Medical Care
Ecthyma gangrenosum (EG) requires prompt diagnosis and treatment with appropriately selected antibiotics for the underlying etiology. If the lesion fails to respond to antimicrobials, surgical debridement of the spreading, necrotic lesion may be required. [27, 28] The presence of EG should alert the physician to the likelihood of pseudomonal bacteremia, and the early implementation of antimicrobial agents is necessary to reduce the high mortality associated with pseudomonal sepsis.
Treatment of EG requires the use of antipseudomonal penicillins, aminoglycosides, fluoroquinolones, third-generation cephalosporins, or aztreonam. While awaiting results, an antipseudomonal penicillin (piperacillin) should be used in conjunction with an aminoglycoside (gentamicin). Further adjustment of antibiotics may be required after sensitivity results are known. Granulocyte-macrophage colony-stimulating factor may also be administered to patients with severe leukopenia and ecthyma gangrenosum to aid in recovery. [29]
Systemic antifungal coverage should be considered if fungemia is suspected, including coverage against Aspergillus, Candida, and Mucor species with azole agents (eg, voriconazole, fluconazole) and/or amphotericin B if appropriate.
If empiric antimicrobial and antifungal therapy is used, it must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity results whenever feasible.
Consultations
See the list below:
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Dermatologist - For evaluation of cutaneous lesions
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Infectious disease specialist - For evaluation and treatment of infection
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Internist or pediatrician - For evaluation of possible immunocompromised states
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General surgeon - For evaluation of possible surgical excision of lesions that failed to respond to antibiotics
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Violaceous plaques and necrotic ulcers on the abdomen of a renal transplant patient. Tissue cultures were positive for Pseudomonas aeruginosa.
