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Pop IC, Ilies RA, Baican C, Strilciuc S, Muntean V, Muntean M. Pyoderma Gangrenosum Post-Breast Surgery: A Case Report and Comprehensive Review of Management Strategies. J Clin Med 2024; 13:3800. [PMID: 38999365 PMCID: PMC11242064 DOI: 10.3390/jcm13133800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/04/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Pyoderma gangrenosum (PG) is a rare, autoimmune skin condition characterized by painful, rapidly progressing ulcers, often associated with autoimmune dysregulation. Managing PG following breast surgery presents unique challenges due to its pathergy phenomenon, which complicates surgical interventions. This article outlines the case of PG in a 48-year-old female post-breast surgery and reviews management strategies through a systematic analysis of the literature. Methods: A systematic literature review from 2018 to 2023 identified 24 relevant articles on PG management post-breast surgery. The studies were analyzed to compare the efficacy and complications of conservative versus combined (conservative and surgical) treatment strategies. Results: Results indicate that while conservative management, primarily with corticosteroids, remains preferred, combined strategies, including systemic therapies, vacuum-assisted closure, and surgery, offer significant benefits in select cases. Conclusions: Our findings suggest that a personalized, multifaceted treatment plan is crucial for managing PG effectively, emphasizing the need for early detection, meticulous planning, and comprehensive care to optimize patient outcomes.
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Affiliation(s)
- Ioan Constantin Pop
- Plastic Surgery Department, “Prof. Dr. I Chiricuta” Institute of Oncology, 400015 Cluj-Napoca, Romania; (I.C.P.); (R.A.I.); (M.M.)
| | - Radu Alexandru Ilies
- Plastic Surgery Department, “Prof. Dr. I Chiricuta” Institute of Oncology, 400015 Cluj-Napoca, Romania; (I.C.P.); (R.A.I.); (M.M.)
| | - Corina Baican
- Dermatology Department, County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Stefan Strilciuc
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 400337 Cluj-Napoca, Romania
| | - Valentin Muntean
- General Surgery Department, Humanitas Clinical Hospital, 400012 Cluj-Napoca, Romania;
| | - Maximilian Muntean
- Plastic Surgery Department, “Prof. Dr. I Chiricuta” Institute of Oncology, 400015 Cluj-Napoca, Romania; (I.C.P.); (R.A.I.); (M.M.)
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2
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Yanıkoğlu E, Ekinci C, Kose AA. A Rare Entity Developing After Breast Reconstruction: Pyoderma Gangrenosum. Cureus 2024; 16:e62361. [PMID: 39006718 PMCID: PMC11246777 DOI: 10.7759/cureus.62361] [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: 06/14/2024] [Indexed: 07/16/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a rare and persistent neutrophilic dermatosis with an unknown cause. The condition typically manifests clinically as a pustule or plaque that quickly evolves into a necrotic ulcer with undermined violet-colored margins. A surgical debridement might worsen the disease due to the pathergy phenomenon. This case report presents a 48-year-old woman who underwent a late breast reconstruction with a transverse rectus abdominis myocutaneous flap and was subsequently diagnosed with PG. The report details the delays in the diagnosis and management of the disease, providing a comprehensive account of the course of events.
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Affiliation(s)
- Erkan Yanıkoğlu
- Plastic, Reconstructive and Esthetic Surgery, Osmangazi University School of Medicine, Eskişehir, TUR
| | - Can Ekinci
- Plastic, Reconstructive and Esthetic Surgery, Osmangazi University School of Medicine, Eskişehir, TUR
| | - Aydan A Kose
- Plastic, Reconstructive and Esthetic Surgery, Osmangazi University School of Medicine, Eskişehir, TUR
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3
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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.
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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
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4
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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.
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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.
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5
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Salado-Rasmussen K, Alsing KK, Mårtensson NL, Burian EA, Larsen HK. Penile Pyoderma Gangrenosum, a Rare Encounter in STI Healthcare: A Case Report and a Review of the Literature. Acta Derm Venereol 2024; 104:adv32160. [PMID: 38551377 PMCID: PMC11000657 DOI: 10.2340/actadv.v104.32160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Kirsten Salado-Rasmussen
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark;Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Køhler Alsing
- Copenhagen Wound Healing Center, Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark.
| | - Nina Løth Mårtensson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Pathology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Ewa Anna Burian
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Helle Kiellberg Larsen
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Łyko M, Ryguła A, Kowalski M, Karska J, Jankowska-Konsur A. The Pathophysiology and Treatment of Pyoderma Gangrenosum-Current Options and New Perspectives. Int J Mol Sci 2024; 25:2440. [PMID: 38397117 PMCID: PMC10889749 DOI: 10.3390/ijms25042440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally. The pathophysiology of PG is not fully understood; however, it is most commonly considered a disease in the spectrum of neutrophilic dermatoses. The treatment of PG remains challenging due to the lack of generally accepted therapeutic guidelines. Existing therapeutic methods focus on limiting inflammation through the use of immunosuppressive and immunomodulatory therapies. Recently, several reports have indicated the successful use of biologic drugs and small molecules administered for coexisting diseases, resulting in ulcer healing. In this review, we summarize the discoveries regarding the pathophysiology of PG and present treatment options to raise awareness and improve the management of this rare entity.
