Skin lesions mimicking septic arthritis

,; ,

Photo Rounds

Skin lesions mimicking septic arthritis

J Fam Pract. 2006 October;55(10):881-884

PDF Download

References

1. Jackson JM, Callen JP. Pyoderma gangrenosum. Available at: Emedicine.com. Accessed on March 21, 2006.

2. Wines N, Wines M, Ryman W. Understanding pyoderma gangrenosum: A Review.Available at www.Medscape.com. Accessed on March 21, 2006.

3. Weenig RH, Davis MD, Dahl PR, Su WP. Skin ulcers misdiagnosed as pyoderma gangrenosum. N Engl J Med 2002;347:1412-1418.

4. Smith EL. Clinical manifestations and diagnosis of Behcet’s disease. Available at www.uptodate.com. Accessed on April 2, 2006.

5. Venables PJW, Maini RN. Diagnosis and differential diagnosis of Rheumatoid arthritis. Available at www.uptodate.com. Accessed on April 2, 2006.

6. Yu DT, Wiesenhutter CW. Course and treatment of Reiter’s syndrome; reactive arthritis and undifferentiated spondyloarthropathy. Available at www.uptodate.com. Accessed on April 2, 2006.

7. Reichrath J, Bens G, Bonowitz A, Tilgen W. Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients. J Am Acad Dermatol 2005;53:273-283.

8. Driesch VD. Pyoderma gangrenosum: a report of 44 cases with follow up. Br J Dermatol 1997;137:1000-1005.

9. Moschella SL. Neutrophilic dermatosis. Available at www.uptodate.com.

These procedures should be avoided in active disease due to risk of pathergy and worsening of original lesions of pyoderma gangrenosum. Similarly, elective surgery should be avoided during active disease, and when necessary should be done alongside systemic pyoderma gangrenosum therapy.

Refractory cases

In refractory or idiopathic cases, disseminated pyoderma gangrenosum is treated systemically with corticosteroids or cyclosporine alone or in combination (strength of recommendation [SOR]: B).⁷ In steroid-resistant pyoderma gangrenosum, thalidomide, mycophenolate mofetil, tacrolimus, dapsone, azathioprine, and infliximab may be tried (SOR: C).⁷

Immunoglobulin, plasmapheresis, and cyclophosphamide have shown some efficacy in patients without systemic disease (SOR: C).⁷ Tumor necrosis factor-α inhibitor infliximab (Remicade) is considered first-line therapy for pyoderma gangrenosum associated with Crohn’s disease (SOR: B).⁷

FAST TRACK

Recognizing that these lesions can occur over the joints would have prevented an unnecessary surgical debridement

The patient’s outcome

The patient did not improve after initial treatment with high-dose systemic corticosteroids. Infliximab in combination with methotrexate dramatically improved her skin and joint lesions and induced remission of Crohn’s disease. Early on, during the active phase of the disease, she also had surgical debridement of the lesions due to confounding diagnosis.

The patient has continued with infliximab infusions every 2 months and weekly oral methotrexate to maintain remission. Data show that 56% of patients with pyoderma gangrenosum require long-term therapy to prevent recurrences.⁸

This case is interesting because the bullous lesions of pyoderma gangrenosum appeared over the joints, mimicking septic arthritis and resulting in preventable surgical debridement. A case report with pyoderma gangrenosum lesions predominantly over the joints has not been described in the published literature. Recognition of lesions over the joints is important because treatment remains nonsurgical and surgery may exacerbate these skin lesions.

CORRESPONDENCE
Shashi Mittal, MD, Faculty Director of Research, Baylor Family Medicine Residency at Garland, Suite 340, Clara Barton Blvd, Garland, TX 75042.

Skin lesions mimicking septic arthritis

References

Pages

Recommended Reading