Pyoderma gangrenosum - rare postoperative wound complication: report of two clinical cases and mini-review of literature
Aim. Analysis of peculiarities of clinical course of two cases of postsurgical pyoderma gangrenosum in the context of diagnosis and treatment approaches based on literature review.
Materials and Methods. Patients' medical cards, laboratory and bacteriological data, results of histological examinations. Analysis of the course of the disease is based on clinical peculiarities.
Results and Discussions. The results of the study of two clinical cases of postsurgical pyoderma gangrenosum were considered. In the first case, a peptic form of the disease with formation of painful ulcers on the edge of the scar developed in five weeks after the back carbuncle excision. In the second case, a bullous form of pyoderma gangrenosum developed on the tenth day after operative treatment of perforated duodenum ulcer. The disease manifested by progressing skin necrosis around the surgical incision and contra-apertures with considerable toxic syndrome. Initial therapy before the correct diagnosis was confirmed was inappropriate in both cases (surgical debridement, antibacterial therapy) and ineffective for pyoderma gangrenosum. The diagnosis was based on clinical manifestations - deep ulcer with necrosis of edges, encircled by violaceous aureoles and hyperemia of adjacent zone in the first case, and progressive widespread skin erosions in the second case. In histological biopsy study of the skin, typical features of the disease were found: epidermis desquamation areas; neutrophil infiltrate with accumulation of lymphocytes and formation of microabscesses; subepithelial hemorrhage; tangles of blood vessels with signs of vasculitis with fibrinoid necrosis in the vessel walls. Prescription of pathogenetic treatment (Prednisolon 90 mg/day) allowed achieving fast clinical effect. In the literature review, the causal factors, main clinical variants of pyoderma gangrenosum, and diagnosis and treatment principles are provided. Special attention is paid to the clinical course and treatment of this disease as a postoperative complication.
Conclusions. Pyoderma gangrenosum is a rare severe postoperative wound complication with fast developing skin necrosis at the site of surgical incision. Progressive painful necrotic skin wounds (erosions/ulcers) with violaceous edges encircled by hyperemia zones are signs of the disease. Clinical manifestation, lack of antibiotic treatment effect and histological examinations are informative methods of pyoderma gangrenosum diagnosis in postsurgical patients.
Bisarya K, Azzopardi S, Lye G, Drew P. Necrotizing Fasciitis Versus Pyoderma Gangrenosum : Securing the Correct Diagnosis! A Case Report and Literature Review. Journal of Plastic Surgery 2011, 218-227.
Cozzani E, Gasparani G, Parodi A. Pyoderma gangrenosum: a systematic review. J Ital Dermatol Venereol 2014, 149, 587-600.
Gameiro A, Pereira N, Cardoso J. Pyoderma gangrenosum: challenges and solutions, 2015; 8: 285-293.
Iosifescu AG, Boiangiu CI, Comanesc CM, Iliescu VA. Pyoderma gangrenosum - a postoperative "pseudo-infection". Chirurgia 2012, 1,119-121.
Nizamoglu M.: Pyoderma Gangrenosum Mimicking an Infected Wound following Dynamic Hip Screw Fixation . Hindawi Publishing Corporation Case Reports in Orthopedics. Vol 2015, 1-3.
Ormerod AD, Thomas KS, Craig FE, Mitchell E, [et al.] Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the stop gap randomised controlled trial. BMJ 2015, 350, 1-8. https://doi.org/10.1136/bmj.h2958
Rosmaninho A, Carvalho S, Teixeira V. Pyoderma gangrenosum: a mini-review. EMJ Dermatol 2015, 3(1), 79-86.
Schintler M, Grohmann M, Donia C, Aberer E, Scharnagl E. Management of an unfortunate triad after breast reconstruction: Pyoderma gangrenosum, full-thickness chest wall defect and Acinetobacter Baumannii Infection. Journal of Plastic, Reconstructive & Aesthetic Surgery 2010, 63, 564-567. https://doi.org/10.1016/j.bjps.2009.12.013
Souza E, Silva G, Santos G, Motta H, Cardoso P, Azevedo M, Pires K, Motta R, Silva W, Ferry F, Pinto J. Pyoderma Gangrenosum Simulating Necrotizing Fasciitis. Hindawi Publishing Corporation Case Reports in Medicine Vol 2015, 1-6.
Su D, Davis M, Weenig R, Powell F, Perry P: Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. International Journal of Dermatology 2004, 43,790-800. https://doi.org/10.1111/j.1365-4632.2004.02128.x
Wangia M, Mitchell Ch, Wesson S, Glavin F. Pyoderma gangrenosum or necrotizing fasciitis? A diagnostic conundrum. Case report and literature review J Ped Surg Case Reports 2013, 1, 139-142.
Wollina U. Pyoderma gangrenosum - a review. Orphanet Journal of Rare Diseases 2007, 2:19,1-8. https://doi.org/10.1186/1750-1172-2-19
Ye M, Ye J. Pyoderma Gangrenosum: A Review of Clinical Features and Outcomes of 23 Cases Requiring Inpatient . Hindawi Publishing Corporation Dermatology Research and Practice Vol 2014, 1-7.
Zapolsky M.E., Lebedyuk M.N., Prokofieva N.B., Komarov S.I., Borisova K.A., Dobrovolskaya A.V. Diffential-diagnostic and clinical features of gangrenous pyoderma. Ukrainian Journal of Dermatology, Venereology, Cosmetology, 4 (63), 2016, 82-87.
Zuo KJ, Fung E, Tredget EE, Lin AN. A systematic review of post-surgical pyoderma gangrenosum: Identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg 2015, 68(3), 295-303. https://doi.org/10.1016/j.bjps.2014.12.036
This work is licensed under a Creative Commons Attribution 4.0 International License.