GENITOURINARY INFECTIONS (J SOBEL, SECTION EDITOR) Rituximab Causing Deep Ulcerative Suppurative Vaginitis/Pyoderma Gangrenosum Priya Selva-Nayagam & Gayle Fischer & Ian Hamann & Jack Sobel & Craig James Published online: 22 April 2015 # Springer Science+Business Media New York 2015 Abstract Pyoderma gangrenosum (PG) is a rare cause of purulent vulvovaginal ulceration. Six recent cases of vulvovaginal pyoderma gangrenosum associated with rituxi- mab are described. All cases were seen in the setting of ritux- imab used for the treatment of B cell non Hodgkin’ s lympho- ma (NHL). Age range was 50–74; symptoms were present for 2–24 months and severe pain, heavy discharge and large, deep purulent ulcers extending into the vagina were seen. This ar- ticle reviews previous reports of vulvovaginal pyoderma gangrenosum, discusses important differential diagnoses in this setting, and provides evidence supporting rituximab as the cause of pyoderma gangrenosum in this cohort. Keywords Vulvovaginal pyoderma gangrenosum . Rituximab . Vulvovaginal ulceration . Intravenous immunoglobulin . Non Hodgkin’ s lymphoma . Neutrophilic dermatosis . Pyoderma gangrenosum . Rituximab complications . Vulvovaginal discharge Introduction Rituximab is a genetically engineered chimeric mouse/human monoclonal antibody. It is directed against the CD20 antigen, found on the surface of normal and malignant B lymphocytes. It was the first monoclonal antibody developed as a specific cancer agent, and was approved in 1997 for the treatment of low-grade B cell non Hodgkin lymphoma (NHL) [1]. Since that time, its therapeutic use has expanded significantly to other B cell malignancies and a large number of autoimmune diseases. In 2010, its sales were estimated to be in excess of $US6.8 billion worldwide [1]. Deep, purulent, vulvovaginal ulceration suggests consider- ation of an infective or inflammatory process. The latter in- cludes non sexually acquired acute genital ulceration (NSAG U), Behcet’s syndrome, Crohn’s disease and pyoderma gangrenosum (PG). PG is an inflammatory, ulcerative, chronic dermatosis of unknown aetiology [2]. The diagnosis is based on clinical features, exclusion of other infective/non infective causes of ulceration and presence of associated diseases [3]. We recently published a series of four women who developed deep, This article is part of the Topical Collection on Genitourinary Infections P. Selva-Nayagam (*) Department of Dermatology, Queen Elizabeth Hospital, Adelaide, Australia e-mail: pselva@senet.com.au P. Selva-Nayagam Department of Gynecology, Royal Adelaide Hospital, Adelaide, Australia G. Fischer Department of Dermatology, Royal North Shore Hospital, Sydney, Australia G. Fischer The University of Sydney, Sydney, Australia I. Hamann Mid North Coast Dermatology, Port Macquarie, Australia I. Hamann The Department of Dermatology, Westmead Hospital, Sydney, Australia J. Sobel Department of Internal Medicine, School of Medicine, Wayne State University, Detroit, MI, USA C. James Adelaide Pathology Partners, Adelaide, Australia Curr Infect Dis Rep (2015) 17: 23 DOI 10.1007/s11908-015-0478-5