Pale Granules Research Articles

The Effectiveness of Wound Dressing with Virana Sanjeevi Thailam (VST) in the Management of Madhumegha Viranam – A Case Report

Diabetic foot ulcer (DFU) is one of the most prevalent consequences for those with uncontrolled diabetes mellitus (DM). The annual incidence of DFU worldwide is between 9.1 to 26.1 million, the mortality and morbidity are the common reasons for hospitalisation of diabetes patients. The available treatment modalities are expensive and unsatisfactory in the clinical management of DFU. In Siddha system of medicine Diabetic ulcers are referred to as Madhumegha Viranam (MV). Various thailam (medicated oil) are used in the management of ulcers. Virana Sanjeevi thailam (VST) is one of the classical Siddha topical formulations indicated for the management of chronic ulcers. As this thailam is not been subjected to clinical evaluation yet, this case study is to report the effectiveness of wound dressing with VST along with adjuvant Siddha medications in 60 years old, post-menopausal, house wife who reported with complaints of ulcer in the plantar aspect of right foot for a period of 6 months, along with a past history of diabetes and systemic hypertension undergoing modern treatment for the past 10 years. The patient was diagnosed to have MV and the ulcer had features of Grade 2 in Maggit Wagner system of classification of diabetic ulcers, wound area was 12cm2, with pale granulation tissues and purulent discharges. Following treatment, ulcer healed completely in a span of 86 days and Leg Ulcer Measurement Tool score improved from 41/68 to 3/68. This may encourage the use of Siddha medicines in management of DFUs.

Effect of laser and exercises in venous ulcer: A case report

Abstract This case report outlines the effect of a low-level laser therapy (LLLT) and exercise regimen on a 59-year-old patient with a venous ulcer. The current case examines the impact of a combination of LLLT and exercise on blood flow and healing in a patient with venous leg ulcer (VLU) brought on by ambulatory venous hypertension due to venous incompetence. Above the left lateral malleolus, the patient had a circular, well-defined raw area covered in pale granulation tissue that was not healing. Wound assessment was done using a two-dimensional method using graph paper. The patient received LLLT therapy and an aerobic exercise regimen, reducing wound size and improving healing. It demonstrates the potential advantages of using LLLT and aerobic exercise to treat venous ulcers.

Comparative study of Vac dressing with moist gauze dressing in the treatment of diabetic foot ulcer in tertiary care center

Background: Diabetic foot ulcers are one of the most commonly encountered cases in any surgical out-patient department. Causes of leg ulcers vary from traumatic, diabetic, chronic venous insufficiency, trophic, hypertensive, and so on. Objectives: To evaluate the safety and clinical efficacy of negative pressure wound therapy compared with moist gauze dressings to treat foot ulcer wounds. Methods: Patients presenting with leg ulcers to the department of general surgery, VMKVC hospital. 40 randomly selected patients will be assigned to the study group based on their willingness for undergoing topical negative pressure dressing and 40 patients to the moist gauze dressing, control group. Results: Most of the ulcer (46%) got healed by secondary intention through VAC. dressing. Treating DFU with VAC therapy results in a better graft take rate (p=0.05) when compared to standard wound care. There is a statistically significant association found between interventions and the area of the ulcer on day 21.Among the study participants according to day 1 ulcer state 16% had healthy granulation tissue, 14% had necrotic granulation tissue, and 50% had their tissue with pale granulation.

EFFICACY OF UNANI FORMULATION MARHAM-E-EJAZ IN THE MANAGEMENT OF NON-HEALING ULCER: A CASE REPORT

Background and Aim: A Non-healing ulcer is defined as an ulcer that does not heal after 6 weeks of conservative therapy. It is estimated that 1-2% of the people of the world experience a chronic wound during their lifetime. There is direct impact on the physical (amputation), psychological (depression) and social life of individual. Present study was carried out to assess the acclaimed effect of Unani formulation Marham-e-Ejaz in a patient. Material And Method: A female patient of Non-healing ulcer presented in the surgery OPD of our institute. She presented with a chief complaint of wound at the right elbow joint. The diagnosis made was post burn wound. The wound had a history of more than 9 month. The case was treated with Unani Topical formulation, Marham-e-Ejaz for 30 days. The formulation was applied after cleaning it with Normal saline, dressing was changed after every alternate day. The wound was assessed for pain, discharge, size and depth of wound at 0th, 15th, 30th day. Result: On the first day wound size was 2 square cm, depth 0.2 cm, and the floor filled with pale granulation tissue. On 30th day ulcer was completely healed with 100% epithelization. Conclusion: It was observed that there was significant healing of the ulcer. So, Marham-e-Ejaz has potential efficacy in healing Non-healing ulcer.

