A Case of Pyoderma Gangrenosum Misdiagnosed as Necrotizing Infection: A Potential Diagnostic Catastrophe

Abstract

In this article, we present a case of pyoderma gangrenosum (PG), misdiagnosed initially as a necrotizing infection that significantly worsened due to repeated surgical debridement and aggressive wound care therapy, almost resulting in limb amputation despite antibiotic therapy. The PG lesions improved after pancytopenia were further investigated, and the diagnosis and treatment of an underlying hematologic malignancy was initiated. The diagnosis and management of PG is challenging given the paucity of robust clinical evidence, lack of standard diagnostic criteria, and absence of clinical practice guidelines. It is imperative that clinicians recognize PG as a clinical diagnosis that must be considered in any patient with enlarging, sterile, necrotic lesions that are unresponsive to prolonged and appropriate antibiotics. Early recognition can prevent devastating sequelae such as deep tissue and bone infections associated with a chronic open wound, severe cosmetic morbidity, and potential limb amputation.

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

“…Multiple types of PG have been described in the literature, the most common is the classical ulcerative type, as patients present with an autoimmune condition, such as IBD (majority UC), inflammatory arthritis, connective tissue disease, hepatitis C and hematological disorders (notably myeloproliferative, myelodysplastic and lymphoproliferative) [5] , [6] , [7] , [9] , [10] , [11] .…”

“…In the setting of a known ulcer and soft tissue swelling, both clinical presentations of PG, MRI can also be useful to assess the presence of cellulitis, fluid collections or nodular lesions. MRI can determine the degree and extension of cellulitis which will present as skin thickening and increased signal intensity within the subcutaneous soft tissue on fluid sensitive sequences [8] , assess the presence, morphology, size and location of a fluid collection and determine the presence of nodular subcutaneous lesions [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] .…”

“…Patients with pyoderma gangrenosum (PG) commonly present in association with an inflammatory bowel disease (IBD, particularly UC), constituting the classical type [5] , [6] , [7] .…”

Post-Cesarean Section Pyoderma Gangrenosum Presenting with Vasopressor-dependent Shock: Long-term Follow-up after Delayed Primary Closure

“… 2 PG is commonly misdiagnosed as infection, but the lesions are culture negative. 3 – 5 Pathergy, the development of PG secondary to trauma, occurs in 20%–30% of cases and is considered pathognomonic. 3 , 4 Misdiagnosis of PG as infection often leads to surgical debridement, which inevitably exacerbates symptoms of PG and further delays definitive diagnosis and treatment.…”

Atypical Pyoderma gangrenosum: a case of delayed recognition

“…This may prompt intervention with surgical debridement, which frequently leads to a vicious cycle of worsening necrosis given the strong association of PG with severe pathergy phenomenon. Significant morbidity can be prevented by early diagnosis and treatment [ 5 ]. PG of the breast is rare, with only 43 reported cases, 70% of which developed after breast surgery [ 6 ].…”