Images for surgeons

An urgent decompressive sternotomy was performed revealing extensive air-pockets, under pressure, in the mediastinum, overlying the right ventricular outflow tract and the pulmonary arteries (Fig. 2). The air-pockets were decompressed with intraoperative haemodynamic improvement immediately noted. Tissues also removed from the mediastinum during sternotomy exhibited widespread pneumatization giving a ‘bubbled’ appearance. No significant bleeding was noted during sternotomy with mediastinal and bilateral pleural drains placed. The chest was closed in standard fashion with stainless steel sternotomy wires and layered closure technique. Drains were placed on −3 kPa suction with negligible bleeding and no air leak observed. The patient remained stable and was returned to the intensive care unit. Several days later, formal neurological testing confirmed brain death with next of kin consenting to organ donation shortly thereafter. Organ retrieval of heart and lungs occurred expediently and without complication. It is hoped the sharing of these images will alert fellow clinicians to the possibility of tension

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pneumomediastinum, especially in ventilated, chest trauma patients and to reinforce the vital importance of organ donation

References 1. Katabathina V, Restrepo C, Martinez-Jimenez S, Riascos R. Nonvascular, non-traumatic mediastinal emergencies in adults: a comprehensive review of imaging findings. Radiographics 2011; 31: 1141–60. 2. Beg M, Reyazuddin M, Ansari M. Traumatic tension pneumomediastinum mimicking cardiac tamponade. Thorax 1988; 43: 576–7.

Scott Jennings, MBBS (Hons) Sheen Peeceeyen, FRACS Matthew Horton, FRACS Department of Cardiothoracic Surgery, St George Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12378

Pyoderma gangrenosum of the penis: an important lesson In this case report, we describe an unusual case of localized pyoderma gangrenosum of the penis in a 62-year-old man. Pyoderma gangrenosum is an inflammatory ulcerative disease that usually occurs with systemic manifestations. Presently, there are fewer than 15 reports of isolated pyoderma gangrenosum of the penis.1–10 A previously healthy 62-year-old man initially presented to the urology clinic with a 16-month history of a chronic penile lesion, secondary to squeezing a small pustule noted on the distal dorsal shaft of his penis.3 There was no prior history of any ulcers, vascular pathology or diabetes in the patient. There was also no associated arthritis, inflammatory bowel disease or known haematological dyscrasias stated. Apart from occasional dysuria, he was able to pass urine normally with no fistulous urine leakage from his ulcer site. Serological and penile swab testing were negative for any sexually transmitted diseases. Tissue penile biopsies were obtained and flow cytometry testing for lymphoma as well as histochemical staining for viral or fungal micro-organisms were performed, all of which were negative. On macroscopic examination, there were multiple deep tender ulcerated areas with purulent discharge on the distal dorsal aspect of the penile shaft and glans. Sloughing was present over most of the ulcer surface. The glans, scrotum and testicles were otherwise all normal and no femoro-inguinal adenopathy was noted. Microscopically, findings were consistent with a chronic inflammatory change. The patient received multiple debridements for his chronic ulcer over a period of 2 years with no improvement in his symptoms and subsequently underwent a penile skin flap with incorporation of his penile shaft into the scrotum for management of his symptoms. Unfortunately, he represented to the acute clinic 2 weeks later with urine leak from the skin flap site while voiding and © 2013 Royal Australasian College of Surgeons

(a)

(b)

Fig. 1. Macroscopic appearance of the male patient’s genitalia on presentation to acute urology clinic. Circumferential wound breakdown was noted with associated urine leak. The glans penis was atrophic and was tethered to the penile shaft by a sliver of viable corpus spongiosum. He subsequently underwent a distal penectomy and indwelling catheter insertion.

circumferential wound breakdown. By this time, the glans penis was atrophic and was tethered to the penile shaft by a sliver of viable corpus spongiosum (Fig. 1). He subsequently underwent a distal penectomy and indwelling catheter insertion (Fig. 2a). All previous histopathological findings were reviewed by an expert panel (Fig. 2b,c) and a diagnosis of pyoderma gangrenosum was made. He was subsequently referred to dermatology and was commenced on a regime of stepped high-dose steroids and immunosuppressants, consisting of prednisolone (50 mg once daily), azathioprine (50 mg once daily) and potassium permanganate baths. Mupirocin cream was also administered topically with oral ciprofloxacin and metronidazole for antibacterial cover. This regime

