Eschar or Ecthyma or Both?

Abstract

We report a case of scrub typhus with coexistent Pseudomonas aeruginosa skin infection in the same patient. A 6-year-old Chinese boy presented with 5 days of fever, 2 days of right thigh swelling, and an insect bite mark over the swelling. A full blood count had been performed prior to hospital consultation, and showed neutropenia and thrombocytopenia. Initial clinical examination revealed a tender erythematous induration with a central punctum on his right thigh, which progressed to form a rolled-up papule with black central necrosis. The clinical suspicion was of an eschar, although ecthyma gangrenosum could not be ruled out. He had recently returned from a recreational trip in the United States 3 weeks earlier, and had travelled to Wisconsin and Las Vegas. He was treated initially for right thigh cellulitis with parenteral ampicillin and cloxacillin, but after infectious disease consultation, he was commenced on intravenous ciprofloxacin. A wound culture grew P. aeruginosa, while rickettsial serology was positive for Orientia tsutsugamushi. He responded clinically to ciprofloxacin and was discharged well, and an outpatient review showed significant improvement of his cutaneous lesion.