Rare Presentation of Postsurgical Pyoderma Gangrenosum Presenting as Necrotizing Soft Tissue Infection

Abstract

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis believed to be mediated by an autoimmune reaction. Typical treatment includes autolytic debridement, management of exudate, protection from trauma, and steroid therapy. A diagnosis of exclusion, PG is frequently mistaken for a wound infection, but antibiotics do not alleviate the condition. Incision and debridement has been observed to cause further spread of the lesions because of pathergy resulting from the additional trauma. This case report describes a patient who was misdiagnosed with necrotic soft tissue infection that was actually postsurgical PG.

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.…”

“…Flynn et al 24 1 A case of acute PG after abdominal surgery; the patient underwent multiple aggressive debridements for potential infection.…”

Practical aspects of the diagnosis and management of pyoderma gangrenosum

“…Owing to the lack of specific biomarkers for PG, it is not realistic to predict the occurrence of PG. Therefore, other phenomena that lead to PG in the surgical area after other operations are often reported ( 68 , 69 ), and the disease is easily misdiagnosed as necrotizing fasciitis or other serious infections in the early stages ( 70 ), thereby misguiding the surgeon to conduct more active debridement and leading to serious consequences ( 71 ). Haag et al conducted a literature review of perioperative management practices and risk factors that may predict the response to surgical intervention ( 67 ).…”