Pyoderma gangrenosum following reduction mammaplasty

The failure of a postoperative local infection to resolve after appropriate antibiotic therapy should prompt consideration of other diagnoses. Reported here is a case of pyoderma gangrenosum, a rare necrotizing disorder, occurring after reduction mammaplasty. The clinical presentation was one of progressive wound deterioration with associated erythema and intense pain. After failure of antibiotic therapy and local wound care, tissue biopsy of the enlarging wound edge confirmed the diagnosis, which then responded rapidly to systemic steroid treatment. Given that the treatment for pyoderma gangrenosum is at odds with the standard treatment for an infection (steroids versus antibiotics), differentiating between the two diagnoses is vital to providing resolution of the process and limiting any untoward scarring resulting from the advancing open wounds that can develop. With this in mind, the physical signs and symptoms that characterize this condition and thus allow early diagnosis are presented, and treatment options discussed.     

Pyoderma gangrenosum following cardiac surgery

Abstract   Pyoderma gangrenosum appeared in multiple incision sites after coronary bypass surgery.     

Pyoderma gangrenosum: a difficult early diagnosis to make

Pyoderma gangrenosum (PG) is a rare, painful, non-infectious, ulcerative, inflammatory skin condition. It is characterised by ulcers that can spread rapidly showing undermined violaceous borders. It may develop at sites of trauma or in surgical wounds. Early diagnosis is not always easy as there is no single diagnostic test and clinical features are often indistinguishable from other more common ulcerative skin conditions. Diagnosis is made on clinical appearance, patient history and exclusion of other conditions. We describe a case of PG, which proved challenging to diagnose, in a man who presented initially with a non-healing leg ulcer at a site of previous trauma and surgery. He subsequently developed further lesions on the contralateral leg with the classical appearance of PG. PG is a condition, which may be encountered by plastic surgeons and should always be considered in the differential diagnosis of any ulcer. Presented at the Summer British Association of Plastic Surgery (BAPS) Meeting as a poster (July 13, 2006).     

Pyoderma gangrenosum following breast reconstruction.

Pyoderma gangrenosum is an unusual cause of skin necrosis following surgery, particularly in those without an associated systemic condition. There have been reports of the condition in this context but not in relation to breast reconstruction. We present a case of pyoderma gangrenosum following latissimus dorsi flap reconstruction of a breast.     

An extensive pyoderma gangrenosum mimicking necrotizing fasciitis: An unusual case report

IntroductionPyoderma Gangrenosum (PG) is a rare, benign and inflammatory disease characterized by ulcerative skin lesions. We report the successful management of an unusual case of PG following a caesarean section, with extensive cutaneous skin involvement and mimicking necrotizing fasciitis.Presentation of caseA 36-year-old woman was admitted with extensive surgical site inflammation after a caesarean section. Despite antibiotic treatment and wound care, the clinical course deteriorated rapidly. Wound debridement following negative pressure closure was performed due to an immediate increase in skin necrosis. A diagnosis of PG was reached based on the absence of a positive wound culture, resistance to wound debridement and the histopathological results. A course of high-dose corticosteroids was started, and a successful clinical course was finally achieved. The patient is now in the 14th month of remission, with no recurrence.DiscussionPG is often reported after bowel surgery, especially after complicated stoma or diverticulitis, breast surgery and occasionally after C-sections. The diagnosis of pyoderma gangrenosum may be challenging because of a wide variety of macroscopic features and its pronounced similarity to necrotizing fasciitis. Treatment with systemic corticosteroids is the most common management option, while surgical treatment is extremely controversial.ConclusionAn extensive PG following surgery can mimic necrotizing fasciitis. An interdisciplinary treatment approach provides early diagnosis and effective treatment resulting in less morbidity.     

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 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.     

Fatal necrotizing fasciitis following suction-assisted lipectomy

Forty-eight hours following extensive blunt suction lipectomy with 3,000 cc of tissue removed, a 36-year-old woman presented to an emergency room with necrotizing fasciitis of both lower extremities extending over the buttock and to the lower third of the back. Tissue cultures and blood culture grew out a pure culture of beta-hemolytic streptococci. The patient rapidly progressed into a comatose state and, despite extensive debridement and appropriate antibiotic therapy, in addition to hyperbaric oxygen treatments, she died on day 9 of her hospitalization (day 11 following the suction lipectomy). To our knowledge this is the first published mortality reported in the United States following this procedure.     

Pyoderma gangrenosum: a great marauder

Pyoderma gangrenosum is a progressively necrotizing and ulcerative skin disease that mimics a severe bacterial infection. However, the cause is not infectious in nature and the lesions are refractory to local wound care and antibiotic therapy. The etiology of pyoderma remains unknown, although pathogenic mechanisms may involve immunologically mediated cutaneous damage. The authors report a 67-year-old woman in whom a necrotic ulcer developed at a chest tube site. Treated with local wound care and antibiotics, this lesion spread progressively to involve 15% of her body surface area. A septic clinical picture developed despite sterile cultures, and she required several operative debridements. Her disease continued to spread and finally a diagnosis of pyoderma gangrenosum was considered. Treated with systemic steroids, hyperbaric oxygen (HBO), and local wound care, she eventually underwent skin grafts.     

