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Ecthyma Gangrenosum Clinical Presentation

  • Author: Mina Yassaee Kingsbery, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Nov 18, 2015
 

History

Ecthyma gangrenosum (EG) typically occurs in patients who are immunocompromised, including patients with hematologic malignancies, immunodeficiency syndromes, severe burns, malnutrition, recent chemotherapy, immunosuppressive therapy, and diabetes mellitus. While a few case reports describe the development of EG in previously healthy children, most of these patients had unrecognized risk factors for the development of EG, including intra-abdominal or appendiceal abscesses, recent viral illness such as influenza B leading to a transient severe neutropenia,[4] or antibiotic treatment for underlying medical conditions such as hypogammaglobulinemia and neutropenia.

Two reports describe toxic epidermal necrolysis followed by EG, one in a 62-year-old woman and the other in a 3-year-old boy.[5, 6]

Breakdown of mechanical defense barriers increases susceptibility to pseudomonal or fungal infections. Pseudomonas sepsis frequently occurs after surgical procedures, especially urologic procedures. Long-term indwelling urinary catheters, long-term intravenous placements, and tracheostomies have been associated with EG.

In several reported cases, patients with EG were on prolonged antibiotic therapy targeting non-Pseudomonas organisms. This may have led to elimination of normal flora and promoted Pseudomonas overgrowth.

Children with EG may develop diarrhea (30%) before the onset of cutaneous lesions.

Patients often present with fever a few days prior to developing EG.

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Physical

Primary lesions

Primary cutaneous lesions of ecthyma gangrenosum (EG) initially appear as painless round erythematous macules that rapidly become pustular with surrounding erythema. A hemorrhagic focus appears in the center, forming a bulla. As the hemorrhagic bulla spreads peripherally, it evolves into a gangrenous ulcer with a central black/gray eschar surrounded by an erythematous halo. The transformation of an early lesion to a necrotic ulcer may occur in as little as 12 hours.

Distribution of lesions

The patient may have a single lesion or multiple lesions. EG may appear at any location on the body; however, it predominately affects the anogenital and axillary areas. Distribution occurs at the following frequencies: gluteal or perineal region (57%), extremities (30%), trunk (6%), and face (6%); bilateral periorbital manifestations are rare but have been reported.[7, 8]

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Causes

Ecthyma gangrenosum (EG) is typically and most commonly caused by P aeruginosa; however, EG-like lesions have been observed in patients with other bacterial and fungal infections.[9] Organisms that cause ecthyma and EG-like lesions include the following:

Gram-positive bacteria are as follows:

  • Staphylococcus aureus
  • Streptococcus pyogenes

Gram-negative bacteria are as follows:

  • Aeromonas hydrophila
  • Burkholderia cepacia [10]
  • Chromobacterium violaceum [11]
  • Citrobacter freundii
  • Corynebacterium diphtheriae
  • Escherichia coli
  • Klebsiella pneumoniae
  • Morganella morganii [12]
  • Neisseria gonorrhea
  • Pseudomonas aeruginosa
  • Pseudomonas stutzeri
  • Serratia marcescens
  • Vibrio vulnificus
  • Yersinia pestis
  • Xanthomonas maltophilia

Fungi are as follows:

  • Aspergillus fumigatus
  • Candida albicans [13]
  • Curvularia species [14]
  • Exserohilum species
  • Fusarium solani [15]
  • Mucor and Rhizopus species
  • Pseudallescheria boydii [14]
  • Scytalidium dimidiatum

Viral causes include herpes simplex virus[16]

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Contributor Information and Disclosures
Author

Mina Yassaee Kingsbery, MD Co-Chief Resident, Department of Dermatology, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons

Mina Yassaee Kingsbery, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

Sarina Berger Elmariah, MD, PhD Resident Physician, Robert O Perelman Department of Dermatology, New York University School of Medicine

Sarina Berger Elmariah, MD, PhD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Frederick Fish, MD Director, Department of Dermatology and Cutaneous Surgery, St Paul Ramsey Medical Center; Associate Clinical Professor, Department of Dermatology, University of Minnesota

Frederick Fish, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physicians, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Dermatopathology, Pacific Dermatologic Association, and Sigma Xi

Disclosure: Nothing to disclose.

Nobuyoshi Kageyama, MD Resident Physician, Assistant Clinical Professor of Dermatology, Department of Dermatology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Disclosure: Nothing to disclose.

Ravi Ubriani, MD Assistant Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Disclosure: Nothing to disclose.

References
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  2. Yan W, Li W, Mu C, Wang L. Ecthyma gangrenosum and multiple nodules: cutaneous manifestations of Pseudomonas aeruginosa sepsis in a previously healthy infant. Pediatr Dermatol. 2011 Mar-Apr. 28(2):204-5. [Medline].

