ARTICLE IN PRESS
Pyoderma gangrenosum after inguinal hernia repair Hideki Katagiri, MD,a Akiko Hanyuda, MD,a Alan T. Lefor, MD, MPH,b and Hironori Yahara, MD,c Chiba, Japan
From the Department of Surgery,a Tokyo Bay Urayasu Ichikawa Medical Center, Noguchi Hideyo Memorial International Hospital, Chiba; the Department of Surgery,b Jichi Medical University, Tochigi; and the Department of Dermatology,c Tokyo Bay Urayasu Ichikawa Medical Center, Noguchi Hideyo Memorial International Hospital, Chiba, Japan
A 75 YEAR-OLD MAN with no significant past medical history underwent inguinal hernia repair with a Kugel patch. Two days after surgery, he was discharged without any complications. Seven days after surgery, he returned to the outpatient clinic for a wound check and complained of redness and pain around the incision. Swelling with redness and bullous lesions at the incision site were observed (Fig 1). We suspected a superficial surgical site infection and opened the wound. However, there was no pus present, so we prescribed antibiotics (amoxicillin/clavulanate). Despite this treatment, the skin lesion rapidly extended over the next 2 days and his temperature increased to 38.68C. On admission to the hospital, he showed no systemic signs of sepsis. Gram stain of the skin lesion revealed no organisms. Examination of the skin lesion showed a pustule surrounded by a halo of inflammation. After consultation with a dermatologist, the diagnosis of pyoderma gangrenosum was suspected. Oral steroids (prednisolone) were administered at 40 mg/ d. The day after starting steroid administration, the skin lesion stopped expanding and the discharge decreased dramatically. The skin lesion gradually improved with steroid therapy (Fig 2). DISCUSSION Pyoderma gangrenosum, first recognized in 1930 by Brunsting et al,1 is a rare neutrophilic dermatosis that may present in ulcerative, pustular, bullous, or vegetative forms. The etiology of this disease remains obscure; however, 50–75% of cases are associated with systemic diseases such as Accepted for publication November 15, 2013. Reprint requests: Hideki Katagiri, MD, 3-4-32, Todaijima, Urayasu city, Chiba, 279-0001 Japan. E-mail: [email protected]
Surgery 2014;j:j-j. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.11.011
Fig 1. Surgical wound on readmission. The surgical incision was surrounded by a purulent discharge and a halo of inflammation.
inflammatory bowel disease, paraproteinemia, arthritis, and myeloproliferative diseases.2-4 In 25% of cases, there is precipitating minor trauma, an insect bite, or an operative procedure.2 The diagnosis of pyoderma gangrenosum is based primarily on clinical presentation and course. Histopathologic findings are nonspecific, and there is no specific test that is helpful for diagnosis.2-4 A rapidly spreading, ulcerative skin lesion refractory to appropriate antibiotic therapy suggests pyoderma gangrenosum. The clinical presentation often begins with an ulcerative, pustular lesion surrounded by a halo of inflammation and extends rapidly.2 In this patient, the skin lesion spread at nearly 2 cm/d. The basic treatment of pyoderma gangrenosum is with high-dose corticosteroids.2-4 Because corticosteroids are contraindicated in patients with surgical site infections or necrotizing fasciitis (which often mimics pyoderma gangrenosum), it is important to exclude infectious diseases before beginning steroid treatment. Operative debridement is also thought to be contraindicated in patients with SURGERY 1
ARTICLE IN PRESS 2 Katagiri et al
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Fig 2. Surgical wound at (A) 3 days, (B) 10 days, (C) 2 months, and (D) 4 months after steroid therapy.
pyoderma gangrenosum because the stimulation can lead to progression of pyoderma gangrenosum. Corticosteroid administration often produces dramatic progress; however, in patients who are refractory to steroid therapy, further immunosuppressive therapy such as cyclosporine may be needed.2-4 As in the present case, the clinical presentation of postoperative pyoderma gangrenosum is frequently misdiagnosed as a wound infection, thereby delaying the diagnosis of postoperative pyoderma gangrenosum.2,4 Operative debridement, if performed, may worsen the clinical course. When the diagnosis of pyoderma gangre-
nosum is suspected, immediate treatment with corticosteroids is indicated. REFERENCES 1. Brunsting AL, Goeckerman WH, O’Leary PA. Pyoderma gangrenosum: clinical and experimental observation in five cases occurring in adults. Arch Derm Syphilol 1930;22:655-80. 2. Kotzampassakis N, Ksontini R. Pyoderma gangrenosum after inguinal hernia repair. Hernia 2012;15:345-7. 3. Brooklyn T, Dunnil D, Probert C. Diagnosis and treatment of pyoderma gangrenosum. BMJ 2006;333:181-4. 4. Ruocco E, Sangiuliano S, Gravina AG, Miranda A, Nicoletti G. Pyoderma gangrenosum: an updated review. J Eur Acad Dermatol Venereol 2009;23:1008-17.