Monoclonal gammopathy (IgG) and chronic ulcerative dermatitis (phagedenic pyoderma)

Pyoderma gangrenosum: From historical perspectives to emerging investigations

Pyoderma gangrenosum (PG) is a rare disease of unknown aetiology, first described over a century ago. Initially thought to have an infectious cause, and now primarily considered an autoinflammatory condition, PG continues to be poorly understood, commonly misdiagnosed, and difficult to treat. In this review, we discuss the journey of our understanding of PG to date, including first descriptions, challenges with diagnosis, presumed pathogenesis, and treatments used. We highlight major historical landmarks and their importance, explain the rationale behind current investigations, note outstanding gaps in knowledge, and explore the future directions of PG research. We summarise what we have known, what we are working on knowing, and what we have yet to explore about PG, illustrating overall trends to invigorate future research.

Pyoderma Gangrenosum and IgA Myeloma

Background:

Pyoderma gangrenosum (PG) is an uncommon condition that is associated with a systemic disease in 50% of patients. The condition may be associated with a monoclonal gammopathy, usually of the IgA type. It is rare for PG to be associated with multiple myeloma.

Observations:

We report the case of an 83-year-old man with PG associated with an IgA myeloma. The myeloma was discovered after the diagnosis of PG had been made. This is the 22nd case of multiple myeloma associated with PG, and only the 14th case of PG with an IgA myeloma.

Conclusions:

We should be aware of the potential association of multiple myeloma with PG, and consider doing a serum protein electrophoresis in the evaluation of patients with PG.

Pyoderma gangraenosum (dermatitis ulcerosa) and monoclonal (IgA) globulin healed after melphalan treatment. Case report and review of the literature

Since 1968 we have been treating a patient, who has had a combination of pyoderma gangraenosum (dermatitis ulcerosa) and signs that may indicate early multiple myeloma. She also had carcinoma of the colon, which was successfully operated. The pyoderma healed later after intensive and successful cytostatic treatment of the "myeloma". The ulcers remain practically healed and the protein pattern is normal in May 1977. Such cases are rare and a search in the literature has not been very rewarding. In our own series of more than 200 cases with myeloma this combination is unique. The lieterature is discussed in detail with data on the follow-up on some of the patients.

Pyoderma gangrenosum--response to topical nitrogen mustard

We report a 69-year-old caucasian male patient with long-standing pyoderma gangrenosum; the lesions preceded the appearance of an IgA monoclonal gammopathy by 2 years. A number of systemic treatments, including high dose steroids and immunosuppressive agents, were poorly tolerated and resulted in serious side-effects. The skin and haematological conditions, however, were kept under control for 2 years with regular plasmapheresis. Pyoderma gangrenosum recurred as vascular access became exhausted but new lesions healed completely with topical application of 20% nitrogen mustard.

Pyoderma gangrenosum treated with hyperbaric oxygen therapy

The management of pyoderma gangrenosum often requires systemic drug therapy, such as corticosteroids, sulfones, or immunosuppressants, either alone or in combination. Inconsistent response to therapy is a source of frustration to both patient and physician. Several reports in the literature document the successful treatment of pyoderma gangrenosum with hyperbaric oxygen therapy. In our patient, a woman with severe rheumatoid arthritis and diabetes mellitus, hyperbaric oxygen therapy not only promoted healing of pyoderma gangrenosum but permitted reduction of systemic corticosteroids.

Hydralazine-induced systemic lupus erythematosus presenting as pyoderma gangrenosum-like ulcers

A 48-year-old white woman who for 3 years had been taking hydralazine, 100 mg three times a day, propranolol, 160 mg twice a day, and chlorothiazide, 500 mg/day, for hypertension suddenly developed rapidly expanding ulcers that looked like pyoderma gangrenosum. Arthralgias, fevers, and occasional shortness of breath were also noted. A pericardial effusion was diagnosed by echocardiography. The antinuclear antibody (ANA) titer on routine mouse liver substrate was initially negative, but the ANA titer was positive (1:1,920) on human epithelioid cell substrate. Antibodies to histones and single-stranded DNA were also elevated. After discontinuing hydralazine, all signs and symptoms cleared over a 4-week period. At the time of discharge the ANA titer had decreased to 1:480.

Pyoderma gangrenosum: successful treatment with intralesional steroids

A case of pyoderma gangrenosum (PG) responsive to intralesional injection of corticosteroid is reported. Improvement was detected by 48 hours, and complete healing had occurred by 6 weeks. The association with various underlying systemic diseases, pathogenesis, and modalities of therapy are discussed.

Pyoderma gangrenosum

Since its description 50 years ago, pyoderma gangrenosum has continued to capture the attention and imagination of all those who see its dramatic presentation. Clinical observation still provides the only reliable diagnosis. As investigative techniques increase, more and more intriguing immunologic abnormalities associated with this disorder are discovered, but understanding of the pathogenesis remains elusive. It is now recognized as an independent condition as well as a co-condition with many systemic disorders. Many new treatment options are available, allowing much individualization of treatment. For now, pyoderma gangrenosum remains an impressive, relatively easily recognized, but poorly understood disease.

Postsurgical, chronic, nonprogressive, cutaneous ulcers: a possible variant of pyoderma gangrenosum associated with diabetes mellitus

Two patients developed persistent ulcers on the trunk after cutaneous surgery. Both had "chemical" diabetes mellitus. Bacteriologic and histopathologic studies of the ulcers were not revealing of cause. The characteristics of the ulcers are described, and are contrasted with typical lesions of pyoderma gangrenosum and Meleney's postoperative progressive synergistic bacterial gangrene. We believe these patients had variant lesions of pyoderma gangrenosum.