Bullous pyoderma gangrenosum in a patient with myelodysplastic syndrome during granulocyte colony-stimulating factor therapy

Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.

Pyoderma Gangrenosum After Total Hip Arthroplasty Associated with Administration of Granulocyte Colony-Stimulating Factor: A Case Report

CASE

A 69-year-old woman with myelodysplastic syndrome-related pancytopenia was administered granulocyte colony-stimulating factor (G-CSF) before total hip arthroplasty to prevent postoperative infection. One week postoperatively, she developed peri-incisional ecchymosis and associated leukocytosis. Over the next few weeks, surgical site infection was suspected; however, dermatologist evaluation and subsequent biopsy supported a diagnosis of pyoderma gangrenosum, which resolved after prompt steroid administration.

CONCLUSION

Postoperative pyoderma gangrenosum should be included in the differential diagnosis when considerable postoperative ecchymosis and leukocytosis occur, particularly after preoperative G-CSF administration.

Pyoderma gangrenosum in hematologic malignancies: A systematic review

BACKGROUND

Pyoderma gangrenosum (PG) is a devastating neutrophilic dermatosis that may be associated with trauma or systemic diseases. The associations, characteristics, and temporal relationship of PG with hematologic malignancies are not well understood.

OBJECTIVE

We performed a systematic review of PG associated with hematologic malignancies using data from case reports, case series, and retrospective studies.

METHODS

We searched MEDLINE, EMBASE, Scopus, and Web of Science from each database's inception to December 12, 2018. Two reviewers independently selected studies and extracted data.

RESULTS

Two hundred seventy-nine publications met the inclusion criteria (340 cases). Myelodysplastic syndrome (MDS) was the most commonly reported hematologic malignancy associated with PG, followed by monoclonal gammopathy of undetermined significance and acute myeloid leukemia. The mean age of patients was 56.5 years, with males being more common. There was a predominance of the ulcerative PG subtype and multifocal distributions across all hematologic malignancies. The majority of MDS cases preceded PG, which was reversed for MGUS.

LIMITATIONS

The data were limited by reporting bias because PG subtypes rely on the rendered diagnosis reported. In addition, the classification for hematologic malignancies has evolved since 1978.

CONCLUSION

Patients with PG should be evaluated for hematologic malignancies, with MDS being the most common.

Drug-Induced Pyoderma Gangrenosum: A Review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that may be caused by an adverse drug reaction. We discuss the clinical presentation and outcomes of 52 cases of drug-induced PG reported to date in the literature. We conducted our literature search for case reports of drug-induced PG using keywords on PubMed and Medical Subject Heading (MeSH) terms on MEDLINE and EMBASE. To assess the probability that each case of PG was related to drug therapy, we used the Naranjo criteria. We identified 44 studies in the literature, with a total of 52 cases of drug-induced PG. The mean Naranjo score for cocaine-induced PG (n = 13) was 9.4, indicating a definite adverse drug reaction, while the mean Naranjo scores for isotretinoin (n = 5), propylthiouracil (n = 5), and sunitinib (n = 5) were 6.2, 6.8, and 7.4, respectively, indicating probable adverse drug reactions. Drugs should be considered as a possible triggering event whenever PG is diagnosed, and clinicians should particularly consider this in patients taking isotretinoin, propylthiouracil, or sunitinib, as well as in patients with a history of cocaine use.

Drug-induced pyoderma gangrenosum: a model to understand the pathogenesis of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare autoinflammatory condition in which the alteration of neutrophil function and the innate immune response play key roles in its pathogenesis. Cases of PG have been reported in patients being treated with certain medications, which may help us to understand some of the possible pathways involved in the aetiology of PG. The aim of this review is to review the cases of PG triggered by certain drugs and try to thoroughly understand the pathogenesis of the disease. To accomplish this, a PubMed search was completed using the following words: pyoderma gangrenosum, neutrophilic dermatosis, pathophysiology, drug-induced pyoderma gangrenosum. In total, we found 43 cases of drug-induced PG. Most of them were caused by colony-stimulating factors and small-molecule tyrosine kinase inhibitors. We propose that drugs induce PG through various mechanisms such as dysfunctional neutrophil migration and function, dysregulated inflammatory response, promotion of keratinocyte apoptosis and alteration of epigenetic mechanisms. PG is a rare condition with complex pathophysiology and drug-induced cases are even more scarce; this is the main limitation of this review. Understanding the possible mechanisms of drug-induced PG, via abnormal neutrophil migration and function, abnormal inflammation, keratinocyte apoptosis and alteration of epigenetic mechanisms would help to better understand the pathogenesis of PG and ultimately to optimize targeted therapy.

