Pyoderma gangrenosum--a postoperative "pseudo-infection"

Pyoderma gangrenosum is a skin ulcerative necrosis, due to dermal neutrophilic infiltration, through a non-infectious exacerbation of cell -mediated immunity. Being characterized by pathergy, the disease may be triggered by surgery; in this case, it is easily mistaken for a postoperative infection. We report a case of pyoderma gangrenosum after coronary artery bypass surgery. The patient developed, from the 7th postoperative day, around the incisions, dermo-epidermic lesions specific for the disease, high fever with chills and a severe biological inflammatory syndrome. Treatment for wound sepsis was ineffective. After pyoderma gangrenosum was recognized, corticosteroids (Prednisone 80 mg/d) led, in two days time, to a spectacular improvement, and in 7 weeks, to complete epithelization of the lesions. If after debridement of a supposedly infected wound (with pustules, bullae or ulcerations), there is no improvement, but a centrifugal extension of the lesions, with a "sepsis-like" syndrome and persistent negative cultures, one should think at pyoderma gangrenosum; in that case, not the antibiotics, but corticosteroids (or other immunosuppressants) are the treatment.     

Pyoderma gangrenosum following abdominoplasty—a rare complication

Pyoderma gangrenosum is an uncommon condition characterised by non-infective ulceration of the skin. Pathergy is pyoderma gangrenosum occurring at sites of trauma, and the occurrence at the site of surgery is well described. We present a case of pyoderma gangrenosum after abdominoplasty, a rare complication that has not been described in the literature until now.     

Surgical Management of Pyoderma Gangrenosum: Case Report and Review

BACKGROUND: Commonly used treatments for pyoderma gangrenosum are medical, with immunosuppressive agents employed most often. OBJECTIVE: To report a case and discuss the indications for radical surgical treatment of pyoderma gangrenosum. METHODS: Analysis of a case of Crohn's disease-associated pyoderma gangrenosum treated with immunosuppression followed by amputation, and a review of the literature on surgical management of pyoderma gangrenosum. RESULTS: In unstable patients with intractable multiple medical problems, surgical treatment of pyoderma gangrenosum may be indicated by the existence of these life-threatening comorbidities. The recent literature suggests that surgical management of pyoderma gangrenosum may also be appropriate in other special circumstances. CONCLUSIONS: Surgical management, including amputation, may have a role in the management of pyoderma gangrenosum. Further research is needed to delineate precisely the circumstances and patient factors that are appropriate indications for such surgery.     

Pyoderma gangrenosum at multiple sites in a post‐colostomy ulcerative colitis patient with chronic hepatitis B virus: A case report

Pyoderma gangrenosum is an uncommon ulcerative cutaneous lesion manifesting as rapidly progressing single or multiple skin ulcers. Permanent stoma in inflammatory bowel disease patients remains an independent risk of pyoderma gangrenosum. In the current report, we describe a case of pyoderma gangrenosum in a post‐colostomy ulcerative colitis patient with chronic hepatitis B. Pyoderma gangrenosum began seemingly as peristomal dermatitis that rapidly developed into painful ulcerations with subsequent appearance of sterile pustules and ulcerations in the left lower leg. The patient significantly improved after active management with prednisolone, antiviral therapy with entecavir, and wound dressings. Our case suggests that physicians and surgeons should have a high index of suspicion of pyoderma gangrenosum in post‐colostomy ulcerative colitis patients who develop peristomal dermatitis.     

Pyoderma gangrenosum in a battered child

Pyoderma gangrenosum is an uncommon cutaneous ulceration, which continues to be a difficult disorder to diagnose and treat. A pediatric case of pyoderma gangrenosum with no associated systemic disorder is presented. The disease was precipitated by physical trauma. The disease was controlled with systemic corticosteroid therapy and then the wound was successfully covered with a split-thickness skin graft from the thigh without any healing problem at the donor site. Although pathergy is well described in the etiopathogenesis of the disease, this is the first case reported that was precipitated after physical assault.     

A retrospective study of 12 cases of pyoderma gangrenosum: why we should avoid surgical intervention and what therapy to apply

Lesions of skin are ubiquitous in the medical field. The varying etiopathologies with similar presentation can pose a misleading picture, especially when faced with less common skin diseases. Furthermore, the misdiagnosis can cause detrimental effects on the patient's morbidity and mortality, which was seen in the case series study we performed on pyoderma gangrenosum. The history of 12 patients were analyzed in reference to the course of the disease, accompanying diseases, clinical picture, histopathological examination, surgical intervention before diagnosis, and treatment. Within this group of 12 patients, five were exposed to surgical interventions before diagnosis of pyoderma gangrenosum. The 5 patients were all exposed to prolonged aggravation of the disease process, followed by remission after proper diagnosis and treatment therapy. This study was done to improve the knowledge of surgeons about pyoderma gangrenosum considering the frequency of skin lesion cases in the surgical practice. Knowledge of the disease is essential to diagnose pyoderma gangrenosum in early stages to avoid interventions that may prolong or worsen the outcome. Surgical interventions in these patients should be avoided before proper diagnosis. The key to a better prognosis of pyoderma gangrenosum patients is often in the hands of surgeons.     

