Wegener's granulomatosis of the breast: a rare entity with daily clinical relevance

Cat Scratch Disease of the Breast/Axilla: Recognition of a Rare Disease and Approaches for Differential Diagnosis

Cat scratch disease rarely presents as a breast or axillary mass mimicking carcinoma both clinically and radiologically. Diagnosing breast/axillary cat scratch disease is challenging due to its rarity and nonspecific findings. Here, we reported 2 patients with breast cat scratch disease and reviewed 14 patients with cat scratch disease involving breast/axilla from the past 30 years. It mainly affects women (median age: 48), consistently presenting as axillary lymphadenopathy, and demonstrates ipsilateral breast mass in half of patients (50%, 8/16). The breast mass was most commonly located in the upper outer quadrant (88%, 7/8), indicating the possibility of disease extension from axillary adenopathy. Around half of patients (56%, 9/16) reported cat exposure. Histologically, most patients (93%, 14/15) presented as necrotizing granulomas, with characteristic stellate-shaped necrosis in 5 patients. Although pathologic differential diagnoses between cat scratch disease and cancer are straightforward, distinguishing cat scratch disease from other granulomatous mastitis poses diagnostic challenges. Silver stains should be included in the diagnostic workup panel when highly suspecting cat scratch disease clinically. However, they were only able to highlight the causative microorganism in 54% (7/18) patients, and the gram stain was negative in all 12 tested patients. In contrast, polymerase chain reaction (PCR) for the causative microorganism was consistently positive in all 3 tested patients, while serologic test confirmed diagnosis in 85% (11/13) patients; 1 patient with negative serology showed a positive PCR result. Therefore, upfront PCR tests with or without serologic study should be considered to confirm the diagnosis of cat scratch disease in a timely manner.

Inflammatory Lesions of the Breast

CONTEXT.—

Inflammatory lesions of the breast are rare but not infrequently pose problems both clinically and morphologically, particularly on needle core biopsies. These lesions range from acute inflammatory conditions to chronic lymphoplasmacytic and lymphohistiocytic to granulomatous inflammatory diseases.

OBJECTIVE.—

To provide a comprehensive overview of inflammatory lesions of the breast, with etiopathogenesis and clinical, radiologic, and pathologic features as well as differential diagnostic considerations, clinical management, and prognosis.

DATA SOURCES.—

The existing literature in the English language, including original research articles and review articles describing inflammatory lesions of the breast.

CONCLUSIONS.—

Inflammatory lesions of the breast are characterized by a wide variety of clinical, radiologic, and morphologic features. The histopathologic differential diagnosis often includes a neoplastic process requiring ancillary studies and correlation with clinical and radiologic findings. Although most specimens display nonspecific findings precluding a definitive pathologic diagnosis, pathologists have a unique opportunity to play a crucial role in identifying key histologic features suggestive of certain entities, such as cystic neutrophilic granulomatous mastitis, immunoglobulin (Ig) G4 mastitis, or squamous metaplasia of lactiferous ducts, in the right clinical and radiologic context, and thereby guiding optimal and timely clinical management. The information presented herein will be helpful to practicing anatomic pathologists and pathology trainees in becoming more familiar with specific morphologic features and overcoming differential diagnostic challenges related to pathology reporting of inflammatory lesions of the breast.

Autoimmune rheumatic diseases associated with granulomatous mastitis

Granulomatous mastitis (GM) is a benign, inflammatory condition of the breast that mainly affects women of reproductive age. Although its pathogenesis remains unknown, previous studies revealed an association between autoimmune rheumatic diseases (ARDs) and GM in a subset of patients implicating immune-mediated mechanisms. The aim of this narrative review was to identify and describe the ARDs associated with GM to shed further light on disease pathogenesis. We conducted a comprehensive literature search of patients presenting with GM and coexisting ARDs using electronic databases. An association between GM and various ARDs has been reported, including sarcoidosis, systematic lupus erythematosus, granulomatosis with polyangiitis, psoriasis/psoriatic arthritis, familial Mediterranean fever, ankylosing spondylitis, Sjogren's syndrome, rheumatoid arthritis, and erythema nodosum, with the most common being granulomatous mastitis-erythema nodosum-arthritis syndrome (GMENA), granulomatosis with polyangiitis (Wegener's) and sarcoidosis. In addition, clinical characteristics, diagnostic and therapeutic approaches were recorded. Further research is warranted to better understand the association between GM and ARDs and raise awareness amongst rheumatologists.

