1
|
Delaleu J, Bouaziz JD. Overview of Neutrophilic Biology, Pathophysiology, and Classification of Neutrophilic Dermatoses. Dermatol Clin 2024; 42:147-156. [PMID: 38423677 DOI: 10.1016/j.det.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Neutrophilic dermatoses are a group of inflammatory skin conditions characterized by a neutrophilic infiltrate on histopathology with no evidence of infection. These conditions present with a wide range of clinical manifestations, including pustules, bullae, abscesses, papules, nodules, plaques, and ulcers. The classification of neutrophilic dermatoses is based on the localization of neutrophils in the skin. The pathogenic mechanisms of neutrophilic dermatoses involve autoinflammation, neutrophilic dysfunction, clonal somatic mutation and differentiation of the myeloid precursors as encountered in myeloid neoplasm.
Collapse
Affiliation(s)
- Jérémie Delaleu
- Dermatology Department, Saint Louis Hospital, APHP Nord Université Paris Cité and INSERM u976 "Human Immunology, Pathophysiology and Immunotherapy", Paris, France
| | - Jean-David Bouaziz
- Dermatology Department, Saint Louis Hospital, APHP Nord Université Paris Cité and INSERM u976 "Human Immunology, Pathophysiology and Immunotherapy", Paris, France.
| |
Collapse
|
2
|
Champigny M, Toomey A, Sherbert D. Pyoderma Gangrenosum Presentation After Abdominoplasty and Augmentation Mastopexy. Cureus 2024; 16:e58060. [PMID: 38738036 PMCID: PMC11088448 DOI: 10.7759/cureus.58060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Pyoderma gangrenosum is a rare ulcerative skin disease of uncertain etiology, which in some cases can be misdiagnosed as an infectious process. In even more unique cases, this can occur in the postoperative period. Termed postsurgical pyoderma gangrenosum, this type of inflammatory skin condition requires a high index of suspicion to be able to appropriately treat and reduce complications. We present a 55-year-old female who presented with multiple wounds following mastopexy and abdominoplasty. With a prompt diagnosis and a multidisciplinary approach, we could accurately care for the patient and minimize poor aesthetic sequela.
Collapse
Affiliation(s)
- Michele Champigny
- Plastic and Reconstructive Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Ariel Toomey
- Plastic and Reconstructive Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Daniel Sherbert
- Plastic and Reconstructive Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| |
Collapse
|
3
|
Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
Collapse
Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology; Department of Dermatology, Baylor University Medical Center; University of Texas at Southwestern; Texas A&M University School of Medicine, 1640 FM 544, Suite 100, TX 75056, USA.
| |
Collapse
|
4
|
Keramidas E, Rodopoulou S, Avgerinos N. Early Diagnosis and Treatment of Pyoderma Gangrenosum: Reviewing Mobile Phone Photos Saved a Patient From Unnecessary Surgeries. Cureus 2024; 16:e54797. [PMID: 38405660 PMCID: PMC10893982 DOI: 10.7759/cureus.54797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Pyoderma gangrenosum of the breast following surgery is a rare aseptic inflammatory cutaneous condition that causes very rapid progressing and expanding painful ulceration of the surgical site and the adjacent skin. The greatest issue concerning pyoderma gangrenosum is its diagnosis. Almost invariably, it is misdiagnosed as a wound infection, which results in delayed identification, lengthy antibiotic regimens, and ineffective detrimental surgical debridements, causing significant patient disfigurement. We present a rare case report of pyoderma gangrenosum complicating the surgical site of the breast reduction procedure two months after simultaneous performance of operations including breast reduction, abdominoplasty, and lumbar liposuction. The diagnosis was established within four hours from the initial lesion and symptom presentation due to the accurate evaluation of photographs sent from the patient's mobile phone to the surgeon every half hour. Immediate appropriate treatment with oral corticosteroids within this time interval was initiated, resulting in favorable healing for the patient within four months.
