Painful Ulcers Research Articles

Neutrophil extracellular traps formation in the lesional skin of various types of pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a chronic neutrophilic disorder characterized by recurrent painful ulcers. Aseptic inflammation by neutrophils plays an essential role, and neutrophil extracellular traps (NETs) formation can contribute to the pathogenesis of PG. Seventy-five patients were diagnosed as having PG in our department, among which 58 ulcerative, 4 bullous, 3 pustular and 10 vegetative type. We examined the 20 skin biopsy specimens (11 ulcerative, 3 bullous, 2 pustular and 4 vegetative type), and local NETs formation in various types of PG was compared among each type. The biopsied specimens were double labelled for myeloperoxidase, citrullinated histone H3. Immunofluorescent images indicated that the histopathologic location and depth of NETs formation in PG varied by the clinical subtypes. In ulcerative PG, NETs formation was observed in the upper to deep dermis. In bullous PG, NETs formation was mainly observed in the epidermis. Pustular type showed NETs formation in the epidermis near the pustules, and in vegetative type, showed NETs formation mainly in the upper dermis. These results indicate that NETting neutrophils play an important role in the pathogenesis of various forms of PG, although the location and depth of NETs formation in the skin lesion of PG differ depending on each type. Further studies are necessary to examine what factors identify different clinical features of PG.

Gingival health status in relation to salivary irisin in oral ulcerative patients of Diyala city, Iraq

Background: Gingivitis is the inflammation of the gingival tissue around the teeth initiated by bacteria. Irisin is a newly identified novel anti-inflammatory effect of adipocytokine. Recurrent aphthous ulcer (RAU) remains the most common ulcerative disease in the mucosa tissue of the oral cavity, existing as repeated onset of single or multiple painful ulcers. The study aims to evaluate gingival health status in relation to salivary irisin in oral ulcerative patients of Diyala City/ Iraq. The total sample consists of 200 patients taken from the specialized dental center in Ba'aquba / Diyala governorate from January-March 2022 for both genders within the 20- 31 age group. One hundred patients complaining of recurrent aphthous ulcers without systemic diseases were selected, and 100 patients were free from recurrent aphthous ulcers. The gingival inflammation was examined and recorded using Loe and Silness (1964). According to WHO (1997), a recurrent aphthous ulcer was assessed, and salivary irisin levels were determined using enzyme-linked immunosorbent assay (ELISA). In the study and control groups, the prevalence of gingivitis was 100%, with a higher mean value of GI among the study group than the control group. Minor ulcer prevalence was higher than a significant ulcer. The level of irisin was higher in the study group than in the control group, and the correlation between GI and irisin was negatively weak in the study and positively weak in the control group. Keywords: Gingival health, Irisin, RAU.

A retrospective review of outcomes after hyperbaric oxygen therapy for the treatment of calciphylaxis

Calciphylaxis is a thrombotic vasculopathy characterized by painful necrotic ulcerations. There are no Food and Drug Administration approved therapies despite high mortality. To compare mortality and wound healing outcomes in patients treated with hyperbaric oxygen therapy (HBOT) in addition to intravenous sodium thiosulfate (IV STS) versus patients who received IV STS only. Findings were stratified by dialysis status and modality. 93 patients were included, with 57 patients in the control group (IV STS) and 36 patients in the treatment group (HBOT+IV STS). Mortality data were analyzed with traditional survival analyses and Cox proportional hazard models. Longitudinal wound outcomes were analyzed with mixed effects modeling. Univariate survival analyses showed that full HBOT treatment was associated with significantly (P=.016) longer survival time. Increasing number of HBOT sessions was associated with improved mortality outcomes, with 1, 5, 10 and 20 sessions yielding decreasing hazard ratios. There was also a significant (P=.042) positive association between increasing number of HBOT sessions and increased wound score. Data collection was retrospective. HBOT may have a role in the treatment of calciphylaxis with benefits demonstrated in both mortality and wound healing. Larger prospective studies are needed to identify which patients would most benefit from this intervention.

Pyoderma Gangrenosum: A Challenging Cutaneous Manifestation in Dubowitz Syndrome.

