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An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 2011
WHAT IS YOUR DIAGNOSIS?
Nilton Di ChiacchioI; Susana Lu Chen WuII; Felipe Kezan GabrielIII; Diego Leonardo BetIV; Nilton Gioia Di ChiacchioIV
IPh.D. in Dermatology, School of Medicine, University of São Paulo (USP) - Head of the Dermatology Clinic at the City-Civil-Servant Hospital (Hospital do Servidor Público Municipal) (HSPM-SP) - São Paulo (SP), Brazil
IIPhysician Assistant, Dermatology Clinic, São Paulo City-Civil-Servant Hospital - São Paulo (SP), Brazil
IIIResident Physician, Dermatology Clinic, São Paulo City-Civil-Servant Hospital - São Paulo (SP), Brazil
IVResidents of the Dermatology Department, Taubaté School of Medicine, São Paulo, Brazil
Patients presenting with plantar puncture wounds with presence of foreign bodies are treated in emergency departments, dermatology and orthopedic clinics. The clinical features of these lesions are rarely cited in journals and textbooks of dermatology. We report a case of foreign body in the plantar surface of the foot, in which clinical history and dermatological examination were decisive for the diagnosis.
Keywords: Cutaneous fistula; Foreign bodies; Procedimentos cirúrgicos ambulatórios
A 65-year-old black male patient from São Paulo presented with an injury, which had been present for a year, in the left foot due to having stepped on a piece of iron. He was treated with systemic antibiotherapy (azithromycin), with clinical improvement. Six months later, the patient noticed a painful lump with drainage of secretion, sometimes yellowish, sometimes purulent, on the site of the scar. For eight months, in addition to diagnostic investigation, he was treated with antibiotics and NSAIDs, with periods of improvement and aggravation. The patient had personal history of improperly treated hypertension and chronic alcoholism.
A dermatological examination showed the presence of suppurating fistula with hyperkeratotic border of about 2cm in diameter in the left high arch. Around the lesion, brownish macules of varying sizes and unclear boundaries could be observed (Figure 1).
Direct mycological examination and fungal culture were negative.
An ultrasonography showed nodular image with calcic walls of 0.9 cm in diameter, 1 cm away from the skin, in the plantar arch, and another hypoechoic nodular area with bosselated contours, measuring 2.3 X 2.5 X 2.4 cm at the level of the 4th metatarsal bone, which invaded muscles (Figure 2). A CT scan revealed a hyperdense, heterogeneous, irregular nodular image close to the 2nd metatarsal head, with no periosteal changes of a likely cartilaginous nature. Magnetic resonance revealed an aspect compatible with chronic inflammation associated with foci of inflammation / infection of fungal origin, in addition to small images of partially clear borders, which could be related to areas of edema.
Anatomopathological examination showed ulcerated, suppurating, chronic inflammation with extensive fibrosis. Research on fungi and AFB were negative.
Given these results and after careful observation of the dermatologic lesion (fistula with hyperkeratotic borders), the possibility of a foreign body was suggested and an exploratory surgery was carried out. After incision, the fistulous path was followed until a black fragment was found, identified as a piece of rubber (Figure 3). When enquired about it, the patient reported wearing black "Havaianas" sandals when the accident occurred, confirming the characteristics of the removed fragment.
Cases of puncture lesions with foreign body in the feet are treated in emergency departments, dermatology and orthopedic clinics.1 Skin lesions resulting from plantar-surface foreign bodies, despite their frequent and repetitive characteristics, are rarely mentioned in textbooks or journals of dermatology, complicating the diagnosis. We found only one case report of a foreign body in the posterior nail fold, resulting from resin after bone graft, where the author describes the injury as a suppurating fistula with inflammatory signs. 2 Differential diagnosis must be conducted with bone tumors and soft parts of the feet, 3 furuncular myiasis, 4 acral lentiginous melanoma5 and deep mycoses. 6
Direct mycological exams, fungal cultures and histopathological exams help to differentiate it from fungal infections and neoplasms. Despite the possibility of isolation of opportunistic fungi, these fungi disappear after removal of the foreign body. 6
Ultrasonography is the most useful imaging method in the diagnosis when compared with X-ray, CT scan and MRI. 7
Some complications due to delay in the diagnosis and treatment of the foreign body may be observed, such as plantar fascia lesions,8 superficial cellulitis, osteomyelitis, septic arthritis9 and secondary infections. 10
Surgical removal of the foreign body is mandatory so that clinical improvement can be observed.11
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Mailing address: Approved by the Editorial Board and accepted for publication on 15.12.2010. * Work conducted at São Paulo City-Civil-Servant Hospital (Hospital do Servidor Publico Municipal de São Paulo) - São Paulo (SP), Brazil.
Nilton Di Chiacchio
Rua Dr. Cesar, 62, conj. 35, Santana
02013-000 São Paulo (SP), Brazil
Conflict of interest: None
Financial funding: None
Approved by the Editorial Board and accepted for publication on 15.12.2010.
* Work conducted at São Paulo City-Civil-Servant Hospital (Hospital do Servidor Publico Municipal de São Paulo) - São Paulo (SP), Brazil.