Ulcerative lesion over tongue: a diagnostic dilemma

Tuberculosis even today remains as the most common infectious disease affecting lungs in India despite having advanced diagnostic testing and a national programme to eradicate this disease. It may present with various clinical appearances, of them tongue tuberculosis is rare and it mimics malignant lingual neoplasms on clinical examination which was rarely described in the literature. In this article we are presenting a 69-year-old patient with tuberculosis of tongue presented as a painful ulcer, so far very few cases reported

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

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

Plasma Cell Dyscrasia of the Calcaneus: A Rare and Unusual Case Presentation

A rare and unusual case of plasma cell dyscrasia of the calcaneus is presented. Clinically, the patient had a draining and painful ulcer that was treated with appropriate antibiotics and wound care but failed to show any signs of healing. Radiographic images showed cystic changes of the calcaneus in the vicinity of the ulcer. Blood work was negative for bone and soft-tissue infection, but uric acid and alkaline phosphatase levels were elevated. Nuclear bone scan showed increased uptake in the calcaneus suggestive of osteomyelitis. One possible differential diagnosis was an intraosseous gouty tophus deposit. Not convinced that this was either a bone infection or gout, the author performed a bone biopsy. Pathologic evaluation indicated plasma cell dyscrasia. Continued wound care healed the ulcer completely, with resolution of pain of his heel. Oncology/hematology was consulted, and 16 months after biopsy, he remains asymptomatic.

A Case of Cytomegalovirus-Induced Oral Ulcer in an Older Adult Patient with Nephrotic Syndrome due to Membranous Nephropathy

We report a case of cytomegalovirus- (CMV-) induced buccal ulcer in a patient with nephrotic syndrome. An 82-year-old man with membranous nephropathy was on immunosuppressive therapy presented with an ulcer in the oral cavity and was hospitalized. Intraoral examination revealed an inflamed and painful ulcer on the left buccal mucosa. Blood test results showed CMV positivity, and histopathological examination confirmed the diagnosis. Anti-CMV therapy (ganciclovir) was initiated from the third day of hospitalization. However, he developed dyspnea on the 14th day. Computed tomography images of the chest revealed the presence of ground-glass opacities, and noninvasive positive pressure ventilation was initiated under the provisional diagnosis of pneumocystis pneumonia caused by ganciclovir-associated myelosuppression and/or steroid-induced immunocompromised state. The patient died of pneumocystis pneumonia on the 21st day. The patient had received immunosuppressive therapy for renal dysfunction. Immunocompromised patients with CMV infection should be treated with caution, as drugs for CMV may themselves cause myelosuppression, deteriorating the prognosis of the patient.

Seropositive HIV diagnosis after oral histoplasmosis: the importance of multi-professional care in health

Histoplasmosis is a systemic fungal disease, which can manifest with extrapulmonary lesions. Oral lesions are rarely the first manifestation of late histoplasmosis and can represent an important process of immune imbalance. The objective of this work is to present a clinical case of Histoplasmosis with an oral manifestation of a patient who was unaware of her condition with the Human Immunodeficiency Virus (HIV). The patient's main complaint was a painful ulcer in the central region of the tongue present for two months, whose incisional biopsy resulted in the diagnosis of Histoplasmosis. Although referred for medical treatment with an infectologist, the patient had complications resulting from the disease and died after one month. This situation demonstrates the importance of multidisciplinary care in the prevention, diagnosis and treatment of diseases. The correct diagnosis and treatment can be decisive in the prognosis of patients and demonstrates the relevance of the dentist's knowledge about the various systemic diseases that present oral manifestations.

Applying Intravenous Immunoglobulin and Negative-Pressure Wound Therapy to Treat Refractory Pyoderma Gangrenosum: A Case Report

Pyoderma gangrenosum (PG) is a rare chronic neutrophilic dermatosis that causes undermining ulcers. Unfortunately, standardization of PG treatment remains a challenge. In this article, we describe a case in which a 69-year-old man presented with a painful ulcer on the right lower leg. The diagnosis of PG was made after excluding other diseases. He had a history of PG on his left lower leg 2 years earlier and was cured by the treatment of systemic corticosteroids and cyclosporin A for 43 days. However, such a treatment was not effective this time. Hence, we applied intravenous immunoglobulin and negative-pressure wound therapy, and the patient was cured. Altogether, this case supports the use of intravenous immunoglobulin as an effective adjuvant for refractory PG, and indicates negative-pressure wound therapy as a treatment option to advance ulcer healing under adequate immunosuppression.