Total hip arthroplasty for femoral neck fracture with pyoderma gangrenosum patient: A case report

IntroductionPyoderma gangrenosum is a rare inflammatory aseptic, ulcerative neutrophilic dermatosis which manifest as skin recurrent, painful ulcers.Presentation of caseA 65-year-old man with pyoderma gangrenosum underwent left total hip arthroplasty because of femoral neck fractures. Glucocorticoid, antibiotic, anticoagulant drug, etc. were given in perioperative period. Complication of pyoderma gangrenosum was prevented successfully in perioperative period.DiscussionNo consensus has been reached about whether to use glucocorticoid, as well as the dosage and administration, in perioperative periods for pyoderma gangrenosum patients as prophylactic means of wound complication.ConclusionWe herein report a case of pyoderma gangrenosum patient underwent total hip arthroplasty, meanwhile raise the issue of management in perioperative period for pyoderma gangrenosum patient, especially explore series of standardized therapies for this disease during arthroplasty.     

Pyoderma gangrenosum occurring in a lower limb fasciocutaneous flap--a lesson to learn.

Pyoderma gangrenosum is a destructive cutaneous disease characterised by progressive painful ulceration. The occurrence of pyoderma gangrenosum at a surgical site is rare (especially if there is no predisposing illness), but is well recognised. We present a case of a 63-year-old man who developed erythematous ulcerative lesions due to pyoderma gangrenosum in and around a lower limb fasciocutaneous flap used to cover an exposed total knee prosthesis. The lesions were initially confused with postoperative wound infection. No predisposing disorder, other than the rarely reported association with osteoarthritis, was found. The diagnosis is important because its rapid detection not only avoids unnecessary treatment but also allows for prompt intervention with oral steroids. This case is presented to alert surgeons to the presence of pyoderma gangrenosum and its diagnostic confusion with postoperative wound infection.     

Simultaneous bilateral microvascular tissue transfer for soft-tissue defects of the lower extremities in pyoderma gangrenosum

Pyoderma gangrenosum is a necrotizing skin disease of unknown etiology. The lesions are painful and occur mostly on the lower extremities, either single or multiple, but can appear in any region of the body. The authors report a case of pyoderma gangrenosum involving bilateral skin lesions over the anterior surface of the legs in a 13-year-old male patient. The lesions presented with ulcerative colitis, which is one of the most commonly associated diseases of pyoderma gangrenosum. After examination, systemic immunosuppressive treatment was administered and the progression of the disease was controlled. The lesions were treated with the simultaneous application of two free anterolateral thigh fasciocutaneous flaps after radical debridement. The procedure was successfully performed and no recurrence was observed. Although microvascular free tissue transfer cannot be performed in a standard fashion in pyoderma gangrenosum cases because of the risk of pathergy response, it should be considered as a surgical option in selected cases, otherwise difficult to manage, with the simultaneous application of appropriate systemic medical treatment.     

Atypical pyoderma gangrenosum of the dorsal hand mimicking squamous cell carcinoma

We describe a rare case of atypical pyoderma gangrenosum of the dorsal hand in a patient who presented with the histopathologic diagnosis of squamous cell carcinoma (SCC). Atypical pyoderma gangrenosum is a rare variant of pyoderma gangrenosum that occurs on the upper extremities, presenting as a cutaneous ulcer. The correct treatment is nonsurgical, and surgical intervention often results in trauma-induced expansion of lesions. Pyoderma gangrenosum, most commonly mistaken for infection, has resulted in amputation. Histologic and clinical presentation 1 month after onset of symptoms in the patient reported here mimicked SCC. Awareness by hand surgeons of the possible histologic misdiagnosis of SCC at an early stage in the disease evolution and a high index of suspicion in the face of biopsy-proven SCC may prevent unnecessary digit amputation.     

Pyoderma gangrenosum. A diagnosis not to be missed.

We describe a case of pyoderma gangrenosum which presented with severe wound breakdown after elective hip replacement. The patient was treated successfully with minimal wound debridement and steroids. This diagnosis should always be considered when confronted with an enlarging painful skin lesion which does not grow organisms when cultured and fails to respond to antibiotic therapy, especially if there are similar lesions in other sites. In patients who have a past history of pyoderma gangrenosum, prophylactic steroids may be indicated at the time of surgery or may be required early in the postoperative period.     

Pyoderma gangrenosum and ulcerative colitis in black South Africans. Case reports

Two patients with pyoderma gangrenosum and ulcerative colitis are described. To our knowledge this is the first report of such an association in Blacks. The unusual vesicopustular form of pyoderma gangrenosum was well demonstrated by one patient who also responded remarkably to clofazimine. The associations, pathological findings and therapy are briefly reviewed. Colectomy may ameliorate the skin lesions when conventional therapy is unsuccessful.     