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Affiliation(s)
- Magdalena Łyko
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
| | - Anna Ryguła
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
| | - Michał Kowalski
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
| | - Julia Karska
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Alina Jankowska-Konsur
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
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Taheri A, Mansoori P, Sharif M. Wound Debridement in Pyoderma Gangrenosum. Adv Skin Wound Care 2024; 37:107-111. [PMID: 38241454 DOI: 10.1097/asw.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
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.
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Affiliation(s)
- Arash Taheri
- Arash Taheri, MD, is Internal Medicine Physician, JenCare Senior Medical Center, Atlanta, Georgia, United States. Parisa Mansoori, MD, is Dermatopathologist, Atlanta Dermatopathology, Atlanta, Georgia. Mohammad Sharif, DPM, is Podiatrist, Village Podiatry Centers, Atlanta, Georgia
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8
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Kurimoto T, Mitsui Y. Pathergy in a patient with pyoderma gangrenosum. J Dermatol 2024; 51:e29-e30. [PMID: 38087852 DOI: 10.1111/1346-8138.17076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 02/04/2024]
Affiliation(s)
- Toru Kurimoto
- Department of Dermatology, Nara Prefecture General Medical Center, Nara, Japan
| | - Yasuhiro Mitsui
- Department of Dermatology, Nara Prefecture General Medical Center, Nara, Japan
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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.
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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
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10
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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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11
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Allen JT, Toro D, Lough M, Griswold L. Pyoderma gangrenosum following gynaecological surgery. BMJ Case Rep 2023; 16:e256676. [PMID: 38160031 PMCID: PMC10759017 DOI: 10.1136/bcr-2023-256676] [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] [Accepted: 12/15/2023] [Indexed: 01/03/2024] Open
Abstract
A perimenopausal woman with abnormal uterine bleeding underwent an uncomplicated laparoscopic hysterectomy. Postoperatively, she developed fever, abdominal erythema and pain. Imaging revealed diffuse abdominal wall skin thickening, most pronounced at the right port site with a small area concerning for developing abscess. There was high clinical suspicion for necrotising fasciitis due to rapidly progressive skin deterioration. Despite antibiotics and surgical debridement, her condition progressed. Biopsy of the inflamed tissue confirmed a diagnosis of pyoderma gangrenosum (PG), and treatment with daily prednisone led to rapid improvement of symptoms.Successful diagnosis and treatment of the patient's symptoms required multidisciplinary collaboration among gynaecology, general surgery and dermatology. PG, although a well-known condition among dermatologists, is rarely, if ever, encountered by gynaecologists, and its resemblance to conditions such as necrotising fasciitis complicates early detection and intervention. This case highlights the diagnostic and management challenges associated with PG in the gynaecological setting.
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Affiliation(s)
| | - Diana Toro
- Obstetrics & Gynecology, Augusta University, Augusta, Georgia, USA
| | - Morgan Lough
- Obstetrics & Gynecology, Augusta University, Augusta, Georgia, USA
| | - Lauren Griswold
- Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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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.
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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
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Moelleken M, Erfurt‐Berge C, Ronicke M, Busch D, Hübner UH, Hüsers J, Przysucha M, Dissemond J. Predilection sites of pyoderma gangrenosum: Retrospective study of 170 clearly diagnosed patients. Int Wound J 2023; 20:4227-4234. [PMID: 37528508 PMCID: PMC10681478 DOI: 10.1111/iwj.14323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a non-infectious, neutrophilic dermatosis that was difficult to diagnose in clinical practice. Today, the PARACELSUS score is a validated tool for diagnostics. Based on this score, patients with clearly diagnosed PG were examined with regard to predilection sites. In this retrospective study, the data of patients from the University Hospitals of Essen and Erlangen were analysed in whom the diagnosis of PG could be clearly confirmed using the PARACELSUS score. A total of 170 patients, 49 men (29%) and 121 women (71%) with an average age at first manifestation of 55.5 years, could be included in the analysis. The predilection sites were identified as the lower legs in 80.6% of the patients and the extensor sides in 75.2%. Other localisations of PG were the thighs in 14.1%, mammae and abdomen in 10.0% each, back and gluteal in 7.1% each, feet in 5.9%, arms in 4.7%, genital in 3.5% and head in 2.9%. This retrospective study is the first to identify a collective of PG patients with the highest data quality using the PARACELSUS score. It could be shown that PG can basically occur on the entire integument. However, the predilection sites of PG, which have now been reliably identified for the first time, are the lower legs and in particular the extensor sides.
