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Persistent Wound on the Neck

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BACKGROUND
A 43-year-old man with no significant medical history presents to his primary care provider (PCP) complaining of a "wound that won’t get better" on the left side of his neck. He states that the wound has been slowly growing over the past 2 years after it first appeared as a small pimple. In his efforts to heal the wound, he has used a variety of over-the-counter topical remedies such as hydrogen peroxide and triple antibiotic ointment; however, the wound has continued to spread and worsen. He was finally encouraged to visit his PCP when his brother noticed the now several-centimeters-long lesion (see Images 1-2). The patient denies having weight loss, fevers, or chills. He has not traveled during the past 5 years.

On physical examination, the patient is somewhat overweight. His vital signs are normal except for a blood pressure of 165/93 mm Hg. The examination of the head, eyes, ears, and nose is unremarkable. The patient has a 10-cm ulcer at the collar line on the left side of his neck. A homemade dressing that the patient had placed on this lesion contains a small amount of serosanguineous fluid. No lymphadenopathy and no masses are noted around the neck or in the armpits. The patient’s lungs are clear, and his heart rate is regular with normal heart sounds. The rest of the physical examination findings are unremarkable, except for numerous small hyperpigmented macules on the patient’s chest and back.

What is the most likely diagnosis, and what is the diagnostic test of choice?
CASE DIAGNOSIS
HINT
The ulcer is chronic, is nonhealing, and has a smooth border.
Authors:
Anusuya Mokashi,
Medical Student,
New York Medical College,
Valhalla, NY

Senait Dyson, MD,
Director,
Dermatology-Dermatopathology Lab,
UC Irvine, Irvine, Calif

eMedicine Editors:
Brady Pregerson, MD,
Depts. of Emergency Medicine Cedars-Sinai Medical Center Los Angeles, Calif,
Tri-City Medical Center Oceanside, Calif

Rick G. Kulkarni, MD,
Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, Conn
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