white striae. Case Management: Screening for psychological stress by DASS 42 showed moderate stress and severe anxiety. Autofluorescence examination showed no malignant transformation sign. A complete blood count test showed low neutrophil and lymphocyte count. ANA test was normal. Systemic Methyl Prednisolone 8 mg was prescribed 2 tabs twice a day and tapered off after the lesion resolved within 1 week. Supportive treatments include Benzydamine HCl and multivitamins. Discussion: Stress, anxiety, and depression were possible factors of OLP mediated by the Hypothalamic-pituitary-adrenal (HPA) axis system and the Sympathetic-adrenal-medullary (SAM) system. Specific mechanisms are mediated by Antigen-specific CD8+ (CTLs) that are activated with the help of CD4+ T-cells. Non-specific mechanism mediated by MMP-9 activation. They led to the apoptosis of keratinocytes. Systemic corticosteroids are an important treatment for oral lichen planus that do not responded to topical steroids. Conclusion: Oral Lichen Planus is a chronic inflammatory disease that affects the oral mucosa and can be predisposed by psychological stress. Corticosteroid is very effective to treat oral lichen planus, especially the erosive-ulcerative type. Keywords: Oral Lichen Planus, Psychological Stress, Ulcerative

Assessment of the Effectiveness of Aloe vera Versus Amlexanox in the Treatment of Recurrent Aphthous Ulcers: A Three-Arm Placebo-Controlled Randomized Clinical Trial.

Background Recurrent aphthous ulcers are one of the most common lesions of the oral mucosa. Most currently available treatment methods aim to relieve symptoms, speed up healing and prevent ulcer recurrence. The current study aimed to compare the effectiveness of Aloe vera gel with that of amlexanox 5% oral paste in the treatment of recurrent small-type aphthous ulcers. Materials and Methods The study was conducted on 60 patients (27 males and 33 females) attending the Department of Oral Medicine at the Faculty of Dentistry at Damascus University. The sample age ranged between 15 to 25 years, with an average age of 20.3 ± 2.4 years. Patients were diagnosed with recurrent aphthous ulcers of the small type. The sample was divided into three groups with equal numbers of patients (n=20 for each group) according to the provided drug: Aloe vera, amlexanox, and the placebo groups. Patients' ulcer size was measured on day 0 of treatment, and the ulcer size reduction was assessed on day 3 and day 5. The pain was also recorded at the first visit, and then pain reduction was assessed during follow-up visits. Results The mean ulcer size on the fifth day of treatment was 1.85 mm2, 4.05 mm2, and 6.20 mm2 in the Aloe vera, the amlexanox, and the placebo groups, respectively. The differences between groups were significant (p=0.003). The mean pain on the fifth day was 0.80 cm, 1.60 cm, and 3.20 cm in the Aloe vera, the amlexanox, and the placebo groups, respectively. The differences between groups were significant (p=0.026). Conclusions Within the limits of the current trial, both treatment groups proved effective in accelerating ulcer healing with the superiority of Aloe vera compared to amlexanox, as it achieved a greater reduction in ulcer size and pain when assessed on the fifth day of treatment.

Evaluation of physicochemical parameters of Acacia catechu Willd.

