Atypical hemorrhagic bullous pyoderma gangrenosum

• Published in: International journal of dermatology 2001-05, Vol.40 (5), p.327-329
• Main Authors: Altunay, İlknur Kıvanç, Sezgin, Saliha Aslan, İleri, Ümran, Ekmekçi, Tuğba Rezan, Kuran, İsmail, Köşlü, Adem, Baş, Lütfü
• Format: Article
• Language: English
• Subjects: Anti-Inflammatory Agents - therapeutic use; Biological and medical sciences; Biopsy; Bullous diseases of the skin; Dermatology; Female; Humans; Leg Ulcer - pathology; Medical sciences; Middle Aged; Prednisolone - therapeutic use; Pyoderma Gangrenosum - drug therapy; Pyoderma Gangrenosum - pathology; Skin Diseases, Vesiculobullous - drug therapy; Skin Diseases, Vesiculobullous - pathology; Tropical medicine
• ISSN: 0011-9059; 1365-4632
• DOI: 10.1046/j.1365-4362.2001.01091.x

A 55‐year‐old woman was seen in the Plastic and Reconstructive Surgery Clinic because of a nonhealing wound on her left leg of approximately 2 months' duration. She had an 8‐month history of multiple wounds appearing on her arms and legs. The patient noted that the majority of the wounds had been treated and healed with the use of topical medications. One wound on her left leg had continued to enlarge rapidly despite topical treatments. Therefore, hyperbaric oxygen therapy had been administered for 15 sessions. No additional healing had occurred with this treatment. Skin grafting was performed on the affected area. She developed ulcers and blistering lesions at surgical and nonsurgical sites after skin grafting. The patient was referred to the Dermatology Department. Dermatologic examination revealed a deep, necrotic ulcer, 30 cm × 10 cm, with surrounding violaceous erythema on the donor area, ulceration (18 cm × 8 cm) on the graft area, a hemorrhagic bullous plaque (5 cm × 15 cm) over the right malleolus, scattered ecchymotic lesions and small hemorrhagic bullae on both legs, and small pustules around the staplers (Fig. 1a,b). Cutaneous biopsy of a new lesion revealed a focal, dense neutrophilic infiltrate, liquefaction degeneration in the center, lymphocytic and mild plasmacytic infiltration around the venules, and fibrinoid deposits in the walls and lumen of the vessels (Fig. 2a). In addition, excessive polymorphonuclear leukocytes and extravasated erythrocytes were present in the papillary and reticular dermis (Fig. 2b). The patient had a 14‐year history of asthma bronchiale. Physical examination did not reveal any abnormality, except for crackling rales at the base of each lung. Laboratory examinations were within normal limits, except for the sedimentation rate (55 mm/h). Protein electrophoresis, peripheral blood smear, abdominal ultrasound, and thorax and abdominopelvic computed tomography scans were all normal. Swab cultures from the ulcers were negative. 1 (a) Hemorrhagic bullous lesion on the right malleolus. (b) Ulceration on the donor area 2 (a) Histopathologic section of a bullous lesion. Mild subepidermal separation, dense polymorphonuclear infiltration, and fibrinoid deposits in the lumen of the vessels (hematoxylin and eosin, × 10). (b) Focal, dense, neutrophilic infiltrate, liquefaction degeneration, and considerable separation Bullous pyoderma gangrenosum was diagnosed on clinical and histopathologic grounds. Prednisolone 80 mg/day was st