Breast involvement in granulomatosis with polyangiitis: a case report

Background

Granulomatosis with polyangiitis (GPA) previously known as Wegener's granulomatosis is a rare complex immune-mediated disease and a multisystem disorder with varying presentations where many of the imaging features of GPA overlap with those of other diseases, and hence its diagnosis can be challenging.

Case presentation

Here we report a case of a 48-year-old female who presented with complaints of hemoptysis, difficulty in speech, bilateral progressive hearing loss and, a palpable lump in the right breast. The case was initially misdiagnosed as breast carcinoma but biopsy proved to be GPA. Here we present the multisystem manifestations of GPA involving the head and neck, breast, lungs, spleen with involvement of the breast being very rare. The breast lesion showed improvement with steroids on follow-up.

Conclusions

GPA is a multisystem disease and though breast lesions in GPA are rare, a thorough knowledge about this uncommon manifestation is required and clinical, radiological, and histopathological correlation is of utmost importance in the evaluation of a breast lesion in cases of multisystem involvement to avoid unnecessary surgeries. The differential diagnosis of breast tumors should include such rare conditions that can sometimes mimic breast cancer. Early diagnosis and initiation of the immunosuppressive treatment help in a better prognosis of the disease.

From Head to Toe: Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis (GPA) is an antineutrophil cytoplasmic antibody-associated vasculitis. It is an uncommon multisystem disease involving predominantly small vessels and is characterized by granulomatous inflammation, pauci-immune necrotizing glomerulonephritis, and vasculitis. GPA can involve virtually any organ. Clinical manifestations are heterogeneous and can be classified as granulomatous (eg, ear, nose, and throat disease; lung nodules or masses; retro-orbital tumors; pachymeningitis) or vasculitic (eg, glomerulonephritis, alveolar hemorrhage, mononeuritis multiplex, scleritis). The diagnosis of GPA relies on a combination of clinical findings, imaging study results, laboratory test results, serologic markers, and histopathologic results. Radiology has a crucial role in the diagnosis and follow-up of patients with GPA. CT and MRI are the primary imaging modalities used to evaluate GPA manifestations, allowing the differentiation of GPA from other diseases that could simulate GPA. The authors review the main clinical, histopathologic, and imaging features of GPA to address the differential diagnosis in the affected organs and provide a panoramic picture of the protean manifestations of this infrequent disease. The heterogeneous manifestations of GPA pose a significant challenge in the diagnosis of this rare condition. By recognizing the common and unusual imaging findings, radiologists play an important role in the diagnosis and follow-up of patients with GPA and aid clinicians in the differentiation of disease activity versus disease-induced damage, which ultimately affects therapeutic decisions. Online supplemental material is available for this article. ^©RSNA, 2021.

A Case of Granulomatosis with Polyangiitis with Various Breast Lesions as the Initial Symptoms: A Case-Based Review

A 44-year-old woman presenting with pus-like discharge from the nipples visited our hospital for scleritis. Subcutaneous induration and ulceration were found on her breast. She was diagnosed with granulomatosis with polyangiitis (GPA) considering scleritis, sinusitis, cutaneous granuloma formation, and antiproteinase 3-antineutrophil cytoplasmic antibodies and was successfully treated with glucocorticoids. Fifteen months later, she developed pulmonary consolidation and a right breast nodule. Biopsies of the breast nodule showed granulomatous vasculitis, and she was treated with rituximab. While breast involvement in GPA is rare, unilateral breast mass is a typical clinical feature; thus, GPA should be considered in such cases.

18F-Fluorodeoxyglucose positron emission tomography computed tomography detection of single organ vasculitis of the breast: A case report

RATIONALE

Although single organ vasculitis (SOV) is a rare occurrence and it is difficult to diagnose, its possibility as a cause of fever of unknown origin (FUO) must be considered. Recently, the usefulness of 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) in the diagnosis of unknown fevers due to vasculitis, especially in cases of small and medium-sized vasculitis, has begun to be pointed out.

