Case report: Unusual complications of severe hidradenitis suppurativa

Abstract

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic follicular occlusive disease that affects the folliculopilosebaceous unit, mainly, but not exclusively, in intertriginous axillary, groin, perianal, perineal, genital and inframammary skin. The clinical course is highly variable. The disease is difficult to treat, and has a severe impact on quality of life. An 18-year-old female was diagnosed with bilateral axillary HS/AI in 2014. She was a known smoker, with a body mass index of 21, no known comorbidities and retroviral-disease negative. She presented in 2017 with advanced Hurley stage III disease, with extensive painful open wounds and purulent material draining. The patient also had bilateral shoulder contractures with reduced abduction. She was clinically malnourished, anaemic and hypoalbuminaemic. Wound swabs showed a Pseudomonas infection. Wide local excision was performed of the diseased areas and skin grafted, and arm splints were designed to keep both arms in fixed abduction, to allow for adequate healing and wound care management. However, all grafts failed to take. We employed a multidisciplinary approach to manage this patient. Negative-pressure wound therapy was utilised to assist with wound management. The patient had developed a spontaneous pneumothorax owing to the severity of the disease, which eroded into the chest wall. This was managed conservatively with an intercostal drain. Despite all these efforts, the patient’s condition did not improve. She subsequently went into septic shock, and died in the intensive care unit. This case illustrates the fact that early diagnosis and management of HS/AI is essential. As the disease advances, it becomes increasingly difficult to manage, and requires a multidisciplinary treatment approach.