Peritoneal Dialysis Exit Site Pyoderma Gangrenosum: A Case Report

Multiple Pyoderma Gangrenosum Overlying AV Fistula Treated With Colchicine: A Case Report

Rationale

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis which gives rise to painful ulcers. Pyoderma gangrenosum can be triggered by trauma, a phenomenon called pathergy. Here, we report the first case of PG arising from pathergy due to needle insertion overlying an arteriovenous fistula (AVF). This case report seeks to inform nephrologists about PG, this yet unreported presentation, and management in the context of hemodialysis.

Presenting concerns

A 69-year-old woman presented to dermatology clinic for erythemato-violaceous plaques with central ulceration at the site of needle insertion overlying her AVF. The patient was known for chronic renal insufficiency secondary to C3 glomerulonephritis, for which she received hemodialysis. After an accidental burn which lead to appearance of a painful ulcer, following each needle insertion for hemodialysis, she would develop an erythematous papule that progressed to a painful ulcer with erythematous-violaceous borders.

Diagnosis

Pyoderma gangrenosum was clinically diagnosed and both clinical and paraclinical evaluation did not reveal any secondary cause of PG.

Intervention

Dialysis via AVF was suspended due to the risk of triggering more PG and was temporarily pursued by central venous catheter. The patient was initially treated with prednisone and topical corticosteroids. Furthermore, owing to the high recurrence rate of PG, colchicine was initiated in prevention to avoid resorting to immunosuppressive or long-term corticotherapy.

Outcomes

The patient's lesions improved on prednisone, which was then tapered over 1 month. Following prednisone taper and continuing improvement of PG on colchicine and topical corticosteroids alone, the decision was taken to recommence dialysis via AVF after performing a negative pathergy test. Topical corticosteroids were ceased due to the risk of cutaneous atrophy and were replaced by pimecrolimus ointment. The patient has continued dialysis via AVF ever since, without recurrence.

Novel Finding

This is the first case reported of PG arising from pathergy due to needle insertion overlying an AVF. Colchicine may be a safe and effective therapy for long-term treatment of PG in the context of hemodialysis.

Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis

Rationale:

Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum can be associated with Koebner phenomenon and rarely results in systemic inflammatory response syndrome and shock.

Presenting concerns of the patient:

A 61-year-old woman had recently started maintenance hemodialysis, using a tunneled catheter. She was admitted with fever and signs of inflammation at the catheter exit site and along the tunnel.

Diagnoses:

The initial diagnosis was catheter-related tunnel infection. The exit site broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar lesion developed at a subcutaneous injection site in her abdomen. Clinical diagnosis of pyoderma gangrenosum was made. She remained febrile despite broad antibiotic coverage and catheter removal and developed systemic inflammatory response syndrome (SIRS) that necessitated transfer to intensive care unit.

Interventions:

She responded well to fluids and intravenous steroids. Viral and bacterial cultures were negative throughout; echocardiography and computed tomography were unrevealing. Insertion of a new hemodialysis catheter was deferred as long as clinically possible, was undertaken while the patient was taking steroids, and was uncomplicated.

Outcomes:

She remained hemodynamically stable and was discharged after rehabilitation. Her wounds slowly granulated and healed. Steroids were tapered.

Teaching points:

To our knowledge, this is the first case report of a patient with pyoderma gangrenosum developing at the site of tunneled hemodialysis catheter. Our patient developed SIRS with no evidence of infection. We summarize 11 previous case reports of pyoderma leading to SIRS and responsive to steroids.