Multiple pulmonary nodules in association with pyoderma gangrenosum

Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.

Cavitary lung nodules as an extraintestinal manifestation of ulcerative colitis

A man in his 30s with ulcerative colitis (UC) on immunosuppressive agents and extensive travel history presented with subacute dyspnoea and dry cough. CT of the chest demonstrated numerous cavitary pulmonary nodules. An extensive infectious, malignant and autoimmune evaluation was pursued, ultimately with histopathology most consistent with necrobiotic lung nodules as an extraintestinal manifestation of UC. Steroids and ustekinumab were initiated with improvement in symptoms and resolution of cavitary lesions on follow-up imaging. In a patient with inflammatory bowel disease and cavitary lung lesions, necrobiotic lung nodules should be considered, particularly when evaluation for infectious causes is negative.

Pyoderma gangrenosum with pulmonary involvement: a pulmonary special report and literature review

INTRODUCTION

Pyoderma gangrenosum (PG) is the prototypical neutrophilic dermatosis, commonly associated with inflammatory bowel disease, with pulmonary involvement being the commonest extracutaneous manifestation. PG with tracheobronchial involvement may present as upper airway obstruction and can be life-threatening.

AREAS COVERED

To evaluate the clinical characteristics and predictors of PG with pulmonary involvement, we reported a case of PG with tracheobronchial involvement in China, and performed a literature retrieval on PG with pulmonary involvement. Demographic data, clinical presentations, underlying diseases, radiological and histopathological findings, treatments, and clinical outcomes were collected and subjected to statistical analysis. Forty-seven cases (including ours) were identified. Diseases associated with PG with pulmonary involvement were similar. Clinical presentation of PG with pulmonary involvement was non-specific, with cough and dyspnea being the most common clinical symptoms, and pulmonary infiltrates and cavitation being the most common radiological signs. Further univariate analysis suggested stridor and young age (p < 0.01) may be predictors of tracheobronchial involvement in PG.

EXPERT OPINION

PG with tracheobronchial involvement can be life-threatening, with young age and stridor being possible predictors. Therefore, prompt airway assessment and management are required in younger patients with PG with pulmonary involvement presenting with stridor.

Thoracic Manifestations of Ankylosing Spondylitis, Inflammatory Bowel Disease, and Relapsing Polychondritis

Ankylosing spondylitis, inflammatory bowel disease (IBD), and relapsing polychondritis are immune-mediated inflammatory diseases with variable involvement of lungs, heart and the chest wall. Ankylosing spondylitis is associated with anterior chest wall pain, restrictive lung disease, obstructive sleep apnea, apical fibrosis, spontaneous pneumothorax, abnormalities of cardiac valves and conduction system, and aortitis. Patients with IBD can develop necrobiotic lung nodules that can be misdiagnosed as malignancy or infection. Relapsing polychondritis involves large airways in at least half of the patients. Relapsing polychondritis can mimic asthma in some patients. Medications used to treat these inflammatory conditions can cause pulmonary complications such as infections, pneumonitis, and rarely serositis.

Multiple pulmonary cavitary nodules with pyoderma gangrenosum in patient with rheumatoid arthritis

Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic disorder of skin. Its pulmonary manifestations are uncommon and only less than forty cases have been reported in the literature previously. PG is associated with variable systemic diseases, most commonly inflammatory bowel disease and hematologic malignancies. It reported rarely in rheumatoid arthritis (RA). We report a case of PG lung involvement in patient with RA associated interstitial lung disease. A 66-year-old woman presented with productive cough and recurrent ulcerative lesion on her left ankle. She had a 15-year history of RA associated interstitial lung disease and treated with methotrexate, sulfasalazine, hydroxychloroquine and methylprednisolone. On physical examination, there were a few tender, erythematous subcutaneous nodules ranging from 1 to 3 cm in diameter on her left thigh and left elbow. Anti-neutrophil cytoplasmic antibodies (ANCAs) are negative. Her chest CT scan demonstrated multifocal cavitary consolidations on the background of reticular opacity and honeycombing. Punch biopsy of erythematous nodule on thigh showed neutrophilic abscess with necrotic debris. The skin and lung lesions were rapidly improved with 0.5 mg/kg/day of prednisolone.