Pyoderma gangrenosum (PG) is a challenging cutaneous manifestation associated with Dubowitz syndrome, a rare genetic disorder characterized by multiple congenital anomalies, developmental delay, and distinctive facial features. This review article aims to provide a comprehensive overview of the association between Dubowitz syndrome and pyoderma gangrenosum, emphasizing the clinical presentation, challenges in diagnosis and management, and potential underlying mechanisms. A comprehensive literature search was conducted to gather relevant studies, and inclusion and exclusion criteria were applied to select appropriate articles. The association between Dubowitz syndrome and pyoderma gangrenosum has been documented in reported cases and studies. Clinical characteristics of Pyoderma gangrenosum in Dubowitz syndrome include painful necrotic ulcers with undermined borders. Diagnosing pyoderma gangrenosum in the context of Dubowitz syndrome can be challenging due to the overlapping clinical features and complexities associated with the syndrome. Managing pyoderma gangrenosum involves a multidisciplinary approach, with general principles of wound care, systemic therapy, and pain management. Specific considerations for treating pyoderma gangrenosum in Dubowitz syndrome include collaboration among specialists and careful monitoring. Future directions for management include further research to understand the underlying mechanisms and develop targeted therapies. Recognizing and addressing pyoderma gangrenosum in Dubowitz syndrome is crucial for optimal patient care. This review enhances awareness among healthcare professionals and provides insights for improving diagnosis, management, and treatment outcomes for individuals with this challenging combination of conditions.

Endothelial dysfunction, thrombophilia, and nailfold capillaroscopic features in livedoid vasculopathy

BackgroundLivedoid vasculopathy (LV) is a rare, disabling disease characterized by painful ulcers, livedo reticularis and atrophy blanche. Hypercoagulation, endothelial, and microcirculatory dysfunction are believed to be responsible for the pathogenesis of this difficult-to-treat disease. ObjectivesThis study sought to investigate the frequency of endothelial dysfunction, hypercoagulability, and nailfold capillaroscopic features in LV patients to shed light on its etiology. MethodsThis case-control study included 16 patients with LV, 24 with systemic sclerosis (SSc), and 23 control subjects. Serum markers of endothelial dysfunction soluble endoglin, endocan, endothelin-1, lipoprotein a, plasminogen activator inhibitor-1 (PAI-1), soluble thrombomodulin, and von Willebrand factor were measured using enzyme-linked immunosorbent assays. Flow-mediated dilation and carotid intima-media thickness were examined as markers of endothelial dysfunction, and microcirculation was assessed with nailfold capillaroscopy. Thrombophilia-related parameters, including gene polymorphisms of factor V Leiden, prothrombin, PAI-1 genes, methylenetetrahydrofolate reductase (MTHFR) and factor XIII mutation and serum levels of protein C, protein S, antithrombin, homocysteine, D-dimer and antiphospholipid antibodies were investigated in LV patients. ResultsPlasminogen activator inhibitor-1 and soluble thrombomodulin levels were significantly higher in LV patients compared to control subjects (2.3 [2.05–2.79] ng/ml vs. 1.89 [1.43–2.33] ng/ml, p = 0.007; 1.15 [0.88–1.4] ng/ml vs. 0.76 [0.56–0.9] ng/ml, p = 0.004, respectively). Flow-mediated dilation was 25.4 % lower in the LV patients compared to the control group (14.77 % [11.26–18.26] vs. 19.80 % [16.47–24.88], p = 0.034). Capillaroscopic features, including ramifications (75 % vs. 8.7 %, p < 0.001), avascular areas (25 % vs. 0 %, p = 0.011) and dilatations (33.2 % vs. 0 %, p = 0.016), were significantly higher in LV patients than in controls. LV patients had multiple biochemical or genetic abnormalities related to thrombophilia, including heterozygous factor V Leiden mutations (6.3 %), MTHFR (C677T) mutations (heterozygous 43.8 %, homozygous 18.8 %), MTHFR (A1298C) mutations (heterozygous 37.5 %, homozygous 12.5 %), factor XIII heterozygous mutation (12.5 %), antithrombin deficiency (31.3 %), protein S deficiency (12.5 %), hyperhomocysteinemia (31.3 %), D-dimer elevation (25 %), anti-β2-glycoprotein I (12.5 %), lupus anticoagulant antibodies (6.3 %), and anticardiolipin antibodies (6.3 %). ConclusionsIn conclusion, LV patients were characterized by an increased presence of thrombophilia-related parameters, and also exhibited vascular endothelial and microcirculatory dysfunction, resembling SSc. These findings support the complex interaction of thrombophilia, endothelial dysfunction, and microcirculation dysregulation in the pathogenesis of LV. Thus, the treatment of LV patients should be individualized, based on the identification of the predominant pathological pathways.

