Acute Dyspnea In Emergency Department Research Articles

Diagnostic Utility of NT-Pro BNP in Elderly Patients Presenting With Acute Dyspnea in Emergency Department

ABSTRACT
 BACKGROUND: Acute dyspnea may be related to lungs pathology or cardiac pathology or due to involvement of both. Rapid diagnosis of the cause of dyspnea in emergency can help in early start of treatment preventing further progress of the symptoms, prolong hospital stay, need of more invasive medical procedures like intubation and ventilation thereby decrease the morbidity and mortality of the patients.
 METHODOLOGY: The study was conducted for three months i.e, from 16th May 2023 till 17th August 2023. 150 patients fulfilling inclusion criteria were taken. Clinical diagnosis in these patients was established based on medical history as well as echo and chest X-ray. Based on their clinical diagnosis, the patients were divided into three groups: group A diagnosed with pulmonary dyspnea (PD), group B diagnosed with congestive heart failure (CHF), and group C diagnosed with combined dyspnea (CHF+PD). NT-proBNP level in these patients was measured and compared.
 RESULTS: The study population constituted 60% males and 40% female with mean age of 68.9±10.99. Out of 150 patients presenting with acute dyspnea in emergency department, 65 patients were diagnosed with congestive heart failure, 55 patients were diagnosed with pulmonary dyspnea and 30 patients diagnosed with combined dyspnea. Average NT-proBNP among group A patients was (1300±175) ng/l, among group B patients was (275±70) ng/l and among group C patients was (1276±165) ng/l.
 CONCLUSION: NT-proBNP is the reliable marker to differentiate the cardiac and pulmonary causes of acute dyspnea among elderly patients presenting to emergency.
 
 KEY WORDS: N-terminal pro-B-type natriuretic peptide (NT-proBNP), emergency, elderly patients, dyspnea, biomarker

Role of Transthoracic Ultrasound in Patient with Acute Dyspnea in Emergency Department

Role of Transthoracic Ultrasound in Patient with Acute Dyspnea in Emergency Department

Amino acids predict prognosis in patients with acute dyspnea

BackgroundTo identify amino acids that can predict risk of 90-day mortality in patients with acute dyspnea.MethodPlasma levels of nine amino acids were analyzed 663 adult patients admitted to the Emergency Department (ED) with acute dyspnea. Cox proportional hazards models were used to examine the relation between amino acid levels and the risk of 90-day mortality.ResultEighty patients (12.1%) died within 90 days of admission. An “Amino Acid Mortality Risk Score” (AMRS), summing absolute plasma levels of glycine, phenylalanine and valine, demonstrated that among the patients belonging to quartile 1 (Q1) of the AMRS, only 4 patients died, compared to 44 patients in quartile 4. Using Q1 of the AMRS as reference, each increment of 1 SD in the AMRS was associated with a hazard ratio (HR) of 2.15 for 90-day mortality, and the HR was > 9 times higher in Q4.ConclusionGlycine, phenylalanine and valine are associated with a risk of 90-day mortality in patients admitted to the ED for acute dyspnea, suggesting that these amino acids may be useful in risk assessments.

In acute dyspnea with diagnostic uncertainty, ACP suggests POCUS may be added to the standard diagnostic pathway.

Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate use of point-of-care ultrasonography in patients with acute dyspnea in emergency department or inpatient settings: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021;174:985-93. 33900792.

Accuracy of lung ultrasound and chest X-rays in diagnosing acute pulmonary oedema in patients presenting with acute dyspnoea in emergency department.

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Oedema in patients presenting with acute dyspnoea in emergency department, a study was conducted at the emergency department of Shifa International Hospital, Islamabad, from July 31, 2018 to January 31, 2019. A total of 225 patients presenting with dyspnoea and satisfying the inclusion criteria were assessed through clinical examination, lung ultrasound (LUS) and chest X-ray. The results of chest X-ray and lung ultrasound were compared with clinical diagnosis. The study revealed sensitivity of chest X-ray and LUS (60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. The present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of acute pulmonary oedema.

Role of point-of-care ultrasound study in early disposition of patients with undifferentiated acute dyspnea in emergency department: a multi-center prospective study.

