|Year : 2020 | Volume
| Issue : 4 | Page : 313-315
Ecthyma gangrenosum in a neonate
Bishnupriya Sahoo1, Himani Bhasin2, Shikhar Ganjoo3, Pankaj Abrol1
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 Submission||04-Jan-2020|
|Date of Decision||05-Feb-2020|
|Date of Acceptance||06-May-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Himani Bhasin
Department of Pediatrics, North Delhi Municipal Corporation Medical College, Delhi
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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.,, Here, we report the development of EG in a normal neonate.
| Case Report|| |
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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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|| |
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. 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.
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., 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.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]