Challenging differential diagnosis, Unusual setting of medical care, Rare disease
Mohsen Pourmorteza, Fady Tawadros, Gilbert Bader, Mohamed Al-Tarawneh, Emilie Cook, Wael Shams, Mark Young
Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
Am J Case Rep 2016; 17:434-438
Pyoderma gangrenosum is a rare, ulcerative cutaneous condition that was first described by Brocq in 1916. This diagnosis is quite challenging as the histopathological findings are nonspecific. Pyoderma gangrenosum is usually associated with inflammatory bowel disease, leukemia, and hepatitis C. We describe a rare clinical case of a patient with hepatitis C (HCV), mixed cryoglubinemia, and pyoderma gangrenosum, which was successfully treated with prednisone in combination with the new antiviral medication ledipasvir/sofosbuvir.
CASE REPORT: A 68-year-old male with a history of untreated HCV presented to the clinic with a left lower extremity ulcer that had progressively worsened over 4 days after the patient sustained a minor trauma to the left lower extremity. Examination revealed a 2×3 cm purulent ulcer with an erythematous rim on medial aspect of his left lower leg. HCV viral load and genotype analysis revealed genotype 1A with polymerase chain reaction (PCR) showing viral counts of 9,506,048 and cryoglobulinemia. With a worsening and enlarging erythematous ulcer and failure of IV antibiotic therapy, the patient underwent skin biopsy, which showed acanthotic epidermis with superficial and deep perivascular lymphoplasmacytic dermatitis admixed with mild neutrophilic infiltrate. The patient was subsequently started on ledipasvir/sofosbuvir and prednisone with a high suspicion of pyoderma gangrenosum. At one-month follow-up at the hepatology clinic, the patient demonstrated a near resolution of the lower extremity ulcer with undetectable viral load.
CONCLUSIONS: Pyoderma gangrenosum is an inflammatory process of unknown etiology, and establishing the correct diagnosis can be a difficult task. For this reason it is prudent for clinicians to consider Pyoderma gangrenosum in their differential diagnosis, especially in the setting of a nonhealing surgical wound or skin infection.
Keywords: Anti-Inflammatory Agents - therapeutic use, Aged, Antiviral Agents - therapeutic use, Benzimidazoles - therapeutic use, Cryoglobulinemia - drug therapy, Fluorenes - therapeutic use, Hepatitis C, Chronic - drug therapy, Humans, Male, Prednisone - therapeutic use, Pyoderma Gangrenosum - drug therapy, Uridine Monophosphate - therapeutic use, Viral Load