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Shono Y, Sekioka A, Ota S, Ito T, Adachi Y. A Rare Case of Severe Post-operative Pyoderma Gangrenosum After Surgery for Perforated Diverticulitis at the Sigmoid Colon. Cureus 2023; 15:e35807. [PMID: 37025752 PMCID: PMC10074223 DOI: 10.7759/cureus.35807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a nonbacterial ulcerating skin condition. It is typically associated with other systemic disorders. However, approximately 20%-30% of cases are idiopathic. Post-operative PG (PPG) is a rare type of PG with a rapidly expanding cutaneous ulcer at a surgical site and is often misdiagnosed as a wound infection. The difficulty in diagnosis can lead to unnecessary surgical interventions and delay in the treatment of PG. Herein, we present the case of a 68-year-old patient with severe PPG with no underlying diseases. He underwent an emergency laparotomy (Hartmann's procedure) for perforated diverticulitis. After the operation, systemic inflammatory response syndrome (SIRS) developed and the skin around the incisional wound, stoma, injection venous lines, and electrocardiogram monitoring pads gradually became erythematous. Skin biopsy and the absence of a source of infection confirmed the diagnosis of PG. Drug therapy for PG with steroids, and tumor necrosis factor-α inhibitors improved SIRS and the patient recovered.
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[Pyoderma gangrenosum in a grade 3 open fracture after a forest accident : When one cannot see the wood for the trees]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:168-172. [PMID: 35420293 DOI: 10.1007/s00113-022-01176-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 02/07/2023]
Abstract
We describe the case of a forest worker with a Gustilo-Anderson III dislocation fracture of the ankle joint. After initial external fixation, round necrotic skin lesions with hyperemic border walls appeared on the entire lower leg. Recurrent débridements worsened the soft tissue instead of improving it. An immunoglobulin and corticosteroid treatment was initiated, which diminished the inflammatory reaction and granulation of soft tissue began. Posttraumatic pyoderma gangrenosum is a rare diagnosis. Nevertheless, it needs to be on the list of differential diagnoses if uncommon soft tissue reactions appear.
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Ackerman D, Phan C, Kuroki M, Helm M, Jeganathan NA. A Case Report of Necrotizing Neutrophilic Dermatosis: A Sheep in Wolf's Clothing. Cureus 2022; 14:e26498. [PMID: 35923500 PMCID: PMC9339259 DOI: 10.7759/cureus.26498] [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: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Neutrophilic dermatosis (ND) is a category of diseases characterized by trauma-induced, autoinflammatory cutaneous eruption. Comorbid systemic disease is common with a predilection for malignancy, inflammatory bowel disease, and rheumatologic disease. Rarely, it can manifest with aseptic shock, an entity referred to as necrotizing neutrophilic dermatosis (NND). NND may occur in the postoperative setting and is often misdiagnosed as a necrotizing soft tissue infection. Unfortunately, the treatment for a necrotizing soft tissue infection, namely, wide debridement, is often detrimental in the setting of NND. We present the case of a woman with underlying myelodysplastic syndrome who developed episodic postoperative hemodynamic collapse followed by delayed necrotic peristomal ulceration following colonic diversion for complicated diverticulitis. Infectious workup and operative re-exploration were unrevealing. Pathologic assessment of affected skin tissue showed changes consistent with ND, ultimately leading to the diagnosis of NND. Her clinical course dramatically improved with the initiation of immunosuppressive therapy. The mimicry of NND to a potentially lethal necrotizing soft-tissue infection creates a grave diagnostic dilemma in the postoperative period. A general lack of knowledge of NND among non-dermatologic specialists produces an opportunity for misdiagnosis and inappropriate surgical interventions, namely, serial debridement. Several clinical cues may aid in the earlier recognition of NND. The cornerstone of treatment involves systemic corticosteroid therapy with adjunctive therapy for refractory cases. NND must be considered in the differential diagnosis of necrotizing soft tissue infection as early recognition may result in the avoidance of deleterious surgical interventions.
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Affiliation(s)
- Devon Ackerman
- College of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Chandat Phan
- College of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Marcos Kuroki
- General Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Matthew Helm
- Dermatology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Nimalan A Jeganathan
- Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Loomis R, Merrit M, Aleshin MA, Graw G, Lee G, Graw B. Pyoderma Gangrenosum After Bilateral Total Knee Arthroplasty. Arthroplast Today 2021; 11:73-79. [PMID: 34485653 PMCID: PMC8397920 DOI: 10.1016/j.artd.2021.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022] Open
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis, which mimics both infection and necrotizing fasciitis, that can present after surgical interventions. We present the case of a 62-year-old male who underwent one-stage bilateral total knee arthroplasty. Nine days after the surgery, he presented with wound breakdown, high fever, and elevated white blood cell count. Repeated debridement was performed, and empiric antibiotics were given. All tissue cultures and aspirates remained negative throughout treatment course, and the patient remained unresponsive to therapy. The patient was eventually diagnosed with pyoderma gangrenosum after infectious etiologies were ruled out and after a skin biopsy and dermatologic consultation. His condition rapidly improved after treatment with corticosteroids, and soft-tissue defects were repaired with skin substitute and full-thickness skin grafting. In patients with aseptic wound breakdown after total knee arthroplasty, pyoderma gangrenosum is a rare but devastating complication and should be considered.
