Pyoderma Gangrenosum-Like Presentation of Herpetic Panniculitis in a Patient With Immunosuppression

Victoria E. Orfaly, BS; Erika L. Hagstrom, MD; Kevin P. White, MD; Alex G. Ortega-Loayza, MD, MCR


Wounds. 2021;33(5):E39-E41. 

In This Article

Abstract and Introduction


Introduction: This case of herpes virus–induced panniculitis originally diagnosed as pyoderma gangrenosum (PG) illustrates the need for a high index of suspicion for atypical causes of cutaneous ulcers in patients who are immunocompromised.

Case Report: A 79-year-old male presented with a 3-month history of a painless chronic ulcer on the left buttock that was refractory to antibiotic therapy and intralesional corticosteroid. The medical history was notable for diabetes mellitus type 2 and rheumatoid arthritis managed with long-term methotrexate and low-dose prednisone. Because the patient initially had a painful and enlarging skin ulcer after intralesional treatment with corticosteroids, an undermined and violaceous ulcer, and an autoimmune condition, PG was suspected at the initial evaluation. A subsequent skin biopsy to complete the workup confirmed the unexpected diagnosis of herpetic panniculitis. The patient was started on antiviral therapy; a prolonged therapeutic and suppressive dose was required. This case highlights the importance of skin biopsy in the diagnosis of chronic ulcers to rule out infectious etiologies. Maintaining a high index of suspicion for rare causes of cutaneous ulcers in the patient with immunosuppression is paramount.

Conclusions: Herpes virus infection is only one atypical cause of ulcerative nodules in the immunocompromised patient. Skin biopsy should be considered in the immunocompromised patient with presumed PG that is not responding to standard of care treatment.


The nonspecific clinical presentation of panniculitides requires clinical pathological correlation to determine the etiology. Infection-induced panniculitis is often seen in the immunocompromised patient and presents as 1 or more fluctuant nodules that ulcerate on the lower extremities.[1] Infection with herpes virus usually presents as an easily distinguishable vesicular rash. In the patient with immunosuppression, however, herpes virus infection can manifest with uncommon clinical findings.[2] The 2 subtypes of infection-induced panniculitis are primary, that is, a direct infection into the fat tissue, and secondary, which occurs through hematogenous spread of the pathogen.[3,4] However, the presence of ulcerative nodules may also be suggestive of the presence of other underlying etiologies, such as medium-sized vasculitis and vasculopathies (eg, calciphylaxis), factitial etiology, or inflammatory ulcerations (eg, pyoderma gangrenosum [PG]).