USING NITRIC OXIDE DONOR SOLUTION WITH VACUUM THERAPY IN THE TREATMENT OF PURULENT WOUNDS OF SOFT TISSUES

In recent years, the incidence of purulent septic soft tissue diseases has decreased insufficiently. In order to improve the results of surgical treatment of purulent soft tissue processes, vacuum therapy with instillations of L-arginine, a nitric oxide donor solution, has been developed. This method is complementary to the complex surgical treatment: it accelerates wound cleaning, reduces microbial contamination, and causes a wound surface decreasing, promotes the development of tissue granulation and epithelisation processes. This article presents the clinical case of successful application of vacuum therapy with the nitric oxide donor (L-arginine) installation in a patient after the drainage of phlegmon in the right thigh. The patient underwent a course of vacuum instillation therapy, which consisted of three changes of sponge and tubes after their use for three days. After a course of local instillation vacuum therapy, the patient's condition became better. Starting from day 3, there was a decrease in the number of leukocytes and erythrocyte sedimentation rate in the general blood test and, accordingly, decreased leukocyte intoxication index, and on day 4 there was no hyperaemia and oedema. When opening the phlegmon from the wound infected by St. aureus, and during vacuum instillation therapy with a solution of donor nitric oxide microbial decontamination the results of intermediate cultures were not observed. The wound was completely cleaned, filled with pale pink granulations, which allowed for 10 days to put secondary sutures on the wound, which were removed on the 7th day in the ambulatory after complete healing of the wound.

Autologous Fat Grafting - A Step Forward in Wound Management.

Autologous fat grafting (AFG) is an emerging therapeutic option for wounds that are not ready for grafting. The regenerative potential of autologous fat lies in the adipose derived stem cells (ADSCs) contained within the stromal vascular fraction (SVF), which are capable of differentiating into multiple cell lineages. However to date, there has been no comprehensive evaluation of its efficacy in acute complicated wounds. This study aims to critically evaluate the efficacy and safety of AFG in cutaneous wound healing. Materials and Methods: This prospective, quasi experimental study was conducted in the Department Of Plastic Surgery, SIMS, Lahore, between June 2020 and June 2021. Thirty patients with pale granulation, not ready for grafting with no vital structure exposed were included in the study after detailed history, examination and were photographed pre and postoperatively. The procedure was performed under local anaesthesia. 40 to 80 ml fat was harvested from lower abdomen and after emulsification, placed over the wound wrapped in sufra tulle dressing. The dressing was changed on third postoperative day and outcome was assessed on clinical grounds. Results: Thirty patients (M:F Ratio 1.75:1) with mean age 30 years (Range 13-45 years) were included in this study with post traumatic (n = 23) and post infective (n = 7). Of 27 patients who completed their follow up, all had healthy granulation tissue which was later on grafted. Mean number of fat dressing sessions were 2 (Range 1-3). Conclusion: Autologous fat grafting has shown promising results for cutaneous wounds without any unacceptably high complication rates reported so far. Randomised controlled trials should be done on a larger scale to prove its efficacy in the management of complicated wounds.

