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The Journal of Emergency Medicine, Vol. 43, No. 2, pp. e133–e134, 2012Copyright © 2012 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$–see front matter

http://dx.doi.org/10.1016/j.jemermed.2009.08.035

Visual Diagnosisin Emergency Medicine

ECTHYMA GANGRENOSUM

Fahad Khan, MD and Turandot Saul, MD

Department of Emergency Medicine, Emergency Ultrasound Division, St. Luke’s/Roosevelt Hospital Center, New York, New YorkReprint Address: Turandot Saul, MD, Department of Emergency Medicine, Division of Emergency Ultrasound, St. Luke’s/Roosevelt

Hospital Center, 1000 Tenth Avenue, Room GE-01, New York, NY 10019

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CASE REPORT

A 75-year-old woman with a past medical history ofnon-Hodgkin’s lymphoma presented to the EmergencyDepartment with complaints of fever, chills, and a lesionon her left flank. She had undergone chemotherapy andher last treatment was 10 days before presentation. Threedays before presentation, she had noticed a rash on herleft flank that was neither pruritic nor painful. Vital signswere: blood pressure 95/75 mm Hg, heart rate 98 beats/min, respiratory rate 18 breaths/min, and temperature39.3°C (102.7°F). On physical examination, she was illappearing. On her left flank was a 4-cm area of erythemawith a 1-cm area of hemorrhagic bulla in its center. Itwas not warm or tender and did not blanch when pressurewas applied. There were no other dermatologic findings,and the remainder of the physical examination was un-remarkable. Laboratory analysis was significant for awhite blood cell count of 0.3 K/�L, and the laboratoryreported that there were too few neutrophils to perform adifferential. Blood cultures were drawn, the patient wasplaced in isolation, and intravenous antibiotics and fluidresuscitation were administered. The Dermatology ser-vice was consulted and a biopsy of the skin lesion wastaken. An image of the skin lesion is shown in Figure 1.

DISCUSSION

Diagnosis: Ecthyma Gangrenosum

Ecthyma gangrenosum is found in patients with extremeneutropenia and is most often associated with Pseudomo-

RECEIVED: 17 June 2009; FINAL SUBMISSION RECEIVED: 15

CCEPTED: 30 August 2009

e133

as aeruginosa sepsis. Lesions may occur anywhere onhe body, although the groin, axilla, and anogenital re-ion are the most common areas. The patient will oftenppear toxic, with a high fever.

Ecthyma gangrenosum begins as a painless, round,ell-circumscribed erythematous macule. Over time, the

esion becomes indurated and then, progressively, a hem-rrhagic bulla forms in the center (1). The bulla eventu-lly sloughs off, leaving an ulcerated area behind. Thisrocess occurs rapidly over the course of 12–24 h. It can

t 2009;

Figure 1. Area of erythema with central 1-cm area of hem-orrhagic bullae.

Augus

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e134 F. Khan and T. Saul

be differentiated from pyoderma gangrenosum by theabsence of suppuration (2).

The pathophysiology is thought to occur in the fol-lowing manner. Bacteria, either via hematogenousspread or direct inoculation, invade the walls of thearteries and veins in the dermis, leading to hemorrhageand bulla formation. Eventually, necrotizing vasculitisoccurs (1). Bacteria can be found in both biopsy samples,as well as cultures taken from the base of the ulceration.Blood cultures will often also be positive. Patients withthis lesion should be strongly suspected for Pseudomo-nas bacteremia, and appropriate antibiotic coverageshould be initiated, such as an anti-pseudomonal penicillinwith an aminoglycoside (3). In many cases, surgical de-bridement of the lesion is necessary (4). Recognizing thislesion is especially important because many neutropenicpatients will lack the classic inflammatory features of in-fection that a normal host would manifest (5).

Serratia marcescens, Klebsiella pneumoniae, andscherichia coli, as well as other pseudomonas species,ave been associated with ecthyma gangrenosum (1). It

can also be caused by a variety of fungal and bacterialagents (6). The prognosis is poor for patients presenting

with this disease entity. There is a high mortality rate,

especially when diagnosis and antibiotic therapy isdelayed.

The patient was admitted to the Medicine service.Blood cultures and cultures taken from the base of thelesion grew P. aeruginosa. The patient responded well tofluid resuscitation and intravenous antibiotics, and grad-ually improved. She was discharged home 2 weeks afteradmission.

REFERENCES

1. Weber DJ, Cohen MS, Rutala WA. Mandell, Douglas, and Ben-nett’s principles and practice of infectious diseases, 6th edn. Man-dell GL, Bennett JE, Dolin R, eds. Philadelphia, PA: Elsevier;2005:730–42.

2. Goolamali S, Fogo A, Killian L, et al. Ecthyma gangrenosum: animportant feature of pseudomonas sepsis in a previously well child.Clin Exp Dermatol 2009;34:e180–2.

3. Nicolasora N, Kaul D. Infectious disease emergencies. Med ClinNorth Am 2008;92:427–41.

4. Khalil BA, Baillie CT, Kenny SE, et al. Surgical strategies in themanagement of ecthyma gangrenosum in pediatric oncology pa-tients. Pediatr Surg Int 2008;24:793–97.

5. Doughty CB, Cruz AT, Kaplan SL. A bullous lesion in a neutro-penic adolescent. Pediatr Emerg Care 2009;25:100–1.

6. Sen H, Inangil G, Sahin L, Dere K, Ozkan S, Dagli G. Ecthyma-gangrenosum-like lesions associated with methicillin-resistant

Staphlococcus aureus infection. Int J Infect Dis 2009;13:e173–5.