Unusual Presentation of Blastomycosis-Like Pyoderma Gangrenosum

The patient is a 74-year-old female who was referred to the Jobst Vascular Institute wound care clinic with biopsy proven Squamous Cell Carcinoma (SCC) to the left and right lower extremities. The left lower extremity being more affected than the right side.

Background

The patient had originally been treated for SCC by her dermatologist, then a general surgeon, several months prior to referral to the wound clinic, with subsequent the biopsies continuing to demonstrate microscopically positive margins. After the second excision by general surgery, the left lower extremity became inflamed, erythematous and edematous. The extremity demonstrated a non-healing wound with cellulitis. The patient was admitted to the hospital and empirical antibiotics were initiated; computerized tomography (CT) of her abdomen and lower extremities demonstrated focal skin lesions measuring 25 X 10 X 18mm. No enlarge lymph nodes were seen. Vascular and wound consultations were initiated. Her vascular status was adequate. Wound examination revealed a near mirror lesion on her right lower extremity but with less severity.

Case Report and Atypical Discovery

The patient was taken to the operating room by the plastic and reconstructive surgeon and underwent excision of her left leg SCC with frozen section to clean the margins. This resulted in a large defect down to the tibial periosteum. Hyalomatrix was applied to the wound bed along with negative pressure wound therapy (NPWT) to stimulate the development of granulation tissue in the wound bed. The patient was followed in the wound center weekly for the following month and the NPWT was changed twice a week. The decision was made to postpone any surgical procedure to the right lower extremity pending pathology report. To our surprise the permanent final pathology report confirmed the diagnosis of reactive Squamous hyperplasia and dermal abscess formation with features of Blastomycosis-Like Pyoderma Gangrenosum (PG).

In consultation with Dermatology the patient was started on oral steroids and was followed closely. No pathergy was noticed in the postoperative follow ups. One month after her first procedure a thick layer of granulation formed in the wound bed and during a second procedure she received split thickness skin graft to cover her wound. NPWT was used as a bolster dressing over the graft for 2 weeks. She was tapered off oral steroid while receiving topical steroids over the thigh donor site to prevent formation of another site of PG. In the next 2 weeks the skin graft and donor sites healed and the right leg lesion had disappeared without any surgical intervention.