Pyoderma gangrenosum after immediate deep inferior epigastric perforator flap breast reconstruction: a case report

Pyoderma gangrenosum is a rare skin condition which is difficult to diagnose as it often presents similarly to common complications such as wound infection, tissue ischemia and necrotizing fasciitis. We present a patient who underwent immediate DIEP free flap breast reconstruction and developed post-surgical pyoderma gangrenosum (PSPG), initially with non-characteristic signs and symptoms. Our patient first developed severe headache, fever and erythema surrounding her wound. The classical signs of painful ulcers with undermined bluish borders and surrounding violaceous rash were not seen for nearly 4 weeks. This, in combination with positive wound culture, made for a challenging diagnosis in an elective breast reconstruction patient. Diagnosis of PSPG relies on clinical signs first and is supported by wound swab culture and sensitivity and tissue biopsy for histopathology. The treatment of choice for PSPG is high-dose systemic steroids followed by an oral prednisolone taper over a period of 4–6 weeks. Early diagnosis of PSPG can optimize outcomes and reduce morbidity. We should consider PSPG as a differential diagnosis when post-operative wound infection is suspected, particularly if a non-classical pattern is seen. We could also consider discussion of PSPG as a rare, yet serious complication during the consent process.

Level of evidence: Level V, diagnostic study.