Winning the Battle after Three Years of Suffering: A Case of a Refractory Pyoderma Gangrenosum Treatment Challenge

Pyoderma gangrenosum is an uncommon inflammatory disorder characterized by neutrophilic infiltration of the skin. It can present as skin papules or pustules that progress into painful ulcers. 30–40% of the cases are associated with other systemic diseases such as inflammatory bowel diseases, rheumatoid arthritis, and proliferative hematological disorders. Uniquely, this condition has been associated with systemic lupus erythematosus (SLE). The rarity of this disorder poses a diagnostic and therapeutic challenge. We present a case of a 55-year-old female with a history of SLE and chronic right leg ulcer, presented with increased pain from the ulcer associated with a mild flare of her cutaneous lupus; examination revealed circumferential skin ulcer measuring about 25 cm extending around the right leg above the ankle with prominent fibrinous material and surrounding erythema. Blood work showed elevated WBC with neutrophilic predominance. Serology revealed a positive ANA, elevated RNP, smith, and SSA/Ro antibodies with normal anti-CCP level. Skin biopsy was taken, and it showed a diffuse neutrophilic and lymphocytic infiltrate consistent with the diagnosis of pyoderma gangrenosum. The patient was then treated with topical and systemic steroids and sequentially with dapsone, methotrexate, mycophenolate, and cyclosporine for over a two-year period but failed to show any improvement. Therefore, a trial of intravenous immunoglobulin (IVIG) therapy was attempted and produced a dramatic response after two-month infusions characterized by shrinking in the size of the ulcer and resolving pain. We believe that refractory PG poses a therapeutic challenge, and despite a lack of specific guidelines, IVIG can be attempted if initial suppressive treatment fails to show signs of improvement

Health economics: direct cost of osteoporotic hip fracture in Egypt—an analysis for the Egyptian healthcare system by the Egyptian Academy of Bone Health

Abstract Mini abstract This work studies the direct cost of hip fractures in Egypt. The direct cost was calculated based on the incidence of hip fracture in Egypt retrieved from the national database. The result of this work raises red flags to the policy makers in Egypt that such fragility fractures are preventable, should appropriate approaches be implemented. Background This study provides an analysis for the healthcare system in Egypt. It was carried out to assess the direct annual cost incurred to the Egyptian healthcare system in 2023 as a result of fragility hip fractures in older adult Egyptians. Results The direct costs of hip fractures incurred during the first year after the injury were estimated at 1,969,385,000 Egyptian pounds (US $63,734,142.4). Time from fracture to surgery was 2.2 + 0.5 days. The average hospital stay after hip fracture surgery was 5.2 + 2.6 days. 4.5% of patients died after surgery, on average 2.3 + 0.4 months. After being discharged from the hospital, all patients needed home care. Conclusion Hip fractures have a significant clinical and financial impact on patients and the healthcare system. This study raises red flags for the healthcare policy makers in Egypt, as the financial burden due to the direct costs of hip fractures justifies extensive prevention programs for osteoporosis and fragility fractures. There is an urgent need to implement diagnostic approaches and validated management protocols for bone health disorders and its associated fractures in Egypt