Virginia Via Research Day Book 2026

Medical Student Research Case Reports

40 REFRACTORY PYODERMA GANGRENOSUM MANAGED WITH COD FISH SKIN GRAFT IN A SEVERELY IMMUNOCOMPROMISED PATIENT WITH MULTIPLE COMORBIDITIES

Nitya Reddy, OMS-III; Jawad Khan, OMS-III; Mary Quillinan, DO; George Mitchell, DO Corresponding author:nreddy@vcom.edu

VCOM-Virginia, Blacksburg, Virginia Cleveland Clinic Indian River, Vero Beach, Florida

Pyoderma gangrenosum (PG) is a rare inflammatory skin disorder with neutrophilic predominance that is characterized by the rapid development of painful ulcerative skin lesions. The exact cause of this disease is unclear, but it has been linked to immune system dysregulation, which poses significant management challenges. Many cases of PG have been linked to underlying diseases such as irritable bowel syndrome (ulcerative colitis and Crohn’s disease), arthritis, and blood disorders such as leukemia. We present a case of a patient with chronic pyoderma gangrenosum initially diagnosed in October 2019 after 4 months of bilateral ulcers on his legs, refractory to prednisone and compression therapy. This patient went under bilateral XR IR angiograms of his legs and biopsies to rule out vasculitis and confirm the diagnosis of PG. At the time of diagnosis, the patient had hypertension,

hyperlipidemia, and prediabetes, but no common underlying disorders related to PG. The patient has now progressed to have type 2 diabetes, stage 3 chronic kidney disease, obesity class I, and a severely immunocompromised state, leading to multiple bacterial, fungal, and mold infections. The patient was initially treated with topical clobetasol and mupirocin, followed by intermittent prednisone therapy. Despite escalation to aggressive immunosuppressive therapy, including Remicade (infliximab), systemic prednisone, Cellcept (mycophenolate mofetil which is a DMARD), and Mepron (atovaquone for PJP prophylaxis), the patient experienced persistent wound chronicity and infections. Given this patient's severely immunocompromised state, poor healing response, and no underlying trigger for his disease, the patient is now pursuing innovative treatment with fish skin (atlantic cod) graft therapy as of October

2025. This case highlights the challenges of managing refractory PG in patients with multiple comorbidities and severe immunosuppression, and demonstrates the potential application of fish skin grafts as an adjunctive therapy. The fish skin graft represents a novel biological approach that may convert chronic inflammatory wounds to a healing phenotype through omega-3 fatty acids and structural matrix properties. The safety and efficacy of skin grafts in PG has been studied in a meta analysis in 2020, but placebo-controlled trials are still yet to be conducted. This case contributes to the growing literature supporting alternative wound management strategies for complex neutrophilic dermatoses in high risk patient populations.

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78 Edward Via College of Osteopathic Medicine (VCOM)