VP4: Effectiveness of Autologous Fat Grafting in the Treatment of Cutaneous Wounds

INTRODUCTION: Autologous fat grafting (AFG) is an emerging therapeutic option for wounds that are not ready for grafting. The regenerative potential of autologous fat lies in the adipose derived stem cells (ADSCs) contained within the stromal vascular fraction (SVF), which are capable of differentiating into multiple cell lineages. However to date, there has been no comprehensive evaluation of its efficacy in acute complicated wounds. This study aims to critically evaluate the efficacy and safety of AFG in cutaneous wound healing. MATERIALS AND METHODS: This prospective, quasi experimental study was conducted in the Department Of Plastic Surgery, SIMS, Lahore, between June 2020 and June 2021. Thirty patients with pale granulation, not ready for grafting with no vital structure exposed were included in the study after detailed history, examination and were photographed pre and postoperatively. The procedure was performed under local anaesthesia. 40-80 ml fat was harvested from lower abdomen and after emulsification, placed over the wound wrapped in sufra tulle dressing. The dressing was changed on 3rd postoperative day and outcome was assessed on clinical grounds. RESULTS: Thirty patients (M:F Ratio 1.75:1) with mean age 30 years (Range 13-45 years) were included in this study with post traumatic (n=23) and post infective (n=7). Of 27 patients who completed their follow up, all had healthy granulation tissue which was later on grafted. Mean number of fat dressing sessions were 2 (Range 1- 3). CONCLUSION: Autologous fat grafting has shown promising results for cutaneous wounds without any unacceptably high complication rates reported so far. Randomized controlled trials should be done on a larger scale to prove its efficacy in the management of complicated wounds.

Normal Saline versus Honey Dressing in the Preparation for Skin Grafting

Objective: To compare the continuously wet normal saline and honey gauze dressings in terms of days required for wound preparation for skin grafting and graft take. Material and Methods: The present study was a Quasi-experimental which was conducted in the Department of General Surgery, GEMS, Ragolu, Srikakulam Andhra Pradesh from January to November 2019. Methodology: Eighty wounds with small patches of slough and pale granulation tissue requiring preparation for skin grafting were included and divided into two groups by simple random sampling. Wounds requiring mechanical debridement or grossly infected wounds, diabetics, and patients with age > 60 years, Hb <10 g/dl, and serum albumin level ≤ 3 g/dl were excluded. Time for wound preparation in days was noted. Split thickness skin grafts meshed to 1-1.5 were applied. The largest area of graft loss in both wounds was measured in the two largest dimensions and noted in cm2. This was the endpoint of the study. Results: Average time for preparation in the saline group was 10 days whereas the average time in the honey group was 27 days. The average area of graft loss in the saline group and honey group was 2 cm2 and 3 cm2 respectively. Conclusion: Normal saline dressing is a hyperosmolar physiological dressing and prepares the wound faster than honey dressing at a low cost with quite satisfactory graft take.

Squamous cell carcinoma in an atrophic scar of Porphyria Cutanea Tarda

Introduction: Porphyria’s are group of inherited metabolic disorders of heme biosynthesis. Porphyria cutanea tarda (PCT) the most frequent type of porphyria worldwide and present with skin symptoms only. PCT develops due to acquired deficiency in fifth enzyme Uroporphyrinogen deaminase (UROD) in hepatocytes. Skin cancers are known to arise from site of trauma or chronic irritation like scars, ulcers, sinuses of diverse aetiology. Squamous cell carcinoma, Basal cell carcinoma, Adenocarcinoma are the common carcinoma identified in these situations. Hereby we present a case squamous cell carcinoma in an atrophic scar of PCT. Case Report: A 65 years old male, diagnosed case of PCT since 20 years, presented with non-healing ulcer on left cheek since 6 months. It was overlying a preexisting scar of PCT and was progressively increasing in size. Dermatological examination shows single well-defined ulcer on left malar area with rolled out edge and pale granulation tissue on floor. Diagnosis of Squamous cell carcinoma was confirmed on histopathological examination. Patient underwent wide local excision with 1cm margin all around with propeller flap reconstruction which was conducted by plastic surgeons. Conclusion: Patients of Porphyria Cutanea Tarda are at high risk of facial malignancy and need stringent monitoring for early detection and timely management. Keywords: Porphyria cutanea tarda squamous cell carcinoma atrophic scar.

A Rare Case of Primary Tuberculous Otitis Media with Bezold's Abscess.

