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Ecthyma Gangrenosum Workup

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

Laboratory Studies

See the list below:

  • Gram stain: A Gram stain of fluid from the central hemorrhagic pustule or bulla can rapidly indicate the diagnosis. If no fluid is present, the eschar should be elevated and the underlying tissue swabbed for a Gram stain.
  • Blood cultures: Two specimens should be collected prior to initiating antibiotic therapy. The optimal time of collection is during temperature spikes. Sensitivity studies should be performed on isolated organisms.
  • Urine culture
  • Skin biopsy: One 4- to 5-mm deep skin biopsy specimen should be obtained and placed in formalin fixative. Specimens should be stained with tissue Gram stain in addition to standard hematoxylin and eosin. Staining with special stains (eg, periodic acid-Schiff, methamine silver, Fite stains) should be performed to rule out other organisms that may cause ecthyma gangrenosum (EG)–like lesions.
  • Tissue cultures: A second skin biopsy specimen should be placed in a sterile container for tissue culture. Specimens should be tested for bacteria, fungus, yeast, and mycobacteria. Preservative-free anesthetics and saline should be used for the procedure. Sensitivity studies should be performed on isolated organisms.
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Imaging Studies

In a confirmed diagnosis of ecthyma gangrenosum (EG) of the plantar foot, magnetic resonance imaging (MRI) showed edema of the skin, subcutaneous fat, deep and superficial fascia, and plantar muscles. The postcontrast fat-suppressed images showed a geographic pattern of absent enhancement, which was consistent with muscle ischemia and/or necrosis. Deep fascial enhancement was absent; this is in contrast to necrotizing fasciitis, which on MRI demonstrates fascial enhancement after contrast administration.[17]

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Histologic Findings

Skin biopsy specimens of ecthyma gangrenosum (EG) lesions show a necrotizing hemorrhagic vasculitis with few inflammatory cells but many surrounding bacilli. In sections stained with Gram stain, gram-negative rods are numerous in the media and adventitia of the necrotic vessels, but typically spare the intima.[18] Extravasation of blood, edema, and necrosis are seen around the involved vessels.

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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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  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].

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  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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