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Interesting case for discussion, sending on behalf of a colleague - 50 yo male patient s/p surgical excision of large mass on neck. Wound vac applied after excision. Colleague is concerned about possible atypical or malignant etiology. Pt presented to ED 14 days prior to surgery w hx of “two pimples” that enlarged, and hx of mild fever at home. Was given Bactrim and keflex and sent home until day of surgery. Presented again 3 days prior to surgery because it “burst open”. Prior hx of large abscess on the same region 30 years ago. Pt has DM (A1c 12.9, HTN and had tonsillectomy years ago. No biopsy was taken prior to excision. Surgical specimen submitted to path: abscess and necrosis q cutaneous ulceration and pseudoepitheliomatous epidermal hyperplasia, focal atypical squamous proliferation. Pathologist could not exclude focal squamous neoplasia, and asked for more tissue. Second analysis pending. Attached are pics of mass/ulcer immediately before excision, post initial excision and 2 days post wound vac. Given limited information, what are your thoughts on the etiology of the wound?
Jun 7, 2019 by Elaine Horibe Song, MD, PhD, MBA
4 replies
Eugene Worth
Well, I’m certainly not the expert, but I have a couple of guesses. At first glance (first picture), I would have picked a fungating squamous cell carcinoma. The second picture looks like what I would expect. The last picture, however, has me scratching my head. I really want to know where (in the country) this case came from ... If in the major river valleys, I would hazard a guess that it’s cutaneous blastomycosis. If Mojave desert, then change that to cutaneous coccidiomycosis. So, I would recommend a dermatopathologist read this tissue and ask for a fungal stain, if for nothing else than to rule out these two insidious skin processes.

The clue to me was the ‘foamy’ appearance of the skin in the first picture. That suggests fungal etiology.

I’m going to sit on the sidelines now ... and see what develops. :-)
Jun 7, 2019
Nataliya Lebedinskaya
It does look like SCC, but multiple organism infection with his A1C could be present as well. This patient needs another Bx and bacterial and fungal Cx. not a place for guess work
Jun 7, 2019
Elaine Horibe Song
Thank you for your input! Agree that it looks like SCC at first glance. Amending caption of the third pic - Left: surgical wound, immediately after excision of the mass. Right: wound bed 2 days post NPWT with cleanse choice foam. Patient lives in Oklahoma. Nice suggestions regarding Ddx. Agree that dermatopathologist should read the tissue and rule out infectious etiology as well. Colleague sent another deep and margin specimen, will keep you posted on results. Thanks!
Jun 7, 2019
I have nothing to add. Agree w/ Gene and Nataliya. need path and max cultures including fungal and afb.
Jun 10, 2019
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