Pyoderma gangrenosum and pregnancy: an example of abnormal inflammation and challenging treatment

Pyoderma gangrenosum (PG) is a neutrophil-predominant inflammatory disease that initially presents as a sterile pustule and may progress to ulcerations. Its root cause is unknown, but the presentation is commonly associated with systemic inflammatory conditions such as inflammatory bowel disease, arthritis and haematological abnormalities. On the other hand, pregnant women show a progressive neutrophilia during gestation, which culminates in a major inflammatory event to help drive labour. Although uncommonly, PG has been associated with pregnancy, which provides an additional link to systemic inflammation as an underlying cause of PG. We reviewed documented presentations of PG in gravid and post-partum patients, and have speculated on the possible pathogenesis based on their clinical presentations. Also, we summarize the reported treatments and their outcomes in these patients.

Bullous pyoderma gangrenosum associated with pancytopenia of unknown origin

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis of unknown origin. Clinically it starts with a pustule, nodule or bulla that rapidly progresses and turns into a painful ulcer with raised, undermined borders. The etiopathogenesis of PG remains unknown. However it is frequently associated with systemic diseases such as inflammatory bowel disease (IBD), haematological disorders or arthritis. The latest multicentric retrospective analysis published by Ghazal et al. shows that anaemia has been observed very often in German patients suffering from PG (in 45.6% of 259) so this disorder is supposed to be a possible cofactor in the pathogenesis of PG. According to its progressive course, patients require intensive diagnostic procedures and rapid initiation of the treatment. In this article, we report a case of bullous pyoderma gangrenosum in association with pancytopenia of unknown origin, according to its diagnostic and therapeutic difficulties.

[The modern concepts of pyoderma gangrenosum]

The review provides an update on pyoderma ganrenosum, a rare chronic disease from a group of neutrophilic dermatoses. It considers its pathogenesis, its association with background visceral disease, and the specific features of skin and visceral involvement. Major and minor diagnostic criteria and differential treatment approaches are given.

Neutrophilic dermatoses as systemic diseases

Neutrophilic dermatoses (ND) are inflammatory skin conditions characterized by a sterile infiltrate of normal polymorphonuclear leukocytes. The main clinical forms of ND include Sweet syndrome, pyoderma gangrenosum, erythema elevatum diutinum, subcorneal pustular dermatosis, and their atypical or transitional forms. ND are often idiopathic, but they may be associated with myeloid hematologic malignancies (Sweet syndrome), inflammatory bowel disease or rheumatoid arthritis (pyoderma gangrenosum), and monoclonal gammopathies (erythema elevatum diutinum, subcorneal pustular dermatosis). The possible infiltration of internal organs with neutrophils during the setting of ND underlies the concept of a neutrophilic systemic disease. ND may be seen as a polygenic autoinflammatory syndrome due to their frequent association with other autoinflammatory disorders (monogenic or polygenic) and the recent published efficacy of interleukin-1 blocking therapies in their management.

Bullous pyoderma gangrenosum of the bilateral dorsal hands

Pyoderma gangrenosum (PG) shows characteristic non-infectious ulcers that are commonly associated with systemic diseases such as inflammatory bowel diseases, myeloproliferative disorders or aortitis syndrome. The typical clinical appearance is undermining ulcers with reddish and irregular borders on the legs. As PG has these notable signs, the diagnosis is relatively easy and its treatment depends on the severity of underlying complications. We report a case of a 60-year-old Japanese man, diagnosed with bullous PG, who also had been suffering from myeloperoxidase antineutrophil cytoplasmic antibody-positive microscopic polyangiitis and pulmonary aspergillosis. This case displayed soft whitish ulcers that existed on the rough ulcer base, with irregular borders, on his bilateral dorsal hands. Initially, it seemed to be cutaneous secondary aspergillosis because the host was already infected with pulmonary aspergillosis in both lungs. The differential diagnosis of PG from aspergillosis was from the sterile bullae or neutrophilic bullae on his right forearm, which evolved into ulcers in a few days. This case was finally diagnosed as bullous PG and a topical glucocorticoid was very effective to epithelize the ulcers in 2-3 weeks.

