An extensive pyoderma gangrenosum mimicking necrotizing fasciitis: An unusual case report

Abstract

Introduction: Pyoderma Gangrenosum (PG) is a rare, benign and inflammatory disease characterized by ulcerative skin lesions. We report the successful management of an unusual case of PG following a caesarean section, with extensive cutaneous skin involvement and mimicking necrotizing fasciitis.

Presentation of case: A 36-year-old woman was admitted with extensive surgical site inflammation after a caesarean section. Despite antibiotic treatment and wound care, the clinical course deteriorated rapidly. Wound debridement following negative pressure closure was performed due to an immediate increase in skin necrosis. A diagnosis of PG was reached based on the absence of a positive wound culture, resistance to wound debridement and the histopathological results. A course of high-dose corticosteroids was started, and a successful clinical course was finally achieved. The patient is now in the 14th month of remission, with no recurrence.

Discussion: PG is often reported after bowel surgery, especially after complicated stoma or diverticulitis, breast surgery and occasionally after C-sections. The diagnosis of pyoderma gangrenosum may be challenging because of a wide variety of macroscopic features and its pronounced similarity to necrotizing fasciitis. Treatment with systemic corticosteroids is the most common management option, while surgical treatment is extremely controversial.

Conclusion: An extensive PG following surgery can mimic necrotizing fasciitis. An interdisciplinary treatment approach provides early diagnosis and effective treatment resulting in less morbidity.

Keywords: Case report; Cesarean section; Inflammatory disease; Necrotizing fasciitis; Pyoderma gangrenosum.

Fig. 1

Pyoderma gangrenosum in the C-section incision (7th day postpartum).

Fig. 2

Violaceous wound borders have spread, progressively expanding the ulcerative area (8th day postpartum) (A), and tretmanet of vacuum assisted closure (B).

Fig. 3

Extensive painful ulcerative open wound with erythematous plaques and violaceous border involving the whole lower abdomen (9th day postpartum) (A) and late of second weeks of postoperative (B).

Fig. 4

The abscess formation: a neutrophilic inflammation within subcuticular and deep dermis layers (Hematoxylin&Eosin X100).

Fig. 5

Recovery of the wound after corticosteroid treatment (1st month).

Fig. 6

The complete healing of the wound (A, 10th month and B, 1st year postpartum).