PATIENT CONCERNS

We report the case of an 84-year-old woman with persisting fever for more than 2 weeks. She had no accompanying symptoms, other than fever, and the physical examination, echocardiography, and contrast-enhanced CT did not reveal any diagnostic clue.

DIAGNOSES

The FDG PET/CT revealed positive uptakes of FDG in the left breast, with a standardized uptake value (SUV) of 2.9. The biopsy specimen of the left breast lesion revealed rupture of the elastic plate and evidence of fibrinoid necrosis of arteries, leading to the diagnosis of polyarteritis (PAN). Further angiographic examination and additional imaging did not reveal the presence of other lesions. Therefore, the diagnosis was established as a PAN-SOV of the left breast.

INTERVENTIONS

This patient has improved with follow-up only.

OUTCOMES

There has been no evidence of a relapse of PAN over a 5-year follow-up period.

LESSONS

SOV presenting with unspecific local symptoms is difficult to diagnose based on the medical history and clinical examination. Our findings show that early "Combination of PET-CT and biopsy" can be a powerful diagnostic tool in patients with FUO for whom diagnosis of the underlying cause is difficult despite appropriate clinical examination.

Mastitis in Autoimmune Diseases: Review of the Literature, Diagnostic Pathway, and Pathophysiological Key Players

Mastitis frequently affects women of childbearing age. Of all the pathological breast conditions requiring specific management, autoimmune mastitis is in the third position after infection and breast cancer. The aim of this literature review was to make a comprehensive description of autoimmune diseases targeting the mammary gland. Four main histological patterns of autoimmune mastitis are described: (i) lymphocytic infiltrates; (ii) ductal ectasia; (iii) granulomatous mastitis; and (iv) vasculitis. Our literature search found that all types of autoimmune disease may target the mammary gland: organ-specific diseases (diabetes, thyroiditis); connective tissue diseases (such as systemic erythematosus lupus or Sjögren’s syndrome); vasculitides (granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, giant cell arteritis, polyarteritis nodosa, Behçet’s disease); granulomatous diseases (sarcoidosis, Crohn’s disease); and IgG4-related disease. Cases of breast-specific autoimmune diseases have also been reported, including idiopathic granulomatous mastitis. These breast-limited inflammatory diseases are sometimes the first symptom of a systemic autoimmune disease. Although autoimmune mastitis is rare, it is probably underdiagnosed or misdiagnosed. Early diagnosis may allow us to detect systemic diseases at an earlier stage, which could help to initiate a prompt, appropriate therapeutic strategy. In case of suspected autoimmune mastitis, we hereby propose a diagnostic pathway and discuss the potential pathophysiological pathways leading to autoimmune breast damage.

Cystic neutrophilic granulomatous mastitis: an update

Cystic neutrophilic granulomatous mastitis (CNGM) is a rare subtype of granulomatous mastitis with a highly distinct histological pattern often associated with Corynebacterium species. CNGM is characterised by suppurative lipogranulomas that are composed of central lipid vacuoles rimmed by neutrophils and an outer cuff of epithelioid histiocytes. Some of the lipid vacuoles may contain sparse, rod-shaped, gram-positive bacilli that can be easily missed or dismissed. The surrounding mixed inflammatory infiltrate contains Langhans-type giant cells, lymphocytes and neutrophils. CNGM occurs in reproductive age women with a history of pregnancy and typically presents as a palpable mass that can be painful. CNGM has many mimickers, most significantly breast carcinoma. In many cases, CNGM has significant pathological and clinical overlap with other forms of granulomatous mastitis. Given the association with Corynebacterium species, early diagnosis of CNGM is essential in offering patients the most appropriate treatment. Prolonged antibiotic therapy specifically directed to corynebacteria is required, sometimes even beyond resolution of clinical symptoms. This comprehensive review of the existing literature on CNGM describes clinical-pathological features, microbiological findings, challenges associated with the microscopic differential diagnosis, clinical implications of this diagnosis and emerging treatment options. Morphological criteria and suggested comments to convey the degree of diagnostic certainty are also proposed for standard pathology reporting.

