Case and Research Letters
Usefulness of Ultrasound in the Diagnosis and Follow-up of Pyoderma Gangrenosum
Utilidad de la ecografía en el diagnóstico y seguimiento del pioderma gangrenoso
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(c) y (d) control evolutivo tras una semana de tratamiento: disminución de banda hipoecoica subepidérmica, así como vascularización en el modo Doppler color, persistiendo tractos hipoecogénicos a nivel subepidérmico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Pousa-Martínez, D. Sánchez-Aguilar, C. Aliste, H. Vázquez-Veiga" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Pousa-Martínez" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Sánchez-Aguilar" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Aliste" ] 3 => array:2 [ "nombre" => "H." 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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "965" "paginaFinal" => "966" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liquen <span class="elsevierStyleItalic">aureus:</span> ¿un caso congénito?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1645 "Ancho" => 1980 "Tamanyo" => 290524 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical and dermoscopic images of the patient. A, Grouped, shiny erythematous-purpuric plaques with fine superficial desquamation on the left knee. B, Dermoscopy showing red dots on a brownish-gray background with a fine network. C, Clinical course of the lesion after several attempted treatments. Note persistence of the plaques but with a slight reduction in color.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Corral-Magaña, J. Escalas Taberner, A. Bauzá Alonso, A. Martin-Santiago" "autores" => array:4 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Corral-Magaña" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Escalas Taberner" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Bauzá Alonso" ] 3 => array:2 [ "nombre" => "A." 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Pousa-Martínez, D. Sánchez-Aguilar, C. Aliste, H. Vázquez-Veiga" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Pousa-Martínez" "email" => array:1 [ 0 => "m.pousa.martinez@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Sánchez-Aguilar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Aliste" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "H." "apellidos" => "Vázquez-Veiga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Facultad de Medicina, Santiago de Compostela, La Coruña, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complexo Hospitalario Universitario de Santiago de Compostela, Facultad de Medicina, Santiago de Compostela, La Coruña, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la ecografía en el diagnóstico y seguimiento del pioderma gangrenoso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 159586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Initial phase of pyoderma gangrenosum. B, Clinical course after a week of treatment. A reduction can be seen in the erythema and edema of the lesions. Oral prednisone treatment was then tapered by 10<span class="elsevierStyleHsp" style=""></span>mg. C, Appearance at 7 weeks, with residual erythematous-purpuric lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 78-year-old woman, with a past history of systemic hypertension and a chronic myeloproliferative syndrome, came to the dermatology emergency room for the presence of 2 painful, erythematous-purpuric lesions that had arisen on her left lower limb a week earlier. She stated that the lesions were increasing in size and that the pain now interfered with walking. She did not report fever or other associated symptoms. Dermatologic examination revealed 2 poorly defined, tender erythematous-violaceous nodules on her left leg (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Additional tests included skin ultrasound with a linear 18<span class="elsevierStyleHsp" style=""></span>MHz probe (Esaote MylabGold 25), which revealed a well-defined, hypoechoic subepidermal structure measuring 3.29<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.14<span class="elsevierStyleHsp" style=""></span>cm. This area was continuous with an irregular, heterogeneous hypoechoic area that formed tracts that extended into a destructured hypodermis. Color Doppler showed increased local vascularity. Other additional tests included a complete blood count, which showed no evidence of infection, cultures, which were negative, and a skin biopsy from one of the lesions, which revealed an abundant neutrophilic inflammatory infiltrate in the dermis and that extended into the subcutaneous cellular tissue, as well as foci of abscess formation in the dermis, dissecting through the tissue (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Based on these findings, we made a diagnosis of chronic myeloproliferative syndrome-associated pyoderma gangrenosum (PG) and started treatment with oral prednisone at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient's clinical follow-up (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>,<span class="elsevierStyleHsp" style=""></span>B and<span class="elsevierStyleHsp" style=""></span>C) included serial ultrasound studies. After a week of treatment, ultrasound showed a reduction in local vascularity and a decrease in the size of the lesion to 2.87<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.88<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>,<span class="elsevierStyleHsp" style=""></span>A-D); we therefore started to taper the treatment.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Clinically, PG presents as a painful papule, pustule, or nodule that progresses to a violaceous ulcer with undermined borders.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Fistulous tracts draining into this ulcer can be observed on ultrasound. The correlation between the ultrasound and pathology findings helps to confirm the clinical diagnosis. Four clinical variants of PG have been described: ulcerative or classic, bullous, pustular, and vegetative or superficial granulomatous.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">PG is associated with a systemic disease in 50% of cases, the most common being inflammatory bowel disease, followed by arthritis, hematologic neoplasms, and autoinflammatory syndromes.