Introduction: Acacia catechu willd. (Mimosoideae) is a deciduous, thorny tree which grows up to 15m height; widely distributed throughout India. This plant is rich source of flavonoids, tannins and phenolic compounds. It is used traditionally for the treatment of asthma, bronchitis, pain in chest, ulceration, wound healing, mouth ulcer, colic, vitiligo, cancer, sore throats, and diarrhoea. It possesses antioxidant, antipyretic, antileprotic, antimicrobial, antiviral, antifungal, spasmolytic, antibacterial, hypoglycaemic, antifertility, immunomodulatory, hepatoprotective, hypotensive and wound healing properties. Material and Method: In the present study, plant has been explored for detailed pharmacognostic and microscopic study. Preliminary phytochemical screening has been performed for evaluation of various phyto-constituents present in the plant. Physicochemical parameters such as moisture content, ash value, extractive values have been determined as per procedure given in IP. Presence of heavy metal, aflatoxin, microbial contamination and pesticidal residue has been assessed as per WHO guidelines. Result: A. catechu stem is reddish brown, cylindrical, hard to fracture and astringent in taste. Microscopy showed the presence of medullary rays, vessels, xylem fibres, parenchyma, fibres and calcium oxalate crystals. Heavy metal, aflatoxin, microbial contamination and pesticidal residue contents were found within limits as per WHO guidelines. Preliminary phytochemical screening showed the presence of tannins, flavonoids and reducing sugar. Conclusion: Present study was carried out to establish quality parameters for A. catechu plant which will be further utilised for evaluation of pharmacological activity.

Calcific uremic arteriolopathy in a young man on intermittent hemodialysis

A 42‐year‐old man with ESKD who has been on intermittent hemodialysis for 7 years, presented with extremely painful inguinal ulcer and abdominal mass. The lesion was developed 2 weeks after repairing aneurysmal cubital AVF. At first, it was a small and painful red nodule but then its size increased and a large ulcer was developed. In addition, the physical examination revealed a palpable and painful large mass at left lower side of abdominal wall. He did not have important risk factors such as diabetes mellitus, treatment with warfarin, and use of calcium containing phosphate binders, vitamin D or calcium supplements. The patient suffered a long standing and severe secondary hyperparathyroidism. The parathyroid hormone level was too high (3100 pg/ml). In addition, serum calcium and phosphorus levels were 9.4 mg/dl and 9.8 mg/dl respectively. The SPECT-CT scan with 99 m Tc-MIBI of parathyroid glands confirmed persistence of an adenoma in right lower parathyroid gland (Figure 1, green arrow). The BMI was 32 kg/m2. He had no adherence to use of phosphate binder or calcimimetic drugs. The radiological studies showed extensive microvascular calcification in soft tissues (Figure 1, small arrow) and osteitis fibrosa cystica in long bones (Figure 1, star). The patient underwent surgical debridement of ulcer and palpable abdominal mass, wound care, intensive dialysis therapy with low calcium dialysis bath, cinacalcet, sevelamer carbonate, antibiotic and analgesic therapy. The histological sample (H&amp;E, 200X) shows Intramural calcification and obliteration of arteriole (large arrow) with extensive calcification in fat tissue (Figure 1, arrow head) which was consistent with Calcific Uremic Arteriolopathy (CUA). In addition to patient’s poor compliance to treatment of severe secondary hyperparathyroidism, the recent surgery of aneurismal AVF could also be an important trigger to development of calcific uremic arteriolopathy.

Recalcitrant pediatric pyoderma gangrenosum controlled with adalimumab

Introduction: Pyoderma gangrenosum (PG) refers to an autoinflammatory cutaneous disorder characterized by bizarre painful ulcerations. Clinical data of pediatric PG are rare in China. We herein present the first report of adalimumab in the treatment of pediatric PG in China. Case presentation: An 8-year-old boy presented with multiple painful ulcerations on both lower legs. He was diagnosed with PG according to his clinical manifestations and results of a histological examination. His condition showed resistance to corticosteroids, immunosuppressants, and even intravenous immunoglobulin. We then treated him with adalimumab, which induced remission of the disease. Discussion: PG poses both diagnostic and therapeutic challenges. Increased levels of inflammatory mediators, including interleukins 1β, 8, and 17 and tumor necrosis factor-α, induce development of the disease. Despite the availability of traditional treatments, new therapeutic regimens should be taken into consideration. Conclusion: No previous data regarding adalimumab for the treatment of pediatric PG have been reported in China. Our case demonstrates that adalimumab has a beneficial effect on pediatric patients with recalcitrant PG. However, further evaluation and long-term follow-up of this treatment are required. Because infliximab has been studied in a randomized, double blind, placebo-controlled trial, we anticipate forthcoming multicenter randomized trials and research of adalimumab.

