PMC4736519_01
Chest/abdominal X-rays showing a 2 cm diameter ground lesion in inferior right lung lobe.
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Colitis (UC) (Montreal classification E2, Mayo endoscopic subscore 3 at the last colonoscopy), who had already failed multiple courses of steroids and 5ASA, was referred to our third level Gastroenterology Unit because of rapid worsening of rectal bleeding and dyspnea of 4 days duration. Chest X-rays showed a round lesion in inferior right lung lobe (Fig. 1).
Pyoderma Gangrenosum located in left popliteal region, internal side, diameter 5 cm.
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In the internal side of the left popliteal region the patient had a purple skin lesion (diameter 5 cm), compatible with Pyoderama Gangrenosum (PG) (Fig. 2).
(A-D) High-resolution CT scan showing 2.5 cm diameter lesion with irregular borders in keeping with benign lesion.
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Before starting steroid therapy we performed a High-Resolution CT, confirming a nonhomogeneous 2.5 cm diameter lesion, close to the pleura, with irregular borders compatible with a benign lesion (Fig. 3).
(A) Pulmonary parenchyma completely occupied by a chronic inflammatory reaction in the absence of necrosis; hematoxylin/eosin (HE), (10x): (B, C) Epithelioid noncaseating lung granuloma with a monocytic infiltrate consisting primarily of lymphocytes, plasma cells, neutrophils, and some eosinophils; hematoxylin/eosin (HE), (20x): (D) Ziehl-Neelsen immunostaining (10x) negative for acid and alcohol-fast bacilli.
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A CT-guided biopsy was therefore performed and histology showed lymphocytes, granulocyte, and activated mesothelium, whereas immunochemistry for Anti-keratin antobodies (AKA) was negative: these findings were consistent with pulmonary non-necrotizing granuloma (Fig. 4).
Timeline of lower limb pyoderma evolution.
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Proctectomy with ileal pouch-anal anastomosis (IPAA) was then performed. Postoperative course was regular, PG achieved the remission in few weeks after the complete removal of the rectum (Fig. 5) and subsequent chest CT scan showed the concomitant resolution of the pulmonary lesion (Fig. 6).