Ectima gangrenoso en el paciente inmunocomprometido: debut leucemia aguda

El Ectima gangrenoso es un trastorno infeccioso infrecuente, clásicamente relacionado a bacteriemia, descrito principalmente en poblaciones inmunodeprimidas. Se asocia con la sepsis y bacteriemia por P. aeruginosa en pacientes inmunodeprimidos, incluidos aquellos con neutropenia o inmunodeficiencias, también se han descrito casos por hongos filamentosos y levaduras. Se ha observado en aproximadamente un 1,3-3 % de los casos de bacteriemia por P. Aeruginosa1. Se ha descrito ectima en pacientes con déficit en su inmunidad2, como en el caso que se describe a continuación. El Ectima puede presentarse como lesión única o múltiple, caracterizadas por máculas eritematosas que progresan a vesículas, bullas o pústula, evolucionando hasta la necrosis central con halo eritematoso. Se presenta el caso de un paciente con Ectima Gangrenoso, refractario inicialmente a tratamiento, que evolucionó con empeoramiento progresivo, presentándose en el hemograma hiperleucocitosis asociado a anemia y trombopenia, con diagnóstico ulterior de Leucemia Mieloide Aguda.

Ecthyma gangrenosum is an uncommon infectious disorder classically associated with bacteremia and found mainly in immunocompromised populations. It is associated with sepsis and Pseudomonas aeruginosa bacteremia in immunocompromised patients, including those with neutropenia or immune deficiencies. There have also been cases caused by filamentous fungi and yeasts. It has been seen in approximately 1.3 ­ 3% of Pseudomonas aeruginosa bacteremias. Ecthyma has been reported in immune-deficient patients, as in the case described below. Ecthyma can present with a single or multiple lesions with erythematous macules progressing to vesicles, bullas or pustules, which develop central necrosis with an erythematous halo. We present the case of a patient, later diagnosed with Acute Myeloid Leukemia, with ecthyma gangrenosum, initially refractory to treatment, which worsened progressively, presenting hyperleukocytosis associated with anemia and thrombocytopenia in the whole blood count.

Ectima gangrenoso, manifestación cutánea infrecuente de una infección por diversos agentes / Ecthyma gangrenosum, a rare cutaneous manifestation of infection by various agents

El ectima gangrenoso es un trastorno infeccioso infrecuente clásicamente relacionado a bacteriemia, descrito principalmente en poblaciones inmunodeprimidas. El agente más comúnmente relacionado es Pseudomonas aeruginosa, sin embargo, se han descrito otras etiologías bacterianas, hongos filamentosos y levaduras. Su patogénesis está dada por la invasión de la pared de los vasos sanguíneos, causando trombosis arterial y venosa, desencadenando necrosis de epidermis y tejidos subdérmicos. Clínicamente, se manifiesta como máculas, vesículas o pústulas hemorrágicas que evolucionan a úlceras de superficie necrótica rodeadas por un halo eritematoso característico, habitualmente en un contexto clínico de sepsis. El diagnóstico de este cuadro es clínico, sin embargo, el estudio microbiológico es clave en la identificación del agente etiológico y un posterior tratamiento dirigido. En su manejo es esencial una alta sospecha clínica y el inicio de tratamiento antibiótico en forma precoz. La duración del tratamiento es variable y en algunos casos debe asociarse a debridación quirúrgica. El pronóstico es variable dependiendo de múltiples factores: estado inmunológico, agente etiológico, presencia de sepsis y el tiempo de inicio de tratamiento.(AU)

Ecthyma gangrenosum is an infrequent infectious disorder classically related to bacteremia, described mainly in immunosuppressed populations. The most related agent is Pseudomonas aeruginosa, however other bacterial etiologies, filamentous fungi and yeasts have been described. Its pathogenesis is given by the invasion of the blood vessel wall, causing arterial and venous thrombosis, triggering necrosis of epidermis and subdermal tissues. Clinically, it manifests as hemorrhagic macules, vesicles or pustules that evolve into ulcers with a necrotic surface surrounded by a characteristic erythematous halo, usually in a clinical setting of sepsis. The diagnosis of this condition is clinical, however the microbiological study is key in the identification of the etiological agent and a subsequent directed treatment. In its management, a high clinical suspicion and an early start of antibiotic treatment are essential. The duration of treatment is variable and in some cases it must be associated with surgical debridement. The prognosis is variable depending on multiple factors: immunological status, etiological agent, presence of sepsis and time of initiation of treatment.(AU)

Ecthyma gangrenosum and agranulocytosis in a previously healthy 12-month-old girl: Report of 1 case with a literature review

Ecthyma gangrenosum (EG) is a rare skin manifestation which starts with a maculopapular eruption and followed by a necrotic ulcer covered with black eschar. EG usually occurs in immunosuppressed patients with Pseudomonas aeruginosa sepsis. We present a previously healthy 12-month-old girl with EG by P. aeruginosa and agranulocytosis due to influenza A and then rhinovirus infection, without bacteremia. It is important for allergists to culture wound and differentiate EG from other skin disorders including Tsutsugamushi disease and initiate appropriate empiric antipseudomonal antibiotic treatment, and to evaluate for possible immunodeficiency, even in a healthy child.

