Coexistent pyoderma gangrenosum and tibialis anterior myositis as presenting manifestations of Crohn’s disease: case report and review of the literature

Clinical Mimickers Misdiagnosed as Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a rare, ulcerative, neutrophilic dermatosis that can be challenging to diagnose. Diagnosis of PG is clinical due to a lack of specific histopathologic, immunologic, or imaging findings associated with the disease, although several clinical frameworks exist to guide diagnosis. However, misdiagnosis of PG is frequent and leads to increased patient morbidity and mortality. This article highlights common mimickers of PG and offers clinical pearls to aid in accurate diagnosis with the goal of decreasing diagnostic delay and misdiagnosis and improving patient outcomes.

[Differential diagnosis of a vasculitic syndrome of the lower limb]

Vasculitides can present with various clinical signs and symptoms. Besides disease-specific organ manifestations, the skin, peripheral nerves and musculature are frequently involved. The combination of elevated serological inflammatory markers, vasculitic skin lesions, active polyneuropathy and immobilizing myalgia of the lower limb musculature is highly suspicious for muscular polyarteritis nodosa (mPAN). Based on the case of a 63-year-old female patient with a vasculitic syndrome confined to the lower limb due to mPAN, important differential diagnoses of the these disease manifestations are discussed. Magnetic resonance imaging of the affected muscles and subsequent muscle biopsy (including skin and fascia) provide the relevant diagnostic data.

Crohn’s disease-related ‘gastrocnemius myalgia syndrome’ successfully treated with infliximab: A case report

BACKGROUND

Extra-intestinal manifestations in inflammatory bowel diseases (IBD) are frequent and involve virtually all organs. Conversely, the clinical characteristics and course of inflammatory myopathies in IBD remain poorly described and mostly related to orbital myositis. Moreover, alternative therapeutic strategies in non-responder patients to corticosteroid therapy must still be clarified.

CASE SUMMARY

A 33-year-old woman with a history of unclassified colitis presented with acute bilateral calf pain. On admission, her clinical and biological examinations were non-specific. However, magnetic resonance imaging showed bilateral inflammatory changes in gastrocnemius muscles suggestive of myositis. Muscle biopsy confirmed the diagnosis of myositis and demonstrated an inflammatory infiltrate mainly located in the perimysial compartment including lympho-plasmocytic cells with the formation of several granulomatous structures while the endomysium was relatively spared. The combined clinical, biological and histomyopathological findings were concordant with the diagnosis of ‘gastrocnemius myalgia syndrome’ (GMS), a rare disorder associated with Crohn’s disease (CD). Ileocolonoscopy confirmed CD diagnosis and systemic corticosteroids (CS) therapy was started, resulting in a rapid clinical improvement. During CS tapering, however, she experienced a relapse of GMS together with a severe active ileocolitis. Infliximab was started and allowed a sustained remission of both conditions at the latest follow-up (20 mo).

CONCLUSION

The GMS represent a rare CD-associated inflammatory myopathy for which anti-tumour necrosis factor-α therapy might be considered as an effective therapeutic option.

MRI features of pyoderma gangrenosum in a diabetic patient with ulcerative colitis: A case report and review of the literature

Pyoderma gangrenosum (PG) is a rare noninfectious skin condition which clinical picture can overlap with that of the diabetic foot. Meticulous physical examination along with biopsy and magnetic resonance imaging (MRI) can make the distinction easier, saving the patients from undergoing a debilitating intervention.

We report a case of pathologically proven PG in the right ankle region of a 55-year old male with known uncontrolled diabetes mellitus and inflammatory bowel disease.

Radiographs revealed increased soft tissue density overlying the lateral melleolus of the right ankle. MRI showed a well-defined soft tissue mass with heterogeneously intrinsically high signal intensity on T1- and on T2-weighted images, and heterogeneous peripheral enhancement on fat-suppressed, contrast-enhanced T1-weighted images. Histologically, diffuse neutrophilic infiltrate throughout the dermis was present without micro-organisms. This is the first report of MRI findings of PG in the ankle. We also summarize the findings of previously reported cases of PG.

Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease that presents a therapeutic challenge. Tumour necrosis factor alpha (TNFα) inhibitors have been reported to successfully control PG. Our aim was to systematically evaluate and compare the clinical effectiveness of TNFα inhibitors in adults with PG. A literature search including databases such as PubMed, Embase, Scopus, and Web of Science was conducted, using search terms related to PG and TNFα inhibitors. Studies and case reports were included if patients were diagnosed with PG, over the age of 18 and administered TNFα inhibitor. A total of 3212 unique citations were identified resulting in 222 articles describing 356 patients being included in our study. The study we report found an 87% (95% CI: 83%-90%) response rate and a 67% (95% CI: 62%-72%) complete response rate to TNFα inhibitors. No statistically significant differences in the response rates (P = 0.6159) or complete response rates (P = 0.0773) to infliximab, adalimumab, and etanercept were found. In our study TNFα inhibitors demonstrated significant effectiveness with response and complete response rates supporting the use of TNFα inhibitors to treat PG in adults. Our study suggests that there is no significant difference in effectiveness among infliximab, adalimumab, and etanercept.

