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Blastomycosis-like pyoderma, a rare skin lesion which may clinically resemble true blastomycosis, is seen in immuno-compromised individuals. We report one such case in chronic myeloid leukaemia.
A 24 year old woman with airway injury, lung infiltration and pleural effusion due to pyoderma gangrenosum is reported.
Thirty dogs with superficial pyoderma were randomly allocated to treatments with either lincomycin hydrochloride (22 mg/kg twice daily) or clindamycin hydrochloride (11 mg/kg once daily), initially for three weeks. Samples were taken from pustules, from adjacent apparently uninvolved skin, and from the nares. These were submitted for bacterial culture and sensitivity testing. The dogs were re-examined after three weeks treatment and samples for bacteriology were taken from the nares, from any pustules that were present or from skin in the area that was previously affected; the treatment was extended if necessary. Seventy-one per cent of the dogs given lincomycin hydrochloride responded within three weeks compared with 81 per cent of the dogs treated with clindamycin hydrochloride. The overall response rates, including those given longer courses of treatment were 93 per cent for those treated with lincomycin hydrochloride and 94 per cent for those treated with clindamycin hydrochloride, and there was no statistically significant difference between the groups either after three weeks treatment or after extended treatment. The microbiological results demonstrated that Staphylococcus intermedius was present on the skin adjacent to pustules and suggested that the nasal carriage of S intermedius was a result of cutaneous colonisation.
Thirty dogs with superficial pyoderma were treated orally with tylosin at a dose of 20 mg/kg twice daily for three weeks. Staphylococcus intermedius was recovered from 21 (70 per cent) of the dogs. Twenty-two of the dogs were free of clinical signs after three weeks of treatment and two dogs responded to a further two weeks of treatment, giving a total response rate of 80 per cent. Five cases (16.6 per cent) failed to respond and three of these subsequently responded to other antibacterial treatment. One dog suffered transient gastritis after the doses of tylosin and subsequently responded to a different antibacterial agent.
In a prospective study involving eight veterinary clinics during 1995 and 1996, samples from first-time and recurrent cases of canine pyoderma were collected by a needle technique. Three hundred and ninety-four staphylococci were isolated and their susceptibility to various antimicrobial drugs was assessed by a microdilution technique. Resistance to macrolides, lincosamides, fusidic add, tetracycline and streptomycin was significantly more common in isolates from the recurrent cases than from the first-time cases; 20 per cent of the isolates from the first-time cases were resistant to three or more of the antimicrobials tested, compared with 45 per cent of those from the recurrent cases. Coresistance between macrolide-lincosamides, tetracyclines and streptomycin was common. No resistance to penicillinase-stable beta-lactams was observed. A comparison with earlier studies indicated that there had been a marked increase in resistance during the previous five years.
We report a case of the superficial granulomatous (vegetating) form of pyoderma gangrenosum, involving the forehead and the left temporal area in a 44-year-old woman. No association with other pathologies could be found. Lesions responded dramatically to systemic ciclosporine (5 mg/kg/day), and complete healing was reached after 6 months. Doses were tapered progressively. Treatment was discontinued after 4.5 years. Discontinuation was not followed by recurrence of the disease. Healing is maintained after another 4.5 years of follow-up.
The treatment of pyoderma gangraenosum (PG) is still a therapeutic challenge. Although several drugs such as corticosteroids, dapsone, clofazimine, azathioprine, tacrolimus and cyclosporine A have been shown to be effective in this disease, side-effects of these agents limit their systemic use in seriously ill patients. In recent years, topical treatment of the disease has gained attention. Several reports show an improvement of cutaneous lesions of PG following topical treatment. These earlier reports as well as our own observations suggest that topical therapeutic regimens can be a useful and safe alternative to systemic immunosuppressive therapy in the treatment of PG. We give a review about these topically used drugs and the mechanisms probably involved.
