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| ORIGINAL CONTRIBUTIONS |
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| Year : 1990 | Volume
: 56
| Issue : 4 | Page : 281-285 |
Asymptomatic ulcerative colitis and pyoderma gangrenosum
Arti Nanda, Bhushan Kumar, D Bishan Radotra, Rakesh Kochhar, Surrinder Kaur
,
Correspondence Address:
Arti Nanda
A Total of 11 patients of pyoderma gangrenosum (PG); 5 males and 6 females were observed over 8 years. The ages ranged between 35-72 years. Nine patients were associated with ulcerative colitis, one with chronic renal failure, and one was labelled idiopathic. Three of the 9 patients of PG, who had ulcerative colitis presented first with skin lesions and had clinically silent, but acute, ulcerative colitis, diagnosed only after colonoscopy and rectal biopsy. This highlights the need for investigation including colonoscopy and biopsy even in asymptomatic patients of PG. Most of the cases benefitted from medical treatment (Corticosteroids + Salazopyrin).
Keywords: Pyoderma gangrenosum, Asymptomatic ulcerative colitis
How to cite this article:
Nanda A, Kumar B, Radotra D B, Kochhar R, Kaur S. Asymptomatic ulcerative colitis and pyoderma gangrenosum. Indian J Dermatol Venereol Leprol 1990;56:281-5 |
How to cite this URL:
Nanda A, Kumar B, Radotra D B, Kochhar R, Kaur S. Asymptomatic ulcerative colitis and pyoderma gangrenosum. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2013 May 24];56:281-5. Available from: http://www.ijdvl.com/text.asp?1990/56/4/281/3547 |
Pyoderma gangrenosum (PG) is a chronic, painful, ulcerating skin disease of unknown etiology. Its association with ulcerative colitis has been recognized ever since Brunsting et al[1] described the first case in 1930. In the largest single series,[2] 31 of 62 (50%) patients with PG had ulcerative colitis. Conversely 0.5 to 5% patients with ulcerative colitis have PG.[3],[4] These lesions generally appear during the course of active bowel disease and frequently concur with exacerbation of colitis.[3],[4],[5] However, lesions of PG also occur during inactive colitis,[3],[6] and may not appear until sometime after total colectomy for extensive ulcerative colitis.[3] Occasionally skin lesions may precede active inflammation of the colon.[7] Recently we encountered 2 patients of PG with clinically silent, but active and extensive bowel disease diagnosed on sigmoidoscopy and rectal biopsy. We review our experience of 11 patients of pyoderma gangrenosum seen over a period of 8 years.
| Material and methods | |  |
All patients of pyoderma gangrenosum were admitted under departments of Dermatology and Gastroenterology between January 1980 to December 1988. They included 5 males and 6 females and their ages ranged between 35-72 years. Clinical diagnosis was confirmed on histopathology. A detailed clinical examination and investigations including hemogram, urinalysis, liver function tests, microscopic stool examination, serum proteins, serum electrophoresis, skin cultures, X-ray chest, collagen profile, neutrophil function tests, barium meal, barium enema, sigmoidoscopy and rectal biopsy were carried out.
| Results | | |
The clinical features and course in all these cases have been outlined below.
Case 1
A 72 yrs old housewife was admitted to dermatology ward in November 1988 for extensive ulceration on the face, legs, arms, hands, and ankle region of one month duration. The lesions started as small painful pustules on the face and gradually increased in size and number to involve the other sites. On examination, ulcers varying in size from 1-10 cm were present on the face, trunk, arms, legs, hands and feet. They were covered by necrotic material or pus and had classical edematous rolled out, undermined edges with surrounding zone of violaceous erythema [Figure - 1][Figure - 2]. She had no systemic symptoms. Her general physical and systemic examination were nc mal. All other laboratory parameters except for raised ESR (58 mm Ist hr) were grossly within the normal limits. The H and E stained sections [Figure - 3] from the lesion on the right arm showed extensive neutophilic infiltrate in the dermis and extension of inflammation into the epidermis.