Collapse
|
5
|
Obinwanne V, Hoffmann Guarda N, Araoye E, James AJ. Extensive Pyoderma gangrenosum following breast reduction and abdominoplasty: a challenging case. Case Reports Plast Surg Hand Surg 2024; 11:2302124. [PMID: 38274559 PMCID: PMC10810620 DOI: 10.1080/23320885.2024.2302124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024]
Abstract
Post-surgical pyoderma gangrenosum (P SP G) is a subtype of pyoderma gangrenosum in which non-infectious, painful, inflammatory ulcerative nodules develop in incision sites. Delayed diagnosis and surgical interventions of P SP G often contribute to worsened morbidity. We present a case of a 55-year-old female diagnosed with severe P SP G after breast augmentation and abdominoplasty.
Collapse
Affiliation(s)
- Vera Obinwanne
- Western Michigan Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathalia Hoffmann Guarda
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Erinolaoluwa Araoye
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alaina J. James
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Hashim A, Boucher F. A case report and a call for early recognition: post-operative Pyoderma Gangrenosum after breast-conserving surgery in a locally advanced breast tumor. Case Reports Plast Surg Hand Surg 2024; 11:2304620. [PMID: 38250334 PMCID: PMC10798280 DOI: 10.1080/23320885.2024.2304620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
We present a case of a patient addressed to our plastic surgery department after a breast tumor resection and subsequent necrosis and ulceration of the right breast. A diagnosis of pyoderma gangrenosum was made based on the clinical criteria, early recognition resulted in complete recovery without further reconstructive surgery.
Collapse
Affiliation(s)
- Abdulrahman Hashim
- Department of Plastic and Reconstructive Surgery, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France, Department of Surgery, University of Jeddah Medical School, Jeddah, Saudi Arabia
| | - Fabien Boucher
- Department of Plastic and Reconstructive Surgery, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| |
Collapse
|
7
|
Brucato D, Bonomi F, Pompei B, Schmauss D, Meani F, Harder Y. Pyoderma gangrenosum following reduction mammoplasty: Systematic review of the literature and case report. J Plast Reconstr Aesthet Surg 2024; 88:535-546. [PMID: 38118291 DOI: 10.1016/j.bjps.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that can develop at a surgical site. Diagnosis can be challenging at its presentation causing delays in appropriate treatment. The aim of this study is to review the current literature as well as to describe the clinical presentation, diagnostic pathway, and treatment of PG after reduction mammaplasty in order to define a standardized multidisciplinary diagnostic and therapeutic approach. In the future, this may ease early identification and prompt treatment, and eventually minimize severe morbidity and long-term sequelae. METHODS The entire PubMed/Medline database was screened following the PRISMA guidelines to identify studies describing PG that have occurred after reduction mammoplasty. RESULTS Twenty-eight articles including 31 patients reported a PG after breast reduction surgery between January 1988 and March 2022. Twenty-one (68%) patients presented with skin ulcerations, 14 (45%) with erythema, and 5 (16%) with vesicles. Out of the 30 cases that underwent bilateral surgery, 18 (60%) developed PG bilaterally. In 12 out of 31 patients, nipple-areolar complex (NAC) involvement was evaluated, though in 10 patients (83%) the NAC was spared. Of the 20 patients (65%) who underwent skin biopsies for histopathological examination, 18 (90%) showed neutrophilic infiltration of the dermal layers. All 31 patients (100%) showed rapid clinical improvement after the introduction of immunosuppressive therapy. CONCLUSIONS PG can result in devastating skin alterations also after reduction mammoplasty, if misdiagnosed. However, it presents with constant yet unspecific local and general signs and symptoms that can be recognized to early initiate an appropriate pharmacological treatment.
Collapse
Affiliation(s)
- Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Francesca Bonomi
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Barbara Pompei
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesco Meani
- Breast Cancer Service, Clinica Luganese Moncucco and Clinica Santa Chiara, Locarno, Switzerland
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| |
Collapse
|
8
|
Valaas LA, Johnston C, Bax T. Postoperative pyoderma gangrenosum after gunshot wound: A case report. Trauma Case Rep 2023; 48:100949. [PMID: 37810538 PMCID: PMC10550833 DOI: 10.1016/j.tcr.2023.100949] [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] [Accepted: 09/23/2023] [Indexed: 10/10/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of unclear etiology that exhibits pathergy and can develop post-operatively in surgical incisions. To the best of our knowledge, this is the first case report of PG developing after a gunshot wound (GSW) injury or in a contaminated surgical wound. We further propose umbilical sparing as a key clinical finding differentiating the diagnosis of PG from more common infectious etiologies.
