LAUSR

A 71-year-old-male with hypertension, type 2 diabetes mellitus, morbid obesity, and diastolic heart failure presented to the hospital with mild symptoms of sore throat, fevers, and shortness of breath and tested positive for COVID-19 by RT-PCR. He did not require admission and was discharged home with instructions to self-quarantine for 14 days. About 10 days after diagnosis, he developed painful and pruritic pustules on his left scrotum that quickly ulcerated within a few days. After self-treatment with over-the-counter antifungal and antibiotic creams, the patient was treated at an urgent care facility with cephalexin 500 mg three times daily and valacyclovir 1000 mg twice daily due to concern for cellulitis and shingles. Over the next few weeks, the small ulcers coalesced to form a large painful ulcer (Figure 1(a)), followed by the appearance of a similar lesion in the lower abdomen (Figure 1(b)). He was prescribed topical triamcinolone by his physician and referred to a wound care center where he was diagnosed with pressure ulcers and treated with topical collagenase, a debriding agent, which worsened the ulcers. The patient gradually developed more ulcers on the penis, groin, buttocks, and abdomen over a span of two to three months. He eventually underwent a lesional biopsy revealing neutrophilic dermatosis with perivascular and interstital neutrophilic infiltrates in the dermis and was diagnosed with pyoderma gangrenosum (PG) based on the clinical presentation and histopathology. The patient was started on 60 mg prednisone daily and topical corticosteroids with prompt improvement of ulcers and he is currently being transitioned to infliximab for long-term treatment. Work up for PG-associated disorders including rheumatoid arthritis and other major autoimmune diseases, MGUS, inflammatory bowel disease, and hematological malignancies were all negative.