My Most Interesting Case: The Value of Being Suspicious
Stephanie Wu, DPM, MSc, FACFAS
Associate Dean of Research, Professor of Surgery, Professor, Stem Cell and Regenerative Medicine, Director, Center for Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
Today is a special day for one of our dear patients as her chronic, extremely painful wounds have finally healed. Our patient is a 68-year-old Hispanic woman who has suffered from painful leg wounds for the past 8 years. I’ll never forget the day I first met her; she had curled her entire body into a ball and was trembling in anticipation of the pain she was about to endure when “doctors debride her wounds”. Although the initial presentation of the wounds resembled venous leg ulcers with characteristic hemosiderin deposition in the gator area, the wound edges were somewhat undermined, and the base slightly raised and a little atypical compared to that of most venous leg ulcers. After examining the patient, I opted to biopsy the wound. The wound biopsy demonstrated lymphocytic infiltrate in the dermis, and the pathologist suspected pyoderma gangrenosum.
Pyoderma gangrenosum is a rare inflammatory disorder that causes progressive necrotizing ulceration. Manifestations of pyoderma gangrenosum are predominantly cutaneous; however, there is often an association with ulcerative colitis, Crohn’s disease, rheumatoid arthritis, and multiple myeloma. Topical treatments include potent steroid preparations and calcineurin inhibitors, and systemic treatments include oral steroids and immunosuppressants. Because of the rarity of the disease, pyoderma gangrenosum has a weak evidence base for treatment. In this particular case, the patient responded well to a topical calcineurin inhibitor and healed in 10 weeks.
In the treatment of chronic wounds, it is imperative to have a high index of suspicion when a wound fails to heal or is atypical in appearance, especially following 2 to 3 months of proper treatment involving debridement, adequate vascularity, bioburden control, and management of the underlying disease.
Left Ankle Wound (inital, after 4 weeks, after 8 weeks, healed)
Right Leg Wound (initial, after 3 weeks, after 6 weeks, after 9 weeks)