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Affiliation(s)
- Reilly Loomis
- Palo Alto Medical Foundation, Center for Total Joint Replacement, Palo Alto, CA
| | - Mellanie Merrit
- Sequoia Hospital, Center for Joint Replacement, Redwood City, CA
| | | | - Grace Graw
- Department of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Gordon Lee
- Department of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Bradley Graw
- Palo Alto Medical Foundation, Center for Total Joint Replacement, Palo Alto, CA
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Alonso-León T, Hernández-Ramírez HH, Fonte-Avalos V, Toussaint-Caire S, E Vega-Memije M, Lozano-Platonoff A. The great imitator with no diagnostic test: pyoderma gangrenosum. Int Wound J 2020; 17:1774-1782. [PMID: 32779354 DOI: 10.1111/iwj.13466] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022] Open
Abstract
Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis that wound care specialists must be prepared to recognise. This condition has clinical features analogous to infectious processes. There is no specific diagnostic test and the diagnosis is usually obtained from exclusion. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential to improve the quality of life and the prognosis of patients.
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Affiliation(s)
- Teresa Alonso-León
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | | | - Veronica Fonte-Avalos
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Sonia Toussaint-Caire
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - María E Vega-Memije
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
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Wanner B, Saridakis S, Sammons D. Consecutive Cases of Pyoderma Gangrenosum Following Dermatologic Surgery. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2020; 13:49-50. [PMID: 33178383 PMCID: PMC7595358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative skin disease commonly associated with pathergy and systemic comorbidities. We present the case of a patient who experienced two episodes of PG following consecutive dermatologic surgeries to the left hand. The initial PG ulcerations occurred simultaneously following Mohs surgery and a standard elliptical excision. Five months later, her PG recurred after Mohs surgery. Our patient denied a history of PG, however, further questioning elicited a medical history significant for Crohn's disease. Dermatologists and Mohs surgeons should consider the diagnosis when evaluating patients with poor postoperative wound healing. Unfortunately, a delay in diagnosis often occurs, as the presentation of postsurgical PG can mimic other common skin conditions. Awareness of PG prior to dermatologic surgery is critical to prevent further postoperative complications and unnecessary debridement.
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Affiliation(s)
- Brian Wanner
- Dr. Wanner is a dermatology resident, PGY-3, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Saridakis is an intern, PGY-1, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Sammons is Dermatology Residency Program Director at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
| | - Stephanie Saridakis
- Dr. Wanner is a dermatology resident, PGY-3, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Saridakis is an intern, PGY-1, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Sammons is Dermatology Residency Program Director at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
| | - Dawn Sammons
- Dr. Wanner is a dermatology resident, PGY-3, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Saridakis is an intern, PGY-1, at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
- Dr. Sammons is Dermatology Residency Program Director at OhioHealth Riverside Methodist Hospital in Columbus, Ohio
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Rout AN, Sahu K, Sirka CS. Pyoderma Gangrenosum Over Hypertrophic Scar: Report of a Rare Presentation. Indian Dermatol Online J 2020; 11:222-225. [PMID: 32477984 PMCID: PMC7247654 DOI: 10.4103/idoj.idoj_153_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a chronic neutrophilic dermatoses characterised by large ulcer healing with cribriform scar. PG can rarely occur over the healed scar. Its diagnosis depends on clinical morphology and exclusion of other diseases. We report a case of large pyoderma gangrenosum ulcer on a hypertrophic scar since 1 year. Biopsy from ulcer edge was suggestive of PG and hypertrophic scar. The hypertrophic scar had been formed by healing of a large ulcer 2 years back. The ulcer healed to two-third size over next three months with monthly dexamethasone pulse, daily oral steroid and dapsone. This case was unique since the PG ulcer had occurred over a hypertrophic scar. Such a presentation in PG is rare and physicians should be aware of such occurrence of PG.
