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An unusual cause of ulcer

An 82-year-old Caucasian man was referred to respiratory medicine with a three-month history of dry cough, lethargy, and weight loss. He was previously well with no significant medical history. His general practitioner had treated him with two courses of oral amoxicillin and one course of oral clarithromycin, both producing dramatic but transient improvement in his symptoms. He was a retired electrician but denies any exposure to asbestos and never smoked. He denied recent or past exposure to tuberculosis. A chest radiograph performed after his first respiratory team consultation showed right basal shadowing. A computed tomography scan of his chest subsequently showed right-sided bulky hilar nodes and ipsilateral calcified pleural plaques suggestive of mesothelioma (Fig. 1). With a working diagnosis of mesothelioma, he underwent a computed tomography-guided pleural biopsy. The pleural tissue histology consisted of a chronic inflammatory, fibrotic process with no evidence of malignancy. Bacterial and fungal cultures from pleural sampling were all negative. Three weeks after the pleural biopsy, he developed an 8 · 2 cm non-tender cutaneous ulcer around the biopsy entry site (Fig. 2). Fine needle aspirate of the ulcer showed a mixed inflammatory cell infiltrate. Ultrasound of surrounding tissues showed a strand of hypoechoic chord from an ulcer on the right, in continuation with the 12th rib, which has a connection to fibrotic pleura. A dermatological opinion was sought at this time. Four punch biopsies were taken from each quadrant of the ulcer, and the debrided curettings of the ulcer’s central portion were all sent for histological analysis. Multiple swabs from the surface of the ulcer were sent. All the wound swabs were negative for organisms. The punch biopsies all showed inflamed granulation tissue. Curettings from the central portion of the ulcer revealed necrotic, inflamed granulation tissue with collagen deposition, which was positive for both periodic acid-Schiff and Grocott stains, suggestive of actinomycosis (Fig. 3).