Postoperative Pyoderma Gangrenosum Following Video-Assisted Thoracic Surgery

July 2017 | Volume 16 | Issue 7 | Case Report | 711 | Copyright © 2017

Stanislav N. Tolkachjov MD,a Philip Y. Sun MS,b and Alina G. Bridges DOa

aSurgical Dermatology Group. Birmingham, AL bMayo Clinic College of Medicine, Mayo Clinic, Rochester, MN

Abstract

Pyoderma gangrenosum (PG) is a neutrophilic, ulcerative dermatosis that can develop at sites of cutaneous trauma, including surgical incisions, a phenomenon known as pathergy. The characteristic lesion is a painful, rapidly expanding ulceration with a violaceous undermined border.1 A biopsy taken from the expanding violaceous border shows predominantly neutrophilic dermal inflammation with neutrophilic abscess formation.

The etiology of PG appears to be variable among patients, as about a half of the reported cases are associated with systemic disease such as inflammatory bowel disease, rheumatoid arthritis, or myeloproliferative disorders, while the other half seem to be idiopathic.2 PG is difficult to diagnose as other etiologies, including infectious, vasculitic, and other inflammatory dermatoses, must be excluded.1 Histopathologic and biochemical markers of PG, such as dermal neutrophilic infiltrate or overexpression of interleukin-8,3 respectively, are not pathognomonic. Given that several drugs, such as hydralazine, mesalamine, and sunitinib, are reportedly associated with PG, failure to recognize this association and stop these medications may delay diagnosis and therapy. We report a case of idiopathic postoperative PG following video-assisted thoracic surgery (VATS).

J Drugs Dermatol. 2017;16(7):711-713.

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CASE REPORT

A 61-year-old previously healthy Caucasian female was hospitalized with 2 expanding peri-incisional ulcerations on her right upper back at the site of an operative scar (Figure 1). A VATS was performed 4 weeks prior for an incidental pulmonary nodule, eventually diagnosed as a necrotizing granuloma. Although infectious work-up was negative, the surgical team proceeded with débridement for wound dehiscence and possible infection (Figures 2A and 2B). Vancomycin and piperacillin/tazobactam were initiated while awaiting dermatology and infectious diseases consultations. On physical examination, 2 prominent ulcerations, each with a fibrinoid base, violaceous border, and surrounding erythema were observed. The patient complained of substantial pain out of proportion to the clinical presentation. A skin biopsy of the necrotic undermined border revealed diffuse dermal neutrophilic inflammation with abscess formation (Figures 3A and 3B). On additional questioning, the patient revealed poor wound healing several years earlier after removal of an epidermoid cyst from her back. A thorough investigation, including laboratory and imaging studies, failed to identify an underlying systemic disease in this patient.

DISCUSSION

The characteristic appearance of the lesions, with their rapidly advancing violaceous borders, negative cultures, and typical histopathology, in consideration with the patient’s history of prolonged wound healing, are consistent with a diagnosis of PG.1 Although half of the reported cases of PG are associated with systemic disease,2 our patient’s presentation was idiopathic. Atypical infection and vasculitis may be labeled as PG. Conversely, PG may be misdiagnosed as infection, resulting in inappropriate treatment.4 Nevertheless, postoperative infection must be ruled out in a timely manner in order to avoid additional morbidity.After a diagnosis of PG is made in the postoperative setting, therapy will vary depending on the presence or absence of comorbidity and the extent of involvement. Corticosteroids are used in most cases of idiopathic PG, while steroid-sparing agents, including cyclosporine, mycophenolate mofetil, azathioprine, and other anti-inflammatory drugs, may be utilized as monotherapy or adjuvants to systemic corticosteroids.5,6,7 A commonly utilized alternative for systemic corticosteroids is cyclosporine, an inhibitor of T-lymphocyte activation.5,8,9 Although antibiotics are typically not used as monotherapy, certain antimicrobials such as dapsone and tetracyclines may be used adjunctively for their anti-inflammatory effects. Local wound care is often used in conjunction to systemic therapy.10To our knowledge, the only randomized control study for treatment of PG has been done in the setting of inflammatory bowel disease and showed that 5 mg/kg infliximab is efficacious in treating PG associated with Crohn disease.11 Also, the STOP-GAP (Study of Treatments fOr Pyoderma GAngrenosum Patients) project, an ongoing randomized trial in the United

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