The diagnosis of PG can be difficult. It depends upon a combination of clinical presentation, histology, history of underlying diseases, and exclusion of

other conditions. Given the nonspecific histological findings ZD1839 in vitro and a positive blood culture for S. haemolyticus, it was very difficult to exclude a necrotizing wound infection. The leukocytosis in the absence of lymphocytosis cannot be explained by chronic lymphocytic leukemia or bacteremia. Cases of postoperative PG with leukaemoid reaction (WBC >50,000/mm3) in the absence of hematologic malignancies have been reported [20, 21]. Despite a positive blood culture, the wound culture remained negative and the skin lesion responded to corticosteroids instead of antibiotics. Similar features can be found in Proteasome inhibitor Fournier’s gangrene, a rare but life threatening disease affecting patients with

comorbidities, especially diabetes mellitus and alcoholism. It is a fulminant form of infective necrotising fasciitis affecting the perineal, genital, or perianal regions [22]. Wound culture is commonly positive for at least three organisms, including aerobes and anaerobes [23]. Fournier’s gangrene requires an aggressive approach, including broad spectrum antibiotics, hemodynamic stabilization, and surgical debridement. It was highlighted that early surgical debridement is the first therapeutic intervention and has a major impact on the prognosis P-type ATPase [24]. In contrast, surgical intervention can aggravate PG due to the pathergy phenomenon [25]. Other diseases to be considered in the differential diagnosis are malignancy, vasculitis, Sweet syndrome, or factitious ulcerations [1]. Conclusion In conclusion, faced with postoperative necrotizing ulceration resistant to correctly administered antibiotics, PG must be considered in any case of apparently delayed wound healing. Since the most important

findings suggestive for PG are painful ulcers with rapid outgrowth and undermined, violaceous borders in absence of infection, the diagnosis must not be guided primarily by histology and early advice of a dermatologist is recommended. Acknowledgments This work was not supported financially or otherwise. Dr. Chiticariu is the guarantor for this article, and takes responsibility for the integrity of the work as a whole. Conflict of interest Dr. Solovan, Dr. Smiszek, Dr. Wickenhauser, and Dr. Chiticariu declare no conflict of interest. Compliance with ethics guidelines Informed consent was obtained from the patient for being included in the study. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. References 1. Wollina U. Pyoderma gangrenosum—a review. Orphanet J Rare Dis. 2007;2:19.