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CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 4  |  Page : 313-315

Ecthyma gangrenosum in a neonate


1 Department of Pediatrics, Shree Guru Gobind Singh Tricentenary Medical College and Hospital, Gurugram, Haryana, India
2 Department of Pediatrics, North Delhi Municipal Corporation Medical College, Delhi, India
3 Department of Dermatology, Shree Guru Gobind Singh Tricentenary Medical College and Hospital, Gurugram, Haryana, India

Date of Submission04-Jan-2020
Date of Decision05-Feb-2020
Date of Acceptance06-May-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Himani Bhasin
Department of Pediatrics, North Delhi Municipal Corporation Medical College, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_132_19

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  Abstract 


Ecthyma gangrenosum (EG) is pathognomonic of invasive Pseudomonas infection or septicemia. It is characterized by pustules that rapidly evolve into hemorrhagic blister with central necrosis with the surrounding erythema. It is more often seen in immunocompromised patients but can be seen in healthy neonate also. We report the case of a 4-day-old neonate presenting with Pseudomonas bacteremia and EG.

Keywords: Ecthyma gangrenosum, eschar, necrotic ulcer, Pseudomonas


How to cite this article:
Sahoo B, Bhasin H, Ganjoo S, Abrol P. Ecthyma gangrenosum in a neonate. Indian J Paediatr Dermatol 2020;21:313-5

How to cite this URL:
Sahoo B, Bhasin H, Ganjoo S, Abrol P. Ecthyma gangrenosum in a neonate. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Oct 19];21:313-5. Available from: https://www.ijpd.in/text.asp?2020/21/4/313/296847




  Introduction Top


Ecthyma gangrenosum (EG) is a well-known cutaneous manifestation of severe, invasive infection by Pseudomonas aeruginosa. The characteristic lesions of EG are hemorrhagic pustules that evolve into necrotic punched-out gangrenous ulcers with black–gray eschar. It is usually seen in immunocompromised and critically ill patients. However, there are isolated reports of its occurrence in normal healthy individuals.[1],[2],[3] Here, we report the development of EG in a normal neonate.


  Case Report Top


A 4-day-old term male neonate with a birth weight of 2.6 kg, delivered through normal vaginal delivery, presented with the complaints of multiple skin lesions that began on the 2nd postnatal day, associated with fever and decreased oral acceptance since the 3rd day of life. Initially, red macules developed over the inguinal and perineal region with subsequent ulceration over the next 3–4 days. Similar lesions developed on the abdomen, face, and left eyelid.

The skin lesions were associated with continuous low-grade fever and lethargy. There was a history of redness around the umbilicus without any discharge. There was no history of burns, drug intake, catheterization, or diarrhea. The mother was admitted in the intensive care unit for puerperal sepsis and had urinary tract infection.

On examination, the baby was of term gestational age, weighing 2480 g. The baby was lethargic, hyperthemic (core temperature 101°F), tachypneic (respiratory rate 64/min), and not accepting feeds. Bilateral inguinal region showed multiple, well-defined, punched-out gangrenous ulcers with raised erythematous borders and central black eschar. The largest lesion was seen at the left groin measuring 3 cm × 2 cm, erythematous and necrotic with central eschar. Similar lesions were present over the abdomen and face. Induration was present around the umbilicus [Figure 1]a, [Figure 1]b, [Figure 2] and [Figure 3].
Figure 1: (a and b) Multiple deep ulcerations with necrosis and surrounding halo on the perianal area and perineum

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Figure 2: Necrotic ulcer on the abdomen

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Figure 3: Necrotic ulcer on the face

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On investigation, hemoglobin was 18.2 g/dl and total leukocyte count was 20,000/mm 3, with absolute neutrophil count of 9200/mm 3 and thrombocytopenia (platelets = 45000/mm 3). Peripheral smear showed toxic granulations and band forms. Quantitative C-reactive protein was 68 mg/L. 15–20 red blood cells/high-power field were seen in the suprapubic urine sample. Coagulation profile was deranged (international normalized ratio – 1.7). Chest radiography, TORCH profile, and cerebrospinal fluid examination were normal. HIV infection was ruled out by enzyme-linked immunosorbent assay testing of both parents.