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Affiliation(s)
- Maurice Moelleken
- Department of Dermatology, Venerology and AllergologyUniversity Hospital of EssenEssenGermany
| | - Cornelia Erfurt‐Berge
- Department of DermatologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐NürnbergErlangenGermany
| | - Moritz Ronicke
- Department of DermatologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐NürnbergErlangenGermany
| | - Dorothee Busch
- Department of DermatologyUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐NürnbergErlangenGermany
| | | | - Jens Hüsers
- Health Informatics Research GroupOsnabrück University of ASOsnabrückGermany
| | - Mareike Przysucha
- Health Informatics Research GroupOsnabrück University of ASOsnabrückGermany
| | - Joachim Dissemond
- Department of Dermatology, Venerology and AllergologyUniversity Hospital of EssenEssenGermany
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Varas-Rodríguez E, Cedeño F, Gonzalez-Diaz G, Vivas J, Salgueiro A, Dávila K, Nevarez Pomales O, Duyos O. Postsurgical Pyoderma Gangrenosum After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00034. [PMID: 38015935 DOI: 10.2106/jbjs.cc.23.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
CASE A 61-year-old woman with lower back and radicular leg pain underwent minimally invasive spinal fusion at L5-S1. By postoperative day 6, she exhibited erythema, wound dehiscence, and necrotic changes. Although a necrotizing infection was initially suspected, multiple debridements and antibiotic therapy failed to improve her condition. The patient was eventually diagnosed with pyoderma gangrenosum (PG) and was managed with immunosuppressants and extended wound care. CONCLUSION PG is a rare dermatosis that is often misdiagnosed, leading to inappropriate treatment, debridements, and additional complications. Prompt identification and multidisciplinary collaboration are key to preventing unnecessary interventions and achieving the best outcomes.
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Affiliation(s)
| | - Francis Cedeño
- School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Joshua Vivas
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Ariana Salgueiro
- Department of Environmental Sciences, Loyola University, New Orleans, Louisiana
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Wang J, Jiang S, Shi X, Li W, Yu Q, Pan T, Mu Y, Chen L. A Case of Pyoderma Gangrenosum after Partial Small Bowel Resection. Adv Skin Wound Care 2023; 36:1-3. [PMID: 37729170 DOI: 10.1097/asw.0000000000000045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
ABSTRACT Pyoderma gangrenosum (PG) is a rare, noninfectious inflammatory disease of unknown etiology that affects the skin and mucous membranes. The development of PG after partial small bowel resection is very rare and can initially resemble an infectious complication, although it is an inflammatory disease.This report presents the case of a 55-year-old man who underwent partial small bowel resection for incomplete intestinal obstruction and developed postoperative infection-like manifestations, including redness and swelling of the incision, severe pain, and yellow-green turbid fluid from the drainage tube. After completing a skin biopsy that suggested massive neutrophil infiltration, multiple secretion cultures for Pseudomonas aeruginosa (+), and systemic screening without other comorbidities, a diagnosis of postoperative PG and P aeruginosa infection was determined.Early detection of this complication is essential for patient recovery because primary surgical treatment, which is contraindicated in such cases, can worsen PG. Therefore, PG should be treated conservatively with corticosteroids.
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Affiliation(s)
- Jianing Wang
- In the Department of Dermatology, the Second Affiliated Hospital of Soochow University, Suzhou, China, Jianing Wang, MD, and Shiyao Jiang, MD, are Residents; Xin Shi, BS, is Chief Physician; and Wenlin Li, MD, and Qianchun Yu, MD are also Residents. In the Department of Dermatology, Suzhou Municipal Hospital, Ting Pan, MD, and Yuzhu Mu, MD, are Residents; and Lingling Chen, MD, is Chief Physician
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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.
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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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Petrov A, Kappert U, Schmidt T, Matschke KE, Wilbring M. Pyoderma Gangrenosum after Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:53-61. [PMID: 34894635 DOI: 10.1055/s-0041-1735960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection. METHODS A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided. RESULTS A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries. CONCLUSION Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis-the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.
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Affiliation(s)
- Asen Petrov
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Anesthesiology, University Heart Center Dresden, Dresden, Germany
| | | | - Manuel Wilbring
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
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An aggressive course of pyoderma gangrenosum mimicking bacterial osteomyelitis after open reduction and internal fixation of a distal radius fracture with a titanium plate. Reumatologia 2022; 60:292-302. [PMID: 36186837 PMCID: PMC9494791 DOI: 10.5114/reum.2022.119046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare condition characterized by the development of aseptic, non-healing skin ulcers. Any skin trauma, such as a surgical incision, can trigger an outbreak of lesions. Our case and literature review show that a physician should consider PG in every event of a non-healing, aseptic wound after surgery. The treatment of PG requires collaboration within a multidisciplinary team and immunosuppressive therapy is the first line of treatment, while surgical interventions should be avoided in the active stage of PG.