On sigmoidoscopy loss of mucosal pattern, edema and erythema of the lower colon (20 cms) was observed. Rectal biopsy [Figure - 4] revealed changes of acute ulcerative colitis.
Rapid resolution of the lesions occurred° within 2 months of treatment with prednisolone (80 mgs) and Salazopyrin (2 gms). The dose of prednisolone was slowly tapered to 30 mgs and no bowel symptoms appeared till the last follow up (March 1989).
Case 2
A 57 years old male was admitted with recurrent ulcers and discrete pustules on the right buttock, lower back, face and trunk of 4 years duration. In the present episode of 4 months duration the lesions showed no tendency to heal. These were not associated with any systemic symptoms. Cultures from the pustules as well as from ulcers were sterile. Biopsy from the lower back lesion showed changes consistent with pyoderma gangrenosum. Sigmoidoscopy and rectal biopsy showed changes of acute ulcerative colitis. Other laboratory parameters were within normal limits. The lesions responded satisfactorily to treatment.
Case 3, 4 and 9
Patients 3 had to admitted twice in skin ward for the management. No underlying systemic ailment could be identified either time. During her first admission (August 1987), she was treated with prednisolone, which was slowly tapered. A relapse one month prior to her second admission (December 1988) was managed with 200 mg of clofazimine daily to avoid steroid toxicity. A rapid resolution of the lesions was noticed over next 2 months and no new lesions had appeared when seen last.
Patient 4 was known case of essential hypertension for 10 years and was diagnosed to have chronic renal failure 2 years back. Kidney biopsy showed changes of benign nephrosclerosis. For the same duration she had non healing ulcers on both the lower legs. The lesions had the classical morphology of PG and was confirmed on histopathology. Patient subsequently died of chronic renal failure. No other systemic ailment could be detected.
Patient 9 was brought to the emergency with large, rapidly progressive ulcer on the left high with septicemia. There was no history of abdominal complaints whatsoever. She died of septic shock 2 days after admission and diagnosis of pyoderma gangrenosum and ulcerative colitis was made on autopsy.
Case 5-8, 10 and 11
All were known cases of idiopathic ulcerative colitis and had active bowel disease at the time of skin lesions. Skin lesions and bowel symptoms in all these cases could be managed with prednisolone and salazopyrine. Patient 10 in addition required skin graft for the large non-healing ulcer on the abdominal wall.
| Comments | | |
Four of the five patients of pyoderma gangrenosum described by Brunsting et al[1] had chronic ulcerative colitis. Subsequent reports[2],[8],[9] emphasized the importance of PG with inflammatory bowel disease including Crohn's disease. As the condition became increasingly recognized as a clinical entity other associated diseases including arthritis,[9],[10],[11] paraproteine mias,[12],[13]chronic active hepatitis [14] blood dyscrasias[16] and many indolent illnesses[16]' were described. In our series of 11 patients, 9 (82%) patients had ulcerative colitis. One (Patient 4) had chronic renal failure and hypertension, whereas in patient 3 no associated illness could be identified. Three (patient 1, 2 and 9) of these cases presented primarily with the skin lesions and concomitant ulcerative colitis was diagnosed on colonoscopy and rectal biopsy. In other 6 (Patients 5-8, 10 and 11) cases having the established chronic idiopathic ulcerative colitis, the duration between the bowel symptoms and onset of skin lesions varied between 1-10 years. In a review by Powell et al,[11] out of 31 patients having PG with inflammatory bowel disease, 29 patients had preexisting bowel disease, in one the onset of both the skin and bowel symptoms was simultaneous, and in one skin lesions preceded the bowel symptoms.
It has been suggested[3],[5] that there is preferential occurrence of skin lesions in early onset colitis or in younger patients. In late onset colitis, PG appears less frequently. Thronton et al[6] found that chronic ulcerative colitis was present for an average of 10 years before the appearance of PG. Our observations do not seem to support all these previous observations. All our patients had the onset of ulcerative colitis above 40 years of age. Rather in patient 1 disease manifested for the first time at the age of 72 years. All patients except 2 (Patient 5 and 10) developed the skin disease within first 3 years of the bowel disease.
