Progressive skin ulceration in a febrile returning traveller

Two weeks prior to admission, while in Cape Verde, a 66-year-old man developed a fever and a necrotic ulcer on his right leg following an insect bite. He was treated with intravenous Flucloxacillin, but subsequently developed an abscess at the intravenous cannula site on his left forearm. On his return to the UK, he underwent an incision & drainage of the abscess which yielded sterile fluid. During the next ten days the incision site progressively deteriorated and became necrotic, the right leg ulcer enlarged, and fever and rigors continued despite treatment with intravenous Piperacillin/Tazobactam and Clindamycin. We suspected pyoderma gangrenosum or a systemic vasculitis. Treatment commenced with high-dose Prednisolone, Meropenem and liposomal Amphotericin. A skin biopsy from the right leg confirmed pyoderma gangrenosum; no fungi were seen. Aspergillus fumigatus was cultured from the left forearm wound. A blood film showed a leucoerythroblastic picture with 3% blasts, and a bone marrow biopsy confirmed acute myeloid leukaemia. The skin lesions progressively improved and the anti-fungal therapy was changed to Posaconazole. He received chemotherapy for acute myeloid leukaemia, before proceeding to an allogeneic bone marrow transplant. He remains well one year post-transplant. Pyoderma gangrenosum should be considered in a febrile patient who has non-healing ulcer(s) at sites of trauma. It is often associated with a systemic disease, most commonly inflammatory bowel disease, inflammatory arthritis or haematological malignancies. Because these conditions and their treatments are associated with immunocompromise, patients with pyoderma gangrenosum may also be at risk of a superimposed cutaneous fungal infection.