Pyoderma gangrenosum induced by episiotomy

Abstract

We present a patient who developed genital ulceration within hours following episiotomy procedure during a normal vaginal delivery. This was initially treated by the gynaecology and medical team as cellulitis with no improvement. A diagnosis of pyoderma gangrenosum (PG) was made by the dermatology team 12 days later. On further investigation, she was found to be hepatitis C positive. We report this case to highlight the phenomenon of pathergy and frequent misdiagnosis of PG by other medical teams. When a postsurgical wound is not healing despite relevant systemic treatment, the clinician should suspect PG as an early diagnosis and treatment is crucial.

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.…”

“…Karim et al presented a case with a familial history of pyoderma gangrenosum, with the patient's sister also suffering from the disease [26]. Associated pathologies identified included ulcerative colitis [23], chronic type C hepatitis [24,38], Takayasu arteritis and type B hepatitis [27], weakly positive antiphospholipid antigen [14], antiphospholipid syndrome with weakly positive lupus anticoagulant and three spontaneous abortions [37], type B hepatitis [49], thrombocytopenia early in pregnancy [51], and a fatal association between PG and postpartum cardiomyopathy [41].…”

“…Eight cases received a combination of corticotherapy and cyclosporine, with one case also involving skin grafting [14,[23][24][25][26]47,48,53]. Other treatment approaches included systemic corticotherapy and local tacrolimus [10]; systemic corticotherapy and dapsone [33,39]; a combination of corticotherapy, cyclosporine, and dapsone in two cases [29,34]; and a combination of corticotherapy, cyclosporine, and dapsone in Alani et al's case with mycophenolate mofetil [38]. Several cases required complex therapies, such as corticotherapy and azathioprine followed by vacuum-assisted closure and splitthickness skin graft [15]; negative pressure wound therapy and high-dose corticosteroid therapy [43,46]; corticotherapy and human immunoglobulin therapy; wound debride-ment, vacuum sealing negative pressure drainage, skin grafting, and hyperbaric oxygen therapy [4]; intravenous immunoglobulin alone [45]; and corticotherapy combined with intravenous immunoglobulin [49] or cyclosporine with skin grafting [53].…”

Perineal pyoderma gangrenosum in pregnancy: A case report

“…Several case reports of PG during pregnancy have been published, but many of these patients developed the disease in the lower legs or chest [ 1 ], [ 2 ], [ 9 ] [ 10 ]. Additionally, there have been multiple reports of PG occurring at the site of a cesarean incision [ 3 ], [ 4 ], [ 8 ], [ 10 ] and at the site of episiotomy during the puerperal period [ 11 ]. With regard to PG of the perineal region, a previous case report described PG at episiotomy sites [ 11 ].…”

“…Additionally, there have been multiple reports of PG occurring at the site of a cesarean incision [ 3 ], [ 4 ], [ 8 ], [ 10 ] and at the site of episiotomy during the puerperal period [ 11 ]. With regard to PG of the perineal region, a previous case report described PG at episiotomy sites [ 11 ]. However, there have been few case reports of PG in the perineal region during pregnancy, as in the current case.…”