Pyoderma gangrenosum: a reappraisal of associated systemic diseases

A shared and unique epitope(s) on human colon, skin, and biliary epithelium detected by a monoclonal antibody

An immune-complex-mediated inflammation has been suggested in the pathogenesis of skin and biliary complications in ulcerative colitis, although specific antigen-antibody complexes have not been found. We recently identified an Mr 40,000 colonic protein that reacts with tissue-bound immunoglobulin G eluted from colon specimens of patients with ulcerative colitis and not with immunoglobulin G eluted from colon specimens of patients with other diseases (J Clin Invest 1985;7:311). Murine monoclonal antibodies to the purified Mr 40,000 colonic protein are developed. The presence of the Mr 40,000 protein was examined with a monoclonal antibody (7E12H12, immunoglobulin M isotype) by an immunoperoxidase assay against various human epithelial tissues (74 specimens) including colon, ileum, jejunum, duodenum, stomach, esophagus, pancreaas, liver, respiratory, urinary, and genital tracts. In addition, gall bladder, bile duct, hepatic ducts, skin, synovial membrane, and eye tissue were also examined for any cross-reactivity with 7E12H12 and another anti-Mr 40,000 monoclonal antibody (7E6A5, immunoglobulin G1 isotype). 7E12H12 reacted only with colonic-epithelial cells mainly along the basolateral domains of plasma membrane and apical areas. The reactivity was present in both adult and fetal colon including the appendix. Among all the noncolonic tissue specimens, 7E12H12 reacted only with the gall bladder, the bile duct, the hepatic ducts, and the skin. All other epithelial tissues from 15 different organs, including the small intestine, synovium, and eye tissue, did not react. In the skin and biliary tract the immunoreactivity was exclusively present in the epidermal epithelial cells and mucosal epithelium respectively. 7E6A5 stained colonic mucosal cells but did not react with skin, biliary epithelium, synoyium and eye tissue. These results indicate the presence of a unique epitope or epitopes on Mr 40,000 colonic epithelial protein that is shared by the skin and biliary tract epithelial cells. Future studies of this shared epitope or epitopes and its immune recognition may provide further understanding in the pathogenesis of extraintestinal complications involving these organs in patients with ulcerative colitis.

Superficial granulomatous pyoderma: clinicopathologic spectrum

Superficial granulomatous pyoderma is a form of pyoderma gangrenosum characterized by superficial ulceration and a chronic course. Histopathologic examination shows a granulomatous response. We report two new cases of superficial granulomatous pyoderma in detail and briefly review the clinical data of five previous cases included in a recent series. These lesions typically begin as single furunculoid papules that most commonly occur on the trunk and that may arise at sites of surgical treatment or other pathergic stimuli. The lesions progress to superficial ulcers with a relatively clean base and vegetative borders. Tetracycline, minocycline, sulfapyridine, dapsone, and intralesionally administered corticosteroids have been effective anti-inflammatory agents, producing healing and allowing avoidance of the use of systemic corticosteroids in the management of most patients with superficial granulomatous pyoderma.

Pyoderma gangrenosum: a review

Pyoderma gangrenosum is a poorly understood disease characterized by exacerbations and remissions of morphologically unique skin ulcers. It frequently is thought to be the cutaneous manifestation of an underlying systemic disease. In this review of pyoderma gangrenosum, the characteristics of the disease are described and a differential diagnosis is formulated. Associations with systemic diseases are made through a review of the literature. The pathophysiology of pyoderma gangrenosum and probable causes are considered, and special consideration is given to the immunologic mechanisms that may be operative in the disease. Finally the currently available therapeutic alternatives are reviewed.

Pyoderma gangrenosum occurring at multiple surgical incision sites

Ten weeks after subtotal colectomy and ileostomy for ulcerative colitis, a 16-yr-old girl developed wound drainage and back pain. Massive ulceration and skin separation occurred at the abdominal wound incision as well as at the incision sites of a previous central venous line. A diagnosis of pyoderma gangrenosum was made. High-dose steroid treatment induced prompt healing of the abdominal wound as well as the catheter sites. Pyoderma gangrenosum has rarely been seen in surgical wounds. To our knowledge, this is the first reported case of pyoderma gangrenosum occurring simultaneously in multiple surgical incision sites in a patient with ulcerative colitis.

