Cases Of Post-surgical Pyoderma Gangrenosum Research Articles

Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review.

Pyoderma gangrenosum is a neutrophilic dermatosis characterized by immune dysfunction and pathergy. Thus, it is frequently seen in patients with underlying systemic illnesses or postoperatively. For the performance of the debridement or closure of the resultant defect, plastic surgeons are often involved in the care of pyoderma patients. However, both procedures may exacerbate the injury. Therefore, plastic surgeons must be familiar with the presentation of postsurgical pyoderma to avoid further damage and safely repair related soft tissue defects. A systematic search of the PubMed/Medline database was performed using the following keywords: "pyoderma gangrenosum" and "surgery." This online database search has identified 656 studies published between 1958 and 2022. Only reconstructed cases of postsurgical pyoderma gangrenosum were selected. Twenty-eight patients who developed pyoderma after dermatologic, plastic, orthopedic, cardiovascular, general, or obstetric surgery were included in this study. The average time to the PG presentation and diagnosis was 5.5 and 17 days, respectively. Diagnostic scoring tools were not used, and the diagnosis was primarily based on histopathology after repeated treatment failures. The patients received split- or full-thickness skin grafts, local, pedicled, and free flaps. An estimated 82.1% underwent skin grafting, whereas 42.9% underwent flap reconstruction. In addition, 21.4% got both the graft and flap. Accurate diagnosis of PSPG, prevention of further surgical injury, and timely medical management are vital for improving patient outcomes. Reconstruction can be performed, if required. However, despite the availability of different reconstructive techniques, there is no standard approach to the management of the PSPG.

The Management of Postsurgical Pyoderma Gangrenosum following Breast Surgery.

Background:Postsurgical pyoderma gangrenosum is a rare condition characterized by ulcerative lesion development at surgical sites. It is frequently misdiagnosed as infection and mismanaged with surgical debridement, which only worsens the condition. Achieving the correct diagnosis is crucial to delivering the appropriate medical therapy. This article presents four clinical cases of postsurgical pyoderma gangrenosum in breast surgery patients, and proposes a work-up schematic to aid in its diagnosis based on literature review and author experience.Methods:Four patients who developed postsurgical pyoderma gangrenosum following breast surgery were identified by chart review at our institution.Results:The cases include two breast reduction patients, an abdominally based breast reconstruction patient, and a breast augmentation patient. The time to diagnosis and treatment varied greatly between the patients, with diagnosis achieved as early as 13 days postoperatively to as late as one year postoperatively. Two of the four patients were initially mismanaged with surgical debridement, and all patients were treated with at least one course of antibiotics for a misdiagnosis of surgical site infection before they were correctly diagnosed.Conclusions:Postsurgical pyoderma gangrenosum is a rare, ulcerative condition that is difficult to diagnose and often mismanaged with surgical debridement. Diagnosis requires a high clinical suspicion and should be considered in patients with ulcerative lesions resistant to antibiotic therapy, in patients who have bilateral lesions with NAC sparring, and in those with systemic inflammatory conditions. Diagnosis is usually delayed, so it is imperative that surgeons keep this diagnosis in mind when treating breast patients with postsurgical wounds.

Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator (DIEP) Breast Reconstruction: A Case Report

Pyoderma gangrenosum (PG) is a rare dermatologic condition manifesting as sterile, rapidly progressing painful skin ulcerations. It is commonly associated with autoimmune disorders such as inflammatory bowel disease. This case report illustrates a severe case of post-surgical pyoderma gangrenosum (PSPG) following bilateral deep inferior epigastric perforator flap breast reconstruction in a 56-year-old Caucasian woman. Factors delaying diagnosis included negative personal/family history of inflammatory disorders and a clinical presentation more suggestive of breast cellulitis. Refractory antibiotic therapy, subsequent ulceration at multiple breast and abdominal incisions, and pathergic response to tissue biopsy supported an eventual clinical diagnosis of PSPG, 12 days postoperatively, despite equivocal histopathologic findings. Initiation of intravenous immunoglobulin, prednisone therapy, local wound care, and avoidance of debridement led to a full resolution by 5 months postoperatively. This study raises awareness for PSPG and highlights the importance of early recognition and urgent dermatology consultation to expedite optimal treatment and minimize subsequent fat necrosis.

Postsurgical Pyoderma Gangrenosum Versus Necrotizing Fasciitis: Can We Spot the Difference?

Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris. Exceptionally, it can be precipitated by surgery alone, and this entity has been described as postsurgical pyoderma gangrenosum (PSPG). Cases of PSPG in the literature are rare. We performed a retrospective review of the current literature on PSPG and highlight some observed differences between these conditions. We also present our experience of PSPG imitating an infectious process post reduction mammoplasty. Although PSPG can demonstrate fever, malaise, systemic signs, and serology that mimic the sepsis of necrotizing fasciitis, we identify some features that can aid diagnosis of pyoderma gangrenosum in the absence of pathergy (which is pathognomonic). These include premorbid inflammatory bowel disease, hematological malignancy, or inflammatory polyarthritis; the exquisite and disproportionate pain associated (in particular within surrounding normal skin); symmetrical changes on both breasts; specific histopathological changes with absence of microorganisms; cutaneous wounds demonstrating an ulcerated, violaceous, and undermined edge; and, in this case, bilaterally spared nipple-areola complexes suggesting progression within continuous skin up to but not across incision lines. We hope that, in encouraging a higher index of suspicion, prompt diagnosis, and accurate treatment, a better outcome for both patient and surgeon can be achieved in future cases.

Pyoderma gangrenosum with pathergy: A potentially significant complication following breast reconstruction

The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy should alert the clinician to other diagnoses. Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that is typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a condition known as pathergy. We present a case series of PG arising after immediate reconstruction for breast oncological surgery from 1st January 2006 to 1st September 2014. 395 immediate breast reconstructions were performed in 335 patients. Three cases of post-surgical PG were identified (0.9%), all in the setting of mastectomy for breast cancer. Two cases underwent immediate reconstruction with pedicled transverse rectus abdominus myocutaneous flaps, and one underwent submuscular expander insertion. A mean delay of 6.3 days was observed from first presentation of symptoms to diagnosis of PG. Immunosuppressants commonly used included methylprednisolone, prednisone, and ciclosporin, with good success at halting disease progress. Significant scarring affected all three women. Once the disease was deemed quiescent, intravenous immunoglobulin used in the perioperative period for further surgical procedures provided favorable results. A diagnostic algorithm is suggested to guide surgeons in investigations and management when post-surgical PG is suspected.

Postsurgical Pyoderma Gangrenosum After Autologous Breast Reconstruction

Pyoderma gangrenosum (PG) is a rare skin disorder of unknown etiology that is believed to be part of the spectrum of neutrophilic dermatoses. Although 25% to 50% of cases are idiopathic, PG is associated with systemic disease in up to 70% of patients, most notably inflammatory bowel disease, rheumatoid arthritis, and paraproteinemia. Although a multitude of PG cases after breast reduction have been reported, only recently has an association of PG with breast reconstruction been acknowledged. In the present article, the case of postsurgical PG (PSPG) after autologous breast reconstruction is presented along with a review of the literature. The importance of early diagnosis and initiation of appropriate treatment is discussed. The authors discuss the possibility that the increased number of breast reconstructions being performed may increase the incidence of PSPG cases seen by plastic surgeons. As such, it is critical to remove PSPG from the list of "exotic" diseases and place it higher on the list of differential diagnoses as delays in treatment can result in debilitating complications with substantial patient morbidity.