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  IN THIS Article
 ::  Abstract
 :: Introduction
 :: Case Report
 :: Discussion
 ::  References
 ::  Article Figures

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  Table of Contents     
CASE REPORT
Year : 2015  |  Volume : 61  |  Issue : 1  |  Page : 42-43

Postoperative pyoderma gangrenosum: A rare complication after appendectomy


Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission07-Dec-2013
Date of Decision29-Jan-2014
Date of Acceptance21-Feb-2014
Date of Web Publication15-Dec-2014

Correspondence Address:
Dr. B Abtahi-Naeini
Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: Skin Diseases and leishmanias is research center, School of Medicine, Isfahan University of Medical Sciences. Isfahan, Iran., Conflict of Interest: None


DOI: 10.4103/0022-3859.147042

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 :: Abstract 

Pyoderma gangrenosum (PG) is an uncommon inflammatory ulcerative skin disease. It is characterized by painful progressive necrosis of the wound margins. Rarely, postoperative pyoderma gangrenosum (PPG) manifests as a severe disturbance of wound healing following surgical interventions. Only rare cases of this complication have been reported after appendectomy. We report a case of PPG in a 29-year-old female after appendectomy. She was successfully treated with oral prednisolone. Postoperative pyoderma gangrenosum should be kept in mind in the differential diagnosis of any postoperative delayed wound healing, because this disease is simply distinguished from a postoperative wound.


Keywords: Appendectomy, postoperative, pyoderma gangrenosum


How to cite this article:
Faghihi G, Abtahi-Naeini B, Nikyar Z, Jamshidi K, Bahrami A. Postoperative pyoderma gangrenosum: A rare complication after appendectomy. J Postgrad Med 2015;61:42-3

How to cite this URL:
Faghihi G, Abtahi-Naeini B, Nikyar Z, Jamshidi K, Bahrami A. Postoperative pyoderma gangrenosum: A rare complication after appendectomy. J Postgrad Med [serial online] 2015 [cited 2019 Jul 18];61:42-3. Available from: http://www.jpgmonline.com/text.asp?2015/61/1/42/147042



 :: Introduction Top


Pyoderma gangrenosum (PG) is a rare inflammatory skin disease of unknown cause. Lesions typically begin as pustules, nodules, or bullae that rapidly evolve into shallow or deep ulcers with ragged, undermined, violaceous, or gunmetal-colored borders. Clinically, the patient has classically high fever and severe local pain. [1] The disease may show two patterns an acute course and a slow indolent one. [2] Postoperative pyoderma gangrenosum (PPG) is an unusual clinical entity with rapidly progressive skin necrosis that can occur after any surgical procedure. [3],[4] It is important for surgeons, internists, and dermatologists to be familiar with this entity, as a delay in diagnosis and management can be life-threatening and lead to considerable tissue loss. [3] We report the case of a young female in whom PG developed after an uncomplicated appendectomy; we then discuss the nature and method of diagnosis in this case.


 :: Case Report Top


A 29-year-old previously healthy female, presented with fever, chills, and dehiscence of the surgical wound (a well defined lesion with raised edges and an irregular base) following an apparently uncomplicated appendectomy. She suffered from an acute attack of appendicitis two weeks prior to presenting to us. She had no history of previous illness such as inflammatory bowel disease, arthritis, or hematological diseases. The patient was treated with systemic antimicrobial treatment following diagnosis of surgical wound infection. Despite the local wound care, parenteral antibiotic treatment and repeated surgical debridement, there was no improvement and there was rapid worsening and extension of the lesion. Blood and wound cultures, were negative for any pathogens. A skin biopsy after a dermatological referral confirmed the diagnosis [Figure 1]. It revealed the presence of intense neutrophilic infiltrates consistent with PG without any evidence of infection [Figure 2]. Treatment with oral prednisolone (50 mg /day) was immediately initiated. She was successfully treated with this regimen and her symptoms dramatically responded after a fortnight of steroid therapy. She was discharged on Day 14 in good general condition while tapering off the steroids, under supervision of dermatological service, and was freed from medication after 6 weeks. The wound healed completely with a fine atrophic scarring.
Figure 1: Postoperative pyoderma gangrenosum. Dehiscence of the surgical wound, with erythematous raised edges at the site of recent appendectomy

