(654) Beyond Infection: The Diagnostic Challenge of Pyoderma Gangrenosum

Introduction: Pyoderma Gangrenosum (PG) is a rare, inflammatory skin condition often associated with systemic diseases such as inflammatory bowel disease, arthritis, and hematologic malignancies. It can rarely be associated with trauma, including prior surgery, characterized by painful ulcers that typically worsen with trauma, a phenomenon known as pathergy. The diagnostic challenge is due to its non-specific criteria and variable presentation, often leading to misdiagnosis as a wound infection. Mismanagement, including unnecessary surgical debridement, can worsen PG and increase patient morbidity. This report highlights the importance of accurate diagnosis in appropriately managing PG.

Description: A 62-year-old female with type 2 diabetes, chronic kidney disease, and heart failure underwent a Roux-en-Y gastric bypass seven years ago, which led to candy cane syndrome. This required a revision surgery, and her postoperative course was complicated by hemorrhagic and septic shock, necessitating SICU admission and multiple laparotomies. Six weeks later, she developed a rapidly progressing ulcer at her incision site with purulent drainage. Initial management plan included antibiotics and planned debridement. Due to the atypical presentation, a dermatology consultation was obtained. Wound cultures and a biopsy revealed neutrophilic infiltration, consistent with pyoderma gangrenosum (PG). Topical and systemic immunosuppressants were started, avoiding surgical debridement. Dermatology followed her throughout her hospitalization and as an outpatient, documenting her recovery.

Discussion: Pyoderma Gangrenosum (PG) is a challenging diagnosis, often mistaken for wound infections. Our case demonstrates the necessity of considering PG in postoperative ulcerative lesions, particularly in patients with systemic conditions. Although biopsy findings are non-specific, they are essential for accurate diagnosis. This case also highlights dermatology's crucial role in diagnosing PG, as surgical debridement can worsen the condition due to pathergy. Early, accurate diagnosis and immunosuppressive therapy are key to reducing morbidity and improving outcomes. The case emphasizes the need for heightened awareness and a multidisciplinary approach in managing a critically ill patient with pyoderma gangrenosum.