Pyoderma gangrenosum and spinal epidural abscess after subcutaneous administration of recombinant human erythropoietin.

the right upper arm, lower back, left thigh, and both Pyoderma gangrenosum is an uncommon nonankles. Five days earlier rHuEpo has been administered contagious condition of unknown aetiology resembling by s.c. injection on the lateral aspect of the right upper a Shwartzman-like hypersensitivity reaction. It typicarm. One day after injection, high fever and multiple ally begins as a pustule and presents as solitary or erythematous macules and papules appeared at the site multiple sterile ulcerated nodules or plaques. The pusof injection and at other areas of the skin. On admistules may progress to large necrotic ulcerative lesions sion, the patient was alert, had a temperature of with painful undermined dusky margins [1]. Pyoderma 30.2°C, regular pulse (96/min), a blood pressure of gangrenosum may appear spontaneously or after 100/60 mmHg, and a respiration rate of 20/min. trauma to the skin. It may be associated with systemic Cardiopulmonary examination was unremarkable. diseases, e.g. Crohn’s disease, ulcerative colitis, polyartThere was no lymphadenopathy, hepatosplenomegaly, eritis, or a variety of haematological disorders [2]. or arthralgia. The neurological examination was unreRecently pyoderma gangrenosum has been reported markable. Laboratory investigations revealed WBC after administration of haematopoietic colony14 000/mm3 (segment 88%), haemoglobin 7.4 g/dl, stimulating factors [3,4]. Although the exact mechanhaematocrit 23%, and platelets 50 000/mm3. Other ism involved remains uncertain, many findings point findings included BUN 25.8 mg/dl, creatinine to abnormal or depressed immune responses in patients 3.5 mg/dl, total protein 4.7 g/dl, albumin 3.0 g/dl. with pyoderma gangrenosum [5,6 ]. Fibrin degradation products and fibrinogen were Although infections and bacteraemia are common within the normal range. Repeated blood cultures and in haemodialysis patients, spinal epidural abscess swabs taken from the lesions remained negative. formation is rare. Infection of the epidural space is Septicaemia was suspected and cephalosporin and most frequently the result of haematogenous dissemgentamicin were administered. On the 3rd day, the ination from a distant focus [7], e.g. bacteraemia patient was afebrile and a skin biopsy was taken from secondary to infected arteriovenous graft or haemodiathe site of injection (Figure 1). It revealed acute necrotlysis catheter. Staphylococcus aureus was found in izing inflammation with perivasculitis in the subcutaneabout 60% of the cases. Early recognition and prompt ous tissue (Figure 2). The finding was consistent with treatment with antibiotics and decompressive laminecpyoderma gangrenosum. Sigmoidoscopy, barium tomy improve the otherwise poor outcome [7,8]. enema examination, antinuclear antibodies (ANA), We report a case of spinal epidural abscess formation anti-dsDNA, antineutrophil cytoplasm antibody, C3, subsequent to pyoderma gangrenosum which had C4, rheumatoid factor, serum protein electrophoresis, developed after subcutaneous administration of recomand immunoelectrophoresis were all normal. On the binant human erythropoietin (rHuEpo). 12th day, the patient was started on steroids and