Transcript Differential Diagnosis

Differential Diagnosis
Staphylococcus aureus
Mycobacterium marinum
Vibrio vulnificus
Ecthyma gangrensum
Aeromonas
Deep fungal infection
Anthrax
Erysipeloid
Orf
Tularemia
vasculitis
Diagnostic Procedure(s) and Result(s)
• Cultures of the lesion on the left leg and right
hand, obtained on admission, grew rare
methicillin-susceptible Staphylococcus aureus
colonies; the culture of the leg also grew
Enterococcus in the thioglycollate broth tube,
which was thought to be a contaminant.
• Cultures of the leg and right hand obtained in
the operating room were sterile.
• All other wound cultures, including for fungi
and mycobacteria, were sterile, as were blood
cultures. Testing for 1, 3 beta D glucan was
negative.
• Indirect immunofluorescence testing for antineutrophil cytoplasm antibodies (ANCA),
serum protein electrophoresis and testing for
lupus anticoagulant and syphilis were also
negative.
Histopathological examination
• revealed normal tissue, as well as an
intraepidermal blister, a dense dermal acute
inflammatory infiltrate and tissue necrosis.
normal skin
dense acute inflammatory infiltrate
epidermal necrosis and an
intraepidermal blister
Final Diagnosis
Pyoderma gangrenosum of the hands
and left leg
Physical findings, post-operatively.
Physical findings, post-operatively.
• Pyoderma gangrenosum is an idiopathic
inflammatory disease that is often mistaken
for an infectious process.
• Diagnosis of this condition is based upon
clinical history, pathology, and exclusion of
other diseases that cause erosive or ulcerative
skin lesions.
Pyoderma gangrenosum
Pyoderma gangrenosum
Pyoderma gangrenosum
• While an underlying systemic disease such as
inflammatory bowel disease,
myeloproliferative disorder, or inflammatory
arthritis is found in approximately 50% of
cases of pyoderma gangrenosum, this disease
has also been associated with trauma
(including burns) and surgery.
• It is important to consider this disease in
patients with non-healing wounds and obtain
early dermatologic consultation whenever
possible, because surgical intervention,
including debridement, may exacerbate
pyoderma gangrenosum and lead to
worsening ulceration.
• While there is no published algorithm for the
treatment of pyoderma gangrenosum, the
literature suggests the use of prolonged
systemic glucocorticoid therapy;
• A subset of patients requires the use of other
immunomodulators (e.g. cyclosporine,
thalidomide, and tumor necrosis factor (TNF)alpha blockers such as infliximab).
Differential Diagnosis
ecthyma gangrenosum
ecthyma gangrenosum
ecthyma gangrenosum
vibrio vulnificus
vibrio vulnificus
vibrio vulnificus
mycobacterium marinum
mycobacterium marinum
mycobacterium marinum
Orf
Anthrax