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Abstract
IntroductionEcthyma gangrenosum (EG) is a cutaneous lesion commonly caused by Pseudomonas aeruginosa that involves mainly the lower limbs and gluteal region, seen more in immunosuppressed patients with neutropenia. Cancrum oris (Noma) is a gangrenous necrosis of the face that begins as a gingival ulcer and progresses rapidly to destroy contiguous tissues in malnourished children.Case PresentationThis article reports a case of facial EG which was similar to Noma in a malnourished child: a 16-month old girl with fever, cough, weight loss, watery stool and swelling on right cheek. She was febrile, pale, wasted with bilateral pitting pedal oedema. She had a solitary circumscribed round necrotic lesion, with surrounding hyperaemia on the right malar area which extended to destroy the right ala nasi. No intra-oral rashes but she had left ear discharge. She received blood transfusion, antibiotics, antiseptic wound care and nutritional rehabilitation.Management and OutcomeSwabs of the lesion and ear discharge both revealed Gram-negative bacilli and culture yielded P. aeruginosa. Retroviral, Mantoux and Gene Xpert tests were negative. She had moderate anaemia, normal white blood cell count, and neutropaenia. Parenteral ceftriazone was changed to ciprofloxacin based on sensitivity results and lack of clinical response. The wound healed with residual scarring and partial destruction of right ala nasi.DiscussionAlthough this patient had facial necrosis to suggest Noma, she did not have initial oral involvement, and clinical features such as Pseudomonas sepsis and neutropaenia suggested EG. Facial necrosis in malnourished children may be due to EG.
Highlights
Ecthyma gangrenosum (EG) is a cutaneous lesion commonly caused by Pseudomonas aeruginosa that involves mainly the lower limbs and gluteal region, seen more in immunosuppressed patients with neutropenia
We report the case to highlight that a necrotic facial ulcer presenting in a malnourished child may be EG and may mimic orofacial gangrene of Noma if not aggressively managed
This progression is because the bacteria invades the walls of the dermal and subdermal vessels leading to vascular damage and interruption of blood supply to the skin causing necrosis of the skin with eschar and ulcer formation.[17]
Summary
Ecthyma gangrenosum (EG) is a cutaneous lesion commonly caused by Pseudomonas aeruginosa,[1,2] though it has been associated with other bacterial, viral and fungal aetiological agents.[3,4,5] It occurs commonly in immunosuppression of various causes and is associated with neutropaenia.[6]. Aetiology is usually polymicrobial by opportunistic organisms related to malnutrition and immune dysfunction.[14] Some writers have described Noma-like necro-ulcerative lesions involving the face for which, if diagnosed early, intensive therapy may limit progression and confer better prognosis.[15]. We highlight a case of a malnourished child who presented with a necrotic ulcer involving the face which was similar to Noma but, on further review of the evolution of the ulcer http://www.ajlmonline.org. We report the case to highlight that a necrotic facial ulcer presenting in a malnourished child may be EG and may mimic orofacial gangrene of Noma if not aggressively managed
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