A case of multiple deep and necrotic ulcers on the face

Abstract

A 31-year-old male presented with painful facial ulcers over bilateral cheeks and the forehead for the past 2 weeks (Figure 1). Recent contact history included superficial chemical peeling with glycolic acid and self-squeezing of his cystic acne. The ulcers were shallow, clean and had a relatively broad base, with particular lesions over the left face arranged in a bizarre linear pattern. Self-induced pyoderma was suspected. However, the ulcers did not improve with antibiotic treatment. One month later, the patient was admitted under the impression of pulmonary tuberculosis and meningitis because of fever, cough, yellowish sputum, headache and nuchal rigidity for 3 weeks. Routine blood sampling revealed significant leukocytosis (19.2 × 109/L), elevated C-reactive protein levels (149.83 mg/L [1427 nmol/L]), elevated liver functions (glutamate oxaloacetate transaminase, 94 IU/L; glutamic pyruvic transaminase, 121 IU/L), elevated erythrocyte sedimentation rate (43 mm/hr), pyuria and microscopic hematuria. X-ray and computed tomography revealed multisinus sinusitis and lung cavitations in the bilateral lung apex. Bronchoscopy showed inflammatory change over bilateral bronchi. Further autoimmune investigation demonstrated elevated levels of anti-neutrophil cytoplasmic antibody with antiproteinase 3 specificity (C-ANCA, 502 U/mL) (reference range: < 7 U/mL), negative perinuclear(p)-ANCA, and elevated rheumatoid factor (RA factor, 293 IU/mL) (reference range < 30 IU/mL). During admission, the patient developed pain over the elbow joints, shoulders and thighs. The facial ulcers became more necrotic and deeper with purulent yellowish discharge, with an undermined cavity and purpuric overhanging border; they were associated with severe pain (Figure 2). These symptoms were suggestive of malignant pyoderma.1–3 In addition, new ulcers developed on bilateral shoulders. Aerobic, anaerobic, and mycobacteria wound pan-cultures were negative. Skin biopsy at the edge of the ulcer showed massive destruction of the dermis, many multinucleated giant cells, diffuse lymphocytic infiltration, and extravasation of erythrocytes (Figure 3).