Abstract / Summary
Abstract Background The xiphoid process is the smallest and most morphologically variable component of the sternum, and anterior (ventral) deviation is a recognized anatomical variant. Symptomatic xiphoid disease typically presents as localized pain (xiphodynia). Cutaneous complications are exceedingly uncommon, and only a single previous report describing an ischemic xiphisternal ulcer associated with a protruding xiphoid has been published. To the best of our knowledge, we identified no previous English-language report describing complete transcutaneous perforation of the skin by a protruding xiphoid process associated with chronic sinus formation and secondary infection. Case presentation A 71-year-old bedbound man with type 2 diabetes mellitus, hypertension, and post-traumatic cervical myelopathy with spastic weakness developed progressive protrusion of the xiphoid process. The angulated xiphoid tip gradually eroded through the overlying skin, producing a chronic midline ulcer with sinus tract formation and superimposed infection. Lateral radiography demonstrated marked anterior angulation of the xiphoid process with prominent ventral protrusion and irregularity of the distal tip. The patient underwent xiphoidectomy with en-bloc excision of the ulcer and debridement of devitalized soft tissue. Intraoperative culture of the resected xiphoid specimen yielded extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli, and culture-directed carbapenem therapy was administered. Histopathological examination revealed extensive ulceration with inflamed granulation tissue and a sinus tract, accompanied by reactive squamous epithelial hyperplasia (pseudoepitheliomatous hyperplasia), whereas the underlying bone was unremarkable and showed no evidence of malignancy. Conclusions A protruding xiphoid process can rarely progress beyond pain and superficial ulceration to cutaneous breach with sinus tract formation and secondary infection, particularly in debilitated patients with chronic immobility, diabetes mellitus, and reduced soft-tissue padding. This process appears mechanistically analogous to a pressure ulcer developing over an atypical bony prominence. Xiphoidectomy combined with debridement and culture-directed antimicrobial therapy appears to provide definitive treatment. Histopathological examination is essential because reactive pseudoepitheliomatous hyperplasia at the ulcer margin may mimic cutaneous malignancy.