Keywords
pyoderma gangrenosum - nasal septum - diagnosis
Palavras-chave
Pioderma Gangrenoso - Septo Nasal - Diagnóstico
Introduction
The cocaine it is a extracted alkaloid gives to plant do Erythroxylon gender, Andean
and Amazon cultivated shrub command post region. Its dependence possible must to its
psychostimulants properties and local anesthetic action. Under the hydrochloride form
it is managed by different ways, being able to be inhaled and to be absorbed by the
nasal mucous what cause vasoconstriction of nasal arterioles, taking the necrosis
and perforation of nasal septum with the drawn out use.
Already the Pyoderma Gangrenosum is a rare, chronic, pertaining dermatosis to the
specter of the neutrophil dermatosis that is reactive inflammatory processes[1]. For being a rare, recognized illness individually only in century XX for Brunsting et al.[2], its incidence is difficult to determine, since the published cases are generally
isolated or with small number of sick people[3]. Generally the injuries are multiple and the skin of the inferior members is the
reached place more. In 50% to 70% of the patients, associate it a base illness, as
intestinal inflammatory illness, rheumatic, hematologic illness or malignancy[3]
[4]. However, the association of Pyoderma with cocaine, as in this in case that physician,
were described in only three stories of case in literature.
The case to be related is about a patient with Pyoderma Gangrenosum diagnosised after
exclusion of the too much auto-immune illnesses; however its form of presentation
atypical and rare must in such a way to the condition of the face how much to the
use of cocaine associated with the base pathology.
Case Reports
E.A., 27 years, feminine sex, medium brown, divorced, of the home, natural and coming
from Rio de Janeiro, presenting it has 5 years left half-face ulcer that it evolved
for inferior members, hard palate and complete destruction of nasal septum. It affirms
to be using of great amount of cocaine per 10 years.
In the physical examination, it presented face with edge ulcer badly delimited and
erythematosus base with purulent pardon with some epithelized edge areas, occupying,
practically, all left half-face. In inferior members, injury ulcerated in right leg.
No longer otolaryngologic examination, there was in the previous rhinoscopy destruction
of all nasal septum without areas of inflammatory process and in the oroscopy perforation
of hard palate. The otoscopy was normal. It became endoscopy nasal visualizing ample
septum perforation, mucous complete without aspect of active infection and presence
of residues of mucus ([Figures 1] to [2] [3] [4] [5] [6]).
Figure 1. Ulcer of face before the treatment.
Figure 2. Face ulcer after treatment.
Figure 3. Nasal perforation of septo[1].
Figure 4. Nasal perforation of septo[2].
Figure 5. Hard perforation of palate.
Figure 6. Ulcer of right leg.
In the laboratory examinations, did not evidence systemic illness associate. Anti-HTLV1
and 2 negatives; Ac anti DNA, anti - RNP, C3, C4, FAN, Anti-Ro, Anti-cardiolipin IgM
and IgG, PCR and FR inside of the normal values; PPD: 4mm. Swab of ulcerated injury
of skin became, having as resulted S. Aures. Biopsy of skin of the face, being suggestive
of Pyoderma Gangrenosum and of fragment of mucous of hard palate: ulcerated chronic
inflammatory process with necrosis.
In the treatment, the analgesic use was carried through for pain. Vidisic gel in left
eye, since it was without lubrication due to extensive injury. Bandage with silver
sulfadiazine in face. Azatioprina 50mg at the day and Prednisona 45mg at the day.
Use of dental prosthesis for occlusion of palatine perforation and transplant of cornea
in left eye.
Discussion
The Pyoderma Gangrenosum is a rare neutrophil illness; of uncertain etiology and that
it associates the systemic illnesses in 50% of the cases as intestinal inflammatory
illness, rheumatic, hematologic illness or malignity. It is an inflammatory illness
that attacks mainly the skin and is characterized for the presence of painful, destructive
ulcers and that they are become enlarged centrifugal, attacking more frequently the
inferior members. In this patient, it had the presence of typical injuries ([Figure 6]) and atypical ([Figure 1]). The diagnosis of pyoderma gangrenosum is of exclusion, being based on the clinic.
The laboratory examinations are non-specific, and, most of the time, only the erythrocyte
sedimentation speed is increased. The histopathological examination also is not specific
and presents changeable aspects depending on the size of the biopsy and the duration
of the illness, but it is basic to exclude other diagnostic (deep mycosis, vascular
ulcers, pricked of insects, neoplasias and vasculitis). As in this in case that presented
there was an atypical picture with face involvement and previous history of cocaine
use in great amount, had necessity to differentiate the illness of base with the use
of drugs in the histopathological, what in it helped us in the final diagnosis. Moreover,
it has only three described cases in the literature of association between Pyoderma
and cocaine considering, thus, greater rarity of the case. One of the reports was
in the EWMA, of the Department of Dermatology in Essen in Germany in 2009 on a patient
of the using masculine sex of great amount of cocaine it has 10 years and suggesting
this fact as cause of the beginning of the Pyoderma. Already to another publication,
in 2008, of the Department of Dermatology of the Universitary General Hospital of
Valencia in Spain, reports two cases of cocaine users of 30 and 37 years that had
also developed the Pyoderma.
Until the moment, the treatment of pyoderma gangrenosum is controversial and it does
not have established and adopted protocols. The options are different antibiotic projects
of ample specter, corticosteroids, immunosuppressants and immune-modulatory. It known
that the precocious institution of aggressive treatment is capable to diminish pain
and to prevent extensive scars. In this in case that, corticosteroids was opted to
the use of associated immunosuppressants, getting itself resulted satisfactory with
partial healing of the injury of the face, therefore it was sufficiently extensive,
and it improves of the general state of the patient. The cares of support as well
as local cares are important in the prevention of complications and secondary infections
as the use of sulfadiazine of silver. As it had commitment of face and difficulty
of ocular occlusion, it resulted in ulcer of cornea and posterior transplant what
it got success. In the palatine perforation, prosthesis dental for improvement of
the deglutition was made one. Already the septal perforation only becomes fulfilled
accompaniment, since the patient persists in the use of inhalable drugs.
Conclusion
The Pyoderma Gangrenosum is a rare inflammatory illness, being necessary to exclude
other pathologies for its diagnosis. As it was an atypical case, involving the face,
since this illness attacks, generally, inferior members, had necessity to differentiate
if the injuries nasal and verbal would be for chemical aggression or the illness of
base. Moreover, its association with cocaine is little described, since it only has
two cases in literature.