Pyoderma gangrenosum with Marfan syndrome and Crohn’s disease: A rare association

A 22-year-old man presented with multiple, painful ulcers on the thighs, legs, and face of 10-day duration and diarrhea and bleeding per rectum of 2-year duration. The ulcers were tender and had a peripheral violaceous border. General examination revealed tall stature, long extremities, kyphosis, arachnodactyly, and hyperextensible wrist and thumbs. The arm span was more than the height and the thumb sign and wrist sign were positive, diagnostic of Marfan syndrome. Skin biopsy from the edge of the ulcer showed infiltrates of neutrophils and lymphocytes in the dermis and subcutaneous tissue. A detailed evaluation ruled out other causes for skin ulceration and we made a diagnosis of pyoderma gangrenosum. Echocardiogram demonstrated mitral valve prolapse. Computed tomography of abdomen showed segmental mucosal thickening as skip lesions in the colon and rectum. Endoscopy showed chronic colitis with multiple punched out ulcers. Colonic biopsy showed noncaseating granulomas suggestive of Crohn’s disease. Although inflammatory bowel disease is a well-known association of pyoderma gangrenosum, we did not come across any previous reports of coexistence of pyoderma gangrenosum, Crohn’s disease, and Marfan syndrome.

Tratamiento crónico ambulatorio con sevoflurano tópico en pacientes con úlceras vasculares

ObjectiveTo show the effectiveness and safety of topical sevoflurane after ambulatory and prolonged administration in patients with refractory vascular ulcers. MethodsRetrospective observational study analyzing clinical improvement and vascular ulcers surface area variation after topical application of sevoflurane. Inclusion criteria were patients with painful vascular ulcers refractory to usual therapies and who were treated with topical sevoflurane for at least 36 months. The following variables were collected: age, sex, medical history, associated comorbidity, ulcer etiology and medical treatment. The visual analog scale was used to measure baseline and break through pain intensity before and after treatment. ResultsNine patients met the inclusion criteria of the total number of patients treated whose median age was 74.8 ± 7.5 years. Cases 2 and 9 died during follow-up. In all cases, the analgesic action of topical sevoflurane was rapid (3.1 ± 2.1 minutes), intense (visual analog scale: 7 ± 1.1 to 1.4 ± 1.1 points) and long-lasting (6 to 24 h). With the exception of case 4, all patients experienced a large reduction in vascular ulcers surface area (15.1 ± 5.0 a 2.7 ± 4.2) and tolerance was not observed over time. ConclusionTopical application of sevoflurane is an analgesic and re-epithelializing strategy for vascular ulcers with a successful safety profile.

Fej-nyaki régióra lokalizálódó atípusos fekélyek egy eset kapcsán

The authors report the case of a 31-year-old male patient who presented with rapidly evolving, painful cutaneous ulcers localized in the head and neck regions, destroying the surrounding tissues. He had a 10 year history of inflammatory bowel disease, which remained untreated due to poor compliance. Owing to the atypical localization and bizarre manifestation of the ulcers, the possibility of cutaneous tuberculosis and Crohn’s disease/ / other inflammatory bowel disease associated pyoderma gangrenosum was raised. Based on the clinical characteristics, the histological examination and the use of PARACELSUS scoring system, the diagnosis of pyoderma gangrenosum was confirmed. The implementation of systemic immunosuppressive therapy resulted in the complete healing of the ulcers and total remission of inflammatory bowel disease. The authors underline the possibility of pyoderma gangrenosum in the case of atypical ulcers appearing in the head and neck region, in the diagnosis of which PARACELSUS scoring system can help.