Tuberculous Otitis Media is a rare clinical presentation. The signs and symptoms are variable that leads to delayed diagnosis and treatment. Persistent ear discharge not responding to topical and systemic antibiotics should be considered for investigation of tuberculosis. We report a case of Primary Tuberculous Otitis Media who presented with Bezold's Abscess. Patient underwent Mastoidectomy. Diagnosis was made with the Histopathological examination of the suspicious extensive pale granulation tissue. Patient was started on ATT immediately. Greater awareness regarding the disease is needed to make an early diagnosis. Late diagnosis increases the risk of complications. Anti Tubercular Therapy is the treatment of choice. Surgical intervention may be added to drug therapy. In cases with complications, radical surgery will be needed. Bezold's abscess is a rare complication of Otitis Media. CT imaging should be considered in suspected neck abscess patients with history of ear discharge to rule out aural cause of abscess.

A Rare Case of Tubercular Cholesteatoma with TB Meningitis

Tubercular otitis media is an uncommon condition. Tuberculosis can affect any part of ear ranging from tympanic membrane to labyrinth. The symptoms of tubercular otitis media like painless otorrhea, multiple perforations, pale granulations, facial paralysis and severe SNHL though well described in literature, are not always present hence diagnosis is often missed. Diagnosis is usually made by clinical and histopathology examination of specimen obtained intra operatively. Here, we discuss clinical presentation, diagnosis and management of a case with cholesteatoma and TB meningitis.

Tuberculous Otitis Media—A Rare Entity or a Missed Diagnosis

Objective: The aim of the study is to look for indicators of Tuberculous Otitis Media in all cases of chronic suppurative otitis media. Study Design: This is a retrospective study. Setting: This study was conducted in a tertiary care centre. Subjects and Methods: Detected cases of tuberculous otitis media (TBOM) cases studied retrospectively from January 2011 to December 2013 were included in the study. Investigations for tuberculosis were considered in the cases showing suspicious pale granulation tissue in the external auditory canal and middle ear and also in cases showing exuberant pale granulation tissue during mastoid surgery where Zeihl Nielson staining, histopathology, molecular genetic study was done. Cases showing positive result were included in the study. Results: During the study period 751 cases of CSOM were seen in outpatient room of which 18 cases of TBOM were diagnosed. Three patients were diagnosed preoperatively and 181 underwent surgery of which 15 cases were diagnosed positive, from the tissue obtained during the procedure. Direct smear was positive in four cases, concentration techniques in seven cases. Line probe assay was taken as diagnostic in all the cases. None of the cases were positive on histopathology. Conclusion: Tuberculous otitis media is often missed as the classical features are not seen in all cases of TBOM. The absence of these should not stop the clinician from diagnosing the disease. Suspicious tissue should therefore be tested properly to avoid missing the diagnosis and to prevent any complications.

A Rare Case of Facial Palsy Due to Mucormycosis

A very uncommon instance of facial nerve palsy involving isolated temporal bone with associated uncontrolled diabetes mellitus has been noticed. A 53-year-old diabetic male presented himself with facial asymmetry, ear pain, and discharge in the right ear of one-month duration. Clinical examination revealed grade IV [House-Brackmann] right sided facial palsy, and otoscopy of small central perforation. Clinically acute otitis media with facial palsy diagnosis was made. There was minimal response to medical treatment. As per CT scan and audiometry findings, patient was subjected for exploratory mastoidectomy showing pale granulation tissue involving geniculate ganglion of facial nerve. The histopathology was suggestive of mucormycosis, an unusual presentation in middle ear. The patient was treated with injectable Amphotericin B. This case highlights a rare cause of isolated facial palsy and physicians should be aware of such atypical clinical presentation.

Tuberculous Mastoiditis: A rare occurrence

Tuberculous mastoiditis was first described by Jean Louis Petit in the 18th century; Wilde in 1853 presented the classical picture of tuberculosis otitis media as a disease characterized by painless, insidious onset of ear discharge, multiple perforations in the tympanic membrane, and pale granulations in middle ear cleft. Politzer discussed the destructive nature of this disease in 1882. In 1892, Koch demonstrated the tubercle bacilli [1]. The incidence of tuberculosis otitis media has been reported to be 0.04% to 0.9% of all Chronic Suppurative Otitis Media (CSOM) in the developed countries [2,3].

