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Cutaneous Wegener's granulomatosis (malignant pyoderma) in a patient with Crohn's disease.

We report a case of an unusual presentation of Wegener's granulomatosis (WG) in a patient with Crohn's disease (CD). She presented to our Wound Care Center with 7th cranial nerve palsy and facial pyoderma-like ulcerations. Although WG has a predilection for the lung, kidney, and eyes, cutaneous involvement can be seen in 50% of the cases, and it can be the presenting sign in 9-14%. Because of the lethality of WG if not properly treated, the diagnosis is imperative.

Aged↗

Wegener's granulomatosis presenting as pyoderma gangrenosum.

A 59-year-old male patient developed a necrotizing ulceration on the right shin. Both clinical and histopathologic examinations suggested pyoderma gangrenosum. After temporary improvement of skin symptoms under peroral glucocorticoid treatment, a hemorrhagic-purulent discharge started from the nose, he began to have fever, malaise, cough, and a chest X-ray revealed inflammation in the lung. Cerebral CT and MRI disclosed midline bone loss within the nasal septum and granulomatosus tissue masses protruding into the right orbit. The c-ANCA test was positive, serum IgA was elevated, and he had microhaematuria and proteinuria. In this severe case of Wegener's granulomatosis prolonged methylprednisone and cyclophosphamide treatment was initiated. Both the skin symptoms and the granulomatosus infiltrations resolved.

Granulomatosis with Polyangiitis↗

Pyoderma gangrenosum associated with sclerosing cholangitis, type 1 diabetes mellitus and ulcerative colitis.

We describe the case of a 22-year-old black female with type 1 diabetes mellitus diagnosed when she was 12 years old. She first presented (March 1994) with pustules and ulcerations on the upper and lower limbs, trunk and scalp at the age 17. The diagnosis of pyoderma gangrenosum was made. Since presentation, changes in liver function were detected and subsequent study led to the diagnosis of sclerosing cholangitis. The diagnosis of ulcerative colitis was made after colonoscopy. Partial response was obtained with minocycline and clofazimine, but treatment with 5-aminosalicylic acid achieved no improvement of the ulcerations. Liver transplantation, followed by immunosuppressive therapy led to complete regression of the cutaneous lesions.

Adult↗

Mycosis fungoides presenting with extensive pyoderma gangrenosum-like ulcers.

Mycosis fungoides (MF) may present with atypical clinical manifestations. Usually it mimics various chronic dermatoses, with the appearance of ulcers during the tumour stage. Infrequently, cutaneous ulcers are the main or initial sign of lymphoma. We report the case of a man who presented multiple skin lesions that clinically appeared to be pyoderma gangrenosum (PG). However, histological and immunohistochemical examination revealed MF. This case illustrates that PG-like ulcers maybe atypical cutaneous manifestations of MF and exceptionally the presenting sign of this disease.

Biopsy, Needle↗

Aberrant integrin (CR4; alpha(x)beta2; CD11c/CD18) oscillations on neutrophils in a mild form of pyoderma gangrenosum.

We have previously shown that the beta2 integrins CR3 and CR4 physically and functionally interact with urokinase receptors (uPAR) on neutrophil plasma membranes in an oscillatory fashion. In this study we have analyzed neutrophils from patient SC, a 34 y old African American female, with aberrant skin window results and recurrent perianal abscesses and pretibial lesions diagnosed as pyoderma gangrenosum. Although untreated migrating normal neutrophils exhibited 20 s sinusoidal oscillations in CR4-uPAR proximity, neutrophils from SC demonstrated a faster oscillation (10 s) in the form of a flyback sawtooth wave. This waveform mimicked that observed for normal neutrophils treated with subsaturating doses of the kinase inhibitors staurosporine, genistein, and erbstatin. As beta2 integrins are regulated by phosphorylation, we tested the hypothesis that the aberrant CR4-uPAR proximity oscillations seen in SC's neutrophils are due to defective kinase activity that might be balanced by a decrease in phosphatase activity. When SC's cells are exposed to subsaturating concentrations of the phosphatase inhibitor pervanadate, this caused the CR4-uPAR oscillations to become sinusoidal in shape with a 20 s period, as seen in normal migrating neutrophils. Although SC's neutrophils were deficient in spontaneous and N-formyl-methionyl-leucyl-phenylalanine-induced polarization, 0.5 microM pervanadate returned cell polarization to nearly normal levels, thus paralleling the acquisition of normal receptor interactions. Inasmuch as SC's cellular phenotype is mimicked by kinase inhibitors and corrected by phosphatase inhibitors, we suggest that a mutation(s) affecting the kinetics of intracellular signaling enzymes, but not blocking the pathway per se, may be responsible for this clinical state.

