Letters to the Editor

Marjolin’s ulcer: A rare report Sir, Marjolin ulcer is the term commonly used to describe squamous cell carcinoma (SCC) arising on scar tissue. It is a malignant transformation of a chronic ulcer, sinus tract, fistula or longstanding scar of various etiologies. Jame Nicholas Marjolin in 1828 published the classical description of Marjolin’s ulcer. The most frequent malignancy that develops in burns scars is squamous in type.[1] Melanoma, schwannoma, sarcoma, trichilemmal carcinoma have also been described.[2] Limbs are the common site for Marjolin’s ulcer. Two different clinical presentations are common ulcerative form and less frequent, exophytic papillary form.[3] We report a case of a 58-year-old lady who developed ulcerative and exophytic mass from a 10 year old burns scar over the back She reported with discomfort over the back to the family physician who found and ulcer over the scar and suspected malignancy. Within four months, the ulcer rapidly progressed to a cauliflower-shaped growth. She was not a diabetic or hypertensive. There was no family history of malignancy. On examination, there was a large exophytic ulcerated growth and a small superficial ulcer arising from a large depigmented atrophic scar over the back [Figure 1]. There was no lymphadenopathy. The other skin and mucosal sites appeared normal. Relevant investigations were normal. Histopathology showed a welldifferentiated SCC with horn pearls [Figure 2]. She was advised radiation therapy. The exact pathogenesis of Marjolin’s ulcer remains unclear. Theories suggest that cellular mutations as a result of toxins released by damaged, ischaemic and nutritionally deficient tissues are responsible for neoplastic change, with a locally impaired immune function contributing as trigger. Persistence of burns ulcer, induration or elevation of margin of such ulcer, ulceration or nodule formation over a burns scar may indicate malignant transformation. The latent period is shorter in elderly and in cases of basal cell epithelioma. Metastasis among squamous carcinomas following a burns scar is much more common than among those associated with actinic damage.[4] Punch biopsy should be avoided, due to the focal nature of the malignant changes in burn scar.[5] In our case, the spine region being more prone for pressure-induced damage, the resultant necrosis could have initiated the malignant process. This case is reported the rarity of occurrence of Marjolin’s ulcer over the back, presenting as both ulcerative and exophytic growth. Even a small abrasion over a long standing burns scar should be viewed with suspicion. All burn scars should be grafted as the incidence of carcinoma is reduced if such wounds are grafted at an early stage.

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Figure 1: An exophytic ulcerated growth and a small superficial ulcer with intervening erosion over a large depigmented atrophic scar

Figure 2: Histopathology H and E, ×400 showing well-differentiated squamous cell carcinoma with horn pearls

ACKNOWLEDGMENT We acknowledge the Department of Pathology, Thanjavur Medical College for facilitating in getting the histology slide.

Kumar Parimalam, M. Vinnarasan, G. Senthil, V. Arumugakani, B. M. Amutha Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1

Letters to the Editor Department of Dermatology, Thanjavur Medical College, Thanjavur, Tamil Nadu, India Address for correspondence: Dr. Parimalam Kumar, Old 33A, New 4/1, East Ellaiamman Koil Street, Dr. Radhakrishnan Nagar, Thiruvottiyur, Chennai - 60 0019, Tamil Nadu, India. E-mail: [email protected]

REFERENCES 1.

2.

Tamura A, Ohnishi K, Ishikawa O, Miyachi Y. Flow cytometric DNA content analysis on squamous cell carcinomas according to the preceding lesions. Br J Dermatol 1996;134:40-3. Ko T, Tada H, Hatoko M, Muramatsu T, Shirai T. Trichilemmal carcinoma developing in a burn scar: A report of two cases. J Dermatol 1996; 23:463-8.

Hypersensitivity reaction to scorpion antivenom Sir, A 21-year-old female patient was admitted to our hospital with generalized rash and severe itching since five days after being stung by a small yellow scorpion on her abdomen and receiving scorpion antivenom. According to her detailed history, on the day of the accident, she had presented to a local emergency department (ED) complaining fatigue and burning sensation at the site of the sting. The physician in the ED had intramuscularly administered one ampoule of polyvalent scorpion antivenin after skin test. However, the indication of the administration of antivenin was not clear. The antivenom used was purified polyvalent anti-scorpion serum produced by the Razi Vaccine and Serum Research Institute in Iran. The serum was prepared from the purified plasma of healthy horses immunized with venoms of the six dangerous scorpion species in Iran including Odontobuthus doriae, Mesobuthus eupeus, Androctonus crassicauda, Buthotus saulcyi, Buthotus sach and Hemiscorpius lepturus. This antivenin is usually presented in the 5-mL ampoules. Three hours after receiving the antivenom, she had developed the current symptoms which had improved with corticosteroids and antihistamines but had continued to relapse and remit. In our hospital, examination showed edematous, urticarial plaques intermixed with generalized flushing [Figures 1 and 2]. Neither lymphadenopathy nor discrete urticarial wheals were observed. The oral cavity and conjunctivae were not involved. The history, presentation and Naranjo adverse drug reaction probability score of nine[1] led to the diagnosis of immediate hypersensitivity reaction to scorpion antivenom. High doses of prednisolone and hydroxyzine were administered with sustained improvement of her signs and symptoms over 10 days. Indian Dermatology Online Journal - 2014 - Volume 5 - Supplement Issue 1

3. 4.

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Das S, Roy AK, Maiti A. Marjolinulcer with multifocal origin. Indian J Dermatol 2009;54:14-5. Arons MS, Lynch JB, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. I. A clinical study with special reference to burn scar carcinoma. Ann Surg 1965; 161:170-88. Phillips TJ, Salman SM, Bhawan J, Rogers GS. Burn scar carcinoma. Diagnosis and management. Dermatol Surg 1998;24:561-5.

Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.144534

Scorpion stings have local and systemic effects. [2-5] Mild envenomations can be managed by supportive care. However, severe and life-threatening envenomations should be treated with scorpion antivenoms although the use of these products has potential risk of immediate and a more delayed-onset form of hypersensitivity reactions. [2,6-8] This case shows that a hypersensitivity skin test is ineffective

Figure 1: Edematous, urticarial plaques and generalized flushing on the patient’s back

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Marjolin's ulcer: A rare report.

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