Necrobiosis lipoidica in childhood: a review of literature with emphasis on therapy.

Necrobiosis lipoidica (NL) is a rare chronic granulomatous disease that manifests as sharply demarcated, telangiectatic, brownish-red plaques with atrophic yellowish centers prone to ulceration and occurs predominantly on the shins. In children, NL is extremely rare, but resistance to therapy, troublesome cosmetic appearance, painful ulcerations, and possible development of squamous cell carcinoma in long-persisting lesions are challenges during treatment. Our review includes 29 reports of NL in patients aged <18 years published from 1990 on PubMed, EMBASE, and Medline. The mean age of patients was 14.3years, with a female predominance of 2:1 and a high prevalence of diabetes mellitus (80%). Data showed that potent topical steroids up to twice daily is the first-line treatment. For refractory cases, therapy can be switched to tacrolimus. Ulcerations benefit from phase-adapted wound care and anti-inflammatory medical dressings such as medical honey. Adding hyperbaric oxygenation to local or systemic therapy in difficult-to-treat ulcerated lesions can be considered. Refractory cases may be switched to topical photochemotherapy or systemic treatment with TNF-α inhibitors, systemic steroids (preferably in non-diabetic patients), pentoxifylline, or hydroxychloroquine. Necrobiosis lipoidica in childhood is difficult to treat, with a treatment failure rate of 40%. Therefore, further research through patient registries is recommended.

Multimodal therapy for peristomal pyoderma gangrenosum with topical cyclosporine

Pyoderma gangrenosum (PG) is arare neutrophilic disease. Clinically it shows arapidly evolving painful ulceration with undermined violaceous wound edges. Peristomal PG is particularly resistant to treatment due to mechanical irritation. Two cases illustrate amultimodal therapeutic concept based on topical cyclosporine, hydrocolloid dressing and systemic glucocorticoids. In one patient re-epithelialization was attained after 7weeks and the other patient experienced downsizing of the wound edges over 5months.

WITHDRAWN: Painful Genital Ulcers in Syphilis – an Atypical Presentation

WITHDRAWN: Painful Genital Ulcers in Syphilis – an Atypical Presentation

Hindfoot fusion with various auxiliary techniques in Charcot’s management

Abstract Introduction: Management of Charcot’s arthropathy of the hindfoot (Sanders/Frykberg Type IV) is a challenging situation to address. Complex deformities linked with ankle/hindfoot Charcot’s disease are frequently multiplanar. Due to the collapse of the distal tibia and the two bones of the hindfoot, the talus, and calcaneus, the limb frequently shortens when the skeletal architecture is damaged. A varus ankle or heel results in increased lateral column plantar pressure of the foot due to changed foot pressure loading, predisposing the patient to develop lateral foot ulceration. Collapse and secondary avascular necrosis of the talus; additional stress on the injured bone exacerbates these deformities and contributes to ulcers in the foot, instability during walking, and limb-length discrepancy. Management: The primary indication for surgical ankle stabilization is a foot that cannot be braced and is unstable during walking. Other surgical indications include imminent ulceration, nonhealing ulcers, recurring ulcers, osteomyelitis, and/or severe pain. Achieving ankle and/or hindfoot arthrodesis and correcting these complex multiplanar deformities in this location stabilizes the hindfoot. Various auxiliary techniques that can be combined with Tibio-talo-calcaneal (TTC) are tricortical iliac crest graft and femoral head allograft to build hindfoot, plate augmentation, distally mobilized fibula as biological augmentation and multiple 6.5-mm screws. The choice between internal or exterior fixation is mostly determined by the presence or absence of an active infection and the quality of the bone. Conclusion: Surgical stabilization with TTC nail for Charcot’s arthropathy of the ankle and hindfoot is associated with good clinical outcomes. Despite the high likelihood of complications, limb salvage rates are between 80% and 90%. A meticulous selection of cases, a diligent multimodal strategy, and an experienced team are required to attain this result. Assessment of vascular status, glycemic control, optimum foot care, use of protective footwear during the acute inflammatory phase to prevent inadvertent trivial foot injuries, correction of calcium and vitamin D deficiencies, and cessation of tobacco and alcohol use are preoperative factors that can improve outcomes. Various auxiliary techniques can be combined with TTC nailing for optimum results.

