On February 19, Attending Physician Tang Yan, Prof. Shi Wei, and Prof. Li Ji of Department of Dermatology of Xiangya Hospital, Central South University jointly published a case review titled “A rapidly progressing, painful ulcer at a surgical wound site” in the Endgames column of international top medical journal-The British Medical Journal (IF: 39.89) in print. The Endgames column of BMJ is known to be important for global continuing medical education, which focuses on instructional clinical cases that are easily misdiagnosed by physicians worldwide, especially general practitioners and family physicians.
Postsurgical Pyoderma Gangrenosum (PSPG) is an unusual inflammatory skin disorder leading to rapidly progressive, painful, and exudative skin ulceration around the periphery of surgical wounds. Its pathological conditions include dermal edema and massive neutrophil infiltration. PSPG mostly occurs between POD (postoperative day) 7 and POD 11, it is also accompanied by feverish symptoms in patients and thus easily misdiagnosed as postoperative wound infection, which requires active debridement and systemic anti-infective therapy. However, the homomorphic reactions triggered by the debridement are the primary causes of the rapid exacerbation of PSPG. Furthermore, once diagnosed with PSPG, patients should be treated with an adequate number of systemic glucocorticoids and immunosuppressive agents at an early stage, which further highlights the importance of early and timely diagnosis.
In September 2017, the woman patient featured in this case had high fever symptoms post-cesarean section at the Municipal Specialized Hospital. The ulceration became rapidly extensive and pain increased, despite a range of intravenous broad spectrum antibiotics and intravenous immunoglobulin. After surgery, the ulceration measured 25 cm×15 cm and showed an irregular eminence and overhanging violaceous edge around the incision site, reaching deeply into the subcutaneous fat layers. At the critical moment of the patient’s life and death, the local hospital sought help from Xiangya Hospital. Xiangya Hospital organized multidisciplinary care team (Obstetrics, ICU, dermatology, hospital infection control, microbiology, pathology, burns, rheumatology, hematology and wound care) for the patient. Guided by his rich clinical experience, Prof. Shi Wei of Department of Dermatology instantly delivered the diagnosis of PSPG. The patient was thus immediately transferred to Xiangya hospital for treatment. Following the accurate treatment plan devised through MDT consultation, Professor Ren Licheng of the original Department of Burn and Plastic Surgery boldly and meticulously carried out negative pressure wound therapy and thin skin graft after the inflammation was under control. The patient’s wound was fully healed in merely one month (Such wounds usually take months to more than half a year to heal) .After discharge, the patient continued with follow-up visits at the Dermatology Clinic. Medication was completely withdrawn within six months and no evidence of relapse or recurrence has been identified for over four years.
The case review put forward three major suggestions for surgeons: first, PSPG must be considered when faced with rapidly progressive, necrotic, painful postsurgical ulceration which is non-responsive to antibiotics treatment; second, when PSPG is suspected, physicians should consult with dermatologists; third, histopathology is a necessary approach for PG diagnosis, the tissue specimen should also be sent for microbial culture test to further eliminate infection.
BMJ reviewers and editors gave high praises to the timely diagnosis and rational treatment of Xiangya Hospital teams. The review was published both online and in print (only a few cases in the BMJ's ENDGAMES column are published in print) which represents the high recognition of BMJ for the PSPG diagnosis and treatment delivered by MDT for difficult and complicated dermatoses headed by Department of Dermatology of Xiangya Hospital.
Under the leadership of Prof. Chen Xiang, Department of Dermatology of Xiangya Hospital, focuses on four major clinical research areas: cutaneous tumor, discosmetic dermatosis and skin aging, immune-associated dermatoses, and difficult and complicated dermatoses. The team also established a complete development system that incorporates basic, clinical, and translational research, cohort study and big data, Internet hospital, artificial intelligence, and drug R&D, yielding great influence in the related field. The Department of Dermatology of Xiangya Hospital was top-ranked in the 2020 Chinese Hospital Specialist Reputation List. (The Department of Dermatology crowned the national ranking with the value of scientific research for two successive years, overall ranking top 5) As former directors of the Department of Dermatology, Prof. Chen Fuwen, Prof. Liu Zhiran, Prof. Xie Hongfu, and Prof. Li Juan attached great importance to the study of skin pathology and fully supported its development by sending Prof. Chen Mingliang, Prof. Shi Wei for clinical pathology study in the United States. Thanks to this experience, their clinical diagnosis capability is significantly enhanced. Keynote speeches and presentations of the Department of Dermatology of Xiangya Hospital were highlighted each year in the difficult and complicated case review and skin pathology continuing education columns of the Chinese Medical Association, and the Chinese Dermatologists Association. The Department of Dermatology of Xiangya Hospital is now a national leader for its expertise in difficult and complicated disease diagnosis and treatment. The publication of the clinical case review in BMJ fully attested to the clinical competency of Department of Dermatology of Xiangya Hospital, further promoted the hospital’s international influence, and boosted the construction of first-class medical disciplines.
Xiangya Hospital Central South University
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