A 49-year-old woman with a history of bronchial asthma.
The patient was diagnosed with ductal carcinoma of the left breast in periodic gynecologic review and underwent modified radical mastectomy with axillary closure by the Department of General Surgery, receiving adjuvant treatment with radiotherapy and chemotherapy.
The extension study was negative for locoregional lymph nodes and distant metastases (pT3pN0M0).
At the end of treatment the patient requests breast reconstruction, so she is referred to the Plastic Surgery Service.
Four years after mastectomy, breast reconstruction was performed with several procedures described below.
First, reconstruction of the left breast with transverse rectus abdominis myocutaneous flap (TRAM), suffering partial loss of it that was resolved with debridement and direct closure.
Two years later, a subTRAM Becker expander prosthesis was placed, and finally, the expander was replaced by a definitive breast prosthesis and the contralateral nipple-complexing mastopexy of the nipple reconstruction was completed.
In the postoperative period of the last intervention begins the appearance of small pustular lesions in the periareolar area of the right breast and in the center of the left breast flap with subsequent development of painful ulcers with violet edge.
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With the presumed diagnosis of surgical wound dehiscence biopsy was performed which reported granulation tissue, so the patient underwent cures with debridement for more than 12 months.
Due to the poor evolution, it was decided to consult the Pathological Service where, when faced with the initial suspicion of pyoderma gangrenosum, an exhaustive study was carried out to rule out other processes.
The following tests were requested:
- Analytical, including autoimmunity study (ANAs and ENAs) and proteinogram: without pathological changes.
- Luetic serology, hepatitis B and C virus, HIV: negative
- Mantoux: negative.
- chest X-ray: diffuse thickening of the bronchial walls; surgical changes in the left breast with staples in the axillary region.
- Biopsy with PAS techniques, Gro fixation and Ziehl-sen: epidermal ulceration with consolidation and follicular, chronic inflammation of the dermal and focal perivascular distribution of focal segmentation, and focal lymphocytic superficial spreading.
Histopathological findings compatible with the clinical suspicion of classic pyoderma gangrenosum or ulcerated pyoderma.
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- Negative biopsy (erobic, anaerobic, and mycobacterial).
After the exclusion diagnosis of classic pyoderma gangrenosum, we started treatment with oral prednisone at a dose of 60 mg/day with topical clobetasol propionate 0.05% for 3 months.
When the steroid regimen was reduced to 30 mg/day, the patient began with a re-growth of the lesions, due to the fact that topical corticosteroids were combined during the period with cyclosporine at 4 mg/kg of weight, and tacrolimus was substituted for topical corticosteroids.
Initially, the patient has a favorable evolution except hypertension controlled with a thiazide diuretic and good reepithelialization of the lesions is achieved. However, after 2 months of treatment with cyclosporine, the patient has a new gingival hyperplasia tacrolimus obliges us to:
Intolerance of the patient to the side effects of cyclosporine caused complete withdrawal after 4 months of treatment.
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Finally, in view of the appearance of new lesions and poor tolerance to previous treatments, we decided to start treatment with infliximab (anti-TNF agent), starting with an induction therapy of 5 mg/kg every week of inflammatory psoriasis infusion similar to maintenance.
Once the patient has achieved a satisfactory response to treatment, complete reepithelization is achieved 2 months after the new treatment. Treatment should be maintained similarly to other inflammatory dermatoses until stabilization is achieved.