Collapse
Affiliation(s)
- Laura A Valaas
- Division of Dermatology, University of Washington, Seattle, WA, United States of America
| | - Cassidy Johnston
- Spokane Teaching Health Clinic, Spokane, WA, United States of America
| | - Timothy Bax
- Columbia Surgical Specialists, Spokane, WA, United States of America
| |
Collapse
|
9
|
Yamamoto T, Yamasaki K, Yamanaka K, Komine M, Kawakami T, Yamamoto O, Kanekura T, Higuchi T, Takahashi T, Matsushima Y, Kikuchi N. Clinical guidance of pyoderma gangrenosum 2022. J Dermatol 2023; 50:e253-e275. [PMID: 37311717 DOI: 10.1111/1346-8138.16845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.
Collapse
|
10
|
Teknős D, Simsay L, Váradi G, Trávnyik S, Bíró E, Grics L, Lellei I, El-Meouch H. [Pyoderma gangrenosum of the breast – Case report]. Magy Seb 2022; 75:211-213. [PMID: 36006767 DOI: 10.1556/1046.2022.30001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) of the breast is a rare, ulcerative disease of rapid onset normally associated with systemic disorders and triggered by surgery or trauma. Early diagnosis and appropriate treatment of this disease pose a real challenge. We present a case of a PG of the breast in a patient with associated diabetes mellitus, with minor triggering injury. Our patient's condition was diagnosed and treated as an infected breast ulcer; after getting the correct diagnosis we treated her with systemic steroids and finally (at the patient's request) with breast ablation.
Collapse
Affiliation(s)
- Dániel Teknős
- 1 Jávorszky Ödön Kórház, Sebészet, Vác, Magyarország
| | - Laura Simsay
- 1 Jávorszky Ödön Kórház, Sebészet, Vác, Magyarország
| | - Gábor Váradi
- 1 Jávorszky Ödön Kórház, Sebészet, Vác, Magyarország
| | | | - Erik Bíró
- 1 Jávorszky Ödön Kórház, Sebészet, Vác, Magyarország
| | - László Grics
- 1 Jávorszky Ödön Kórház, Sebészet, Vác, Magyarország
| | - Ilona Lellei
- 2 Jávorszky Ödön Kórház, Pathológiai Osztály, Vác, Magyarország
| | | |
Collapse
|
11
|
Wound complications following reduction mammaplasty: which patients are at risk and what can we do about it? A systematic review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-01990-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
12
|
Martinelli VF, Martinelli Barbosa P, Dantas de Oliveira LS, de Melo LDALV, Casa Nova JM, de Brito CAA. Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review. Int Med Case Rep J 2022; 15:449-456. [PMID: 36051090 PMCID: PMC9427006 DOI: 10.2147/imcrj.s376915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition. Case Presentation Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab. Conclusion PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.
Collapse
Affiliation(s)
- Valéria Ferreira Martinelli
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
| | - Pedro Martinelli Barbosa
- Department of Internal Medicine, Medical Sciences Center, Pernambucana of Health College, Recife, Pernambuco, Brazil
| | | | | | - João Manoel Casa Nova
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Carlos Alexandre Antunes de Brito
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Pernambuco, Brazil
- Department of Immunology, Autoimune Research Institute, Recife, Pernambuco, Brazil
- Correspondence: Carlos Alexandre Antunes de Brito, Department of Immunology, Autoimune Research Institute, Avenue Rui Barbosa 715, Recife, Pernambuco, 52011-040, Brazil, Tel +55 81 31480101, Email
| |
Collapse
|
13
|
The Management of Postsurgical Pyoderma Gangrenosum following Breast Surgery. Plast Reconstr Surg Glob Open 2022; 10:e4282. [PMID: 35494881 PMCID: PMC9038501 DOI: 10.1097/gox.0000000000004282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
Abstract
Background: Methods: Results: Conclusions:
Collapse
|
14
|
Hirai K, Tsuge I, Usui S, Takada M, Yamanaka H, Katsube M, Sakamoto M, Morimoto N. Pyoderma Gangrenosum after Breast Cancer Resection: A Less-invasive and Early Treatment Using the Skin around Ulcers. Plast Reconstr Surg Glob Open 2022; 10:e4111. [PMID: 35186644 PMCID: PMC8846357 DOI: 10.1097/gox.0000000000004111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
Surgical invasion is a risk factor of pyoderma gangrenosum (PG). A total of 25% of postoperative PG cases were reported to occur after breast surgeries, including bilateral breast reduction and breast reconstruction following cancer resection. Immunosuppressive therapy and less-invasive wound therapy are necessary; however, the complete healing of ulcers takes 5.1 months on average. We herein report a case of skin grafting under a surgical concept of less-invasive and short-term treatment. An 82-year-old woman complained of a high fever and severe pain at her breast wounds after bilateral breast cancer resection. Although we performed emergency debridement surgery to remove the necrotic tissue, suspecting surgical site infection and inflammation, her high fever persisted. She was diagnosed with PG because of the physical findings of characteristic painful, sterile ulcerations, bullae and pustules, and the pathological abundance of neutrophils in the absence of infection and vasculitis. Oral administration of prednisolone 30 mg/day improved the symptoms, and we applied negative-pressure wound therapy (NPWT) from day 16 following debridement surgery. After the gradual reduction of oral steroid intake to 12.5 mg/day, we performed skin grafting surgery. To limit the surgical invasion, we used the surplus skin around the ulcers. Split-thickness mesh skin grafts were fixed by NPWT to avoid the use of tie-over sutures. We achieved short-term treatment of PG with a less-invasive surgical strategy using skin around the ulcers and NPWT.
