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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 559-563
Pyoderma Gangrenosum in a Renal Transplant Recipient: A Case Report


Consultant Internist/Nephrologist, Department of Internal Medicine, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia

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   Abstract 

Pyoderma gangrenosum (PG) is an ulcerative disease of the skin of unknown etiology. Its association with infection, autoimmune disease, inflammatory bowel disease, malignancy, and certain drugs suggests a hypersensitivity reaction. We herewith present a renal transplant recipient who developed PG. The patient presented with multiple necrotizing skin ulcers on both the upper and lower extremities associated with malaise, myalgia, arthralgia, weight loss and low-grade fever. To our knowledge, the association between PG and renal transplant has not been reported previously.

Keywords: Renal transplant, Pyoderma gangrenosum, Multiple necrotizing skin ulcer, Subcutaneous nodule, Cytomegalovirus.

How to cite this article:
Al-Hwiesh AK. Pyoderma Gangrenosum in a Renal Transplant Recipient: A Case Report. Saudi J Kidney Dis Transpl 2006;17:559-63

How to cite this URL:
Al-Hwiesh AK. Pyoderma Gangrenosum in a Renal Transplant Recipient: A Case Report. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Dec 13];17:559-63. Available from: http://www.sjkdt.org/text.asp?2006/17/4/559/32495

   Introduction Top


Pyoderma gangrenosum (PG) is an ulcerative disease of the skin of unknown etiology. The association of PG with infection, autoimmune disease, inflammatory bowel disease, malign­ancy, and drugs suggests a hypersensitivity reaction. The initial hypothesis, which has not been supported by experimental data, includes an immune-complex vasculitis, T­cell activation, and altered neutrophil function. It is currently thought that cytokine dys­regulation accounts for most of the clinico­pathological changes seen in PG.

Among the cytokines involved are interleukin (IL)- 1, IL-3, IL-6, IL-8, granulocyte colony stimulating factor (G-CSF), granulocyte macrophage colony stimulating factor GM­CSF and interferon gamma. [1],[2]

The skin lesions of PG may be single or multiple and chronic or recurrent. The lesions occur most commonly on the leg, especially the peritibial area, but can develop in any part of the body. The initial lesion usually begins as follicular erythematous papules or pustules, or inflammatory nodules [Figure - 1]. The lesion then forms an ulcer with a purulent base and a ragged undermined, violaceous gunmetal color border, which spreads peri­pherally [Figure - 2].

Approximately one-half of cases of PG are associated with underlying systemic disease such as inflammatory bowel disease, arthritis, or lymphoproliferative disorders. [3],[4],[5],[6] The disease occurs in up to 5% of patients with ulcerative colitis and 2% of those with Crohn's disease. [7] PG has been described in patients with Sweet's syndrome, Behcet's disease, subcorneal pustulosis, and as a complication of therapy with G-CSF. [8],[9]

The occurrence of PG in a renal transplant recipient has not been reported previously. We herewith describe a middle-aged male renal transplant recipient, who developed lesions typical of PG. To our knowledge, this is the first report in the literature of such an association.


   Case History Top


A 57-year-old Saudi gentleman, a known case of chronic renal failure (CRF) of unknown etiology, underwent a living unrelated donor kidney transplant in India in 1992. His transplanted kidney functioned for six years after which he developed chronic rejection and returned to hemodialysis (HD), performed three times per week, through a left arterio­venous (AVF).

He remained on dialysis for six years after which, in July 2004, he went to Pakistan for a second living unrelated donor kidney trans­plantation. After transplantation, he experienced multiple rejection episodes. He was treated with pulse steroids and maintained on immuno­suppression with cyclosporine A (CyA), myco­phenolate mofetil (MMF), oral steroids, along with amlodipine for hypertension. Four weeks prior to presentation at our institution, he developed easy fatigability, low-grade fever, myalgia, arthralgia and active arthritis of the right ankle. He also had multiple painful necrotic skin ulcers on the extensor surfaces of the upper and lower extremities, especially at the peritibial area with subcutaneous nodules. There was sparing of the palms, soles, and mucous membranes. These symptoms were associated with weight loss and loss of appetite. No history of nausea, vomiting, diarrhea, cough, hemoptysis, orthropnea, alopecia, Raynaud's phenomenon, or dryness of the eyes and mouth was elicited. There was no history of recent treatment with antibiotics or non-steroidal anti-inflammatory drugs (NSAIDs).


   Clinical Examination Top


At presentation, the patient had a blood pressure of 110/70 mm Hg, pulse rate of 90/ min, temperature of 38.5 o C and a respiratory rate of 20/minute. His body weight was 50 kg and height was 165 cm. There were multiple necrotic skin ulcers [Figure - 3] and subcuta­neous nodules. Examination of the cardio­vascular, nervous and respiratory systems as well as abdominal examination did not reveal any abnormality. The transplanted kidney was palpable and non-tender. The lower limbs showed multiple necrotic skin ulcers. The initial differential diagnosis included Kaposi's sarcoma, PG, paniculitis, T-cell lymphoma, bacillary angiomatosis, and fungoid mycosis.

