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CASE REPORT
Year : 1997  |  Volume : 63  |  Issue : 1  |  Page : 58-60

Pyoderma gangrenosum in HIV patient


Department of Dermatology and Venereology, AFMC, Pune - 411040, India

Correspondence Address:
S K Sayal
Department of Dermatology and Venereology, AFMC, Pune - 411040
India
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Source of Support: None, Conflict of Interest: None


PMID: 20944265

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  Abstract 

Pyoderma gangrenosum (PG) has previously been reported in very few patients with HIV infection. We describe here a 30-year-old housewife with HIV infection having multiple ulcerations over lower limbs characteristic of PG.


Keywords: HIV, Pyoderma gangrenosum


How to cite this article:
Sayal S K, Malik A K, Banerjee S. Pyoderma gangrenosum in HIV patient. Indian J Dermatol Venereol Leprol 1997;63:58-60

How to cite this URL:
Sayal S K, Malik A K, Banerjee S. Pyoderma gangrenosum in HIV patient. Indian J Dermatol Venereol Leprol [serial online] 1997 [cited 2020 May 25];63:58-60. Available from: http://www.ijdvl.com/text.asp?1997/63/1/58/4509



  Introduction Top


There have been very few cases reports of HIV infected patients with lesions of pyoderma gangrenosum (PG).[1][2][3] None of the reported cases in HIV patients had other conditions commonly associated with PG.


  Case Report Top


A 30-year-old housewife developed a small erythematous plaque on outer aspect of lower part of left leg, which soon become pustular and evolved into an ulcer, which gradually increased in size and became deeply necrotic over next 2 weeks. During next one month, she developed similar lesions on her left and right thighs. The patient had no abdominal pain, arthritis or bloody stools. There was no history suggestive of any HIV related opportunistic infections.

The patient was married for 4 years and had one male child, one year old. Her husband gave history of ruptured bubo in right inguinal region 3 months back and was found to be ELISA positive for HIV. General examination revealed the patient to be of asthenic built, pale, with no significant lymphadenopathy. Dermatological examination revealed asymmetrically distributed multiple irregularly shaped deep ulcers varying in size from 2x3 cm to 8x20 cm over left leg and both thighs [Figure - 1]. The ulcers had violaceous overhanging borders and necrotic foul smelling slough. There were no other significant systemic or dermatological findings.

Laboratory examination revealed Hb 9.7 gm% and ESR 36mm. Metabolic parameters were within normal limits. Other investigations viz rheumatoid factor, VDRL, HBsAg, ANA were all negative. Stool for occult blood was negative. Bacterial culture grew Staphylococcus aureus Scientific Name Search  and Pseudomonas aeruginosa. Biopsy from margin of ulcer showed a neutrophilic dermatosis consisting of diffuse inflammatory infiltrate of polymorphonuclear leucocytes which extended from the ulcer bed to beneath the adjacent epidermis. ELISA for HIV-1 and Western Blot tests were found positive.

She was treated with oral prednisolone 1 mg/kg, systemic antibiotics in form of ciprofloxacin and other supportive management. The ulcers healed completely within 6 weeks. After follow up of 3 months, she showed no evidence of recurrence of ulcerations.


  Discussion Top


Pyoderma gangrenosum (PG) is a necortizing non-infectious ulcerative condition which presents morphologically in various forms eg furuncle, bullae or necrotic gangrenous ulceration. It is usually related to a defective immune system with paralysis of reticuloendothelial system, which can not protect the tissues from minimal infection. PG is usually associated with disorders of gastrointestinal tract, joints and haematological disorders in immunocompetent persons. Immunosuppressed persons with primary immunodeficiency constitute another group. Till date there have been reports of only 5 cases of PG associated with HIV infection.[1]

In the previously reported cases the appearance of PG preceded detection of HIV in 2 patients, followed it in 2 and occurred concurrently in 1 patient.[1] In our case, HIV infection was detected concurrently. PG typically involves lower limbs of persons without HIV infection but it has been reported to involve the perineum of HIV patients. All the reported cases of PG have also been reported to respond to systemic steroids. Our patient also showed an excellent response to treatment with systemic steroids within six weeks. However, in an immunocompromised individual the use of prolonged systemic steroids carries its own risks. In a retrospective study of 130 HIV patients treated with systemic steroids, 11 developed cytomegalovirus disease (retinitis in 8 and colitis in 3) within one month of completion of therapy.[4] In another study of 12 HIV infected patients with idiopathic oesophageal ulceration who were treated with systemic steroids, mild asymptomatic candidial oesophagitis occurred in 3 patients and dermatomal herpes zoster in one patient.[5] Nelson et al[4] observed that short term systemic corticosteroid therapy appears to be well tolerated by HIV infected patients with CD4 counts greater than 50. It is therefore, important to asses the degree of immunosuppression in HIV patient by testing for CD4/CD counts and other immunological tests, to carefully monitor the side effects of steroids and its effect on the course of HIV disease and pyoderma gangrenosum.

 
  References Top

1.Clark HH, Cohen PR. Pyoderma gangrenosum in an HIV infected patient. J Am Acad Dermatol 1995;32:912-4.  Back to cited text no. 1  [PUBMED]    
2.Paller AS, Sohn EE, Garen PD, Dobson RL, Chadwick EG. Pyoderma gangrenosum in paediatric acquired immunodeficiency syndrome. J Paediatr 1990;117:63-6.  Back to cited text no. 2      
3.Schwartz BK, Clenderning WE, Blasik EG. Pyoderma gangrenosum in a patient with HTLV-III antibody. Arch Dermatol 1986;122:508-9.  Back to cited text no. 3      
4.Nelson MR, Erskine D, Hawkins DA, Gazzard. BG. Treatment with corticosteroids-a risk factor for the development of clinical cytomegalovirus disease in AIDS. AIDS 1993;7:375-8.  Back to cited text no. 4      
5.Wilcox CM, Schwatz DA. A pilot study of oral corticosteroid therapy for idiopathic oesophageal ulceration associated with human immunodeficiency virus infection. Am J Med 1992;93:131-4.  Back to cited text no. 5      


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