Generalized pyoderma gangrenosum associated with unrecognized ulcerative colitis.

We present a case of a 36-year-old female patient who was initially admitted to the Department of Infectious Diseases for evaluation of diarrhea. Two years prior to admission, she had been treated in another hospital for erythema nodosum on her calves. There was no further diagnosis at that time. The patient presented with frequent loose stool for three weeks before admission to our Department, at the time without any bloody tinge present. Four days before admittance, the patient’s temperature rose to 39°C, with bloody loose stools and a C-reactive protein (CRP) level of 42.8 mg/L. On the fourth day of hospitalization, laboratory tests showed anemia and erythrocyte sedimentation rate (ESR) of 62 mm/3.6 ks. The next day, the patient developed generalized pyogenous pustules with necrotizing borders on her skin. Serologic testing was negative for VDRL, HIV, ANA, HBsAg, and HCV antibodies, as well as and RA factor. Skin ulcer smear was sterile, and chest X-ray and abdominal ultrasound did not reveal any abnormality. Pathohistological analysis of the skin biopsy specimen was compatible with pyoderma gangrenosum (PG). The dermatologist established a diagnosis of severe generalized PG. Stool samples tested negative for infectious agents. Laboratory tests showed progressed anemia, higher leukocyte levels, ESR of 86 mm/3.6 ks, and CRP level of 151 mg/L. On the fourteenth day of hospitalization, a colonoscopy was performed and showed that the mucosa of the descending colon and rectum was completely covered with ulcerations and pseudopolypous lesions (Figure 1). The patient was transferred to our Department. Pathohistological specimens taken during colonoscopy were confirmed to be positive for ulcerative colitis (UC). Within a few days of the commencement of appropriate treatment, the patient’s general condition improved considerably, stool frequency diminished, her laboratory parameters (ESR, CRP) regressed, and her skin lesions showed significant signs of healing (Figure 2). PG is a sterile inflammatory neutrophilic dermatosis characterized by recurrent cutaneous ulcerations with mucopurulent or hemorrhagic exudate (1). Esti-