Post-Cesarean Section Pyoderma Gangrenosum Presenting with Vasopressor-dependent Shock: Long-term Follow-up after Delayed Primary Closure

Abstract

Summary: A 28-year-old woman with poor wound healing and surgical site pain presented 5 days post-cesarean section (post-CS) with vasopressor-dependent shock and was eventually diagnosed with postoperative pyoderma gangrenosum (PG). A worsening clinical picture consistent with presumed necrotizing infection necessitated surgical debridement. The patient was ultimately taken to the operating room 4 times with transient improvement after the operations when she received perioperative corticosteroids. We were unable to identify an infectious source and cultures revealed no microorganisms. Dermatopathology revealed neutrophilic infiltrate and focal necrosis without microorganisms. The biopsy site began to concurrently exhibit pathergic changes, leading to a diagnosis of PG. Twelve weeks later, she underwent DPC of her abdominal wound while maintained on an immunosuppressive regimen of cyclosporine and prednisone. Incisional negative pressure wound therapy with a small window was used in the immediate postoperative period to allow for direct visualization of the closed incision. She healed without issue and her immunosuppressive regimen was ultimately discontinued. Postoperative PG is an uncommon diagnosis with high risk of morbidity. It is often mistaken for necrotizing infection. We report a unique case of post-CS PG presenting as vasopressor-dependent shock that was successfully closed with incisional negative pressure wound therapy with a small window.

Wound Debridement in Pyoderma Gangrenosum

“…In nearly all of the cases (33/34) described in these reports, the lesions worsened after debridement (Table ). 4,7,[17][18][19][20][21][22][23][24][25][26][27][39][40][41][42][43][44][45][46][47][48][49]51 In addition, 13 reports describe patients with PG on immunosuppressant medication who had lesions debrided and sometimes grafted. None of these patients had any reported worsening of their PG wounds (Table ).…”

“…In nearly all of the cases (33/34) described in these reports, the lesions worsened after debridement (Table). 4,7,17–27,39–49,51 …”

“…None of the reported procedures resulted in pathergy, with no reports of aggravation of inflammation or worsening of the wound (Table ). 4,7,[17][18][19][20][21][22][23][24][25][26][27][39][40][41][42][43][44][45][46] Thus, surgical procedures may not be contraindicated for PG in remission.…”

“…Zolper et al 39 1 Radical surgical debridement for presumed necrotizing infection was performed after cesarean section before a diagnosis of aggressive PG was made.…”

Pyoderma Gangrenosum, a Challenging Postpartum Diagnosis—Case Report and Literature Review

“…Premature birth occurred in 13 cases due to various emergencies, such as chorioamnionitis, abruptio placenta, and vaginal bleeding [10,20,21,33,35,37,40,[42][43][44]47,48,51]. However, the method of delivery was unspecified in 16 cases [4][5][6]18,24,[27][28][29]31,36,38,39,45,46,49,52], with the remaining cases delivering at term. Notably, 15 cases of postpartum C-section site PG were recurrent [15,24,25,27,30,[32][33][34][40][41][42][43]46,48,52], only 1 case exhibited the first episode of the disease linked to surgical intervention with subsequent relapses [23], and in the rest of the included cases, this was the first manifestation of the disease.…”