Pyoderma Gangrenosum After Hand Surgery: A Case Report

Turkhan Mehdiyev, MD; Robert Zimmermann, MD

Disclosures

Wounds. 2021;33(2):E14-E16. 

In This Article

Discussion

In 1983, the first case of PG on the hand was reported.[6] It presented as an acute suppurative hand infection, which was unresponsive to drainage and antibiotics.[6] Pyoderma gangrenosum may develop spontaneously or may be triggered by a minor trauma or surgery at any location of the body surface. Due to the clinical features of PG mimicking pyogenic wound infections, post-surgical PG is often initially misdiagnosed as an actual wound site infection.[4] Hence, antibiotic therapy and unnecessary wound debridement not only fail to curb the extension of the ulcer, but they could also worsen its conditions by inciting a pathergic response.[7] Pathergy phenomenon is a state of an enhanced inflammatory response of the skin after any cutaneous trauma.[8] Incorrect therapy on the grounds of misdiagnosis may result in devastating consequences, including limb amputation.[7,9] Lack of specific clinical, histopathological, and laboratory benchmarks makes PG a diagnostic and therapeutic challenge for surgeons. The diagnosis of PG in the present case was made after a consultation with a dermatologist and corticosteroid had been prescribed, with an appropriate clinical response. Successful systemic therapies have been reported with glucocorticoids, azathioprine, cyclosporine, tacrolimus, mycophenolate mofetil, methotrexate, chlorambucil, thalidomide, colchicine, cyclophosphamide, dapsone, minocycline, sulfapyridine, and tumor necrosis factor alpha inhibitors.[10]

Postsurgical PG is a rare but serious complication of surgery and is difficult to recognize. It is often initially diagnosed as a postoperative infection. In this particular case, the patient had a history of a trochanterica bursitis with a rupture of the gluteus medius muscle. After the surgical treatment by bursectomy and reattachment of the torn muscle back onto the greater trochanter, the patient had to undergo a revision and was transferred to the department of infectious diseases for the further antibiotic treatment. The present case report illustrates that despite the patient's history of confirmed PG in the gluteal region after the bursectomy and reattachment of the gluteus medius muscle, the hand surgeons, who did not recognize the presentation of this condition, allowed the patient to undergo a CTR. Surgeons should consider PG in cases of rapidly enlarging ulcers that are unresponsive to antibiotics and aggravated by repeated debridement, so as to prevent a delayed diagnosis and to start an adequate therapy at an early stage. Especially in patients with prior episode of PG, this diagnosis should be high on the differential diagnosis if the surgical incision appears to be "infected." For patients with PG in their medical history, dermatological consultation should be initiated prior to surgeries in order to carry out immunosuppression with steroids to avoid a recurrence.

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