Extracutaneous involvement of pyoderma gangrenosum

Pyoderma Gangrenosum (PG) is an inflammatory neutrophilic dermatosis (ND) associated with underlying chronic inflammation and/or malignancy. Diagnosis remains to be challenging as a gold standard diagnostic test is lacking. Initial manifestations may include papules, vesicles, or pustules that subsequently develop into ulceration with features of undermining and violaceous borders. Timely recognition of pyoderma gangrenosum is impeded by clinical findings shared with other etiologies, such as granulomatosis with polyangiitis, polyarteritis nodosa, and antiphospholipid syndrome. As with any other ND, extracutaneous involvement may also occur preceding, during, or following the appearance of skin lesions. Sterile neutrophilic infiltrates have been found to affect internal organs supporting the concept of PG being a systemic disease, with lung being the most common extracutaneous manifestation followed by ocular and visceral compromise. Therefore, in this review, we describe the current knowledge of extracutaneous involvement of PG and its respective clinical manifestations to aid dermatologists in diagnosis, management, and determining prognosis.

Biologic and small-molecule medications in the management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder characterized by neutrophil dysfunction. There are currently no FDA-approved drugs for the treatment of this disease, and treatment has typically relied on traditional immunosuppressive medications such as prednisone or cyclosporine. The efficacy of biologics in the treatment of other pro-inflammatory conditions such as psoriasis, rheumatoid arthritis, and inflammatory bowel disease is well-documented in the literature. Therefore, the use of biologic medications for the treatment of rarer inflammatory skin conditions, such as PG, is a compelling topic for investigation. Biologic and small-molecule therapies allow physicians to target specific pro-inflammatory mediators that underlie PG pathogenesis. This review provides an update on the use of biologic and small-molecule medications for the treatment of PG and summarizes the latest data on the clinical efficacy and pharmacology of these treatments.

Systematic review: IBD-associated pyoderma gangrenosum in the biologic era, the response to therapy

BACKGROUND

Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is uncommon and therapeutically challenging. Its treatment remains poorly characterised due to limited individual centre or practitioner experience. No large series are reported since 2003, yet IBD treatment has changed substantially.

AIM

To provide an up-to-date review of the published treatment efficacy of currently available therapies for IBD-related PG in the biologic era.

METHODS

Systematic review of cases published post-2003 since the broad availability of anti-tumour necrosis factor-alpha (TNFα) therapy. Cases which did not have coexistent IBD, were non-English language, of paediatric age or without data on response to therapy were excluded.

RESULTS

Sixty cases were identified; 55% female, 50% UC, 45% CD, 5% IBD-U. At PG diagnosis, 58% had active and only 15% inactive IBD, with 27% with IBD activity unspecified. Predominant sites were lower limb (48%) and peristomally (25%); 42% had multiple lesions. In 12%, trauma preceded PG. In 42%, new PG appeared whilst on IBD-specific therapy, whilst 28% were on no therapy and in 30%, IBD therapy was unspecified. Of patients on no therapy at PG onset (n = 17), 16 healed; seven with first- and eight with second-line therapy. In total, 34/60 patients received infliximab, four received adalimumab, two had both; with 33 (92%) responding to one or the other. There was no correlation of PG duration or size with healing times.

CONCLUSIONS

Pyoderma gangrenosum appears predominantly during active IBD and is seen equally in CD and UC. New PG may be a manifestation of recrudescent IBD or it follow trauma. Anti-TNFα therapy as a first-line agent for PG should be considered, as it appears to be highly effective.

A case of pyoderma gangrenosum with ulcerative colitis treated with combined approach: infliximab and surgery

Pyoderma gangrenosum (PG) is an ulcerating noninfectious disease of the skin seen in 1-2% of patients with inflammatory bowel disease (IBD). The pathogenesis of PG has yet to be determined, but may be related to abnormal T cell responses and the production of TNF-α, a pathway also involved in IBD pathogenesis. Infliximab, a chimeric monoclonal antibody to TNF-α, is used to treat moderate to severe IBD and several case reports and studies suggest the efficacy of infliximab in the treatment of PG. The surgical approach to PG is reserved to a few selected cases. We report here the case of a patient with ulcerative colitis (UC) and PG localized on the left breast, treated with a simultaneous combined medical and surgical approach.

Management of neutrophilic dermatoses

Neutrophilic dermatoses, including Sweet's syndrome, pyoderma gangrenosum, and rheumatoid neutrophilic dermatitis, are inflammatory conditions of the skin often associated with underlying systemic disease. These are characterized by the accumulation of neutrophils in the skin. The associated conditions, potential for systemic neutrophilic infiltration, and therapeutic management of these disorders can be similar. Sweet's syndrome can often be effectively treated with a brief course of systemic corticosteroids. Pyoderma gangrenosum, however, can be recurrent, and early initiation of a steroid-sparing agent is prudent. Second-line treatment for both of these conditions includes medications affecting neutrophil function, in addition to immunosuppressant medications.