Baiying qingmai formulation ameliorates thromboangiitis obliterans by inhibiting HMGB1/RAGE/NF-κB signaling pathways.

Baiying Qingmai Formulation (BF) is a classical clinical prescription used for decades to treat thromboangiitis obliterans (TAO). Although it effectively relieves pain and ischemic ulcers in patients with TAO, its anti-TAO mechanisms remain unclear. The chemical components of BF were analyzed using high-performance liquid chromatography and the potential targets of the compounds identified in BF were analyzed using molecular docking. Further, the signaling pathways and molecular mechanism of BF in treating TAO were studied using a rat model of TAO. Seven compounds (gallic acid, catechin, chlorogenic acid, caffeic acid, paeoniflorin, quercetin, and paeonol) were identified in BF, and molecular docking predicted their high affinities with HMGB1/RAGE/NF-κB proteins. In in vivo studies, BF not only inhibited the protein expression of HMGB1, RAGE, ICAM-1, and VCAM-1; mRNA levels of HMGB1 and RAGE; and the phosphorylation of NF-κB, ERK, Janus kinase (JNK) and p38 MAPK in the femoral artery, but also reduced the levels of inflammatory cytokines (IL-6, TNF-α, IL-1β, HMGB1) and stable metabolite (TXB2) of cytokine promoting thrombosis (TXA2) in the plasma. Moreover, BF stimulated the secretion of stable metabolite (6-keto-PGF1α) of cytokine inhibiting thrombosis (PGI2) in the plasma. BF inhibited the inflammatory response and thrombosis in the femoral artery, thus reducing the degree of vascular occlusion, which alleviated the symptoms in rats with TAO. Our findings suggest that BF ameliorates TAO by inhibiting the activation of the ERK, JNK, p38 MAPK and HMGB1/RAGE/NF-κB signaling pathways, thereby providing novel ideas for the treatment of TAO and essential information for the further development and utilization of BF as a promising drug to treat TAO.

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

ATYPICAL PRESENTATION OF GRANULOMATOUS INFLAMMATION

Tuberculosis of the tongue

Introduction: Tuberculosis mostly affects the lungs, but may also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones, joints, and skin. Extrapulmonary involvement in tuberculosis is rare, accounting for just 10 to 15% of cases. The lymph nodes are the second most common site of tuberculosis infection. Oral tuberculosis has long been thought to be an unusual phenomenon. Oral manifestations are thought to occur in just 0.05 to 5% of all tuberculosis cases. Surface ulcers, patches, papillomatous lesions, and indurated soft tissue lesions are the most common oral manifestations. Case Presentation: A 69-year-old man presented to the Department of Ear, Nose, Throat at MGM Hospital in Aurangabad, India, with a painful ulcer and tiny nodules on the tongue’s tip and lateral surface. The ulcer appeared 3–4 weeks ago without any obvious trigger with a prickling feeling and increased soreness over the area., Onintraoral inspection multiple small nodules is measuring about 0.1 cm and multiple circular ulcer measuring about 0.2 x 0.1 cm in diameter at the tip and lateral border of the tongue. A granulomatous center and a whitish, well-defined border with mild elevation characterized the ulcer. Conclusion: Despite the rarity of tuberculosis evidence in the oral cavity, oral tuberculosis should be included in the differential diagnosis of chronic oral lesions. To prevent ineffective oral therapy, accurate diagnosis is crucial for successful care by concentrating on the pathological source.