Correlating Salivary Levels of Immunoglobin E and Human Eosinophil Cationic Protein in the Aseer Cohort with Recurrent Apthous Stomatitis.

Repeated Aphthous Stomatitis (RAS) is the most prevalent inflammatory disorder of the oral mucosa, characterized by recurrent emergence of single or numerous painful ulcers. RAS usually affects healthy people without systemic illnesses.There is evidence linking atopy to the progression of this illness. Immunoglobulin E (IgE) and human eosinophil cationic protein (HECP) levels in the saliva of individuals with aphthous stomatitis were assessed as allergy-related indicators. Sixty people were assessed for this study. 30 patients with RAS were included in the patient group, while 30 healthy individuals made up for the control group. Sixty participants' non-stimulated saliva was taken and IgE and HECP were evaluated using enzyme-linked immunosorbent assay (ELISA). Data were analyzed in SPSS 20 through the Mann-Whitney test and p<0.05 was considered significant. The salivary level of HECP was significantly (p 0.05) higher among cases (0.83 0.70) compared to controls (0.170 0.15), whereas the salivary level of IgE was not significantly (p = 0.41) higher among cases (35.60 11.19) compared to controls (67.42 18.34). Even though this study found a positive correlation between elevated HECP levels and RAS, additional research with larger sample sizes is required to identify the biological mechanisms responsible for the observed associations and to include salivary HECP levels in the RAS patient's evaluation.

P09 A case of suspected COVID-19 vaccine-induced antiphospholipid syndrome

Abstract A 50-year-old man presented with an acute onset, painful leg ulcer affecting his right calf. This developed 2 weeks after his second COVID-19 vaccine. It started with a painful erythematous plaque, which evolved slowly into a deep-seated 5-cm ulcer over a 6-week period. A thorough review was unremarkable. He had no significant medical history and was a keen athlete and nonsmoker. His father had an unspecified stroke in his 80s. Examination revealed no signs of chronic venous insufficiency or discoloration to his foot, and his neurovascular examination was unremarkable. Investigations for antineutrophil cytoplasm antibodies, antinuclear antibody, complement, paraprotein, HIV and hepatitis were all unremarkable. Biopsy demonstrated nonspecific inflammatory changes, and wound swabs were unremarkable. Initial treatment with oral antibiotics, regular dressings, compression, topical emollients, Dermovate® and prednisolone (0.5 mg kg−1) was only partially effective. He subsequently developed additional painful superficial erosions and ulcers affecting the same limb involving the calf and shin, with a surrounding erythematous livedoid-like rash involving his shin. Rebiopsy demonstrated superficial and deep dermal and subcutaneous thrombosis without vasculitis. Direct immunofluorescence showed the presence of fibrinogen within dermal vessels. Further investigations demonstrated the presence of lupus anticoagulant. Factor V Leiden, protein C and S, anti-B2-GP1 and anticardiolipin antibodies, antithrombin III, homocysteine and coagulation profile were all unremarkable. Histological confirmation of thrombosis and the presence of serum lupus anticoagulant confirmed the diagnosis of antiphospholipid syndrome (APS). He was started on warfarin and the ulcers improved. APS is a rare autoimmune disorder characterized by recurrent miscarriage, thrombophilia and the presence of antiphospholipid autoantibodies (either serum lupus anticoagulant, anti-B2-GP1 or anticardiolipin autoantibodies). Positivity for APS antibodies can be found in up to 5% of the general population. An individual must have the clinical features and antibody positivity to be diagnosed with APS. The temporal relationship with his second COVID-19 vaccine raises the possibility of vaccine-induced APS. COVID-19 vaccine-induced APS is limited to just a few case reports (Moreno-Torres V, Gutiérrez A, Valdenbro M et al. Catastrophic antiphospholipid syndrome triggered by mRNA COVID-19 vaccine. Clin Exp Rheumatol 2022; 40:1054–5). It is postulated that mRNA vaccines may induce a rare complex immunogenic response characterized by a type 1 interferon reaction. This results in a prothrombotic cascade in individuals with pre-existing APS autoantibody positivity (Talotta R, Robertson E. Antiphospholipid antibodies and risk of post-COVID 19 vaccination thrombophilia: the straw that breaks the camel’s back? Cytokine Growth Factor Rev 2021; 60:52–60).

