A Rare Case of Severe Disseminated Pyoderma Gangrenosum of the Upper Body With Concurrent Nasopharyngeal and Inferior Orbital Wall Necrosis

Sep 30, 2026

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis usually linked to autoimmune disease or inflammatory bowel disease and typically affects the lower extremities. This open-access case describes extensive upper-body, oropharyngeal, and nasal involvement without an underlying autoimmune disorder. A 56-year-old man with chronic cocaine use and stage IV renal cell carcinoma developed rapidly progressive facial, neck, shoulder, and back ulcerations with mucosal destruction and sterile neutrophilic biopsy findings, supporting PG as a diagnosis of exclusion.

LanguageEnglish

CategoryHealthcare

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Pages6

Reading Time15 min

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Abstract

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Case Presentation

Review began 11/14/2025 Review ended 12/02/2025 Published 12/08/2025 © Copyright 2025 Branstetter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98737 Open Access Case Report A Rare Case of Severe Disseminated Pyoderma Gangrenosum of the Upper Body With Concurrent Nasopharyngeal and Inferior Orbital Wall Necrosis Robert M. Branstetter IV 1, Isabel E. Baird 1, Mohammed S. Rais 1, Danielle N. Ledet 2 , Megan N. Terrebonne 2 1. Medicine, Louisiana State University Health Sciences Center, New Orleans, USA 2. Internal Medicine, Louisiana State University Health Sciences Center, Baton Rouge, USA Corresponding author: Robert M. Branstetter IV, [rbran5@lsuhsc.edu](rbran5@lsuhsc.edu) Abstract Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis usually linked to autoimmune or inflammatory bowel disease and typically affects the lower extremities. This case is notable for extensive upper-body, oropharyngeal, and nasal involvement in a patient without an underlying autoimmune disorder. A 56-year-old man with chronic cocaine use and stage IV renal cell carcinoma presented with rapidly progressive ulcerations of the face, neck, shoulders, and back, along with nasal septal collapse and oropharyngeal destruction. Prior biopsy demonstrated sterile neutrophilic inflammation without vasculitis, infection, or malignant infiltration, supporting PG as a diagnosis of exclusion. Imaging showed erosive sinonasal disease. He was treated with systemic and topical corticosteroids and antibiotics for concurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, as well as MRSA and Pseudomonas aeruginosa wound colonization. Cyclosporine was avoided because of his metastatic cancer, and both percutaneous endoscopic gastrostomy (PEG) placement and parenteral nutrition were deferred due to infection risk and concern for pathergy. With limited therapeutic options and an advanced malignancy, care transitioned to comfort measures. This case illustrates the diagnostic difficulty of PG when cocaine exposure, malignancy, and mucosal destruction coexist. The absence of vasculitides or cytopenias, combined with biopsy findings, supported PG as the unifying diagnosis. Clinicians should consider PG inatypical facial or upper-body ulcerations and recognize how comorbid conditions may restrict standard treatment. Categories: Internal Medicine, Dermatology, Otolaryngology Keywords: cocaine use, levamisole-adulterated cocaine, nasal septal perforation, neutrophilic dermatosis, paraneoplastic syndrome, pathergy, polysubstance use, pyoderma gangrenosum, renal cell carcinoma Introduction Pyoderma gangrenosum (PG) is a rare, inflammatory skin disorder characterized by neutrophilic dermatosisand tender, ulcerated cutaneous lesions, most commonly found on the lower extremities [1] . It is often associated with systemic conditions, such as rheumatoid arthritis, ulcerative colitis, and Crohn’s disease [2] . Although the pathogenesis remains incompletely understood, immune dysregulation and aberrant neutrophil activity are believed to play key roles [3] . Classic PG usually presents as a painful ulcer on the legs, whereas disseminated, upper-body, mucosal, or head and neck involvement is uncommon and typically reflects atypical or severe variants [4] . PG remains a diagnosis of exclusion, and distinguishing it from infection, vasculitis, malignancy-related ulceration, or drug-induced vasculopathy can be challenging, especially when multiple risk factors coexist [1] . Cocaine and levamisole exposure have increasingly been recognized to cause PG-like ulcerations, including cribriform lesions and destructive midline changes, adding further diagnostic complexity in affected patients [4] . Atypic

FAQs

What makes this pyoderma gangrenosum case unusual in presentation?

It involves severe disseminated disease affecting the upper body, oropharyngeal region, and nasal structures rather than the typical lower-extremity distribution.

How was pyoderma gangrenosum diagnosed when infection, vasculitis, and malignancy were considered?

Biopsy showed sterile neutrophilic inflammation without vasculitis, infection, or malignant infiltration, and PG was treated as a diagnosis of exclusion supported by accompanying clinical and imaging findings.

Why were cyclosporine and nutrition procedures deferred in this patient?

Cyclosporine was avoided due to metastatic cancer, and both PEG placement and parenteral nutrition were deferred because of infection risk and concern for pathergy.

Sep 30, 2026

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