Rare complication after cardiac surgery: a case report of pyoderma gangrenosum

Abstract   Pyoderma gangrenosum is an uncommon, idiopathic, chronic ulcerative inflammatory skin disease characterized by a rapidly progressive necrosis of the wound edges, and mimics a postoperative infection. Few cases have been reported after cardiothoracic surgery. We present a case of a pyoderma gangrenosum occurring after coronary artery bypass graft.     

Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report

Excision of tumors from the hand often leaves tissue defects with exposed tendons or neurovascular structures that require coverage. Various types of free and pedicled grafts have been described for use in these situations. We present a patient who had a tumor excision in the hand followed by wound coverage with a stacked dermal regeneration template. A 50-year-old man presented with a mass over the palm of the hand. He had an incisional biopsy procedure, the results of which suggested malignancy. He then had wide excision with planned temporary skin coverage with a dermal regeneration template. The dermal template incorporated nicely. With adequate skin coverage the palmar defect still was substantial in terms of depth. This was raised with layering or stacking of the template followed by a split-thickness skin graft. Excellent wound healing and coverage of the defect ultimately were achieved. Additionally the patient went on to obtain full range of motion. Stacking of a dermal regeneration template coupled with split-thickness skin grafting was used to fill a soft-tissue defect over the median and nerve and flexor tendons after wide tumor excision.     

Pyoderma gangraenosum – seltene Ursache einer unerwarteten Wundheilungsstörung

Pyoderma gangrenosum represents a rare but severe disturbance of wound healing following operative interventions. A case report of pyoderma gangrenosum after breast surgery is presented and the aetiology and the various options regarding investigations and treatment are discussed considering the current literature.     

Pyoderma gangrenosum presenting as Fournier's gangrene

We report a case of pyoderma gangrenosum presenting as Fournier's gangrene. Although both processes have a similar presentation effective management is markedly different. Whereas broad-spectrum antibiotics and aggressive surgical débridement are necessary to control Fournier's gangrene, immediate institution of corticosteroids and local wound care are indicated for pyoderma gangrenosum.     

Pyoderma gangrenosum after reduction mammoplasty

The authors report a case of pyoderma gangrenosum in a 37-year-old woman that occurred at surgical sites after reduction mammoplasty. The diagnosis was delayed, but treatment with intralesional triamcinolone resulted in complete resolution o the condition. Pyoderma gangrenosum in this setting can mimic infectious causes of wound necrosis. Early recognition of its characteristics features may prevent unnecessary and ineffective treatment, thereby avoiding frustration for both patient and physician.     

Pyoderma gangrenosum at the parastomal site in patients with Crohn's disease

Pyoderma gangrenosum is a rare idiopathic skin condition often associated with other diseases, including Crohn's disease. We believe this is the first report of cases in which pyoderma gangrenosum was identified at the parastomal site in patients with Crohn's disease. Four episodes of the condition occurred in three patients. In these patients, pyoderma gangrenosum first appeared after two to three surgical procedures and between ten months and five years after the initial surgery. The disease course varied from resolution within two months with corticosteroid therapy to resolution only after revision or relocation of the stoma with resection of recurrent disease segments. Parastomal pyoderma gangrenosum at the ileostomy site in patients with Crohn's disease may be more common than previously thought. Optimal treatment has not yet been established, and treatment needs to be tailored for each patient.     

Dermal Regeneration Template in the Surgical Management of Diabetic Foot Ulcers: A Series of Five Cases

Soft-tissue defects in the feet of patients with diabetes continue to pose a challenge because adequate debridement often leaves an extensive defect with exposed bone, tendon, and cartilage. The use of a dermal regeneration template followed by split-thickness skin grafts in the treatment of recalcitrant diabetic foot wounds was retrospectively reviewed. In a case series of 5 patients with diabetes and extensive tissue deficits of the foot, the use of a dermal regeneration template and split-thickness skin graft enabled closure of the lower-extremity defect. All patients completely healed and were able to resume ambulation with the aid of extradepth shoes and multidensity insoles. The take of the dermal regeneration template was excellent in all patients, and the grafts (dermal regeneration templates and split-thickness skin) were durable even when placed on difficult areas such as the plantar surface and heel. No infections occurred. Exposed bone, tendon, cartilage, and fascia were successfully covered. The experience in this case series suggests that the use of the dermal regeneration template followed by split-thickness skin graft offers an option for patients with diabetes with chronic wounds that have foot defects as a result of extensive tissue loss resulting from infection.     

Pyoderma gangrenosum following AICD implantation: differential diagnosis to necrotizing fasciitis

Pyoderma gangrenosum is rarely seen in the surgical disciplines. In the described case the patient was initially diagnosed with necrotizing fasciitis and admitted to the intensive care unit suffering from septic shock. The automated implantable cardioverter defibrillator (AICD), the suspected focus for infection, had already been removed. Following weeks of broad spectrum antibiotics and wound debridement without clinical improvement the alternative diagnosis of pyoderma gangrenosum was reached. Consequently the patient was treated with immunosuppressive therapy and his condition improved rapidly such that he was ultimately discharged to rehabilitation.