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

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.


Abstract
A 40-y ear-old Caucasian, the otherwise healthy male patient, presented with 3-y ears history of a prominent tumor-like f ormation, located on his back, without subjectiv e complaints. Initially , the lesion was 1-2 cm in size but gradually increased to a visible-pronounced tumor-like f ormation. No other dermatologic diseases, neither other known abno rmalities were reported f or the medical and f amily history. Softly -elastic on palpation tumor-like f ormation was established in the lef t inf rascapular area of the back, measuring 8/9 cm in diameter. The lesion was clinically suspected f or lipoma or another sof t-tissue tumour with benign natur e, so the patient underwent plan ned surgical excision under local ana esthesia. A tumour was excited with deep e lliptical excision and f urthered f or histological ev aluation, while the wound edges wer e sutured with sing le cutaneous stitches. Additionally , a large black-colored tattoo of the Bulg arian historical no ble Khan Krum was also o bserv ed within the clinical examination, cov ering almost the whole upper 1/3 part of the patient's back Within the caref ul clinical observ ation of the tattoo, we noticed a f ibroma-like lesion, affecting the noble's right iris. Fibromas are common benign tumours in Caucasians, composed of f ibrous or connectiv e tissue. They can be seen in all organs f rom mesenchymal tissue, in v aries size. Ey elids are of ten commonly aff ected in elderly . Although v ery commonly seen in ev ery day dermatological practice, f ibromas hav e been nev er reported, located in the iris. In the presented case, a small ʺiris-f ibromaʺ, hidden within a black-colored tattoo was diagnose d in a patient with lipoma, as a sporadic clinical f inding.
A 40-year-old Caucasian, the otherwise healthy male patient, present ed with 3-y ears 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 visiblepronounced tumor-like formation.
No other dermatologic diseases, neither other known abnormalities were reported for the medical and family history. Softly-elastic on palpation t umor-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 nat ure, so the patient underwent planned surgical excision under local anaesthesia (Fig. 1b, 1c,  1d, 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 historic al noble Khan Krum was also obs erved within the clinical examination, covering almost the whole upper 1/3 part of the patient's back (Fig. 1a, 1f). Within the c areful clinical observation of the t attoo, we noticed a fibroma-like lesion, affecting the noble's right iris (Fig.  1f).
Fibromas are common benign tumours in Cauc asians, 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 t hrone aft er 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 t he 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 t o a legend, he questioned A varian prisoners of war what led to the collaps e and destruction of their state and created their laws by their ans wers [2]. In the presented case, a small ʺiris-fibromaʺ, 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.