Persistent Wound on the Neck

[JNUS]

CLINICAL BACKGROUND

A 43-year-old man with no significant medical history presents to his primary care provider (PCP) complaining of a "wound that won’t get better" on the left side of his neck. He states that the wound has been slowly growing over the past 2 years after it first appeared as a small pimple. In his efforts to heal the wound, he has used a variety of over-the-counter topical remedies such as hydrogen peroxide and triple antibiotic ointment; however, the wound has continued to spread and worsen. He was finally encouraged to visit his PCP when his brother noticed the now several-centimeters-long lesion (see Images 1-2). The patient denies having weight loss, fevers, or chills. He has not traveled during the past 5 years.

On physical examination, the patient is somewhat overweight. His vital signs are normal except for a blood pressure of 165/93 mm Hg. The examination of the head, eyes, ears, and nose is unremarkable. The patient has a 10-cm ulcer at the collar line on the left side of his neck. A homemade dressing that the patient had placed on this lesion contains a small amount of serosanguineous fluid. No lymphadenopathy and no masses are noted around the neck or in the armpits. The patient’s lungs are clear, and his heart rate is regular with normal heart sounds. The rest of the physical examination findings are unremarkable, except for numerous small hyperpigmented macules on the patient’s chest and back.

What is the most likely diagnosis, and what is the diagnostic test of choice?

HINT
The ulcer is chronic, is nonhealing, and has a smooth border.

[de.malady]

'with no significant medical history'?!
to me, he seems to be missing on his blood sugar level comlicating that simple ulcer to a diabetic one,, may be that 'tatto' life style he has also hints something useful,, [but i'm lost]..

[Rajiv]

what about (if available) ESR, CRP, LDH, Albumin.. ?

He has not traveled during the past 5 years.

where is the patient from (country) ? If he is e.g. from India or Malawi, he does not need to travel away to get a sort of infectious disease.

With info provided I would go for skin disease. It can be cutaneous tuberculosis or skin cancer.

Great pics. If you know the answer (which I guess for obvious since you have given the hint) give DD, we will then try to sort out.

thanx for sharing

[Walrus]

Could be Basal Cell Carcinoma.

We need a biopsy.

But, we need few more data like Rajiv said.

[JNUS]

Patient is from United States.
He states that the wound has been slowly growing over the past 2 years after it first appeared as a small pimple.
No lymphadenopathy and no masses are noted around the neck or in the armpits...
lungs are clear, with no h/o TB present , past.

D/D :
Tubercular Sinus
Diabetic Non Healing Wound
Basal Cell Carcinoma
Malignant Melanoma

[Walrus]

I stay with my diagnosis.

[Rajiv]

I go for one of my two diagnoses, id est skin cancer (Basal Cell Carcinoma)

[JNUS]

Walrus / Rajiv : Remain stick to ur answer and u gonna win it..

[JNUS]

ANSWER

Basal cell carcinoma (BCC): The diagnosis is advanced BCC of the neck. Most skin cancers can be placed into 1 of 3 categories: malignant melanomas, which have the highest rate of metastasis; BCCs, which almost never metastasize but can be locally invasive; and squamous cell carcinomas (SCCs), which are locally invasive and also occasionally metastasize.

Exposure to UV radiation is the most common and important etiologic factor for BCC. The UV spectrum of sunlight is divided into long-wave (UV-A, 320-400 nm), intermediate-wave (UV-B, 290-320 nm), and short-wave (UV-C, 200-290 nm). UV-B and UV-C can alter nucleic acid bonds, leading to mutations caused by the activation of oncogenes or by the inactivation of tumor suppressor genes. UV-C does not penetrate the atmospheric ozone layer; therefore, UV-B is the primary culprit for most skin cancers. Areas of skin exposed to the sun, such as the head and neck, are affected in 75-80% of cases. The nose, specifically the nasal tip and alae, are common locations for BCC.

Other etiologic and risk factors associated with BCC are exposure to other forms of radiation, arsenic exposure, immunosuppression, xeroderma pigmentosa, Bazex syndrome, and previous nonmelanoma skin cancers.

Seven clinical and histologic subtypes of BCC are described. The most common form is nodular BCC, which typically results in waxy papules with a central depression, a pearly appearance, erosions or ulcerations, crusting, rolled or raised borders, translucency, telangiectasias over the surface, and a history of bleeding with minor trauma. Pigmented BCCs contain increased amounts of brown or black pigment and are most common in individuals with dark skin. Cystic BCCs are translucent blue-gray cystic nodules that may mimic benign cystic lesions. Superficial BCCs appear as scaly patches or papules that are pink to red-brown, often with central clearing. A threadlike border is common with superficial BCCs, and lesions usually occur on the trunk. The papules may mimic psoriasis or eczema, but they are slowly progressive and are not prone to fluctuations in appearance. Micronodular BCCs may appear yellow-white when stretched, and they are firm to the touch. They may have seemingly well-defined borders and may metastasize. Morpheaform and infiltrating BCCs can also metastasize and cause sclerotic plaques or papules. The borders are usually ill defined and often extend well beyond clinical margins. Ulceration, bleeding, and crusting are not common with morpheaform BCCs, which may be mistaken for scar tissue.

Skin cancers, such as BCCs, are best diagnosed by means of a shave or punch biopsy of the lesion. On histologic evaluation, a basaloid appearance of epithelial islands is a pathognomonic feature. The cells of BCC mimic germinative epithelium and have an increased nucleus-to-cytoplasm ratio.

Once the diagnosis is confirmed, BCCs can be treated medically or with surgical excision. Local therapy with chemotherapeutic and immunomodulating agents, such as 5-fluorouracil, interferon alfa-2b, and imiquimod, may be used to manage superficial and small lesions. In individuals with a history of BCC, 5-fluorouracil is used to treat subclinical lesions on areas of chronic sun exposure or on areas at risk (eg, basal cell nevus syndrome). Surgical options for treating BCC include curettage, excision, and cryotherapy. On areas of cosmetic concern, such as the face, Mohs micrographic techniques are used to minimize damage to healthy tissue and to improve the cosmetic outcome. When tumors are advanced, radiation therapy can be considered in addition to surgery. The patient in this case was treated by surgical excision.

Measures to prevent BCC include wearing protective clothing and sunscreens and avoiding sun exposure during peak hours of UV radiation, which are between 10 am to 4 pm.