A Case Report: The Efficacy of Human Amniotic Membrane

Mesenchymal Stem Cells-Conditioned Medium (hAMMSC-CM) for

Treating Plantar Pedis Trophic Ulcer in Leprosy Patients

Karina Dyahtantri Pratiwi

, Trisniartami

, Medhi Denisa Alinda

, Bagus Haryo Kusumaputra

, Linda

Astari

, M Yulianto Listiawan

, Indropo Agusni

, Fedik A Rantam

2,3

, Cita Rosita Sigit Prakoeswa

Department of Dermatology Venereology, Faculty of Medicine Universitas Airlangga, Dr Soetomo General Hospital,

Surabaya, Indonesia

Stem Cell Research and Development Center, Universitas Airlangga, Surabaya, Indonesia

Virology and Immunology Laboratory, Department of Microbiology, Faculty of Veterinary Medicine, Universitas

Airlangga, Surabaya, Indonesia

Keywords: amniotic membrane stem cells, plantar ulcer, leprosy

Abstract: Leprosy is an endemic disease in many countries with consequences of neuropathy that may leads to plantar

trophic ulcer. The management of trophic ulcers is difficult due to its recurrent and recalcitrant

characteristics. Placental derived cells are known to release factors with potential immunomodulatory and

trophic activities. In this study we use the human amniotic membrane mesenchymal stem cells-conditioned

medium (hAMMSC-CM) gel to promote the wound healing of trophic ulcer. A-50-years-old female

presented with a trophic ulcer over the sole of her right foot since 3 years ago. The patient gave a history of

decreased sensation over the right foot and was a known case of lepromatous leprosy released from

treatment 2 years back after completing multibacillary multi-drug therapy for 1 years. Cutaneous

examination revealed a single non-healing ulcer over the plantar aspect of the right foot with pale

granulation tissue and seropurulent discharge at the base. Touch and pain sensation were lost over the foot

and up to the lower leg one-third of the leg. The result of microbiology Mycobacterium leprosy examination

was bacterial index (BI) 0 and morphological index (MI) was negative. A diagnosis of plantar pedis trophic

ulcer in a treated case of leprosy was made. The ulcer managed by given topical hAMMSC-CM gel and

covered with transparent film dressings. Application of gel was done every 3 days, and weekly evaluation

included measurement of the size and the depth of the ulcer was done. The patient was treated with

hAMMSC-CM for 8 weeks. The ulcer was significantly resolved, but there was no complete healing.

1 INTRODUCTION

Trophic ulcer that may occur in leprosy patient due

to their nerve impairment is a condition of an ulcer

that lack of nutrition. It is defined as a pressure ulcer

caused by external trauma to a part of the body that

is in poor condition because of disease, vascular

insufficiency or loss of afferent nerve fibres by

Mosby in 2016 (Puri, Venkateshwaran, and Khare,

2012).

Plantar tophic ulcer is a physical disability

that occurs in 10-20% of leprosy patient.

Conventional therapies such as normal saline

dressings and surgical debridement do not show a

satisfactory improvement (Sari, Listiawa, and

Indramaya, 2018).

2 CASE

A 50 years old female presented with an ulcer over

the sole of her right foot since 3 years ago. The

patient gave a history of decreased sensation over

the right foot and was a known case of lepromatous

leprosy released from treatment 2 years back after

completing multibacillary multi-drug therapy for 1

years. She had been treated intermittently with

topical antibiotics in addition to normal saline

dressing for her ulcer, but complete resolution was

never achieved. Cutaneous examination revealed a

single non-healing ulcer measuring 1,8 x 1,8 x 0,4

cm over the plantar aspect of the right foot with pale

granulation tissue and seropurulent discharge at the

base.Touch and pain sensation were lost over the

442

Pratiwi, K., Trisniartami, ., Alinda, M., Kusumaputra, B., Astari, L., Listiawan, M., Agusni, I., Rantam, F. and Prakoeswa, C.

A Case Report: The Efﬁcacy of Human Amniotic Membrane Mesenchymal Stem Cells-Conditioned Medium (hAMMSC-CM) for Treating Plantar Pedis Trophic Ulcer in Leprosy Patients.

