S4993 Post-Partum Pyoderma Gangrenosum in Young Woman With Ulcerative Colitis

Introduction: Pregnancy and post-partum state are well known to change normal physiology and immunology. The post-partum period, especially immediately following delivery is a very pro-inflammatory state and can exacerbate underlying auto-immune conditions. Here we present a case of post-partum pro-inflammatory state exacerbating underlying ulcerative colitis (UC) complicated by pyoderma gangrenosum. Case Description/Methods: A 22-year-old woman who initially presented during her third trimester of pregnancy for abdominal pain. Her course was complicated by acute fatty liver of pregnancy for which she had an emergency cesarean section requiring intubation and was later admitted to the medical intensive care unit for management of multi-organ dysfunction. Later during the admission, she endorsed bilateral lower extremity weakness, erythema and edema. She was fluid resuscitated, started on epinephrine and antibiotics for Escherichia coli bacteremia. As her clinical course was improving, she developed bilateral lower extremity bullous lesions as well as non-healing cesarean surgical wound. Biopsy of the lower extremity lesions demonstrated neutrophilic dermatosis. Given underlying UC, she was diagnosed with pyoderma gangrenosum. She was started on steroid therapy with immediate improvement. Discussion: With respect to immunology, early pregnancy is known to be a pro-inflammatory state, mid-pregnancy as an anti-inflammatory state, and both late pregnancy and postpartum are both a pro-inflammatory state. Cytokines and interleukins (IL) such as IL-6, IL-8, IL-10, Tumor Necrosis factor alpha and interferon gamma are in higher concentrations during the postpartum state. In this patient with neutrophilic dermatosis during postpartum the differential included DRESS, pyoderma gangrenosum, sweet syndrome: acute febrile neutrophilic dermatosis, Behcet syndrome and neutrophilic eccrine hidradenitis. In order to differentiate between these diagnosis, it was important to take into account the clinical context, which for this patient included history of UC. Nonhealing surgical scar and lower extremity lesions were treated with steroids and patient went on to make a speedy recovery.