Collapse
|
15
|
Peoples AE, Pestana IA. Post-breast Reduction Pyoderma Gangrenosum Managed With Gender-Affirming Top Surgery. Cureus 2021; 13:e20777. [PMID: 35111462 PMCID: PMC8794428 DOI: 10.7759/cureus.20777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/05/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare skin condition characterized by ulcerative lesions and most often associated with inflammatory bowel diseases (IBDs), ulcerative colitis, or Chron’s disease. Postsurgical pyoderma gangrenosum (PSPG) of the breast is exceptionally rare and can occur in the absence of IBD. We report on a patient with pyoderma gangrenosum following elective breast reduction and subsequent reconstruction with gender-affirming top surgery. Through discussion of this IRB-reviewed case, we encourage reconstructive surgeons to incorporate understanding of a patient’s gender identity, expression, or goals during treatment to optimize their patient-centered care.
Collapse
|
16
|
Dermatologic Complications Following Cosmetic and Reconstructive Plastic Surgery: A Systematic Review of the Literature. Aesthetic Plast Surg 2021; 45:3005-3018. [PMID: 34231016 DOI: 10.1007/s00266-021-02362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Plastic surgery procedures, including minimally invasive cosmetic procedures, continue to grow in popularity. Although dermatologic complications following plastic surgery procedures are rare, the authors have encountered several of these complications in their practice, including herpes simplex virus (HSV-1) and varicella zoster virus (VZV) infections, pyoderma gangrenosum (PG), contact dermatitis, and suture hypersensitivity. These cases prompted a systematic literature review of dermatologic complications following plastic surgery procedures. METHODS The authors conducted a systematic review of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library to identify relevant articles published from 1975 to 2021. Articles were independently reviewed by the authors to determine whether studies met inclusion criteria. RESULTS The majority of articles that met inclusion criteria represented level V evidence. The most robust evidence in the literature was for PG, for which there were 63 total studies. Pyoderma gangrenosum was most frequently reported following breast surgery (85.1%), while HSV-1 infections were frequently seen following minimally invasive procedures (84.6%). VZV reactivation was reported after a range of interventions, including pedicled flap surgeries and laser treatments. Other complications, such as suture hypersensitivity, were less frequently reported in the literature, usually as isolated case reports. CONCLUSIONS Dermatologic complications represent a rare but serious concern following plastic surgery procedures. While most dermatologic complications resolve with appropriate treatment, sequelae of these conditions can be devastating to the patient's overall outcome. Plastic surgeons performing procedures at a high risk of these complications should recognize the diagnostic criteria to facilitate appropriate treatment. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
|
17
|
Pyoderma gangrenosum after immediate deep inferior epigastric perforator flap breast reconstruction: a case report. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01882-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Briffa J, Wang YTT, Murphy L, Bunker D, Kode G. Post-surgical pyoderma gangrenosum as a cause of unexplained wound breakdown. ANZ J Surg 2021; 92:865-867. [PMID: 34365724 DOI: 10.1111/ans.17130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/22/2021] [Accepted: 07/24/2021] [Indexed: 11/28/2022]
Affiliation(s)
- James Briffa
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Yu-Ting Tina Wang
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Lisa Murphy
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Daniel Bunker
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Gary Kode
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| |
Collapse
|
19
|
Rich MD, Sorenson TJ, Schubert W. Post-surgical pyoderma gangrenosum in otherwise healthy patient with history of COVID-19. Breast J 2021; 27:671-674. [PMID: 34028140 PMCID: PMC8242535 DOI: 10.1111/tbj.14242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