  3. Prindaville B, Nopper AJ, Lawrence H, Horii KA. Chronic granulomatous disease presenting with ecthyma gangrenosum in a neonate. J Am Acad Dermatol. 2014 Aug. 71(2):e44-5. [Medline].

  4. Koo SH, Lee JH, Shin H, Lee JI. Ecthyma gangrenosum in a previously healthy infant. Arch Plast Surg. 2012 Nov. 39(6):673-5. [Medline]. [Full Text].

  5. Downey DM, O'Bryan MC, Burdette SD, Michael JR, Saxe JM. Ecthyma gangrenosum in a patient with toxic epidermal necrolysis. J Burn Care Res. 2007 Jan-Feb. 28(1):198-202. [Medline].

  6. Gresik CM, Brewster LP, Abood G, Supple KG, Silver GM, Gamelli RL, et al. Ecthyma gangrenosum following toxic epidermal necrolysis syndrome in a 3-year-old boy-a survivable series of events. J Burn Care Res. 2008 May-Jun. 29(3):555-8. [Medline].

  7. Ghosheh FR, Kathuria SS. Bilateral periorbital ecthyma gangrenosum. Ophthal Plast Reconstr Surg. 2006 Nov-Dec. 22(6):492-3. [Medline].

  8. Inamadar AC, Palit A, Athanikar SB, Sampagavi VV, Deshmukh NS. Periocular ecthyma gangrenosum in a diabetic patient. Br J Dermatol. 2003 Apr. 148(4):821. [Medline].

  9. Reich HL, Williams Fadeyi D, Naik NS, Honig PJ, Yan AC. Nonpseudomonal ecthyma gangrenosum. J Am Acad Dermatol. 2004 May. 50(5 Suppl):S114-7. [Medline].

  10. Aygencel G, Dizbay M, Sahin G. Burkholderia cepacia as a Cause of Ecthyma Gangrenosum-like Lesion. Infection. 2008 Jun. 36(3):271-3. [Medline].

  11. Brown KL, Stein A, Morrell DS. Ecthyma gangrenosum and septic shock syndrome secondary to Chromobacterium violaceum. J Am Acad Dermatol. 2006 May. 54(5 Suppl):S224-8. [Medline].

  12. Del Pozo J, García-Silva J, Almagro M, Martínez W, Nicolas R, Fonseca E. Ecthyma gangrenosum-like eruption associated with Morganella morganii infection. Br J Dermatol. 1998 Sep. 139(3):520-1. [Medline].

  13. Leslie KS, McCann BG, Levell NJ. Candidal ecthyma gangrenosum in a patient with malnutrition. Br J Dermatol. 2005 Oct. 153(4):847-8. [Medline].

  14. Bonduel M, Santos P, Turienzo CF, Chantada G, Paganini H. Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation. Bone Marrow Transplant. 2001 Jun. 27(12):1311-3. [Medline].

  15. Fergie JE, Huang DB, Purcell K, Milligan T. Successful treatment of Fusarium solani ecthyma gangrenosum in a child with acute lymphoblastic leukemia in relapse. Pediatr Infect Dis J. 2000 Jun. 19(6):579-81. [Medline].

  16. Kimyai-Asadi A, Tausk FA, Nousari HC. Ecthyma secondary to herpes simplex virus infection. Clin Infect Dis. 1999 Aug. 29(2):454-5. [Medline].

  17. Kim JS, Ricafort R, Garfein ES, Levin TL. Imaging findings of ecthyma gangrenosum, an unusual complication of pseudomonas sepsis. HSS J. 2011 Oct. 7(3):279-81. [Medline]. [Full Text].

  18. Halpern AV and WR Heymann. Bacterial Diseases. Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. Spain: Elsevier Limited; 2008. Vol 1: Ch 73.

  19. Craigie RJ, Ahmed S, Mullassery D, Panarese A, Caswell M, Kenny SE. A spot that can kill. Lancet. 2007 May 5. 369(9572):1540. [Medline].

  20. Khalil BA, Baillie CT, Kenny SE, Lamont GL, Turnock RR, Pizer BL, et al. Surgical strategies in the management of ecthyma gangrenosum in paediatric oncology patients. Pediatr Surg Int. 2008 Jul. 24(7):793-797. [Medline].

  21. Gregorini M, Castello M, Rampino T, Bosio F, Bedino G, Esposito P, et al. GM-CSF contributes to prompt healing of ecthyma gangrenosum lesions in kidney transplant recipient. J Nephrol. 2012 Jan-Feb. 25(1):137-9. [Medline].

 
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