Pyoderma Gangrenosum Triggered by Acute Ischemia of Lower Extremity: A Case Report

Abstract

Pyoderma gangrenosum is a very rare condition of unclear etiology with an estimated incidence of 3 to 10 cases per million people per year. We report a case of pyoderma gangrenosum triggered by acute ischemia of lower extremity without a prior history. Seventy-seven years old female patient was admitted to the emergency department with necrosis on the anterior side of her left limb. Digital subtraction arteriography revealed total occlusion of the left common femoral artery for which thrombectomy under local anesthesia was performed successfully. The necrotic area was debrided and biopsies were obtained. Pathological examination revealed pyoderma gangrenosum and steroid treatment was began. The patient was discharged on the 10th postoperative day with prednisone 48 mg per day for the following 30 days. During the management of ischemic peripheral artery disease patients with persistent skin findings, pyoderma gangrenosum should be in the list of differential diagnoses.

Keywords

• Pyoderma gangrenosum,risk factors,wound healing

Alt Ekstremitenin Akut İskemisi ile Tetiklenen Pyoderma Gangrenosum: Olgu Sunumu

Öz

Piyoderma gangrenozum, tahmini insidansı yılda milyon kişi başına 3 ila 10 vaka olan, etiyolojisi açıklanamamış çok nadir görülen bir durumdur. Alt ekstremitenin akut iskemisi ile tetiklenen, daha önce öyküsü olmayan bir pyoderma gangrenozum vakası bildiriyoruz. Yetmiş yedi yaşında kadın hasta acil servise sol alt ekstremite anteriyor yüzde nekrotik yara ile başvurdu. Digital subtraction arteriography ile total tıkalı olduğu saptanan sol ana femoral artere lokal anestezi altında başarılı bir şekilde thrombektomi uygulandı. Nekrotik alan debride edildi ve biyopsiler alındı. Patolojik incelemede pyoderma gangrenozum saptandı ve steroid tedavisi başlandı. Hasta postoperative 10. günde 30 gün boyunca günlük 48 mg prednisone tedavisi ile taburcu edildi. Sebat eden cilt lezyonlu iskemik perifer arter hastalığı olan hastaların tedavisi sırasında, piyoderma gangrenozum ayırıcı tanılar listesinde bulunmalıdır.

Anahtar Kelimeler

• Piyoderma Gangrenozum,risk faktörleri,yara iyileşmesi

References

1. Ruocco E, Sangiuliano S, Gravina AG, Miranda A, Nicoletti G. Pyoderma gangrenosum: an updated review. J Eur Acad Dermatol Venereol. 2009;23(9):1008-17.
2. DeFilippis EM, Feldman SR, Huang WW. The genetics of pyoderma gangrenosum and implications for treatment: a systematic review. Br J Dermatol. 2015;172(6):1487-97.
3. Inan I, Myers PO, Braun R, Hagen M. E, Morel P. Pyoderma gangrenosum after totally implanted central venous access device insertion. World J Surg Oncol. 2008;6:31.
4. Simsek S, van den Haak RF, Voskuyl AE, Rauwerda JA, Strack van Schijndel RJ. Symmetrical, painful ulceration of the lower limbs in a vascular surgery ward: a diagnostic challenge Pyoderma gangrenosum associated with IgG-kappa paraproteinaemia. Neth J Med. 2004;62(5):168-71.
5. Neill BC, Seger EW, Hooton TA, Bailey G, Rajpara A, Stoecker WV. The 5 P's of pyoderma gangrenosum. J Drugs Dermatol. 2019;18(12):1282-3.
6. Weenig RH, Davis MD, Dahl PR, Su WP. Skin ulcers misdiagnosed as pyoderma gangrenosum. N Engl J Med. 2002;347(18):1412-8.
7. Nguyen KH, Miller JJ, Helm KF. Case reports and a review of the literature on ulcers mimicking pyoderma gangrenosum. Int J Dermatol. 2003;42(2):84-94.
8. Bryan CS. Fatal pyoderma gangrenosum with pathergy after coronary artery bypass grafting. Tex Heart Inst J. 2012;39(6):894-7.

9. Thomas CY Jr, Crouch JA, Guastello J. Hyperbaric oxygen therapy for pyoderma gangrenosum. Arch Dermatol. 1974;110(3):445-6.
10. Davis JC, Landeen JM, Levine RA. Pyoderma gangrenosum: skin grafting after preparation with hyperbaric oxygen. Plast Reconstr Surg. 1987;79(2):200-7.
11. Mazokopakis EE, Kofteridis DP, Pateromihelaki AT, Vytiniotis SD, Karastergiou PG. Improvement of ulcerative pyoderma gangrenosum with hyperbaric oxygen therapy. Dermatol Ther. 2011;24(1):134-6.
12. Bennett ML, Jackson JM, Jorizzo JL, Fleischer AB Jr, White WL, Callen JP. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore). 2000;79(1):37-46.
13. Saracino A, Kelly R, Liew D, Chong A. Pyoderma gangrenosum requiring inpatient management: a report of 26 cases with follow up. Australas J Dermatol. 2011;52(3):218-21.