Pyodera gangrenosum after aortic valve replacement

Pyoderma Gangrenosum after Cardiac Surgery

BACKGROUND

Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection.

METHODS

A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided.

RESULTS

A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries.

CONCLUSION

Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis-the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.

Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases

Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.

Pyoderma gangrenosum after cardiac surgery masquerading as a fulminant sternal wound infection

INTRODUCTION

Pyoderma gangrenosum (PG) is a rare, ulcerative inflammatory skin pathology frequently associated with systemic inflammatory disease. While rare after surgery, recognition of this disease in the post-surgical setting is important as it can mimic wound infection. There have been ten case reports to date of PG occurring immediately after cardiac surgery, with all of them presenting within the first week post-operatively.

PRESENTATION OF CASE

We herein present a delayed and dramatic presentation of PG nine days after mitral valve replacement and repair of patent foramen ovale, two days after being discharged with a seemingly normal healing wound. Diagnosis of this disease in the postoperative period requires high suspicion when the characteristic ulcerative lesions are seen diffusely in all surgical wounds and show minimal improvement with antibiotic treatment or debridement.

DISCUSSION/CONCLUSION

Our case highlights the importance of recognizing this disease in the postoperative period, even in a delayed presentation and initially limited to one of the surgical sites. This case calls for an awareness of this disease entity amongst cardiac surgeons as well as intensivists.

Cavitary pyoderma gangrenosum treated with local infusion of corticosteroid

BACKGROUND

Pyoderma gangrenosum (PG) is a rare inflammatory skin condition, characterized by progressive and recurrent skin ulceration, often representing a pathergy response.

OBSERVATIONS

We report a case of spontaneous retrosternal PG that developed on the background of previous PG of the skin of the back. The patient had underlying ulcerative colitis. After failure of prednisone, minocycline, and dapsone, a novel method was instituted. Local flushing with dexamethasone, by a radiologically inserted retrosternal catheter with precordial suction, induced a rapid and sustained response. Subsequently maxillary sinus PG developed after the patient's tooth extraction. This responded to local corticosteroid injections in combination with systemic corticosteroid.

LIMITATIONS

Further reports of this technique are required to consolidate its use and infusion variables.

CONCLUSIONS

Two unusual sites of PG have been described, with successful treatment by a novel local steroid infusion. The profound sensitivity to trauma is demonstrated, which suggests that prophylactic corticosteroid may be useful for essential surgical intervention.

Management of pyoderma gangrenosum

The management of pyoderma gangrenosum (PG) requires a structured approach to establishing diagnosis of the disease and assessment of the patient. Clinical management of active PG lesions should be carried out in coordination with other specialists (such as nurses and pain managers) and often necessitates a flexible, innovate attitude to therapy, because the needs of individual patients may vary widely. Although there is no single successful treatment for this disease, certain types of PG lesions are recognized to respond more readily to accepted therapies than others. We outline guidelines to the management of the patient with PG and discuss alternative therapies.