Vegetative pyoderma gangrenosum: an unusual presentation

A 44-year-old woman presented with a 6-month history of subcutaneous nodules involving her face and shins. Her past history revealed myomatous uterus with menometrorrhagia, resulting in an iron deficiency anemia, treated by ferrum sulfate tablets. She also had diabetes mellitus type II treated by glibenclamide and metformin tablets. There was no evidence of bromide or iodide ingestion. On initial examination, several firm, tender, erythematous subcutaneous nodules, 2–4 cm in diameter, were present on the face ( Fig. 1 ) and shins ( Fig. 2 ), two with normal overlying skin. Within a few weeks, the nodule on the left shin enlarged and several superficial ulcers appeared, surrounded by purplish borders, secreting sinuses, and a vegetative exophytic surface ( Fig. 3 ). Physical examination was normal. Incisional biopsies from the ulcer margins showed pseudoepitheliomatous hyperplasia, diffuse neutrophilic infiltration with microabscess formation (Fig. .4), and the presence of a dense infiltrate composed of epithelioid cells, giant cells, and a few lymphocytes forming non-necrotizing granulomas within the dermis and subcutaneous lobules ( Fig. 5 ). Leukocytoclastic vasculitis was also present in the lower dermis. Routine blood tests and urine analysis were normal, except for a high erythrocyte sedimentation rate (120/h) and anemia with a hemoglobin level of 10 g%. The results of the following laboratory tests were found to be within normal limits: rheumatoid factor; antinuclear antibody; C3; C4; serum immunoglobulins; serum protein electrophoresis; stool for parasites and occult blood; X-ray of the chest, left shin, hands, and facial bones; isotopic bone scanning; abdominal ultrasonography; chest and

Figure 1 Open in figure viewer PowerPoint Erythematous nodule on the chin