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Pyoderma Gangrenosum

Clinical Cases

Case 1

  • 67-year-old male
  • No significant past medical history
  • Review of systems is notable for six-month history of unexplained weight loss, night sweats, fatigue
  • Presents for management of an extremely painful leg ulcer that rapidly developed over the past four days without inciting trauma
  • Currently using antibiotic ointment daily covered by a bandage
  • Reports rapid progression of the ulcer

Initial evaluation

  • Thin, tired-appearing male
  • Left leg ulcer that is approximately 2×2 cm in size with a violaceous, undermined border
  • Diagnosis: pyoderma gangrenosum
  • A skin biopsy to exclude infectious or other inflammatory etiology is declined by the patient
  • Clobetasol ointment 0.05% applied daily under an occlusive hydrocolloid dressing is recommended
  • Concern for an underlying inflammatory condition or malignancy triggers a diagnostic evaluation including age-appropriate cancer screening, chest X-ray, and blood tests including complete blood count with differential, erythrocyte sedimentation rate, and rheumatologic serologies
  • Follow-up in 1 week

Follow-up evaluation

  • The ulcer has not progressed in size but also shows no improvement in healing
  • The patient reports that he has mild reduction in ulcer pain
  • Blood tests indicate a pancytopenia with atypical granulocytes noted on peripheral smear, and widespread mediastinal lymphadenopathy is noted on chest X-ray
  • The patient is referred to hematology/oncology for a bone marrow biopsy
  • Ongoing wound care with clobetasol ointment under occlusion is recommended
  • Minocycline 100 mg twice daily is added
  • Follow-up in 1 week

One-week follow-up evaluation

  • Minimal interval improvement
  • The patient’s bone marrow biopsy reveals acute myeloid leukemia; he is admitted to the hospital and started on induction chemotherapy; in the hospital, his wound care is continued
  • As his leukemia goes into remission, his PG lesion heals with characteristic atrophic, cribiform scarring

Case 2

  • 37-year-old male
  • Past medical history notable for inflammatory bowel disease (IBD) for which he takes 6-mercaptopurine
  • Review of systems is notable for one-month history of weight loss, fatigue, blood diarrhea typical of his IBD flares
  • Presents for management of extremely painful leg ulcers present on bilateral ankles that rapidly developed over the past two weeks without inciting trauma
  • Currently covering the ulcers with bandages only
  • Reports rapid progression of the ulcers over the past two days

Initial evaluation

  • Thin, ill-appearing male
  • Bilateral leg ulcers approximately 4x6cm in size with a violaceous, undermined border and sieve-like ulceration within
  • Diagnosis: pyoderma gangrenosum
  • A skin biopsy to exclude infectious or other inflammatory etiology is performed
  • Tacrolimus ointment 0.1% applied daily under an occlusive hydrocolloid dressing is recommended
  • Concern for an underlying inflammatory condition or malignancy triggers a diagnostic evaluation including age-appropriate cancer screening, chest X-ray, and blood tests including complete blood count with differential, erythrocyte sedimentation rate, and rheumatologic serologies
  • The patient is urgently referred to gastroenterology for colonoscopy to confirm a suspected IBD flare
  • Follow-up in 1 week

Follow-up evaluation

  • The patient was seen by gastroenterology and given the high suspicion for recurrent IBD flare, he was started on prednisone 1 mg/kg daily; the ulcers have improved significantly and the patient reports that he has marked reduction in ulcer pain
  • Blood tests indicate evidence of systemic inflammation and mild anemia; age-appropriate malignancy screening does not reveal an underlying malignancy
  • Ongoing wound care with tacrolimus ointment under occlusion is recommended
  • Follow-up in 1 week

One-week follow-up evaluation

  • Ongoing interval improvement
  • The patient’s diarrhea and skin ulcerations are greatly improved; his prednisone is tapered and he is started on a TNF cytokine blockade for management of both IBD and PG (with subsequent clinical improvement)