Case Report
Pyoderma Gangrenosum Associated With Inflammatory Bowel Disease. Report of Two Cases With Good Response to Infliximab
Pioderma gangrenoso asociado a enfermedad inflamatoria intestinal. Descripción de 2 casos con buena respuesta a infliximab
Carmen Carrasco Cubero
, M. Mar Ruiz Tudela, José Javier Salaberri Maestrojuan, José Javier Pérez Venegas
Corresponding author
Servicio de Reumatología, Hospital de Jerez de la Frontera, Cádiz, Spain
Read
11519
Timeswas read the article
3098
Total PDF
8421
Total HTML
Share statistics
array:24 [ "pii" => "S2173574312000068" "issn" => "21735743" "doi" => "10.1016/j.reumae.2011.07.006" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "354" "copyright" => "Elsevier España, S.L.. All rights reserved" "copyrightAnyo" => "2011" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:90-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4264 "formatos" => array:3 [ "EPUB" => 64 "HTML" => 3358 "PDF" => 842 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1699258X11002518" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2011.07.003" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "354" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:90-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 23679 "formatos" => array:3 [ "EPUB" => 166 "HTML" => 20751 "PDF" => 2762 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Pioderma gangrenoso asociado a enfermedad inflamatoria intestinal. Descripción de 2 casos con buena respuesta a infliximab" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "90" "paginaFinal" => "92" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Pyoderma gangrenosum associated with inflammatory bowel disease. Report of two cases with good response to infliximab" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 699 "Ancho" => 1500 "Tamanyo" => 122298 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A) Pioderma gangrenoso en tobillo derecho. B) Mejoría de la lesión tras tratamiento con infliximab.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carmen Carrasco Cubero, M. Mar Ruiz Tudela, José Javier Salaberri Maestrojuan, José Javier Pérez Venegas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Carmen" "apellidos" => "Carrasco Cubero" ] 1 => array:2 [ "nombre" => "M. Mar" "apellidos" => "Ruiz Tudela" ] 2 => array:2 [ "nombre" => "José Javier" "apellidos" => "Salaberri Maestrojuan" ] 3 => array:2 [ "nombre" => "José Javier" "apellidos" => "Pérez Venegas" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574312000068" "doi" => "10.1016/j.reumae.2011.07.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000068?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X11002518?idApp=UINPBA00004M" "url" => "/1699258X/0000000800000002/v2_201405280955/S1699258X11002518/v2_201405280955/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173574311000244" "issn" => "21735743" "doi" => "10.1016/j.reumae.2011.05.005" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "344" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:93-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 13810 "formatos" => array:3 [ "EPUB" => 87 "HTML" => 11937 "PDF" => 1786 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Continuing medical education</span>" "titulo" => "Premenopausal Osteoporosis: How to Treat?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "93" "paginaFinal" => "97" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteoporosis premenopáusica: ¿cómo tratarla?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Melania Martínez-Morillo, Dolors Grados, Susana Holgado" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Melania" "apellidos" => "Martínez-Morillo" ] 1 => array:2 [ "nombre" => "Dolors" "apellidos" => "Grados" ] 2 => array:2 [ "nombre" => "Susana" "apellidos" => "Holgado" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X11001823" "doi" => "10.1016/j.reuma.2011.05.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X11001823?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574311000244?idApp=UINPBA00004M" "url" => "/21735743/0000000800000002/v1_201305061636/S2173574311000244/v1_201305061636/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173574311000840" "issn" => "21735743" "doi" => "10.1016/j.reumae.2011.06.004" "estado" => "S300" "fechaPublicacion" => "2012-03-01" "aid" => "374" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:87-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2559 "formatos" => array:3 [ "EPUB" => 56 "HTML" => 1970 "PDF" => 533 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Dermatomiositis y meningioma en el mismo paciente" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "89" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatomyositis and Meningioma in the Same Patient" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1623 "Ancho" => 1577 "Tamanyo" => 207660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial cranial T1 magnetic resonance imaging after the administration of intravenous gadolinium that shows the presence of a left frontal mass of 3.5<span class="elsevierStyleHsp" style=""></span>cm×4<span class="elsevierStyleHsp" style=""></span>cm×3<span class="elsevierStyleHsp" style=""></span>cm with heterogeneous peripheral enhancement.