A 35‐year‐old man presented with 4 days of right leg pain secondary to a chronic ulcer. Though the ulcer on his shin had been present for 2 months, he recently noted the pain and new purulent drainage. He also noted the new onset of painful penile lesions. He was seen 2 weeks earlier, diagnosed with a skin abscess. The lesion was incised and drained in the ED, and he was sent home with oral antibiotics. The lesion worsened prompting his presentation to the hospital. His physical exam was normal; afebrile and vital signs were normal. There was a 2 centimeter ulcer with heaped edges on the lower right ankle. There was pumlence on the medial aspect of the lesion, posterior to the medial malleolus. There was also a large area of fluctuance on the lateral aspect of the patient's right calf with surrounding erythema. The genital lesions were dark purple and painful. The while blood cell count was 10.3. A radiograph of the right ankle revealed no osteomyelitis; an MRI revealed an intramuscular abscess within the exlensor digitorum longus muscle measuring 4 × 3 × 7 cm along with myositis of the medial and lateral gastrocnemius. There were multiple microabscesses within the medial head of the gastrocnemius.
Cellulitis and soft‐tissue abscesses are commonly encountered by the hospitalisls. Although most are responsive to drainage and antibiotics, it is important that the hospitalisls recognize the clinical presentation of those disorders that are not responsive to antibiotics alone. Pyoderma gangrenosum (PG) is a noninfectious neutrophilic disease affecting the skin. PG presents as painful ulcers with purulent or hemorrhagic exudates. These ulcers often have bluish, undermined borders with surrounding erythema. Although PG lesions are sterile, they can become purulent and malodorous secondary to superinfection. PG is often associated with an underlying inflammatory bowel disease, rheumatic disorder, or neoplasia. It is important for the hospitalist to elicit a full history to exclude these underlying disorders. PG is thought to be an aberrant immune response from an unknown trigger causing the normal protective pathways of the epidermis to degrade resulting in tissue necrosis. PG is diagnosed by exclusion, anc there is no specific test for identification. Histopathology is helpful in establishing the diagnosis.
Since PG is a sterile, noninfectious disease, the mainstay of treatment is corticosteroids. Alternative therapies include mycophenolate mofetil, cyclosporine, tacrolimus, thalidomide, or infliximab. In patients with PG, incision and drainage will accelerate Ihe formation of more lesions, making early clinical detection essential lest the disease is exacerbated by standard management of bacterial abscess. Surgery is only recommended in patients who are in partial remission. PG patients must be aware of their disease and inform health care providers of their condition in order to avoid surgery leading to a worsening of their condition.
L. Carpenter, none; C. Cao, none.