Hyperthyroidism and Pyoderma Gangrenosum

Abstract

Pyoderma gangrenosum (PG) is a rare, inflammatory, noninfective skin disorder, which is often associated with systemic disease. PG mainly affects adults between age 30 and 50. It can also occur in children, usually in association with systemic disease. In adults, PG may occur in otherwise healthy persons. Occasionally, the occurrence of PG may herald the onset of serious systemic disorders. We report a patient with PG associated with hyperthyroidism. The diagnosis of PG was confirmed by histologic examination of a skin biopsy specimen obtained from lesions on the legs. Systemic corticosteroid therapy resulted in dramatic improvement of skin lesions with complete healing within several weeks. P yoderma gangrenosum (PG) is an inflammatory condition of the skin characterized histologically by necrosis, ulcerations, and vasculitis, but with no identifiable infective pathogens. It was first described by Brunsting et al. 1 It can have a pustular, follicular, nodular, bullous, or cribriform structure. Typical lesions arise on the trunk and neck. Macroscopically, the lesions have a pathognomonic undermined violaceous border and a clean base. Lesions may be solitary or multiple. They can be purely cutaneous or associated with a systemic disease such as inflammatory bowel disease, polyarthritis, IgA-gammopathy, some malignancies, and autoimmune diseases. 2,3 The association of PG and hyperthyroidism has been described in only a few patients. In 2 of them, it was the initial presentation of hyperthyroidism. 4 PG predominantly affects adults, both men and women. The age at onset is commonly between 30 and 50 years. There are no specific serologic or histologic markers of PG, and the diagnosis is established on clinical and histopathologic criteria. 5 We report a patient who developed PG during the initial presentation of hyperthyroidism. The most interesting aspect of this case was the striking correlation between the course of PG and thyroid gland activity. CASE REPORTA 78-year-old woman was admitted to our hospital with progressive pain in her legs for 6 months. Nodular lesions and bleeding ulcers (Fig. 1A) were obvious causes of the pain. She had weight loss, general weakness, and fatigue. There was no history of skin injury. Her medical history revealed arterial hypertension, cholecystectomy, hysterectomy, and adnexectomy. Diabetes mellitus type 2 was present for 12 years.She had an enlarged thyroid gland in addition to the ulcers and hemorrhages on her legs. She was reluctant to move her extremities. Blood pressure was 110/70 mm Hg, heart rate 77/min, temperature 36.5°C, and respiration rate 26/min. The rest of physical examination was unremarkable.Laboratory findings were normal, except for C-reactive protein of 82.3 mg/L (reference range Ͻ5), IgA 5.22 g/L (reference range 0.9 -4.5), IgG 21.26 g/L (reference range 8 -18). A Latex rheumatic factor was 137 IU/mL (reference range Ͻ40). Free T 4 was 38.3 pmol/L (reference range 10 -28), free T 3 was 8 pmol/L (reference range 4 -8), and the thyroid-stimulating hormone was s...