Oral methotrexate therapy for chronic rheumatoid arthritis ulcerations

Eight patients with long-standing rheumatoid arthritis and cutaneous vasculitis ulcerations resistant to conventional therapy were treated successfully with a low-dose intermittent regimen of oral methotrexate. Objective clinical response was prompt and complete resolution was observed at about 12 weeks of therapy. The drug was well tolerated. Mild gastrointestinal side effects were the most common untoward reaction. We conclude that methotrexate therapy is an effective agent for some of the extraarticular manifestations of rheumatoid arthritis including vasculitis, and further clinical evaluation should be a consideration.

Pyoderma gangrenosum and chronic persistent hepatitis

Pyoderma gangrenosum is a diagnosis of exclusion. A 36-year-old woman was clinically diagnosed as having pyoderma gangrenosum and appropriate exclusion tests were performed. Pyoderma gangrenosum may occur in association with underlying diseases such as leukemia, monoclonal gammopathy, inflammatory bowel disease, arthritis, and chronic active hepatitis. However, these diseases were excluded in this patient who did have chronic persistent hepatitis. To our knowledge, this is the first reported case of chronic persistent hepatitis and pyoderma gangrenosum.

Hyperbaric oxygen therapy for pyoderma gangrenosum

Hyperbaric oxygen administered systemically has been advocated in the treatment of pyoderma gangrenosum. Owing to the serious potential risks of oxygen toxicity with systemic administration, we have devised a simplified technique for the administration of hyperbaric oxygen topically, and have used this method successfully to treat two patients with pyoderma gangrenosum, in whom the underlying etiology was not apparent, and specific therapy, therefore, not possible. The abundant formation of granulation tissue and the ability of the hyperbaric oxygen to arrest further extension of the ulceration suggests that this form of therapy might become the treatment of choice for all ulcers of the pyoderma gangrenosum type.

Erythema nodosum progressing to pyoderma gangrenosum as a complication of Crohn's disease

Erythema nodosum occurs more frequently than pyoderma gangrenosum in Crohn's disease. We report the occurrence of both lesions in a woman with Crohn's disease and the transformation of one to the other. Pyoderma gangrenosum has been described at the site of previous trauma in Crohn's disease and at the site of other skin conditions in other circumstances, but, to the best of our knowledge, actual progression from erythema nodosum to pyoderma gangrenosum has been reported on only one previous occasion in Crohn's disease.

Pyoderma gangrenosum

Since its description 50 years ago, pyoderma gangrenosum has continued to capture the attention and imagination of all those who see its dramatic presentation. Clinical observation still provides the only reliable diagnosis. As investigative techniques increase, more and more intriguing immunologic abnormalities associated with this disorder are discovered, but understanding of the pathogenesis remains elusive. It is now recognized as an independent condition as well as a co-condition with many systemic disorders. Many new treatment options are available, allowing much individualization of treatment. For now, pyoderma gangrenosum remains an impressive, relatively easily recognized, but poorly understood disease.

Cutaneous manifestations of rheumatoid arthritis

Rheumatoid arthritis is a systemic disease which can have multiple cutaneous manifestations. In particular, rheumatoid vasculitis may be difficult to diagnose because of the wide array of clinical presentations. Early recognition can assist the physician in diagnosis and in determination of the proper therapy. Every physician caring for patients with rheumatoid arthritis should be aware of these common dermatologic complications.

Cutaneous cryptococcosis simulating pyoderma gangrenosum

A 33-year-old white man with a history of chronic ulcerative colitis presented with multiple cutaneous ulcers and an indurated cellulitic area on his right thigh. Clinically, the ulcers were considered to represent pyoderma gangrenosum. However, tissue biopsy revealed copious yeast forms that were identified as Cryptococcus neoformans. The indurated area on the right thigh later ulcerated, and tissue culture of this area also revealed Cryptococcus. This case illustrates that when pyoderma gangrenosum is diagnosed, the possibility of deep fungal infection should be considered and excluded by appropriate studies.