Question:

A 66-year-old female presents to the ER with a chronic left face wound. Vitals are significant for a fever and tachycardia. She has a history of diabetes, homelessness, and medical non-compliance. She complains of persistent face wounds with erythema and purulence. She also complains of left eye pain and redness. She admits to frequent picking at her wounds. Attached are photos of her face and left eye. Additionally, a head CT was performed the same day. What is her diagnosis?

Answer:

This patient has been diagnosed with pyoderma gangrenosum, a rare inflammatory skin disease where painful pustules or nodules become ulcerated and progressively grow. The patient was diagnosed from a previous biopsy. The patient has had one year of left ear hearing loss, a four month history of left eye proptosis and double vision, and chronic pain. She has had an extensive workup to rule out autoimmune conditions and infectious etiologies (including negative bacterial, viral, fungal, mycobacterial tissue cultures; negative PCR tests for cutaneous TB; and a negative workup for malignancy). The patient has responded well to methotrexate in the past, but is often non-compliant with medical treatment.  

Wound cultures were positive for gram-positive cocci due to a secondary superinfection. 

The patient had a CT scan showing subcutaneous emphysema throughout the left frontotemporal scalp extending from the left ear to the left orbit. There was concern for possible orbital cellulitis and dacryocystitis.  

The patient was placed on vancomycin. Ophthalmology and dermatology, who have seen her in the past, were consulted. Social work was also consulted to help the patient maintain proper medical follow-up and to help her obtain methotrexate and other medications.