Skin Ulcerations in a Lupus Hemodialysis Patient With Hepatitis C Infection

A 47 years old female patient with lupus nephritis on hemodialysis for 18 years presented with an inflammatory lesion that interested the right leg. She was on prednisone, 7.5 mg/d. Dermatological examination showed grouped papular lesions with hemorrhagic content on the front of the right leg. In a few days, large ulcerations appeared with elevated and undetermined borders that gradually expanded. Serology was positive for hepatitis C. Histological examination of the lesion showed a nonspecific diffuse neutrophilic infiltration in the superficial dermis, accompanied by edema and interspersed lymphocytes. These features were consistent with a neutrophilic dermatosis. A diagnosis of pyoderma gangrenosum (PG) was made. Pyoderma gangrenosum is an uncommon neutrophilic dermatosis that can be primitive or associated with a systemic disease. The diagnosis is usually based on clinical evidence. Pyoderma gangrenosum has previously been described in patients undergoing hemodialysis. There are rare cases of association between systemic lupus erythematous and PG.1 In these cases, the onset of PG is usually associated with active lupus. In this case, there were no immunological signs of lupus reactivation. Pyoderma gangrenosum is also described to be secondary to hepatitis C associated-cryoglobulinemia or to interferon therapy.2 In this patient, hepatitis C was untreated and cryoglobulinemia was negative. This case illustrates the difficulty of the etiologic diagnosis and therefore treatment of PG in a patient accumulating multiple comorbidities.