Pale yellow granules forming in hemodialysis circuit

血液透析施行時，透析開始直後から血液回路内に淡黄色顆粒物が付着し回路内凝固などのトラブルの原因となることがある．冬季に多く，プライミング時に血液回路を37℃まで加温すると回避される場合がある．今回この顆粒物の本態を検討し成因を推定した．電子顕微鏡所見から，顆粒物は活性化血小板による血小板血栓であった．5名の症例に性差，透析歴や原疾患の共通性はなく，回路内凝固以外共通症状もなかった．低温刺激に関与するクリオグロブリン血症や寒冷凝集素症も認められず，ヘパリン起因性血小板減少症関連の抗体もすべて陰性であった．顆粒物が形成されない透析患者と比較して血液検査上の差はなく血小板数も正常範囲にあったが，ヘパリン化による平均血小板容積（MPV）の低下率が大きかった（p＝0.016）．未分画ヘパリンの増量は顆粒物形成に影響しなかったが，プライミング時の回路内加温および低分子ヘパリンやナファモスタットへの抗凝固薬の変更で抑制され回路内凝固の回避に成功した．この病態は低体温下手術時の全身ヘパリン化で認められる血小板減少症に類似し，淡黄色顆粒物の成因として回路内の低温刺激と高分子分画のヘパリンが複合的に関与していると考えられた．

Intracytoplasmic Crystalline Inclusions in the Hepatocytes of an Antelope

This case report describes intracytoplasmic crystalline inclusions in the hepatocytes of a 13-year-old female Thomson's gazelle. Histologically, multifocal to coalescing areas of many hepatocytes contained large cytoplasmic vacuoles filled with pale eosinophilic homogeneous material and rare fine basophilic granules. Von Kossa staining showed the presence of calcium within cytoplasm, mainly in the inclusions, of hepatocytes. Transmission electron microscopy, scanning electron microscopy, energy dispersive X-rays analyses, and infrared spectroscopy on the liver showed the hepatocellular material consistent with protein and carbohydrate with secondary accumulation of calcium and phosphorus. It was concluded that crystalline inclusions may have been derived due to failure of normal physiological hepatocellular clearance associated with a severe chronic disease. To the authors' knowledge this is the first reported case of hepatocellular crystalline inclusions in an antelope.

Comparison of Normal Saline and Honey Dressing in Wound Preparation for Skin Grafting

Objective: To compare the continuously wet normal saline and honey gauze dressings in terms of cost of treatment, days required for wound preparation for skin grafting and graft take. Study Design: Quasi experimental. Place and Duration of Study: Plastic and Burn surgery unit, Mayo hospital, KEMU, Lahore from April to September 2009. Methodology: Sixty wounds with small patches of slough and pale granulation tissue requiring preparation for skin grafting were included and divided into two groups by simple random sampling. Wounds requiring mechanical debridement or gros-sly infected wounds, diabetics and patients with age > 60 years, Hb <10 g/dl and serum albumin level ≤ 3 g/dl were excluded. Time for wound preparation in days and cost of treatment in Pakistani rupees was noted. Split thickness skin grafts meshed to 1-1.5 were applied .Largest area of graft loss in both wounds was measured in two largest dimensions and noted in cm 2 . This was the end point of the study. Results: Average time for preparation in saline group was 10 days where as the average time in honey group was 27 days (p value = 0.02). Average area of graft loss in saline group and honey group was 2 cm 2 and 3 cm 2 respectively (p value = 0.67). In saline group average cost of treatment was 800 rupees as compared to 2400 rupees in honey group. Conclusion: Normal saline dressing is a hyperosmolar physiological dressing and prepares the wound faster than honey dressing at a low cost with quite satisfactory graft take. Key words: Normal saline, Honey, Dressing.