Neonate blood culture grew P. aeruginosa. However, culture and Gram staining of discharge from skin lesions did not grow any organism. Urine culture was sterile. Based on the history suggestive of sepsis, typical skin lesions, and blood culture growing P. aeruginosa, the diagnosis of EG associated with Pseudomonas infection was made. Skin biopsy was considered for diagnostic confirmation, but it was deferred by the guardians. Maternal urine culture demonstrated Klebsiella, and her blood culture was sterile.

At our hospital, on admission, the child was started empirically on cefotaxime and amikacin. Based on pus culture report, antibiotics were upgraded to meropenem and vancomycin. Wound dressings were done daily along with the application of local antibiotics (mupirocin) and silver sulfadiazine. Fresh frozen plasma and platelet transfusion was given. During the course of treatment, fever subsided, the lesions started healing, and no new lesions were seen [Figure 4]. Antibiotic therapy was given for 14 days, and the neonate was discharged on supplements with follow-up ensured in the newborn high-risk clinic after 1 week. On follow-up, there was a great improvement of the skin lesions by 2 weeks and clearing by 4 weeks.
Figure 4: Healing skin lesions on the face, abdomen, and thighs during follow-up

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  Discussion Top


EG is a known but uncommon skin manifestation of invasive Pseudomonas infection. In 1897, Baker first described EG in association with Pseudomonas septicemia and was later given the name “ecthyma gangrenosum” by Hitschmann and Kreibich.[4] Other organisms implicated in similar lesions include  Escherichia More Details coli, Aeromonas, Citrobacter freundii, Corynebacterium diphtheriae, Klebsiella pneumoniae,  Neisseria More Details gonorrhoeae, Staphylococcus aureus, Streptococcus pyogenes, and  Yersinia More Details pestis, and fungi such as Aspergillus fumigatus, Candida albicans, and herpes simplex virus.[3]

Initially, the lesions begin as painless, erythematous macules in the skin, which rapidly become pustular with surrounding redness and induration. Subsequently, a hemorrhagic focus appears at the center of the lesion, forming a bulla, and as the bulla spreads laterally, it evolves into a gangrenous ulcer with a black scab or eschar surrounded by a red halo.[3],[5] These lesions may be single or multiple.

EG may appear at any site in the body, but commonly affected sites are anogenital area and armpits. The arms and legs, trunk, and face are less often involved.[3]

In the present case, the lesions were distributed just below the inguinal area in the medial part of the thigh, abdomen, and face [Figure 1] and [Figure 2].

Diagnosis is made by demonstrating the organism on Gram stain of fluid from the central hemorrhagic pustule or blister, blood culture, skin biopsy, or tissue cultures. If there is no discharge, then the swab should be taken from underneath of the scab. Skin biopsy shows vascular necrosis with few inflammatory cells and surrounding bacteria. Management includes administration of appropriate antibiotics. As there is high likelihood of EG being associated with Pseudomonas septicemia, antipseudomonal antibiotics (such as piperacillin tazobactam and third-generation cephalosporins) are empirically started. Subsequently, antibiotics are modified as per culture reports and sensitivity of isolated organism.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huminer D, Siegman-Igra Y, Morduchowicz G, Pitlik SD. Ecthyma gangrenosum without bacteremia. Report of six cases and review of the literature. Arch Intern Med 1987;147:299-301.  Back to cited text no. 1
    
2.
Foca MD. Pseudomonas aeruginosa infections in the neonatal intensive care unit. Semin Perinatol 2002;26:332-9.  Back to cited text no. 2
    
3.
Patel JK, Perez OA, Viera MH, Halem M, Berman B. Ecthyma gangrenosum caused by Escherichia coli bacteremia: A case report and review of the literature. Cutis 2009;84:261-7.  Back to cited text no. 3
    
4.
Vaiman M, Lazarovitch T, Heller L, Lotan G. Ecthyma gangrenosum and ecthyma-like lesions: Review article. Eur J Clin Microbiol Infect Dis 2015;34:633-9.  Back to cited text no. 4
    
5.
Dorff GJ, Geimer NF, Rosenthal DR, Rytel MW. Pseudomonas septicemia. Illustrated evolution of its skin lesion. Arch Intern Med 1971;128:591-5.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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