Case Presentation: A 64-year-old woman with a history of macromastia presented five days after undergoing bilateral mammoplasty with pain, fever, and purulent discharge from surgical sites. Due to concern for surgical site infection, she underwent washout and debridement, and tissue cultures were obtained. Empiric broad-spectrum intravenous antibiotics (Piperacillin-Tazobactam and Linezolid) were initiated. Despite intravenous antibiotic therapy and appropriate local wound care, she continued to experience worsening wounds with exudative discharge and necrotic tissue. Later, a repeat debridement was performed, and necrotic tissue was eventually sent for histopathologic examination. Tissue cultures remained negative for bacterial growth. Infectious disease consultation recommended continued antibiotic therapy with empiric coverage for necrotizing fasciitis. Unfortunately, the patient showed no clinical improvement. Histological examination revealed suppurative inflammation with fat necrosis. Given persistent non-healing ulcers despite antibiotics and negative cultures, PSPG was suspected. Systemic corticosteroid therapy with prednisone 60 mg daily was initiated. The patient showed good improvement and was subsequently discharged in stable condition with advice to follow up with dermatology.
Discussion: Pyoderma Gangrenosum is recognized as an autoinflammatory disorder driven by immune dysregulation and cytokine-mediated neutrophil activation. Several clinical variants exist, including ulcerative, bullous, pustular, and post-surgical types. Post Surgical PG accounts for 10–20% of all PG cases. It typically develops within 3–14 days postoperatively. PSPG is frequently misdiagnosed as surgical site infection or necrotizing fasciitis, often leading to inappropriate antibiotic use or surgical intervention. Diagnosis is clinical and by exclusion. Surgical debridement is avoided as it can exacerbate lesions due to the pathergy phenomenon. Immunosuppression remains the mainstay of treatment, with systemic corticosteroids and cyclosporine being the first-line choices. TNF-α inhibitors are typically reserved for severe cases that do not respond to conventional therapy. This case highlights the diagnostic challenge of distinguishing PSPG from infection. It emphasizes the importance of maintaining a high suspicion when surgical wounds fail to improve despite antibiotics and surgical debridement. Early immunosuppressive therapy is essential in preventing ulcer progression and reducing associated morbidity.
Conclusions: Post-surgical pyoderma gangrenosum is a rare but important differential diagnosis in patients with postoperative wound dehiscence and necrosis unresponsive to antibiotics or debridement. This case highlights the diagnostic challenge of distinguishing PSPG from infection. It emphasizes the importance of maintaining a high suspicion when surgical wounds fail to improve despite antibiotics and surgical debridement. Early recognition and prompt initiation of immunosuppressive therapy are crucial to prevent disease progression and avoid unnecessary surgical interventions.