An extensive pyoderma gangrenosum mimicking necrotizing fasciitis: An unusual case report

Pyoderma Gangrenosum in a 75-Year-Old Male With Follicular Diffuse Large B-cell Lymphoma

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that characteristically presents with progressive ulcerative lesions. The association of PG with hematological malignancies remains unclear due to its varied clinical presentation. Herein, we report the unusual case of PG in a 75-year-old male with stage III follicular diffuse large B-cell lymphoma. Seven days subsequent to his first dose of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) therapy, he presented to the emergency department with generalized malaise, bilateral lower extremity edema, and ecchymoses with ulcerative wounds on the dorsal of his feet. Due to the rapid progression of the patient's dermatological manifestations and declining clinical status, he required serial surgical wound debridement and a biopsy, which revealed an occlusive vasculopathy with dermal and epidermal necrosis. These pathological findings, along with the patient's clinical presentation, led to the diagnosis of PG. The patient was treated with negative pressure wound therapy, steroids, and tacrolimus ointment, which led to a marked improvement in the appearance of the patient's dermatological features and clinical status.

Pyoderma Gangrenosum, a Challenging Postpartum Diagnosis-Case Report and Literature Review

Background/Objectives: The infrequent occurrence of pyoderma gangrenosum (PG) during pregnancy and in postpartum, with its subsequent diagnostic intricacies, caused us to present the following case. Methods: This article describes a rare case of PG in postpartum in a patient without any prior pathology and a short review of the literature, aiming to identify similar rare instances. Results: We conducted a literature review to ascertain the prevalence of postpartum pyoderma gangrenosum, and we identified a total of 41 cases. Conclusions: Our article underlines again the importance of interdisciplinary collaboration for the prompt identification and commencement of necessary therapeutic interventions in postpartum women afflicted by pyoderma gangrenosum.

Wound Debridement in Pyoderma Gangrenosum

BACKGROUND

Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG).

OBJECTIVE

To determine whether published evidence supports conservative wound debridement for PG.

DATA SOURCES

The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement."

STUDY SELECTION

Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG.

DATA EXTRACTION

Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles.

DATA SYNTHESIS

There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission.

CONCLUSIONS

There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.

Practical aspects of the diagnosis and management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.

Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, severe soft tissue infection, characterized by rapid and extensive necrosis of the skin, subcutaneous tissue, and superficial and deep fascia. It is frequently misdiagnosed as other infectious diseases, leading to inappropriate treatment and potentially serious consequences. It may be complicated by septic shock and multiple organ failure with a fatal outcome.

PATIENT CONCERNS

A 73-year-old woman presented with continuous itching, skin lesions, pain, and swelling of the outer side of her left leg. The patient was diagnosed with septic shock and multiorgan failure caused by left leg NF.

DIAGNOSIS

Septic shock and multiorgan failure caused by left leg NF.

INTERVENTIONS

Two surgeries were performed on the patient's leg, which effectively treated her septic shock and multiple organ dysfunction.

OUTCOMES

The patient was followed up three times after her discharge. She had a good recovery, was generally well with no significant sequelae, and returned to her regular life.

CONCLUSION

NF is an acute severe illness with high mortality. It is easily misdiagnosed, leading to delayed or erroneous treatment and serious (or potentially fatal) outcomes. Rapid and accurate diagnosis of NF is essential for patient recovery. In difficult cases, multidisciplinary consultations may be helpful. The management of NF includes early and thorough surgical debridement, antibiotics, and symptomatic treatment.

A Case Report of Extensive Pyoderma Gangrenosum on the Upper Third of the Body

Pyoderma gangrenosum (PG) is a sterile inflammatory neutrophilic dermatosis that can present as a peristomal, pustular, bullous, vegetative, or ulcerative variant. It commonly affects the lower extremities, mainly in the pretibial area. We describe a case of extensive PG in an 18-year-old Indonesian man, involving the upper third of the body. Dermatological examination showed multiple painful ulcers with violaceous borders on the face, occipital region of scalp, neck, shoulder, upper chest, and back. The diagnosis of PG was established based on the histopathological examination that revealed massive dermal neutrophilic infiltration mixed with lymphocytic inflammatory infiltrates accompanied by leukocytoclastic vasculitis. The patient was treated with methylprednisolone equivalent to 1 mg/kg/day of prednisone. An excellent response to therapy also confirmed the diagnosis of PG. Since lesions of PG can appear on any part of the body, including the upper third of the body, a complete and appropriate examination is useful in establishing diagnosis.