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raquel Almodóvar, Daniel Paul Lindo, Helena Martín, Ramón Mazzuchelli, Javier Pardo, Francisco Javier Quirós, Pedro Zarco" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Raquel" "apellidos" => "Almodóvar" ] 1 => array:2 [ "nombre" => "Daniel Paul" "apellidos" => "Lindo" ] 2 => array:2 [ "nombre" => "Helena" "apellidos" => "Martín" ] 3 => array:2 [ "nombre" => "Ramón" "apellidos" => "Mazzuchelli" ] 4 => array:2 [ "nombre" => "Javier" "apellidos" => "Pardo" ] 5 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Quirós" ] 6 => array:2 [ "nombre" => "Pedro" "apellidos" => "Zarco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1699258X11002713" "doi" => "10.1016/j.reuma.2011.06.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X11002713?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574311000840?idApp=UINPBA00004M" "url" => "/21735743/0000000800000002/v1_201305061636/S2173574311000840/v1_201305061636/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Pyoderma Gangrenosum Associated With Inflammatory Bowel Disease. Report of Two Cases With Good Response to Infliximab" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "90" "paginaFinal" => "92" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carmen Carrasco Cubero, M. Mar Ruiz Tudela, José Javier Salaberri Maestrojuan, José Javier Pérez Venegas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Carmen" "apellidos" => "Carrasco Cubero" "email" => array:1 [ 0 => "maricarmen.carrasco@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M. Mar" "apellidos" => "Ruiz Tudela" ] 2 => array:2 [ "nombre" => "José Javier" "apellidos" => "Salaberri Maestrojuan" ] 3 => array:2 [ "nombre" => "José Javier" "apellidos" => "Pérez Venegas" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Reumatología, Hospital de Jerez de la Frontera, Cádiz, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pioderma gangrenoso asociado a enfermedad inflamatoria intestinal. Descripción de 2 casos con buena respuesta a infliximab" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 820 "Ancho" => 2502 "Tamanyo" => 150246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Pyoderma gangrenosum: ulcer with purplish edges and geographic contours located on an erythematous nodule (lesion after 24<span class="elsevierStyleHsp" style=""></span>h of administration of bolus methylprednisolone, with obvious improvement). (B) Favorable progression after 6 weeks of treatment with infliximab.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pyoderma gangrenosum (PG) is a neutrophilic dermatosis of unknown cause that manifests as painful skin ulcers. It was described by Brunsting et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 1930. Approximately 50% of patients have a background systemic disease, the most common being inflammatory bowel disease (IBD), myeloproliferative disorders, and different forms of arthropathy (both spondylitis and rheumatoid arthritis).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Sometimes skin lesions can precede, follow, or occur simultaneously with the disease with which it is associated. In some patients with IBD, control of bowel disease also leads to the control of PG, but this does not occur in all patients. The diagnosis is based on clinical suspicion and exclusion of other causes of ulceration by histology and microbiological studies.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">Male patient, 55 years old with a history of type 2 DM, HLA-B27+ankylosing spondylitis, diagnosed at 18 years of age, followed up by the rheumatology service and treated with sulfasalazine. The patient had Gleason 7 acynar adenocarcinoma of the prostate (T2-3N0M0 p) and was operated by radical prostatectomy in September 2008, subsequently receiving adjuvant radiotherapy from January through March 2009. He also presented cellulitis and a perianal abscess. No other relevant history was present.