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Old 12-07-2011
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Skin Non-healing sore on the leg!

A 23-year old woman comes to the office because of a nonhealing sore that appeared on her leg several weeks earlier. She remembers injuring her leg in that general area before the appearance of the skin lesion when she fell off her bicycle. First, a tender pimple resembling an insect bite appeared that enlarged over several days and then broke down to form a painful sore that has been expanding slowly ever since. She has applied topical antibiotics daily without improvement. Her past medical history is significant for environmental allergies and occasional joint pains. The family history is unremarkable. On physical examination, the patient does not seem to be in distress and her vital signs are within normal limits. Inspection of the skin reveals a 5 5-cm ulcer on the left lateral thigh as shown in the photograph. Otherwise the examination is within normal limits. You order a panel of blood tests, including serologic studies and cultures, chest x-ray, and an upper gastrointestinal series. You also perform a skin biopsy for histopathologic examination and tissue culture.


Which of the following is the most likely finding in this patient?

A. Air-fluid levels in the colon
B. Elevated blood glucose level
C. Numerous eosinophils on skin biopsy
D. Positive blood and tissue cultures of Pseudomonas aeruginosa
E. Pulmonary infiltrates on chest x-ray

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Old 12-07-2011
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good one

pyoderma gangrenosum

Pulmonary infiltrates on chest x-ray
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Old 12-08-2011
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not sure of the diagnosis just taking a wild guess

C. Numerous eosinophils on skin biopsy??
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Old 12-08-2011
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D. Positive blood and tissue cultures of Pseudomonas aeruginosa - Just a Guess
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Old 12-08-2011
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The correct answer is E. This patient has pyoderma gangrenosum, an uncommon ulcerative skin disease of uncertain etiology. It is associated with systemic diseases in more than 50% of the patients. Most frequent associations include inflammatory bowel disease (either ulcerative colitis or Crohn disease), polyarthritis, and hematologic diseases. Classic skin lesions are deep ulcerations with undermined, violaceous borders that may have visible pustules at the active edge. They are seen most commonly on the legs. The diagnosis is made by excluding other causes of similar skin ulcers and the histopathologic finding of diffuse neutrophilic abscesses in the skin. Lesions of pyoderma gangrenosum may occur after trauma or injury of the skin, a process called pathergy that is not specific to the disease but that may aid in making the correct diagnosis. Patients may have involvement of other organ systems with sterile neutrophilic infiltrates, such as the lungs, heart, central nervous system, gastrointestinal tract, eye, liver, spleen, bone, and lymph nodes. Sterile pulmonary infiltrates are the most common extracutaneous manifestation. The prognosis is generally good, but recurrences are common and the lesions leave unsightly scars.
Air-fluid levels in the colon (choice A) of an adult are observed in large bowel obstruction. Causes of this surgical problem include neoplasms, strictures, incarcerated hernia, volvulus, intussusception, and impaction. Clinically, the patient complains of failure to pass stool or flatus.
An elevated blood glucose level (choice B) is associated with diabetes mellitus, which is not typically associated with pyoderma gangrenosum.
Numerous eosinophils on skin biopsy (choice C) would not be found in pyoderma gangrenosum. Typically, tissue infiltrates are composed almost entirely of neutrophils that form diffuse, very marked infiltration in the form of widespread abscesses.
Positive blood and tissue cultures of Pseudomonas aeruginosa (choice D) are seen with ecthyma gangrenosum, a disease of infants and severely ill patients. The characteristic skin lesion is a friable, undermined ulceration covered by a thick, adherent, black eschar. The patients are severely ill.
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