Secondary Streptococcus pyogenes peritonitis following necrotizing fasciitis

We report the case of a 66-year-old woman with diabetes mellitus and disseminated lupus treated with immunosupressive drug. She was admitted for an inflammatory oedema of the right lower limb associated to diffuse abdominal pain and vomiting. The occurrence of septic shock with multiple organ failure and surgical abdominal picture led us to perform urgent laparotomy without taking in account the evolutive signs of cutaneous lesions i.e. purpuric elements and haemorrhagic phlycthena. The abdominal cavity exploration showed peritonitis without digestive tracts perforation. The patient died few hours after surgical procedure. All bacteriological samples i.e. peritoneal effusion, blood cultures and phlycthena liquid were positive for Streptocoque pyogenes (group A) and peritonitis was considered to be related to haematogen diffusion from rapid course necrotizing fasciitis.     

Face necrotizing fasciitis following spinocellular epithelioma excision

Necrotizing fasciitis is a bacterial dermo-hypodermitis with superficial aponevrosis necrosis due to Streptococcus pyogenes. Head and neck region are some rare localization of this infection especially after surgery. We report herein a case of a face necrotizing fasciitis following minor face surgery. A 86 year-old Caucasian male without any antecedents, nor treatment, has been operated for a fronthead spinocellular epithelioma under local anesthesia. Twelve hours later, a severe pain localized to the face occurred, with sleeplessness, followed up with a face orbitary oedema and fever. Twenty-four hours later, an intravenous antibiotherapy was therefore started and surgical treatment was performed as soon as the diagnosis of necrotizing fasciitis was considered. An important inflammatory oedema was noticed, associated to a large necrotic softening of the face, the eyelid and the neck sub-cutaneous tissues. Then, the patient has been transferred in intensive care unit because multi-organ failure clinical and biological signs occurred. Pre-operatory bacteriological samples culture identified Streptococcus pyogenes. Repeated surgical explorations and debridement (excision, cleaning, draining and bandages recovery) were performed daily as needed until all the necrotic tissue was all eradicated. The antibiotherapy was prescribed to totalised 15 days. Our report underlines the importance of an early recognition of the diagnosis of soft tissue infection, because early surgical treatment has a better prognosis and antibiotic treatment alone is inefficient for the recovery. Alert is delivered by the local signs quickly followed up by skin changes. Anti-inflammatory therapy must be avoid in case of any soft tissue infection sign: they may increase the lesions, hide alarm signs and delay surgical treatment.     

Fatal necrotizing fasciitis following elective inguinal hernia repair

Necrotizing soft tissue infections (NSTIs) following elective hernia repair are extremely uncommon, though they can occur following emergency surgery for complicated hernias. They are also usually seen in individuals with impaired immunity. We report a case of fatal necrotizing fasciitis following elective hernia repair in an otherwise healthy young patient. A high index of suspicion is required to diagnose this condition early, as it is difficult to differentiate it from superficial surgical site infection.     

坏疽性脓皮病三例诊治分析

目的 加强外科医生对坏疽性脓皮病的认识,避免误诊误冶。方法 回顾性分析10年来经外科治疗的3例坏疽性脓皮病的临床资料。结果 3例患者均表现为皮肤软组织坏死,形成潜行性疼痛性溃疡,伴发热;均按“感染”治疗,但创面分泌物多次培养阴性;各种抗生素治疗无效,积极清创换药而创面继续扩大,溃疡活检病理为非特异性炎症。诊断为坏疽性脓皮病后经全身糖皮质激素及免疫抑制剂治疗结合创面局部换药,病情均迅速得到控制并逐步缓解。结论 坏疽性脓皮病易被误诊。确诊后病情重者应早期使用糖皮质激素和免疫抑制剂系统治疗,病情可迅速得到控制,创面经温和换药可自行愈合。     

Approach to debridement in necrotizing fasciitis

Aggressive debridement is a cornerstone intervention in necrotizing fasciitis. Our approach consists of 4 steps: (1) confirming the diagnosis and isolate the causative organism; (2) defining the extent of fasciitis; (3) surgical excision; and (4) post-excision wound care. The extent of the infection is defined by probing the wound bluntly. Systematic excision follows. Fascial excision must be complete and uncompromising with the full extent of the involved wound laid open. We classify the infected skin into zones 1, 2, and 3. Zone 1 is necrotic tissue. Zone 2 is infected but potentially salvageable soft tissue, and zone 3 is non-infected skin. Zone 1 is completely excised. Zone 2 is meticulously assessed and cut back as necessary to remove nonviable tissue while maximally preserving salvageable tissue. Zone 3 is left alone. The aim of surgical debridement is to remove all infected tissue in a single operation. This halts the progression of the fasciitis and minimizes unnecessary returns to the operating room.