The Case

A 30-year-old man presented to the emergency department with a left leg wound that had been present for five years and “worsening over the past four months.” The patient presented because he was on the verge of losing his job because of the odor from the wound. The patient described the lesion as painful, making it difficult to ambulate. He denied recent trauma to the area. However, he had a remote history of a car accident years ago but didn’t remember any injury to the leg. He reported subjective fevers, nausea, and vomiting over the past few weeks. His past medical history was significant for smoking and nephrotic syndrome. No family history of autoimmune disorders was reported, and he denied any prior dermatological conditions.

Figure 2: Large ulcers with undermined borders and erythematous edges on the patient’s left medial leg.
GINA VENTO, MATTHEW ROEHRS, DAVID EFFRON

Upon entering the patient’s room, an intense, putrid odor was noted. The patient appeared in no acute distress, and his vital signs were normal. The patient had large ulcers with undermined borders and erythematous edges on the entire aspect of his left lateral and medial leg (see Figures 1 and 2). The leg was diffusely tender to palpation, with distal strength and sensation intact. No edema was noted. Dorsalis pedis and posterior tibial pulses were intact.

Workup for the patient included basic labs and a wound culture. Radiographs of the tibia showed a large soft tissue defect overlying the medial aspect of the proximal and mid tibia with no periosteal reaction to suggest osteomyelitis. The patient’s labs were significant for a leukocytosis of 13.7, hemoglobin of 9.7, normal lactate, and renal dysfunction with a creatinine of 2.67. The patient was started on vancomycin and Zosyn (piperacillin and tazobactam) and admitted to the medicine service. Dermatology and general surgery were consulted once the patient was admitted.

Background

Skin complaints are common reasons for visits to the emergency department, with skin infections, such as cellulitis, being one of the most common. Differentiating toxic skin conditions from benign skin conditions is essential. This patient’s condition could be concerning for a necrotizing infection, but that possibility is less likely given the time frame. Initial concern was for a chronic infection. The patient’s wound cultures grew Staph, which could have been a contaminant versus infection. Punch biopsy revealed acute and chronic inflammation. Dermatology concluded that this presentation was consistent with pyoderma gangrenosum.

The incidence of pyoderma gangrenosum is estimated to be three to 10 cases per million people per year. It is often associated with systemic disease such as inflammatory bowel disease, arthropathies, and hematologic diseases. The pathogenesis is thought to be related to neutrophil dysfunction with a component related to abnormal immune system response. Treatment is dependent on the severity of the disease. Local pyoderma gangrenosum is treated with a barrier cream and wound care to try to prevent infection. Topical steroids can also be used. If the disease is more severe, systemic corticosteroid therapy should be considered. If this does not seem to be helping, cyclosporine should be considered. Systemic steroids can result in improvement in as little as one week. It is also important to address underlying systemic disease that may be contributing to the condition.

Case Resolution

This patient was discharged on prednisone 50 mg twice a day, with a plan to taper over several weeks. It was also recommended that the patient use Vaseline with Xeroform and Kerlix for dressing changes. Cyclosporine could not be considered for this patient as he had renal disease. The patient was discharged from the hospital and was told to follow up closely with dermatology. The patient did not show up for his follow-up visits and was lost to follow-up.

Dr. Vento is an emergency medicine resident at MetroHealth in Cleveland.

Dr. Roehrs and Dr. Effron are emergency physicians at MetroHealth.