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21
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Perforator propeller flap for coverage of Achilles region defects caused by pyoderma gangrenosum. JPRAS Open 2022; 33:139-144. [PMID: 35935517 PMCID: PMC9352399 DOI: 10.1016/j.jpra.2022.06.008] [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] [Received: 12/14/2021] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic inflammatory skin disease. Systemic corticosteroid and immunosuppressive agents are the mainstay treatment. PG usually precludes a surgical approach due to pathergy phenomenon. Recent literatures show skin grafting and negative pressure wound therapy are safe if performed under adequate immunosuppression. We present a case of a 61-year-old male patient suffered from PG induced left posterior leg wound with Achilles tendon exposure. We made timely diagnosis and treated him with adequate immunosuppression therapy followed by perforator propeller flap for wound coverage. This case report emphasizes the need for high index of suspicion for PG diagnosis. Furthermore, with adequate immunosuppression, operative intervention may not be an absolute contraindication for PG.
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22
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YAMAUCHI SUGURU, ANDO YUJI, KAJI SANAE, JUN CHEN, EGAWA HIROKI, YOSHIMOTO YUTARO, KUBOTA AKIRA, YUBE YUKINORI, ORITA HAJIME, FUKUNAGA TETSU. Postoperative Pyoderma Gangrenosum in a Laparoscopic Gastrectomy Port Site: A Case Report. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2022; 68:521-525. [PMID: 39081583 PMCID: PMC11284291 DOI: 10.14789/jmj.jmj22-0017-cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/09/2022] [Indexed: 08/02/2024]
Abstract
Background Postoperative pyoderma gangrenosum (PPG) is a rare inflammatory skin disease of unknown etiology characterized by blistering and ulcerative lesions in postoperative wounds. Untreated pyoderma gangrenosum (PG) is potentially life-threatening; therefore, immediate and appropriate treatment is essential. Although PPG and surgical site infection (SSI) present similar clinical findings, they should be differentiated because of their conflicting treatment modalities. Case presentation An 82-year-old man with comorbidities of pulmonary tuberculosis, chronic obstructive pulmonary disease, and diabetes underwent laparoscopic gastrectomy for gastric cancer. On postoperative day 6, fever exceeding 39°C, port wound redness, and pain was observed. Laboratory tests revealed severe inflammatory reactions: white blood cell, 42,800/μL and C-reactive protein, 30.2 mg/mL. The patient was diagnosed with SSI and treatment with antibiotics and drainage was started; however, his general and wound conditions also worsened. Therefore, he was diagnosed with PG because painful skin findings were exacerbated by external stimuli and no significant bacteria were detected in the culture test. Treatment with oral prednisolone was started, which significantly improved his skin and inflammatory conditions. Conclusion We managed a rare case of PPG that occurred in a port wound after laparoscopic gastrectomy. If atypical clinical findings of postoperative SSI are observed, general surgeons should recognize and consider PPG as a differential diagnosis.
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Affiliation(s)
- SUGURU YAMAUCHI
- Corresponding author: Suguru Yamauchi, Department of Esophageal and Gastroenterological Surgery, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan, TEL: +81-3-3813-3111 FAX: +81-3-5802-1557 E-mail:
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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] [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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24
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Owen BS, Pacult MA, Lee BS. Pyoderma Gangrenosum Masquerading as Wound Infection in the Early Postoperative Period After Lumbar Spine Deformity Correction Surgery. Cureus 2022; 14:e25545. [PMID: 35800799 PMCID: PMC9246455 DOI: 10.7759/cureus.25545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/05/2022] Open
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25
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Ten Dam L, Ten Broeke M, Poot AM, Gilbers MD, Halfwerk FR. Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach. J Card Surg 2022; 37:2419-2422. [PMID: 35524433 PMCID: PMC9321867 DOI: 10.1111/jocs.16570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/06/2022] [Accepted: 04/17/2022] [Indexed: 11/28/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare, chronic inflammatory noninfectious dermatosis. It is associated with underlying systemic or hematological diseases such as myelodysplastic syndrome (MDS) and can be triggered after surgery. Recognition and diagnosis of PG can be difficult as it can mimic a wound infection. Misdiagnosis could lead to invasive procedures which worsen the disease and have possible disastrous aftermath. A 74‐year‐old male with a history of MDS presents with an atypical sternal wound inflammation. Diagnosis confirmed PG after skin biopsy. No surgical or invasive procedures were performed and the patient was treated on an outpatient basis with prednisolone, clobetasol cream, and cyclosporine. This case shows the importance of a rapid diagnosis of the disease. Awareness is required for the diagnosis of PG in a wound with pronounced livid borders, without improvement after antibiotic treatment or worsening after debridement. Rapid diagnosis and treatment reduce high healthcare costs, morbidity, and mortality.
