title: Successful Treatment of Pyoderma Gangrenosum with Cryoglobulinemia and Hepatitis C.
abstract: BACKGROUND
  Pyoderma gangrenosum is a rare, ulcerative cutaneous condition that was first described by Brocq in 1916. This diagnosis is quite challenging as the histopathological findings are nonspecific. Pyoderma gangrenosum is usually associated with inflammatory bowel disease, leukemia, and hepatitis C. We describe a rare clinical case of a patient with hepatitis C (HCV), mixed cryoglubinemia, and pyoderma gangrenosum, which was successfully treated with prednisone in combination with the new antiviral medication ledipasvir/sofosbuvir.
  
  
  METHODS
  A 68-year-old male with a history of untreated HCV presented to the clinic with a left lower extremity ulcer that had progressively worsened over 4 days after the patient sustained a minor trauma to the left lower extremity. Examination revealed a 2×3 cm purulent ulcer with an erythematous rim on medial aspect of his left lower leg. HCV viral load and genotype analysis revealed genotype 1A with polymerase chain reaction (PCR) showing viral counts of 9,506,048 and cryoglobulinemia. With a worsening and enlarging erythematous ulcer and failure of IV antibiotic therapy, the patient underwent skin biopsy, which showed acanthotic epidermis with superficial and deep perivascular lymphoplasmacytic dermatitis admixed with mild neutrophilic infiltrate. The patient was subsequently started on ledipasvir/sofosbuvir and prednisone with a high suspicion of pyoderma gangrenosum. At one-month follow-up at the hepatology clinic, the patient demonstrated a near resolution of the lower extremity ulcer with undetectable viral load.
  
  
  CONCLUSIONS
  Pyoderma gangrenosum is an inflammatory process of unknown etiology, and establishing the correct diagnosis can be a difficult task. For this reason it is prudent for clinicians to consider Pyoderma gangrenosum in their differential diagnosis, especially in the setting of a nonhealing surgical wound or skin infection.
authors.affiliation: Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Mohsen
authors.initials: M
authors.lastname: Pourmorteza
authors.affiliation: Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Fady
authors.initials: F
authors.lastname: Tawadros
authors.affiliation: Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Gilbert
authors.initials: G
authors.lastname: Bader
authors.affiliation: Department of Infectious Disease, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Al-Tarawneh
authors.affiliation: Department of Pathology, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Emilie
authors.initials: E
authors.lastname: Cook
authors.affiliation: Department of Infectious Disease, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Wael
authors.initials: W
authors.lastname: Shams
authors.affiliation: Department of Gastroenterology, East Tennessee State University, Johnson City, TN, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Young
mesh_terms: D000368:Aged; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D001562:Benzimidazoles / Q000627:therapeutic use; D003449:Cryoglobulinemia / Q000188:drug therapy*; D005449:Fluorenes / Q000627:therapeutic use; D019698:Hepatitis C, Chronic / Q000188:drug therapy*; D006801:Humans; D008297:Male; D011241:Prednisone / Q000627:therapeutic use; D017511:Pyoderma Gangrenosum / Q000188:drug therapy*; D000069474:Sofosbuvir; D014542:Uridine Monophosphate / Q000031:analogs & derivatives / Q000627:therapeutic use; D019562:Viral Load
chemical_list: D000893:Anti-Inflammatory Agents; D000998:Antiviral Agents; D001562:Benzimidazoles; D005449:Fluorenes; C000595958:ledipasvir, sofosbuvir drug combination; D014542:Uridine Monophosphate; D011241:Prednisone; D000069474:Sofosbuvir