Pyoderma Gangrenosum as the Initial Manifestation of Small Cell Lung Cancer with Dermatomyositis

To the Editor: A 54‐year‐old man developed painful ulcers on the neck one month ago, followed by periorbital edema. The ulcers then spread to his trunk, back, and upper arms. He had muscle weakness, mild muscle soreness with activity, and dysphagia for foods for the past three weeks. He was diagnosed as drug eruption in a local hospital and received irregular corticosteroids therapy for two weeks. Thereafter, the ulcers started to heal. He had a 40 years’ history of smoking. The patient was emaciation, and physical examination revealed heliotrope sign, poikiloderma involving the face, “V” sign of the chest, and the upper arm, nail fold telangiectasia, and large well‐defined ulcers on the abdomen, back, and upper arms, there was no Gottron sign [Figure 1]. It was hard for him to raise his arms and squat. The triceps and quadriceps were tender to palpation. Investigation revealed elevated levels of antinuclear antibodies (1:40; normal range, <1:40), creatin kinase (382 U/L; normal range, 56–244 U/L), lactic dehydrogenase (254 U/L; normal range, 109–245 U/L), white blood cell (19.71 × 109/L, normal range, 3.5–9.5 × 109/L), erythrocyte sedimentation rate (78 mm/h; normal range, 0–15 mm/h), C‐reactive protein (117.52 mg/L; normal range, <8 mg/L), neurospecific enolase (25.03 ng/ml; normal range, 0–16.30 ng/ml), and electromyography showed muscle damage. Chest computed tomography plain and enhanced scan suggested possible malignant tumor in left upper lobe [Figure 1]. The biopsy of axillary lymph node showed “small cell lung cancer”. Histopathology of ulcer edge revealed ulceration of the epidermis with a dense neutrophils infiltration. There was no organisms or vasculitis [Figure 1].