Arch Pediatr Infect Dis. 2014 January; 2(1):e16471. DOI: 10.5812/pedinfect.16471 Published online 2014 January 18. Case Report Diagnostic Dilemma in a Patient With Chronic Fistulating Nonhealing Ulcer Sedigheh Rafiei Tabatabaei 1 , Abdollah Karimi 1 , Ali Amanati 1,* , Maryam Kazemi Aghdam 2 , Bibi Shahin Shamsian 3 , Javad Ghoroubi 4 1 Pediatric Infections Research Center, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran 2 Pediatric Pathology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran 3 Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran 4 Pediatric Surgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran *Corresponding author: Ali Amanati, Pediatric Infections Research Center, Department of Pediatric Infectious Diseases, Mofid Children's Hospital, Dr. Shariati Ave., P.O.BOX: 1546815514, Tehran, IR Iran. Tel/Fax: +98-2122226941, E-mail: ali_amanati_1356@yahoo.com. Received: November 29, 2013; Revised: December 24, 2013; Accepted: January 8, 2014 Here, we report on a ten-year-old girl with chronic draining nonhealing ulcer in her neck and unilateral cervical chronic lymphadenopathy. Her ulcer had poor clinical response to broad spectrum antibiotics and anti-tuberculosis treatment. She had undergone several wound biopsies with no conclusive results. She was otherwise healthy with no known underlying disease. Final wound excisional biopsy with specific immunohistochemistry (IHC) staining confirmed her diagnosis. Histopathology report and IHC were compatible, indicating an anaplastic large cell lymphoma. Keywords: Wounds and Injuries; Neck; Lymphatic Diseases; Lymphoma, Large-Cell, Anaplastic Implication for health policy/practice/research/medical education: We hoped to emphasize to all clinicians that close follow up of chronic disease is an important part of accurate management. Attention to any possible underlying cause, which could contribute to poor clinical response, should always be kept in mind. As in our case repeated biopsy may be needed to at- tain diagnosis. Copyright © 2014, Pediartric Infections Research Center; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Com- mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Introduction A chronic nonhealing wound is described as a wound failing to heal within three months and it is extremely complex to manage and diagnose contributing factors of poor healing (1, 2). Complications of these wounds are risk of severe pain, septicemia, hospitalization, and in some cases severe morbidity. Exact identification of pathogenic organisms in chronic wounds is difficult and varies depending on the modes of sampling and the diagnostic methods (culturing or molecular methods). The most common bacteriological dilemma in chronic wounds is differentiation between nonpathogenic colo- nization and other pathogenic organisms. The most common bacterial isolates on wounds are Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, Proteus species, anaerobic bacteria, and Pseudo- monas aeruginosa, yet other significant pathogens such as tuberculosis, atypical mycobcteria, nocardiosis, actinomy- cosis and fungal infection should always be considered. On the other hand, when chronic nonhealing wounds are difficult to treat with antibiotics, consideration of biofilm formation, which necessitates overcoming in- creased minimal inhibitory concentrations (MICs) of bio- film growing organisms such as Pseudomonas aeruginosa, is warranted (3, 4). Another significant issue in managing these wounds is investigation of the underlying predis- posing factors contributing to failure in wound healing such as ischemia, venous insufficiency, diabetes, neurop- athy, malnutrition, corticosteroids therapy, vasculitis, immune suppression and malignancy (2, 5). 2. Case Report A ten-year-old girl was admitted to our center with a chronic fistulating nonhealing wound. In the initial physical examination she had a large (about 5 × 7 centi- meters) draining deep ulcer in the anterior cervical trian- gle below her right mandible and surrounded swelling. As her mother notified, she had a unilateral neck swell- ing since three months ago. She had been hospitalized 2 times before admission to our ward. The neck sonogra- phy performed in the primary center revealed unilateral multiple lymph nodes on the right side. She was put on anti-tuberculosis treatment after discovery of acid-fast bacilli (AFB) in the lymph nodes fine needle aspiration in her first admission to that center. She stopped her medi- cations after about 3 weeks and was admitted to another center for excisional lymph nodes biopsy because of poor clinical improvement after the primary treatment. In first pathology report only necrosis with inflamma- tion without evidence of tuberculosis were noted. She was also examined for bone marrow aspiration which revealed no evidence of malignancy and tuberculosis. Fi- nally, because of no remarkable change in her neck swell- ing and draining wound despite previous treatment, she