Lichen sclerosus following genital piercing.

Male genital lichen sclerosus (MGLSc) is a chronic inflammatory dermatosis that predominantly affects uncircumcised males. Several aetiological factors have been described, with growing evidence supporting chronic urine exposure of susceptible epithelium being crucial to its pathogenesis. We describe a 45-year-old man with a 2-year history of MGLSc at the site of a urethrocutaneous fistula secondary to a penile piercing. To our knowledge, this is the first documented case of MGLSc occurring at the site of a genital piercing.

Dermal tunnels influence time to clinical response and family history influences time to loss of clinical response in patients with hidradenitis suppurativa treated with adalimumab.

BACKGROUND: Clinical response in hidradenitis suppurativa (HS) is most commonly assessed using the Hidradenitis Suppurativa Clinical Response (HiSCR) measure. Dermal tunnels, increased body mass index, smoking and antibiotic use significantly decrease the odds of achieving HiSCR. However, there are few data exploring if clinical features are also associated with length of time to achieve clinical response and/or time to lose clinical response. AIM: To explore whether variables associated with achievement of HiSCR are associated with time to achieve HiSCR and time to loss of HiSCR in patients with HS treated with adalimumab 40 mg weekly in the PIONEER open-label extension study. METHODS: Time-to-event analyses were performed to estimate time to achieve HiSCR and time to loss of HiSCR. The log rank test was used to compare cumulative incidence curves for a priori patient- and disease-associated factors. Cox regression analysis was performed to compare time-to-event outcomes in the presence of a priori variables. All statistical analyses were completed with R software (V3.5.3). RESULTS: Presence of dermal tunnels significantly increased the time to achieve HiSCR (median 32.6 vs. 14.3 weeks, P = 0.02) and the hazard ratio (HR) was significant after controlling for patient and disease factors (HR = 0.70, 95% CI 0.51-0.96, P = 0.03). A positive family history of HS significantly decreased the time to loss of HiSCR (median 11.4 vs. 18 weeks, P < 0.001) and remained significant in Cox regression analysis (HR = 2.01, 95% CI 1.40-2.88, P < 0.001). CONCLUSION: The presence of dermal tunnels significantly influences the odds of achieving HiSCR and the time to achieve HiSCR, while family history influences time to loss of HiSCR.

Clinical, microbiological, immunological and imaging characteristics of tunnels and fistulas in hidradenitis suppurativa and Crohn's disease.

Hidradenitis suppurativa (HS) tunnels and Crohn's disease (CD) fistulas are a challenge to treat. Although pathogenic similarities have been described between HS and CD, recent studies indicate that clinical, microbiological, immunological and imaging characteristics differ between these diseases. This review highlights the differences between HS tunnels and CD fistulas. Next-generation sequencing studies demonstrate a microbiome in HS tunnels dominated by Porphyromonas spp., Prevotella spp. whereas no specific bacteria have been associated with cutaneous CD. Immunologically, TNF has been found upregulated in HS tunnels along with various interleukins (IL-8, IL-16, IL-1α and IL-1ß). In CD fistulas, Th1, Th17, IL-17, IFN-ɤ, TNF and IL-23 are increased. US imaging is an important tool in HS. US of HS tunnels depict hypoechoic band-like structure across skin layers in the dermis and/or hypodermis connected to the base of a widened hair follicle. In CD, MR imaging of simple perianal fistulas illustrates a linear, non-branching inflammatory tract relating to an internal opening in the anus or low rectum and an external opening to the skin surface. An increased awareness of the immediate potential differences between HS tunnels and CD fistulas may optimize treatment regimens of these intractable skin manifestations.

Refractory Complex Crohn's Perianal Fistulas: A Role for Autologous Microfragmented Adipose Tissue Injection.

BACKGROUND: Complex perianal fistulas represent one of the most challenging manifestations of Crohn's disease. Combined surgical and medical therapy with biologic drugs today represent the first-line treatment option, but its efficacy does not exceed 60%. Recently, new therapeutic approaches, such as the use of mesenchymal stromal cells, have shown promising results. The adipose tissue is an abundant and easy to access source. The effectiveness, safety, and feasibility of local injections of microfragmented adipose tissue in patients with refractory complex fistulizing perianal Crohn's disease (PCD) were evaluated. METHODS: Fifteen patients with persistent complex fistulizing PCD after biosurgical approach and subsequent surgical "rescue" repair were treated in S. Orsola-Malpighi Hospital with a single-local administration of microfragmented adipose tissue prepared using a minimal manipulation technique (Lipogems) in a closed system. Clinical outcomes were determined at 24-week follow-ups assessing success rate, defined as combined clinical and radiological remission. RESULTS: Upon clinical examination at 24 weeks, 10 patients had combined remission (clinical and radiographic), 4 patients showed improvements, and 1 patient failed. The results were confirmed in all patients by pelvic MRI. No relevant postoperative complications nor adverse events were reported. CONCLUSION: These results suggest that the local injection of autologous microfragmented adipose tissue is a safe and promising "rescue therapy" for patients with multiresistant complex fistulizing PCD. This approach might be proposed as routine because it is affordable, is minimally invasive, has no risk of sphincteric damage, and can be carried out in a day-surgery setting.

