Mucocutaneous pyoderma gangrenosum: a case report and literature review

Abstract

Case presentationA 57-year-old male patient presented to our clinic in September 2021 with five large painful ulcerated lesions on his lower back (Fig. 1), shoulder (Fig. 2), head, right hip, and nasal septum. The first lesions appeared a year earlier, as pustules, and in later months they grew and eroded, forming ulcers with a purulent discharge. He was prescribed various topical antibiotic and antimycotic creams by a general practitioner, which did not result in improvement. He was first referred to a dermatologist in November 2020. A bacterial swab of the ulcer was negative. A skin biopsy suggested the possibility of pyoderma gangrenosum (PG) due to extensive ulceration with undermined edges and suppurative inflammation with multinucleated giant cells in the ulcer base (Fig. 3). Bacterial and fungal stains were negative, but additional microbiological tests were performed to confirm or exclude the possibility of PG. He was prescribed topical antibiotics (mupirocin and clindamycin) and an antiseptic lotion. After the biopsy, the wound initially healed completely, but after a few months two new growing papules formed under the scar, forming an ulcer larger than the previous one.Nasal symptoms appeared simultaneously with skin lesions. First a clear nasal discharge was present, which then became green and partially bloody. Bumps formed on the nasal septum and turned into an erosion. He was referred to an otorhinolaryngologist in December 2020, who described an extensive perforation of the anterior nasal septum measuring 2.5 cm and some crusts in both nostrils. A biopsy of the lesion showed nonspecific granulations adjacent to the ulceration. A swab of the nasal erosion was positive for Staphylococcus aureus, sensitive to all antibiotics tested. He was prescribed a 2-week course of systemic ciprofloxacin.In January 2021 he was referred to a rheumatologist. Clinical history for rheumatologic diseases was negative, except for brief morning stiffness, but he mentioned that he had unintentionally lost 4 kg in the previous 3 weeks. Routine laboratory tests showed only mildly raised C-reactive protein (CRP, 24 mg/l), erythrocyte