Saturday, September 15, 2018

85 yo man with sinus tracts for diagnosis

Presented by: Dr. Neha Sagar,
Resident physician, Chhattisgarh, India

The patient, an 85 yo man with no known past medical history, presented to our OPD with large lesion with sinuses tracts on back since past 4 years. 

The lesion appeared as small sinus tracts with swelling over the right sided back.  These were pruritic in nature with  slowly & progressively increasing in size over 1 year & the lesion has not increased in size since past 3 years.   There was no history fever or cough or any other lesions noted.  He is not diabetic nor hypertensive.

No h/o specific medicinal intake or food allergy noted by the patient preceding the back lesion.

On examination:
A large lesion of approx 25 x 15 cm in size papular in nature with multiple discharging pustules noted over the same; scratch marks are present..
Swelling firm in consistency; & skin over the lesion is non-adherent to the lesion; Lesion is freely mobile over the base of scapula & muscles.

Clinical Photos:

 There are no specific systemic finding.

We approached this skin lesion as mycetoma or fungal infection; Scrofuloderma was also one of the D/D. But the skin biopsy revealed “Lobular Capillary Hemangioma.”

Path Report:
What other D/Ds can this lesion be?? 

How should we treat such lesion? How long can we treat this patient medically??
What specific counselling in terms of resolution of skin lesion should be done for the patient?
When can we consider surgical option (? wide excision); if any? What are the specific indications of the surgical removal of the lesion? 


  1. Comment of Jag Bhawan, Professor of Dermatology at Boston University: Lobular capillary hemangioma is not likely, given the clinical! It could be a sampling issue. Multiple biopsies should be performed including the one from a discharging lesion. The lesions should also be cultured.

  2. based on the 4-year chronic history and presence of multiple discharging sinuses and pustules in a large localised swelling, chronic infective causes need to be considered eg deep fungal, TB, as well as nocardia infection (mycetoma).
    Aerobic culture in blood agar/ TB culture/ fungal culture from the biopsy materials would be useful. KOH stains, Gm, PAS, AFB stains would all be contributory to the diagnosis. One interesting point in the skin biopsy form noted the presence of possible black granules. Probably nocardiosis. Suggest repeat biopsy from a representative site and send for HPE and aerobic culture in blood agar too. The sero-purulent materials and granules can be sent for KOH exam and may show multilobulated vermiform grains of Nocardia.

  3. From Krystal Jones, Fellow in Pediatric Dermatology, The Children's Hospital, Boston:
    Path showed “lobular capillary hemangioma” aka pyogenic granuloma, which can look just like granulation tissue under the scope. If they cut deeper they’d probably see the splendore hoeppli phenomenon somewhere. They didn’t do any infectious stains on path. I would worry about mycetoma, just as they did, and rebiopsy for tissue culture. They may be able to see sulfur granules on gram stain also....

  4. From Professor Khalifa Sharquie, Baghdad, Iraq: This is suppurative apocrine acne localized to back only and treatment will be Accordingly [in this case, low dose isotretinoin - 20 mg per day - would be safe and possibly helpful. DJE]

  5. From Dr. Yoon Cohen, Falmouth, Maine:
    I agree with the presenter's thoughts. The pathology report does not seem to reflect his clinical presentation with history. I think it is important to rule out deep fungal infection (mycetoma bacteria vs fungi, lobo, chromo, nocardiosis, etc / Mycobacterial infection (cutaneous TB, or atypical mycobacterium) by adding tissue culture, AFB, etc.

    I wonder if empirical therapy for fungal/bacterial infection should be considered.

  6. From Dr Ong Cheng Leng, Malaysia:
    At time like this, you will wish you work together with at least one senior dermatologist, who will take a look at the case and tell you the good news. " I have seen this before....."

    But we do have more that that advantage in VGRD, pooling young and old minds together.

    Clinically the multiple sinuses make scrofuloderma less likely. Hidradenitis suppurativa is out of place, location wise, and also the age group does not fit in.

    When we get stuck, we may want to reverse our gear and work backwards from the histopathology. I would not dismiss the pathologist input as the multiple popular lesions draining into the sinus may be individual pyogenic granuloma ( lobular capillary hemangioma), after all they are isomorphic. We are used to seeing single pyogenic granuloma, why can't they exist in a bigger number, due to the same underlying cause? Of course we have to dig deeper for possible causes, but we would not be too disappointed since pyogenic granuloma usually eludes us looking for its cause.

    May I suggest if we are still clueless, therapeutic trials that won't do more harm than the condition:-

    Firstly, try a course of cotrimaxazole three tablets twice daily, if he is not allergic to it. Actinomycosis and nocardiasis may respond. Are these diseases endemic in his part of India?

    Failing which a course of vitamin A analogues in low dose, eg isotretinoin.

    Lastly, tender loving care on top of symptomatic treatments. Thank God it has stopped progressing.

    1. Thank You so much for your reply. & I am sorry that i could not reply earlier.

      We have tried to convince him to stay back for multiple biopsy; but had to leave for some family emergencies. We have currently treated him just the way you suggested & have called him back for repeat Biopsy.
      Thank you so much for your opinion.

  7. from Professor Bhushan Kumar, PGIMER Chandiagrh:
    Thanks for the honour.

    1. Nocardiosis

    2. Actinomycosis


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