Pyoderma gangrenosum is a rare clinical condition encountered in surgical clinics. This disease, typically diagnosed in dermatology clinics, is treated with medical therapies targeting the underlying systemic disease. Lesions can occur singly or in multiples, with or without association with systemic diseases such as ulcerative colitis, Crohn's disease, polyarthritis, and monoclonal gammopathy (1,2).
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Differential diagnosis is crucial for this disease. Differential diagnoses should consider bacterial skin infections, necrotizing fasciitis, skin mycoses, vasculitis, parasitic infections, and antiphospholipid syndrome (2,3). Here, we present a patient with atypically located pyoderma gangrenosum associated with ulcerative colitis, initially misdiagnosed as necrotizing fasciitis and subjected to repeated debridements at another facility.
With this case, we aim to explore the diagnosis and treatment of pyoderma gangrenosum in surgical clinics.
Case Presentation
A 34-year-old male patient presented to our clinic with fever and a 20x10 cm purulent necrotic wound on his neck, exposing vascular and neural structures. His symptoms reportedly began 6 days earlier with a 2x4 cm painful, red, and swollen area on his left clavicle. He was diagnosed with an abscess and underwent surgical drainage at an external center.
Progression of the abscess and necrosis led to repeated debridements.
The patient was started on imipenem and metronidazole along with debridements. Due to irregular use of salazopyrin for ulcerative colitis, the patient reported 4–5 episodes of bloody mucus-containing stools per day over the past 15 days. On physical examination, his temperature was 38°C, blood pressure 110/80 mmHg, pulse rate 90/min, and respiratory rate 20/min. Examination revealed a necrotic wound with purulent discharge, extending from the upper line of the left nipple to the lateral anterior axillary line, medially to the sternum, and superiorly to the submandibular region, crossing to the right side of the trachea.
Laboratory tests showed hemoglobin 9.0 g/dL, white blood cell count 40,000/mm³, platelets 200,000/mm³, CRP 140 mg/dL, and erythrocyte sedimentation rate 120 mm/hour. Cultures from the wound and blood revealed no growth, and Gram staining showed no microorganisms. The patient was diagnosed with pyoderma gangrenosum secondary to acute ulcerative colitis flare by gastroenterology and infectious diseases specialists.
Pathological examination of neck biopsies revealed inflammatory granulation tissue and chronic inflammatory changes. The treatment included imipenem (4x500 mg), metronidazole (2x500 mg), fluconazole (1x200 mg), and salazopyrin. Additionally, 60 mg/day of methylprednisolone was added when fever persisted. Daily wet dressings were applied to the lesions, and no further debridement or surgical intervention was performed.
By the fourth day of treatment, the patient’s fever subsided, and his clinical condition improved. Follow-up included daily wound care and steroid therapy.
On the 15th day of treatment, inflammatory features of the wounds had significantly diminished. After clinical improvement, the patient was transferred to the plastic surgery department.
Discussion
Abscesses are common in surgical wards and are typically treated with simple drainage and debridement without considering differential diagnoses. In cases with underlying systemic diseases and atypical abscess presentations, like this one, viewing treatment as simple abscess drainage can lead to worse outcomes (4).
Considering rare, rapidly progressing necrotic ulcerative conditions like pyoderma gangrenosum in differential diagnosis can often change the course of the disease. Pyoderma gangrenosum has four clinical types: ulcerative, pustular, bullous, and vegetative (5). Lesions usually appear on the trunk and extremities, with atypical locations such as the head and neck being rarer.
In a study, minor trauma and surgical procedures were attributed to lesion formation in 25–50% of cases (6). In our case, the initial lesion in the neck presented as an abscess, complicating the diagnosis. The fact that pyoderma gangrenosum is managed in gastroenterology and dermatology clinics, not surgical units, is another factor that hinders its consideration in differential diagnosis. In undiagnosed cases, aggressive debridement worsens the clinical course and leads to progressive lesion enlargement (7).
Diagnosis of pyoderma gangrenosum begins with clinical suspicion. The presence of ulcerated necrotic skin wounds accompanying systemic diseases is a major diagnostic clue. Histopathological evaluation aids the diagnosis but lacks pathognomonic features (8). Microscopic findings include aseptic skin necrosis, hemorrhage, and neutrophilic infiltration.
Recent studies have defined major and minor criteria. Patients meeting 2 major and 2 minor criteria are diagnosed with pyoderma gangrenosum. Confirmed cases are treated with standard wound care instead of conventional debridement. Resistant cases require high-dose steroids (methylprednisolone 0.5–1 mg/kg/day) or cyclosporine (5 mg/kg/day), along with medication targeting systemic diseases (2,9-11).
Intralesional steroid application is another alternative therapy (2,12,13). TNF-alpha inhibitors (infliximab 5 mg/kg) have recently been recommended as an adjunct in resistant cases (14).
In conclusion, wound care is a critical issue in general surgery. Systemic diseases should be investigated in patients with atypically located and unexplained inflammatory lesions, and pyoderma gangrenosum should be included in the differential diagnosis.
Recognizing pyoderma gangrenosum in cases of complicated and atypically located lesions associated with systemic diseases is essential for reducing potential morbidity and mortality.