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was hospitalized (July 7, 2009) for presenting an ulcerated lesion with loss of substance and a purplish erythematous halo on the back of the left hand (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), in addition to severe fistulizing perianal lesions. He had no fever, abdominal pain, or altered bowel habits, nor joint, eye, or constitutional symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On examination, the patient had mucocutaneous pallor. The abdomen showed no tenderness or other abnormalities on examination. It showed two skin ulcers on the back of the left hand, infiltrated, with a jagged edge, elevated and erythematous, painful to the touch, with a fibrinous background and hemorrhagic exudation. We performed a skin biopsy of the ulcers’ margin. The next day, the ulcer had expanded aggressively into that margin. In the perianal region there were severe fistulizing lesions.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The CBC only showed normochromic normocytic anemia, hemoglobin of 11.6<span class="elsevierStyleHsp" style=""></span>g/dl and hematocrit of 33.2%, without changes in basic biochemistry, liver function, or hemostasis. There was elevated C-reactive protein (11.63<span class="elsevierStyleHsp" style=""></span>mg/dl). Serologic testing for hepatitis B and C, human immunodeficiency virus, and syphilis were negative as were rheumatoid factor and antinuclear antibodies. Electroimmunoforesis, quantification of immunoglobulins, complement levels, and blood smear showed no abnormalities.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The histological study of the biopsied skin ulcer showed necrosis of the epidermis and dermis, with a mixed inflammatory infiltrate and abscess formation at the base. The edge of the ulcer showed pseudoepitheliomatous hyperplasia. We did not detect bacteria, fungi, parasites, or cytopathic effects induced by viral infection. Biopsy cultures for bacteria, mycobacteria, and fungi were negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The colonoscopy revealed a severe impairment and a pancolonic perianal fistulizing pattern. The colon mucosal biopsy showed ulceration and architectural distortion, with acute and chronic inflammatory signs.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the symptoms, signs, histological findings of skin lesions, and the exclusion of other diseases through microbiological testing, the patient was diagnosed with Crohn's disease associated with PG.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Initially, the progression was favorable after treatment with intravenous corticosteroids, but the patient later showed new lesions on both forearms, also suggestive of pyoderma.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the severity of the disease, we opted for the use of infliximab with the approval of the oncology and gastroenterology departments. After ruling out latent TB, treatment was begun with anti-TNF alpha.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After starting therapy with infliximab (5<span class="elsevierStyleHsp" style=""></span>mg/kg), the patient progressed favorably, with progressive improvement of skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and bowel lesions and is currently under maintenance therapy with infliximab every 8 weeks after completing the induction with good response.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case 2</span><p id="par0060" class="elsevierStylePara elsevierViewall">33-year-old male with a history of Crohn's disease of several years of progression, treated with mesalazine. He presented frequent outbreaks of intestinal disease and polyarthritis, which required treatment with corticosteroids.</p><p id="par0065" class="elsevierStylePara elsevierViewall">One week before admission, the patient had a painful ulceration on the right perimalleolar region appear and begins to suppurate without fever or gastrointestinal symptoms. Because of the suspicion of septic arthritis, we performed a surgical drainage of the abscess in addition to starting intravenous antibiotic therapy with unfavorable results. A few days later, there was necrosis of the surgical wound with great loss of substance, showing progressive worsening after each lavage.</p><p id="par0070" class="elsevierStylePara elsevierViewall">After his hospitalization (September 15, 2007), the patient presented fever, abdominal pain, and diarrhea (more than 20 stools per day), with pathological features. The patient had mucocutaneous pallor, with general malaise and abdominal tenderness. Upon the anal inspection, he presented several tracts and drainage sites. His right ankle had a skin ulcer, with significant loss of tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">He also presented significant anemia (hemoglobin 7.9<span class="elsevierStyleHsp" style=""></span>g/dl, hematocrit 23.2%), WBC 24<span class="elsevierStyleHsp" style=""></span>300 with 77% PMN, platelets 647<span class="elsevierStyleHsp" style=""></span>000. The basic biochemistry, liver profile, and hemostasis tests were normal. There were elevated acute phase reactants (CRP: 12.3<span class="elsevierStyleHsp" style=""></span>mg/dl and ESR 82<span class="elsevierStyleHsp" style=""></span>mm/h). Serologic testing for hepatitis B and C, human immunodeficiency virus, and syphilis were negative. Mantoux and rheumatoid factor and antinuclear antibodies were also negative.