Case Presentation:

A 69-year-old Caucasian male with a history of hypertension, COPD, psoriasis and basal cell carcinoma underwent robotic assisted laparoscopic prostatectomy for treatment of prostate cancer. One week after surgery, he presented to his surgeon with pain and erythema around the supra-umbilical port. He was treated with amoxicillin-clavulanate for presumed surgical site infection; however his pain and erythema progressed. The patient presented to the emergency department and laboratory studies showed a white blood cell count of 23,000 cells/cubic millimeter. He was hospitalized for sepsis and initially treated with ampicillin/sulbactam and vancomycin. CT scan of the abdomen showed no abdominal abscess, blood cultures were negative and wound culture showed rare diptheroids. Rheumatologic workup included anti-neutrophilic cytoplasmic antibody, lupus anticoagulant, anti-cardiolipin antibodies, beta-2-glycoprotein-I and cryoglobulins which were negative. His liver function test and hepatitis virology profile were unremarkable. Infectious disease escalated the antibiotic regimen to meropenem and daptomycin due to worsening wounds. On hospital day 16, rheumatology was consulted for rapidly growing, painful ulceration of four out of the six port sites. Biopsy of the ulcer was obtained which showed neutrophilic infiltration of the dermis and subcutaneous tissue.  He was started on 60 mg of prednisone, 1500mg of mycophenolate mofetil plus tacrolimus ointment. There was complete resolution of the ulcers three weeks post immunosuppressive therapy.

Discussion:

Pyoderma Gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, rapidly expanding noninfectious ulcers. There are few reported cases of PG after laparoscopic surgery. Pathogenesis remains unclear but the phenomenon of pathergy in which trauma provokes skin lesions remains a plausible cause. Pyoderma Grangrenosum is usually associated with systemic diseases, with inflammatory bowel disease being most common. It is also seen in rheumatoid arthritis, certain hematological and solid malignancies or following trauma or surgery. It begins as a tender papule that rapidly expands by one to two centimeters a day or doubles in size within one month. Diagnosis of PG is usually one of exclusion. Treatment consists of stringent wound management, steroids and immunosuppressive medications. Often mistaken for an infectious ulcer, it can lead to inappropriate antibiotic use and surgical interventions. Surgical debridement is not indicated for PD, and in fact, can lead to enlargement of the lesions and delayed healing. 

Conclusions:

Association with laparoscopic surgery is rare likely due to less trauma. Despite its rarity, the clinician’s awareness and timely diagnosis can help change the course of treatment. This increased awareness can help improve the  mortality and morbidity usually seen with Pyoderma Gangrenosum.