Postoperative Pyoderma Gangrenosum Following Video-Assisted Thoracic Surgery

July 2017 | Volume 16 | Issue 7 | Case Reports | 711 | Copyright © July 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.

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