Dear Editor
The authors report on clinical diagnosis of Pyoderma Gangrenosum (PG) as ‘difficult, due ‘its rarity, unfamiliarity and a variable clinical presentation.’ Another equally important differential, often mimicking is Necrotizing Fascitis (NF), which was alluded to but not clearly mentioned by the authors.
They recognise that PG can often present in the acute, highlighting that in a 2002 study, 64 patients had been incorrectly diagnosed and treated.(1) Indeed, the reverse if also true for NF (2). Both conditions have a recognised pathergy and clinical course , however it is vital that clinicians have an underlying suspicion for necrotising fascitis in the same way that in any 50 year old male with chest pain, Myocardial Infarction has to be considered before it is excluded. Misdiagnosis can be a surgeon’s nightmare! (3)
The diagnostic pitfalls between the two have been well documented (4) often contributing to a clinical conundrum! The management varies greatly leading to very different sequelae. The authors recommend the use of steroids in the management, avoiding unnecessary debridement, which is valid - yet in a patient with undiagnosed necrotising fascitis, the use of steroid will in fact hasten their mortality!
It is recognised that clinical diagnosis is still the mainstay for diagnosis of these rare conditions, a valuable diagnostic would be the ‘Finger Test’ (5), with samples for microbiology and histology and is widely used. This will indeed be diagnostic and avoid any unnecessary debridement.
References
1.Xu A, Balgobind A, Strunk A, Garg A, Alloo A. Prevalence estimates for pyoderma gangrenosum in the United States: An age- and sex-adjusted population analysis. J Am Acad Dermatol 2020;83:-9. doi: 10.1016/j.jaad.2019.08.001 pmid: 31400451
2.Wangia MW, Mitchell CL, Wesson SK, Scott E, Glavin FL. Pyoderma gangrenosum or necrotizing fasciitis? A diagnostic conundrum. Case report and literature review. Journal of Pediatric Surgery Case Reports. 2013 Jun;1(6):139–42.
3.Slocum AMY. A surgeon’s nightmare: pyoderma gangrenosum with pathergy effect mimicking necrotising fasciitis. BMJ Case Reports. 2017 Dec 20;bcr-2017-222145.
4. Bisarya K, Azzopardi S, Lye G, Drew PJ. Necrotizing fasciitis versus pyoderma gangrenosum: securing the correct diagnosis! A case report and literature review. Eplasty [Internet]. 2011 [cited 2023 Sep 28];11:e24. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097992/
Rapid Response:
Re: Pyoderma gangrenosum
Dear Editor
The authors report on clinical diagnosis of Pyoderma Gangrenosum (PG) as ‘difficult, due ‘its rarity, unfamiliarity and a variable clinical presentation.’ Another equally important differential, often mimicking is Necrotizing Fascitis (NF), which was alluded to but not clearly mentioned by the authors.
They recognise that PG can often present in the acute, highlighting that in a 2002 study, 64 patients had been incorrectly diagnosed and treated.(1) Indeed, the reverse if also true for NF (2). Both conditions have a recognised pathergy and clinical course , however it is vital that clinicians have an underlying suspicion for necrotising fascitis in the same way that in any 50 year old male with chest pain, Myocardial Infarction has to be considered before it is excluded. Misdiagnosis can be a surgeon’s nightmare! (3)
The diagnostic pitfalls between the two have been well documented (4) often contributing to a clinical conundrum! The management varies greatly leading to very different sequelae. The authors recommend the use of steroids in the management, avoiding unnecessary debridement, which is valid - yet in a patient with undiagnosed necrotising fascitis, the use of steroid will in fact hasten their mortality!
It is recognised that clinical diagnosis is still the mainstay for diagnosis of these rare conditions, a valuable diagnostic would be the ‘Finger Test’ (5), with samples for microbiology and histology and is widely used. This will indeed be diagnostic and avoid any unnecessary debridement.
References
1.Xu A, Balgobind A, Strunk A, Garg A, Alloo A. Prevalence estimates for pyoderma gangrenosum in the United States: An age- and sex-adjusted population analysis. J Am Acad Dermatol 2020;83:-9. doi: 10.1016/j.jaad.2019.08.001 pmid: 31400451
2.Wangia MW, Mitchell CL, Wesson SK, Scott E, Glavin FL. Pyoderma gangrenosum or necrotizing fasciitis? A diagnostic conundrum. Case report and literature review. Journal of Pediatric Surgery Case Reports. 2013 Jun;1(6):139–42.
3.Slocum AMY. A surgeon’s nightmare: pyoderma gangrenosum with pathergy effect mimicking necrotising fasciitis. BMJ Case Reports. 2017 Dec 20;bcr-2017-222145.
4. Bisarya K, Azzopardi S, Lye G, Drew PJ. Necrotizing fasciitis versus pyoderma gangrenosum: securing the correct diagnosis! A case report and literature review. Eplasty [Internet]. 2011 [cited 2023 Sep 28];11:e24. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097992/
5.Clark RR, McGill DJ. Necrotising Fasciitis: Always use the finger. [Internet]. The BMJ. 2019 [cited 2019 Dec 1].Available from: https://www.bmj.com/rapid-response/2011/10/30/necrotising-fasciitis-alwa...
Competing interests: No competing interests