There are increasing reports of autoimmune and dermatologic sequelae of COVID‐19. We describe an otherwise healthy patient with recent history of serious COVID‐19 infection who developed post‐surgical pyoderma gangrenosum following bilateral reduction mammoplasty and was successfully treated with infliximab, mycophenolic acid, and corticosteroids. We present this case to highlight the lingering systemic proinflammatory effects of COVID‐19 infection that may increase the risk of rare autoimmune complications of surgery. As a complete understanding of the long‐term effects of COVID‐19 is poorly understood, patients with a history of COVID‐19 infection should be appropriately counseled to these possible risks when discussing surgery.
Collapse
Affiliation(s)
- Matthew D Rich
- Division of Plastic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Warren Schubert
- Division of Plastic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.,Department of Plastic and Hand Surgery, Regions Hospital, Saint Paul, MN, USA
| |
Collapse
|
20
|
Kim D, Hur SM, Lee JS, Chin S, Lim CW, Kim Z. Pyoderma Gangrenosum Mimicking Wound Infection after Breast Cancer Surgery. J Breast Cancer 2021; 24:409-416. [PMID: 34128363 PMCID: PMC8410616 DOI: 10.4048/jbc.2021.24.e25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/06/2021] [Accepted: 04/03/2021] [Indexed: 11/30/2022] Open
Abstract
Postoperative pyoderma gangrenosum (PPG) is rare, and its diagnosis is often delayed because of its wound infection-mimicking course. A 53-year-old breast cancer patient who underwent breast-conserving surgery of the right breast presented with fever, leukocytosis, C-reactive protein elevation, and redness of the right breast on postoperative day (POD) 3. The breast wound showed desquamation with painful ulcerative changes from POD 6, and fever was sustained under antibiotic administration. Wound irrigation was attempted; however, inflammatory skin damage progressed to involvement of the entire skin overlying the breast. With clinical suspicion of PPG, skin biopsy and systemic corticosteroid initiation were performed on POD 12. Wound damage progression ceased, and the systemic inflammation subsided. The patient underwent split-thickness skin grafting under intravenous corticosteroid administration, and the wound healed after 30 days. PPG is a rare clinical scenario. Early diagnosis is critical to avoid unnecessary treatment and aggravation of the surgical wound.
Collapse
Affiliation(s)
- Dabin Kim
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sung-Mo Hur
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae Seok Lee
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Susie Chin
- Department of Pathology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Cheol Wan Lim
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Zisun Kim
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
| |
Collapse
|
21
|
Pyoderma Gangrenosum after Breast Mammoplasty Sur-gery: A Case Report. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
22
|
Hammond D, Chaudhry A, Anderson D, Alameddine KO, Tajran J. Postsurgical Pyoderma Gangrenosum After Breast Surgery: A Plea for Early Suspicion, Diagnosis, and Treatment. Aesthetic Plast Surg 2020; 44:2032-2040. [PMID: 32767036 DOI: 10.1007/s00266-020-01899-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a rare inflammatory cutaneous disorder. Although PG is a diagnosis of exclusion, prompt recognition is essential to attain the desired outcomes. From an aesthetic standpoint, this is especially critical with breast involvement and other body segments. We present a consecutive case series of four patients who developed PG following breast surgery and responded to early intervention. METHODS A chart review identified four patients who were identified as having developed PG after either aesthetic or reconstructive breast surgery. Their histories, associated risk factors, diagnosis, course of treatment, and results were documented. The PubMed database was then searched to find the literature for comparison. RESULTS The average time from surgery to the onset of symptoms was 11 days, and the average time from the onset of symptoms to the correct diagnosis of PG was 41 days. The average length of steroid therapy was 25 days. The average time from the initiation of steroids to complete wound closure was 51 days. The average time from the onset of symptoms to complete wound closure bilaterally was 87 days. All wounds healed with conservative management. CONCLUSION Postsurgical PG is a rare but recognized cause of postoperative wound breakdown in patients who have undergone plastic surgery procedures to the breast. Early recognition and treatment can facilitate prompt reversal of the inflammatory process leading to complete wound healing and limitation of the morbidity that can be associated with the disease. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Dennis Hammond
- Spectrum Health/Michigan State University Plastic Surgery Residency, Partners in Plastic Surgery, 4070 Lake Dr., Suite 202, Grand Rapids, MI, 49546, USA.
