Pyoderma gangrenosum - rare postoperative wound complication: report of two clinical cases and mini-review of literature

Abstract

Aim. Analysis of peculiarities of clinical course of two cases of postsurgical pyoderma gangrenosum in the context of diagnosis and treatment approaches based on literature review. Materials and Methods. Patients' medical cards, laboratory and bacteriological data, results of histological examinations. Analysis of the course of the disease is based on clinical peculiarities. Results and Discussions. The results of the study of two clinical cases of postsurgical pyoderma gangrenosum were considered. In the first case, a peptic form of the disease with formation of painful ulcers on the edge of the scar developed in five weeks after the back carbuncle excision. In the second case, a bullous form of pyoderma gangrenosum developed on the tenth day after operative treatment of perforated duodenum ulcer. The disease manifested by progressing skin necrosis around the surgical incision and contra-apertures with considerable toxic syndrome. Initial therapy before the correct diagnosis was confirmed was inappropriate in both cases (surgical debridement, antibacterial therapy) and ineffective for pyoderma gangrenosum. The diagnosis was based on clinical manifestations - deep ulcer with necrosis of edges, encircled by violaceous aureoles and hyperemia of adjacent zone in the first case, and progressive widespread skin erosions in the second case. In histological biopsy study of the skin, typical features of the disease were found: epidermis desquamation areas; neutrophil infiltrate with accumulation of lymphocytes and formation of microabscesses; subepithelial hemorrhage; tangles of blood vessels with signs of vasculitis with fibrinoid necrosis in the vessel walls. Prescription of pathogenetic treatment (Prednisolon 90 mg/day) allowed achieving fast clinical effect. In the literature review, the causal factors, main clinical variants of pyoderma gangrenosum, and diagnosis and treatment principles are provided. Special attention is paid to the clinical course and treatment of this disease as a postoperative complication. Conclusions. Pyoderma gangrenosum is a rare severe postoperative wound complication with fast developing skin necrosis at the site of surgical incision. Progressive painful necrotic skin wounds (erosions/ulcers) with violaceous edges encircled by hyperemia zones are signs of the disease. Clinical manifestation, lack of antibiotic treatment effect and histological examinations are informative methods of pyoderma gangrenosum diagnosis in postsurgical patients.

Keywords

• pyoderma gangrenosum, postsurgical complication, diagnosis, histopathologic findings, treatment