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The colonoscopy revealed colon Crohn's disease with severe activity. We performed an MRI of the abdomen and pelvis, which showed severe involvement of the descending colon, sigmoid and rectum with loss of haustrae, edema of the colon wall and perirectal fat and severe complex and bilateral perianal fistulizing disease.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Parenteral nutrition was begun in the operating room and catheterization was performed for perianal fistula drainage with placement of two separate drains, partially improving intestinal function.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Steroid and antibiotic treatment, in addition to general measures, improved the patient's general condition without achieving success regarding the right ankle ulcer. A biopsy was taken from the wound edge and was compatible with PG.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Treatment was initiated with intravenous infliximab (5<span class="elsevierStyleHsp" style=""></span>mg/kg), with dramatic improvement. Gradually, the patient achieved remission of bowel disease. The ulcer required a skin graft to cover the severe loss of substance (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Extraintestinal manifestations complicate the course and treatment of IBD in 20%–40% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Among the extraintestinal manifestations, mucocutaneous PG appears in 1%–5% of patients with IBD.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">It is more common in ulcerative colitis than Crohn's disease, and manifests itself initially as painful pustules that increase in size forming ulcers with purple edges and a necrotic base, may be multiple and scars after healing. It is most frequently located in the lower extremities.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">PG can respond to the basic treatment of IBD, but its relationship disease activity is less obvious than in other mucocutaneous extraintestinal manifestations, such as erythema nodosum.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The pathogenesis of PG is not fully elucidated but appears to be an immune-mediated injury similar to IBD. Therefore, various therapies that act to control the inflammatory response, such as infliximab, have been used in its treatment. It has also been speculated that the effect of infliximab in PG is a consequence of the healing of intestinal lesions underlying IBD, or is a direct drug effect on skin<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> injuries.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of infliximab on extraintestinal manifestations such as mucocutaneous PG has recently been described in some publications of small series or isolated cases<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> and opens new perspectives in its management. The skin lesions responded well in most cases. The dosing of infliximab used in cases published is very diverse and in many of them chose an initial infusion and then at weeks 2 and 6, and a significant percentage of new doses were administered thereafter. In our case, we chose to follow the recommendations of the Spanish Group for the Study of Crohn's disease and ulcerative colitis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">On the other hand, there are studies in which it has been shown that patients with chronic skin ulcers, such as PG, have an increased risk of serious infections (septic shock) while undergoing treatment with anti-TNF alpha, so individual prophylaxis should be provided before initiation of treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">In the cases reported, treatment with infliximab proved to be able to achieve remission of PG associated with Crohn's disease after failure of immunosuppressive therapy.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Disclosures</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres125720" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec113010" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125719" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec113011" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical Cases" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Disclosures" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-02-12" "fechaAceptado" => "2011-07-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113010" "palabras" => array:3 [ 0 => "Crohn's disease" 1 => "Infliximab" 2 => "Pyoderma gangrenosum" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113011" "palabras" => array:3 [ 0 => "Enfermedad de Crohn" 1 => "Infliximab" 2 => "Pioderma gangrenoso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Among the extraintestinal manifestations of inflammatory bowel disease (IBD), pyoderma gangrenosum (PG) often poses a therapeutic challenge. We describe two cases of PG associated with inflammatory bowel disease, who responded to treatment with Infliximab.