Pyoderma Gangrenosum After Hand Surgery: A Case Report

Turkhan Mehdiyev, MD; Robert Zimmermann, MD


Wounds. 2021;33(2):E14-E16. 

In This Article

Case Report

An 81-year-old female was referred to the authors' department with the characteristic symptoms of carpal tunnel syndrome (CTS): numbness and nightly paresthesia in the thumb, index finger, and middle finger of the right hand as well as difficulties with fine motor activities like buttoning shirts. Phalen's sign was positive whereas Tinel's was negative. The sonographic measurements of the median nerve showed a delta of 7 and a wrist-to-forearm ratio of 2. The neurophysiologic study demonstrated severe sensorimotor CTS with absent sensory potentials and motor latency to abductor pollicis brevis (APB) of 6.8 ms; the threshold defining abnormal is greater than 1.2 to 1.8 ms.[5]

The patient's medical history included arterial hypertonia, hyperlipidemia, hyperuricemia, multinodular goiter, urinary incontinence, post-hepatitis B infection status, and PG in the gluteal region after a bursectomy were present. Previous therapies included both the oral administration of cortisone (40 mg per day) and wearing a positioning splint at night for 2 weeks. The conservative treatment brought noticeable relief of the symptoms, but the numbness remained. After 14 days of treatment, it was decided to suspend the medication with cortisone and to proceed with an open carpal tunnel release (CTR) with wide-awake local anesthesia.

An experienced hand surgeon performed the CTR of the right hand without complication, and the patient was discharged to the outpatient treatment on postoperative day 1. A week after the surgery, the patient was referred to the authors' outpatient clinic by the patient's general practitioner with a wound presenting redness and swelling (Figure 1). Following the diagnosis of wound site infection, the patient was immediately admitted to the authors' department. On the day of admission, the patient underwent a second surgery with debridement of the skin necrosis (Figure 2A). A proximal prolongation of the incision was performed, the Loge de Guyon released, and a drain inserted (Figure 2B). In spite of the appropriate wound debridement and antibiotic treatment, the lesion continued to deteriorate (Figure 3). Staining for microorganisms were negative and cultures were sterile. Hence, a dermatological consultation followed, and PG was diagnosed. The patient was consequently transferred to the Department of Dermatology, Venereology and Allergology at the Medical University of Innsbruck in Austria. The patient was treated with methylprednisolone (80 mg daily) in addition to antibiotic therapy, which led to a significant reduction of the swelling and red to violaceous coloration, cessation of lesion expansion, and eventually, wound reepithelization. The patient was discharged from the inpatient treatment 3 weeks after admission to the authors' department. Treatment with glucocorticoid (20 mg cortisone) was gradually reduced (10 mg per day in alternation for 2 weeks, after which 10 mg for 2 weeks) and eventually stopped 7 weeks after the second surgery. The first follow-up was 2 weeks after hospital discharge. Further follow-ups occurred every 3 months. The follow-up examinations after discharge occurred for 7 months; there was an inconspicuous scar on the palm as well as an improvement of the sensitivity of the thumb and the fine motor skills (Figure 4).

Figure 1.

This was the status of the right hand 1 week following carpal tunnel release.

Figure 2.

Intraoperative view (A) before debridement and (B) after debridement and release of the Loge de Guyon.

Figure 3.

Wound condition 2 days after the second surgery and prior to the corticosteroid therapy.

Figure 4.

Image of the right hand after 4-week follow-up examination and administration of corticosteroids.