PYODERMA-GANGRENOSUM ASSOCIATED WITH ANTICARDIOLIPIN ANTIBODIES IN A PREGNANT PATIENT

A 40-year-old pregnant woman at 17 weeks of gestation presented with a 10-day history of pain and erythema in the right leg. She had experie nced a similar episode in the postpartum period (1 week) 14 months ear lier, lasting 2 months. This was diagnosed as cellulitis and resolved following antimicrobial therapy. The patient had no fever or chills. P ertinent past medical history involved a possible history of ampicilli n allergy. The initial differential diagnosis included cellulitis and thrombophlebitis. Antibiotic therapy with intravenous (IV) cefazolin w as started at the same time as anticoagulation with heparin. Over the next few days the ulceration enlarged. No microbial growth was detecte d on wound cultures and Doppler studies carried out prior to admission revealed normal venous flow. The patient did not respond to therapy. A dermatology consult was requested. When the patient was first examin ed by us, the ulceration had been progressively increasing in size. Th ere was an oozing ulcerated patch 7 cm in diameter on the right distal medial thigh (Pig. I). The ulcer contained crater-like holes and fist ulous tracts from which pus could be expressed upon application of pre ssure. The surrounding border was undermined and violaceous. A clinica l diagnosis of pyoderma gangrenosum (PG) was made. Antinuclear antibod ies and antibodies to Smith antigen were negative; anticardiolipin ant ibody was positive. A 3-mm punch biopsy showed an intense neutrophilic response with fibrinoid change in some vessels (Pig. 2), which was fe lt to be consistent with PG with a concomitant small vessel vasculitis . No fibrin thrombi were noted. The heparin was replaced with aspirin and the IV antibiotics were changed to oral cephalexin. Intralesional triamcinolone (40 mg/cc) was started and a 3-day course (80 mg/40 mg/2 0 mg) of oral prednisone was initiated. Within 2 days of starling ster oid therapy, the inflammation and discharge were greatly reduced. Appr oximately 2 weeks after admission the therapy was noted to halt the pr ogression. The lesion became more well demarcated with healthy granula tion tissue and decreased tenderness and warmth. The patient was disch arged on Burow's solution, saline soaks, and bacitracin and was seen b y us on two occasions after discharge for intralesional steroid admini stration. One flare-up since discharge was controlled by increasing he r prednisone from 10 mg to 20 mg daily. The patient had premature rupt ure of membranes at 37 weeks, had a spontaneous vaginal delivery, and delivered a healthy baby boy weighing 5 Ib 14 oz. Since then, the ulce r had re-epithelialized with tapering doses of prednisone.