| | - Arif Chaudhry
- Partners in Plastic Surgery, 4070 Lake Dr., Suite 202, Grand Rapids, MI, 49546, USA
| | - Daniella Anderson
- Spectrum Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
| | | | - Jahan Tajran
- School of Medicine, Wayne State University, Detroit, MI, 48201, USA
| |
Collapse
|
23
|
Milam EC, Rangel LK, Pomeranz MK. Dermatologic sequelae of breast cancer: From disease, surgery, and radiation. Int J Dermatol 2020; 60:394-406. [PMID: 33226140 DOI: 10.1111/ijd.15303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 01/24/2023]
Abstract
The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.
Collapse
Affiliation(s)
- Emily C Milam
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Lauren K Rangel
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Miriam K Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
24
|
Zapata Alvarez J, Patrón Gómez A. Post Reduction Mammaplasty Pyoderma Gangrenosum: An Unusual Presentation of a Misdiagnosed Entity. Cureus 2020; 12:e11432. [PMID: 33324515 PMCID: PMC7732732 DOI: 10.7759/cureus.11432] [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] [Indexed: 11/05/2022] Open
Abstract
Pyoderma gangrenosum is a rare skin disorder that could be triggered after surgical trauma. However, more uncommon, this condition could follow breast surgery. An opportune diagnosis and adequate treatment are essential in order to avoid wound chronicity and aesthetic sequels. We report a 51-year-old woman who presented multiple wound complications after a reduction mammaplasty. This particular case is unique, because bilateral and unusual presentation after another uncomplicated previous surgical procedure, and illustrates how a patient could be taken through different rational surgical therapeutic modalities without improvement, and deterioration of clinical picture. Finally, a diagnosis of Pyoderma gangrenosum was established, and immunosuppressive treatment was completed, with an appropriate resolution of this problematic condition.
Collapse
|
25
|
Brambilla L, Minuti A, Brambilla M, Tourlaki A, Genovese G, Berti E. Late-onset post-mammoplasty pyoderma gangrenosum treated with tobacco-pouch suture combined with oral corticosteroids. GIORN ITAL DERMAT V 2020; 155:702-704. [PMID: 30229642 DOI: 10.23736/s0392-0488.18.06123-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lucia Brambilla
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Minuti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Massimiliano Brambilla
- Unit of Plastic Surgery, Department of General Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Athanasia Tourlaki
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy -
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Emilio Berti
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
26
|
Cabañas Weisz LM, Vicario Elorduy E, García Gutiérrez JJ. "Pyoderma gangrenosum of the breast: A challenging diagnosis". Breast J 2020; 26:2188-2193. [PMID: 32713082 DOI: 10.1111/tbj.13984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
Pyoderma gangrenosum (PG) of the breast is a rare, ulcerative disease of rapid onset normally associated with systemic disorders and triggered by surgery or trauma. Pyoderma gangrenosum poses a diagnostic challenge. Early diagnosis and appropriate treatment are essential to minimize morbidity and sequelae. We performed a retrospective review of all breast PG cases admitted to Cruces University Hospital over a 5-year (2015-2019) period. Medical history, clinical course, and management strategies were assessed. Three patients were analyzed. None of them had previous surgery. No definitive etiology was identified in one case, and the other two were probably biopsy-driven. Histological findings were reported as nonspecific. Similar skin lesions elsewhere on the body and resistance to wide-spectrum antibiotic therapy were observed. These features raised awareness on the diagnosis of PG. Ulcerations healed completely within 2 months following treatment with Cyclosporine A or corticosteroid therapy. A complicated late-diagnosis case that presented with advanced breast and forearm necrosis was managed with steroids followed by trans-forearm amputation and mastectomy. The breast is an unusual site for PG, but this differential diagnosis should be considered in the presence of breast ulceration. In patients with a strong clinical and histological PG suspicion, we suggest early management with systemic corticosteroids and immunosuppressive therapy prior to any surgical debridement to minimize morbidity and poor esthetic outcomes.