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Affiliation(s)
- Lotte Ten Dam
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Miarca Ten Broeke
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Angelique M Poot
- Department of Dermatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Martijn D Gilbers
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Frank R Halfwerk
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, The Netherlands
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26
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Peterson DM, Damsky WE, Vesely MD. Fever, Hypotension, and a Worsening Necrotic Wound. JAMA 2022; 327:1496-1497. [PMID: 35311923 DOI: 10.1001/jama.2022.2806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - William E Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Matthew D Vesely
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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Rao S, Tang Y, Li J, Shi W. A rapidly progressing, painful ulcer at a surgical wound site. BMJ 2022; 376:e068211. [PMID: 35172990 DOI: 10.1136/bmj-2021-068211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Shijia Rao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenomics, Changsha, Hunan, China
| | - Yan Tang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ji Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Aging Biology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei Shi
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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28
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Krajewski PK, Chlebicka I, Szepietowski JC, Maj J. Pyoderma Gangrenosum in a Splenectomy Incision in a Patient with Haemolytic Anaemia due to Hereditary Spherocytosis: a Case Report and Literature Review. Acta Derm Venereol 2021; 101:adv00599. [PMID: 34694421 PMCID: PMC9455314 DOI: 10.2340/actadv.v101.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Jacek C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Chalubinskiego 1, PL-50-368 Wroclaw, Poland.
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Bellamy JT, Ananthakrishnan D. Postoperative Pyoderma Gangrenosum After Thoracolumbar Spinal Fusion with Instrumentation: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00051. [PMID: 34762609 DOI: 10.2106/jbjs.cc.21.00461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 65-year-old man with scoliosis underwent posterior spinal fusion with instrumentation from T4 to pelvis and subsequently developed wound complications eventually diagnosed to be secondary to postoperative pyoderma gangrenosum (PPG). Once immunosuppressant medications were initiated, the wound gradually improved and went on to heal after a prolonged period of wound care. CONCLUSION Postoperative PG is a challenging problem for the orthopaedic surgeon; a multidisciplinary approach is beneficial. Early recognition of the diagnosis is imperative to limit morbidity because debridements for a presumed infectious etiology are likely to exacerbate the disease through a process called pathergy.
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Affiliation(s)
- J Taylor Bellamy
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Walton E, Wolner Z, Hammett J. Vaginal cuff pyoderma gangrenosum with associated ureteral stricture: A case report. Urol Case Rep 2021; 39:101826. [PMID: 34522619 PMCID: PMC8424502 DOI: 10.1016/j.eucr.2021.101826] [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] [Received: 08/03/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022] Open
Abstract
Pyoderma gangrenosum is a sterile inflammatory disease of unknown etiology characterized by recurrent cutaneous ulcers. It can occur in extracutaneous locations, especially at operative sites, and has been reported following gynecologic surgery. This report is the first case of pyoderma gangrenosum as a remote complication of pelvic surgery with associated ureteral stricture. It demonstrates the diagnostic challenge of this rare disease and the importance of broadening the differential diagnosis when apparent infections do not respond to treatment to minimize the morbidity of ineffective antibiotic and surgical interventions.
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Affiliation(s)
- Eric Walton
- Department of Urology, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite B 1400, Atlanta, GA, 30322, USA
| | - Zachary Wolner
- Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd #3, Atlanta, GA, 30322, USA
| | - Jessica Hammett
- Department of Urology, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite B 1400, Atlanta, GA, 30322, 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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Fulminant Pyoderma Gangrenosum After Outpatient Knee Arthroscopy. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202108000-00008. [PMID: 34415854 PMCID: PMC8382322 DOI: 10.5435/jaaosglobal-d-21-00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/15/2021] [Indexed: 01/15/2023]
Abstract
Pyoderma gangrenosum is an immunologic, ulcerative cutaneous condition often associated with systemic disease and frequently precipitated by trauma. It is noninfectious, but the inflammatory assault can resemble a malignant infection such as necrotizing fasciitis. Despite its clinical resemblance to infection, surgical débridement worsens the condition and may remove morphologic clues to the true disease, thus creating a vicious cycle of surgical débridements and disease progression. Furthermore, diagnostic histopathologic and laboratory features are nonspecific, requiring exclusion of other processes. Therefore, appropriate nonsurgical treatment and immunosuppression are commonly delayed, often at a significant cost to the patient. We present a case of pyoderma gangrenosum occurring after outpatient knee arthroscopy that masqueraded as a postsurgical infection. We discuss the diagnostic approach and how a complex reconstruction involving cartilage restoration and soft-tissue coverage was achieved.
