Pyoderma gangrenosum and urinary tract infection

Introduction

Pyoderma gangrenosum is a destructive, necrotizing, non - infective ulceration of skin, presenting as a furuncle - like nodule, pustule or haemorrhagic bulla.[1] Histopathologically it falls within spectrum of neutrophilic dermatoses.[2] A variety of systemic diseases are associated but in 10-30% of cases it occurs as an isolated cutaneous phenomenon.[3] Here we report a case where the patient was initially diagnosed as an isolated case of pyoderma gangrenosum (PG), but investigations revealed urinary tract infection thus proving the association of PG secondary to hidden focus of infection.

Case Report

A 52 - year - old male patient presented with one ulcerated skin lesion which started as a vesiculopustule on left hand, of one month duration and one lesion each, on right hand and right cheek of 15 days duration. The lesions were painless and non- pruritic. There was no history of fever, joint pain, constipation, diarrhoea, malena or burning micturition. History of extramarital contact was absent.

On examination, the lesion, on dorsum of left index finger, was an ulcerated plaque 6 x 3 cm [Figure - 1] with ragged and udermined edge, erythematous and bluish tinged margin and necrotic base. The lesion

on dorsolateral aspect of right hand [Figure - 1] was a noduloplaque 3 x 3 cm with crusting and ulceration, and one on right cheek was a 1 cm folliculo nodular lesion with superficial ulceration.

Laboratory investigations showed Hb-13.5 gm%, normal peripheral blood film, TLC - 8400/mm3, DLC-N-61%, L-33%, E-5%, B-1%, ESR-30 mm/first hr, FBS -105mg%, SGOT - 14 IU/L, and SGPT - 161U/ L. Urine examination showed 9-10 pus cells/HPF;2-4 RBCs, culture examination showed E.coli sensitive to norfloxacin. Consecutive 3 stool tests, and chest X-ray were normal. Mantoux test was negative.

Clinically, diagnosis of pyoderma gangrenosum was made. A wedge biopsy was taken from the bigger lesion. The patient was put on treatment for UTI with norfloxacin 400mg BD for 5 days. Institution of steroid was deferred in view of biopsy report and patient was called for follow up after 5 days.

Meanwhile, histopathological report showed the following:--

The epidermis showed acanthosis, hyperkeratosis and necrosis at places with predominance of degenerated neutrophils. The deeper dermis showed mononuclear cells with lymphocytes and plasma cells. Fibrinoid deposits and thrombi were seen in the vessel wall. The dermal papillae showed numerous extravasated RBCs and small areas of haemorrhage. All the findings were consistent with our diagnosis of PG.

Re-examination of the patient after five days showed dramatic improvement. The lesion on face and right hand had healed with mild scarring whereas the size of lesion on left hand had decreased in size and showed no signs of activity.

Discussion

Pyoderma gangrenosum has been described in association with ulcerative colitis, Crohn′s disease, rheumatoid arthritis, monoclonal gammopathies, myeloproliferative diseases, post traumatic infectious diseases, diabetes etc.[3] In 10 - 30% of cases it occurs as an isolated cutaneous phenomenon. In our case PG was clinically diagnosed as an isolated cutaneous phenomenon without any association. Our investigations revealed asymptomatic UTI. The temporal correlation of healing of the lesions with treatment of UTI confirms the association of PG with UTI. The dramatic improvement in short time, as in our case, is unlikely without corticosteroid or treatment of the cause. A careful examination and complete investigation should be done in all cases of PG and if any hidden focus of infection is present, as in our case, a full course of antibiotics should be administered. This will lead to reduction in the number of isolated cases of PG and unnecessary administration of corticosteroids can also be avoided.