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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [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: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Pyoderma gangrenosum-like ulcerations in granulomatosis with polyangiitis: two cases and literature review. Rheumatol Int 2018; 38:1139-1151. [PMID: 29721696 DOI: 10.1007/s00296-018-4035-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a systemic necrotizing small vessel vasculitis associated with circulating anti-neutrophil cytoplasmic antibodies (ANCAs). Skin manifestations, mostly represented by palpable purpura, papulonodular lesions and livedo reticularis, are present in up to 50% of the cases. Ulcerations with undermined, raised erythematous-violaceous border resembling pyoderma gangrenosum (PG) have rarely been reported as skin involvement in GPA. The presence of circulating ANCAs with a cytoplasmic labelling pattern, the involvement of internal organs, particularly of the lung, and the absence on histology of a mainly neutrophilic infiltrate in early phases of the cutaneous lesions may be regarded as clues to rule out true PG and confirm the diagnosis of GPA skin ulcerations simulating PG. Herein, we describe two paradigmatic cases of such a unique presentation of GPA and a literature review focusing on clinicopathological features of GPA presenting with PG-like ulcerations in the skin has been provided. Moreover, referring to the scenario observed in these two cases, an easy-to-use working approach for the differential diagnosis between the two conditions has also been proposed.
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Kishore S, Mittal V, Ahuja S, Majithia V. When a wound is the harbinger of a serious underlying systemic illness. BMJ Case Rep 2018; 2018:bcr-2017-222491. [PMID: 29386209 DOI: 10.1136/bcr-2017-222491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old woman presented with progressive enlarging and painful non-healing ulcers on her bilateral lower extremities; biopsy was consistent with pyoderma gangrenosum. Workup for an underlying illness revealed a cavitary lung nodule and an ulcerating mass in the anal canal. Patient did not have any respiratory or gastrointestinal symptoms. Differential diagnosis included inflammatory bowel disease, rectal carcinoma or infection such as tuberculosis, fungal process. Histopathology did not reveal any malignancy, inflammatory bowel disease or infection. Serological studies were positive for perinuclear antineutrophil antibodies specific to proteinase-3 antigen, and the patient was ultimately diagnosed with granulomatosis with polyangiitis. Intravenous pulse dose steroids were initiated followed by monthly pulse cyclophosphamide for 6 months, resulting in rapid and significant improvement of the wounds.
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Affiliation(s)
- Shweta Kishore
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Varun Mittal
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Shradha Ahuja
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Vikas Majithia
- Department of Rheumatology, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Feygina VM, Hahn TF, Muchant DG. Refractory skin lesion, hypertension, and acute kidney injury in a young boy: Answers. Pediatr Nephrol 2017; 32:2053-2056. [PMID: 28101638 DOI: 10.1007/s00467-016-3567-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/02/2016] [Accepted: 12/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Valeriya M Feygina
- Department of Pediatrics, Division of Pediatric Nephrology, Geisinger Medical Center, 100 Academy Avenue, Danville, PA, 17822, USA.
| | - Thomas F Hahn
- Department of Pediatrics, Division of Pediatric Rheumatology, Geisinger Medical Center, 100 Academy Avenue, Danville, PA, 17822, USA
| | - Dianne G Muchant
- Department of Pediatrics, Division of Pediatric Nephrology, Geisinger Medical Center, 100 Academy Avenue, Danville, PA, 17822, USA
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Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord 2016; 5:280-292. [PMID: 28214498 DOI: 10.1016/j.jvsv.2016.09.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/01/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic wounds are a major cause of morbidity and mortality. Approximately 20% to 23% of nonhealing wounds that are refractory to vascular intervention have other causes, including vasculitis, pyoderma gangrenosum, and other autoimmune diseases. The purpose of this article was to review the literature across medical and surgical specialties with regard to refractory chronic wounds associated with vasculitis and autoimmune diseases and to delineate clinical outcomes of these wounds in response to vascular and other interventions. METHODS An electronic search encompassing MEDLINE, PubMed, Cochrane Library, and Scopus was completed using the following search terms: rheumatoid arthritis; systemic sclerosis; systemic lupus erythematosus; antineutrophil cytoplasmic antibody-associated vasculitis; mixed connective tissue disease; antiphospholipid syndrome; pyoderma gangrenosum; thromboangiitis obliterans; cryoglobulinemia; hydroxyurea; sickle cell; atrophie blanche; livedoid vasculitis; cholesterol emboli; calciphylaxis; antiphospholipid antibodies; prothrombotic; combined