Could your case of necrotising fascitis be Pyoderma gangrenosum?

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines

INTRODUCTION

Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery.

METHODS

This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included.

RESULTS

Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days.

CONCLUSIONS

Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

[Complex treatment of pyoderma gangrenosum after minor trauma and primary surgical intervention with suspected necrotizing fasciitis]

This article presents the case of a rapidly progressing pyoderma gangrenosum (PG) following a minor trauma and surgical intervention. A 46-year-old patient was admitted to hospital after a minor trauma of the right lower leg with a suspected diagnosis of erysipelas bullosum. A magnetic resonance imaging (MRI) scan showed the suspicion of necrotizing fasciitis (NF) with indications for immediate incision and fascia resection. According to the results of the histopathological analysis and microbiological assessment without signs for a bacterial infection, high-dose steroid treatment and immunosuppressive treatment with cyclosporin A were initiated under the assumption of PG. Additionally, the patient was treated with hyperbaric oxygenation (HBO). The 2‑year follow-up showed a gradual restitution of the soft tissues.

A surgeon's nightmare: pyoderma gangrenosum with pathergy effect mimicking necrotising fasciitis

A 53-year-old woman was admitted for vulval swelling and fever. She was initially diagnosed with vulval cellulitis and given parenteral antibiotics. Within 1 week, she developed necrotic-looking skin lesions extending from her vulva to her buttock. Emergency surgical debridement with diversion colostomy was performed in view of suspected necrotising fasciitis. Shortly after the surgery, she developed necrotic-looking skin lesions at the peripheral venous cannula insertion site, central line insertion site, and around her surgical wounds and stoma. A second surgical debridement was performed and shortly afterwards, similar skin lesions appeared around her surgical wounds. Her clinical progression was suggestive of pyoderma gangrenosum with pathergy effect. Hence, she was started on topical steroid, systemic steroid and immunosuppressant. The skin lesions responded well to medical therapy. Further systemic workup for conditions associated with this disease revealed findings suspicious for myelodysplastic syndrome.

Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases

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.

Severe, Steroid-responsive, Myositis Mimicking Necrotizing Fasciitis following Orthopedic Surgery: A Pyoderma Variant with Myonecrosis

Summary:

Postoperative pyoderma gangrenosum is a rare neutrophilic dermatosis that may be confused for necrotizing fasciitis. The inflammatory response is triggered by the trauma of surgery and thus must be managed nonsurgically. Clinical and pathological findings in the 2 diseases can be identical, leading to misdiagnosis and massive surgical defects from the ensuing surgery. This report documents a severe case of postsurgical pyoderma following an elective rotator cuff repair presenting with myositis and myonecrosis. The patient was initially treated as having an infection, which resulted in multiple aggressive surgical debridements. Despite this, the patient continued to deteriorate and was in a critical and hemodynamically unstable condition. Following administration of high-dose intravenous corticosteroids, the patient made a dramatic recovery and went on to have internal fixation of the shoulder and closure of the wound with a combination of a free flap and a rotational flap. Extensive myositis, as seen in this case, has not been previously reported in postoperative pyoderma gangrenosum variants. Clinicians should be aware that the presence of myositis and myonecrosis should not preclude this diagnosis.

Etiology and management of pyoderma gangrenosum: a comprehensive review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, necrotic ulceration. It typically affects patients in the third to sixth decades of life, with almost equal incidence in men and women. PG occurs most frequently on the lower extremities. Five clinical variants are currently recognized: classic, bullous, pustular, vegetative, and peristomal types. Half of PG cases are seen in association with systemic disease. Mimickers include infection, vascular insufficiency ulcers, systemic vasculitides, autoimmune disease, cancer, and exogenous tissue injury, among others. PG is often a diagnosis of exclusion, as there are no specific laboratory or histopathologic findings to confirm the diagnosis. PG thus presents many clinical challenges: it is difficult to diagnose, is frequently misdiagnosed, and often requires a work-up for underlying systemic disease. Successful management of PG typically requires multiple modalities to reduce inflammation and optimize wound healing, in addition to treatment of any underlying diseases. Prednisone and cyclosporine have been mainstays of systemic treatment for PG, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor-α inhibitors, for refractory cases of PG. Here, we review the clinical presentation and pathophysiology of PG, as well as its associated conditions, diagnostic work-up, and management.

