Case reports
69
(34) Pyoderma gangrenosum, hypoplastic anaemia, tabes dorsalis DR D.I.VOLLUM Lewisham Hospital
H., male, aged 62 years. Retired civil servant. Hospital case no. E 88392, History. In February 1975 he was found to have aleukaemic leukaemia. In September 1975 he bruised his left leg. The whole lower leg became oedematous and he developed a raw haemorrhagic area at the site ofthe bruise. Over the next 3 weeks this almost healed but in October 1975 it broke down to form an ulcer extending from the lateral side of the left knee to the lateral malleolus. The ulcer was 6 in. across and had a purulent sloughing base and a ragged bluish red overhanging border. He had a swinging fever and there was no response to a course of Pyopcn. In November treatment was started with prednisone 30 mg daily, the fever settled and the ulcer gradually healed over the next 6 weeks. Recovery was complicated by a left hemiparesis of unknown aetiology. The anaemia responded to oxymetholone 100 mg daily. Examination. There is a tissue paper scar on the lateral side of the left lower leg extending from just below the knee to the lateral malleolus (Fig. i). The patient has a steroid facies, Argyll Robertson pupils and a high stepping gait. Investigations. February 1975: Hb, 6-6 %%\ PCV 22%; Total WBC 1300/mm-^; Platelets 44,000/
FIGURE I. Scarring on left lower leg.
70
Case reports
mm^; Marrow hypoplastic. February 1976: Hb 11 g%; PCV 32/^; Total WBC i6oo/mm^'; Platelets 31,000/mm^. Biopsy from the ulcer 6.11.75: The epidermis appears pale staining and slightly oedematous with an infiltration of polymorphs. The dermis and subcutaneous tissue are congested and show an extensive diffuse infiammatory reaction with numerous polymorphs. The histology is compatible with pyoderma gangrenosum. Comment. There have been several reports of pyoderma gangrenosum in patients with leukaemia. So far this patient has only a hypoplastic anaemia but it may be that he will eventually develop overt leukaemia. REFERENCE PERRY, H . O . & WINKELMANN, R.K. (1972) Bullous pyoderma gangrenosum and leukemia. Archives of Dermatology, 106, 901.
(35) Chronic intravascular coagulopathy with? pyoderma gangrenosum DR R.C.D.STAUGHTON FOR DR P.W.M.COPEMAN Westminster Hospital, London
P.M., female, aged 68 years. History. Ulceration developed on her right flank 6 years ago whilst she was under treatment for recurrent abscesses of her abdominal wound. Ten months after routine cholecystectomy at St George's Hospital (in i967),atender mass appeared at the site of her wound. Emergency surgical exploration revealed a large extra-peritoneal abscess and staphylococcus aureus was cultured. Over the ensuing months a further wound abscess developed and formal drainage was performed on two occasions. During this period a 'craggy indurated ulcer' appeared lateral to the involved area. Biopsy revealed a granulomatous infiltrate, but no evidence either of foreign bodies or of any micro-organisms. Various antibiotics, metronidazole (Flagyl) and a 6-week course of Lugol's iodine and intramuscular penicillin proved unsuccessful. After 3 years (1972) a spht skin graft was applied but failed to take. Moreover the donor area on the right thigh broke down to produce an exactly similar, but larger, granulomatous ulcer. A further graft from left to right thigh was unsuccessful. On this occasion the donor area healed. The ulcers have changed little over the years, showing no tendency to resolve spontaneously or to respond to the many forms of treatment tried. On Examination. She shows an incisional hernia with several persistently draining sinuses, and indurated ulcers with violaceous undermined edges on her right fiank (15 x io cm) and right thigh (30 X 25 cm). Investigations giving abnormal results
Haematology. Chronic anaemia (Hb 9-5 g/ioo ml). Film, schistocytes. Reticulocyte count 4-6%.
69
(34) Pyoderma gangrenosum, hypoplastic anaemia, tabes dorsalis DR D.I.VOLLUM Lewisham Hospital
H., male, aged 62 years. Retired civil servant. Hospital case no. E 88392, History. In February 1975 he was found to have aleukaemic leukaemia. In September 1975 he bruised his left leg. The whole lower leg became oedematous and he developed a raw haemorrhagic area at the site ofthe bruise. Over the next 3 weeks this almost healed but in October 1975 it broke down to form an ulcer extending from the lateral side of the left knee to the lateral malleolus. The ulcer was 6 in. across and had a purulent sloughing base and a ragged bluish red overhanging border. He had a swinging fever and there was no response to a course of Pyopcn. In November treatment was started with prednisone 30 mg daily, the fever settled and the ulcer gradually healed over the next 6 weeks. Recovery was complicated by a left hemiparesis of unknown aetiology. The anaemia responded to oxymetholone 100 mg daily. Examination. There is a tissue paper scar on the lateral side of the left lower leg extending from just below the knee to the lateral malleolus (Fig. i). The patient has a steroid facies, Argyll Robertson pupils and a high stepping gait. Investigations. February 1975: Hb, 6-6 %%\ PCV 22%; Total WBC 1300/mm-^; Platelets 44,000/
FIGURE I. Scarring on left lower leg.
70
Case reports
mm^; Marrow hypoplastic. February 1976: Hb 11 g%; PCV 32/^; Total WBC i6oo/mm^'; Platelets 31,000/mm^. Biopsy from the ulcer 6.11.75: The epidermis appears pale staining and slightly oedematous with an infiltration of polymorphs. The dermis and subcutaneous tissue are congested and show an extensive diffuse infiammatory reaction with numerous polymorphs. The histology is compatible with pyoderma gangrenosum. Comment. There have been several reports of pyoderma gangrenosum in patients with leukaemia. So far this patient has only a hypoplastic anaemia but it may be that he will eventually develop overt leukaemia. REFERENCE PERRY, H . O . & WINKELMANN, R.K. (1972) Bullous pyoderma gangrenosum and leukemia. Archives of Dermatology, 106, 901.
(35) Chronic intravascular coagulopathy with? pyoderma gangrenosum DR R.C.D.STAUGHTON FOR DR P.W.M.COPEMAN Westminster Hospital, London
P.M., female, aged 68 years. History. Ulceration developed on her right flank 6 years ago whilst she was under treatment for recurrent abscesses of her abdominal wound. Ten months after routine cholecystectomy at St George's Hospital (in i967),atender mass appeared at the site of her wound. Emergency surgical exploration revealed a large extra-peritoneal abscess and staphylococcus aureus was cultured. Over the ensuing months a further wound abscess developed and formal drainage was performed on two occasions. During this period a 'craggy indurated ulcer' appeared lateral to the involved area. Biopsy revealed a granulomatous infiltrate, but no evidence either of foreign bodies or of any micro-organisms. Various antibiotics, metronidazole (Flagyl) and a 6-week course of Lugol's iodine and intramuscular penicillin proved unsuccessful. After 3 years (1972) a spht skin graft was applied but failed to take. Moreover the donor area on the right thigh broke down to produce an exactly similar, but larger, granulomatous ulcer. A further graft from left to right thigh was unsuccessful. On this occasion the donor area healed. The ulcers have changed little over the years, showing no tendency to resolve spontaneously or to respond to the many forms of treatment tried. On Examination. She shows an incisional hernia with several persistently draining sinuses, and indurated ulcers with violaceous undermined edges on her right fiank (15 x io cm) and right thigh (30 X 25 cm). Investigations giving abnormal results
Haematology. Chronic anaemia (Hb 9-5 g/ioo ml). Film, schistocytes. Reticulocyte count 4-6%.