Collapse
|
27
|
Eisendle K, Thuile T, Deluca J, Pichler M. Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases. Adv Wound Care (New Rochelle) 2020; 9:405-425. [PMID: 32320362 DOI: 10.1089/wound.2020.1160] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.
Collapse
Affiliation(s)
- Klaus Eisendle
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
- IMREST Interdisciplinary Medical Research Center South Tyrol, Claudiana, College of Health-Care Professions, Bolzano/Bozen, Italy
| | - Tobias Thuile
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
| | - Jenny Deluca
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
| | - Maria Pichler
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
| |
Collapse
|
28
|
van Donkelaar CE, de Haan JMH, Lange JFM, de Vries M, Horváth B. Pseudo-wound infection after a caesarean section: Case report of unrecognized Pyoderma Gangrenosum. Int J Surg Case Rep 2020; 69:79-82. [PMID: 32305662 PMCID: PMC7171254 DOI: 10.1016/j.ijscr.2020.03.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 11/29/2022] Open
Abstract
Pyoderma Gangrenosum (PG) is a rare auto-inflammatory disease. It can develop after surgery due to the pathergy phenomena. Consider PG in the differential diagnosis of a suspected surgical wound infection. Avoid surgical treatment as long as the disease is active to reduce morbidity.
Background Pyoderma Gangrenosum (PG) is a rare auto-inflammatory disease, characterized by painful ulcerative skin-lesions often developing at sites of injury or surgery because of the typical pathergy phenomena. We describe an unusual case of PG after a caesarean section with excessive extra-cutaneous manifestation within internal organs. Presentation of case A 21-year-old Dutch primigravida developed signs of sepsis after a caesarean section. Despite antibiotic treatment, fast clinical deterioration occurred. Exploration of the wound showed necrosis of the uterus and surrounding tissues. Due to the progression of necrosis, consecutive debridement procedures were executed resulting in a substantial abdominal wall defect. The progressive clinical course of the necrosis combined with absence of positive wound cultures and histology of prominent interstitial neutrophilic infiltration, led to the diagnosis ‘Pyoderma Gangrenosum’. Treatment with high dose corticosteroids led to rapid regression of the disease. After several weeks, the abdominal wall defect was surgically corrected under systemic corticosteroid therapy. Discussion This case of PG is unique due to the excessive extra-cutaneous presentation, which contributed to delayed diagnosis. Several surgical interventions in the active stage of disease resulted in expansion of PG and substantial morbidity for the patient. Conclusion Post-operative PG can mimic infectious diseases, but treatment is substantially different. This case of extensive PG highlights the importance of timely recognition and treatment of the disease to reduce iatrogenic morbidity.
Collapse
Affiliation(s)
| | - Johanna M H de Haan
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Johan F M Lange
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marjolijn de Vries
- Department of Obstetrics and Gynecology, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Barbara Horváth
- Department of Dermatology, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
29
|
Reese AM, Haag CK, Jung E, Nauta AC, Swerlick RA, Ortega-Loayza AG. Pyoderma gangrenosum underrepresentation in non-dermatological literature. Diagnosis (Berl) 2020; 8:85-90. [DOI: 10.1515/dx-2019-0079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/06/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).
Methods
We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).
Results
Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.
Conclusions
There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.