Prevalence of Recurrent Aphthous Ulcers (RAUs) in the Population of Ludhiana

Introduction: Recurrent aphthous ulcer (RAU) is one of the most common oral mucosal disorders characterized by recurrent and painful ulcerations on movable or nonkeratinized oral mucosa. It affects approximately 20% of the general population. These present as recurrent, multiple, small, round, or ovoid ulcers with circumscribed margins, having yellow or gray floors, surrounded by erythematous halos. Aims and Objectives: To compare the prevalence and occurrence of RAU among the age group from 20 to 80 years. To compare the prevalence and occurrence among the gender. To correlate the causes of the recurrent aphthous stomatitis (RAS). To check for tobacco and its role in the occurrence of RAS. Materials and Methods: A cross-sectional study was conducted, and a total of 600 questionnaire forms were distributed and filled by students (undergraduates and postgraduates), staff, skilled workers, and patients reporting to the department over a period of 3 years. Results and Discussions: In total, 71.1% had experienced oral aphthous ulcerations. When both the genders were compared, RAS more commonly affected females (60.33%) than males (39.67%). The regression coefficient for gender revealed that females were more prone to RAS than males. Conclusion: Understanding the prevalence and distribution of recurrent aphthous ulceration among the population of Ludhiana gives an indication of the section of people who suffer from the condition. Based on the results of our study, females were more commonly affected than males, and the second- and third-decades age groups were affected.

Psychological Distress among Healthcare Workers with Chronic Diseases during the COVID-19 Crisis

Background. Healthcare workers (HCWs) are a vulnerable group to psychological distress (PD) because they are subjected to strict working conditions, and the nature of the work implies a heavy level of emotional involvement. Objective. This study is aimed at determining psychological distress among healthcare workers with chronic diseases during the COVID-19 crisis. Methods. This was a quantitative cross-sectional correlation study. An online self-administered questionnaire was completed from July 2021 to October 2021 by a convenience sample of 302 HCWs at two primary healthcare centers in Saudi Arabia. The Kessler psychological distress scale was used to assess psychological distress among HCWs. Results. The prevalence of HCWs who contracted COVID-19 was 59.9%. The overall mean score of K10 was 4.38 ( SD = 0.706 ). The majority of HCWs that had the highest percentage of a very high level of distress were female (66.2%), between the ages of 30 and 40 years (35.1%), had more than 10 years of work experience (48.0%), and were nurses (49.7%), married (61.6%), and infected with COVID-19 (59.9%). There was a significant association between the age, working experience, and PD scores of the HCWs P value &lt; 0.05. A significant correlation between each of the variables of (heart disease, high blood pressure, lung disease, diabetes, ulcer, anemia, depression, and back pain) and PD whereas the P value &lt; 0.05 and the R value &lt; 0.3. Conclusion. HCWs with associated comorbidities have been greatly affected by the COVID-19 pandemic. There was a very high level of PD among the studied population. HCWs with hypertension and back pain were the most affected by psychological distress, and emotional distress could be exacerbated if the HCWs contracted COVID-19.

P24 A case of limited cutaneous systemic sclerosis evolving into an overlap syndrome with systemic lupus erythematosus and pyoderma gangrenosum

P24 A case of limited cutaneous systemic sclerosis evolving into an overlap syndrome with systemic lupus erythematosus and pyoderma gangrenosum

Lingual Mucosal Ulceration with Bony Sequestration

This case report describes a rare condition of lingual mucosal ulceration associated with bony sequestration following non-surgical lower molar tooth extraction of a healthy 58-year-old female patient. Clinically, she presented with a painful ulcer on the lingual aspect of the posterior mandible and noticed a sharp bone which caused irritation to the side of the tongue. The exposed bone was removed surgically, and the ulcer was completely healed. Thus, emphasizing the understanding of the causative factors of oral ulcers can help in giving a proper treatment plan.

Lingual Mucosal Ulceration with Bony Sequestration

This case report describes a rare condition of lingual mucosal ulceration associated with bony sequestration following non-surgical lower molar tooth extraction of a healthy 58-year-old female patient. Clinically, she presented with a painful ulcer on the lingual aspect of the posterior mandible and noticed a sharp bone which caused irritation to the side of the tongue. The exposed bone was removed surgically, and the ulcer was completely healed. Thus, emphasizing the understanding of the causative factors of oral ulcers can help in giving a proper treatment plan.