Skin lesions generally appear during the clinically active bowel disease.[3],[6] In all patients of Thronton et al,[6] the lesions of pyoderma gangrenosum appeared for the first time during clinically quiescent phase of colitis. In our series all patients with symptomatic (Patients 5-8, 10 and 11) as well as a symptomatic (Patients 1, 2 and 9) bowel disease, had the changes of acute ulcerative colitis on histopathology at the time of active skin lesions. However the serial biopsies of the colon were not carried out, after the subsidence of skin lesions to look for simultaneous subsidence of colitis also.
Conventional medical treatment (steroids + salazopyrin) as reported earlier[7],[8] was observed to benefit the skin lesions in all our patients.
Although seen in association with many systemic disorders, ulcerative colitis still forms the most significant association with PG. In all the patients presenting with PG, colonoscopy and rectal biopsy must be carried out even when no bowel symptoms are presented. This will help in early detection of bowel involvement and better management.
| References | | |
| 1. | Brunsting LA, Goeckerman WH and O'Leary PA Pyoderma (ecthyma) gangrenosum : Clinical and experimental observation in five cases occurring in adults. Arch Dermatol, 1930; 20:655-680.  |
| 2. | Perry HO : Pyoderma gangrenosum, South Med. J, 1969; 62:899-908. |
| 3. | Joghnson ML and Wilson HT : Skin lesions in ulcerative colitis, Gut, 1969; 10:255-263. |
| 4. | Basler RSW : Ulcerative colitis and the skin, Med Clin North Am, 1980; 64:941-954. |
| 5. | Mir-Madjlessi SH, Taylon SJ and Farmer RG Clinical course and evolution of erythema nodosum and pyoderma gangrenosum in chronic ulcerative colitis : A study of 42 patients, Am J Gastroenterol, 1985; 80:615-620. |
| 6. | Thronton JR, Teague RH, Low-Beer TS et al Pyoderma gangrenosum and ulcerative colitis, Gut, 1980; 21:247-248. |
| 7. | Edwards FC and Truelove SC : The course and prognosis of ulcerative colitis, Gut, 1964; 5:1-22. |
| 8. | Perry HO and Brunsting LA : Pyoderma gangrenosum : a clinical study of nineteen cases. Arch Dermatol, 1957; 75:380-386. |
| 9. | Schoetz DJ, Coller JA and Veidenheimer MC Pyoderma gangrenosum and Crohn's disease, Dis Colon Rectum, 1983; 26 : 155-158. |
| 10. | Stolman LP, Rosenthan D, Yaworsky R et al Pyoderma gangrenosum and rheumatoid arthritis, Arch Dermatol, 1975; 111 : 1020-1023. |
| 11. | Powell PC, Schroster AL and Perry HO : Pyoderma gangrenosum : A review of 86 patients, Quart J Mod, 1985; 55 : 173-186. |
| 12. | Sluis I V.D. : Two cases of pyoderma (ecthyma) gangrenosum associated with the presence of an abnormal serum protein (BA- paraprotein) : With a review of literature, Dermatologica, 1966; 2 : 409424. |
| 13. | Pyrstowsky JH, Kahn SN and Lazarus GS : Present status of pyoderma gangrenosum, Arch Dermatol, 1989; 125 : 57-64. |
| 14. | Byrne JPH, Hevitt M and Summerly R : Pyoderma gangrenosum associated with active chronic hepatitis : report of two cases, Arch Dermatol, 1976; 112 : 1291-1301. |
| 15. | Perry HO and Winkelmann RK : Bullous pyoderma gangrenosum and leukemia, Arch Dermatol, 1972; 101:901-905. |
| 16. | Schwaegerle SM, Bergfeld WF, Senitzer D et al Pyoderma gangrenosum : A review, J Am Acad Dermatol 1988; 18 : 559-568. |
Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
| This article has been cited by | | 1 |
Pyoderma gangrenosum |
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| Devi, B., Mohanty, J. | | Indian Journal of Dermatology, Venereology and Leprology. 2003; 69(2): 193 | | [Pubmed] | |
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