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Logo of oamjmsMacedonian Journal of Medical SciencesOpen Access Macedonian Journal of Medical SciencesArchivesSubmissionsAuthorsId DesignId Press
 
Open Access Maced J Med Sci. 2017 August 15; 5(5): 696–697.
Published online 2017 August 10. doi:  10.3889/oamjms.2017.156
PMCID: PMC5591607

Khan Krum - “The Fearsome”: A Noble Bulgarian with Iris-Fibroma?

Abstract

A 40-year-old Caucasian, the otherwise healthy male patient, presented with 3-years history of a prominent tumor-like formation, located on his back, without subjective complaints. Initially, the lesion was 1-2 cm in size but gradually increased to a visible-pronounced tumor-like formation. No other dermatologic diseases, neither other known abnormalities were reported for the medical and family history. Softly-elastic on palpation tumor-like formation was established in the left infrascapular area of the back, measuring 8/9 cm in diameter. The lesion was clinically suspected for lipoma or another soft-tissue tumour with benign nature, so the patient underwent planned surgical excision under local anaesthesia. A tumour was excited with deep elliptical excision and furthered for histological evaluation, while the wound edges were sutured with single cutaneous stitches. Additionally, a large black-colored tattoo of the Bulgarian historical noble Khan Krum was also observed within the clinical examination, covering almost the whole upper 1/3 part of the patient’s back Within the careful clinical observation of the tattoo, we noticed a fibroma-like lesion, affecting the noble’s right iris. Fibromas are common benign tumours in Caucasians, composed of fibrous or connective tissue. They can be seen in all organs from mesenchymal tissue, in varies size. Eyelids are often commonly affected in elderly. Although very commonly seen in every day dermatological practice, fibromas have been never reported, located in the iris. In the presented case, a small “iris-fibroma”, hidden within a black-colored tattoo was diagnosed in a patient with lipoma, as a sporadic clinical finding.

Keywords: fibroma, surgery, ocular, outcome, tattoo, sporadic observation

A 40-year-old Caucasian, the otherwise healthy male patient, presented with 3-years history of a prominent tumor-like formation, located on his back, without subjective complaints. Initially, the lesion was 1-2 cm in size but gradually increased to a visible-pronounced tumor-like formation. No other dermatologic diseases, neither other known abnormalities were reported for the medical and family history. Softly-elastic on palpation tumor-like formation was established in the left infrascapular area of the back, measuring 8/9 cm in diameter (Fig. 1a). The lesion was clinically suspected for lipoma, angiomyolipoma, or another soft-tissue tumor with benign nature, so the patient underwent planned surgical excision under local anaesthesia (Fig. 1b, ,1c,1c, ,1d,1d, ,1e).1e). The tumour was removed with deep elliptical excision and furthered for histological evaluation, while the wound edges were sutured with single cutaneous stitches. Histological examination confirmed the clinical diagnosis of a lipoma. The postsurgical period underwent without complication. A large black-colored tattoo of the Bulgarian historical noble Khan Krum was also observed within the clinical examination, covering almost the whole upper 1/3 part of the patient’s back (Fig. 1a, ,1f).1f). Within the careful clinical observation of the tattoo, we noticed a fibroma-like lesion, affecting the noble’s right iris (Fig. 1f).

Figure 1
1a) – Clinical presentation of a pronounced tumor-like formation on the back of a 40-year-old male patient. 1b, 1c, 1d, 1e) – Intraoperative findings. Surgical excision of the lesion. 1f) – Clinical presentation of an iris fibroma ...

Fibromas are common benign tumours in Caucasians, composed of fibrous or connective tissue [1]. They can be seen in all organs from mesenchymal tissue, in varies size [1]. Eyelids are often commonly affected in elderly. Although very commonly seen in every day dermatological practice, fibromas have been never reported, located in the iris.

Krum is a medieval Bulgarian monarch who ascended to the throne after Kardam [2]. During his reign, Bulgaria has strengthened its position on the Balkan Peninsula and in Europe, thanks to numerous victories on the battlefield [2]. Krum began to incorporate the Slavs into power, passed the first valid laws in the First Bulgarian Kingdom, and started an administrative reform [2]. Besides a talented warlord, Krum is also a talented statesman. He creates the first written laws. According to a legend, he questioned Avarian prisoners of war what led to the collapse and destruction of their state and created their laws by their answers [2].

In the presented case, a small “iris-fibroma”, hidden within a black-colored tattoo was diagnosed in a patient with lipoma, as a sporadic clinical finding.

Various cutaneous diseases could be triggered by a tattoo procedure, including psoriasis, lichen planus, contact dermatitis, sarcoidosus, dermatofibromas, warts, etc. [3]. Despite triggering the diseases by Koebner phenomenon, the tattoo could camouflage different cutaneous neoplasms, resulting in easily misdiagnosis and therapeutic failures [3, 4]. Superficial and deep local infections, as well as systemic infections, are also not unusual [3]. Therefore, all tattoos should be carefully evaluated in order to prevent misdiagnosis of various cutaneous pathologies.

Footnotes

Funding: This research did not receive any financial support.

Competing Interests: The authors have declared that no competing interests exist.

References

1. John M, Chirayath S, Paulson S. Multiple soft fibromas of the lid. Indian J Ophthalmol. 2015;63(3):262–4. https://doi.org/10.4103/0301-4738.156932 PMid:25971174 PMCid:PMC4448242. [PMC free article] [PubMed]
2. Nikolov A. Khan Krum in the Byzantine tradition:terrible rumours, misinformation and political propaganda. Studies in honour of Professor Vassil Gjuzelev (=Bulgaria Mediaevalis, 2). Sofia. 2011:39–47.
3. Kluger N. Cutaneous Complications Related to Tattoos:31 Cases from Finland. Dermatology. 2017 Apr 26; doi:10.1159/000468536. [Epub ahead of print]. https://doi.org/10.1159/000468536. [PubMed]
4. Tchernev G, Chokoeva AA. Melanoma in a Chinese dragon tattoo. Lancet. 2015 pii:S0140-6736(15)01038-7. [PubMed]

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