with the terms: chronic wound and leg ulcer. Full-text articles published in English up to March 1, 2016, that investigated the clinical outcomes of chronic wounds associated with autoimmune diseases were included. Review articles and evaluations of management of chronic wounds were also reviewed. Primary outcomes included in the review were amputation, ulcer healing, reduction in wound size, overall survival, and freedom from reintervention. Owing to the heterogeneity of data reporting among articles, qualitative analysis is also reported. RESULTS Vasculitis and autoimmune diseases play a role in 20% to 23% of patients with chronic lower extremity ulcers. Furthermore, patients with autoimmune disease have a significantly high rate of split thickness skin graft failure (50% compared to 97% in patients without autoimmune disease; P = .0002). The management of leg ulcers associated with autoimmune diseases is discussed. CONCLUSIONS Autoimmune and vasculitic causes should be considered in patients with chronic wounds who do not respond to appropriate vascular intervention and standard local wound care. A multidisciplinary approach with the involvement of rheumatologists allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Extensive Pyoderma Gangrenosum Associated With Granulomatosis With Polyangiitis With Both Responsive to Rituximab. J Clin Rheumatol 2016; 22:393-5. [PMID: 27660945 DOI: 10.1097/rhu.0000000000000447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Shanmugam VK. Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing In Chronic Wounds. CURRENT DERMATOLOGY REPORTS 2016; 5:270-277. [PMID: 27833788 DOI: 10.1007/s13671-016-0157-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection. RECENT FINDINGS Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20-23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases. SUMMARY In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, The George Washington University, School of Medicine and Health Sciences, 701 Ross Hall, 2300 Eye Street, NW, Washington, DC 20037
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de Cambourg G, Mahé A, Banea S, Moulinas C, Blaison G. Granulomatose avec polyangéite révélée par une ulcération cutanée mimant un pyoderma gangrenosum : à propos de 2 cas. Rev Med Interne 2016; 37:632-5. [DOI: 10.1016/j.revmed.2015.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/31/2015] [Accepted: 12/07/2015] [Indexed: 11/28/2022]
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Sen M, Dogra S, Rathi M, Sharma A. Successful treatment of large refractory pyoderma gangrenosum-like presentation of granulomatosis with polyangiitis by rituximab. Int J Rheum Dis 2016; 20:2200-2202. [PMID: 27126548 DOI: 10.1111/1756-185x.12882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mitali Sen
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology and Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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de Boysson H, Martin Silva N, de Moreuil C, Néel A, de Menthon M, Meyer O, Launay D, Pagnoux C, Guillevin L, Puéchal X, Bienvenu B, Aouba A. Neutrophilic Dermatoses in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A French Multicenter Study of 17 Cases and Literature Review. Medicine (Baltimore) 2016; 95:e2957. [PMID: 26986103 PMCID: PMC4839884 DOI: 10.1097/md.0000000000002957] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A few reports suggest combination of ANCA-associated vasculitis (AAV) and neutrophilic dermatoses (ND). We aimed to describe the main characteristics of patients presenting with both AAV and ND in a French cohort and through a systematic literature review, and to discuss the possible common pathogenic process involved. We conducted a retrospective study of patients with both conditions. Patients were selected via the French Internal Medicine Society (SNFMI) and the French Vasculitis Study Group (FVSG). A literature review focusing on a combination of both conditions, concentrated only on publications with well-established diagnoses and individual detailed data. Seventeen patients diagnosed with AAV and ND were identified in this cohort. Twelve patients had granulomatosis with polyangiitis (GPA), 4 had microscopic polyangiitis (MPA) and one had eosinophilic GPA (EGPA). Eight patients, all with GPA, displayed pyoderma gangrenosum (PG). Sweet's syndrome was observed in 6 patients (4 with MPA, one with GPA and one with EGPA) and erythema elevatum diutinum in the other three (2 with GPA and 1 with MPA). The literature review identified 33 additional patients with both conditions, including 26 with GPA. Altogether, of the 50 patients (17 from our study and 33 from the literature review), 33 (66%) patients presented with PG associated with GPA in 29 cases (89%). Corticosteroids were the first-line treatment in conjunction with an immunosuppressive agent in most cases. Outcomes were good and a total of 15 patients experienced a relapse. Patients who relapsed were more likely to have ear, nose and throat manifestation than patients who did not [12/15 (80%) relapsing patients vs. 15/35 (43%) non-relapsing patients; p = 0.03)]. In our stud, the most frequent association concerned GPA and PG. ND should be considered and specifically researched within the spectrum of cutaneous manifestations observed in AAV.
