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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C, Increased vascularity in the non-nodular area of the lesion.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Vilas Boas, Antonio Ruedas-Martínez, Ofelia Baniandrés-Rodriguez, Cristina Ciudad-Blanco" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Vilas Boas" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Ruedas-Martínez" ] 2 => array:2 [ "nombre" => "Ofelia" "apellidos" => "Baniandrés-Rodriguez" ] 3 => array:2 [ "nombre" => "Cristina" "apellidos" => "Ciudad-Blanco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731017303095" "doi" => "10.1016/j.ad.2017.02.026" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017303095?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303372?idApp=UINPBA000044" "url" => "/15782190/0000010800000010/v1_201711300824/S1578219017303372/v1_201711300824/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Usefulness of Ultrasound in the Diagnosis and Follow-up of Pyoderma Gangrenosum" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "962" "paginaFinal" => "964" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. 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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 11 | 22 |
| 2024 Octubre | 90 | 53 | 143 |
| 2024 Septiembre | 83 | 22 | 105 |
| 2024 Agosto | 120 | 53 | 173 |
| 2024 Julio | 121 | 34 | 155 |
| 2024 Junio | 103 | 30 | 133 |
| 2024 Mayo | 89 | 27 | 116 |
| 2024 Abril | 98 | 29 | 127 |
| 2024 Marzo | 97 | 26 | 123 |
| 2024 Febrero | 98 | 23 | 121 |
| 2024 Enero | 94 | 30 | 124 |
| 2023 Diciembre | 126 | 31 | 157 |
| 2023 Noviembre | 141 | 25 | 166 |
| 2023 Octubre | 120 | 20 | 140 |
| 2023 Septiembre | 127 | 36 | 163 |
| 2023 Agosto | 133 | 15 | 148 |
| 2023 Julio | 99 | 30 | 129 |
| 2023 Junio | 110 | 24 | 134 |
| 2023 Mayo | 116 | 23 | 139 |
| 2023 Abril | 129 | 22 | 151 |
| 2023 Marzo | 159 | 21 | 180 |
| 2023 Febrero | 115 | 26 | 141 |
| 2023 Enero | 105 | 34 | 139 |
| 2022 Diciembre | 99 | 32 | 131 |
| 2022 Noviembre | 84 | 23 | 107 |
| 2022 Octubre | 77 | 21 | 98 |
| 2022 Septiembre | 89 | 41 | 130 |
| 2022 Agosto | 76 | 31 | 107 |
| 2022 Julio | 40 | 33 | 73 |
| 2022 Junio | 48 | 20 | 68 |
| 2022 Mayo | 112 | 48 | 160 |
| 2022 Abril | 127 | 31 | 158 |
| 2022 Marzo | 85 | 41 | 126 |
| 2022 Febrero | 107 | 29 | 136 |
| 2022 Enero | 207 | 43 | 250 |
| 2021 Diciembre | 101 | 35 | 136 |
| 2021 Noviembre | 103 | 45 | 148 |
| 2021 Octubre | 182 | 57 | 239 |
| 2021 Septiembre | 108 | 36 | 144 |
| 2021 Agosto | 98 | 35 | 133 |
| 2021 Julio | 91 | 32 | 123 |
| 2021 Junio | 139 | 31 | 170 |
| 2021 Mayo | 126 | 36 | 162 |
| 2021 Abril | 265 | 71 | 336 |
| 2021 Marzo | 150 | 38 | 188 |
| 2021 Febrero | 116 | 33 | 149 |
| 2021 Enero | 62 | 12 | 74 |
| 2020 Diciembre | 111 | 12 | 123 |
| 2020 Noviembre | 95 | 27 | 122 |
| 2020 Octubre | 46 | 14 | 60 |
| 2020 Septiembre | 116 | 17 | 133 |
| 2020 Agosto | 97 | 21 | 118 |
| 2020 Julio | 88 | 14 | 102 |
| 2020 Junio | 91 | 28 | 119 |
| 2020 Mayo | 73 | 13 | 86 |
| 2020 Abril | 63 | 18 | 81 |
| 2020 Marzo | 58 | 23 | 81 |
| 2020 Febrero | 7 | 0 | 7 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 10 | 0 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 3 | 0 | 3 |
| 2019 Marzo | 3 | 0 | 3 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 32 | 5 | 37 |
| 2018 Enero | 47 | 9 | 56 |
| 2017 Diciembre | 235 | 31 | 266 |
| 2017 Noviembre | 9 | 12 | 21 |
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