Ecthyma Gangrenosum: A Rare Manifestation of Staphylococcus Aureus Infection

Abstract

INTRODUCTION: Ecthyma gangrenosum (EG) is a necrotizing vasculitis, commonly observed in immunocompromised patients with Pseudomonas aeruginosa bacteremia. Rarely, it can be seen with other bacterial, fungal, and viral infections. We report a rare etiology of EG in an immunocompetent patient caused by methicillin-sensitive Staphylococcus aureus (MSSA). CASE PRESENTATION:A 62-year-old man with hypertension presented to the emergency department for pain and swelling of the right lower extremity after a crush injury one week prior. Initial vital signs were remarkable for a blood pressure of 84/43 mmHg and a pulse rate of 134 beats per minute. Examination revealed a gangrenous right great toe and well-circumscribed purpuric papules with a violaceous border and central pallor on the patient's skin most prominent over the legs and lower abdomen. Laboratory findings were significant for leukocytosis and lactic acidosis. Intravenous fluids were initiated, blood cultures were collected, and he was started on vancomycin and cefepime. He rapidly progressed to septic shock requiring vasopressors and was admitted to the intensive care unit. The patient underwent amputation of the right great and punch biopsies of the skin lesions. Despite aggressive critical care management, he continued to deteriorate and developed acute hypoxemic respiratory failure and acute kidney injury requiring renal replacement therapy. Blood, wound, and urine cultures grew MSSA. Skin biopsy results revealed necrobiosis and suppurative dermatitis with gram-positive cocci in clusters, consistent with EG due to MSSA bacteremia. Antibiotic coverage was narrowed to nafcillin, however, he continued to deteriorate with progressive multiorgan failure. He was ultimately transitioned to comfort measures and died peacefully in the presence of family.DISCUSSION: To the best of our knowledge, there are only two reported cases of EG secondary to MSSA infection (1,2). One of a healthy 15-month-old girl who developed EG, and toxin-mediated systemic findings and the second of a 54-year-old female with metastatic gastric adenocarcinoma and recent chemotherapy. This is the first reported case of an immunocompetent adult patient with MSSA EG. Reported predisposing risk factors for EG include immunodeficiency, recent chemotherapy, burns, malnutrition, and tuberculosis infection. The literature describes two different forms of EG, bacteremic and non-bacteremic. Mortality rates in patients with EG due to bacteremia are significantly higher compared to patients without bacteremia (3).CONCLUSIONS: This case is unique as our patient had a rare presentation of EG due to MSSA bacteremia with none of the previously described predisposing risk factors.

Ecthyma Gangrenosum in Children With Cancer: Diagnosis at a Glance: A Retrospective Study From the Infection Working Group of Italian Pediatric Hematology Oncology Association

“…6 There are scant reports describing the occurrence of EG in oncohematologic patients, mainly as case reports or small case series. [7][8][9][10][11][12][13][14][15][16] We report the results of a large multicenter pediatric retrospective collection of 38 cases of proven EG diagnosed between 2009 and 2019 in children with hematologic disease and cancer. The aim is to describe the clinical picture and characteristics of EG, to early recognize and diagnose it, since timely treatment influences the outcome of this infection.…”

Palaeodermatological aspects of Duke Federico da Montefeltro's case: A multidisciplinary assessment

“…As a limitation to this study, we acknowledge that the antiquity of ecthyma gangrenosum has not yet been clarified, its first clinical description by Lewellys Barker dating back to 1897 14 . Nonetheless, its aetiologic agent, Pseudomonas aeruginosa , certainly has a much longer history as clarified by palaeopathological research 15 …”

Ecthyma gangrenosum caused by Staphylococcus aureus in hematological malignancies: Case reports and literature review

“…Hematological malignancies Turnbull and Parry [5] (1981) 68 M Erythroleukemia MSSA + + + Oxacillin sodium: 4 wk − Turnbull and Parry [5] (1981) 59 M Waldenström's macroglobulinemia MSSA − + NA Oxacillin: duration unclear − Chang et al [6] (2012) 35 F ALL MRSA − + + Vancomycin: duration unclear − Dassan et al [7] [10] (2012) 8 mo F No comorbidities MRSA − + − Vancomycin: 21 d − Apstolova [11] (2012) 59 M FVL mutation MRSA − + − Antimicrobials and surgical debridement: type of regimen and duration unclear − Ungprasert et al [12] (2013) 40 M HIV MRSA − + − Vancomycin: 10 d; linezolid PO: 1 mo − Song et al [13] (2015) 15 mo F No comorbidities MSSA − + − Ceftriaxone → cefepime and clindamycin: 14 d − Ivanaviciene [14] (2016) 54 F Gastric adenocarcinoma MSSA − + + Acyclovir, meropenem, vancomycin → intravenous oxacillin: 2 wk − Santhaseelan and Muralidhar [15] (2017) 47 M Chronic alcoholic MRSA − + − Ceftriaxone → imipenem and amikacin with surgical debridement: duration unclear − Ulpiano Trillig et al [16] (2019) 27 M No comorbidities S. aureus, GAS − + − Antimicrobial therapy: 7 d − Ulpiano Trillig et al [16] (2019) 31 M HIV S. aureus, GAS − + − Antimicrobial therapy with surgical debridement: 14 d − Barry et al [17] (2021) 19 M CKD MRSA − + − Linezolid without surgical debridement: 4 wk − Shah et al [18] blood cultures returned positive. In the previous reports, 44% (74/167) of EG (any pathogen) was associated with positive blood culture results, while only 9% (4/44) of nonpseudomonal EG was associated with positive blood culture results.…”