Penile pyoderma gangrenosum
A 70-year old male, living with spouse presented with relatively asymptomatic ulcers over the penis of 1 month duration. He denied any extramarital contact. He was not a known diabetic or hypertensive.\nGeneral examination was within normal limits. Local examination showed two indurated ulcers 1.5 × 1 cm and 0.5 × 0.4 cm over the penis at the junction of foreskin and coronal sulcus. The ulcers bled on touch. There was no inguinal or femoral lymphadenopathy [].\nSquamous cell carcinoma penis, tuberculous ulcer, donovanosis, and Herpes genitalis (either because of immunocompromise or development of resistant mutation) were considered as the differential diagnosis. The following investigations: Routine blood and urine examinations, peripheral smear, ANA, rheumatoid factor, VDRL, ELISA-HIV, HBsAg, anti-HCV, Mantoux test, Chest X-ray PA view, Ultrasound abdomen, gram stain from the ulcer, and tissue smear for Donovan bodies were negative or within normal limits.\nA biopsy was done, and the patient was started on doxycycline 100 mg twice daily. Biopsy revealed a chronic ulcer with no evidence of malignancy. Tissue culture for mycobacteria and fungi were negative. Despite 3 weeks of doxycycline, the ulcers were found to be increasing in size and extent. A repeat biopsy was done, and the patient was circumcised to accelerate the healing process.\nThe second biopsy showed an ulcer with hyperplasia of the adjacent epidermis and a dense inflammatory cell infiltrate in the dermis composed of lymphocytes, neutrophils, Langhans, and foreign body type of multinucleate giant cells. Proliferation of capillary-sized blood vessels with perivascular accumulation of inflammatory cells was noted [].\nWith these histopathological findings and clinical correlation, an alternative diagnosis of PG was considered. He was started on 40 mg of prednisolone per day. The ulcer started healing on the third day. Prednisolone was tapered and stopped by 4 weeks. There has been no recurrence even 12 months after stopping treatment [].\nThis case is reported for its extreme rarity. PG is rare, and there are only very few reports of penile PG.