Successful treatment of pyoderma gangrenosum, Crohn's disease and systemic lupus erythematosus with anti-TNF alpha blocker (infliximab) in a patient. Case report

Malignant pyoderma was developed in a middle-aged female patient, gradually spreading through out the whole body. Pyoderma affected the crooks of the body as well as both ears, as a rare manifestation and resulted in considerable pain. Local treatment with topical steroids and antibiotics did not result in any improvement. Based on her existing inflammatory bowel disease (Crohn's disease: CD) and also her clinical findings and histological test results pyoderma gangrenosum (PG) was diagnosed. The patient's clinical and immune serologic test results indicated systemic lupus erythematosus (SLE) as well. The therapy consisted of intravenous steroid pulses and later the gradual decrease of oral doses, combined with metronidazol and 5-ASA. A month later there was a significant improvement in the necrotic skin lesions and the patient's inflammatory bowel disease was also in remission. However this improving condition did not turn out to be permanent, because a few months later her skin and gastrointestinal symptoms returned, moreover became steroid dependent/refractory, and the applied immunosuppressive therapy was not effective. Biological therapy was started, which meant the administration of infliximab at three equal doses of 300mg, and this was followed by a maintaining treatment with metothrexate at a dose of 15mg per week. The patient became symptom-free, and her condition (PG, CD and SLE) got stabilized. This case can be some interest for us: on one hand the rare coincidental occurrences of the above mentioned three illnesses, and also because of the rare form of manifestation of pyoderma gangrenosum. On the other hand the successful implementation of the biological therapy.