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Figure 2: Postoperative pyoderma gangrenosum. Massive neutrophilic infiltration, necrosis of the overlying epidermis. Neutrophils are around the vessel walls, without evidence of leukocytoclasia, granuloma formation is not seen. (Hematoxylin-eosin ×400)

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 :: Discussion Top


Between 50% and 70% of the cases of PG are associated with other diseases, the most frequent being inflammatory bowel disease. Other associated diseases include arthritis and hematologic disorders. [5]

PG can appear spontaneously or as a result of the pathergy phenomenon after trauma or surgery. [4],[6] Many patients can relate the development of the skin lesions to recent trauma to the affected area, a phenomenon known as pathergy. Based on pathergy, it has been suggested that minor trauma to the skin may initiate the development of PG. [7] Postoperative PPG represents a specific entity; it shares some clinical aspects of PG, but has a series of its own features. The onset of PPG follows a sequence. After an apparently normal evolution of scar formation following a surgical procedure, the scar presents with small foci of dehiscence, which will progressively coalesce to some larger areas of wound ulceration. [8] The delay between surgery and the beginning of symptoms is variable, from 4 days to 6 weeks. The skin ulcerations become larger, despite any local treatment or antibiotics and debridement. [8] PG has been reported in case reports and case series. The delay in diagnosis likely accounts for the high mortality. [9]

In the majority of cases it is misdiagnosed as severe wound infection leading to improper debridement and thus exacerbating the problem, [5],[10] as was the case of our patient. Failing to consider postoperative pathergy, which is likely to occur in previously undiagnosed cases of PG, usually leads to debridement that worsens the lesions. [1] Long et al. recommend subcuticular sutures in order to minimize the risk of PPG; as this method avoids puncturing the skin surface [11] and we recommend the same as these are inexpensive.

 
 :: References Top

1.
Le Huu S, Spertini F, Roggero P, Egloff DV, Raffoul W. Pyoderma gangrenosum: A rare pathology or an omitted diagnosis?. Ann Chir Plast Esthet 2009;54:82-7.  Back to cited text no. 1
    
2.
Singh I, Bedi G, Handa U, Mehta S, Handa S. Widespread indolent pyoderma gangrenosum: Case report. Indian J Dermatol 1994;39:54.  Back to cited text no. 2
    
3.
Grillo MA, Cavalheiro TT, da Silva Mulazani M, Rocha JL, Semchechen D, da Cunha CA. Postsurgical pyoderma gangrenosum complicating reduction mammaplasty. Aesthetic Plast Surg 2012;36:1347-52.  Back to cited text no. 3
    
4.
Sarkar R, Thami G, Bhardwaj S, Kanwar A. Superficial Granulomatous Pyoderma. Indian J Dermatol 2003;48:87.  Back to cited text no. 4
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5.
Sanz-Munoz C, Martinez-Moran C, Miranda-Romero A. Pyoderma gangrenosum following cesarean delivery. Actas Dermosifiliogr 2008;99:477-80.  Back to cited text no. 5
    
6.
Ferrandiz-Pulido C, Bartralot R, Fuente MJ, Heras C, Bassas P, Aparicio G, et al. Postoperative pyoderma gangrenosum: Diagnostic value of 16s ribosomal RNA sequencing and review of the literature. Clin Exp Dermatol 2009;34:598-602.  Back to cited text no. 6
    
7.
deCastro SM, Songun I, Dwars BJ. An unexpected severe complication after a negative laparoscopic appendectomy. Can J Surg 2009;52:E295-6.  Back to cited text no. 7
    
8.
Ouazzani A, Berthe JV, de Fontaine S. Post-surgical pyoderma gangrenosum: A clinical entity. Acta Chir Belg 2007;107:424-8.  Back to cited text no. 8
    
9.
Langan SM, Groves RW, Card TR, Gulliford MC. Incidence, mortality, and disease associations of pyoderma gangrenosum in the United Kingdom: A retrospective cohort study. J Invest Dermatol 2012;132:2166-70.  Back to cited text no. 9
    
10.
Pishori T, Qureshi AH. Post-colectomy peristomal pyoderma gangrenosum. J Coll Physicians Surg Pak 2005;15:121-2.  Back to cited text no. 10
    
11.
Long CC, Jessop J, Young M, Holt PJ. Minimizing the risk of post-operative pyoderma gangrenosum. Br J Dermatol 1992;127:45-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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