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Pyoderma gangrenosum (PG) is an uncommon, progressive ulcerative condition of skin. It presents with deep ulceration characterised by an overhanging violaceous border, which can occur on any body surface. It is frequently confused with other more common ulcerating skin conditions such as necrotising fasciitis, vasculitis, pustular drug reactions and skin infections. Since surgery may be used to treat some of these conditions, but is relatively contraindicated in PG, early diagnosis is critical and is usually made in conjunction with a dermatologist.
This 76-year-old male had a laparoscopic assisted right hemi-colectomy for an apparent ascending colonic tumour, however histology actually revealed a well differentiated neuroendocrine tumour of the terminal ileum. Serum pancreatic polypeptide, N and C-terminal glucagon, chromogranin A and urinary 5-HIAA collection were all elevated.
On day 7 this man's left iliac fossa port site was noted to be indurated and erythematous. Cefuroxime was empirically commenced for a presumed wound infection. He became pyrexic with a leukocytosis of 30,000 mm3 and skin at the port site quickly became sloughly and ischaemic (Figure 1). Following debridement he required transfer to intensive care as a case of suspected necrotising fasciitis.
The patient's necrotising skin condition progressed relentlessly. He required 4 further debridement's with intermittent returns to the intensive care unit for supportive therapy (Figure 2). Microbiology of the skin specimens was insignificant and pathology described neutrophillic abscesses with no evidence of vasculitis, granulomatous inflammation or metastatic tumour. Following a dermatological opinion a diagnosis of PG was made.
Intravenous antibiotics were stopped and high dose prednisolone was commenced in addition to the already prescribed somatostatin (Octreotide®). The patient was maintained on azathioprine (Imuran®) once the prednisolone had been tapered. His large abdominal defect was dressed with Activon tulle® honey dressings. He progressed well and was discharged. Follow up revealed satisfactory recovery of the wound.
The literature yields only one other case connecting PG with carcinoid tumour1, while most reports correlate the occurrence of PG to trauma, typically surgery2. The delay in the recognition of this serious dermatological condition was associated with increased morbidity for our patient. PG is a serious and potentially fatal skin condition when correct treatment is not quickly commenced. Management is relatively simple once recognised with the use of corticosteroids and immunosuppressant. Surgery is not thought to be beneficial and in many circumstances can worsen the condition3.
We recommend that in any significant skin condition, particularly post-operatively or in one not responding to treatment effectively, one must seek the early advice of a dermatologist and not be guided primarily by histology.
The authors have no conflict of interest.