Ecthyma gangrenosum

Abstract

Ecthyma gangrenosum (EG) is a severe potentially lethal cutaneous infection that progresses sequentially from maculopapular rash to haemorrhagic bulla and then to necrotic ulceration with surrounding erythema. It usually occurs in immunocompromised patients (aplasia secondary to chemotherapy, HIV infection, neutropenia or functional deficit of neutrophils, agammaglobulinemia). It rarely affects healthy people. Differential diagnosis includes leishmaniasis, pyoderma gangrenosum, eschars and papulonecrotic tuberculides. Blood cultures and/or local sample allow the isolation of P. aeruginosa, which is the causative germ. Treatment is based on suitable parenteral antibiotic therapy according to results of susceptibility tests (third-generation cephalosporins, fluoroquinolones). We here report the case of a 2-year old child with no particular past medical history presenting with multiple necrotic ulcers on the back with erythematous border evolving in a febrile context. Blood culture was negative. Laboratory tests showed sedimentation rate 30 mm, CRP 80mg/l. Bacteriological sampling of pus revealed pseudomonas aeruginosa. The diagnosis of ecthyma gangrenosum was made. The patient underwent parenteral third-generation cephalosporins. Complete patient recovery with healing occurred after 4 weeks.

Tender Annular Plaque on the Thigh

“…Ecthyma gangrenosum is an uncommon cutaneous manifestation of bacteremia that most commonly occurs secondary to P aeruginosa in immunocompromised patients, particularly patients with severe neutropenia in the setting of recent chemotherapy. 1,2 Ecthyma gangrenosum can occur anywhere on the body, predominantly in moist areas such as the axillae and groin; the arms and legs, such as in our patient, as well as the trunk and face also may be involved. 3 Other causes of EG skin lesions include methicillin-resistant Staphylococcus aureus, Citrobacter freundii, Escherichia coli, fungi such as Candida, and viruses such as herpes simplex virus.…”

“…7,8 Resultant ischemic necrosis results in the classic macroscopic appearance of an erythematous macule that rapidly progresses into a central necrotic lesion surrounded by an erythematous or violaceous halo after undergoing a hemorrhagic bullous stage. 1,9 A Wood lamp can be used to expedite the diagnosis, as Pseudomonas bacteria excretes a pigment (pyoverdine) that fluoresces yellowish green. 10 Ecthyma gangrenosum can be classified as a primary skin lesion that may or may not be followed by bacteremia or as a lesion secondary to pseudomonal bacteremia.…”

“…7 Initial broad-spectrum antibiotics include antipseudomonal β-lactams (piperacillin-tazobactam), cephalosporins (cefepime), fluoroquinolones (levofloxacin), and carbapenems (imipenem). 1,7 Medical therapy alone may be sufficient without requiring extensive surgical debridement to remove necrotic tissue in some patients. Surgical debridement usually is warranted for lesions larger than 10 cm in diameter.…”

Ectima gangrenoso en pacientes pediátricos hematooncológicos, infección oportunista. Revisión de casos clínicos en el Centro Médico Nacional 20 de Noviembre

“…1 El EG es una infección profunda de la piel considerada potencialmente letal que se asocia en 74% de los casos a sepsis causada por Pseudomonas aeruginosa, se presenta con mayor frecuencia en brazos (área axilar), piernas, tronco, cara, región lumbosacra y área anogenital de pacientes inmunocomprometidos que cursan con aplasia secundaria a quimioterapia, infección por virus de inmunodeficiencia humana (VIH), neutropenia, mieloma múltiple, diabetes mellitus, agammaglobulinemia y pacientes con quemaduras extensas. 2 Aunque el EG es poco frecuente, compromete el sistema microvascular de la dermis, progresa clínicamente de forma secuencial desde erupciones maculopapulares hasta ampollas o bulas hemorrágicas, posteriormente al denudarse forman ulceraciones necróticas con eritema circundante o halo eritematoso que, por lo general, no presentan una evolución clínica favorable en pacientes inmunocomprometidos. 1,2 Como se mencionó previamente, 74% de los casos de EG están causados por Pseudomonas aeruginosa, otros agentes en menor porcentaje se han asociado con esta patología, entre ellos Streptococcus pyogenes, Staphylococcus aureus, Aeromonas hydrophila, Serratia marcescens, Aspergillus spp., Candida albicans, Escherichia coli, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Yersinia pestis y virus del herpes simple.…”

“…2 Aunque el EG es poco frecuente, compromete el sistema microvascular de la dermis, progresa clínicamente de forma secuencial desde erupciones maculopapulares hasta ampollas o bulas hemorrágicas, posteriormente al denudarse forman ulceraciones necróticas con eritema circundante o halo eritematoso que, por lo general, no presentan una evolución clínica favorable en pacientes inmunocomprometidos. 1,2 Como se mencionó previamente, 74% de los casos de EG están causados por Pseudomonas aeruginosa, otros agentes en menor porcentaje se han asociado con esta patología, entre ellos Streptococcus pyogenes, Staphylococcus aureus, Aeromonas hydrophila, Serratia marcescens, Aspergillus spp., Candida albicans, Escherichia coli, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Yersinia pestis y virus del herpes simple. En general, el EG es causado por un solo agente infeccioso, excepcionalmente se han reportado casos con dos agentes causales.…”