DOI: 10.5220/0008159304420445

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 442-445

ISBN: 978-989-758-494-7

foot and up to the lower leg one-third of the right

leg. Nerve thickening and regional

lymphadenopathy were absent. The routine

laboratory examinations were normal. There’s no

increasing of blood glucose level and no glucose in

urine examination. The result of microbiology

Mycobacterium leprosy examination was bacterial

index (BI) 0 and morphological index (MI) was

negative.

Figure 1: (a). A single non-healing trophic ulcer

measuring 1,8 x 1,8 x 0,4 cm over the plantar aspect of the

right foot with pale granulation tissue and seropurulent

discharge at the base. (b), (c), and (d) the healing process

of the ulcer treated with hAMMSC gel every 3 days for 8

weeks.

Based on the clinical findings, a diagnosis of

plantar pedis ulcer in a treated case of leprosy was

made. The initial treatment for the ulcer was sterile

normal saline debris. After obtaining a clean ulcer,

wound area and wound depth measurements were

performed. Then the ulcer was given framycetin

gauze dressing (FGD) and sterile gauze above the

FGD but there was no clinical improvement after 8

weeks. On the next following week, the ulcers begin

to be given topical hAMMSC-CM gel and covered

with transparent film dressings. Application of gel

was done every 3 days, and weekly evaluation

included measurement of the size and the depth of

the ulcer was done. The patient was treated with

hAMMSC-CM for 8 weeks. The ulcer was

significantly resolved, but there was no complete

healing.

3 DISCUSSION

The global registered prevalence of leprosy by The

World Health Organization (WHO) at the end of

2015 was 0.2 cases per 10.000 people. The number

of new cases reported globally in 2015 was 2,9 new

cases per 100.000 people.

As the latest data

published by WHO in the Weekly Epidemiological

Record defines leprosy as a public health problem

in countries where the prevalence of the disease

exceeds one case per 10.000 inhabitants (Oliviera et

al., 2017). Indonesia was in the third rank of leprosy

endemic country. About 5.284 new cases reported

by East Java health profile in 2015.

Skin ulcers, such as those seen in patients with

leprosy, are a serious public health problem. Infected

chronic ulcers can lead to amputation of the affected

limbs. The well-being and selfesteem of these

individuals may be diminished by pain, loss of the

ability to walk, and loss of independence. The

appearance and unpleasant odour of the lesions may

lead to social isolation. Most lesions in patients with

leprosy are located on the lower limbs. Lower-

extremity ulcers in patients with leprosy patients can

be divided into two categories: leprous ulcers (due to

the disease itself) and neuropathic ulcers (due to

nervous system involvement). Plantar ulcers can

cause a loss of protective sensitivity or lack of

sensation in the plantar region from damage to the

tibial nerve. Other factors increase the risk of

developing plantar ulcers, including paralysis,

volume loss of intrinsic foot muscles, loss of the fat

pad under the metatarsal head, anhidrotic skin,

biomechanical alterations, and/or deformities (e.g.,

foot drop, structural bone alterations) (Walsh,

DeJong, Meyers, and Portaels, 2015; Rohatgi,

Naveen, Salunke, Someshwar, Jerajani, and Joshi,

2016).

An expert in leprosy, Dr. Paul Wilson Brand

(19142003), made major contributions to the

understanding of the pathogenesis of the

neurological complications of leprosy. It was

considered that leprosy patients had nonhealing

tissues and that nothing could be done about them.

Neuropathic ulcers on the sole of feet usually

develop at sites exposed to repetitive high pressures

during activities of daily living like walking or

working (Puri, Venkateshwaran, and Khare, 2012;

Rohatgi, Naveen, Salunke, Someshwar, Jerajani, and

Joshi, 2016).