Adult↗

Pyoderma gangrenosum in two siblings: a familial predisposition.

We report pyoderma gangrenosum in two siblings with onset during childhood and no associated systemic abnormalities. The patients were born of nonconsanguineous, healthy parents. Treatment with oral corticosteroids produced an excellent clinical response, followed by recurrence after cessation of therapy. Steroids were restarted in combination with dapsone to prevent further recurrence.

Administration, Oral↗

Pyoderma gangrenosum complicating bilateral mammaplasty.

Pyoderma gangrenosum (PG) is an idiopathic necrotising cutaneous disorder. It is associated with systemic diseases like inflammatory bowel disease, monoclonal gammopathy, arthritides and haematological malignancy. PG occurring at sites of trauma, a phenomenon called pathergy, is well described. One of the manifestations of pathergy is PG occurring at sites of surgery. We describe a case of PG at sites of reduction mammaplasty and review the literature so far.

Adult↗

[Pyoderma gangrenosum and portal vein thrombosis in a 33-year-old female patient].

HISTORY AND CLINICAL FINDINGS: The diagnosis of pyoderma gangraenosum (PG) was made in a 33-year-old woman with ulcerative (palm-sized) skin changes and pain of the lower leg that had developed over two weeks and was accompanied by fever (39 degrees C). Treatment with prednisolone and azathioprine was initiated. As soon as the medication was reduced new skin changes developed. Two months after onset of the illness she had to be hospitalized because of fever, epigastric pain on pressure and deteriorating general condition. Physical examination provided no significant further information. LABORATORY RESULTS: The differential count demonstrated leucocytosis (15.5 Gpt/l) with a marked monocytosis (25%) as well as anaemia (haemoglobin concentration 5.2 mmol/l). C-reactive protein was elevated (120.20 mg/l). Thromboplastin time was 60%, D-dimer 1000 micrograms/l, thrombin-antithrombin-III complex 9.7 micrograms/l. ADDITIONAL INVESTIGATIONS: Sonography and computed tomography of the upper abdomen revealed splenomegaly, ascites, thrombosis of the portal, splenic and superior mesenteric veins. Bone marrow puncture showed marked increase in blasts (14%) and monocytes (10%). TREATMENT AND COURSE: The findings indicated chronic myelomonocytic leukaemia with PG and the described venous thromboses. The cutaneous changes completely receded on administration of hydroxyurea (1.0 g/d). Other causes of the skin eruption were excluded. Phenprocoumon (INR between 2 and 3) was given in treatment of the thromboses. CONCLUSION: When PG is diagnosed, intensive search for an underlying cause must be undertaken, because of its frequent association with serious systemic disease. Only early specific treatment will improve the skin condition.

Adult↗

German shepherd dog pyoderma: a genetic disorder.

In this study the pedigrees of 42 German Shepherd dogs with German Shepherd dog Pyoderma (GSP) were analysed. Parents, littermates and offspring of the affected dogs were traced and their owners were questioned on characteristic skin lesions. Evidence suggesting an autosomal recessive trait was found. Breeders are advised to exclude affected animals and their relatives from further breeding.

Animals↗

Investigations on the role of flea antigen in the pathogenesis of German shepherd dog pyoderma (GSP).

Skin reaction patterns to the intradermal injection of a whole-body flea extract were examined in five physically healthy dogs and in 24 dogs with German Shepherd dog Pyoderma (GSP) at 15 and 30 minutes and at 1, 2, 4, 8, 24, 48 and 72 hours after the injection. In 10 out of 24 GSP dogs a positive skin reaction was observed macroscopically after 15 minutes. Delayed reactions at 24 or 48 hours were not observed. In the control group neither immediate nor delayed reactions were observed. The histopathologic skin changes were basically the same in both groups: an initial polymorphonuclear reaction followed by a mononuclear cell reaction. In the GSP dogs, however, these changes occurred earlier and were more prolonged than in the normal dogs. No flea-antigen-specific IgGd antibodies could be demonstrated by enzyme-linked immunosorbent assay. It is concluded that delayed type hypersensitivity to flea antigen does not play a role in the pathogenesis of GSP. Immediate type hypersensitivity may contribute to the disease in some cases.

