Pyoderma gangrenosum associated with anticardiolipin antibodies in a pregnant patient

Alan M. Freedman, Robert G. Phelps, Mark Lebwohl

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20 Scopus citations

Abstract

A 40-year-old pregnant woman at 17 weeks of gestation presented with a 10-day history of pain and erythema in the right leg. She had experienced a similar episode in the postpartum period (1 week) 14 months earlier, lasting 2 months. This was diagnosed as cellulitis and resolved following antimicrobial therapy. The patient had no fever or chills. Pertinent past medical history involved a possible history of ampicillin allergy. The initial differential diagnosis included cellulitis and thrombophlebitis. Antibiotic therapy with intravenous (IV) cefazolin was started at the same time as anticoagulation with heparin. Over the next few days the ulceration enlarged. No microbial growth was detected on wound cultures and Doppler studies carried out prior to admission revealed normal venous flow. The patient did not respond to therapy. A dermatology consult was requested. When the patient was first examined by us, the ulceration had been progressively increasing in size. There was an oozing ulcerated patch 7 cm in diameter on the right distal medial thigh (Fig. 1). The ulcer contained crater-like holes and fistulous tracts from which pus could be expressed upon application of pressure. The surrounding border was undermined and violaceous. A clinical diagnosis of pyoderma gangrenosum (PG) was made. Antinuclear antibodies and antibodies to Smith antigen were negative; anticardiolipin antibody was positive. A 3-mm punch biopsy showed an intense neutrophilic response with fibrinoid change in some vessels (Fig. 2), which was felt to be consistent with PG with a concomitant small vessel vasculitis. No fibrin thrombi were noted. The heparin was replaced with aspirin and the IV antibiotics were changed to oral cephalexin. Intralesional triamcinolone (40 mg/cc) was started and a 3-day course (80 mg/40 mg/20 mg) of oral prednisone was initiated. Within 2 days of starting steroid therapy, the inflammation and discharge were greatly reduced. Approximately 2 weeks after admission the therapy was noted to halt the progression. The lesion became more well demarcated with healthy granulation tissue and decreased tenderness and warmth. The patient was discharged on Burow's solution, saline soaks, and bacitracin and was seen by us on two occasions after discharge for intralesional steroid administration. One flare-up since discharge was controlled by increasing her prednisone from 10 mg to 20 mg daily. The patient had premature rupture of membranes at 37 weeks, had a spontaneous vaginal delivery, and delivered a healthy baby boy weighing 5 lb 14 oz. Since then, the ulcer had re-epithelialized with tapering doses of prednisone.

Original languageEnglish
Pages (from-to)205-207
Number of pages3
JournalInternational Journal of Dermatology
Volume36
Issue number3
DOIs
StatePublished - Mar 1997

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