PMC4996061_01
Clinical course of the patient during the first admission. A: Initial clinical appearance. The anterior surface of the trunk exhibits a deep burn. B: Appearance after the first series of debridement and skin grafting. C and D: Multiple ulcers in the grafted skin and donor sites.
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A 51-year-old female presented with a 35% third-degree burn and 4% deep dermal burn as a result of a fire in the beginning of February (Figure 1A). She received debridement followed by split-thickness skin grafts, an artificial dermal graft, and autologous cultured epidermal sheet grafts five times during the next two months, during which most of the injured tissue was covered (Figure 1B). Approximately 80 days after the burn injury, multiple ulcers appeared on the trunk and right temporal area, and the lesions rapidly increased in both size and number (Figure 1C and D).
Clinical course after the second admission. A and B: Initial appearance on the second admission. Multiple recurrent ulcers are scattered in the grafted skin (A) and donor sites (B). C: Close-up view of the recurrent ulcers. D: Progression of the lesions. The lesions started as pustules (1), which then transformed to form a crust (2). When the crust was removed, a fresh ulcer appeared (3). E: Recent appearance of the patient after treatment with oral corticosteroids. The ulcers were restricted to limited areas; no ulcers are seen in this field.
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Upon an examination, many punched-out ulcers were scattered along the trunk and donor sites on the back and thighs (Figure 2A, B), and some had fused to form irregularly shaped lesions (Figure 2C). The patient is currently under follow-up at our outpatient clinic, with residual small-sized ulcers restricted to limited areas (Figure 2E).
Histological findings of a recurrent ulcer. A: Early lesion. A pustule was biopsied, although it broke during handling. Heavy infiltration is seen in the upper dermis. A crust is already noted (arrow). Inlet: A close-up view of the epidermis at the periphery of the pustule, showing many neutrophils. B: Advanced lesion. The periphery of an ulcer was biopsied. Note the sharply demarcated border and heavy infiltration that extends to a part of the fat layer (arrows). Fibrosis is already seen on the right side. Inlet: A close-up view of the infiltration, showing neutrophils to predominate.
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Biopsy specimens demonstrated the findings of an ulcer with heavy neutrophil infiltration devoid of any evident vasculitis (Figure 3).
Clinical course of the present case. Trends in the leukocyte count ( ) and neutrophil content ( ). Operations are indicated by arrows; the oral prednisolone dose is shown within the panel. The extent of ulcers due to PG is indicated above the panel.
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The clinical course of this case is summarized in Figure 4.