[Rare Forms of Mastitis]

Rare Forms of Mastitis Abstract. Inflammatory breast diseases caused by bacterial infections represent the main cause for mastitis in breastfeeding and non-breastfeeding women. The clinical appearance and a standardized evaluation can indicate rare inflammatory breast diseases. An underlying comorbidity or the evidence of rare pathogens could be suggestive. However, core needle biopsy is the main step in diagnostics. Malignancy, e.g. an inflammatory breast cancer must consistently be excluded. This mini review outlines a few rare inflammatory breast diseases, their initial presentation, and how to diagnose them accurately.

Granulomatosis with polyangiitis with breast involvement mimicking metastatic cancer: Case report and literature review

Granulomatosis with polyangiitis (GPA) is a systemic inflammatory disease, characterized by the presence of necrotizing vasculitis of small and medium-sized vessels, granulomatous inflammation and anti-neutrophil cytoplasmic antibodies (ANCAs). The diagnosis can be challenging due to the variable clinical presentation and possible involvement of virtually all organ systems. A correct diagnosis is indispensable for a timely start of medical treatment and to avoid unnecessary surgery. Therefore, cooperation with and the input of the pathologist is crucial. We report a case of a woman presenting with suspected metastatic cancer. The diagnosis of GPA was made mainly based on breast biopsy, and the patient was treated accordingly, with full recovery. This report provides a case description and a brief review of the literature.

Breast Involvement in Anti-Neutrophil Cytoplasmic Antibodies Positive Granulomatosis With Polyangiitis in a 64-Year-Old Female Patient

In this article, we present a case of a female patient suffering from granulomatosis and polyangiitis with active glomerular disease, who developed exacerbation of pulmonary vasculitis and palpable tumors of right breast. A possibility of neoplastic disease was excluded by histopathological examination of percutaneous biopsy specimen, revealing granulomatous inflammatory infiltrate, without any features of neoplasia. Moreover, both pulmonary and breast lesions subsided following intensification of immunosuppressive/antiinflammatory treatment.

Granulomatous Mastitis in a Hispanic Woman

A 33-year-old mother of 2 healthy children presented with bilateral recurrent breast infections despite successful treatment of each episode of an infection. With a negative rheumatologic medical history as well as a negative review of systems, she continued to have these infections frequently. Hence, a breast biopsy was performed after the treatment with a course of antimicrobials, which revealed changes suggestive of granulomatous mastitis. She was started on methotrexate (MTX) with a good response. But, due to persistent nodularity, corticosteroids were added to the regimen with MTX dose escalation. Patient remained disease free thereafter without any adverse effects.

Blindness in a Sri Lankan woman with bilateral breast lumps: a case report

BACKGROUND

Granulomatosis with polyangiitis is a rare multisystemic autoimmune disorder predominantly affecting the upper and lower respiratory tracts and the kidneys, and rarely affecting other organ systems. Tuberculosis can mimic the presentation of granulomatosis with polyangiitis, and both can occur simultaneously in the same patient. Here we report what we believe to be the first case of concurrent granulomatous breast lesions and hemorrhagic retinal angiopathy in a Sri Lankan woman with refractory granulomatosis with polyangiitis complicated by probable tuberculosis.

CASE PRESENTATION

A 48-year-old Sri Lankan Moorish woman presented with a 6-month history of ulcerating bilateral breast lumps, a 3-month history of non-healing painful ulcers on the palate, and sudden bilateral painless loss of vision. Retinoscopy confirmed left-sided retinal hemorrhages and bilateral panuveitis. An examination of her respiratory system showed bilateral coarse crepitations. Histologic examination of the palatal and breast lesions showed chronic granulomatous inflammation. Her levels of immune markers were elevated but her renal function was normal. Chest radiography showed bilateral mid-zone and lower-zone infiltrates with cavitation and small pleural effusions. Her serum proteinase 3 anti-neutrophil cytoplasmic antibody titer and the level of adenosine deaminase in her pleural fluid were significantly elevated. She was diagnosed with generalized granulomatosis with polyangiitis complicated with probable pulmonary tuberculosis, and was started on methylprednisolone and cyclophosphamide pulse therapy with anti-tuberculous treatment. She later developed cerebral vasculitis, indicating refractory disease, and was treated with second-line rituximab with excellent response.