Collapse
Affiliation(s)
- Ashley M. Reese
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Carter K. Haag
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Enjae Jung
- Division of Vascular Surgery , Oregon Health and Science University , Portland , OR , USA
| | - Allison C. Nauta
- Division of Plastic and Reconstructive Surgery , Oregon Health and Science University , Portland , OR , USA
| | | | - Alex G. Ortega-Loayza
- Department of Dermatology , Oregon Health and Science University , Portland , OR , USA
| |
Collapse
|
30
|
|
31
|
Zaouak A, Chamli A, Boufarguine S, Hammami H, Fenniche S. Breast pyoderma gangrenosum. Presse Med 2019; 48:1007-1008. [PMID: 31471093 DOI: 10.1016/j.lpm.2019.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Anissa Zaouak
- Habib-Thameur Hospital, Dermatology Department, Research Unit "Genodermatoses and cancers LR12SP03", Tunis, Tunisia.
| | - Amal Chamli
- Habib-Thameur Hospital, Dermatology Department, Research Unit "Genodermatoses and cancers LR12SP03", Tunis, Tunisia
| | - Sarra Boufarguine
- Habib-Thameur Hospital, Dermatology Department, Research Unit "Genodermatoses and cancers LR12SP03", Tunis, Tunisia
| | - Houda Hammami
- Habib-Thameur Hospital, Dermatology Department, Research Unit "Genodermatoses and cancers LR12SP03", Tunis, Tunisia
| | - Samy Fenniche
- Habib-Thameur Hospital, Dermatology Department, Research Unit "Genodermatoses and cancers LR12SP03", Tunis, Tunisia
| |
Collapse
|
32
|
Demirdover C, Geyik A, Vayvada H. Necrotising fasciitis or pyoderma gangrenosum: A fatal dilemma. Int Wound J 2019; 16:1347-1353. [PMID: 31418533 DOI: 10.1111/iwj.13196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 11/30/2022] Open
Abstract
Necrotising fasciitis (NF) is mostly a polymicrobial, severe soft tissue infection that progresses rapidly, penetrating through the subcutaneous tissue to the fascial planes and the muscles. The pyoderma gangrenosum (PG), on the other hand, is a rare, rapidly progressive (except for the post-surgical PG), autoinflammatory ulcerative skin and soft tissue condition. In this study, we tried to emphasise the importance of diagnosing the NF as well as the PG. Although these two clinical presentations have some standard features, awareness of different symptoms in detail affect the outcome. Any surgical discipline can face NF or PG and, therefore, should be aware of them to decrease the mortality rate. Forty-five patients with NF and PG who were treated between January 2008 and October 2018 were included in the study and evaluated retrospectively for age, sex, localisation, onset of symptoms and diagnosis, predisposing factors, characteristics of tissue defects, laboratory findings, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scores, isolated microbiological agents, surgical intervention, and mortality rate. Demographic, laboratory, and clinical data were analysed. Among these 45 patients, 14 patients had PG, and 31 patients had NF. The mean age and SD for the NF and PG groups were 50.80 ± 17.67 and 50.78 ± 12.72, respectively. Five patients had rheumatological disorders; four patients had diabetes mellitus (DM) in the PG group. Males had higher risk than females in NF (odds ratio [OR] = 0.077, 95% confidence interval [CI] 0.017-0.34), and females had higher risk in PG (relative risk [RR] = 5). We compared the LRINEC score of NF patients with PG patients. The mean value of this score was 4.53 for PG patients, and 6.06 for NF patients. Fifteen patients (33.3%) had a radiological evaluation. MRI, CT, and USI were used as imaging modalities. Necrotising fasciitis and PG are two distinct entities that are in general difficult to distinguish. Therefore, differential diagnosis and rapid treatment are crucial for lowering the mortality rate.
Collapse
Affiliation(s)
- Cenk Demirdover
- Department of Plastic, Reconstructive and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | - Alper Geyik
- Department of Plastic, Reconstructive and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | - Haluk Vayvada
- Department of Plastic, Reconstructive and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| |
Collapse
|
33
|
Solis E, Salindera S, Kanesalingam K, Elder E. Post-surgical pyoderma gangrenosum of the breast: a diagnostic dilemma? ANZ J Surg 2019; 90:E89-E90. [PMID: 31230408 DOI: 10.1111/ans.15316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Edgardo Solis
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Shehnarz Salindera
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kavitha Kanesalingam
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| |
Collapse
|