Suprapubic versus prepubic sinus: a literature review.

Urachal sinus usually presents with umbilical discharge and the opening can rarely be located between the umbilicus and the symphysis pubis and the so called suprapubic sinus (SPS). There is another different entity of cases reported in literature with a similar presentation but with an opening anywhere between the umbilicus and symphysis pubis but differs from SPS in the pathway of the tract and the epithelial lining. We report a case of a 2-year-old boy presenting with a prepubic sinus that was managed with surgical excision. After a thorough literature review, we compare our case to other prepubic and SPS.

Small bowel stricture is associated with abnormal motility on the cine MRI sequence in patients with Crohn's disease.

PURPOSE: A multiphasic cine sequence performed during magnetic resonance enterography (MRE) has been shown to increase diagnostic accuracy of MRE demonstrating limited movement in inflamed intestine in patients with Crohn's disease (CD). Our aim was to confirm in our study population that intestinal inflammation was associated with decreased motility and determine if factors suggestive of complicated disease such as the presence of a stricture or fistula were associated with decreased motility on the MRE cine sequence. METHODS: This was a retrospective study of 59 patients (mean age 40.8 ±â€¯16.1) with Crohn's disease who had a small bowel lesion on MRE. Two gastrointestinal radiologists independently scored MRE findings using a qualitative, subjective scoring system. Univariate and multivariable ordered logistic regression models were used to evaluate the associations between cine sequence score, radiologic image findings, and clinical data. RESULTS: On univariate analysis, radiologic findings reflecting active inflammation, the presence of a stricture, and penetrating disease were associated with decreased motility. On multivariable analysis, hyper-enhancement, the presence of a comb sign, and global evidence of active inflammation remained associated with decreased motility. Of the factors suggesting complicated disease, the presence of stricture (Odds Ratio 0.40, 95% Confidence Interval 0.17-0.95, p-value 0.038) was associated with decreased motility. CONCLUSIONS: As previously shown, well-established radiologic findings of bowel inflammation were associated with decreased small bowel motility. In this study, we have added that the radiologic finding of a fixed stricture is also associated with decreased motility.

Malakoplakia of the colon following renal transplantation in a 73 year old woman: report of a case presenting as intestinal perforation.

BACKGROUND: Malakoplakia is a chronic inflammatory disease characterized by tissue infiltrates of large granular macrophages containing distinctive intracytoplasmic inclusions termed Michaelis-Gutmann (MG) bodies. The genitourinary system is the most commonly involved site, followed by the gastrointestinal tract. Malakoplakia may occur as a complication of primary or secondary immunosuppression and, therefore, renal transplant recipients are at risk. The graft itself or extra-renal sites may be involved. Regarding the latter, six cases of colorectal malakoplakia have been reported following renal transplantation, with all but one patient experiencing significant morbidity. We describe a further example of colorectal malakoplakia following renal transplantation. The other previously reported cases are reviewed. CASE PRESENTATION: A 72 year old female presented with left lower quadrant abdominal pain and vaginal bleeding. She had received a cadaveric renal transplant for chronic renal failure ten months previously. Abdomino-pelvic computerized tomography (CT) scanning demonstrated two lesions in the mesocolon: the first adjacent to the descending colon and the second involving the sigmoid colon. A diagnosis of sub-acute perforated diverticulitis with two phlegmons was proposed. The sigmoid lesion was resected. The descending colon lesion was treated by creation of a cutaneous fistula. Microscopy of the sigmoid lesion showed the typical features of malakoplakia. She was discharged on sulfamethoxazole-trimethoprim. Nine months later, no longer receiving antibiotic therapy, the patient reported lower left quadrant discomfort. CT scanning showed para-rectal and pelvic abdominal masses with cutaneous and intestinal fistulas. Treatment with tazobactam-piperacillin was begun and sulfamethoxazole-trimethoprim was reinstated, with subsequent slow clinical improvement. Subsequent abdominal CT scans have shown persistence of the lesions. CONCLUSIONS: Physicians caring for renal transplant recipients should be aware of colorectal malakoplakia as a rare but serious complication. The onset may be within months or as long as a decade or more following transplantation. The clinical presentation is varied, nonspecific, and will likely suggest more common diseases. Although radiologic imaging is also nonspecific, awareness of malakoplakia is of importance to radiologists when formulating the differential diagnosis of mass lesions of the colorectum in this clinical setting. Definitive diagnosis remains dependent on pathologic examination of a biopsy or surgical resection specimen.