CONCLUSION

Proteinase 3 anti-neutrophil cytoplasmic antibody may be a valuable diagnostic marker in patients with atypical symptoms of granulomatosis with polyangiitis or in the presence of probable tuberculosis. Retinal vascular angiopathy needs to be diagnosed and treated early to prevent the development of complete blindness. Concomitant cytotoxic and anti-tuberculous treatments may be safe and effective in patients with simultaneous refractory disease with probable tuberculosis.

Systemic granulomatous diseases associated with multiple palpable masses that may involve the breast: case presentation and an approach to the differential diagnosis

Palpable mass is a common complaint presented to the breast surgeon. It is very uncommon for patients to report breast mass associated with palpable masses in other superficial structures. When these masses are related to systemic granulomatous diseases, the diagnosis and initiation of specific therapy can be challenging. The purpose of this paper is to report a case initially assessed by the breast surgeon and ultimately diagnosed as granulomatous variant of T-cell lymphoma, and discuss the main systemic granulomatous diseases associated with palpable masses involving the breast.

Tuberculous mastitis presenting as a lump: a mimicking disease in a pregnant woman case report and review of literature

Tuberculosis (TB) of the breast is a rare entity, and can be confused with many other breast disorders, like mamma carcinoma or inflammatory breast cancer. When finding granulomatous mastitis (GM) on histology, it is important to make a differential diagnosis and seek actively for clues on the presence of tuberculosis, sarcoidosis, Wegener's granulomatosis, or idiopathic granulomatous mastitis, since treatment strategies differ and maltreatment has major implications on morbidity and mortality. An extensive clinical evaluation, laboratory work up, and imaging will lead in most cases to the right diagnosis. Anti-tuberculous therapy is the core treatment for breast TB, and surgery is indicated for extensive or persistent residual disease. Here we present a case of tuberculous mastitis and a review of literature on GM.

Wegener's granulomatosis of the breast: A case report

BACKGROUND

Differential diagnosis and detection of malignant lesions in mammography poses a challenge for many diagnosticians. Although mammography continues to be the best and cost-effective way to detect breast cancer, it has its limitations due in part to the radiological appearance of changes of a very rare condition. We are presented with changes that have met well-known radiologic criteria for the diagnosis of malignancy, yet they turn out to be benign, because they belong to a group of extraordinary lesions.

CASE REPORT

In June 2010, a 56-year-old woman found a lump in her right breast. Mammography performed at another medical center, revealed a change 12 mm in diameter, rated as BI-RADS 4C. Physical examination revealed a palpable lesion, 15 mm in diameter. Ultrasonography revealed hypoechogenic change with ill-defined outlines, size 14×10 mm - BI-RADS 5. Fine needle aspiration biopsy was done and revealed no atypical cells. The patient underwent an open surgical biopsy and a histopathological diagnosis was suggested to be a type of Wegener's granulomatosis. Exclusion of cancer enabled the continuation of medical treatment of the underlying disease. There were no changes in the breast in follow-up studies.

CONCLUSIONS

The differential diagnosis of breast tumors should include rare conditions that can sometimes mimic breast cancer. One of them is Wegener's granulomatosis. Both, the diagnosis and treatment of the disease, require the cooperation of specialists from various fields, including clinicians, pathologists and radiologists.

[Granulomatosis with polyangiitis (previously Wegener's granulomatosis) mimicking malingering]

INTRODUCTION

ANCA vasculitis may involve the skin and develop slowly without specific histology, and without autoantibodies.

CASE REPORT

We report a 50-year-old woman who experienced bilateral mastectomy because of ulcero-necrotic, non-specific inflammatory cutaneous lesions of the breasts. First considered by others as a malinger patient, she developed oto-neurological lesions leading to the diagnosis of Wegener's granulomatosis. Five years later, specific antibodies of the disease were present.

CONCLUSION

Cutaneous involvement by ANCA vasculitis can be isolated for a long time. Physicians must have a high degree of suspicion to avoid diagnostic delay of ANCA vasculitis.

Wegener's granulomatosis: a review of clinical features and an update in diagnosis and treatment

Wegener's granulomatosis (WG) is an idiopathic, systemic inflammatory disease characterized by necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis of upper and lower respiratory tract and kidneys. The condition affects both genders equally, although some inconsistent gender differences have been observed. The aetiology of WG remains unknown although a number of exogenous factors have been suggested to be of aetiological relevance. Most clinical characteristics of this disease are non-specific, making clinical diagnosis challenging. Histopathological examination of lesional and peritoneal tissue is not pathognomonic, but is an essential investigation to confirm the presence of disease and exclude other disorders. At present, despite the increasingly wide range of potential therapies, cyclophosphamide plus corticosteroids remain the most recognized and effective means of inducing and sustaining remission of WG.

