Ulcerative Leg Wound in a Patient with Ulcerative ColitisQuestion: A 43-year-old male with a history of ulcerative colitis status post subtotal colectomy with end ileostomy presents with fevers and worsening right shin ulcerative wound. He had minor trauma to his right shin leading to erythema, tenderness, and ulceration (Figure 1 A, B, & C). He received two courses of oral antibiotics for presumed cellulitis yet had rapid wound progression. Biopsy from the wound showed dense dermal neutrophilic infiltrate and no growth in bacterial or fungal cultures (Figure 1 D& E). HIV, Hepatitis B, and C serology, antinuclear antibodies, and anti-cytoplasmic antibodies were all negative. What is the most likely diagnosis?Answer: This is a classic case of ulcerative pyoderma gangrenosum (PG). PG is a rare neutrophilic dermatosis secondary to an aberrant inflammatory process that presents with rapidly progressing painful purulent ulcers, usually after a minor trauma1. PG is often confused with soft tissue infection leading to delayed diagnosis. However, associated conditions such as inflammatory bowel disease and inflammatory arthritis should raise suspicion for PG1. A biopsy is needed for diagnosis after ruling out infection since the treatment is with immunosuppressive therapy2. Debridement should be avoided since it may worsen symptoms in the phenomenon known as the pathergy effect2.