Animals↗

Investigations on the role of staphylococci in the pathogenesis of German shepherd dog pyoderma (GSP).

Skin reaction patterns to intradermal injections of a Staphylococcus intermedius antigen were examined in physically healthy dogs and in dogs with German Shepherd dog Pyoderma (GSP) at 15 and 30 minutes and at 1, 2, 4, 6, 8, 24, 48 and 72 hours after the injection. In both groups the skin histopathology revealed an aspecific inflammatory response of an early polymorphonuclear reaction, followed by a mononuclear cell reaction at 24 and 48 hours. It is concluded that hypersensitivity to staphylococcal antigens does not play a role in the pathogenesis of GSP.

Animals↗

Review of 26 cases of classical pyoderma gangrenosum: clinical and therapeutic features.

BACKGROUND: Classical pyoderma gangrenosum (CPG) is an uncommon, idiopathic, neutrophilic skin disease, generally associated with other skin conditions and systemic diseases, and with several treatment options. OBJECTIVE: The objective of this review was to know the clinical and therapeutic features of our cases of CPG. METHODS: Twenty-six cases of CPG were included; 65 episodes of PG and 120 treatment courses were analysed; and the mean follow-up was 4.6 years. RESULTS: 21 cases (80%) had lesions on the lower extremities, 16 (61%) had recurrences, 22 (84%) had some disease associated, and 13 (50%) had autoimmune inflammatory conditions. Cyclosporin A (CSA) was used in 22 (84%) patients and 51 (78%) episodes, and prednisone (PDN) was used in 15 (57%) patients and 26 (40%) episodes. CONCLUSIONS: CSA efficacy was excellent, with an early response and acceptable toxicity, although it did not seem to have any impact on the incidence of PG recurrences.

Adolescent↗

Management of pyoderma gangrenosum.

Management of pyoderma gangrenosum continues to be a therapeutic challenge, both because the low incidence of the disease makes it difficult to conduct large-scale randomized studies and because pathogenic mechanisms are not yet well defined. The selection of drugs and dosing schedules is therefore mainly guided by clinical experience.

Cromolyn Sodium↗

A nursery outbreak of Staphylococcus aureus pyoderma originating from a nurse with paronychia.

An outbreak of methicillin-susceptible Staphylococcus aureus pyoderma occurred in the nursery of a tertiary-care referral center. All strains retrieved from the outbreak, including one from a nurse's infected finger, were typed by arbitrarily primed polymerase chain reaction and automated ribotyping. The results indicated that the spread of the outbreak was probably facilitated by contamination of the nurse with paronychia.

Base Sequence↗

Pyoderma fistulans sinifica (fox den disease): a distinctive soft-tissue infection.

Pyoderma fistulans sinifica (PFS, also referred to as fox den disease because its multiple fistulae and sinuses resemble the structure of a fox den) is a distinct chronic infectious disease in which epithelialized tracts form within the subdermal fatty tissue. PFS, which has not been previously described in the English-language literature, must be differentiated from hidradenitis suppurativa, pilonidal sinus, and perianal fistula. The fistulous tracts of PFS are always lined by stratified squamous-cell epithelium but, unlike those of hidradenitis, reach deep into the subcutaneous fat, run epifascially for long distances, and have no relation to skin appendices. We report on 10 men (mean age +/- SD, 36 +/- 5 years) with PFS (mean duration +/- SD, 11 +/- 7 years). Bacterial cultures of affected tissue from these patients yielded a total of 14 facultative and 31 obligate anaerobic species. Treatment consisted of wide en-bloc excision down to the fascia, including all fistulae. Antibiotic therapy temporarily reduced purulent discharge but did not eradicate the infection. Two patients who underwent fistulotomy without wide en-bloc excision developed recurrences.

Abscess↗

Squamous syringometaplasia in lobular panniculitis and pyoderma gangrenosum.

Squamous metaplasia of eccrine sweat glands has been most frequently described in chronic cutaneous ulcerations with associated epidermal hyperplasia. We found examples of the process in skin biopsy specimens from five patients: three had associated lobular panniculitis and two had lesions of pyoderma gangrenosum. The metaplasia was located in the mid-to-deep reticular dermis in all five patients and extended into the superficial subcutis in one. Immunohistochemical stains for CEA and S-100 protein were used to accentuate the relationship of the metaplastic islands with eccrine ducts. It is postulated that necrosis of a portion of the eccrine duct is the stimulus for this process.

Adenoma↗