Pyoderma Gangrenosum: A Case Report

Introduction

There are various methods for breast reconstruction. The use of the abdominal pedicle flap in breast reconstruction was first introduced by Millard in 1976.  Breast reconstruction with TRAM flap has been defined with alternative methods, which have been developed in studies by different people over time. Various complications such as fat necrosis, flap necrosis, infection, separation in the donor area are seen after reconstruction with TRAM flap. Pyoderma gangrenosum is also a complication that occurs after autologous breast reconstructions and was first mentioned by Louis-Anne-Jean Brocq in 1908 in a case series with ulcerated lesions with similar components, but the terminology was realized after the case series published by Brunsting et al. in 1930. Pyoderma gangrenosum is a neutrophilic dermatosis of unknown etiology and there is no effective standard treatment. In this study, pyoderma gangrenosum developing in a patient who underwent breast reconstruction with TRAM flap is discussed.

Case Report

A 42-year-old patient with a history of 3 pregnancies, 2 births, and breastfeeding for a total of 48 months, was referred to us for breast reconstruction after left modified radical mastectomy due to invasive ductal carcinoma in the left breast. Axillary dissection was also performed on the patient who had a history of neoadjuvant, postoperative chemotherapy and radiotherapy. When the patient was first referred to us, she was using tamoxifen and L-thyroxine for hypothyroidism. The patient was reconstructed with a contralateral pedicled TRAM flap. The patient with minimal ecchymosis in the distal of the flap and the 'T' region of the donor area, which had no problems in the postoperative period, was discharged on the 6th postoperative day after drains were removed.

Figure 1, preoperative examination

Figure 2 postoperative 4.day

In the first postoperative control of the patient, fever and minimal erythema at the suture lines were detected on the 8th day after the operation. The patient, who did not have obvious infective findings, otolaryngology was consulted with the suspicion of sinusitis with PCR and acute phase reactants. The patient, whose cause of infection could not be detected, was called for a followup after 2 days with continuation of antibiotic therapy. At the time of the follow up, the ecchymosis in the distal flap had rapidly progressed to a wider area, become ulcerated, and the necrosis in the T region in the donor area had a tendency to expand and ulcerate, and the patient was hospitalized and followed up closely.

Figure 3. Postoperative 6.day (Before discharged from the hospital)

Figure 4. Postoperative 13.day. Hospitalisation

The patient was followed-up by drawing the lesion borders, and monitored increased acute phase reactants, high fever, and rapid progression in the lesions. With the preliminary diagnosis of pyoderma gangrenosum, the patient was started on steroid therapy and broad-spectrum antibiotics. A biopsy was taken to support the diagnosis. In approximately 24-48 hours of steroid treatment, clinical response was obtained, and the progression stopped and the lesions began to be replaced by necrotic plaques. The acute phase reactants and fever regressed. Pathology result was reported as pyoderma gangrenosum.

Figure 5. Postoperative 17.day

The patient was followed up with appropriate wound care and antibiotic therapy, and debridement was performed in the operation room. In the operation, the flap was slightly released and advanced to the defect to cover the distal defected area. Primary closure was performed after necrosis in the inferior part of the flap and debridement of the donor area. The patient, who had no problems in the follow-ups, was discharged after stopping the antibiotic therapy and switching to the oral form of steroid. During the outpatient follow-ups, the steroid dose of the patient was gradually tapered and discontinued, the distal granulated wound was left to the secondary healing process with appropriate dressing and epithelialization was achieved.

Figure 6. Postoperative first year

Discussion

Pyoderma gangrenosum is a rapidly progressive disease, and it is a complication that should be kept in mind when findings such as unexplained fever and erythema in the suture lines are detected in the patient, as in our case after major surgery. Even if no problems are observed in the patients in the early postoperative period, close follow-up after discharge is very important. In suspected cases of pyoderma gangrenosum, if there is no contraindication without a pathological diagnosis, initiating steroid therapy rapidly provides a serious reduction in the morbidity of the patients. In these patients, it is very important to diagnose as early as possible and to avoid early-aggressive surgery, as other surgical interventions to be performed secondary to the complication may trigger the disease and wound healing may be impaired. 

Dokuz Eylül University Hospital Plastic, Reconstructive and Aesthetic Surgery Departmant Izmir/Turkey 

Prof.Dr. Cenk Demirdöver Dr. Merve Terzi Dr. Hasan Basri Çağlı Dr. Safa Eren Atalmış Dr. Tahir Babahan Dr. Fatih Berk Ateşşahin