Bullous pyoderma gangrenosum: a case report and review of the published work

Pyoderma gangrenosum (PG) is an ulcerative skin disorder characterized by neutrophilic infiltrations. PG is generally classified into four types: (i) ulcerative; (ii) pustular; (iii) bullous; and (iv) vegetative. Among them, bullous PG is known as a rare type. Herein, we report a case of bullous PG together with a summary of the 12 PG cases treated in our department over the previous 15 years, and we review 38 well-documented bullous PG cases (65.8% female; aged 18-80 years [mean ± standard deviation, 51.6 ± 16.8]) in the published work, including the present case, from 1972-2011. Although the disease most frequently associated with PG is inflammatory bowel disease, bullous PG is most commonly associated with hematological disorders (25/38, 65.8%), which indicates the characteristic pathophysiology specific to bullous PG.

Bullous pyoderma gangrenosum as the presenting sign of fatal acute myelogenous leukemia

Bullous pyoderma gangrenosum begins as a bulla, nodule or nonulcerated erythematous plaque that blisters or ulcerates to form a superficial ulcer surrounded by a hemorrhagic, bullous border, which is surrounded by a blue-gray halo. Bullous pyoderma gangrenosum is most commonly associated with hematologic malignancies, specifically, acute myelogenous leukemia (AML). We report a patient whose initial presentation with bullous pyoderma gangrenosum prompted the appropriate diagnostic evaluation and confirmation of AML, which was ultimately fatal. We emphasize that a thorough hematologic investigation, including bone marrow biopsy, should be performed in all patients who present with lesions clinically suggestive of bullous pyoderma gangrenosum because the skin lesion may be the only indicator of the underlying hematologic disorder.

Granulocyte colony-stimulating factor administration: adverse events

Recombinant human granulocyte colony-stimulating factor (G-CSF) has been in clinical use for approximately 2 decades. In healthy donors, it has been used to mobilize peripheral blood progenitor cells for hematopoietic stem cell transplantation and granulocytes for apheresis collection. In patients, it has been used to decrease the duration of neutropenia after chemotherapy and to offset the neutropenia due to myelodysplasia, acquired immunodeficiency syndrome, and genetic disorders of granulocyte production. As the number of uses of G-CSF in clinical practice grows, more side effects of this generally safe pharmaceutical agent are being recognized. Our objective in this article is to provide an in-depth review of the reported adverse events associated with the use of G-CSF.

Granulomatous Dermatitis with Enlarged Histiocytes: A Characteristic Pattern of Granulocyte Colony-Stimulating Factor

Two patients developed a pruritic maculopapular rash following treatment with granulocyte colony-stimulating factor (G-CSF). Histopathological examination disclosed a superficial dermal inflammatory infiltrate composed of interstitially arranged large histiocytic CD68+ cells and perivascularly disposed lymphocytes. Large histiocytes were interspersed among the collagen bundles with associated slight deposits of mucin. Elastophagocytosis was occasionally observed, and a slight reduction of dermal elastic fibers was also noted. There was no evidence of frank granuloma formation, fibrosis or significant changes of collagen bundles. This histopathological variant of granulomatous dermatitis with "enlarged histiocytes" seems to be characteristic of an unusual cutaneous reaction secondary to CSF treatment.

[Skin manifestations associated with myelodysplastic syndromes]

PURPOSE

Our purpose was to describe cutaneous manifestations associated with myelodysplastic syndromes.

METHODS

Data from seven patients with cutaneous vasculitis (four cases), neutrophilic dermatosis (one case), relapsing polychondritis (one case), and possible erythema elevatum diutinum (one case) in association with myelodysplastic syndrome (refractory anaemia RA, RA with excess of blasts--RAEB-, RAEB in transformation RAEBt, chronic myelomonocytic leukaemia--CMML-), and analysis of the literature were reviewed.

RESULTS

The cutaneous manifestations of myelodysplastic syndrome may or may not be specific, and may reveal hemopathy transformation. The cutaneous vasculitis are the most frequent and polymorphic. The relation with neutrophilic dermatosis is more specific; they are a spectrum of diseases including pyoderma gangrenosum, Sweet's syndrome, erythema elevatum diutinum (nuclear segmentation anomalies of neutrophils both in the skin and in the blood are a biological marker of the association). Relapsing polychondritis is significantly associated with myelodysplastic syndromes. Their pathogenesis are controversial.

CONCLUSION

Early biopsy of cutaneous lesions in myelodysplastic syndromes is indicated. Analysis of blood cell count (and more bone marrow biopsy in relapsing polychondritis) is indispensable in these neutrophilic cutaneous or vasculitis diseases.