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Thornburg DA, Aime V, James S, Gupta N, Bernard R, Johnson ML. Pyoderma Gangrenosum: A Rare Disease With Dire Consequences in Facial Aesthetic Surgery Patients. Aesthet Surg J 2021; 41:NP709-NP716. [PMID: 33471065 DOI: 10.1093/asj/sjab026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, inflammatory dermatologic condition characterized by painful cutaneous ulcerations. Herein, we describe the third documented case of PG arising in an elective plastic surgery patient who had undergone an otherwise uncomplicated facelift. We describe the course of her diagnosis and management of PG, which involved her face and neck and then progressed to her lower extremities. Although the etiology remains unknown, PG often arises in a host with another autoimmune disease. In the case described, the patient was diagnosed with an immunoglobulin A gammopathy shortly after she developed PG. Following the case report, the pathogenesis, diagnosis, and treatment strategy of PG is briefly reviewed. Level of Evidence: 5.
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Affiliation(s)
- Danielle A Thornburg
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | - Victoria Aime
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | | | - Nikita Gupta
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Robert Bernard
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | - Martin L Johnson
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
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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.
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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.
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Mizushima M, Miyoshi H, Yonemori K. Pyoderma Gangrenosum After Total Hip Arthroplasty Associated with Administration of Granulocyte Colony-Stimulating Factor: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00041. [PMID: 33878038 DOI: 10.2106/jbjs.cc.20.00924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 69-year-old woman with myelodysplastic syndrome-related pancytopenia was administered granulocyte colony-stimulating factor (G-CSF) before total hip arthroplasty to prevent postoperative infection. One week postoperatively, she developed peri-incisional ecchymosis and associated leukocytosis. Over the next few weeks, surgical site infection was suspected; however, dermatologist evaluation and subsequent biopsy supported a diagnosis of pyoderma gangrenosum, which resolved after prompt steroid administration. CONCLUSION Postoperative pyoderma gangrenosum should be included in the differential diagnosis when considerable postoperative ecchymosis and leukocytosis occur, particularly after preoperative G-CSF administration.
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Affiliation(s)
- Masaki Mizushima
- Department of Orthopaedics, Yonemori Hospital, Ryokusenkai Group, Kagoshima, Japan
| | - Hayao Miyoshi
- Department of Dermatology, Takada Hospital, Gyokushoukai Group, Kagoshima, Japan
| | - Koji Yonemori
- Department of Orthopaedics, Yonemori Hospital, Ryokusenkai Group, Kagoshima, Japan
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Luo H, Bian H, Sun C, Zheng S, Xiong B, Huang Z, Liu Z, Ma L, Li H, Chen H, Lai W. Pyoderma gangrenosum secondary to caesarean section treated with negative pressure wound therapy and skin graft. Dermatol Ther 2021; 34:e14858. [PMID: 33559207 DOI: 10.1111/dth.14858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/05/2021] [Accepted: 01/31/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Hongmin Luo
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Huining Bian
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chuanwei Sun
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shaoyi Zheng
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bing Xiong
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhifeng Huang
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zuan Liu
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lianghua Ma
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hanhua Li
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Huade Chen
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen Lai
- Department of Burns and Wound Repair Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Ghumra W, Gold A, Azurdia RM. Pyoderma gangrenosum following an unplanned caesarean section: a patient revisited. BMJ Case Rep 2021; 14:14/2/e238702. [PMID: 33619133 PMCID: PMC7903115 DOI: 10.1136/bcr-2020-238702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 35-year-old woman was referred urgently to the dermatology department because of significant wound breakdown 3 weeks following an emergency caesarean section. Examination revealed a full thickness, undermined ulcer spanning the width of the patient's caesarean scar, exposing the patient's uterus. Clinical appearances were consistent with pyoderma gangrenosum. The patient has a history of complicated pyoderma gangrenosum, having undergone skin grafts 14 years prior, for ulcers on her lower legs. That episode was the subject of a case report, published in the BMJ, in 2007. On this occasion, the patient was treated with oral corticosteroids, and ciclosporin based on its efficacy during her previous episode, which in conjunction with negative pressure wound therapy, resulted in complete re-epithelialisation of her ulcer within 6 months.