Pulmonary manifestations of pyoderma gangrenosum: 2 cases and a review of the literature

Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatologic disease that occasionally is accompanied by extracutaneous manifestations, amongst these is pulmonary involvement. The etiology is unknown. More than 50% of PG cases are associated with an underlying systemic disease such as inflammatory bowel disease, rheumatoid arthritis, hematological disorder or malignancy. Extracutaneous manifestations are rare and only 29 cases of pulmonary involvement have been reported previously in the literature. Pyoderma gangrenosum is usually diagnosed in the third to sixth decade, but early debut in childhood is also described. Skin manifestations are usually evident before pulmonary involvement, although primary lung affection is seen. Pulmonary involvement is diagnosed simultaneously or from a few weeks up to several years after the diagnosis of cutaneous PG. The most important differential diagnoses are lung cancer, lung abscess and Wegener's granulomatosis. Histological specimens will exclude these diagnoses. The treatment of PG is immune modulation, but due to the rarity of the disease, only one randomized treatment trials exists [1] and the long term course of PG with pulmonary involvement is unknown. We present two cases of pulmonary manifestations of pyoderma gangrenosum and a review of the literature.

Fatal Case of Vulvar Pyoderma Gangrenosum with Pulmonary Involvement: Case Presentation and Literature Review

Introduction:

We report a case of a 61-year-old woman with locally destructive vulvar pyoderma gangrenosum (PG) with pulmonary involvement who was refractory to numerous systemic therapies and developed complications resulting in her demise.

Objective:

To report a rare case of treatment-resistant vulvar PG with pulmonary involvement that proved to be fatal.

Methods:

PubMed was used to search for other reports that discuss PG, or more specifically perigenital PG, with pulmonary involvement.

Results and Conclusion:

A thorough review of the literature revealed 33 cases of PG with pulmonary involvement, with only 4 involving the perigenital region. We report the second case of a female with vulvar PG and pulmonary involvement. In contrast to the first case described, our patient did not respond to systemic therapy, and, ultimately, her disease was fatal. It is hoped that with continued documentation of this rare and potentially lethal presentation of PG, physicians will determine more effective treatments.

An unusual presentation of Takayasu's arteritis in two Mexican siblings

Takayasu's arteritis (TA) is an idiopathic vasculitis characterized by granulomatous arteritis of the aorta and its main branches. Here we describe two cases with atypical presentation of TA in Mexican siblings. Both patients had pyoderma gangrenosum and pulmonary nodules throughout the course of their disease. We discuss skin manifestations associated with TA, as well as parenchymal lung involvement, which is unusual in TA and can be related to pyoderma. These cases exemplify the protean manifestations of TA.

A case of aseptic abscesses syndrome treated with corticosteroids and TNF-alpha blockade

Aseptic abscesses syndrome (AA) is an emerging clinicopathological entity characterized by visceral sterile collections of mature neutrophils that do not respond to antibiotics but regress quickly when treated with corticosteroids. Although most previous case reports of AA have been restricted to Europe, we present here a Japanese woman with AA showing recurrence of splenic abscesses, ileocolitis, pyoderma gangrenosum, and arthritis. Although both steroid therapy and tumor necrosis factor (TNF)-alpha blockade were effective, relapses remained frequent.

Multiple cavitary pulmonary nodules in association with pyoderma gangrenosum: case report

Pyoderma gangrenosum is a rare neutrophilic disease of unknown origin that is associated with systemic diseases in 50% of cases. It is characterized by erythematous-violaceous nodular lesions that quickly progress to painful ulcers, with undermined edges, necrotic-hemorrhagic, varying in size and depth, located mainly in the lower limbs. Extracutaneous locations of pyoderma gangrenosum are rare, usually involving the lungs; the main differential diagnosis in these cases is Wegener granulomatosis. We report a case of pyoderma gangrenosum, which showed multiple cavitary lung nodules, with good response to high doses of steroids. Once excluded the possibility of Wegener granulomatosis, the authors concluded that it was the manifestation of systemic pyoderma gangrenosum with pulmonary involvement.