Congenital prepubic sinus presenting with purulent discharge after circumcision: a case report.

BACKGROUND: Congenital prepubic sinus is a rare anomaly found in the midline of the lower abdomen. Congenital prepubic sinus is usually asymptomatic in neonates, and a diagnosis is often achieved later in life after spontaneous extrusion of purulent material from the pre-existing hole in the pubic region. We present a case of congenital prepubic sinus presenting with purulent discharge after circumcision. A 4-year-old Caucasian boy presented to our urology out-patient clinic with purulent discharge from the distal part of the dorsum of his penis. He had a history of circumcision performed at a different center, 6 months ago. His parents stated that although various antibiotics were used, the purulent discharge continued for 6 months and the child had no complaints before circumcision. His condition was reported as superficial dorsal venous thrombosis, known as penile Mondor disease, in magnetic resonance imaging that was performed in the previous hospital. A physical examination revealed a small pinhole lesion at the distal part of his penis and a rigid cylindrical tube extending to the proximal side of his penis. We performed fistulography by injecting contrast material through a small angiocatheter and confirmed the diagnosis of prepubic sinus. Surgical exploration was performed and a long sinus, apparently ending as a fibrous tract at the anterior surface of his pubic symphysis, was found and resected. CONCLUSIONS: Before congenital prepubic sinus surgery, it is critically important to rule out penile Mondor disease and the possibility of a circumcision complication (especially infective complications) mimicking congenital prepubic sinus.

Healing of spongiosus-cutaneous fistula with Hyperbaric Oxygen Therapy (HBOT): a case report.

INTRODUCTION: We present a case of a spongiosus-cutaneous fistula in a 39-year-old man with recurrent episodes of cutaneous abscess in dorsal middle third penis (5 × 3 cm) treated with Hyperbaric Oxygen Therapy (HBOT). CASE REPORT: After emptying nodular abscess, the patient was noncompliant for further surgery. Therefore, it was suggested the association between HBOT and antibiotic therapy. HBOT is carried out in a hyperbaric room, where the internal pressure is increased (compression phase) by entering compressed air up to 283.71 kPa in about 10 minutes. Every HBOT cycle lasted 24 days in which the patient had been taking Amoxicillin/Clavulanic Acid 875 mg/125 mg 3 tabs/day and Sulfamethoxazole/Trimethoprim 160 mg/800 mg 2 tabs/day for 2 weeks. At the end of the treatment, a penile magnetic resonance imaging and an ultrasonography were executed and they evidenced a complete remission of the lesion. In the subsequent 22 months, there was no recurrence. CONCLUSIONS: Our results suggest that HBOT is an effective treatment for chronic wounds, including a spongiosus-cutaneous fistula of unknown cause, when used in combination with conventional standard therapy or further interventions. At present time, the gold standard remains surgery; nevertheless, our experience with HBOT may stimulate its use in clinical trials.

Comparison of pharyngocutaneous fistula closure with and without bacterial cellulose in a rat model.

OBJECTIVE: The present study aimed to compare the effects of bacterial cellulose used for closure of pharyngocutaneous fistulae, a complication of total laryngectomy, with those of primary sutures in a rat model. METHODS: Thirty female Sprague-Dawley underwent experimental pharyngoesophagotomy and were grouped depending on the material used for pharyngocutaneous fistula closure: group I, which received primary sutures alone, group II, which received bacterial cellulose alone; and group III, which received both. After 7 days, the rats were sacrificed. Pharyngocutaneous fistula development was assessed, the gross wound was inspected, and histological examination was conducted. RESULTS: Pharyngocutaneous fistulae developed in 12 rats (41%) in all: 6 from group I (21%), 4 from group II (14%) and 2 from group III (7%). CONCLUSION: Fibroblast density and inflammatory cell infiltration were significantly greater in group III than group I. We concluded that bacterial cellulose may be useful for pharyngocutaneous fistula closure.

Spontaneous external biliary fistula arising from an intrahepatic duct.

A spontaneous external biliary fistula is most commonly a cholecystocutaneous fistula secondary to acute cholecystitis. A fistula arising from an intrahepatic duct is extremely rare. An 87-year-old man presented with swelling of the epigastric region and right upper quadrant abdomen. He had a history of cholecystectomy and endoscopic sphincterotomy. After antibiotic treatment and surgical opening of both lesions, abdominal computed tomography demonstrated a soft tissue mass cephalad to the umbilicus. We excised the mass, and found it to be associated with a fistula through the linea alba. Fistulography showed an abscess cavity communicating with the intrahepatic duct in segment III. Histopathological examination of the mass showed an abscess without malignancy. The fistula closed spontaneously without laparotomy. In this case, the underlying pathology was considered to be associated with a subcapsular hepatic cyst in segment III.