Introducing a Case of Pyoderma Gangrenosum in the Breast

Introduction: Pyoderma gangrenosum (PG) of the breast is a rare that present as a painful ulcer on the skin. It usually affects people in their 20s to 50s and occurs in both men and women. Typically, PG affects the legs in adults. In children, it may affect the legs, buttocks, head, and neck. Pyoderma gangrenosum is characterized by a papule, nodule, or pustule that progresses to an injured lesion with unknown boundaries. In this study, a case of Pyoderma gangrenosum is introduced after breast surgery. A 38-year-old woman with a 3 cm wound in the right breast area that has gradually grown has been examined for exudative bloody discharge for the past 2 weeks. Two weeks after breast surgery, a three-centimeter progressive wound has formed on the surface of the breast, which gradually grew larger. During treatment, several oral and injectable antibiotics were prescribed that have not been effective in healing the wound. A biopsy lesion was reported in which a non-specific skin lesion with hyperplasia and vesicle formation without malignancy was reported. The patient had no gastrointestinal symptoms. Infliximab was started and continued for the patient. Conclusion: In the differential diagnosis of resistant skin wounds, especially in the leg area, and in this case in the breast the diagnosis of pyoderma gangrenosome should always be considered. Even if the patient has no history of inflammatory bowel disease, pyoderma gangrenosum may occur before intestinal manifestations.

Management of Recurrent Aphthous Stomatitis Major in a Bipolar Affective Disorder Patient with Food Allergy

This is the case of a 35-year-old female diagnosed by medical and psychiatric examinations as suffering from bipolar affective disorder and food allergy. Evident characteristic included mood swings. Her main complaint was extensive painful ulcer on the palate and lower lip. Current condition had caused her weight loss. Management included anamnesis, clinical and laboratory examinations, psychometrics, and referral to a psychiatrist. The dentist played an important role in identifying recurrent aphthous stomatitis and in the optimal and comprehensive treatment of the patient through multidisciplinary assessment.

Urinary Tract and Genital Infections including Sexually Transmitted Infections (STIs)

Urethritis, characterized by inflammation of the urethra in men, is caused by Neisseria gonorrhoeae (gonococcus), Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. Other causes of non-gonococcal urethritis include ureaplasmas, adenoviruses, and herpes simplex viruses. The presence of urethritis is confirmed by the presence of five or more polymorphs in urethral smear by high-power microscopy. Symptoms can be minor to profound and vary from clear to mucopurulent discharge. Gonococcus is commoner in men who have sex with men (MSM) compared to heterosexuals, and high-risk activities such as chemsex parties increase spread with significant public health consequences. Antibiotic resistance in gonococcus has clinical and public health implications as three cases of extensively drug-resistant Neisseria gonorrhoeae with resistance to ceftriaxone (MIC = 0.5 mg/L) and high-level resistance to azithromycin (MIC > 256 mg/L) have been described compromising current treatment recommended by British Association for Sexual Health and HIV Guidelines (BASHH). In England an outbreak of high level azithromycin-resistant gonococcus has also been described by Public Health England (PHE), who alerted clinicians about the need for follow up and test of cure, contact tracing, and treatment failure. C. trachomatis infection can be treated with azithromycin 1g orally as a single dose or with seven days of oral doxycycline. Risk factors for chlamydia include age younger than twenty-five years, multiple sexual partners, and avoidance of barrier methods for contraception. Metronidazole 2g single dose or 400– 500mg twice daily for seven days is recommended for treatment of trichomonas, which can cause a moderate discharge in up to 60% of males. Resistance to azithromycin and doxycycline is common in M. genitalium strains and management of these patients with urethritis requires GUM referral for comprehensive investigation, contact tracing, and public health notification. Molecular methods are used for the diagnosis of these organisms and gonococcal culture is undertaken to obtain antimicrobial susceptibility data from patients with a previous diagnosis by molecular method, in GUM attendees, and their contacts. Herpes simplex infection results in a painful ulcer preceded by a vesicle. The diagnosis can be confirmed using polymerase chain reaction (PCR) tests of a swab taken from the vesicle or ulcer.