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Guliyeva G, Janis JE. Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5505. [PMID: 38250211 PMCID: PMC10798700 DOI: 10.1097/gox.0000000000005505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/03/2023] [Indexed: 01/23/2024]
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis characterized by immune dysfunction and pathergy. Thus, it is frequently seen in patients with underlying systemic illnesses or postoperatively. For the performance of the debridement or closure of the resultant defect, plastic surgeons are often involved in the care of pyoderma patients. However, both procedures may exacerbate the injury. Therefore, plastic surgeons must be familiar with the presentation of postsurgical pyoderma to avoid further damage and safely repair related soft tissue defects. A systematic search of the PubMed/Medline database was performed using the following keywords: "pyoderma gangrenosum" and "surgery." This online database search has identified 656 studies published between 1958 and 2022. Only reconstructed cases of postsurgical pyoderma gangrenosum were selected. Twenty-eight patients who developed pyoderma after dermatologic, plastic, orthopedic, cardiovascular, general, or obstetric surgery were included in this study. The average time to the PG presentation and diagnosis was 5.5 and 17 days, respectively. Diagnostic scoring tools were not used, and the diagnosis was primarily based on histopathology after repeated treatment failures. The patients received split- or full-thickness skin grafts, local, pedicled, and free flaps. An estimated 82.1% underwent skin grafting, whereas 42.9% underwent flap reconstruction. In addition, 21.4% got both the graft and flap. Accurate diagnosis of PSPG, prevention of further surgical injury, and timely medical management are vital for improving patient outcomes. Reconstruction can be performed, if required. However, despite the availability of different reconstructive techniques, there is no standard approach to the management of the PSPG.
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Affiliation(s)
- Gunel Guliyeva
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
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Alosaimi MM, Sebzali F, Iqbal A, Rabbat CG, Clase CM. Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis. Can J Kidney Health Dis 2022; 9:20543581221120618. [PMID: 36160315 PMCID: PMC9493685 DOI: 10.1177/20543581221120618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Indexed: 12/03/2022] Open
Abstract
Rationale: Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of
pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum
can be associated with Koebner phenomenon and rarely results in systemic
inflammatory response syndrome and shock. Presenting concerns of the patient: A 61-year-old woman had recently started maintenance hemodialysis, using a
tunneled catheter. She was admitted with fever and signs of inflammation at
the catheter exit site and along the tunnel. Diagnoses: The initial diagnosis was catheter-related tunnel infection. The exit site
broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar
lesion developed at a subcutaneous injection site in her abdomen. Clinical
diagnosis of pyoderma gangrenosum was made. She remained febrile despite
broad antibiotic coverage and catheter removal and developed systemic
inflammatory response syndrome (SIRS) that necessitated transfer to
intensive care unit. Interventions: She responded well to fluids and intravenous steroids. Viral and bacterial
cultures were negative throughout; echocardiography and computed tomography
were unrevealing. Insertion of a new hemodialysis catheter was deferred as
long as clinically possible, was undertaken while the patient was taking
steroids, and was uncomplicated. Outcomes: She remained hemodynamically stable and was discharged after rehabilitation.
Her wounds slowly granulated and healed. Steroids were tapered. Teaching points: To our knowledge, this is the first case report of a patient with pyoderma
gangrenosum developing at the site of tunneled hemodialysis catheter. Our
patient developed SIRS with no evidence of infection. We summarize 11
previous case reports of pyoderma leading to SIRS and responsive to
steroids.
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Affiliation(s)
- Majed M Alosaimi
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Fatemah Sebzali
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Ali Iqbal
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Christian G Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Frey P, Akret C, Irles D, Dompnier A, Bing AC. Pyoderma gangrenosum complicating a permanent pacemaker implantation: a case report and literature review. Eur Heart J Case Rep 2020; 4:1-7. [PMID: 32352047 PMCID: PMC7180522 DOI: 10.1093/ehjcr/ytaa049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/10/2019] [Accepted: 02/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Pocket complications are common after cardiac implantable electronic device implantation. We report a rare case of pyoderma gangrenosum (PG) complicating a permanent pacemaker implantation, and the first literature review of 10 published cases. CASE SUMMARY Five days after pacemaker implantation for heart failure and 2:1 atrioventricular block, a 93-year-old man had pain in the scar and bleeding on contact. Two days later, he had fever, inflammatory syndrome, and a necrotic 7-cm wound. The pacemaker was removed and he was started on antibiotics. Due to a lack of bacterial growth in samples, PG (a rare aseptic, destructive inflammatory cutaneous condition) was suspected, and histology was compatible with this diagnosis. High-dose corticosteroids vastly improved his condition within 1 week, and after 2 months of decreasing-dose corticosteroid therapy, complete healing and normalization of the inflammatory syndrome were observed. DISCUSSION Pyoderma gangrenosum should be considered if there is aseptic skin ulceration that is not controlled by antibiotic treatment. The first-line treatment for PG is high-dose systemic corticosteroids.
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Affiliation(s)
- Pierre Frey
- Department of Cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - Chrystelle Akret
- Department of Cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - Didier Irles
- Department of Cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - Antoine Dompnier
- Department of Cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - Anne-Claire Bing
- Department of Dermatology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370 Metz-Tessy, France
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Sousa LC, Bellodi AJ, Braga DO, Pauna HF. Pyoderma gangrenosum after stapedotomy - First report in otolaryngology literature. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Hackl S, Merkel P, Hungerer S, Friederichs J, Müller N, Militz M, Bühren V. [Pyoderma gangrenosum after intramedullary nailing of tibial shaft fracture: A differential diagnosis to necrotizing fasciitis]. Unfallchirurg 2016; 118:1062-6. [PMID: 25672810 DOI: 10.1007/s00113-015-2737-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pyoderma gangrenosum is a rare non-infectious neutrophilic dermatitis, whereas necrotizing fasciitis is a life-threatening bacterial soft tissue infection of the fascia and adjacent skin. As in the case described here after intramedullary nailing, the clinical appearance of both diseases can be similar. Because of the completely different therapeutic approach and a worse outcome in the case of false diagnosis, pyoderma gangrenosum should always be taken into consideration before treating necrotizing fasciitis.
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Affiliation(s)
- S Hackl
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland.
| | - P Merkel
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - S Hungerer
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - J Friederichs
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - N Müller
- Klinikum Kempten, Kempten, Deutschland
| | - M Militz
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
| | - V Bühren
- BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Deutschland
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Tolkachjov SN, Fahy AS, Cerci FB, Wetter DA, Cha SS, Camilleri MJ. Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases. Mayo Clin Proc 2016; 91:1267-79. [PMID: 27489052 DOI: 10.1016/j.mayocp.2016.05.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.
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Affiliation(s)
| | | | - Felipe B Cerci
- Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba, Brazil
| | | | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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