European Journal of Case Reports in Internal Medicine
Pyoderma gangrenosum and haematochezia in a patient with previous cocaine abuse
By Myrianthi Hadjicharalambous, Sofia Symeonidou, George M Georgiou and 2 others.
Abstract
Introduction
Pyoderma gangrenosum (PG) is an autoinflammatory neutrophilic dermatosis that may rarely occur in association with granulomatosis with polyangiitis (GPA). Management of refractory disease remains challenging.
Case description
A 48-year-old man with a history of previous cocaine abuse was admitted due to impaired feeding in the context of a chronic hard palate perforation and a large oro-sinus fistula. During hospitalisation, he developed haematochezia and painful ulcerative skin lesions involving the right upper limb and lower extremities. Upper and lower gastrointestinal endoscopy revealed a Forrest IIc gastric lesion and a non-bleeding ileocecal ulcer. Histopathological examination of skin lesions demonstrated dense neutrophilic infiltration consistent with PG, while gastrointestinal biopsies excluded inflammatory bowel disease. An extensive evaluation excluded infection, antiphospholipid syndrome, cryoglobulinaemia, malignancy and vascular occlusive disease, all of which may mimic PG. Autoimmune screening workup yielded positive for anti-proteinase-3 antibodies (C-ANCA). The patient initially received high-dose methylprednisolone followed by mycophenolate mofetil and infliximab. Despite treatment, disease activity persisted with recurrent relapses, requiring hospitalisations. Upadacitinib was subsequently introduced, resulting in rapid clinical improvement, near-complete healing of skin lesions and successful glucocorticoid withdrawal.