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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.
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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.
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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.
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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
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3
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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:
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Qureshi A, Persaud K, Zulfiqar S, Dande R, Puri C, Awasthi S. Atypical Pyoderma gangrenosum: a case of delayed recognition. J Community Hosp Intern Med Perspect 2021; 11:242-248. [PMID: 33889329 PMCID: PMC8043550 DOI: 10.1080/20009666.2020.1866250] [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: 11/03/2022] Open
Abstract
Pyoderma gangrenosum (PG) is an inflammatory skin condition that is often misdiagnosed as a necrotizing infection. This diagnosis must be considered in any patient with underlying systemic disease who presents with large ulcerating lesions that are unresponsive to antibiotics. Early diagnosis and a multidisciplinary approach to treatment are crucial to achieving improvement in quality of life and minimizing cosmetic morbidity. .
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Affiliation(s)
- Anum Qureshi
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Kia Persaud
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Sajida Zulfiqar
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Ranadheer Dande
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Chahat Puri
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
| | - Shankar Awasthi
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD, USA
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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.
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Bazaliński D, Karwiec A, Kucharzewski M, Więch P. Negative Pressure Wound Therapy in Pyoderma Gangrenosum Treatment. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922581. [PMID: 32520925 PMCID: PMC7304651 DOI: 10.12659/ajcr.922581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patient: Male, 83-year-old Final Diagnosis: Pyoderma gangrenosum Symptoms: Infection Medication: — Clinical Procedure: Negative pressure wound therapy Specialty: Dermatology • Geriatrics • Palliative Medicine • Surgery
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Affiliation(s)
- Dariusz Bazaliński
- Father B. Markiewicz Podkarpackie Specialist Oncology Center, Specialist Hospital in Brzozów, Brzozów, Poland.,Institute of Health Sciences, College of Medical Sciences of the University of Rzeszów, University of Rzeszów, Rzeszów, Poland
| | - Anna Karwiec
- Hematology Clinic, Fryderyk Chopin Clinical Provincial Hospital No. 1 in Rzeszów, Rzeszów, Poland
| | - Marek Kucharzewski
- Chair and Department of Descriptive and Topographic Anatomy, Medical University of Silesia, Katowice, Poland
| | - Paweł Więch
- Institute of Nursing and Health Sciences, Faculty of Medicine, College of Medical Sciences, University of Rzeszów, Rzeszów, Poland
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Pellegrino SA, Cham A, Pitcher M. Pyoderma gangrenosum of the breast 17 years after breast cancer treatment. BMJ Case Rep 2020; 13:13/3/e232983. [PMID: 32193178 DOI: 10.1136/bcr-2019-232983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We present a case of pyoderma gangrenosum (PG) affecting the breast of a 74-year-old woman, with a history of breast cancer treated with breast conserving surgery and adjuvant radiotherapy 17 years prior. She presented to the hospital with worsening breast ulceration, after a punch biopsy was performed at the site. She had surrounding cellulitis and concurrent infection to that breast which required antibiotics. The ulceration persisted even after treatment, and incisional biopsies of the area of ulceration confirmed the diagnosis of PG. Her condition was managed effectively with the use of immunosuppressive therapy, and she continued to display a good clinical response 2 months post discharge from the hospital.
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Affiliation(s)
| | - Alvin Cham
- Breast and General Surgery, Western Health, Melbourne, Victoria, Australia
| | - Meron Pitcher
- Breast and General Surgery, Western Health, Melbourne, Victoria, Australia
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Ehrl DC, Heidekrueger PI, Broer PN. Pyoderma gangrenosum after breast surgery: A systematic review. J Plast Reconstr Aesthet Surg 2018; 71:1023-1032. [PMID: 29748073 DOI: 10.1016/j.bjps.2018.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/16/2018] [Accepted: 03/10/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post-surgical pyoderma gangrenosum (PSPG) is a rare inflammatory skin disorder of unknown aetiology. Given its similar presentation to wound infection and lack of reliable diagnostic tests as well as pathognomonic clinical features, PSPG is difficult to diagnose. The aim of this review was to identify factors contributing to PSPG to aid with timely diagnosis and appropriate therapy. METHODS A systematic literature review was performed by following PRISMA guidelines, focusing on PSPG after reconstructive and aesthetic breast surgery. The online databases PubMed, Medline, EMBASE, Scopus, and Cochrane were used, and additionally, a Google© search was performed. RESULTS A total of 68 articles describing 87 cases of PSPG following aesthetic and reconstructive breast surgery were found. The majority of PSPG (44%) occurred after breast reduction surgery and microsurgical breast reconstruction (16%). The most common associated conditions were malignancies in 37% and autoimmune deficiencies in 17%. Microbiological examinations were found to have a negative result in 90%. The median time from initial presentation with symptoms to correct diagnosis of PG was on average 12.5 days, with unsuccessful first-line therapy on average for 20.0 days. After the diagnosis of PG, medical therapy most commonly involved steroids in 84% and/or Cyclosporine A in 22% of the cases. On average, the duration of this therapy was 4.7 months. CONCLUSION The diagnosis of PSPG remains a challenging issue. However, according to the presented review, several distinct clinical signs in combination with lack of treatment response should prompt further investigation to promote timely diagnosis and correct treatment of this potentially debilitating disease.
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Affiliation(s)
- Denis C Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Marcioninistr. 15, Munich 81377, Germany.
| | - Paul I Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Medical Centre, Franz-Josef-Strauß-Allee, 93053, Regensburg, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Engelschalkingerstr. 77, 81925, Munich, Germany
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Tanini S, Calugi G, Russo GL. Combination of negative pressure wound therapy and systemic steroid therapy in postsurgical pyoderma gangrenosum after reduction mammoplasty; a case of proven efficacy and safety. Dermatol Reports 2017; 9:7209. [PMID: 29279772 PMCID: PMC5729802 DOI: 10.4081/dr.2017.7209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/23/2017] [Indexed: 12/16/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare non-infective inflammatory disease of unknown etiology characterized by cutaneous papulo-pustoles that rapidly evolve into painful ulcerative lesions. Postoperative PG (PPG) is a clinical variant of PG in which pathergic response occurs at surgical sites. It is important to include PG in the differential diagnosis of breast ulceration. An incorrect diagnosis and treatment can potentially worsen the patient state, causing disfigurement with extensive scarring, an unpleasant aesthetic result and produce consequent psychological trauma. We report a case of PPG after bilateral breast reduction mammoplasty treated with negative pressure wound therapy (NPWT) as local treatment for wound dehiscence in combination with systemic steroid therapy. This synergism led to a good aesthetic result. NPWT improved wound perfusion, it decreased the exudate, and promoted adherence of the mammary gland to the pectoral muscle. After 31 days deep sutures were placed to directly close the wound and the patient was discharged. PPG is a rare, devastating occurrence after surgery. Surgeons must know that PPG is an evenience that can occur in otherwise healthy patients and must be considered in the differential diagnosis in case of necrotic ulcers and apparent infection status. NPWT resulted to have benefits in the treatment of PPG, with a role in limiting the size of the defect, avoiding pathergic self-reaction and allowing a faster recovery with higher chances of achieving a better result.
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Affiliation(s)
- Sara Tanini
- Plastic and Reconstructive Microsurgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Gianmarco Calugi
- Plastic and Reconstructive Microsurgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Giulia Lo Russo
- Plastic and Reconstructive Microsurgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
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