Background Facial cellulitis secondary to insect bites, or injury is not an uncommon presentation in the adolescent population. Resolution typically occurs with antibiotic treatment. We report a case that presented as a facial cellulitis with early abscess formation which evolved despite incision and drainage and intravenous antibiotics. Due to an underlying diagnosis of inflammatory bowel disease, pyoderma gangrenosum was suspected and latter confirmed on biopsy.
Case Presentation A 15 year old male with Kabuki's syndrome, seizure disorder, ADHD, and ulcerative colitis presented with a 3 day history of worsening left facial swelling after returning from summer camp. The lesions were intensely painful with areas of drainage. On presentation he was afebrile and passed 200 mL of bloody stool. An incision and drainage was performed and intravenous clindamycin and cloxicillin was initiated. CBC was normal and ESR was 55. Skin cultures were negative. The facial swelling worsened the next day with the onset of pustules appearing on the hands, buttock, and legs.Dermatology was consulted and pyoderma gangrenosum was suspected. A skin biopsy was performed promptly to confirm the diagnosis before starting corticosteroids. Treatment was not initiated until biopsy results confirmed pyoderma gangrenosum as corticosteroids would have been contraindicated if the lesions were truly infected. Pulse steroids were initiated and the lesions regressed.
Discussion Pyoderma gangrenosum is a rare cutaneous disease which can be ulcerative, bullous or pustular. It is associated with systemic illnesses such as inflammatory bowel disease, malignancy, and rheumatoid arthritis in 50% of patients. The lesions are often confused with other cutaneous conditions resulting from trauma, insect bites, infection, vasculititis, and vascular insufficiency. Treatment consists of corticosteroids or immunosuppressives.
Implications for Practice If not treated effectively, these painful lesions progress resulting in significant morbidity. It is important to consider pyoderma gangrenosum when painful cutaneous lesions appear in patients with systemic illnesses. It is also important to rule out systemic disease if the diagnosis is made in an otherwise healthy patient.
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