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Differential Diagnosis

Radiologically, the differential diagnosis of tropical ulcer in its early stages will include almost any cause of a localized periosteal response, but tropical ulcers may be distinguished because of the local soft tissue ulceration overlying them. Thus venous stasis, hypertrophic osteoarthropathy, sickle cell infarction, malignant bone tumor, and osteomyelitis can usually be excluded. When the cortex has become thickened to produce the "ivory osteoma" it will have to be distinguished from fibrous dysplasia, osteochondroma, osteoid osteoma, and chronic osteomyelitis. Paget's disease may be considered, but it should be remembered that this is an extremely rare condition in indigenous Africans, is uncommon in Indians, and is infrequent in some other parts of the world. Again, the overlying soft tissue ulceration provides an important distinguishing feature. Only ulceration associated with venous stasis might provide the combination of a large soft tissue ulcer and underlying bone reaction, but when there are varicosities the clinical findings are very different and the periosteal reaction is not so exuberant.

In practice, particularly if the actual patient is seen by the radiologist, the differential diagnosis is not difficult. There is much less edema than in mycotic infections; tuberculous ulcers seldom produce a similar bone reaction, and only yaws and leishmaniasis may show the same combination of skin ulceration and bone changes. The desert sore (Barcoo rot, umballa sore) is much more superficial and may occur in any exposed area (e.g., hands, face). Although the edges are sometimes undermined, deeper tissues and bone are not affected.

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