Oral ulceration in pyoderma gangrenosum

Abstract

A 65-year-old woman presented with a six week history of widespread necrotising cutaneous ulceration. She had a prodrome of superficial ulceration on the lower abdomen that had healed spontaneously. Four weeks later she developed pustules that rapidly progressed to intensely painful deep ulceration involving the tongue, both breasts, oral mucosa, abdomen, perianal skin and feet. Past medical history included rheumatoid arthritis which was quiescent, a left nephrectomy in 1974 for nephrolithiasis and osteoarthritis of the right knee. She smoked 20 cigarettes a day. Her medications were occasional mefenamic acid and paracetamol.Clinical examination revealed multiple violaceous undermined areas of ulceration measuring 8-12 cm in diameter on the above sites ( Fig. 1). There was recent scarring on the lower abdomen. The buccal mucosa and tongue were ulcerated with a deep 3 cm ulcer on the lateral DOI: 10.3315/jdcr.2011DOI: 10.3315/jdcr. .1070 34 PHOTOLETTER TO THE EDITOR AbstractA 65-year-old woman presented with widespread necrotising cutaneous ulceration and oral involvement. Past history included rheumatoid arthritis, and a left nephrectomy.Examination revealed multiple violaceous undermined ulcers. Blood investigations showed an acute inflammatory response. Skin histopathology showed epidermal ulceration with acute and chronic inflammation. Direct immunofluorescence was negative. A diagnosis of pyoderma gangrenosum with oral involvement was made. Mycophenolate mofetil therapy resulted in complete resolution of her pyoderma gangrenosum. Her treatment was complicated by a left proteus mirabilis psoas abscess. This resolved following four weeks of antibiotics.Pyoderma gangrenosum with oral involvement is rare but has been linked with inflammatory bowel disease and hematological disorders. Oral pyoderma gangrenosum has not previously been described in rheumatoid arthritis. Primary psoas abscess is rare but can develop in immunocompromised patients. Proteus mirabilis has been reported in patients years after nephrectomy. This is a rare case of pyoderma gangrenosum with oral involvement. (J Dermatol Case Rep. 2011; 5(2): 34-35.) Key words: mycophenolate mofetil, oral mucosa, oral ulceration, psoas abscess, pyoderma gangrenosum border of the tongue (Fig. 2). Fresh pustules were present on the abdomen and arms. Systemic vasculitis or atypical pyoderma gangrensoum was suspected.

Pyoderma gangrenosum‐like oral ulcerations in an elderly patient

“…Oral lesions in the previously reported cases have appeared in various sizes on the buccal mucosa, palate, tongue and gingiva. Cases of PG with oral involvement have been described for patients with rheumatoid arthritis, ulcerative colitis, inflammatory bowel disease, IgA paraproteinaemia and also in the absence of any underlying systemic disease. We presented a case of PG‐like oral ulcerations that is possibly associated with chronic myeloid leukaemia.…”

Oral Pyoderma Gangrenosum: Diagnosis, Treatment and Challenges: A Systematic Review

“…Lesions on the lips can exhibit crusting [16,29]. Supplementary images of oral PG ulcers showing the variety of morphologic features can be visualized in the case reports [5,10,[20][21][22][23]29]. Oral and skin lesions in PG are non-indurated.…”

“…Other lesions involved the hard palate, oropharynx, lip, commissure, gingiva, and retromolar area [5,14,16,17,19,20]. Generally, mucosal lesions in the oral cavity were smaller than skin lesions, measuring between 1 and 5 cm in greatest diameter [5,14,18,[21][22][23][24][25][26][27]. As with skin lesions, the onset is rapid and ulcers develop over the course of 4-8 Fig.…”

“…Elevated erythrocyte sedimentation rate (ESR) [5,17,27,29] and C-reactive protein [20][21][22]30] have been observed in cases of oral PG. Blood work can be useful to exclude infectious causes and sexually transmitted diseases (ex.…”

“…Similarly, in oral PG, Yco et al reported that a PG ulcer spread to the adjacent alveolar ridge after a biopsy was undertaken [10]. Recurrence of PG is always possible as 10% (2/20) of cases with oral involvement have shown relapses over a period of time without appropriate maintenance therapy [22,30]. Low dosage corticosteroids with or without Dapsone can be used as such [14,29,34,61].…”