Atypical Pyoderma Gangrenosum Presenting as Paronychia
Article Outline
To the Editor:
Pyoderma gangrenosum is a rare neutrophilic dermatosis of unknown etiology, first described by Brunsting et al in 1930.1 The initial lesion can be precipitated by injury to the area or may occur spontaneously. The diagnosis is that of exclusion based on physical findings, laboratory findings, biopsy findings, and clinical suspicion. Any age group can be affected, although it mostly affects those in their third, fourth, and fifth decades.2 This case is unique in that paronychia, to our knowledge, has never been reported as a presentation of pyoderma gangrenosum.
Case Report
An 80-year-old man presented to our geriatric clinic with a painful paronychia involving the 4th metacarpal associated with intermittent non-bloody diarrhea. The paronychia was treated with cephalexin. Two weeks later, he had progression with new ulceration around the distal digit (Figure).
Figure.
Atypical variant of pyoderma gangrenosum.
There was no history of trauma or known spider bite. Laboratory studies at the time demonstrated a normal complete blood count, comprehensive profile, and urinalysis. A biopsy revealed benign skin tissue with ulceration and suppurative exudate. Cultures of the ulcer were negative. He was started on 60 mg of prednisone daily.
Four weeks later there was complete resolution of the digital ulcer. Colonoscopy showed patchy erythema throughout the colon, and biopsies were consistent with inflammatory bowel disease. He had complete resolution and no recurrence on oral steroids, tapered off over 3 months. This unusual presentation was felt to be consistent with pyoderma gangrenosum atypical variant.
Discussion
There are 3 distinct clinical variants of pyoderma gangrenosum described: classical, atypical, and peristomal. The classical variant can occur anywhere on the body, but is usually localized to the legs. The atypical variants are seen usually on the arms, face, and hands. As in our case, pyoderma gangrenosum initially may be mistakenly diagnosed as an infection or cellulitis.3 The most common systemic diseases associated with pyoderma gangrenosum include inflammatory bowel disease, inflammatory arthritis, myeloproliferative disorder, and chronic active hepatitis.4 Atypical pyoderma gangrenosum also may be associated with myelodysplastic disorders and IgA paraproteinemia.5 Vasculitis, infections, malignancy, and factitious ulcers can mimic the lesions of pyoderma gangrenosum and need to be excluded before making a diagnosis.2, 6 Pyoderma gangrenosum lesions usually respond to treatment of the underlying systemic disease.7
This case report highlights that clinicians caring for the elderly should have a high index of suspicion when subtle systemic symptoms occur in conjunction with new skin changes. Osler's comment, “The whole art of medicine is in observation
…” should not be forgotten.8
References
- . Pyoderma gangrenosum: clinical and experimental observations in five cases occurring in adults. Arch Derm Syphilol. 1930;22:655–680
- . Pyoderma gangrenosum. Mt Sinai J Med. 2001;68:287–297
- . Mimickers of hand infections. Hand Clin. 1998;4:519–529
- . Pyoderma gangrenosum. Lancet. 1998;351:581–585
- . Pyoderma gangrenosum and IgA myeloma. J Cutan Med Surg. 1997;2:100–103
- . Diagnosing pyoderma gangrenosum. Adv Skin Wound Care. 2001;14:151–153
- . Diagnosis and treatment of pyoderma gangrenosum. BMJ. 2006;333:181–184
- . The Quotable Osler. Philadelphia, PA: American College of Physicians; 2003;
Funding: None.
Conflict of Interest: None.
Authorship: We verify that all authors had access to the data and a role in writing the manuscript.
PII: S0002-9343(09)00287-3
doi:10.1016/j.amjmed.2009.01.031
Published by Elsevier Inc.