Conquering pyoderma gangrenosum: exploring non-steroidal treatment options

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis frequently related to chronic inflammatory bowel disease (IBD) and often associated with exacerbation of intestinal disease and/or loss of treatment efficacy. The mainstay of treatment is long-term immunosuppression, often with high doses of corticosteroids or low doses of ciclosporin. PG has been reported to respond to TNF alpha inhibitors. We report a patient of recalcitrant PG who responded very well to treatment with golimumab. A 61-year-old known case of PG since 4 years, who also had history of hypertension, pulmonary TB (treated), had been treated with dapsone, thalidomide, colchicine and corticosteroids in the past with partial response and frequent relapses. In February 2021, the patient while being on low-dose oral corticosteroids and colchicine, presented with large painful ulcer over back of his right thigh, which rapidly worsened. In agreement with the pulmonologist, the patient was started on Injection golimumab in addition to intravenous dexamethasone with slow tapering of steroid dosage following the improvement of the cutaneous lesion. Patient reported a near-total resolution of lesion after two doses. He is maintaining well with golimumab. PG can be poorly responsive despite adequate treatment with conventional modalities. High dose steroid therapy with all expected iatrogenic complications and treatment with cyclosporine in such an elderly patient with hypertension and history of tuberculosis seemed to be inappropriate. For all these reasons, a treatment with the TNF alpha inhibitor golimumab, appeared to be the most reasonable therapeutic choice for a patient.

A Review of Clinical Outcomes, Owner Understanding and Satisfaction following Medial Canthoplasty in Brachycephalic Dogs in a UK Referral Setting (2016-2021).

Brachycephalic breeds have increased in popularity despite growing awareness of their predisposition to a wide range of conformation-related diseases. The extreme facial conformation of many popular brachycephalic breeds compromises their ocular surface health, increasing the risk of painful corneal ulceration. Medial canthoplasty (MC) is a surgical procedure to address ocular abnormalities in brachycephalic dogs, which are collectively referred to as brachycephalic ocular syndrome (BOS). This study retrospectively reviewed the records of dogs recommended MC at a referral hospital between 2016 and 2021. A questionnaire was designed to identify owners' perceptions pre- and post-operatively. From 271 brachycephalic dogs recommended MC, 43.5% (118/271) underwent surgery and 72.0% (85/118) were Pugs. The majority of dogs (73.7%, 87/118) that underwent surgery had current or historical corneal ulceration. Follow-up was available in 104 dogs, of which 5.7% (6/104) had corneal ulceration post-operatively. Sixty-four owners completed the questionnaire and reported post-operative corneal ulceration in 12.5% of dogs (8/64), reduced ocular discharge (70.8%, 34/48), reduced ocular irritation (67.7%, 21/31) and less periocular cleaning (52.5%, 32/61). Owners were satisfied with the clinical (85.9%, 55/64) and cosmetic (87.5%, 56/64) outcome. In conclusion, MC has high clinical relevance for the surgical management of BOS, restoring functional conformation and improving the quality of life of affected dogs.