Otitis externa maligna con ectima gangrenoso en un paciente con infección por VIH / Malignant otitis externa with ecthyma gangrenosum in an hiv-positive patient

La otitis externa maligna es considerada una infección invasiva del conducto auditivo externo, infrecuente y sumamente agresiva, que llega, en ocasiones, a comprometer la base del cráneo. Se presenta habitualmente en inmunocomprometidos, incluidos aquellos con infección por VIH. El ectima gangrenoso es una infección cutánea localizada, inusual, causada, en la mayoría de los casos por Pseudomonas aeruginosa, con compromiso multisistémico y evolución tórpida. La asociación entre ambas entidades es aún más rara. A continuación, presentamos el caso de una mujer de 37 años, con el antecedente principal de infección por VIH desde hace 10 años, adherente al tratamiento antirretroviral y, a pesar de mantener una adecuada respuesta inmunológica y virológica, se presenta a la urgencia de nuestro hospital en shock séptico por otitis externa maligna, con ectima gangrenoso y posible síndrome hemofagocítico como complicación, aislándose Pseudomonas aeruginosa como agente causal.

Malignant otitis externa is an aggressive, infrequent and invasive infection of the external auditory canal. In some cases it leads to skull base compromise, particularly in immunocompromised individuals, including HIV-positive patients. Ecthyma gangrenosum is an unusual, localized cutaneous infection, caused mostly by Pseudomonas aeruginosa, with systemic compromise and a torpid evolution. An association between these 2 entities is even more rare. We present the case of a 37-year old woman with a history of 10 years’ HIV infection and good adherence to antiretroviral therapy. Although she had an adequate immunological and virological response, she presented at our emergency department in septic shock due to malignant otitis externa with ecthyma gangrenosum and possible haemophagocytic syndrome as a complication, with Pseudomonas aeruginosa determined to be the causative agent.

Ectima gangrenoso en pediatría / Ecthyma gangrenosum in pediatrics

Resumen El ectima gangrenoso es una infección poco frecuente de la piel, conocida con una característica lesión causada principalmente por la Pseudomoma aeruginosa, pero que también se puede presentar por otro tipo de bacterias del tipo Staphylococcus aureus o el Streptococcus beta hemolítico del grupo A ( S. beta hemolítico del grupo A), entre otros. Esta entidad se asocia frecuentemente con inmunodeficiencias primarias y secundarias. Las lesiones, clínicamente, se presentan como máculas eritematovioláceas, descamativas que rápidamente evolucionan a papulovesículas, ampollas hemorrágicas y costrosas que dejan unas úlceras profundas en sacabocado con fondo necrótico. La mortalidad es alta, entre 40 y 75% de los individuos inmunológicamente comprometidos. Se describe el caso de una niña de 5 años que inicialmente presentó varicela y luego una sobreinfección por S. aureus ocasionando un cuadro clínico de un ectima gangrenoso; al diagnóstico se llega por la clínica, cultivos y biopsias de piel. Se realizó manejo con aciclovir, clindamicina y cefepime endovenoso, con buena y rápida respuesta de la paciente.

Abstract Ecthyma gangrenosum (EG) is a rare infection of the skin, known as a characteristic lesion caused by Pseudomoma aeruginosa , but also can occur from other types of bacteria like Staphylococcus aureus or beta hemolytic group, among others. This condition is often associated with primary and secondary immunodeficiencies. The lesions present clinically as scaly, erythematous violacious macules that rapidly evolve into papule-vesicles, bleeding and crusty blisters leaving a deep punch ulcer with a necrotic base. Mortality is high, between 40% and 75% of immunologically compromised individuals. We describe the case of a girl of 5 years of age who initially presented chickenpox and then superinfection with Staphylococcus aureus, causing a clinical picture of EG. The diagnosis was reached based on symptoms, cultures and skin biopsies. Management was achieved with acyclovir, intravenous clindamycin and cefepime, with a good and quick response by the patient.

