DOI: 10.12890/2026_007405
Pyoderma gangrenosum and haematochezia in a patient with previous cocaine abuse
Authors
an.ioannou@shso.org.cy
Keywords
Pyoderma gangrenosum, granulomatosis with polyangiitis, upadacitinib, JAK inhibitor, ANCA-associated vasculitisAbstract
Introduction: Pyoderma gangrenosum (PG) is an autoinflammatory neutrophilic dermatosis that may rarely occur in association with granulomatosis with polyangiitis (GPA). Management of refractory disease remains challenging.
Case description: A 48-year-old man with a history of previous cocaine abuse was admitted due to impaired feeding in the context of a chronic hard palate perforation and a large oro-sinus fistula. During hospitalisation, he developed haematochezia and painful ulcerative skin lesions involving the right upper limb and lower extremities. Upper and lower gastrointestinal endoscopy revealed a Forrest IIc gastric lesion and a non-bleeding ileocecal ulcer. Histopathological examination of skin lesions demonstrated dense neutrophilic infiltration consistent with PG, while gastrointestinal biopsies excluded inflammatory bowel disease. An extensive evaluation excluded infection, antiphospholipid syndrome, cryoglobulinaemia, malignancy and vascular occlusive disease, all of which may mimic PG. Autoimmune screening workup yielded positive for anti-proteinase-3 antibodies (C-ANCA). The patient initially received high-dose methylprednisolone followed by mycophenolate mofetil and infliximab. Despite treatment, disease activity persisted with recurrent relapses, requiring hospitalisations. Upadacitinib was subsequently introduced, resulting in rapid clinical improvement, near-complete healing of skin lesions and successful glucocorticoid withdrawal.
Conclusion: The coexistence of PG and GPA is rare and presents substantial diagnostic and therapeutic challenges. JAK inhibition with upadacitinib may represent a promising therapeutic option in refractory cases.
References
- Downey K, Zhang R, Ortega-Loayza AG. Pyoderma Gangrenosum and Inflammatory Bowel Disease: Recent Insights into Epidemiology, Pathogenesis, and Therapeutic Approaches. J Inflamm Res. 2025;18:15859-15873. doi: 10.2147/JIR.S540840.
- Chaurasia P, Malik N, Deokar S, Deo KS, Gupta A. Pyoderma Gangrenosum: A Presenting Feature of Rheumatoid Arthritis. Cureus. 2024;16(7):e64288. doi: 10.7759/cureus.64288.
- Ben Brahim M, Abdellatif S, Ben Mabrouk A, Jomaa O, Chebil A, Hasnaoui M, et al. Pyoderma gangrenosum associated with granulomatosis with polyangiitis: a case report. J Med Case Rep. 2025;19(1):639. doi: 10.1186/s13256-025-05226-x.
- Zarraga MB, Swenson N, Glick B. Pyoderma Gangrenosum-associated Granulomatosis with Polyangitis: A Case Report and Literature Review. J Clin Aesthet Dermatol. 2017;10(10):40-42.
- Potentas-Policewicz M, Fijolek J. Granulomatosis with polyangiitis: clinical characteristics and updates in diagnosis. Front Med (Lausanne). 2024;11:1369233. doi: 10.3389/fmed.2024.1369233.
- Moreno-Artero E, Querol-Cisneros E, Rodríguez-Garijo N, Tomás-Velázquez A, Idoate MÁ, Gil-Sánchez MP, et al. Cocaine-induced pyoderma gangrenosum-like lesions. J Dtsch Dermatol Ges. 2018;16(6):763-768. doi: 10.1111/ddg.13523.
- Martínez-Gómez M, Ramírez-Ospina JA, Ruiz-Restrepo JD, Velásquez-Lopera MM. Pyoderma gangrenosum associated to the use of cocaine/levamisole. Series of three cases and literature review. An Bras Dermatol. 2021;96(2):188-195. doi: 10.1016/j.abd.2020.06.014.
- Lemieux A, Ran Cai Z, Belisle A, Chartier S, Bolduc C. Multifocal cocaine-induced pyoderma gangrenosum: A report of two cases and review of literature. SAGE Open Med Case Rep. 2020;8:2050313X20935736. doi: 10.1177/2050313X20935736.
- Van Eycken L, Dens AC, de Vlam K, Neerinckx B, De Haes P. Resolution of therapy-resistant pyoderma gangrenosum with upadacitinib. JAAD Case Rep. 2023;37:89-91. doi: 10.1016/j.jdcr.2023.05.016.
- Weenig RH, Davis MD, Dahl PR, Su WP. Skin ulcers misdiagnosed as pyoderma gangrenosum. N Engl J Med. 2002;347(18):1412-8. doi: 10.1056/NEJMoa013383.