Atypical pyoderma gangrenosum following total knee replacement surgery: first report in dermatologic literature

An atypical pyoderma gangrenosum mimicking a post surgical cutaneous and subcutaneous infection is being reported for the first time in international literature after knee replacement surgery with the operation site being the starting point of pyoderma gangrenosum. Orthopedic surgeons and general surgeons should be aware of the existence of this disease and its association with surgical trauma.

Pyoderma Gangrenosum in Crohn's Disease: Unusual Presentation and Management

Pyoderma gangrenosum is an uncommon, destructive, cutaneous ulceration which presents as ulcerative, pustular, bulluous and vegetative forms, the ulcerative forms being more common. We present the case of 41-year-old woman with Crohn's disease who presented with a rather unusual form of pyoderma gangrenosum, aseptic cutaneous abscess. It was initially misdiagnosed as a fistulous tract in the abdominal wall, but later prompt diagnosis of pyoderma gangrenosum led to a very satisfactory outcome.

Pyoderma gangrenosum masquerading as necrotizing fasciitis

Necrotizing fasciitis is a fulminant advancing soft tissue infection characterized by widespread fascial necrosis, which can result in significant morbidity and even death. This condition requires prompt diagnosis and aggressive management with extensive surgical debridement and appropriate antibiotic coverage. Pyoderma gangrenosum, in contrast, is a noninfectious inflammatory condition of the skin that typically does not require surgical management. Both conditions can present with extensive ulceration and tissue necrosis, and close clinical-pathologic correlation is required to make the appropriate diagnosis. We present a case in which the diagnosis of pyoderma gangrenosum was initially elusive and serves to illuminate the diagnostic pitfalls in dealing with these entities.

Differenzialdiagnose „steriler“ phlegmonöser Entzündungen der Hand

INTRODUCTION

Bacterial infections represent a large proportion of emergencies in hand surgery. In some cases, pyoderma gangrenosum and mycobacterial infection may present with the same symptoms of swelling, pain, and purulent secretion. In these cases, operative treatment would be harmful. Therefore two cases-pyoderma gangrenosum and tuberculosis-are presented here in relation to common bacterial hand infection.

METHODS

Using two case reports of diseases that only rarely affect the hands, their relevance to differential diagnosis is shown with reference to the literature.

RESULTS

In both cases, we found clinical symptoms of bacterial hand infection with negative bacterial smear tests. After several debridements, pyoderma gangrenosum of the dorsum of the hand was diagnosed in one patient after pyodermiform lesions at the thigh and the nasal septum were detected and pre-existing colitis ulcerosa was taken into consideration. Corticoid therapy induced complete remission. The second patient with similar clinical symptoms had been operated on at another hospital several times before being transferred to our institution. The presumptive diagnosis of pyoderma gangrenosum was made, and under treatment with prednisone the symptoms quickly improved. After 2 weeks, the wound conditions and the patient's condition rapidly worsened. Following amputation at the upper arm level, the patient died of septic multiple organ failure. Autopsy studies revealed tuberculous sepsis originating from the hand.

DISCUSSION

Patient history should be evaluated carefully because of its value to correct diagnosis. In case of negative smear tests, especially from immunocompromised, elderly patients and in patients with a history of pulmonary tuberculosis, Ziehl-Neelsen staining should be obtained. In case of multilocular affection or pre-existing chronic inflammatory bowel disease, the presumptive diagnosis of pyoderma gangrenosum can be confirmed by biopsies from the lesions margin. In both cases, unnecessary traumatizing operations could thus be avoided and treatment optimized.

[Strategies of management of necrotizing soft tissue infections]

Necrotizing soft tissue infections represent a group of rapidly progressive diseases requiring early and repeated debridement, associated with broad spectrum antibiotics. Delay in surgery or inadequate therapy are the main risk factors for death. Most patients need aggressive critical care management and intensive nutritional support. The management of these patients by experimented senior surgeons is mandatory. A plastic surgeon can help debridement in order to preserve possibilities of later myocutaneous or rotational skin flaps. Intravenous immunoglobulins are an efficacious adjunctive therapy for severe group A streptococcal infection.