Laboratory investigations revealed the following: white blood cell count (WBC) of 6x10 9 /L with normal differential, hemoglobin of 70 g/L with a microcytic hypochromic picture, serum sodium of 140 mmol/L, potassium of 4.5 mmol/L, chloride of 111 mmol/L, bicarbonate of 22 mmol/L, blood urea nitrogen of 35 mg/dl, serum creatinine of 3 mg/dl, phosphate of 3 mg/dl, glucose of 110 mg/dl, calcium of 8.1 mg/dl, alkaline phosphatase of 200 U/L, total protein of 7.2 g/dl, serum albumin of 3.3 g/dl and liver enzymes which were within normal limits.

Urinalysis was unremarkable except for mild proteinuria. The thyroid function tests as well as serum and urine protein electro­phoresis were within normal limits. The ESR was 120 mm/hour. Bone marrow biopsy and aspiration were normal.

A dermatology opinion was sought and skin biopsy was performed. Histology showed spindle cells and small vessel proliferation with lymphocytic infiltration consistent with PG [Figure - 4]. Due to the active arthritis in the right ankle, an orthopedic opinion was taken and a diagnosis of chronic osteomyelitis was made. Debridement and drainage of the fluid from the right ankle was performed and analysis of the fluid did not show any orga­nisms. Computerized tomographic scans of the chest and pelvis were normal. Endoscopy of the upper and lower gastrointestinal tract was normal. Connective tissue studies that included anti-nuclear antibody (ANA), Anti­DNA, C3, C4, CH50, cryoglobulin, anti-Smith antibodies, and  Brucella More Details and amoeba antibody titers were normal. Multiple blood and skin cultures were negative. Virology studies for hepatitis B, cytomegalovirus (CMV), and human immunodeficiency virus (HIV) were negative except for positive CMV IgG anti­bodies.

The patient was started on pulse steroid therapy, which resulted in the dramatic im­provement of skin lesions. The serum creatinine decreased to 1.5 mg/dl. The steroid dose was gradually tapered but was followed by a recurrence of the fever, skin ulcers and a subcutaneous nodule several days later. The subcutaneous nodule was re-biopsied and showed small blood vessel proliferation with plump endothelial cells showing intra-cyto­plasmic, inter-nuclear inclusions and lympho­cytic infiltration [Figure - 5].

The patient's immunochemistry was negative for Kaposi's sarcoma and T-cell lymphoma. Although his CMV blood test was negative for IgM antibodies, the clinical features were suggestive of CMV infection. Meanwhile, tissue culture of the right ankle came was positive for acid-fast bacilli (AFB). Thus, the patient was treated with anti-tuberculous medications as well as with a short course of ganciclovir and showed dramatic improvement.


   Discussion Top


There are six identified broad disease cate­gories that can cause PG. Vascular occlusive or venous disease, vasculitis, cancer, infection, exogenous tissue injury and other inflammatory disorders should be specifically ruled out before a diagnosis of PG is made. In 1930, Birunstinay et al [10] of Mayo Clinic described five patients with rapidly progressive, pain­ful, suppurative, cutaneous ulcers with edema­tous baggy blue undermined and necrotic borders, which they called PG. This condition falls in the spectrum of neutrophilic dermatosis, a group of inflammatory disorders that com­monly display a tendency for pathergy (indu­ction of the inflammatory process after skin trauma) and the presence of non-infectious neutrophilic infiltration of the skin.

PG is associated with a number of specific diseases including inflammatory bowel disease, paraproteinemia, arthritis, and myeloprolife­rative disorders. The pathogenesis of PG is poorly understood. However, neutrophil dys­function (defect in chemotaxis with hyper­reactivity) and over expression of IL-8 2 and IL-16[ 11],[12] have been reported. These obser­vations suggest that PG represents an over reactive inflammatory response to trauma, inflammatory or neoplastic process in sus­ceptible patients.

There may be one or multiple lesions. They commonly occur on the legs, especially in the pretibial area, but can develop in any area of the body including the abdominal wall adjacent to stoma after colectomy. The initial lesion usually begins as a follicular erythematous papule or pustule, an inflammatory nodule or a hemorrhagic bulla with an erythematous base [Figure - 1]. The lesion breaks down to form an ulcer with a purulent base and a ragged, undermined violaceous gunmetal color border, which spreads peripherally. If there are several ulcers, they may coalesce to form a larger ulcer, and heal with an atrophic, pigmented, cribriform scar.