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The etiology and pathogenesis of PG are unknown and diagnosis is based on a compatible medical history and histopathological examination and the exclusion of other diseases that can present similar findings. Different diagnostic criteria have been proposed for PG, but the exclusion of other similar diseases is always an important consideration, with ultrasound study being particularly important for this purpose.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The differential diagnosis should include infections, nodular syndromes, vascular ulcers, and Sweet syndrome.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Soft tissue infections such as cellulitis and abscesses can be identified on ultrasound. In cellulitis, there is extensive destructuring of the hypodermis and the image tends to be hyperechoic, in contrast to abscesses, in which the collection of pus is observed as a hypoechoic or anechoic area with no color Doppler signal. In our patient we observed a dermo-hypodermal lesion with an intralesional Doppler signal.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment of the PG is based on immunosuppressive drugs such as topical or systemic corticosteroids, depending on clinical severity and on associated comorbid conditions. In cases like ours, systemic corticosteroids (prednisone, 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d) administered by mouth are the treatment of choice. This achieves a rapid control of disease progression, and therapy can then be tapered in parallel with the clinical signs.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> We followed the clinical course on ultrasound, observing a reduction in the hypoechoic subepidermal band and the hypoechoic hypodermal tracts, as well as restructuring of the subcutaneous cellular tissue and deep dermis. In parallel with these findings, there is a reduction in vascularity visible on color Doppler imaging.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we have described a case of pyoderma gangrenosum with its ultrasound findings as a novel feature in the literature, demonstrating the usefulness of this imaging study for follow-up of the clinical course of this disease. However, further studies are needed to establish an ultrasound pattern and the value of ultrasound in the follow-up of PG.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "Références" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pousa-Martínez M, Sánchez-Aguilar D, Aliste C, Vázquez-Veiga H. Utilidad de la ecografía en el diagnóstico y seguimiento del pioderma gangrenoso. Actas Dermosifiliogr. 2017;108:962–964.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 159586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Initial phase of pyoderma gangrenosum. B, Clinical course after a week of treatment. A reduction can be seen in the erythema and edema of the lesions. Oral prednisone treatment was then tapered by 10<span class="elsevierStyleHsp" style=""></span>mg. C, Appearance at 7 weeks, with residual erythematous-purpuric lesions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 225338 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin ultrasound: A and B, Initial phase. The asterisks mark linear hypoechoic areas corresponding fistulous tracts. C and D, Image after a week of treatment: thinning of the hypoechoic subepidermal band, and decreased vascularity in the color Doppler image. The hypoechoic tracts persist in the subepidermal tissue.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 747 "Ancho" => 995 "Tamanyo" => 178349 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology findings. A, A predominantly dermal and hypodermal neutrophilic infiltrate and foci of abscess formation. Hematoxylin and eosin (H&E), original magnification<span class="elsevierStyleHsp" style=""></span>×2.5. B, Greater detail. H&E, original magnification<span class="elsevierStyleHsp" style=""></span>×20.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Références" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pyoderma gangrenosum. A retrospective review of patient characteristics, comorbidities and therapy in 103 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.M. Binus" 1 => "A.A. Qureshi" 2 => "V.W. Li" 3 => "L.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 11 | 20 |
| 2024 October | 90 | 53 | 143 |
| 2024 September | 83 | 22 | 105 |
| 2024 August | 120 | 53 | 173 |
| 2024 July | 121 | 34 | 155 |
| 2024 June | 103 | 30 | 133 |
| 2024 May | 89 | 27 | 116 |
| 2024 April | 98 | 29 | 127 |
| 2024 March | 97 | 26 | 123 |
| 2024 February | 98 | 23 | 121 |
| 2024 January | 94 | 30 | 124 |
| 2023 December | 126 | 31 | 157 |
| 2023 November | 141 | 25 | 166 |
| 2023 October | 120 | 20 | 140 |
| 2023 September | 127 | 36 | 163 |
| 2023 August | 133 | 15 | 148 |
| 2023 July | 99 | 30 | 129 |
| 2023 June | 110 | 24 | 134 |
| 2023 May | 116 | 23 | 139 |
| 2023 April | 129 | 22 | 151 |
| 2023 March | 159 | 21 | 180 |
| 2023 February | 115 | 26 | 141 |
| 2023 January | 105 | 34 | 139 |
| 2022 December | 99 | 32 | 131 |
| 2022 November | 84 | 23 | 107 |
| 2022 October | 77 | 21 | 98 |
| 2022 September | 89 | 41 | 130 |
| 2022 August | 76 | 31 | 107 |
| 2022 July | 40 | 33 | 73 |
| 2022 June | 48 | 20 | 68 |
| 2022 May | 112 | 48 | 160 |
| 2022 April | 127 | 31 | 158 |
| 2022 March | 85 | 41 | 126 |
| 2022 February | 107 | 29 | 136 |
| 2022 January | 207 | 43 | 250 |
| 2021 December | 101 | 35 | 136 |
| 2021 November | 103 | 45 | 148 |
| 2021 October | 182 | 57 | 239 |
| 2021 September | 108 | 36 | 144 |
| 2021 August | 98 | 35 | 133 |
| 2021 July | 91 | 32 | 123 |
| 2021 June | 139 | 31 | 170 |
| 2021 May | 126 | 36 | 162 |
| 2021 April | 265 | 71 | 336 |
| 2021 March | 150 | 38 | 188 |
| 2021 February | 116 | 33 | 149 |
| 2021 January | 62 | 12 | 74 |
| 2020 December | 111 | 12 | 123 |
| 2020 November | 95 | 27 | 122 |
| 2020 October | 46 | 14 | 60 |
| 2020 September | 116 | 17 | 133 |
| 2020 August | 97 | 21 | 118 |
| 2020 July | 88 | 14 | 102 |
| 2020 June | 91 | 28 | 119 |
| 2020 May | 73 | 13 | 86 |
| 2020 April | 63 | 18 | 81 |
| 2020 March | 58 | 23 | 81 |
| 2020 February | 7 | 0 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 3 | 0 | 3 |
| 2019 March | 3 | 0 | 3 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 32 | 5 | 37 |
| 2018 January | 47 | 9 | 56 |
| 2017 December | 235 | 31 | 266 |
| 2017 November | 9 | 12 | 21 |
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