Unusual cause of breast wound: postoperative pyoderma gangrenosum

Abstract

Postoperative pyoderma gangrenosum (PPG) is an unusual clinical entity, which shows rapidly progressive skin necrosis that can occur within surgical sites after any surgical procedure. Usually, it is diagnosed as wound infection at the time of presentation, but antibiotic therapy and wound debridement fail to arrest rapid ulcer enlargement. We report the case of PPG in a 21‐year‐old woman after a reduction mammoplasty surgery. In this report, we emphasise the importance of considering pyoderma gangrenosum (PG) as one of the differential diagnoses of breast ulcers after surgical procedures. Careful clinical assessment may establish an early diagnosis and prevent potential serious complications.

Introduction

Pyoderma gangrenosum (PG) is a destructive inflammatory disease characterised by painful ulcerative lesions with neutrophilic infiltration in the dermis. The disease insidiously causes rapid and devastating soft tissue damage 1. PG has also been reported as a complication of many surgeries, such as heart surgery, plastic surgery of the breasts (breast augmentation or reduction) and appendectomy 1, 2, 3. Thus, postoperative pyoderma gangrenosum (PPG) is a clinical variant of PG that occurs in the postoperative setting 3. Considering the aesthetic criteria in breast surgery, PPG is especially distressing. Hence, early diagnosis and treatment may prevent unnecessary debridement and associated morbidity 4, 5. Here, we report the case of a 21‐year‐old girl who had PPG after a breast reduction mammoplasty operation. The emphasis of the current report is consideration of PG as one of the differential diagnoses of breast ulcers after surgical procedures.

Case presentation

A 21‐year‐old healthy girl presented with dehiscence of the surgical wound after 20 days of breast reduction mammoplasty. She had no history of illness, such as inflammatory bowel disease, arthritis or haematological diseases. Following the diagnosis of dehiscence because of infection, systemic antimicrobial treatment was initiated. Despite the local care, parenteral antibiotic treatment and repeated surgical debridement, there was no improvement, and rapid worsening of the lesion occurred. Blood and wound cultures were negative for any pathogens. A skin biopsy after a dermatological consultation confirmed the diagnosis of PPG (Figure 1). Treatment with 50 mg/day oral prednisolone was immediately initiated, which proved to be successful as her symptoms dramatically appeared to improve after a fortnight of steroid therapy. She was discharged on day 14 of steroid therapy with good general condition and tapering off the steroids plane. Medication was stopped after 6 weeks. The wound healed with a fine atrophic scarring (Figure 2).

Figure 1.

Postoperative pyoderma gangrenosum in right breast after breast reduction mammoplasty 5 weeks after the initial surgery. The wound was exquisitely painful.

Figure 2.

Postoperative pyoderma gangrenosum. The necrotic ulcers with irregular, violaceous and undermined borders.

Discussion

The pathophysiology and mechanisms of PG are elusive and likely multifactorial. The majority of PG cases are associated with underlying diseases and conditions, such as rheumatoid arthritis, inflammatory bowel disease and a broad spectrum of haematological disorders and, rarely, after surgery or minor trauma 1, 5. Diagnosis of PG is challenging as clinical signs closely resemble an infectious process with no diagnostic laboratory or pathognomonic histological findings. Thus, PG is a diagnosis of exclusion based on clinical factors, ulcerative characteristics, failure to respond to antibiotics and surgical therapy and improvement in response to steroid treatment 6. PPG of the breast is a rare condition and, therefore, remains a diagnostic challenge 7. PPG in the setting of surgery can occur after a head and neck surgery 3. Even minimally invasive procedures, such as central line insertion, may cause PPG 8. Symptoms develop on an average of 10 days (wide range from 3 days to 5 weeks) after surgery but appear to develop earlier following obstetric and gynaecological surgeries as well as head and neck surgeries 9. The trauma following surgery, which induces cytokine release and polymorphonuclear neutrophils chemotaxis, is likely the initiating factor for PG 10, 11. The cytokine upregulation is proposed to drive the developmental process of PPG in a patient who has recently undergone surgery 12, 13. Most of the cases of PPG following breast surgery are the patients who have undergone reduction mammoplasty followed by breast reconstruction, lumpectomy or mastectomy without breast reconstruction, augmentation mammoplasty and other procedures (including excision, biopsy or mastopexy) 8. Clinical appearance of discrete wounds with irregular, violaceous and undermined borders involving surgical sites, especially with nipple sparing, should raise the suspicion of PG rather than infection or ischaemia, even with concomitant fever and leukocytosis 14. Thus, a consideration of these features may minimise the associated morbidity 14.

In such cases, surgical debridement should be minimised and steroid therapy initiated 14. Our case highlights the importance of considering PG as one of the differential diagnoses of breast ulcers. Careful clinical assessment could establish an early diagnosis and formulate an effective management plan.

Conclusion

In conclusion, clinicians should consider the possibility of PG as one of the differential diagnoses of breast ulcers following surgical procedures, so the awareness of PPG and subsequent early diagnosis treatment can reduce the associated morbidity.