Biopsy of an early lesion of PG demonstrates a dermal neutrophilic abscess. Later stage lesions show epidermal necrosis and ulceration, superficial dermal edema and a dense mixed dermal infiltration that may extend to pan­niculitis. Histological examination of the advancing, inflamed border reveals dense perivascular lymphatic inflammation, which may at times be associated with vascular destruction. None of these histological features is pathognomonic for PG. No laboratory finding is diagnostic of PG and investigations should focus on identifying associated diseases, if any, and excluding lesions that may simulate PG. The frequency of misdiagnosing PG is approximately 10%.

Treatment directed at PG can itself produce complications or may adversely affect other causes of ulceration. For example, it may promote the progression of infection or lymphoma. It may also result in temporary improvement of disorders such as vasculitis, anti-phospholipid antibody syndrome and lymphoma, and thereby delay the diagnosis of these disorders.

The initial improvement shown by our patient to pulse steroid therapy and the reappearance of the skin lesion and sub­cutaneous nodule after tapering the steroids, along with the classical histopathologic features, are highly suggestive of PG. Biopsy of the subcutaneous nodule showed inclusion bodies consistent with CMV suggesting that PG can be precipitated by CMV infection, especially in patients who are carriers of CMV and do not receive prophylaxis.

The fact that culture from the right ankle was positive for AFB while those from the other skin ulcers and subcutaneous nodules were negative suggests a super-imposed infection. A Medline literature search by the author did not disclose any report of an association between CMV and PG in renal transplant patients.

In conclusion, we present a middle-aged Saudi male renal transplant recipient who developed multiple necrotic skin ulcers consistent with PG, probably precipitated by CMV infection. To our knowledge, such an association has not been reported previously.

 
   References Top

1.Reuss-Borst MA, Puwelec G, Saal JG, et al. Sweet's syndrome associated with myelodysplasia: possible role of cytokinase in the pathogenesis of the disease. Br J Haematol 1993;84:356-8.  Back to cited text no. 1    
2.Reuss-Borst MA, Muller CA, Waller HD. The possible role of G-CSF in the pathogenesis of Sweet's syndrome. Leuk Lymphoma 1994;15:261-4.  Back to cited text no. 2  [PUBMED]  
3.Powell FC, Schroeter AL, Su WP, Perry HO. Pyoderma gangrenosum: a review of 86 patients. Q J Med 1985;55:173-86.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Hickman JA. Pyoderma gangrenosum. Clin Dermatol 1984;1:102.  Back to cited text no. 4    
5.Holt PJ, Davies MG, Saunders KC, Nuki G. Pyoderma gangrenosum: clinical and laboratory finding in 15 patients with special reference to polyarthritis. Medicine 1980;59:114-33.  Back to cited text no. 5  [PUBMED]  
6.Ross HJ, Moy LA, Kaplan R, Figlin RA. Bullous pyoderma gangrenosum after granulocyte colony-stimulating factor treatment. Cancer 1991;68:441-3.  Back to cited text no. 6  [PUBMED]  
7.Mir-Madjlessi SH, Taylor JS, Farmer RA. Clinical course and evaluation of erythema nodosum and pyoderma gangrenosum in chronic ulcerative colitis: a study of 42 patients. Am J Gastroenterol 1985;80:615-20.  Back to cited text no. 7    
8.Callen JP. Pyoderma gangrenosum and related disorders. Med Clin North Am 1989;73:1247-61.  Back to cited text no. 8  [PUBMED]  
9.Su WP, Schroeter AL, Perry HO, Powell FC. Histopathologic and Immunopathologic study of Pyoderma gangrenosum. J Cutan Pathol 1986;13:323-30.  Back to cited text no. 9  [PUBMED]  
10.Brunstiny LA, Goeckerman WH, O'Leary PA. Pyoderma clinical experimental observation in 5 cases. Arch Dermatol Syphilol 1986; 22:655-80.  Back to cited text no. 10    
11.Wollina U, Karamfilov T. Treatment of recalci­traut ulcers in pyederma gangrenosum with mycophenolit mofetil and autolagous keratino­cyte transplantation on a hyaluronic acid matrix. J Eur Acad Dermatol Venerol 2000;14:187-90.  Back to cited text no. 11    
12.Yeon HB, Lindor NM, Seidman JG, Seidman CE. Pyogenic arthritis pyoderma gangrenosum and acne syndrome maps to chromosome 15q. Am J Hum Genet 2000; 66:1443-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Abdullah K Al-Hwiesh
Consultant Internist/Nephrologist, Department of Internal Medicine, P.O. Box 40246, Al-Khobar 31952
Saudi Arabia
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PMID: 17186692

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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    Abstract
    Introduction
    Case History
    Clinical Examination
    Discussion
    References
    Article Figures
 

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