Rare Case of Pyoderma Gangrenosum in the Setting of PAPA Syndrome in a 12-Year-Old Child

We report on a 12-year-old boy who presented with an intermittently painful wound present for months without any tendency to heal after a slackline accident two years ago. A biopsy of the ulcer margin revealed epithelial hyperplasia, marked fibrosis, and vascular proliferation without evidence of vasculitis. Pretibial findings on the right side were a 3.8 × 3.1 cm fibrin-covered, flat ulcer with slight reddening of the surrounding area. Other findings were unremarkable with hypermobility of the wrists and finger joints. Local therapy with a foam dressing, topical steroid in the wound margin, and class II compression stockings showed no effect. The pediatric rheumatologist evaluated the ulcer with a camptodactyly of digit 5, subluxation of the wrists on both sides, and symmetric ulnar deviation. Elevated S100 as an isolated autoimmune phenomenon or concomitant with systemic autoimmune disease or autoinflammation (eg, Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome) was also observed. The therapy with oral steroids, initially 30 mg/day and gradual reduction in the course, only achieved a tissue bridge's formation with the same size extension of the ulcer. Unfortunately, the patient spontaneously developed a second ulcer on the left lateral malleolus, which is why the therapy was changed to dapsone 50 mg/day and tacrolimus in the wound margin after nine weeks. In the absence of success, further treatment with ciclosporin or tumor necrosis factor-alpha antibody therapy is planned in interdisciplinary cooperation.

Frequency of Helicobacter pylori in perforated peptic ulcer cases in a tertiary rural hospital

Background: Helicobacter pylori infections have proven to be associated with gastritis and peptic ulcer, adenocarcinoma, gastric lymphoma. But its association with peptic ulcer perforations has not been completely proved. This study is intended to find out the association and give clarity of the pathology. The objective of the study was to observe the presence or absence of H. pylori in perforated peptic ulcer disease by obtaining biopsy from ulcer margin for rapid urease test, giemsa staining as well as serological method (antibodies IgA and IgG)Methods: This is an observational non-blinded study carried out in all cases of perforated peptic ulcer reporting in surgical wards, Emergency Department of the medical college during 2016-2018. Biopsy was taken from the ulcer margin and the tissue was subjected to histo-pathological examination, rapid urease test and blood sample was sent for serological examination.Results: Of the 46 patients participated in our study, 41 (89.1%) happened to be male, 5 (10.9%) were female. Only 2.2% of the patients were positive for H. pylori and remaining 95.7% were negative for H. pylori. The difference in the age group and H. pylori infection was found to be not statistically significant (p>0.05).Conclusions: In our study, frequency of H. pylori in perforated peptic ulcer cases was found to be only 2.2% which proves that there may be other contributing factors in perforated peptic ulcer cases, which need to be further evaluated.

Measuring sensory and pain thresholds by Semmes-Weinstein monofilaments in patients with leg ulcers: a pilot study

Objective: Pain is a common and disabling symptom in patients with leg ulcers. Clinical quantification of pain mostly depends on subjective pain reports, which do not reveal underlying mechanisms. The aim of this pilot study is to identify mechanisms underlying the pain in patients with leg ulcers by documenting alterations in pain processing using quantitative sensory testing. Methods: In nine ulcer patients the mechanical sensory thresholds and the mechanical pain thresholds were determined by Semmes-Weinstein monofilaments (SWM) at three different sites: on the contralateral (unaffected) leg, on the skin of the affected leg 10cm from the ulcer margin, and on the affected leg, close (1–2cm) to the ulcer margin. Besides the mechanical sensory thresholds and mechanical pain thresholds, pain at the site of the ulcer, using an 11-point numeric rating scale (NRS), was documented. Results: Mechanical sensory thresholds were increased in all subjects. Almost half (44%) of patients consistently showed allodynia at the unaffected site. The lowering of mechanical pain thresholds correlated with higher scores on the NRS. Conclusion: All patients showed diminished touch and/or protective sensation, which might have contributed to ulcer development via (partial) loss of protective function. The allodynia at the unaffected site suggests the presence of central sensitisation of pain processing.

Tuberculosis of the Oral Cavity Affecting Alveolus: A Case Report

We report a first case of tuberculosis of oral cavity affecting the left alveolus from Nepal in a 63-year-old male who came to otorhinolaryngology outpatient department with a complaint of an ulcer in the oral cavity and pain in bilateral ear and throat. An ulcer measuring 1.8 cm in diameter with irregular friable margin and bleeding on touch was found in the left upper alveolar region of the oral cavity. Biopsy from the ulcer margin revealed histological features of necrotizing granulomatous lesion. Stain for acid fast bacilli was positive.

Expression der Gewebe- und Plasminogen-Aktivator-Aktivitäten bei chronischen venösen Ulzera

Background: Chronic wounds have been shown to exhibit elevated levels of several classes of proteinases. Plasminogen activators (PAs) are proteinases which play a major role in the biological processes involved in wound healing and abnormalities in PAs may play a role in the pathology associated with chronic wounds. Here, we investigated the expression of tPA and uPA activities in chronic venous ulcer biopsies. Patients and methods: In 22 patients with chronic venous leg ulcers, punch biopsies were taken from the ulcer base, ulcer margin and uninvolved skin from the thigh of the affected limb and PA activities were assessed using in situ histological zymography. Results: tPA is the main PA activity in uninvolved skin but was reduced in ulcer margin skin and venous leg ulcer tissue compared to normal skin. uPA activity appeared throughout the ulcer margin skin but was at low levels in normal skin. Ulcer base tissue appeared to exhibit a plasminogen-independent proteinase activity not seen in normal or ulcer margin skin. Conclusion: PA activities are altered in and around chronic venous leg ulcers and their distribution suggests that blood vessels in CVI may be damaged and that the tissue is in an inflamed state.

Cigarette smoking delays ulcer healing: role of constitutive nitric oxide synthase in rat stomach

Epidemiological studies have shown that cigarette smoking is associated with peptic ulceration. This study aims to investigate the mechanisms by which cigarette smoking delays ulcer healing in rats. Gastric ulcers were induced by applying acetic acid to the luminal surfaces in rats. Twenty-four hours later, rats were exposed to different concentrations of cigarette smoke (0, 2, or 4%) for a 1-h period once daily for 3 or 6 days. Cigarette smoke exposure delayed ulcer healing and decreased gastric blood flow and angiogenesis at the ulcer margin. These changes were accompanied by a significant reduction of constitutive nitric oxide synthase (cNOS) activity but not PGE2 production and vascular endothelial growth factor levels. Administration ofl-arginine (10 mg/kg iv) completely reversed the adverse actions on ulcer healing, gastric blood flow, and angiogenesis in the mucosa at the ulcer margin but partially restored angiogenesis in granulation tissues. In conclusion, cigarette smoke exposure delays ulcer healing through depression of gastric blood flow and angiogenesis at the ulcer margin. Reduction of cNOS expression and activity is suggested to be involved in these ulcerogenic processes.