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Nguyen M, Borders L, Wesolow JT, Greene J. Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study. Cureus 2024; 16:e55333. [PMID: 38434604 PMCID: PMC10906345 DOI: 10.7759/cureus.55333] [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: 02/29/2024] [Indexed: 03/05/2024] Open
Abstract
Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.
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Affiliation(s)
- Michael Nguyen
- Internal Medicine, Morsani College of Medicine, University of South Florida Health, Tampa, USA
| | - Luke Borders
- Internal Medicine, Morsani College of Medicine, University of South Florida Health, Tampa, USA
| | | | - John Greene
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
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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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Sarwar S, Sajid F, Wasim AU, Waleed MS, Thada PK. Pyoderma Gangrenosum Precipitated by Breast Engorgement Following Lactation Discontinuation: A Rare Case Report. Cureus 2023; 15:e42203. [PMID: 37602127 PMCID: PMC10439785 DOI: 10.7759/cureus.42203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Pyoderma gangrenosum (PG) is an inflammatory disease characterized by recurrent painful ulcers, eventually leading to cribriform scars. PG is mostly a diagnosis of exclusion with neutrophilic skin infiltration. We present a case of a 35-year-old female patient whose first presentation of PG occurred in the first trimester of pregnancy, which recurred after discontinuation of breastfeeding. The patient also had a history of taking prolonged IM and IV analgesics for her chronic migraines. The patient was initially treated with steroids and necessary wound care, during which symptoms remained controlled. However, a year later, the patient presented with an acute flare-up of the disease in her postpartum period, mainly involving her breasts bilaterally. Extensive wound debridement was performed due to the severity of her necrotic ulcers and failure to respond to conservative management, which was followed by partial thickness skin grafting.
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Affiliation(s)
- Sarosh Sarwar
- Medicine and Surgery, Fazaia Medical College, Islamabad, PAK
- Research, Larkin Community Hospital, Miami, USA
| | | | - Asad Ullah Wasim
- Medicine and Surgery, Fazaia Medical College, Islamabad, PAK
- Research, Larkin Community Hospital, Miami, USA
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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. [DOI: 10.3171/2019.7.spine19708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [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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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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Tolkachjov SN, Fahy AS, Cerci FB, Wetter DA, Cha SS, Camilleri MJ. Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases. Mayo Clin Proc 2016; 91:1267-79. [PMID: 27489052 DOI: 10.1016/j.mayocp.2016.05.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.
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Affiliation(s)
| | | | - Felipe B Cerci
- Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba, Brazil
| | | | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Zuo KJ, Fung E, Tredget EE, Lin AN. A systematic review of post-surgical pyoderma gangrenosum: Identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg 2015; 68:295-303. [DOI: 10.1016/j.bjps.2014.12.036] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 11/25/2014] [Accepted: 12/06/2014] [Indexed: 01/17/2023]
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Pyoderma gangrenosum: an exceptional complication of venous access device. J Vasc Access 2013; 15:321-4. [PMID: 24190068 DOI: 10.5301/jva.5000181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a rare disease whose precise etiology remains unknown. It causes rapidly developing skin necrosis and can occur after surgery, or after a nonspecific external stimulus. This condition is difficult to diagnose because it often mimics a fulminant infection. CLINICAL CASE We present a case of very significant local presentation of PG after placement of a venous access device. Fifteen days after placement, the patient developed extensive cutaneous ulcers and necrosis in the subclavicular area, which led to the misdiagnosis of infection. The device was removed and the patient was given antibiotics. Because there was no improvement following antibiotic treatment, combined with the worrying and extensive appearance of the skin and extremely intense pain, the diagnosis of PG was made. The patient was immediately treated with high-dose corticosteroids, resulting in rapid improvement of the lesions and relief of pain. CONCLUSION PG should be considered in cases of extensive, antibiotic-resistant ulceration and treatment with corticosteroids should be initiated. Clinical improvement is usually dramatic, with almost immediate suppression of the pain and arrest of the lesion's progression. Early treatment is the best guarantee for an effective recovery.
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Kratzsch D, Ziemer M, Milkova L, Wagner JA, Simon JC, Kendler M. Facial pyoderma gangrenosum in senescence. Case Rep Dermatol 2013; 5:295-300. [PMID: 24403893 PMCID: PMC3884177 DOI: 10.1159/000356100] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Clinically, pyoderma gangrenosum (PG) is characterized by a rapidly progressive, painful cutaneous ulcer with an irregular, violaceous and undermined border. PG occurs most frequently on the lower extremities and the trunk of middle-aged individuals. The face is only very rarely affected. We present an 89- and a 90-year-old patient, who developed a facial ulcer consistent with PG.
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Affiliation(s)
- Dorothea Kratzsch
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
| | - Mirjana Ziemer
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
| | - Linda Milkova
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
| | - Justinus A Wagner
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
| | - Jan C Simon
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
| | - Michael Kendler
- Department of Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany
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Uchino M, Ikeuchi H, Matsuoka H, Bando T, Ichiki K, Nakajima K, Takahashi Y, Tomita N, Takesue Y. Catheter-associated bloodstream infection after bowel surgery in patients with inflammatory bowel disease. Surg Today 2013; 44:677-84. [DOI: 10.1007/s00595-013-0683-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 03/04/2013] [Indexed: 12/13/2022]
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Patvekar MA, Virmani NC. Pyoderma gangrenosum with an underlying ulcerative colitis associated with bone tuberculosis. Indian Dermatol Online J 2013; 4:43-6. [PMID: 23440150 PMCID: PMC3573453 DOI: 10.4103/2229-5178.105473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pyoderma gangrenosum is a rare noninfective neutrophilic dermatosis, characterized by progressive painful ulceration. It is frequently associated with systemic disorders like inflammatory bowel disease, rheumatoid arthritis and myeloproliferative diseases. However, its association with infectious diseases in particular with tuberculosis is extremely rare. Diagnosis is based on the history of an underlying disease, a typical clinical presentation, histopathology and exclusion of other diseases leading to ulcerations of similar appearance. Immunosuppression with corticosteroids remains the mainstay of treatment. We report a case of a 49-year-old male with long-standing ulcerative colitis, associated with tuberculosis of hip, who presented with nonhealing ulcers over the lower extremity.
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Affiliation(s)
- Milind A Patvekar
- Department of Dermatology, Dr. D.Y. Patil Medical College and Hospital, Pimpri, Pune, India
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Wani I, Bhat IHG, Mir M, Mir M, Hassan N, Mustafa A. Pyoderma gangrenosum of abdominal wall: a case report. Oman Med J 2011; 26:64-5. [PMID: 22043386 DOI: 10.5001/omj.2011.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 12/20/2010] [Indexed: 11/03/2022] Open
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