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Images for surgeons

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Fig. 2. (a) Macroscopic pathological findings post distal penectomy. The atrophied glans penis and ulcerated slough are presented post formalin processing. Low- (b) and high-power (c) microscopic pathological findings post distal penectomy. Histopathology reveals findings of acute inflammation with ulceration as well as chronic changes with giant cell and granulation tissue present as labelled.

has been described previously in the literature2,3,8,10 and was well tolerated by the patient. This continued for a total of 10 days with significant marked improvement at the end of treatment, and the patient was subsequently followed up in outpatient clinic. Pyoderma gangrenosum is an uncommon disease entity whose aetiology is not yet well understood. It can be classified into ulcerative, pustular, bullous and vegetative types. Diagnosis relies mostly on clinical acumen as there are no pathognomonic signs and often, the disease can mimic other systemic pathologies. There have been fewer than 15 reports of pyoderma gangrenosum in the literature isolated to the penis. Early recognition of pyoderma gangrenosum is paramount to initiating early treatment and avoiding unnecessary surgical intervention. The lengthy period of time to diagnosis in this patient serves to illustrate the difficulty in establishing the diagnosis from other ulcerative lesions of the penis1,2,10 and the importance of pyoderma gangrenosum as a differential in chronic ulcers refractory to antibiotics. Most notably, pathergy or worsening of ulceration after multiple debridements and surgical intervention with no improvement is a hallmark of the disease and should alert the clinician to the diagnosis.1,7,10 The mainstay of treatment is high-dose steroid therapy with adjuvant urinary diversion for penile involvement, allowing for healing and topical as well as systemic antibiotic cover. Other described modalities involve the use of thalidomide and anti-mitotic agents.4 Treatment yields a good chance of disease resolution although penile deformity as well as urethrocutaneous fistula formations has been described.

Acknowledgements The authors would like to acknowledge the contributions of Dr Kyra Thompson MBBS (Anatomical Pathology, Royal Brisbane and Women’s Hospital) who provided the histopathological slides, and Dr Philip Wolanski MBBS (Urology, Royal Brisbane and Women’s Hospital) who provided the macroscopic photos that appear in this paper.

References 1. Badgwell C, Rosen T. Penile pyoderma gangrenosum. Dermatol. Online J. 2006; 12: 8. 2. Das NK, Dutta RN. Pyoderma gangrenosum on glans penis: an unusual site. J. Indian Med. Assoc. 2010; 108: 873–4. 3. Ecra E, Ahogo KC, Sangaré A et al. An uncommon localization of pyoderma gangrenosum on the penis of an HIV-infected patient in the Ivory Coast. Bull. Soc. Pathol. Exot. 2009; 102: 85–7. 4. Farrell AM, Black MM, Bracka A, Bunker CB. Pyoderma gangrenosum of the penis. Br. J. Dermatol. 1998; 138: 337–40. 5. Georgala S, Georgala C, Nicolaidou E. Pyoderma gangrenosum of the penis: a potentially dramatic skin disease. Urology 2008; 72: 1185. 6. Gonzalgo ML, de Lacerda DA, De Marzo AM, Chan DY. Persistent purulent drainage from the glans penis: atypical presentation of pyoderma gangrenosum. J. Urol. 2003; 169: 1793–4. 7. Gopi SS, Evans AT, Raza A, Byrne DJ. Superficial granulomatous pyoderma gangrenosum of the penis: a case report. Scientificworldjournal 2007; 5: 2426–9. 8. Gungor E, Karakayali G, Alli N, Artuz F, Lenk N. Penile pyoderma gangrenosum. J. Eur. Acad. Dermatol. Venereol. 1999; 12: 59–62. 9. Kim TH, Oh SY, Myung SC. Pyoderma gangrenosum of the penis. J. Korean Med. Sci. 2009; 24: 1200–2. 10. Kohjimoto Y, Inagaki T, Iba A et al. Pyoderma gangrenosum of the penis presenting as Fournier’s gangrene: a case report. Hinyokika Kiyo 2005; 51: 411–5.

Eugene Ng,* MBBS Michelle Lee,† MBBS Nigel Dunglison,* MBBS, FRACS (Urology) Departments of *Urology and †Plastics and Reconstructive Surgery, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia doi: 10.1111/ans.12394

© 2013 Royal Australasian College of Surgeons

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