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Affiliation(s)
- Waseem Ghumra
- Dermatology, Broadgreen Hospital, Liverpool, Liverpool, UK
| | - Adam Gold
- Dermatology, Broadgreen Hospital, Liverpool, Liverpool, UK
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Post-Cesarean Section Pyoderma Gangrenosum Presenting with Vasopressor-dependent Shock: Long-term Follow-up after Delayed Primary Closure. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3427. [PMID: 33680673 PMCID: PMC7929537 DOI: 10.1097/gox.0000000000003427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
A 28-year-old woman with poor wound healing and surgical site pain presented 5 days post-cesarean section (post-CS) with vasopressor-dependent shock and was eventually diagnosed with postoperative pyoderma gangrenosum (PG). A worsening clinical picture consistent with presumed necrotizing infection necessitated surgical debridement. The patient was ultimately taken to the operating room 4 times with transient improvement after the operations when she received perioperative corticosteroids. We were unable to identify an infectious source and cultures revealed no microorganisms. Dermatopathology revealed neutrophilic infiltrate and focal necrosis without microorganisms. The biopsy site began to concurrently exhibit pathergic changes, leading to a diagnosis of PG. Twelve weeks later, she underwent DPC of her abdominal wound while maintained on an immunosuppressive regimen of cyclosporine and prednisone. Incisional negative pressure wound therapy with a small window was used in the immediate postoperative period to allow for direct visualization of the closed incision. She healed without issue and her immunosuppressive regimen was ultimately discontinued. Postoperative PG is an uncommon diagnosis with high risk of morbidity. It is often mistaken for necrotizing infection. We report a unique case of post-CS PG presenting as vasopressor-dependent shock that was successfully closed with incisional negative pressure wound therapy with a small window.
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40
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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
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Coulie J, Gerdom A, Chrelias T, Lengelé B, Coyette M. The use of MATRIDERM Ⓡ as a single stage salvage procedure to cover exposed dura Mater. JPRAS Open 2020; 27:53-57. [PMID: 33319011 PMCID: PMC7726479 DOI: 10.1016/j.jpra.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/29/2020] [Indexed: 11/30/2022] Open
Abstract
Reconstruction of large full-thickness scalp defects with exposed cranial bone or dura are usually performed with free flaps. However, certain medical conditions in fragile patients may contraindicate this type of surgery. In those circumstances, Dermal Regeneration Templates (DRTs) can provide an alternative solution to flap surgery. We here report the case of a 79-year old woman presenting with a large cranial defect and exposed dura mater after developing postsurgical Pyoderma Gangrenosum and subsequent free flap failure. A one-stage salvage reconstruction was successfully performed with MATRIDERMⓇ (MedSkin Solutions Dr. Suwelack AG, Germany) and a split-thickness skin graft (STSG) with a Vacuum-Assisted Closure (VAC) dressing.
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42
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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.
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Gündüz K, Gülbaşaran F, Hasdemir PS, Temiz P, Inanır I. Successful treatment of severe refractory post-cesarean pyoderma gangrenosum with intravenous immunoglobulin. Dermatol Ther 2020; 33:e14121. [PMID: 32743854 DOI: 10.1111/dth.14121] [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] [Received: 04/22/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressing necrolytic ulceration of the skin. Proper treatment is crucial since it can result in devastating consequences. First-line treatments include systemic corticosteroids or cyclosporine. However, no standardized treatment regimens for refractory cases exist and treatment outcomes are affected by underlying conditions. PG after cesarean section, which is believed to occur in association with underlying pregnancy- and parturition-related immune changes, is extremely rare, and all reported cases in the literature have been successfully treated with systemic or topical corticosteroids. We report a case of a 32-year-old patient with severe PG occurring on her cesarean scar 3 days after the cesarean delivery. Treatment with systemic corticosteroids and first-line immunomodulatory agents resulted in insufficient response and serious complications. Intravenous immunoglobulin (IVIG) was then initiated, and a rapid clinical response was seen. Corticosteroid dose was gradually decreased and ceased. IVIG infusion was continued for 3 months until complete recovery. Reactivation was not observed in a 1-year follow-up period. Due to its cost, IVIG infusion is less suitable as a first-line agent. However, IVIG may be an important therapeutic option in resistant postpartum PG, in which first-line agents have failed or led to complications.
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Affiliation(s)
- Kamer Gündüz
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey
| | - Fatmagül Gülbaşaran
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey.,Department of Dermatology, Salihli State Hospital, Manisa, Turkey
| | - Pınar Solmaz Hasdemir
- Medical Faculty, Department of Obstetrics and Gynecology, Celal Bayar University, Manisa, Turkey
| | - Peyker Temiz
- Medical Faculty, Department of Pathology, Celal Bayar University, Manisa, Turkey
| | - Işıl Inanır
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey
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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: 10] [Impact Index Per Article: 2.5] [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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45
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Perioperative management of pyoderma gangrenosum. J Am Acad Dermatol 2020; 83:369-374. [DOI: 10.1016/j.jaad.2020.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
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Arebro J, Palmgren B. Postsurgical pyoderma gangrenosum and flap necrosis in a head and neck cancer patient following neck dissection. Clin Case Rep 2020; 8:1121-1125. [PMID: 32695340 PMCID: PMC7364074 DOI: 10.1002/ccr3.2828] [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] [Received: 02/04/2020] [Revised: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 11/11/2022] Open
Abstract
Postsurgical pyoderma gangrenosum (PSPG) develops in the skin after surgery without known cause. Immunosuppression constitutes first-line therapy and increases the likelihood of successful surgery when needed. PSPG should be considered when a flap necrosis occurs.
