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J Thorac Cardiovasc Surg 1997;113:795-797
© 1997 Mosby, Inc.
BRIEF COMMUNICATIONS |
Philadelphia, Pa.
Received for publication August 26, 1996 accepted for publication Sept. 24, 1996. Address for reprints: Louis E. Samuels, MD, Allegheny University Hospitals, Hahnemann Division, Broad and Vine Sts., MS 111, Philadelphia, PA 19102-1192.
A 66-year-old white man was admitted to the Allegheny University Hospitals, Hahnemann Division, Philadelphia, in April 1996 with unstable angina and shortness of breath. The medical history was significant for coronary artery disease, chronic renal failure, and hypertension. On admission to the hospital, the white blood cell count was 8100 per microliter, hemoglobin and hematocrit levels were 8.5 gm/dl and 25.1%, and platelet count was 230 K/UL. Cardiac catheterization 2 days after hospital admission showed severe triple-vessel coronary artery dis-ease. Seven days after hospital admission, the patient underwent coronary artery bypass grafting. The immediate postoperative course was uneventful.
On postoperative day (POD) 3, fever (101.7° F) and sternal tenderness with serous drainage developed. The white blood cell count was 15 K/UL. Empiric broad-spectrum antibiotic therapy was started. On POD 5, sternal wound debridement was done. No signs of gross infection were observed. Instead, there was extensive sternal and subcutaneous tissue necrosis. The operative Gram stain test showed negative results for organisms and there was no growth on culture. Skin and subcutaneous tissue necrosis progressed. On POD 6, an abrupt drop in the white blood cell and platelet counts occurred (Figs. 1 and 2). Fever and pancytopenia persisted over the next couple of days.
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The remainder of the hospital course was marked by extensive surgical wound care, steroid therapy, intermittent dialysis, chemical bone marrow stimulation, nutritional support, and physical rehabilitation. The patient was transferred to a rehabilitation center on POD 72. At hospital discharge, the white blood cell count was 9.6 K/UL, hemoglobin and hematocrit values were 7.0 gm/dl and 21.6%, and platelet count was 15 K/UL.
Discussion.
Pyoderma gangrenosum is a rare disorder and only two case reports document the disease after coronary artery bypass grafting procedures.
1,2 The cause of pyoderma gangrenosum is unknown. It is, however, immunologic in nature. 3 Characteristically, the lesions are found after an injury to the skin. 2 There are no organisms found on Gram stain tests and there is no growth on culture. Typically, there are ulcerations marked by well-defined borders with a blue outline indicating necrosis of the subcutaneous tissue. Although the diagnosis of pyoderma gangrenosum is clinical, there are characteristic histopathologic features: acute and chronic inflammatory changes, endothelial proliferation, loss of the epidermis at the ulcerated sites, and epidermal hyperplasia at the borders.
In our case and in another previously described, 4 pyoderma gangrenosum was linked to myeloproliferative disease. In the report of Romano and Safai, 4 the patient was known to have chronic myelocytic leukemia. In that case, the skin lesions responded to a course of oral prednisone beginning with 80 mg per day. 4 In our case, the disease was discovered during the evaluation of pancytopenia. This delay in diagnosis resulted in further skin and subcutaneous necrosis that necessitated extensive debridement. Once the diagnosis was made, steroid therapy arrested the necrotic process and reversed the cutaneous pathologic changes. In a similar case, cyclosporine A (5 mg/kg) was successfully used to avoid the wound-healing problems associated with steroid use. 2 In our case, the use of cyclosporine was not an option because of the chronic renal failure and pancytopenia.
The challenging component of our case was the prevention of sepsis in the setting of pancytopenia with extensive open surgical wounds. Broad-spectrum antibiotic coverage, strict isolation, frequent surveillance cultures, and pharmacologic stimulation of the bone marrow were necessary. Despite these steps, various local infections occurred, including dialysis access–related infection and upper respiratory tract infection. Fortunately, systemic involvement was avoided.
In conclusion, concurrent pyoderma gangrenosum and myeloproliferative disease represents a unique and challenging clinical problem. Early recognition of the skin manifestations of pyoderma gangrenosum is necessary so that steroid therapy can be instituted, thereby avoiding radical debridement of wounds. The therapy for the associated pancytopenia requires support of the bone marrow with chemical stimulants. Prophylactic broad-spectrum antibiotic coverage is necessary to prevent sepsis.
Footnotes
From the Department of Cardiothoracic Surgerya and the Department of Medicine, Division of Cardiology,b Allegheny University Hospitals, Hahnemann Division, Philadelphia, Pa. 
References
This article has been cited by other articles:
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  M. E. Deeb, Y. Shargal, G. Merin, and E. Milgalter Incidental finding of myeloproliferative disorders during sternotomy Ann. Thorac. Surg., June 1, 2002; 73(6): 1951 - 1952. [Abstract] [Full Text] [PDF]
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