Ecthyma Gangrenosum in a Patient With Toxic Epidermal Necrolysis

Abstract

Toxic epidermal necrolysis and Stevens-Johnson syndrome are a spectrum of disease characterized by a delayed hypersensitivity reaction that involves the skin and mucous membranes and typically is associated with either recent upper respiratory infection or with certain medications. Ecthyma gangrenosum is a rare necrotizing vasculitis that most commonly affects immunocompromised and burn patients and is often a sequela of Pseudomonas aeruginosa bacteremia. The cutaneous lesions of ecthyma gangrenosum are characterized by an erythematous halo surrounding a dark gray or black nodule. P. aeruginosa preferentially invades the venules, resulting in secondary thrombosis of the arterioles, tissue edema, and separation of the epidermis. Management of ecthyma gangrenosum includes systemic treatment with antipseudomonal antibiotics and débridment of the lesions, as well as improving the patient's immune status if possible. We present a case of a patient admitted to the burn unit for toxic epidermal necrolysis who developed pseudomonal bacteremia with ecthyma gangrenosum.

Ecthyma Gangrenosum: A Rare Cutaneous Manifestation Caused byStenotrophomonas maltophiliain a Leukemic Patient

“…The vesicles, initially filled with serous fluid, appear on the surface of the edematous skin, and then coalesce to form large bullae. The bullae slough away, leaving ulcerated, necrotic centers with erythematous halos 3,13 . The maturation of the lesion is very rapid and often occurs in less than 24 hours as in our patient 11 .…”

“…It most commonly affects immunocompromised and burn patients but it also occurs in the perineal area of healthy infants after antibiotic therapy in conjunction with maceration of the diaper area 1,3 . The skin lesions of ecthyma gangrenosum are the manifes-tation of a necrotizing vasculitis 3 .…”

“…It most commonly affects immunocompromised and burn patients but it also occurs in the perineal area of healthy infants after antibiotic therapy in conjunction with maceration of the diaper area 1,3 . The skin lesions of ecthyma gangrenosum are the manifes-tation of a necrotizing vasculitis 3 . The lesion characteristically begins as an erythematous nodule, macule, vesicle, or bullae and evolves into gangrenous ulcerations with black eschar and a surrounding rim of erythema 6,11,12 .…”

“…EG is a rare necrotizing vasculitis 3 and a well recognized manifestation that occurs in debilitated persons who are suffering from leukemia, in severely burned patients, in pancytopenia or neutropenia, and in patients with a functional neutrophilic defect, terminal carcinoma, or other severe chronic diseases 1 . It most commonly affects immunocompromised and burn patients but it also occurs in the perineal area of healthy infants after antibiotic therapy in conjunction with maceration of the diaper area 1,3 .…”

“…It usually occurs as a result of bacteremia or, rarely, as a primary cutaneous lesion. The lesions are present in the gluteal and perineal regions or on the extremities, but they can occur anywhere on the body 1,3,4 . Most cases of ecthyma gangrenosum are associated with Pseudomonas aeruginosa bacteremia 5,6 .…”