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Affiliation(s)
- Hubert de Boysson
- From the Department of Internal Medicine, Caen University Hospital, Caen (HDB, NMS, BB, AA); Department of Internal Medicine, Brest University Hospital (CDM); Department of Internal Medicine, Nantes University Hospital (AN); Department of Internal Medicine, Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Paris, France (MDM); Department of Rheumatology, Assistance Publique Hôpitaux de Paris, Bichat University Hospital, Paris, France (OM); Department of Internal Medicine, Lille University Hospital, France (DL); Mount Sinai Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada (CP); and Department of Internal Medicine, Assistancec Publique Hôpitaux de Paris, Cochin Hospital, Paris, France (LG, XP)
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Donmez S, Pamuk ON, Gedik M, A K R, Bulut G. A case of granulomatosis with polyangiitis and pyoderma gangrenosum successfully treated with infliximab and rituximab. Int J Rheum Dis 2014; 17:471-5. [PMID: 24460826 DOI: 10.1111/1756-185x.12274] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Here, we present a young male patient who was admitted with alveolar hemorrhage, arthritis and cutaneous lesions, who later developed bilateral orbital involvement and pyoderma gangrenosum (PG). He also had pathergy test positivity. The patient was refractory to conventional immunosuppressive therapy. Therefore, multiple devastating PG lesions and disease activity in granulomatosis with polyangiitis (GPA) were controlled with infliximab. Later, rituximab was used with success to prevent recurrence of symptoms. The relationship of PG with various autoimmune diseases is known; however, PG in GPA has been only rarely reported. Biologic agents might prove to be effective in GPA and PG patients who are refractory to standard immunosuppressive therapy.
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Affiliation(s)
- Salim Donmez
- Department of Rheumatology, Trakya University Medical Faculty, Edirne, Turkey
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Ene N, Bélénotti P, Benyamine A, Sovaila S, Ben Sahla Talet MH, Kaminsky P, Serratrice J, Weiller PJ. [Granulomatosis with polyangiitis (previously Wegener's granulomatosis) mimicking malingering]. Rev Med Interne 2013; 35:540-2. [PMID: 23886885 DOI: 10.1016/j.revmed.2013.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/13/2013] [Accepted: 06/23/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION ANCA vasculitis may involve the skin and develop slowly without specific histology, and without autoantibodies. CASE REPORT We report a 50-year-old woman who experienced bilateral mastectomy because of ulcero-necrotic, non-specific inflammatory cutaneous lesions of the breasts. First considered by others as a malinger patient, she developed oto-neurological lesions leading to the diagnosis of Wegener's granulomatosis. Five years later, specific antibodies of the disease were present. CONCLUSION Cutaneous involvement by ANCA vasculitis can be isolated for a long time. Physicians must have a high degree of suspicion to avoid diagnostic delay of ANCA vasculitis.
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Affiliation(s)
- N Ene
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - P Bélénotti
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France.
| | - A Benyamine
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - S Sovaila
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - M H Ben Sahla Talet
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - P Kaminsky
- Service de cardiologie, médecine interne, CHU Brabois Médecine J, avenue de Bourgogne, 54500 Vandœuvre-lès-Nancy, France
| | - J Serratrice
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - P-J Weiller
- Service de médecine interne, CHU Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
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Affiliation(s)
- S. Ratnagobal
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
| | - S. Sinha
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
- Wound Clinic, Royal Hobart Hospital, Tasmania, Australia
- University of Notre Dame Australia, School of Medicine Sydney, Australia
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Postoperative Pyoderma Gangrenosum After Elective Abdominoplasty: A Case Report and Review of the Literature. J Burn Care Res 2010; 31:959-63. [DOI: 10.1097/bcr.0b013e3181f93ab1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hernández-Bel P, López J, Sánchez JL, Pérez A, Alegre V. Úlcera cutánea en la mama: una presentación inusual de la granulomatosis de Wegener. Cir Esp 2010; 87:400-2. [DOI: 10.1016/j.ciresp.2009.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Revised: 07/20/2009] [Accepted: 07/21/2009] [Indexed: 10/20/2022]
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