The excessive pressure causes a hypertrophic

reactive response of the local keratinocytes causing

local hyperkeratosis. Hence at points of abnormal

weight bearing and friction, callus formation may

A Case Report: The Efﬁcacy of Human Amniotic Membrane Mesenchymal Stem Cells-Conditioned Medium (hAMMSC-CM) for Treating

Plantar Pedis Trophic Ulcer in Leprosy Patients

443

occur. This callus finally cracks and breaks leading

to ulceration. Hence, the risk of an ulcer is even

higher when a callus is present. Importance of

shaving callus at the margins of the ulcer and callus

removal has shown reduction in dynamic plantar

pressures in the forefoot by 30% during barefoot

walking (Walsh, DeJong, Meyers, and Portaels,

2015; Rohatgi, Naveen, Salunke, Someshwar,

Jerajani, and Joshi, 2016).

Figure 2: Healing progression. Ulcer treated with hAMMSC-CM not healed completely in 8 weeks.

The slow recovery of natural wound healing has

resulted in the entry of exogenous wound healing

treatments. Many treatments have proved to quicken

the healing. This resulted in the discovery of more

advanced treatments, such as tissue engineering,

gene therapy, platelet-rich plasma, growth factors

(GF) and stem cells (SC) therapy. Among these, SC

has become the centre of attraction in wound healing

by promoting microvascular remodelling. Reports

have shown that SC plays a major role in

strengthening wound healing by secreting a

multitude of trophic and survival signals including

GF, chemokines and cytokines. They serve as a tool

among cells to communicate and these molecules

can be traced in the conditioned medium (CM) or

spent medium harvested from cultured cells

(Jayaraman et al., 2013).

Lee et al. (2011) reported that CM of human

embryonic stem cell (hESC)-derived endothelial

precursor cells (EPC) containing high level of GF

and cytokines such as epidermal growth factor

(EGF), basic fibroblast growth factor (bFGF),

fractalkine, granulocyte-macrophage colony-

stimulating factor (GM-CSF) and interleukin (IL)-6

were successfully used in the treatment of excisional

wound healing in rats (Jayaraman et al., 2013).

In embryonic development, the mesodermal

layer harbors multipotent progenitors that give rise

to bone, cartilage, muscle and other mesenchymal

tissues. Based on this embryonic perspective and

previous reports from our group and others, a

hypothetical and comprehensive scheme, proposed

that in adult bone marrow (BM), a population of

mesenchymal stem cells (MSCs) could likewise give

rise to a spectrum of mesenchymal tissues by

differentiating along separate and distinct lineage

pathways (Caplan and Correa, 2011).

The approach has a high proliferative capacity,

immunomodulatory activity, is low immunogenic,

and non-tumorigenic. In its clinical application,

hAMMSC-CM has a few advantages such as

procurement procedures pose no morbidity, and

there were unlimited amount of stem cells available

due to its shorter expansion and doubling time than

other adult stem cells. Mechanism of stem cells in

tissue healing process is associated with the ability

of stem cells to produce growth factors and

cytokines that are necessary in healing. In vitro

condition, these metabolites are also secreted in stem

cell-conditioned medium (Rennie et al., 2012;

Skardal et al., 2012).

Prakoeswa et al (2018) reported their analytical

experimental approach study comparing the topical

hAMMSC-CM and the framycetin gauze dressing

(FGD) in ulcer healing. Ulcer healing in hAMMSC-

CM group was significantly better with significant

clinical and statistical differences (p < 0,005).

Therefore, stem cell-conditioned medium can be

used as a treatment modality because it contains

growth factors and cytokines that are essential for

cell regeneration (Rennie et al., 2012; Prakoeswa et

al, 2018).

1,296

0,9

0,576

0,432

0,333

0,222

0,2

0,185

0,2

0,4

0,6

0,8

1,2

1,4

Week1 Week2 Week3 Week4 Week5 Week6 Week7 Week8

hAMMSC‐CM

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

444

4 CONCLUSIONS

It was found clinically that there were improvements

in wound healing treated with hAMMSC-CM gel.

Its may due to the mesenchymal stem cells that

contain many growth factors. The further study to

analyze the macrophage, vascular endothelial

growth factor, fibroblast growth factor 2,

transforming growth factor β1, keratinocyte growth

factor, and epidermal growth factor is needed to

prove the hypothesis.

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A Case Report: The Efﬁcacy of Human Amniotic Membrane Mesenchymal Stem Cells-Conditioned Medium (hAMMSC-CM) for Treating

Plantar Pedis Trophic Ulcer in Leprosy Patients

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