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Affiliation(s)
- Arpita N Rout
- Department of Dermatology, AIIMS, Bhubaneswar, Odisha, India
| | - Kananbala Sahu
- Department of Dermatology, AIIMS, Bhubaneswar, Odisha, India
| | - Chandra S Sirka
- Department of Dermatology, AIIMS, Bhubaneswar, Odisha, India
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Niu R, Zheng J, Ding D, Kuang W, Lu F, Yin X. Giant pyoderma gangrenosum in a patient with ulcerative colitis: A case report. Medicine (Baltimore) 2020; 99:e18795. [PMID: 32028391 PMCID: PMC7015628 DOI: 10.1097/md.0000000000018795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a phenomenon of cutaneous ulceration with unknown etiology. About half the cases have associated extracutaneous manifestations or associated systemic diseases. The most commonly associated systemic disorders include inflammatory bowel disease (IBD), hematologic malignancies, autoimmune arthritis, and vasculitis. This is a case report about giant PG with ulcerative colitis (UC), which is extremely rare. CASE PRESENTATION A 39-year-old female farmer with UC for the past 3 years presented with multiple painful ulcers, erosion, exudation, and crusting on the right leg for 1 month. A cutaneous examination showed diffusely distributed, multiple, well-defined, deep purulent ulcers on the right medial shank measuring 6 to 20 cm and sporadic worm-eaten ulceration on the right ectocnemial, with severe oozing and erosions. The ulcerations exhibited deep undermined borders, granulated tissue and a black eschar at the base. The right shank and feet were severely swollen, restricting movement. The arteria dorsalis pedis pulse was good, with normal sensation on the skin of the right shank and feet. Laboratory examinations showed a white cell count of 11.8 × 109/L, hemoglobin was 91 g/L, erythrocyte sedimentation rate was 82 mm/h, unelevated procalcitonin, serum C-reactive protein was 131.29 mg/L, and a negative tuberculin skin test. Enteroscopy demonstrated endoscopic evidence of UC. A skin lesion biopsy showed superficial erosion and scarring. Partial epidermal hyperplasia, partial epidermal atrophy and thinning, mild edema of the dermal papill. Most of the middle and lower part of the dermis, showed dense lymphocytes, histiocytes, multinucleated giant cells, and neutrophil infiltration. PG with UC was diagnosed based on clinical manifestations, laboratory examinations and enteroscopy results. INTERVENTIONS She was treated with topical applications of povidone iodine and kangfuxin solution twice daily, methylprednisolone sodium succinate 40 mg and compound glycyrrhizin 60 mg via intravenous drip once a day, along with thalidomide 50 mg twice daily. The UC was controlled with mesalazine. OUTCOMES She required multiple therapies to achieve PG healing 3 months later. No PG recurrence was observed during the 1-year follow-up. CONCLUSION Recognizing the clinical features of PG and its pathogenic nature, ensuring timely management fundamental for preventing severe destruction and deformity, and control of associated diseases are important aspects of treatment. Combination therapy is essential for PG patients with IBD.
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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.
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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
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Ben Abdallah H, Fogh K, Bech R. Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review. Int Wound J 2019; 16:511-521. [PMID: 30604927 PMCID: PMC7949186 DOI: 10.1111/iwj.13067] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/12/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative skin disease that presents a therapeutic challenge. Tumour necrosis factor alpha (TNFα) inhibitors have been reported to successfully control PG. Our aim was to systematically evaluate and compare the clinical effectiveness of TNFα inhibitors in adults with PG. A literature search including databases such as PubMed, Embase, Scopus, and Web of Science was conducted, using search terms related to PG and TNFα inhibitors. Studies and case reports were included if patients were diagnosed with PG, over the age of 18 and administered TNFα inhibitor. A total of 3212 unique citations were identified resulting in 222 articles describing 356 patients being included in our study. The study we report found an 87% (95% CI: 83%-90%) response rate and a 67% (95% CI: 62%-72%) complete response rate to TNFα inhibitors. No statistically significant differences in the response rates (P = 0.6159) or complete response rates (P = 0.0773) to infliximab, adalimumab, and etanercept were found. In our study TNFα inhibitors demonstrated significant effectiveness with response and complete response rates supporting the use of TNFα inhibitors to treat PG in adults. Our study suggests that there is no significant difference in effectiveness among infliximab, adalimumab, and etanercept.
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Affiliation(s)
- Hakim Ben Abdallah
- Institute of Clinical Medicine, Aarhus Faculty of Health SciencesAarhus UniversityAarhusDenmark
| | - Karsten Fogh
- Department of DermatologyAarhus University HospitalAarhusDenmark
| | - Rikke Bech
- Department of DermatologyAarhus University HospitalAarhusDenmark
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Callen JP. Necrotizing Neutrophilic Dermatitis, an Often-Misdiagnosed Entity With Potentially Severe Consequences. JAMA Dermatol 2019; 155:17-18. [DOI: 10.1001/jamadermatol.2018.3788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jeffrey P. Callen
- Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky
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Choi YJ, Yoo WH. Pyoderma gangrenosum masquerading as an ulcer related to antiphospholipid antibodies in a patient with systemic lupus erythematosus. Lupus 2018; 27:2174-2176. [PMID: 30142985 DOI: 10.1177/0961203318793705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Y J Choi
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - W H Yoo
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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