Abstract
Post-operative pyoderma gangrenosum is a rare neutrophilic dermatosis which forms within skin wounds following surgery. This condition is not well recognised, can be difficult to diagnose and often mimics necrotising fasciitis. While wound exploration and debridement remains the standard of care in post-operative wound infection, this can paradoxically exacerbate pyoderma gangrenosum resulting in further morbidity and mortality. As such, surgeons that encounter post-operative pyoderma gangrenosum face a diagnostic dilemma. Here we present a 65 year old gentleman who developed pyoderma gangrenosum following open radical prostatectomy. We reflect on his management and discuss the pertinent points learned from this case.
Keywords: Post-operative pyoderma gangrenosum, Pyoderma gangrenosum, Radical prostatectomy, Radical prostatectomy post-operative complication
1. Introduction
Post-operative pyoderma gangrenosum is a rare neutrophilic dermatosis which forms within skin wounds following surgery. It is characterised by rapidly progressive painful ulceration around the skin incision and typically develops within 2 weeks following surgery.1, 2, 3 This condition is not well recognised and can be challenging to manage as it mimics wound dehiscence, wound infection and necrotising fasciitis.3 While wound exploration and debridement remains the standard of care in post-operative wound infection, this can paradoxically exacerbate pyoderma gangrenosum resulting in further morbidity and deformity. Here we present a 65 year old male who developed complicated pyoderma gangrenosum following open radical retropubic prostatectomy. We reflect on his management and discuss the pertinent considerations which should be taken into account when faced with this challenging condition.
2. Case presentation
Our patient is a 65 year old male who was diagnosed with widespread ISUP 3 prostate cancer in January 2023. Staging PSMA PET did not identify metastatic disease. His documented medical background included necrotising fasciitis and a family history of pyoderma gangrenosum.
He underwent an open radical prostatectomy. Surgery was uncomplicated and the patient was discharged two days post op following removal of his pelvic drain. On day four he noted discomfort, erythema and a purple halo around the drain site (Fig. 1A), which progressively migrated to the inferior aspect of his midline incision. On day nine he presented to the Emergency Department with abdominal pain, nausea, fevers and discharge from both the drain site and inferior abdominal wound. On examination the drain site and midline wound were surrounded circumferentially by skin break down with a violaceous border (Fig. 1B). The skin around the drain site was tender but there was no peritonism or abdominal wall crepitus. Inflammatory markers were raised with a white cell count of 26 × 109/L and a C-reactive protein of 295 mg/L. CT demonstrated a minor leak from the vesicourethral anastomosis and subcutaneous fat stranding with no underlying collection or surgical emphysema.
Fig. 1.
(A) Drain site day four post radical prostatectomy (B) Drain site and midline abdominal wound day nine post radical prostatectomy.
The patient was covered with Co-amoxiclav, Gentamicin and Clindamycin. Given his history, we initially sought a dermatology opinion but this was not immediately available at our regional hospital. After 24 hours, the patient became more unwell with increasing pain and deteriorating vital signs. On further review, his wounds had increasing ulceration, undermining of the peripheral borders and purulent discharge (Fig. 2A). Given an underlying infection could not be excluded the patient was taken to the operating theatre for exploration of the abdominal wound (Fig. 2B). Skin staples were removed and approximately 20ml of purulent material was drained. The deep fascia was intact and the subcutaneous tissue beneath the dermis appeared healthy. There was no evidence of necrotising fasciitis. Minimal debridement was performed around the drain site and inferior wound. Given the possible diagnosis of pyoderma gangrenosum a small amount of tissue was excised and sent for gram strain and histology.
Fig. 2.
(A) Drain site day ten post radical prostatectomy (B) Drain site and abdominal wound prior to exploration.
Post-operatively he was transferred to ICU for blood pressure support and was commenced on IV hydrocortisone. Urine culture grew pan sensitive E. coli but blood cultures, wound aspirate and tissue cultures were all negative. Histology showed extensive neutrophil infiltrate extending into the subcutaneous tissue, supporting the clinical diagnosis of pyoderma gangrenosum. Following consultation with dermatology he was switched from IV hydrocortisone to oral prednisone with a tapering regime. His wound was initially stabilised (Fig. 3) but as his steroid dose was weaned he developed further flares which were complicated by superficial wound infections. He remained in hospital for 3 months post-surgery where he was predominantly managed by the dermatology service. Disease control required a combination of topical tacrolimus, subcutaneous kenacort, Adilimumab and further intravenous hydrocortisone which was then de-escalated to oral prednisone. His admission was complicated by bilateral pulmonary emboli and micro thromboemboli to the left ulnar artery. At six months post-surgery his anterior abdominal wound has significantly improved, his PSA is undetectable but he remains floridly incontinent.
Fig. 3.
Drain site and abdominal wound three weeks post radical prostatectomy.
3. Discussion
Pyoderma gangrenosum is a rare inflammatory dermatological disorder characterised by the accumulation of neutrophils within the skin. Patients typically present with rapidly progressive, painful ulcers arising in normal or traumatised skin. The pathophysiology of the disease is not well understood but it has been proposed that upregulation and infiltration of neutrophils leads to large volume cytokine release driving inflammation and subsequent skin break down.4 It is commonly triggered by skin trauma and surgery is a well-known catalyst.2, 3, 4 The disease is frequently associated with underlying inflammatory conditions but these are not considered a prerequisite.3 It tends to occur in those above the age of 40 and is more common in females. Risk factors include a family history or previous episodes of pyoderma gangrenosum.
The diagnosis of pyoderma gangrenosum in the post-operative setting can be challenging as patients often present with symptoms and signs that mimic necrotising fasciitis. This leads to a diagnostic dilemma as failure to debride a necrotising wound infection may be fatal, yet further trauma to a wound affected by pyoderma gangrenosum can exacerbate the condition leading to debilitating deformity and possible mortality.5 This is further complicated by the fact that patients with post-operative pyoderma gangrenosum may also suffer concurrent wound infection. Based on our experience we believe that pyoderma gangrenosum should always be considered in patients who present with superficial wound breakdown and the wound should be explored if necrotising fasciitis cannot be excluded. If the underlying subcutaneous tissue appears healthy, fluid should be sent for microscopy, a biopsy should be obtained and care should be taken to minimise further trauma to tissue. When post-operative pyoderma gangrenosum remains within the differential diagnosis, urgent dermatology input should be requested as early recognition and treatment leads to a significant reduction in morbidity and mortality.3 In cases where patients have a background of pyoderma gangrenosum and surgery is unavoidable, the potential risks should be discussed during the consent process and peri-operative steroids should be considered.
4. Conclusion
Post-operative pyoderma gangrenosum is a rare surgical complication that is not well recognised and frequently mismanaged. Inappropriate treatment of this condition may increase morbidity and mortality. We hope that this case provides awareness within the urological community and helps to improve pre and post-operative management of this debilitating condition.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
CRediT authorship contribution statement
Samuel MacDiarmid: Writing – original draft, Conceptualization.
Harriet Baxter: Review & editing
Jordan Mann: Review & editing
Christophe Chemasle: Supervision
Declaration of competing interest
There are no known competing financial interests or personal relationships that have influenced the work reported in this paper.
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