Lipschutz Ulcers in an Adolescent After Sars-CoV-2 Infection

This case report describes a 15-year-old female who presented with acute onset of painful genital ulcers. She denied being sexually active and tested positive for severe acute respiratory coronavirus 2 five days prior. Associated symptoms on days 1 to 3 included fatigue, nausea, headaches, and fever. Lipschutz ulcers (LUs), also known as aphthous ulcers, acute genital ulcers, and acquired genital ulcerations; are an uncommon, self-limiting, nonsexually transmitted condition characterized by the rapid onset of painful, necrotic ulcerations of the vulva or lower vagina. The pathogenesis of LUs is unclear, and the diagnosis is one of exclusion.

Pyoderma Gangrenosum of the Breast: A Rare Location of Neutrophilic Dermatoses

Pyoderma gangrenosum (PG) is a rare entity belonging to the neutrophilic dermatoses. It is an inflammatory dermatosis with a chronic evolution by relapses, often revealing an associated underlying disease. The location to the breast represents is unusual, poorly documented in the literature localization and whose diagnosis remains difficult to establish. We report the case of a 51-year-old female patient, with no particular pathological history, who presented for 4 months a painful ulceration of the left breast, of centrifugal extension measuring 9 cm of the great axis, with a hemorrhagic base, well limited by an inflammatory violaceous border with no other localizations and no notion of trauma. A skin biopsy revealed a dermal neutropilic infiltrate. The patient was given oral corticosteroid therapy at a dose of 0.5mg/Kg/day coupled with topical corticosteroids. The results were satisfying: the ulcer gradually healed and the pain reduced. Pyoderma gangrenosum is a poorly understood clinical entity, classically presenting with inflammatory and painful skin ulcerations. It may occur in a post-surgical or post-traumatic context defining the phenomenon of pathergy described in neutrophilic dermatoses. Treatment is mainly based on topical corticosteroids or in severe cases oral immunosuppressants and the treatment of the underlying pathology.

Stomatitis Apthosa Rekurent (SAR) in Menstruating Women at the Djafar Harun General Hospital, North Kolaka Regency, SE Sulawesi, Indonesia

Stomatitis Apthosa Rekurent (SAR), also known as repeated thrush canker sores or cancer pain, is an oral disorder that commonly happens. SAR is characterized by spontaneous recurrence of painful ulcers in the oral mucosa area. The SAR highest prevalence is in the age range of 20-29 years, comprising 36.28% of all cases. Compared to men, SAR commonly happens to women. This statement is supported by previous research that found the majority of patients was women 55.4%, while men patients only comprise 44.6%. There are several caused of SAR such as heredity, imunodisregulasi, certain foods, stress, hormonal disorders, trauma, infections, drugs, smoking, and bad oral hygiene. Most SAR patients are between 26-35 years old. It is found in the literature that incidence of SAR might potentially happen in the third decade of life. On this survey, the results showed that there is relations between the risk of Stomatitis Aphthous Rekurent (SAR) and the menstruation cycle in women of childbearing age.&#x0D; Keywords: Stomatitis Apthosa Rekurent, Djafar Harun General Hospital, North Kolaka Regency.

Systemic Immunoglobulin Light Chain Amyloidosis Presenting as Painful Penile Ulcers

Immunoglobulin light chain (AL) amyloidosis is a systemic form of amyloidosis that commonly affects the heart, kidney, liver, and nervous system. Penile involvement in AL amyloidosis is rare and thus often not considered in the differential diagnosis for penile ulcers. We report a case of an elderly man with nonhealing, painful penile ulcers who had AL amyloidosis with cardiac, renal, and liver involvement. His penile lesions were successfully treated with surgical resection of the amyloid deposits. Even after serologic relapse of his systemic amyloidosis, he has not had recurrence of his penile ulcers many years later.