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Affiliation(s)
- Julia Arebro
- Division of OtorhinolaryngologyDepartment of Clinical Science, Intervention and TechnologyKarolinska InstitutetStockholmSweden
- Department of Otorhinolaryngology, Head and Neck SurgeryKarolinska University HospitalStockholmSweden
| | - Björn Palmgren
- Division of OtorhinolaryngologyDepartment of Clinical Science, Intervention and TechnologyKarolinska InstitutetStockholmSweden
- Department of Otorhinolaryngology, Head and Neck SurgeryKarolinska University HospitalStockholmSweden
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Two-Year Delayed Healing of an Endovascular Access Site Related to an Unusual Etiology. Adv Skin Wound Care 2020; 33:272-275. [PMID: 32304451 DOI: 10.1097/01.asw.0000658576.13716.ff] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this case report, the authors describe a patient who underwent an endovascular abdominal aortic aneurysm repair complicated by more than a 2-year delay in healing of the left inguinal fold access site. Providers initially suspected a chronic infection or foreign body reaction, but eventually the patient was diagnosed with superficial granulomatous pyoderma. Once the correct etiology was determined and appropriate treatment begun, the access site healed within 3 weeks.
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Snyder MH, Ampie L, Forrester VJ, Wilson JC, Nguyen JH, Shaffrey CI, Buchholz AL. Postoperative pyoderma gangrenosum after spinal fusion with instrumentation: case report. J Neurosurg Spine 2020; 32:285-291. [PMID: 31653821 DOI: 10.3171/2019.7.spine19708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/31/2019] [Indexed: 11/06/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory dermatosis that is most often associated with inflammatory bowel disease, but which can occur as a pathergic reaction around surgical incisions. The authors report the case of a patient who developed postoperative PG over the course of several months after undergoing extensive spinal instrumentation between the T4 and iliac levels. This is only the second such case occurring after spine surgery to be reported. The authors additionally review the literature to characterize treatment approaches and outcomes for this condition. The case highlights a potentially severe adverse effect of surgery that can be difficult to recognize and causes delays in effective treatment. It also demonstrates the importance of multidisciplinary collaboration in the effective care of patients.
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Affiliation(s)
| | | | - Vernon J Forrester
- 2Dermatology, University of Virginia Health System, Charlottesville, Virginia; and
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Case Study on Management of Postsurgical Pyoderma Gangrenosum After Spinal Surgery. J Wound Ostomy Continence Nurs 2019; 46:543-546. [PMID: 31651797 DOI: 10.1097/won.0000000000000587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postsurgical pyoderma gangrenosum (PSPG) is a rare autoimmune, neutrophilic dermatosis that results with the occurrence of pyoderma gangrenosum (PG) within surgical incisions. Presenting symptoms include erythema and pain at the surgical incision with wound dehiscence. The clinical appearance of the PSPG wound (similar to PG) shows raised with dusky red or violaceous (violet-colored) wound edges and undermining with little or no evidence of granulation tissue. "Pathergy" is the term used to describe worsening of the wound in response to trauma such as debridement. Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement. CASE A clinical case study of a patient with PSPG from spine surgery is described. CONCLUSION Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement.
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Montagnon CM, Fracica EA, Patel AA, Camilleri MJ, Murad MH, Dingli D, Wetter DA, Tolkachjov SN. Pyoderma gangrenosum in hematologic malignancies: A systematic review. J Am Acad Dermatol 2019; 82:1346-1359. [PMID: 31560977 DOI: 10.1016/j.jaad.2019.09.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a devastating neutrophilic dermatosis that may be associated with trauma or systemic diseases. The associations, characteristics, and temporal relationship of PG with hematologic malignancies are not well understood. OBJECTIVE We performed a systematic review of PG associated with hematologic malignancies using data from case reports, case series, and retrospective studies. METHODS We searched MEDLINE, EMBASE, Scopus, and Web of Science from each database's inception to December 12, 2018. Two reviewers independently selected studies and extracted data. RESULTS Two hundred seventy-nine publications met the inclusion criteria (340 cases). Myelodysplastic syndrome (MDS) was the most commonly reported hematologic malignancy associated with PG, followed by monoclonal gammopathy of undetermined significance and acute myeloid leukemia. The mean age of patients was 56.5 years, with males being more common. There was a predominance of the ulcerative PG subtype and multifocal distributions across all hematologic malignancies. The majority of MDS cases preceded PG, which was reversed for MGUS. LIMITATIONS The data were limited by reporting bias because PG subtypes rely on the rendered diagnosis reported. In addition, the classification for hematologic malignancies has evolved since 1978. CONCLUSION Patients with PG should be evaluated for hematologic malignancies, with MDS being the most common.
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Affiliation(s)
| | | | - Archna A Patel
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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