Images in Clinical Medicine

Atypical Pyoderma Gangrenosum in a Splenectomy Incision

Pareshkumar Patel, M.D., and Arthur Topilow, M.D.

N Engl J Med 2002; 347:1419October 31, 2002

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Figure 1 A 72-year-old woman underwent splenectomy for transfusion-dependent myelofibrosis, and rapidly advancing, nonhealing necrotic skin ulcers developed over the incision site on the eighth postoperative day (Panel A). The abdominal-wall ulcers were treated unsuccessfully with a broad-spectrum antibiotic. Multiple wound cultures remained negative for pathogens. A skin biopsy revealed neutrophilic inflammation involving the dermis. The skin was undermined by necrosis at the margins of the ulcer and showed reepithelialization (arrow in Panel B; hematoxylin and eosin, ×4). No bacteria were seen, and atypical pyoderma gangrenosum (or neutrophilic dermatosis) was diagnosed. A two-month course of oral corticosteroids, in which the dose was gradually tapered, resulted in improvement and, ultimately, healing of the ulcerations (Panel C).

Atypical pyoderma gangrenosum is a rare, idiopathic inflammatory disease that is easily confused with classic pyoderma gangrenosum. The dermal lesions of atypical pyoderma gangrenosum are more superficial than those of classic pyoderma gangrenosum and are frequently located on the arms rather than on the legs, as occurs in the classic form. The lesions of either form may develop after the skin is damaged as a result of trauma, surgery, or venipuncture, a phenomenon referred to as pathergy. Half of all cases are associated with inflammatory bowel disease, arthritis, hematologic cancers, myeloproliferative disorders, or monoclonal gammopathies.

Pareshkumar Patel, M.D.
Arthur Topilow, M.D.
Jersey Shore Medical Center, Neptune, NJ 07754

Citing Articles (3)

Citing Articles

1. 1

   Dubravka Zivanovic, Srdjan Tanasilovic, Dusan Skiljevic, Maja Tomovic, Andrija Bogdanovic, Sonja Vesic, Ljiljana Medenica. (2007) Atypical pyoderma gangrenosum in a patient with osteomyelofibrosis. Vojnosanitetski pregled 64:11, 787-789
   CrossRef

2. 2

   Hayri Sangiray, Josephine C. Nguyen, George W. Turiansky, Christopher Norwood. (2006) Pyoderma gangrenosum occurring near an arteriovenous dialysis shunt. International Journal of Dermatology 45:7, 851-853
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3. 3

   Jörg Reichrath, Guido Bens, Anette Bonowitz, Wolfgang Tilgen. (2005) Treatment recommendations for pyoderma gangrenosum: An evidence-based review of the literature based on more than 350 patients. Journal of the American Academy of Dermatology 53:2, 273-283
   CrossRef