Autoimmune liver disorders and small-vessel vasculitis: four case reports and review of the literature

Autoimmune liver diseases (AILD) are a group of immunologically induced hepatic disorders that can lead to liver cirrhosis and end-stage liver disease. Extra-hepatic involvement and association with rheumatic diseases (such as Sjögren's syndrome, systemic sclerosis and rheumatoid arthritis) are well known, whereas the coexistence of AILD with small-vessel vasculitis in the same patients have been only occasionally reported. In the present paper we report four such cases and an extensive review of the literature. Clinical features of autoimmune-liver diseases associated with small-vessel vasculitis are discussed, as well as possible common pathogenic pathways including HLA genomics, costimulatory molecules and autoantibodies. In conclusion, knowledge about this association can help physicians in recognising and treating an aggressive disease which could otherwise result in severe and multiple organ damage, compromising the overall prognosis and the indication to liver transplantation.

Characteristics of systemic diseases in the breast: clinical, imaging and pathologic features

Despite tremendous efforts placed on advances in diagnosis and treatment of the spectrum of breast disease, the impact of systemic diseases on the breast has remained under recognized. Distinction between a variety of benign breast diseases versus those that are manifestations of a systemic disease is critically important for appropriate treatment planning and follow-up of patients. This article is designed to provide an overview of different systemic diseases that can present as a breast lesion. Attempts are made to highlight the significance of the distinction between benign breast disease versus benign conditions that present as the result of a systemic disease. Naturally, distinction between any benign condition versus breast carcinoma is a part of the evaluation process.

Localized, single-organ vasculitis: clinical presentation and management

The term vasculitis usually evokes a systemic disease with catastrophic outcomes; however, vasculitides may also present in a localized form, with a better prognosis when compared with their systemic counterpart. In order to avoid confusion and facilitate classification, the term single-organ vasculitis (SOV) has been proposed. Remarkably, current criteria for the classification of the vasculitis do not include the SOV term, due in part to the lack of appropriate definitions, since most data come from case series; moreover, the scarce information available is also extremely heterogeneous. This review focuses on the epidemiology, clinical course, prognosis, and suggested treatment of the SOV, with emphasis in the most recent information available.

Breast manifestations of systemic diseases

Although much emphasis has been placed on the primary presentations of breast cancer, little focus has been placed on how systemic illnesses may affect the breast. In this article, we discuss systemic illnesses that can manifest in the breast. We summarize the clinical features, imaging, histopathology, and treatment recommendations for endocrine, vascular, systemic inflammatory, infectious, and hematologic diseases, as well as for the extramammary malignancies that can present in the breast. Despite the rarity of these manifestations of systemic disease, knowledge of these conditions is critical to the appropriate evaluation and treatment of patients presenting with breast symptoms.

Idiopathic granulomatous mastitis associated with risperidone-induced hyperprolactinemia

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease. The etiology and treatment options of IGM remain controversial. Previous case reports have suggested that hyperprolactinemia may be associated with IGM. In the present report, we describe the first case of IGM associated with risperidone-induced hyperprolactinemia.

Development of granulomatosis with polyangiitis (Wegener): listen to the patient

Patients with rare or complex conditions may sometimes come up with the right diagnosis because of their previous exposure to the condition. This may be due to their knowledge of their family history or even concerns based on their exposure to information from electronic or paper repositories. In this case report, a 40-year-old woman who already had 1 rare condition of lymphangioleiomyomatosis developed breast "abscesses" that did not respond to traditional surgical debridement and antibiotics. She wondered if the lesions could be related to granulomatosis with polyangiitis (Wegener) as she had a strong family history of this condition. Subsequent investigations confirmed the diagnosis. Her response to treatment was complete. Breast lesions in granulomatosis with polyangiitis (Wegener) have been infrequently reported in the literature but should be considered in poorly healing lesions, despite the absence of other more typical symptoms at the time of presentation.