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

## TL;DR

This paper presents a rare case of severe pyoderma gangrenosum affecting the upper body and nasal/orbital areas in a patient without autoimmune disease.

## Contribution

The case highlights atypical PG presentation and challenges in diagnosis and treatment due to comorbidities.

## Key findings

- PG was diagnosed in a patient with no autoimmune disorder but with cocaine use and renal cancer.
- Biopsy showed sterile neutrophilic inflammation, ruling out vasculitis, infection, or malignancy.
- Treatment was limited due to cancer and infection risks, leading to comfort care.

## 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 in atypical facial or upper-body ulcerations and recognize how comorbid conditions may restrict standard treatment.