Question

A 24-year-old man presents with a painful ulcer on his left leg and systemic symptoms. The lesion started 1 week ago as a small pustule that developed at the site of mosquito bite, and it rapidly developed into a painful ulcer. Patient describes pain as "stabbing" and debilitating. He also develops symmetrical joints pain, muscle pain, fever, and malaise. His past medical history is significant for ulcerative colitis, which is currently in remission. On examination, you find a deep exudative ulceration, with a well-defined violet border and a worn, erythematous, and indurated edge. There are signs of pathergy as well.

What will you recommend in addition to meticulous wound care?

1. Immunosuppressant (systemic corticosteroids)
2. Antiviral (systemic acyclovir)
3. Surgical debridement
4. Antifungal (systemic fluconazole)
5. Painkiller (systemic paracetamol)

Answer 1

The patient likely has pyoderma gangrenosum, suggesting systemic corticosteroids and meticulous wound care as the best course of treatment, along with systemic pain relief. Surgical debridement, antivirals, or antifungals are not recommended without evidence of such infections.

Step-by-step explanation:

The patient's symptoms suggest a condition known as pyoderma gangrenosum, which is associated with inflammatory disorders such as ulcerative colitis. Considering the painful nature of the ulcer, its rapid development, and systemic symptoms like fever and joint pain, the most appropriate treatment would include immunosuppressive therapy like systemic corticosteroids. This will help in reducing inflammation and preventing lesion progression. Meticulous wound care is essential to prevent secondary infections and optimize healing. Pain management should also be addressed, with systemic painkillers, such as paracetamol, to provide the patient with relief. Surgical debridement is generally not recommended in cases of pyoderma gangrenosum due to the risk of exacerbating the lesions through pathergy. Antiviral and antifungal medications are not indicated in the absence of evidence for these types of infections. It is crucial for the clinician to monitor the patient's response to therapy and adjust treatment as necessary based on the evolution of symptoms.