Images in vascular medicine

A 61-year-old Caucasian female with prior history of bilateral femoro-popliteal bypass grafts, chronic venous insufficiency and long-standing rheumatoid arthritis was admitted with painful bilateral lower extremity ulcerations. Presumptive diagnosis of infected venous or vasculitic ulcers was made and vascular medicine consultation was obtained. Anterolateral aspects of bilateral lower extremities were erythematous and revealed several tender ulcers with well-defined edges. The ulcer bases were composed of predominantly pale granulation tissue and serous discharge (Panel A). Ankle‐brachial index and toe pressures were normal at rest. Pertinent laboratory results included a rheumatoid factor of 392 IU/ml and a Westergren sedimentation rate of 115 mm/h. The serum cryoglobulins, C-ANCA, PANCA and complement levels (C3/C4) were within normal limits. An MRI did not suggest osteomyelitis. A wound biopsy was requested due to the atypical nature of the ulcers and revealed cutaneous large T-cell lymphoma. Panel B shows the microscopic appearance of the large T-cell lymphoma with angioinvasive features. Beneath an ulcerated epidermis, malignant lymphoid cells infiltrate the deep dermis and subcutis and invade small and medium-sized arterioles in the deep dermis (1: hematoxylin and eosin, 200). At higher magnification, the cells have a large cell morphology (2: hematoxylin and eosin, 400). Immunohistochemistry for the T-cell-associated antigen CD3 shows a brown colorimetric reaction decorating the cytoplasmic membranes of the neoplastic cells (3: anti-CD3, 400). CHOP chemotherapy was started but she died several months after the diagnosis. Malignant transformation of chronic ulcers is well documented, although uncommon. 1 Patients with rheumatoid arthritis frequently present with leg ulceration 2 and are at increased risk for lymphoma. 3

The first record of Ensiculifera Balech and Fragilidium Balech (Dinophyceae) from Chinese coast

Resting cysts and vegetative cells of Ensiculifera Balech and Fragilidium Balech have never been reported in China Sea. Such kinds of cysts were collected in the East China Sea and were allowed to germinate. The cyst of Ensiculifera sp. is spherical with a diameter of 22 μm. The cyst consists of two layers and is full of greenish granules, with a bright red body inside. The cyst wall is covered with short organic spines (2 μm long). The cell of Ensiculifera sp. comprises a conical epitheca and a rounded hypotheca, with the dimension of 17.7 μm long and 12.5 μm wide on the average. The plate pattern is po, x, 4′, 3a, 7′′, 5c, 4s, 5′′′, 2′′′′. The cysts of Fragilidium mexicanum Balech are spherical with the diameter ranging from 54–60 μm. They are full of pale white granules and brown protoplasm, with a bright yellow body present. The archeopyle is spherical. The cells of F. mexicanum are 45.3 μm long and 42.8 μm wide, with the plate formula of po, 5′, 7′′, 10c, 7s, 7′′′, 2′′′′, 1P. The cyst of Fragilidium sp. is also spherical with a diameter of 45 μm, which is similar to that of F. mexicanum except that the yellow body is not present. The cells of Fragilidium sp. are 41.6 μm long and 35.3 μm wide with the plate formula of po, 5′, 7′′, 7′′′, 2′′′′, 1P. The Internal Transcribed Spacers (ITS) of Ensiculifera sp. and the small subunit (18S) rDNA of Fragilidium spp. were amplified and sequenced. Their phylogenetic positions agree with the morphological taxonomy.

Histochemical and ultrastructural features of the lingual epithelium of the rat snake (Elaphe climacophora)

The histological, ultrastructural and histochemical characteristics of the lingual epithelium of the rat snake (Elaphe climacophora) were investigated by light and transmission electron microscopy. The cells in the beta-layer of the epithelium of the bifurcated apex were filled with beta-keratin fibers and an amorphous matrix. Round projections covering the surface of the epithelial cells, namely, microfacets which contained pale granules, were clearly visible on the outer faces of Oberhäutchen cells on the epithelium, and they were identified as fine granules filled with lipid. These granules might play an important role as a coating on the surface of the bifurcated lingual apex. The lipid on the surface of the lingual apex might also serve to trap and retain odorant molecules. Keratohyalin-like granules were distributed within the a-layer of the epithelium of the bifurcated apex of the tongue in the resting phase and cellular interdigitation was well developed in this region. Evidence of a shedding line was apparent under the light microscope in the cleft between outer and inner epithelial generations. The epithelial surface of the body of the tongue appeared suitable for retention of odorant and other molecules.