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CORRESPONDENCE
Year : 2012  |  Volume : 57  |  Issue : 1  |  Page : 71-72
Pyoderma vegetans of glans penis


Department of Skin and VD, Government Medical College, Latur, Maharashtra, India

Date of Web Publication10-Mar-2012

Correspondence Address:
Ajay Govindrao Ovhal
Department of Skin and VD, Government Medical College, Latur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.92687

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How to cite this article:
Ovhal AG, Deshmukh AR. Pyoderma vegetans of glans penis. Indian J Dermatol 2012;57:71-2

How to cite this URL:
Ovhal AG, Deshmukh AR. Pyoderma vegetans of glans penis. Indian J Dermatol [serial online] 2012 [cited 2019 Sep 18];57:71-2. Available from: http://www.e-ijd.org/text.asp?2012/57/1/71/92687


Sir,

A 60-year-old male patient presented with the complaint of a mass over the glans penis since 1 year. Initially a pea-sized swelling, it had gradually enlarged and assumed a cauliflower-like appearance [Figure 1]. The mass was 4 × 3 cm in size, encompassed the glans penis, and oozed a foul-smelling mucopurulent discharge. The lesion tended to bleed on slight trauma. The urethra was spared and there was no difficulty in micturition. Our differential diagnoses included squamous cell carcinoma, condyloma acuminata, Buschke-Lowenstein tumor, and pyoderma vegetans.
Figure 1: Cauliflower like asymptomatic mass over glans penis

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Laboratory investigations revealed normal hemogram and normal biochemical parameters, including blood sugar, liver function, renal function, and serum iodide/bromide levels. He was nonreactive for human immunodeficiency virus (HIV), enzyme linked immunosorbent assay (ELISA) and venereal disease research laboratory (VDRL). Biopsy from the lesion was sent for histopathology, and bacterial and fungal culture. Bacterial culture yielded Pseudomonas aeruginosa. Fungal culture did not show any growth. Histopathology showed irregular psoriasiform and some pseudocarcinomatous hyperplasia of the epidermis, with a thick crust that contained numerous neutrophils [Figure 2]. In several foci, the epidermis showed mild spongiosis and was infiltrated by neutrophils that formed small collections in the upper spinous layers. In foci, intraepidermal pustules had formed in the upper spinous layers containing neutrophils. No dysplastic cells/koilocytes or granulomas/malignancy were seen. These findings were suggestive of pyoderma vegetans (also known as blastomycosis-like pyoderma). The patient was given cefotaxime, amikacin, and metronidazole for 2 weeks. The lesion was excised under local anesthesia using a radiofrequency machine. The epidermal plain was identified and the lesion was excised circumferentially [Figure 3]. After the lesion had healed, the patient was maintained on dapsone and 0.03% topical tacrolimus. There has been no recurrence after follow-up for 1 year.
Figure 2: The epidermis shows irregular psoriasiform and some psudocarcinomatous hyperplasia with many neutrophils mentition type of stain and magnification

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Figure 3: Post treatment photograph after 8 days with suture which was given to achieve hemostasis at that place

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Pyoderma vegetans is an inflammatory dermatoses characterized clinically by large exudative vegetating plaques and histopathologically by epidermal pseudoepitheliomatous hyperplasia and dense inflammatory infiltrates. [1] Although pyoderma vegetans is a very rare condition, it is a chronic disorder that may accompany any systemic process that compromises immunity. The exact etiology is unknown but this disease has been attributed to bacterial infection in an individual who is immunocompromised. Pyoderma vegetans has been associated with ulcerative colitis, diffuse T-cell lymphoma, alcoholism with malnutrition, HIV infection, chronic myeloid leukemia (CML), and lupus nephritis. The immunological dysfunction is believed to induce the development of vegetations. [2] Duncan and Perry [3] have proposed the diagnostic criteria for blastomycosis-like pyoderma:

  1. Large verrucous plaques with multiple pustules and elevated border
  2. Pseudoepitheliomatous hyperplasia with abscesses in the tissue biopsy specimen
  3. Growth of at least one pathogenic bacterium from the culture of a tissue biopsy specimen
  4. Negative culture for deep fungi, atypical mycobacteria, and Mycobacterium tuberculosis
  5. Negative fungal serology test result
  6. Normal bromide and iodide levels in the blood
There is no standardized treatment plan available for pyoderma vegetans, although antibiotic treatment has often been used with variable results. Topical treatment includes wound care with copper sulfate or aluminum subacetate dressings, disodium cromoglycate, and tacrolimus. Systemic treatment comprises intravenous antibiotics, dapsone, etretinate, and systemic steroids. Surgical intervention can be done with laser debridement or curettage. [2]

Pyoderma vegetans on the penis is rare. Though pustules were not evident in this case (as required by the criteria of Duncan and Perry), our patient had a purulent exudate. All the other criteria were satisfied in this case. To our knowledge, only one other case has been reported of pyoderma vegetans over the penis, and that case was associated with HIV and recurrent herpes genitalis. [4] In our patient, however, the pyoderma vegetans was not associated with an immunocompromised status, and showed complete remission after treatment. We propose that the development of pyoderma vegetans of penis in this case may be due to local immunological dysfunction as a result of poor hygiene. Correct diagnosis saved the penis of the patient which otherwise would have been amputated due to suspicion of malignancy. The clinician should always be alert to the possibility of pyoderma vegetans occurring in the genitourinary system.

 
   References Top

1.Carrera C, Mascaro JM, Moreno-Romero JA, Iranzo P, Palou J, Zamora E, et al. Pyoderma vegetans associated with severe psoriatic arthritis: Good response to etanercept. Dermatology 2007;214:77-81.  Back to cited text no. 1
    
2.Schwartz RA, Brown J. Pyoderma vegetans. Available from: http://emedicine.medscape.com/article/1055728-overview. [Last accessed on 2010 Sep 3].  Back to cited text no. 2
    
3.Su WP, Duncan SC, Perry HO. Blastomycosis like pyoderma. Arch Dermatol 1979;115:170-3.  Back to cited text no. 3
    
4.Rieder JM, Moresi JM, Parsons JK. Pyoderma vegetans of penis. J Urol 2004;171:354.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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