Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article title: Factitious Ulcer Misdiagnosed as Pyoderma Gangrenosum.
Authors: Elena Conde Montero, MD; Begoña Sánchez-Albisua, MD; Soledad Guisado, RN; María Ángeles Martín-Díaz, MD; Eva Balbín-Carrero, MD; Marta Valdivelso-Ramos, MD; and Pablo de la Cueva Dobao, MD.
Journal name and issue: Wounds, February 2016 (pages 63-67).
Reviewed by: Keval Parikh, fourth year podiatric medical student Temple University School of Podiatric Medicine.

This article discusses a rare neutrophilic dermatosis called Pyoderma Gangrenosum (PG). PG is described as a small, red papule or pustule that transforms into a larger ulcerative lesion with violaceous borders. A minor trauma may lead to the development of the ulceration. Surgical debridement should be avoided to decrease chance of more ulcerative PG lesions that is described as pathergy. Compatible, but nonspecific, clinical and histological features support the diagnosis of PG. PG is a diagnosis of exclusion due to the absence if specific diagnostic characteristics.

Case Report: Patient History and Lesion Characteristics

The authors discussed a case report of a 62 year old female with a history of hypertension, obesity, and anxiety-depressive syndrome who presented with a two week history of an abdominal ulcer. She has had this ulceration two times before. She has associated the recurrence of these ulcers to a mesh placement after surgery for cysts 20 years prior. The current ulcer was 6cmx4cm with well-defined, raised, erythematous borders. Blood tests and histopathology were both found to be normal. The biopsy mainly showed chronic inflammatory changes with dermal fibrosis, with absence of granulomas. Due to clinical suspicion, Prednisone steroid therapy was started. Three weeks later after prednisone and occlusive dressings were used the area underwent re-epithelialization. Two weeks after the last visit, the patient presented with an unexpected abdominal lesion similar to the first. The lesion was painful and showed similar characteristics as PG, so prednisone therapy was started again. One week later the lesion grew to 8cmx6cm. Due to the increase in size the patient was placed on cyclosporine 5mg/kg/day. After a lack of response from the immunosuppressant, the initial diagnosis was reconsidered. New biopsies and blood tests were performed, no abnormal levels were found. Due to the patients history of depression and anxiety, test un-specificity, and unexplainable lesion evolution the authors suspected a factitious ulcer.

The patient was admitted as an inpatient for antibiotic therapy and occlusive dressings. Local treatment was continued after discharge and the total re-epithelization was achieved a month later. Both psychiatrists and dermatologists conducted follow-ups. After a few visits it was found that the patient was a survivor of sexual abuse and also had a conflict filled relationship with her son. The patient would not admit to self-inflicting lesions, the mechanisms were not known to the authors.

Diagnosis of Pyoderma Gangrenosum

Many diseases can mimic PG and about 10% of cases are misdiagnosed. PG is a neutrophilic dermatosis that presents with rapidly progressive, painful, suppurative cutaneous ulcers with edematous, boggy, blue, undermined, and necrotic borders. PG is a diagnosis of exclusion with no pathognomonic lab or histological findings. Some cases of dermatitis artefacta are also a diagnosis of exclusion that can be a challenge for the clinician. DA is a type of factitious disorder that is defined as any condition with self-inflicted lesions that the patient denies responsibilities. The production of these lesions satisfies an unconscious psychological or emotional need. It may even be a part of Munchausen syndrome. The treatment of DA is often unsatisfactory. The patient may not want to be cured, but wants continuous care. There needs to be multiple universal care for the patient including a dermatologist and psychiatrist. The authors experience shows that a monitoring plan, including inpatient treatment can also be useful.

About the Authors:
Keval Parikh is a fourth year podiatric medical student at Temple University in Philadelphia, PA. Keval graduated from Rutgers University in New Brunswick, NJ with a degree in Cell biology and Neuroscience. Keval wanted to broaden his education and took on a minor in Philosophy, which would teach him about the ethics and morals of making decisions.

Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.