International Journal of Case Reports and Images - IJCRI - Case Reports, Case Series, Case in Images, Clinical Images

     
Case Report
 
A case of parastomal pyoderma gangrenosum
Zexi Allan1, Alex Wong2
1MBBS, Surgical Registrar, Department of General Surgery, Eastern Health, Melbourne, Australia
2FRACS, Consultant General Surgeon & Colorectal Surgeon, Department of general surgery, Eastern Health, Melbourne, Australia

Article ID: Z01201710CR10835ZA
doi:10.5348/ijcri-201796-CR-10835

Address correspondence to:
Zexi Allan
230 Burwood Hwy, Burwood East
Victoria 3151
Australia

Access full text article on other devices

  Access PDF of article on other devices

[HTML Abstract]   [PDF Full Text] [Print This Article]
[Similar article in Pumed] [Similar article in Google Scholar]


How to cite this article
Allan Z, Wong A. A case of parastomal pyoderma gangrenosum. Int J Case Rep Images 2017;8(10):631–633.


ABSTRACT

Parastomal pyoderma gangrenosum is a rare condition where classical skin lesions are found around or near abdominal stomas. Literature reports a 2–4.3% prevalence of parastomal pyoderma gangrenosum in patients with inflammatory bowel disease who undergo stoma surgery. This debilitating skin condition is often missed or wrongly treated due to lack of awareness and understanding. We present a 51-year-old female with parastomal pyoderma gangrenosum on a background of Crohn’s disease. Current literature of diagnosis and management is also discussed.

Keywords: Colorectal surgery, Inflammatory bowel disease, Pyoderma gangrenosum, Stoma


INTRODUCTION

Pyoderma gangrenosum is a type of neutrophilic dermatosis which causes progressive painful cutaneous ulcerations. Half of the cases are found to be associated with underlying systemic diseases, such as inflammatory bowel disease (IBD) [1]. Pyoderma gangrenosum can affect any age, with an average onset between 40–60 years, and females are more common affected than males [2]. Parastomal pyoderma gangrenosum is a rare subset where classical skin lesions are found around or near abdominal stomas. Literature reports a 2–4.3% prevalence of parastomal pyoderma gangrenosum in IBD patients who undergo stoma surgery [3]. This is a debilitating skin condition which is often missed or wrongly treated. Timely recognition and appropriate treatment can significantly improve patients’ quality of life.


CASE REPORT

A 51-year-old female with Crohn’s disease presented electively for reversal of loop ileostomy. She previously underwent subtotal colectomy with ileorectal anastomosis and loop ileostomy six months ago for Crohn’s colitis.

The patient had ongoing issues with her stoma since surgery. She was admitted two weeks postoperatively with suspected parastomal wound infection with severe pain and purulent discharge. Abdominal computed tomography scan showed no collection. She was discharged home with oral antibiotics. Since then, she had constant stoma leakage and pain around stoma site. However, parastomal skin remained intact. Outpatient review five months postoperatively indicated that the parastomal skin started to show signs of disease with circumferential ragged edges, induration and severe tenderness to touch. Patient also reported occasional fluid discharge from pinhole breaks of the surrounding skin. Crohn’s associated pyoderma gangrenosum was suspected by stomal therapist, however patient was not referred for medical assessment and was managed with stoma care only.

Pain and local skin changes continued to the time of her reversal procedure. At the time of surgery, her stoma was retracted, with parastomal skin erythema, induration, ulceration and breakdown (Figure 1) and it was very tender to touch around the stoma site. Reversal surgery was performed and skin biopsies were only taken post parastomal skin debridement and curettage. Subsequent histopathology showed chronic inflammation along with reactive epidermal hypertrophy and some fibrosis; features of pyoderma gangrenosum were not seen. Despite the biopsy results, we highly suspect parastomal pyoderma gangrenosum given the clinical appearance and severe pain.


Cursor on image to zoom/Click text to open image
Figure 1: Retracted stoma with skin erythema, induration, ulceration and breakdown.


