Recurrent Pyoderma Gangrenosum with Initial Onset in Early Pregnancy: A PARACELSUS-Supported Clinical Diagnosis in a Resource-Limited Setting in South-Western Uganda.

Abstract

Background: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressive, painful cutaneous ulceration and remains a diagnosis of exclusion because no single laboratory or histopathological test is diagnostic. Establishing a clinically well-supported diagnosis is particularly challenging in resource-limited settings where histopathology and other advanced investigations are often unavailable, necessitating reliance on structured clinical assessment and validated diagnostic frameworks.

Case presentation: A 26-year-old multiparous woman from South-Western Uganda presented with recurrent, progressively painful multifocal ulcerations involving both lower limbs and upper extremities. The initial episode developed during the first month of pregnancy as pruritic pustules that rapidly evolved into ulcerative lesions following minor trauma, with recurrence occurring two years later from a persistent non-healing ulcer. Comprehensive clinical evaluation found no evidence suggestive of inflammatory bowel disease (IBD) or other major associated systemic conditions, while wound cultures were sterile, supporting a non-infectious process. Because histopathology, gastrointestinal endoscopy, and other advanced investigations were unavailable, diagnosis relied on careful clinical assessment, systematic exclusion of important differential diagnoses, characteristic lesion morphology, pathergy, previous response to immunosuppressive therapy, and a PARACELSUS score supportive of PG. The patient was treated with oral prednisolone, cyclosporine, structured wound care, supportive therapy, and physiotherapy, resulting in marked clinical improvement at three-month follow-up.

Conclusion: This case demonstrates how structured clinical reasoning and validated diagnostic frameworks can support a clinically well-substantiated diagnosis of probable PG when confirmatory investigations are inaccessible. It also describes a temporal association between disease onset during early pregnancy and pregnancy loss, an observation that should be interpreted cautiously and requires further investigation rather than implying causality. Careful exclusion of alternative causes of ulceration remains fundamental before initiating immunosuppressive therapy.