A 41-year-old woman with Crohn's disease had a severe and rapidly extensive corticosteroid-resistant pyoderma gangrenosum (PG) of the leg. She had been treated 2 years previously with antibiotics and surgery for a similar lesion of the back of the hand which had been diagnosed as a fulminating infection. Infliximab 5 mg/kg was given at weeks 0, 5 and 9. A dramatic response was observed within 72 h with a favourable effect persisting for 4 weeks after each infliximab infusion. A complete healing was achieved at week 11. This case illustrates that (1). PG of the hand is frequently misdiagnosed as an infection and treated with inappropriate therapies; (2). infliximab may be an interesting alternative in corticosteroid-resistant PG associated with Crohn's disease.
A 45-year-old women presented with a deep ulcerative lesion of the left breast. Two months later, a new cutaneous necrotic lesion located in the right pretibial areas was observed. The only serum abnormality was the presence of circulating lupus anticoagulant. Clinical features suggested the diagnosis of pyoderma gangraenosum and histologic examination showed microthrombosis in the dermal capillary vessels adjacent to a dense, mixed inflammatory infiltrate with some degree of vascular damage. Although thrombosis may be the result of vasculitis, it is likely that in our patient the presence of a lupus anticoagulant activity played a role in the pathogenesis of the cutaneous ulcers.
We report the case of a 66-year-old man presenting 2 chronic, slowly expanding skin lesions having clinical and histopathological characteristics of superficial granulomatous pyoderma. Sulfone treatment induced healing with scar formation.
We report the case of a 47-year-old male with Kartagener's syndrome (KS; situs inversus, bronchitis and sinusitis) who showed three types of cutaneous lesions: recurrent outbreaks of nummular eczema, recurrent deep folliculitis and two episodes of pyoderma gangraenosum. The patient had also IgA gammopathy of undetermined significance. This is the second case of KS associated with cutaneous lesions published so far and suggests that primary ciliary dyskinesia syndromes may have skin symptoms.
Five patients suffering from dermatitis ulcerosa (a variant of pyoderma gangrenosum) were treated with clofazimine in a daily dosage of 200 mg orally. Complete healing was noted in 2 patients, partial response in 2, no effect in 1. Side effects were mild and transitory in form of a red coloring of the skin (all patients) and mild ichthyosis (2 patients).
A case of pyoderma gangrenosum is reported in a patient with a past history of ulcerative colitis. Serial C-reactive protein (CRP) concentrations were measured and were found to be markedly elevated at presentation. Levels were also raised during two subsequent relapses. CRP levels proved to be a useful objective indicator of disease activity and response to therapy, and reflected changes in disease activity before the erythrocyte sedimentation rate.
A case of pyoderma gangrenosum is described in a girl aged 4. The condition was associated with selective IgA deficiency. The father and the 2 brothers suffered from the same deficiency (autosomal dominant transmission). Treatment with prednisolone and clofazimine produced an excellent clinical response.
In a 21-year-old male patient afflicted with widespread recurrent pyoderma resistent to antimicrobial therapy since 3 years, a deficient state of cellular immunity including dysfunctions of both microphages and T lymphocytes was disclosed. After 6 weeks of systemic treatment with levamisole all lesions cleared completely, whereas appropriate long-term antibiotic therapy previously administered had failed to succeed. The immunological parameters, as far as being reexamined, also returned to normal levels during levamisole therapy.
This is a report of a case with a chronic peculiar intractable pyoderma. The process started a year after splenectomy because of trauma. In the absence of an apparent other reason, we assume that a relationship exists between the operation and the skin disease.
Two cases with pyoderma gangrenosum are presented. The course, in both cases, suggested that immunosuppressive therapy may play an etiological role in the disease. The first was a kidney recipient receiving prednisone and azathioprine and the second, a patient with pemphigus vulgaris who was treated with prednisone and methotrexate.
Patients with extensive lower extremity ulcerations initially thought to be vascular disease were subsequently proved to have pyoderma gangrenosum and malignant lymphoma. Both patients died of sepsis; one patient exhibited hypogammaglobulinemia involving immunoglobulins IgA, IgG, and IgE; in the second patient, a polyclonal excess involving IgA and IgE was present.