Pyoderma gangrenosum complicating mammaplasty

Field: Medicine (Health Sciences)

Pyoderma gangrenosum (PG) complicating mammaplasty is scarcely reported in the literature, and in the few published cases, lesions involved exclusively the site of incision (1–3). In this article, we present an extremely rare case of disseminated PG following breast augmentation. A 39-year-old woman visited one of the authors for evaluation of gradually expanding ulcers over both breasts and slightly tender pustules on the shins. The patient also complained of mild arthralgia. According to her medical history, the lesions on her breasts developed 1 month after silicone prosthesis implants, while those on her shins appeared 1 month later. At the initial phase of the disease, under the diagnosis of necrotizing infection, she was ineffectively treated with oral antibiotics. Physical examination showed symmetrically distributed mildly tender, necrotizing and partially eroded plaques, with undermined borders, measuring 5 cm in maximum diameter. The lesions involved the surgical trauma and the proximal skin (Figure 1A). Furthermore, four to five tender pustular lesions, seated on violaceous base, were observed on the shins. Two of them were ulcerated and covered with serohaematogenous slough (Figure 1B). (A) Necrotizing and partially eroded plaques, with undermined borders, affecting the surgical trauma and the proximal skin. (B) Tender pustular lesions, seated on violaceous base, involving the shins. Apart from leucocytosis, mild anaemia and high sedimentation rate (30 mmHg), the haematological and biochemical profile was otherwise unremarkable. Swab and skin cultures for bacteria, mycobacteria and fungi were negative. Histology showed dense interstitial neutrophilic infiltrate, compatible with PG (Figure 2). Histology showed dense interstitial neutrophilic infiltrate, compatible with pyoderma gangrenosum (PG). Diagnosis of PG was based on clinical, laboratory and histological findings, as well as on exclusion of other possible causes. Based on the available literature data, not suggesting disease improvement after removal of the implants, we decided not to remove them. The patient refused any treatment and the disease improved gradually over the ensuring 6 months. PG is a rare, chronic, recurrent, often destructive, inflammatory skin disease that belongs to the spectrum of neutrophilic dermatoses (4). Pathogenesis of the disease still remains obscure, but it is considered to be related to a hyperergic reaction. Pathergy, which is often observed in PG, is a possible sign of an uncontrolled and exaggerated inflammatory response to unspecific causes. Neutrophil dysfunction, including defects in chemotaxis or hyper-reactivity, has also been suggested. Although the disease has been associated with a variety of underlying disorders, it is considered to be idiopathic in 25–50% of patients (4). PG complicating mammaplasty has been reported in a limited number of patients. In all of the cases previously described, development of PG occurred at the site of surgical operation and was suggested to represent a pathergic process (1–3). Davis et al.(5) reported in 2006 a case of PG developing at the site of previous breast reconstruction surgery with an additional lesion located far from the incisions' area. Disseminated lesions of PG following mammaplasty, as in our patient, have not been described up to date. According to the literature data, it seems that the silicone implants do not play a significant role in the pathogenesis of the disease, because their removal in all of the reported cases did not result in PG improvement (3). Furthermore, PG development in breast operations not involving silicone implants, such as breast reduction or reconstruction after breast cancer removal, support further this hypothesis (6). Improvement of PG in our patient without removal of silicone implants is in line with this evidence. Spontaneous regression of PG observed in our patient is not unprecedented, because physical course of PG is unpredictable, with many cases following automatic involution described in the literature. However, in refractory lesions oral steroids, or/and other immunosuppressive drugs should be considered (4). PG represents an uncommon complication of breast surgery, which is usually difficult to recognize. This is supported by the fact that in all of the reported cases in the literature, as in ours as well, PG was initially misdiagnosed and, subsequently, managed inadequately. Delayed diagnosis may result in prolonged patient's morbidity and extensive scaring. Furthermore, early recognition of systemic involvement in the background of PG is crucial. Clinicians should be aware of this infrequent complication of mammaplasty and include PG in the differential diagnosis, especially when evaluating recurrent ulcerations of undetermined aetiology. Zoe Apalla, MD, Aimilios Lallas, PhD, Anatoli Karteridou, MD State Clinic of Dermatology Hospital of Venereal and Skin Diseases Thessaloniki Greece Eleni Sotiriou, PhD First Dermatologic Department Medical School Aristotle University Thessaloniki Greece Kostas Papaioannou, PhD Plastic Surgery Private Office Thessaloniki Greece Georgios Chaidemenos, PhD Dermatology-Venereology Private Office Thessaloniki Greece [email protected]