Pyoderma gangrenosum: a case report highlighting the importance of early diagnosis and treatment

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that occurs spontaneously or after trauma, including surgery - a phenomenon known as pathergy. Postsurgical PG (PSPG) is often misdiagnosed as a pyogenic infection, leading to inappropriate interventions. Surgeons should be familiar with this complication, especially in resource-limited settings where access to specialty care is limited. Early recognition and prompt treatment significantly improve outcomes.

A 65-year-old male developed erythema and edema surrounding the incision, and systemic inflammation within 48 hours of elective left inguinal hernia repair. Despite oral antibiotics, the wound rapidly deteriorated by postoperative day 6 (POD6). Repeated cultures remained negative. Markedly increased C-reactive protein (CRP) and ferritin indicated severe systemic inflammation, prompting a presumptive diagnosis of PSPG. High-dose IV corticosteroids were initiated on POD7 with rapid clinical improvement in erythema, edema, and ulceration size. He was transitioned to oral prednisone and later to oral cyclosporine, achieving complete re-epithelialization by POD32. Colchicine was initiated for maintenance therapy. Molecular testing revealed a PLCG2 mutation. One year later, a subsequent surgical procedure was performed utilizing prophylactic immunosuppression without recurrent PSPG.

This case highlights the diagnostic challenge of PSPG. Misdiagnosis may lead to surgical debridement that can worsen the condition due to pathergy. Immunosuppressive therapy, avoidance of additional trauma, and prophylactic immunosuppression prior to subsequent surgeries are mainstays of treatment. Emerging genetic associations, such as PLCG2 mutations, offer insight into the pathogenesis of PSPG.

Early clinical recognition and prompt immunosuppression are central to management. Serial patient-acquired photographs can support monitoring and guide treatment decisions.