Ecthyma Gangrenosum Caused by Klebsiella Pneumoniae in Immunocompromised Patient Associated with Severe Aplastic Anemia / 임상소아혈액종양

Ecthyma gangrenosum (EG) is a skin infection that is classically associated with Pseudomonas aeruginosa septicemia in immunocompromised patients with severe neutropenia. Other bacterial, viral, and fungal pathogens also have been implicated in EG. EG is rare condition with characteristic clinical appearance of red macule that progresses to a central area presenting a necrotic black or gray-black eschar with surrounding erythema. The skin lesions usually occur in the gluteal and perineal regions or extremities and widespread over the body. Although the usual outcome is poor, early recognition and appropriate systemic antibiotic treatment can lead to successful outcome. Therefore, we describe a case of EG associated with Klebsiella pneimoniae in a 15-year-old patient with severe aplastic anemia and review the literature.

Multiple Ecthyma Gangrenosum in a Hemophagocytic Lymphohistiocytosis Patient / 대한피부과학회지

No abstract available.

Ecthyma Gangrenosum Caused by Klebsiella Pneumoniae in Immunocompromised Patient Associated with Severe Aplastic Anemia / 임상소아혈액종양

Ecthyma gangrenosum (EG) is a skin infection that is classically associated with Pseudomonas aeruginosa septicemia in immunocompromised patients with severe neutropenia. Other bacterial, viral, and fungal pathogens also have been implicated in EG. EG is rare condition with characteristic clinical appearance of red macule that progresses to a central area presenting a necrotic black or gray-black eschar with surrounding erythema. The skin lesions usually occur in the gluteal and perineal regions or extremities and widespread over the body. Although the usual outcome is poor, early recognition and appropriate systemic antibiotic treatment can lead to successful outcome. Therefore, we describe a case of EG associated with Klebsiella pneimoniae in a 15-year-old patient with severe aplastic anemia and review the literature.

The significance of ecthyma gangrenosum in early diagnosis of pseudomonas aeruginosa sepsis in chidren / 中国小儿急救医学

Objective To summarize the characteristics of ecthyma gangrenosum and explore its significance in early diagnosis of pseudomonas aeruginosa sepsis in children.Methods We retrospectively reviewed the medical records of 11 children with ecthyma gangrenosum who were hospitalized at Guangzhou women and children's medical center between May 2008 and Apr 2011.Results Eight cases were male and 7 were less than twelve months,the oldest was 2 years old,all of them were diagnosed as Pseudomonas aeruginosa spesis.Two patients had a single lesion,and the others had multiple lesions.Ecthyma gangrenosum located on the trunks in 7 cases,on anogenital areas in 5 cases,on extremities in 5 cases and on faces in 3.The lesions appeared on day 2 to day 10.On average,they developed on day 5.Seven patients developed ecthyma gangrenosum before admission,the course of the illness before admission was 6 days.Fever and multiple organ dysfunction occurred in all the patients and their cultures grew pseudomonas aeruginosa,blood cultures were positive in 8 cases,the others were isolated psudomonas aeruginosa from tissue of the lesion,discharge,ascites,pleural effusion,respectively.The time of ecthyma gangrenosum appeared was earlier than the time of the culture results reported.All of the patients were started empiric antibiotics therapy on admission,the initial antibiotic regimen was appropriate in 9 patients,8 needed surgical intervention,4 were treated with continuous blood purification.Ten patients survived and 2 died,the hospital stay was from 1 to 63 days,the average was 30.Conclusion Ecthyma gangrenosum is a known cutaneous manifestation of pseudomonas aeruginosa sepsis,which is helpful for early diagnosis and treatment,and then the outcome will be improved.

Sepsis por Pseudomonas aeruginosa en un lactante previamente sano / Sepsis due to Pseudomonas aeruginosa in a previously healthy infant

Pseudomonas aeruginosa, is an opportunistic organism widely distributed in both environmental and nosocomial settings. Invasive infections typically occur in immunocompromised patients, but this agent can also produce sepsis in the immunocompetent host. We report the case of an 8 months old infant, previous healthy, who presented septic shock by P. aeruginosa. Lesions of ecthyma gangrenosum in his limbs required surgical debridement. The patient presented transitory neutropenia and reduced C4 levels but subsequent study of immune defects was normal.

Pseudomonas aeruginosa es un microorganismo oportunista de amplia distribución ambiental y nosocomial. Las infecciones invasoras se producen generalmente en pacientes inmunocomprometidos; sin embargo, este agente ocasionalmente puede ser causa de sepsis en pacientes inmunocompetentes. Presentamos el caso de un lactante de 8 meses de edad, sin antecedentes médicos, que cursó con un shock séptico por P. aeruginosa. Durante su evolución presentó lesiones de ectima gangrenoso en sus cuatro extremidades, que requirieron múltiples desbridamientos quirúrgicos. En el período agudo presentó neutropenia y complemento C4 bajo, que normalizó posteriormente. El estudio de inmunidad para descartar inmunodeficiencia fue normal.