DISCUSSION

Pyoderma gangrenosum typically presents as cutaneous ulceration with a well-defined, undermined violaceous border [4]. This can be mistaken for other causes such as infection, stitch abscess, contact dermatitis and irritation from fecal material [1]. Missed diagnosis occur also due to lack of knowledge and familiarity of clinicians to parastomal pyoderma gangrenosum [5]. It is often a diagnosis of exclusion and is particularly difficult to manage owing to its constant pain resulting in poor application of stoma appliance. Correct recognition and appropriate management is essential to improve patients’ quality of life.

There are no absolute diagnostic criteria for pyoderma gangrenosum. While histology from skin biopsy typically show edema and massive neutrophil infiltration confined to the dermis, diagnosis of parastomal pyoderma gangrenosum is mainly via its clinical appearance, a high degree of pain and its rapid progression. The ulcers are very destructive and can expand by 1 to 2 cm from hours to a day [1][5]. Biopsies are done often to rule out other causes of ulceration rather than to diagnose pyoderma gangrenosum histologically [3]. One study from the Mayo clinic [6] put together a diagnostic guideline; as given in Table 1. The diagnosis is strongly indicated when both major criteria and at least two minor criteria are met.

Once diagnosis is suspected or other causes have been excluded, appropriate management can significantly improve stoma care and patient’s quality of life. A multidisciplinary approach is encouraged involving gastroenterologist, dermatologist, colorectal surgeons and stoma therapist [3]. Medical rather than surgical management is preferred as debridement is not recommended and relocation of stoma is contraindicated unless it is done for other reasons [3]. Given the nature of pathergy, debridement will only exacerbate the problem and relocation often result in recurrence of the disease at the new stoma site [1][5]. Treatment regimen depends on the severity of the disease and whether there is active systemic disease (i.e., IBD). For mild cases, wound management with moisture-retentive dressings plus topical steroids or intralesional injection of triamcinolone or cyclosporine has been shown to be effective [3]. Systemic therapy is indicated when there is lack of response to topical therapy, if the disease is severe and rapid or if there is active underlying disease.


Cursor on image to zoom/Click text to open image
Table 1: Proposed diagnostic criteria of classic, ulcerative pyoderma gangrenosum



CONCLUSION

Parastomal pyoderma gangrenosum is a rare but debilitating condition and prompt recognition, diagnosis and management is required to improve stoma care and patients’ quality of life.


REFERENCES
  1. Wu XR, Mukewar S, Kiran RP, Remzi FH, Hammel J, Shen B. Risk factors for peristomal pyoderma gangrenosum complicating inflammatory bowel disease. J Crohns Colitis 2013 Jun;7(5):e171–7.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Binus AM, Qureshi AA, Li VW, Winterfield LS. Pyoderma gangrenosum: A retrospective review of patient characteristics, comorbidities and therapy in 103 patients. Br J Dermatol 2011 Dec;165(6):1244–50.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Wu XR, Shen B. Diagnosis and management of parastomal pyoderma gangrenosum. Gastroenterol Rep (Oxf) 2013 Jul;1(1):1–8.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Hughes AP, Jackson JM, Callen JP. Clinical features and treatment of peristomal pyoderma gangrenosum. JAMA 2000 Sep 27;284(12):1546–8.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Cairns BA, Herbst CA, Sartor BR, Briggaman RA, Koruda MJ. Peristomal pyoderma gangrenosum and inflammatory bowel disease. Arch Surg 1994 Jul;129(7):769–72.   [CrossRef]   [Pubmed]    Back to citation no. 5
  6. Su WP, Davis MD, Weenig RH, Powell FC, Perry HO. Pyoderma gangrenosum: Clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol 2004 Nov;43(11):790–800.   [CrossRef]   [Pubmed]    Back to citation no. 6

[HTML Abstract]   [PDF Full Text]

Author Contributions
Zexi Allan – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Alex Wong – Substantial contributions to conception and design, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2017 Zexi Allan et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



  Home line About IJCRI line Aim and Scope line Sections line Open Access line Archives
Apply as Editor line Apply as Reviewer line Submit Reviews - Editors line Submit Reviews - Reviewers
Instructions for Authors line Templates to Use line Copyright Form line Author Checklist
Online Submission line Email Submission line Submit Revision line Submit All Forms line Submit Page Proofs
Terms of Service line Privacy policy line Disclaimer line FAQ line Contact: Journal line Contact: Edorium Journals line Site Map
 
  Copyright © 2017. Edorium. All rights reserved.