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dentro de las manifestaciones extraintestinales de la enfermedad inflamatoria intestinal (EII), el pioderma gangrenoso (PG) plantea con frecuencia dificultades terapéuticas. Describimos 2 casos de PG asociados a enfermedad inflamatoria intestinal, con buena respuesta al tratamiento con infliximab.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Carrasco Cubero C, et al. Pioderma gangrenoso asociado a enfermedad inflamatoria intestinal. Descripción de 2 casos con buena respuesta a infliximab. Reumatol Clin. 2012;<span class="elsevierStyleBold">8(2)</span>:90-2.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 820 "Ancho" => 2502 "Tamanyo" => 150246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Pyoderma gangrenosum: ulcer with purplish edges and geographic contours located on an erythematous nodule (lesion after 24<span class="elsevierStyleHsp" style=""></span>h of administration of bolus methylprednisolone, with obvious improvement). (B) Favorable progression after 6 weeks of treatment with infliximab.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1162 "Ancho" => 2502 "Tamanyo" => 233110 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Pyoderma gangrenosum of the right ankle. (B) Improvement of the lesion after treatment with infliximab.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pyoderma gangrenosum: clinical and experimental observations in five cases occurring in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.A. Brunsting" 1 => "W.H. Goeckerman" 2 => "P.A. O’Leary" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1930" "volumen" => "22" "paginaInicial" => "655" "paginaFinal" => "680" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathogenesis and clinical approach to extraintestinal manifestations of inflammatory bowel disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Agrawal" 1 => "S. Rukkannagari" 2 => "S. Kethu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Minerva Gastroenterol Dietol" "fecha" => "2007" "volumen" => "53" "paginaInicial" => "233" "paginaFinal" => "248" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17912186" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pioderma gangrenoso: revisión y puesta al día" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.P. Callen" 1 => "J.M. Jackson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rheum Dis Clin N Am" "fecha" => "2007" "volumen" => "33" "paginaInicial" => "787" "paginaFinal" => "802" "itemHostRev" => array:3 [ "pii" => "S0002937804000286" "estado" => "S300" "issn" => "00029378" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Newer aspects of inflammatory bowel disease and its cutaneous manifestations: a selective review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.T. Apgar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Dermatol" "fecha" => "1991" "volumen" => "10" "paginaInicial" => "138" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1931561" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid improvement of pyoderma gangrenosum after treatment with infliximab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.L. Chan" 1 => "M.S. Graves" 2 => "C.J. Cockerell" 3 => "A.G. Pandya" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Drugs Dermatol" "fecha" => "2010" "volumen" => "9" "paginaInicial" => "702" "paginaFinal" => "704" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20645536" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refractory and infected pyoderma gangrenosum in patient with ulcerative colitis: response to infliximab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. De la Morena" 1 => "L. Martín" 2 => "J.P. Gisbert" 3 => "J. Fernández Herrera" 4 => "R. Goiriz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ibd.20081" "Revista" => array:6 [ "tituloSerie" => "Inflamm Bowel Dis" "fecha" => "2007" "volumen" => "13" "paginaInicial" => "509" "paginaFinal" => "510" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17206663" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for the use of infliximab in Crohn's disease. GETECCU 2001" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Domènech" 1 => "M. Esteve-Comas" 2 => "F. Gomollón" 3 => "J. Hinojosa" 4 => "A. Obrador" 5 => "J. Panes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2002" "volumen" => "25" "paginaInicial" => "162" "paginaFinal" => "169" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11864540" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septic, shock alter treatment of pyoderma gangrenosum with infliximab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Wölbing" 1 => "J. Fierlbeck" 2 => "W. Hötzenecker" 3 => "M. Schaller" 4 => "M. Röcken" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2340/00015555-0540" "Revista" => array:6 [ "tituloSerie" => "Acta Derm Venereol" "fecha" => "2009" "volumen" => "89" "paginaInicial" => "93" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19197554" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000800000002/v1_201305061636/S2173574312000068/v1_201305061636/en/main.assets" "Apartado" => array:4 [ "identificador" => "17376" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000002/v1_201305061636/S2173574312000068/v1_201305061636/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000068?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 96 | 47 | 143 |
| 2024 September | 112 | 35 | 147 |
| 2024 August | 112 | 39 | 151 |
| 2024 July | 103 | 49 | 152 |
| 2024 June | 135 | 39 | 174 |
| 2024 May | 114 | 38 | 152 |
| 2024 April | 82 | 38 | 120 |
| 2024 March | 92 | 51 | 143 |
| 2024 February | 64 | 49 | 113 |
| 2024 January | 53 | 30 | 83 |
| 2023 December | 49 | 35 | 84 |
| 2023 November | 65 | 47 | 112 |
| 2023 October | 72 | 27 | 99 |
| 2023 September | 105 | 58 | 163 |
| 2023 August | 99 | 26 | 125 |
| 2023 July | 87 | 32 | 119 |
| 2023 June | 70 | 33 | 103 |
| 2023 May | 61 | 28 | 89 |
| 2023 April | 50 | 21 | 71 |
| 2023 March | 88 | 32 | 120 |
| 2023 February | 58 | 26 | 84 |
| 2023 January | 52 | 28 | 80 |
| 2022 December | 81 | 54 | 135 |
| 2022 November | 76 | 34 | 110 |
| 2022 October | 69 | 46 | 115 |
| 2022 September | 90 | 48 | 138 |
| 2022 August | 100 | 40 | 140 |
| 2022 July | 78 | 53 | 131 |
| 2022 June | 57 | 32 | 89 |
| 2022 May | 75 | 49 | 124 |
| 2022 April | 83 | 49 | 132 |
| 2022 March | 117 | 89 | 206 |
| 2022 February | 141 | 56 | 197 |
| 2022 January | 109 | 49 | 158 |
| 2021 December | 122 | 43 | 165 |
| 2021 November | 120 | 37 | 157 |
| 2021 October | 98 | 75 | 173 |
| 2021 September | 102 | 49 | 151 |
| 2021 August | 82 | 50 | 132 |
| 2021 July | 87 | 32 | 119 |
| 2021 June | 82 | 47 | 129 |
| 2021 May | 106 | 56 | 162 |
| 2021 April | 225 | 116 | 341 |
| 2021 March | 187 | 28 | 215 |
| 2021 February | 89 | 26 | 115 |
| 2021 January | 112 | 34 | 146 |
| 2020 December | 79 | 35 | 114 |
| 2020 November | 102 | 33 | 135 |
| 2020 October | 75 | 20 | 95 |
| 2020 September | 98 | 42 | 140 |
| 2020 August | 71 | 21 | 92 |
| 2020 July | 91 | 17 | 108 |
| 2020 June | 72 | 33 | 105 |
| 2020 May | 71 | 25 | 96 |
| 2020 April | 61 | 22 | 83 |
| 2020 March | 36 | 8 | 44 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 58 | 10 | 68 |
| 2018 March | 72 | 16 | 88 |
| 2018 February | 39 | 4 | 43 |
| 2018 January | 34 | 6 | 40 |
| 2017 December | 37 | 9 | 46 |
| 2017 November | 49 | 2 | 51 |
| 2017 October | 48 | 6 | 54 |
| 2017 September | 61 | 9 | 70 |
| 2017 August | 67 | 12 | 79 |
| 2017 July | 47 | 14 | 61 |
| 2017 June | 87 | 14 | 101 |
| 2017 May | 104 | 16 | 120 |
| 2017 April | 81 | 7 | 88 |
| 2017 March | 80 | 25 | 105 |
| 2017 February | 52 | 6 | 58 |
| 2017 January | 44 | 8 | 52 |
| 2016 December | 93 | 36 | 129 |
| 2016 November | 142 | 7 | 149 |
| 2016 October | 121 | 21 | 142 |
| 2016 September | 138 | 12 | 150 |
| 2016 August | 90 | 10 | 100 |
| 2016 July | 69 | 14 | 83 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 4 | 0 | 4 |
| 2015 July | 34 | 8 | 42 |
| 2015 June | 61 | 11 | 72 |
| 2015 May | 73 | 17 | 90 |
| 2015 April | 66 | 15 | 81 |
| 2015 March | 48 | 8 | 56 |
| 2015 February | 48 | 12 | 60 |
| 2015 January | 44 | 11 | 55 |
| 2014 December | 56 | 17 | 73 |
| 2014 November | 36 | 15 | 51 |
| 2014 October | 54 | 17 | 71 |
| 2014 September | 39 | 22 | 61 |
| 2014 August | 30 | 20 | 50 |
| 2014 July | 49 | 19 | 68 |
| 2014 June | 76 | 24 | 100 |
| 2014 May | 77 | 15 | 92 |
| 2014 April | 66 | 13 | 79 |
| 2014 March | 77 | 24 | 101 |
| 2014 February | 50 | 15 | 65 |
| 2014 January | 53 | 14 | 67 |
| 2013 December | 40 | 14 | 54 |
| 2013 November | 39 | 23 | 62 |
| 2013 October | 63 | 17 | 80 |
| 2013 September | 51 | 17 | 68 |
| 2013 August | 54 | 27 | 81 |
| 2013 July | 37 | 16 | 53 |
| 2013 June | 57 | 16 | 73 |
| 2013 May | 51 | 20 | 71 |
| 2013 April | 52 | 23 | 75 |
| 2013 March | 37 | 13 | 50 |
| 2013 February | 38 | 20 | 58 |
| 2013 January | 28 | 16 | 44 |
| 2012 December | 42 | 19 | 61 |
| 2012 November | 24 | 28 | 52 |
| 2012 October | 22 | 7 | 29 |
| 2012 September | 16 | 4 | 20 |
| 2012 July | 6 | 0 | 6 |
| 2012 June | 3 | 0 | 3 |
| 2012 May | 13 | 0 | 13 |
| 2012 April | 10 | 0 | 10 |
Show all