Ecthyma Gangrenosum: A Rare Cutaneous Manifestation Caused by Stenotrophomonas maltophilia in a Leukemic Patient

Ecthyma gangrenosum (EG) is a well-recognized cutaneous infection that most commonly affects immunocompromised patients. It typically occurs on the extremities, or in gluteal and perineal regions. Although Pseudomonas aeruginosa is the most well-known pathogen causing EG, other organisms have been reported to cause EG. Herein we report a rare case of ecthyma gangrenosum presenting as aggressive necrotic skin lesions in perioral and infraorbital areas in a 47-year-old patient with acute myelocytic leukemia after allogeneic bone marrow transplantation. It was caused by Stenotrophomonas maltophilia, which is an aerobic, gram-negative pathogen that has been associated only rarely with cutaneous disease. Blood culture and tissue culture were positive for S. maltophilia. Histological examination revealed numerous tiny bacilli in the dermis and perivascular area. Early recognition of skin lesions caused by S. maltophilia is important to decrease associated mortality in immunosuppressed patients.

Ectima gangrenoso en niño sano sin septicemia / Ecthyma gangrenosum in a healthy child without septicemia

El ectima gangrenoso es una manifestación cutánea de infección por Pseudomonas que lleva a confusión diagnóstica y que puede tener consecuencias devastadoras para el paciente y aun llevarlo a la muerte. Se presenta el caso de un niño sano de 2 meses de edad con aparición de lesiones en el 5º dedo del pie sin compromiso sistémico que correspondía a ectima gangrenoso por P. aeruginosa, diagnosticado por lámpara de Wood y a la buena y rápida respuesta del paciente al tratamiento antibiótico específico. Este caso es típico de la variedad localizada, sin neutropenia y sin septicemia, que se puede observar en pacientes sanos.

Ecthyma gangrenosum is a cutaneous manifestation of Pseudomonas infection that confusing to diagnose due to similarities with other pathologies and that can have devastating consequences for the patient and even cause death. A case of a healthy infant with lesions in the 5th toe without systemic compromise corresponding to ecthyma gangrenosum caused by P. aeruginosa, diagnosed by Wood lamp and the patient’s good fast answer to the specific antibiotic treatment. This case is typical of the local variety without neutropenia nor septicemia, as observed in healthy patients.

A Case of Ecthyma Gangrenosum Associated with Liver Abscess and Renal Abscess / 대한피부과학회지

Ecthyma gangrenosum is usually seen in the immunocompromised patients or in the patients with underlying malignancy. Ecthyma gangrenosum is a rapidly progressing skin infection characterized by edema, hemorrhage, bullae and necrosis. We experienced the case of a 13-month-old male who had ecthyma gangrenosum associated with liver absess and renal abscess. The patient initially presented with skin lesions of multiple well defined central necrotic black colored large erythematous bullae. The multiple liver abscess with hepatomegaly and multifocal pyelonephritis with focal renal abscess revealed by abdominal ultrasonogram and computed tomogram. In the bacterial cultures of skin, urine and liver aspiration fluid, Pseudomonas aeruginosa was grown. The patient had no immune deficiency disease. We report this case with a review of related literatures.

A Case of Ecthyma Gangrenosum Associated with Liver Abscess / 대한피부과학회지

Ecthyma Gangrenosum is a rapidly progressing skin infection charact,erized by edema, hemorragic bullae and necrosis. Ecthyma Gangrenosum occurs almost exclusively in severely imrnunocompromised patients during the course of pseudomanas aeruginosa septisemia. A 5 month-old boy was transferred to our department because of multiple well defined central necrotic black-colored large erythematous bullae. In the bacterial cultures of skin, stool and liver aspiration fluid, Pseudomonas aeruginosa was grown. In the abdominal ultrasonogram and computed tomogram, the multiple liver abscess, hepatomegaly and ascites were shown on both hepatic lobes. Herein we report a case of ecthyma gangrenosum associated with liver abscess.

Ecthyma gangrenosum associated with aplastic anemia

Ecthyma gangrenosum is a characteristic skin lesion of systemic infection due to Pseudomonas aeruginosa. It has a high incidence in patients with chronic disease and impaired defense mechanisms. Early diagnosis and appropriate systemic antibiotic therapy is crucial since its mortality rate is very high. We report a case of ecthyma gangrenosum in aplastic anemia.