Pulmonary manifestations of inflammatory bowel disease: case presentations and review

Inflammatory bowel disease (IBD) is associated with a number of extraintestinal manifestations that may involve most organ systems. Extraintestinal manifestations are more common in Crohn disease (CD) and may include rheumatologic, ocular, dermatologic, biliary and pulmonary manifestations. The most common pulmonary manifestations of IBD are drug-induced lung disease. Other manifestations include parenchymal disease, pleuritis and overlap syndromes. We present a case series of 7 patients with non-infectious pulmonary manifestations of IBD, which included cryptogenic organizing pneumonia, usual interstitial pneumonitis (UIP), Langerhan's granulomatosis, and eosinophilic pneumonia. Concurrent extraintestinal manifestations present in these patients included arthralgia, iritis, and pyoderma gangrenosum. In most patients the development of pulmonary disease parallels that of the intestinal disease activity, extraintestinal manifestations and concurrent use of 5-ASA medications.

Pyoderma gangrenosum manifesting as a cavitating lung lesion

We present a case of pyoderma gangrenosum (PG) mimicking a lung carcinoma. A 52-year-old woman presented with an unremitting cough. Computed tomography revealed a cavitating lung lesion. Bronchoscopy and biopsy were interpreted as squamous cell carcinoma. Following a staging mediastinoscopy, a sleeve lobectomy and chest-wall resection was performed. The pulmonary histopathological features suggested Wegener's granulomatosis; no malignancy was found. Three months postoperatively, wound breakdown led to dermatological review. A clinical diagnosis of cutaneous PG was made on the basis of the classic appearance of the surgical wounds and an ulcer on the upper back that had been present before surgery. The patient has been consistently negative for cytoplasmic-staining antineutrophil cytoplasmic antibodies, which supports the diagnosis of PG with cutaneous and pulmonary involvement. Lung manifestations of PG are rare. PG is amenable to systemic therapy. Pulmonary PG is a rare but important differential diagnosis that is not familiar to many physicians and surgeons in this type of presentation.

Aseptic abscesses: a study of 30 patients with or without inflammatory bowel disease and review of the literature

Aseptic abscesses (AA) are characterized by deep, sterile, round lesions consisting of neutrophil that do not respond to antibiotics but improve dramatically with corticosteroids. We report the clinical, laboratory, and radiologic characteristics and the associated conditions of 29 patients from the French Register on AA plus 1 patient from the Netherlands.The mean age of patients at AA diagnosis was 29 years (SD = 14). The main clinical manifestations of AA were fever (90%), abdominal pain (67%), and weight loss (50%). Duration of symptoms was 4.7 months on average until abscesses were discovered. The abscesses involved the spleen in 27/29 patients (93%; the thirtieth patient had a personal history of splenectomy after a trauma). In 7 they were unifocal and in the others they were multifocal, involving in addition the abdominal lymph nodes in 14 (48%), liver in 12 (40%), lung in 5 (17%), pancreas in 2 (7%), and brain in 2 (7%). They were not splenic in 3, including 2 with abdominal lymph nodes and 1 with superficial lymph nodes and testicle and lung involvement. Twenty-two patients (70%) had elevated white blood cell and neutrophil count; antineutrophil cytoplasmic autoantibodies with a perinuclear, cytoplasmic or atypical pattern (negative for antiproteinase 3 and negative for antimyeloperoxidase except for 1) were positive in 21% of the 24 patients tested. Twenty-one patients had inflammatory bowel disease (IBD), which preceded the occurrence of abscesses in 7, was concomitant in 7, and appeared secondarily in 7. Six patients had neutrophilic dermatosis (20%), 3 had relapsing polychondritis as an associated condition, and 3 others had monoclonal gammopathy of undetermined significance. Three patients had no associated condition. Splenectomy was performed in 15 (52%) patients. All patients received steroid therapy. Thirteen (43%) were given additional immunosuppressive therapy, 1 immediately and the others after a relapse, of whom 3 were also treated by anti-tumor necrosis factor-alpha agents. Mean follow-up was 7 years. Eighteen (60%) patients experienced 1 or several relapses, but there was no death related to AA. Relapses occurred on immunosuppressive therapy in 2 patients and off immunosuppressive therapy in the others while corticosteroids were being tapered. We surveyed the literature and analyzed 19 additional cases. AA is an emergent and probably underrecognized entity. It represents an apparently noninfectious inflammatory disorder involving neutrophils that responds to corticosteroid therapy. AA mainly affects patients with IBD but also affects those with other conditions, or with no other apparent disease.

Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria

Pyoderma gangrenosum is a rare but significant cause of ulcerations. It is a diagnosis of exclusion. Herein, we suggest diagnostic criteria and some historical perspectives on the diagnosis of pyoderma gangrenosum.

Pyoderma gangrenosum: a report of 21 cases

BACKGROUND

Pyoderma gangrenosum (PG) is an uncommon, destructive, cutaneous ulceration, belonging to the neutrophilic disease spectrum. It is associated with systemic disease in 50% of cases.

METHODS

We report a retrospective study of 21 cases of PG. All cases studied fulfilled the following criteria: (i) clinical features of PG; (ii) histopathology consistent with a diagnosis of PG, and excluding other specific dermatoses.

RESULTS

The average age of our patients was 41.8 years. The male to female ratio was 1.1. The typical ulcerative variant was found in 17 patients, bullous PG in two patients, and the granulomatous variant in two patients. Sixty-two per cent of our patients had lesions on their lower legs. Two patients had neutrophilic pulmonary involvement concurrent with the ulcers. An association with other internal diseases was noted in 12 patients. Histopathologic study showed vasculitis in 13 patients. Of these, 11 were leukocytoclastic and the others predominantly lymphocytic.

CONCLUSIONS

PG is a rare disease, with the ulcerative variant being most frequent. The lower legs are the most commonly affected sites. The recurrence rate in our study was about 46% regardless of the treatment prescribed. Pulmonary involvement was fatal in two patients.

Multiple aseptic pulmonary nodules with central necrosis in association with pyoderma gangrenosum

Pulmonary manifestations of pyoderma gangrenosum are relatively rare. We report the case of a 45-year-old patient with multiple pulmonary nodules with central necrosis as assessed by CT scan. The patient had a 4-year history of pyoderma gangrenosum with only minor skin manifestations. A CT-guided, fine-needle biopsy of the lung revealed a nonspecific, inflammatory, aseptic necrotic process, which was comparable to the skin biopsy of one pyoderma lesion. Following the initiation of oral prednisolone therapy, a rapid resolution of the pulmonary nodules occurred. We conclude that pulmonary nodules represent a rare pulmonary manifestation of pyoderma gangrenosum.

Cavitating pulmonary infiltrate in an adolescent with pyoderma gangrenosum: a rarely recognized extracutaneous manifestation of a neutrophilic dermatosis

Neutrophilic dermatoses such as pyoderma gangrenosum are characterized by sterile, neutrophilic cutaneous infiltrates. Extracutaneous neutrophilic infiltrates can occur, primarily in the joints, lungs, heart, central nervous system, gastrointestinal tract, and eyes. Pulmonary disease is the most frequently reported extracutaneous manifestation of pyoderma gangrenosum and is characterized by patchy infiltrates or interstitial pneumonitis. We describe an adolescent with typical pyoderma gangrenosum who presented with cavitary pneumonia and responded completely to oral corticosteroids. In patients with inflammatory ulcers, extracutaneous neutrophilic disease should be considered, once an infectious process has been excluded.