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Published byGervais Russell Modified over 9 years ago
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Differential Diagnosis
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Staphylococcus aureus
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Mycobacterium marinum
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Vibrio vulnificus
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Ecthyma gangrensum
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Aeromonas
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Deep fungal infection
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Anthrax
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Erysipeloid
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Orf
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Tularemia
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vasculitis
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Diagnostic Procedure(s) and Result(s) Cultures of the lesion on the left leg and right hand, obtained on admission, grew rare methicillin-susceptible Staphylococcus aureus colonies; the culture of the leg also grew Enterococcus in the thioglycollate broth tube, which was thought to be a contaminant.
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Cultures of the leg and right hand obtained in the operating room were sterile.
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All other wound cultures, including for fungi and mycobacteria, were sterile, as were blood cultures. Testing for 1, 3 beta D glucan was negative.
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Indirect immunofluorescence testing for anti- neutrophil cytoplasm antibodies (ANCA), serum protein electrophoresis and testing for lupus anticoagulant and syphilis were also negative.
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Histopathological examination revealed normal tissue, as well as an intraepidermal blister, a dense dermal acute inflammatory infiltrate and tissue necrosis.
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normal skin
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dense acute inflammatory infiltrate
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epidermal necrosis and an intraepidermal blister
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Final Diagnosis
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Pyoderma gangrenosum of the hands and left leg
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Physical findings, post-operatively.
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Pyoderma gangrenosum is an idiopathic inflammatory disease that is often mistaken for an infectious process.
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Diagnosis of this condition is based upon clinical history, pathology, and exclusion of other diseases that cause erosive or ulcerative skin lesions.
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Pyoderma gangrenosum
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While an underlying systemic disease such as inflammatory bowel disease, myeloproliferative disorder, or inflammatory arthritis is found in approximately 50% of cases of pyoderma gangrenosum, this disease has also been associated with trauma (including burns) and surgery.
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It is important to consider this disease in patients with non-healing wounds and obtain early dermatologic consultation whenever possible, because surgical intervention, including debridement, may exacerbate pyoderma gangrenosum and lead to worsening ulceration.
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While there is no published algorithm for the treatment of pyoderma gangrenosum, the literature suggests the use of prolonged systemic glucocorticoid therapy;
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A subset of patients requires the use of other immunomodulators (e.g. cyclosporine, thalidomide, and tumor necrosis factor (TNF)- alpha blockers such as infliximab).
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Differential Diagnosis
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ecthyma gangrenosum
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vibrio vulnificus
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mycobacterium marinum
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Orf
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Anthrax
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