Letter to the Editor
Postsurgical pyoderma gangrenosum: A diagnosis we cannot miss
Pioderma gangrenoso posquirúrgico: un diagnóstico que no podemos pasar por alto
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Therefore, the diagnosis and treatment can be a challenge. We present the case of a 78-year-old woman who underwent a total hysterectomy in 2014 at another center with subsequent torpid evolution requiring multiple interventions due to surgical wound dehiscence and abscess formation. In addition, she had a past medical history of ulcer formation associated with a venous puncture area. In March 2019, she underwent a new surgery with placement of double preperitoneal mesh and fascia lata flap for repair of the muscle-aponeurotic defect. Fifteen days after surgery, we were notified for assessment for surgical wound dehiscence and clinical signs of wound infection. Physical examination revealed polycyclic plaques with the presence of blistering-purulent-content lesions with purple edges surrounding all the surgical scars. The appearance of cutaneous lesions together with past medical history of postsurgical wounds complications suggested a postsurgical PG. A skin biopsy specimen showed a dermal inflammatory infiltrate with abundant polymorphonuclear cell which supported the diagnosis of PG. The patient presented with cytopenias in three cell lines related to a previously diagnosed myelodysplastic syndrome under conservative treatment. Laboratory test showed an elevated ESR (erythrocyte sedimentation rate). Autoimmunity panel was negative. Immunoglobulin count and complement level were within normal limits. Serum proteinogram, serologic test and microbiological studies (including skin exudate culture and blood and urine cultures) were normal. Despite treatment with intravenous methylprednisolone 80<span class="elsevierStyleHsp" style=""></span>mg daily, supportive therapy with topical treatment and systemic antibiotic therapy, greater dehiscence of the surgical scars was observed. Therefore, cyclosporine was started at 5<span class="elsevierStyleHsp" style=""></span>mg/kg/day. However, a worsening of cutaneous ulcers was observed with clinical signs of wound infection. The patient developed a septic shock and died a month and a half after surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pyoderma gangrenosum is a rare inflammatory neutrophilic dermatosis associated with different comorbidities. There is a wide spectrum of clinical manifestations of PG making its early diagnosis a challenge.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Complete evaluation is essential to identify possible underlying diseases. Most frequently, it is associated with hematological processes and inflammatory bowel disease. A key to the diagnosis of the postsurgical form is the Pathergy phenomenon of the lesions, that has been seen more frequently in patients over 65 years old. This one was very striking in our patient.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Regarding treatment, drugs such as cyclosporine and systemic corticoids have been classically used, especially in acute forms with greater inflammatory activity. Currently, cases treated with biological drugs have been reported, especially with anti-TNFα inhibitors and intravenous immunoglobulins.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Given the therapeutic limitations, high diagnostic suspicion and early treatment are the key for a better prognosis of these patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> It is essential to keep this diagnosis in mind when dehiscence and torpid evolution of postsurgical wounds are observed, especially if there is a previous medical history of similar complications and/or underlying diseases related to PG. Further studies validating new drugs for refractory PG are required, as well as adequate care for these patients in multidisciplinary units.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding sources</span><p id="par0015" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding sources" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and novel clinical treatment strategies for pyoderma gangrenosum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Goldoust" 1 => "E.L. Hagstrom" 2 => "D. Rathod" 3 => "A.G. Ortega-Loayza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/17512433.2020.1709825" "Revista" => array:6 [ "tituloSerie" => "Expert Rev Clin Pharmacol" "fecha" => "2020" "volumen" => "13" "paginaInicial" => "157" "paginaFinal" => "161" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31875484" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The association of age with clinical presentation and comorbidities of pyoderma gangrenosum" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.J. Ashchyan" 1 => "D.C. Butler" 2 => "C.A. Nelson" 3 => "M.H. Noe" 4 => "W.G. Tsiaras" 5 => "S.J. 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Davis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2015.06.054" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2015" "volumen" => "73" "paginaInicial" => "615" "paginaFinal" => "622" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26209218" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000012/v1_202112201710/S2387020621006355/v1_202112201710/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000012/v1_202112201710/S2387020621006355/v1_202112201710/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621006355?idApp=UINPBA00004N" ]
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