Clinical Experience of Pyoderma Gangrenosum with Extensive Soft Tissue Necrosis

광범위 연조직 괴사를 동반한 괴저농피증의 치험례

  • Lim, Sung Yoon (Department of Plastic and Reconstructive Surgery, School of Medicine, Ajou University) ;
  • Park, Dong Ha (Department of Plastic and Reconstructive Surgery, School of Medicine, Ajou University) ;
  • Pae, Nam Suk (Department of Plastic and Reconstructive Surgery, School of Medicine, Ajou University) ;
  • Park, Myong Chul (Department of Plastic and Reconstructive Surgery, School of Medicine, Ajou University)
  • 임성윤 (아주대학교 의과대학 성형외과학교실) ;
  • 박동하 (아주대학교 의과대학 성형외과학교실) ;
  • 배남석 (아주대학교 의과대학 성형외과학교실) ;
  • 박명철 (아주대학교 의과대학 성형외과학교실)
  • Received : 2008.05.02
  • Accepted : 2008.07.14
  • Published : 2008.10.15

Abstract

Purpose: Pyoderma gangrenosum is a rare cutaneous ulcerative disease. First described in 1930, the condition is characterized by progressive ulceration with deeply undermined purple-red edge. The lower extremities are most commonly affected but other parts of the skin and mucous membranes may also be involved. Although medical treatments with topical wound therapy are commonly used, surgical intervention is still controversial. In this paper, we report an atypical case of pyoderma gangrenosum which was characterized by extensive soft tissue breakdown. Methods: A 27-year-old male patient was referred to our institution with a $7{\times}8cm$ sized deeply undermined ulceration with pus-like discharge and fever. Incision and drainage was performed at another clinic 3 days prior to admission to our institution. After a thorough physical examination and the MRI review, a diagnosis of necrotizing faciitis was made. Accordingly, fasciotomy and debridement was performed. However, the wound enlarged progressively and the patient remained highly febrile for 9 days after the treatment. Septic screening did not reveal any occult infection. After a secondary review of the case, the initial diagnosis of necrotizing fasciitis was rejected and changed to pyoderma gangrenosum. With the use of dexamethasone intravenously, the wound improved dramatically and the fever was eliminated. Steroid mediation was tapered with duration of 1 month. The wound was stabilized and subsequently covered with split-thickness skin graft. Results: Split-thickness skin grafting with 1 : 1.5 mesh was successfully taken. Conclusion: Initial clinical features of pyoderma gangrenosum are very similar to that of necrotizing fasciitis. High fever and progressive ulceration with severe pain could invite earlier surgical approach. The advancing wound margins (the well defined violaceous, undermined border and necrotic ulcer base) and lack of isolation of pathogenic organism was used to make the correct diagnosis of pyoderma gangrenosum. We achieved a good result with proper medication and split-thickness skin graft.

Keywords

References

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