Pyoderma Gangrenosum Masquerading as Necrotizing Fasciitis: Stepping Away from Cognitive Shortcuts

  • Rachael Hilton Presbyterian/St. Luke's Medical Center, Denver, CO Medical University of South Carolina, Charleston, SC http://orcid.org/0000-0003-1049-9602
  • Jefferson Berryman Presbyterian/St. Luke's Medical Center, CO University of California, Davis, CA
  • Karina Handoyo Presbyterian/St. Luke's Medical Center University of Colorado Hospital
Keywords: pyoderma gangrenosum, necrotizing fasciitis, anchor bias

Abstract

A patient with post-Cesarean wound complication was treated for necrotizing fasciitis (NF) with sharp debridement and broad-spectrum antibiotics. Several operations and three weeks later, her abdominal skin, subcutaneous fat, right-sided rectus abdominus, and underlying fascia had been removed without any improvement in granulation tissue. Original pathology samples demonstrated sheets of necrosis consistent with NF, but were re-reviewed by a dermatopathologist who diagnosed the patient with pyoderma gangrenosum (PG). She was started on high-dose steroids and dapsone, and her wound quickly showed signs of improvement. Anchor bias delayed the initiation of steroids and diagnosis of PG as the surgical, medical, and consulting teams were hesitant to stray from the diagnosis of NF.

Author Biographies

Jefferson Berryman, Presbyterian/St. Luke's Medical Center, CO University of California, Davis, CA
PGY2 Ophthalmology Resident
Karina Handoyo, Presbyterian/St. Luke's Medical Center University of Colorado Hospital

Internal Medicine Attending Physician

References

  • De Souza EFA, da Silva GAR, dos Santos GR, Motta HL de SN, Cardoso PANM, de Azevedo MCVM, et al. Pyoderma gangrenosum simulating necrotizing fasciitis. Case Rep Med 2015;2015504970.

  • Cozzani E, Gasparini G, Parodi A. Pyoderma gangrenosum: a systematic review. G Ital Dermatol Venereol 2014;149:587–600.

  • Patel F, Fitzmaurice S, Duong, C, He Y, Fergus J, Raychaudhuri S, et al. Effective strategies for the management of pyoderma gangrenosum: a comprehensive review. Acta Derm Venereol 2015;95:525–531.

  • Ormerod AD, Thomas KS, Craig FE, Mitchell E, Greenlaw N, Norrie J, et al. Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial. BMJ 2015;350:h2958.

  • Bisarya K, Azzopardi S, Lye G, Drew PJ. Necrotizing fasciitis versus pyoderma gangrenosum: securing the correct diagnosis! A case report and literature review. Eplasty 2011;11:e24.

  • Shands JW, Flowers FP, Hill HM, Smith O. Pyoderma gangrenosum in a kindred. J Am Acad Dermatol 1987;16:931–934.

  • Harland CC, Jaffe W, Holden CA, Ross LD. Pyoderma gangrenosum complicating caesarian section. J Obstet Gynaecol 1993;13:115–116.

  • Stone N, Harland C, Ross L, Holden C. Pyoderma gangrenosum complicating caesarian section. Clin Exp Dermatol 1996;21:468.

  • Steadman UA, Brennan TE, Daman LA, Curry SL. Pyoderma gangrenosum following caesarean delivery. Obstet Gynecol 1998;91:834–836.

  • Rönnau AC, Schmiedeberg S, Bielfeld P, Ruzicka T, Schuppe HC. Pyoderma gangrenosum after caesarean delivery. Am J Obstet Gynecol 2000;183:502–504.

  • Amin SV, Bajapai N, Pai A, Bharatnur S, Hebbar S. Pyoderma gangrenosum in two successive pregnancies complicating caesarean wound. Case Rep Obstet Gynecol 2014;2014:1–3.

  • Karim AA, Ahmed N, Salman TA, Craven NM. Pyoderma gangrenosum in pregnancy. J Obstet Gynaecol 2006;26:463–466.

  • Banga F, Schuitemaker N, Meijer P. Pyoderma gangrenosum after caesarean section: a case report. Reprod Health 2006;22:1–5.

  • Sanz-Muñoz C, Martinez-Moran C, Miranda-Romero A. Pyoderma gangrenosum following cesarean delivery. Actas Dermo-Sifiliográficas 2008;99:477–480.

  • Pauser S, Goerge T, Eickelmann M, Gaubitz M, Luger TA, Steinhoff M. Pyoderma gangrenosum after cesarean delivery. Clin Med Insights Dermatol 2009;2:23.

  • Park JY, Lee J, Park JS, Jun JK. Successful vaginal birth after prior cesarean section in a patient with pyoderma gangrenosum. Obstet Gynecol Sci 2016;59:62–65.

  • Radhika A, Singal A, Radhakrishnan G, Singh S. Pyoderma gangrenosum following a routine caesarean section: pseudo-infection in a caesarean wound. Qatar Med J 2015;2015:1.

  • Aydın S, Aydın ÇA, Uğurlucan FG, Yaşa C, Dural Ö. Recurrent pyoderma gangrenosum after cesarean delivery successfully treated with vacuum-assisted closure and split thickness skin graft: a case report. J Obstet Gynaecol Res 2014;41:635–639.

  • Nonaka T, Yoshida K, Yamaguchi M, Aizawa A, Fujiwara H, Enomoto T, Takakuwa K. Case with pyoderma gangrenosum abruptly emerging around the wound of cesarean section for placenta previa with placenta accrete. J Obstet Gynaecol Res 2016;42:1190–1193.
  • Published: 2017-09-28

    Issue: Vol 4 No 7 (view)

    Section: Articles

    How to cite:
    Hilton, R., Berryman, J., & Handoyo, K. (2017). Pyoderma Gangrenosum Masquerading as Necrotizing Fasciitis: Stepping Away from Cognitive Shortcuts. European Journal of Case Reports in Internal Medicine, 4(7). https://doi.org/https://doi.org/10.12890/2017_000648