LOW-LEVEL LASER THERAPY FOR SEVERE ORAL PEMPHIGUS VULGARIS MANAGEMENT: A CASE REPORT

A 61-year-old female patient reported odynophagia and the presence of bullous lesions on the trunk, scalp, and limbs. She was hospitalized with epigastralgia associated with gastric ulcers, evolving to painful bullae and ulcers in the pharynx and oral cavity, compromising her nutritional intake. Based on clinical and anatomopathological findings, the diagnosis was conclusive for pemphigus vulgaris. Upon oral clinical evaluation, severe stomatitis, trismus, biofilm accumulation, and tongue coating were observed. The systemic treatment involved the use of immunosuppressants, analgesics, and antibiotics. Oral hygiene guidelines with mechanical and chemical devices and a low-level laser therapy were instituted. After 28 sessions of laser therapy, a significant clinical improvement and resolution of oral lesions were observed. Oral care contributed to a better management of oral lesions, providing patient comfort and preventing major complications during hospitalization. The patient is clinically well and is still routinely monitored by the dental team. A 61-year-old female patient reported odynophagia and the presence of bullous lesions on the trunk, scalp, and limbs. She was hospitalized with epigastralgia associated with gastric ulcers, evolving to painful bullae and ulcers in the pharynx and oral cavity, compromising her nutritional intake. Based on clinical and anatomopathological findings, the diagnosis was conclusive for pemphigus vulgaris. Upon oral clinical evaluation, severe stomatitis, trismus, biofilm accumulation, and tongue coating were observed. The systemic treatment involved the use of immunosuppressants, analgesics, and antibiotics. Oral hygiene guidelines with mechanical and chemical devices and a low-level laser therapy were instituted. After 28 sessions of laser therapy, a significant clinical improvement and resolution of oral lesions were observed. Oral care contributed to a better management of oral lesions, providing patient comfort and preventing major complications during hospitalization. The patient is clinically well and is still routinely monitored by the dental team.

Severe Acute Genital Ulcer: An Unusual Presentation of Behçet’s Disease: A Case Report

Introduction: Genital ulcers are among the main manifestations of Behçet’s disease (BD); however, large severe acute genital ulcers are not common. Case Presentation: A 29-year-old unmarried woman with a history of recurrent oral aphthae presented with a genital ulcer developed 2 weeks before admission. On clinical examination, there were two large painful ulcerations on the right labia majora, painful oral ulcerations, non-follicular pustules on the face and limbs, and painful edema on the left leg with positive Homan’s sign. The D-dimer level was elevated, and a Doppler ultrasound showed deep venous thrombosis of the right common femoral, femoral, and popliteal veins. The BD was diagnosed according to the International Criteria for Behçet’s Disease. The patient was treated with prednisone 40 mg/day and colchicine 1 mg/day, and the lesions developed well and healed within 2 weeks, leaving scarring lesions in the genital area. Conclusions: Behçet's disease is an important nonvenereal cause of genital ulceration. A high index of suspicion in a patient with mucocutaneous lesions might result in the early diagnosis, management, and prevention of complications.

A woman in her thirties with frequent mucosal ulcers

Haploinsuffiency A20 (HA20) was first described in 2016 and is caused by a mutation in TNFAIP3/A20. Non-related families living on different continents were examined with whole exome sequencing (WES). All had symptoms of Behçet's disease. An autosomal dominant mutation was found. When in her early teens, the patient had presented with a painful labial ulcer. She also had recurrent mouth ulcers, sometimes accompanied by fever and elevated CRP, and on occasion by abdominal pain. The ulcers were biopsied, and she was diagnosed with likely Behçet's disease. Some family members were later admitted with similar symptoms, and a genetic cause was suspected. Twenty years later a new genetic test was performed, and a revised diagnosis of HA20 was correctly made. HA20 is a newly identified autoinflammatory disease due to an inherited mutation. This leads to increased production of pro-inflammatory cytokines such as IL-1, IL-6 and TNF α. The disease-causing process in this monogenic, inherited disease is very similar to the immune process in the acquired, multifactorial Behçet's disease. Fever, young age, abdominal involvement and global occurrence are factors that could lead to suspicion of HA20.

Measuring What Really Matters: Disease Specific Health Related Quality of Life in Patients with Chronic Limb Threatening Ischaemia

Disease Specific Health Related Quality of Life in Patients With Chronic Limb Threatening Ischaemia Undergoing Revascularisation of Femoropopliteal LesionsEuropean Journal of Vascular and Endovascular SurgeryPreviewPatients with chronic limb threatening ischaemia (CLTI) suffer from pain and non-healing ulcers, which impact negatively on both their physical and mental health. While maintaining and improving quality of life is a principal aim with all treatments, little is known about the health related quality of life (HRQoL) of CLTI patients and how revascularisation procedures impact on HRQoL endpoints. The aim of this study was to investigate disease specific HRQoL before and after revascularisation in patients with CLTI undergoing femoropopliteal revascularisation. Full-Text PDF Open Access