Sonography is a safe and simple diagnostic modality which can help emergency physicians in their clinical decision makings and improve the patient disposition process in emergency departments. This prospective multi-center study evaluates the role of bedside ultrasound performed by emergency physicians in accelerating the patient disposition process in cases with acute undifferentiated dyspnea. 103 patients were randomized to "early ultrasound" and "routine assessment" groups. In early ultrasound group, emergency physicians performed bedside ultrasound scans on heart and lungs as soon as possible after triage and randomization. In routine assessment group, ultrasound was used whenever the emergency physician or other consultant services ordered or performed it. Mean randomization-to-diagnosis time was compared in two studied groups. Mean randomization-to-diagnosis time was 79.33 (± 38.90) min in routine assessment and 42.61 (± 19.20) min in early ultrasound groups, showing a statistically significant difference (p value < 0.01). Using early sonography in assessing the patients with undifferentiated acute dyspnea in emergency department decreases the patient turnover time while increasing the diagnostic accuracy.

Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians.

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of point-of-care ultrasonography (POCUS) in patients with acute dyspnea in emergency department (ED) or inpatient settings to improve the diagnostic, treatment, and health outcomes of those with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax. The ACP Clinical Guidelines Committee based this guideline on a systematic review on the benefits, harms, and diagnostic test accuracy of POCUS; patient values and preferences; and costs of POCUS. The systematic review evaluated health outcomes, diagnostic timeliness, treatment decisions, and test accuracy. The critical health, diagnostic, and treatment outcomes evaluated were in-hospital mortality, time to diagnosis, and time to treatment. The important outcomes evaluated were intensive care unit admissions, correctness of diagnosis, disease-specific outcomes, hospital readmissions, length of hospital stay, and quality of life. The critical test accuracy outcomes included false-positive results for suspected pneumonia, pneumothorax, and pulmonary embolism and false-negative results for suspected congestive heart failure, pneumonia, pneumothorax, and pulmonary embolism. Important test accuracy outcomes included false-positive results for suspected congestive heart failure and false-negative and false-positive results for suspected pleural effusion. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. The target audience is all clinicians, and the target patient population is adult patients with acute dyspnea in ED or inpatient settings. ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings (conditional recommendation; low-certainty evidence).

Bedside lung ultrasonography by emergency department residents as an aid for identifying heart failure in patients with acute dyspnea after a 2-h training course

BackgroundUltrasonographic B-lines have recently emerged as a bedside imaging tool for the differential diagnosis of acute dyspnea in the Emergency Department (ED). However, despite its simplicity, LUS has not fully penetrated emergency department. This study aimed to assess the accuracy and reproducibility of ultrasonographic B-lines performed by emergency medicine (EM) residents for the diagnosis of congestive heart failure (CHF) in patients admitted to ED for acute dyspnea.Patients and methodsThis is a cross-sectional prospective study conducted between January 2016 and October 2017 including patients aged over 18 years admitted to ED for acute dyspnea. At admission, two consecutive bedside LUS study were performed by a pair of EM residents who received a 2-h course for recognition of sonographic B-lines to determine independently B-lines score and B-profile pattern. All participating sonographers were blinded to patients’ clinical data. B-lines score ≥ 15 or a B-profile pattern was considered as suggestive of CHF. The final leading diagnosis was assessed by two expert sonographers, who were blinded to the residents’ interpretations, based on clinical findings, chest X-ray, brain natriuretic peptide, cardiac and lung ultrasound testing. Accuracy and agreement of B-lines score and B-profile pattern were calculated.ResultsWe included 700 patients with a mean age of 68 ± 12.6 years and a sex ratio (M/F) of 1.43. The diagnosis of CHF was recorded in 371 patients (53%). The diagnostic performance of B-lines score at a cut-off 15 and B-profile pattern was, respectively, 88% and 82.5% for sensitivity, 75% and 84% for specificity, 80% and 85% for positive predictive value, 84% and 81% for negative predictive value. The area under receiver operating characteristic curve was 0.86 [0.83–0.89] and 0.83 [0.80–0.86], respectively, for B-lines score and B-profile pattern. There was an excellent agreement between residents for the diagnosis of CHF using both scores (kappa = 0.81 and 0.85, respectively, for ordinal scale B-lines score and B-profile pattern).ConclusionLung ultrasound B-lines assessment has a good accuracy and an excellent reproducibility in the diagnosis of CHF in the hand of EM residents following a short training program.Trial registration Name of the registry: clinicaltrials.gov; Trial registration number: NCT03717779; Date of registration: October 24, 2018 ‘Retrospectively registered’; URL of trial registry record: clinicaltrials.gov

Subcutaneous emphysema and pneumomediastinum in child with asthma revealing occult foreign body aspiration: a case report

BackgroundExacerbations of asthma constitute the most common cause of pneumomediastinum and subcutaneous emphysema in children. Foreign body aspiration is a rare cause of pneumomediastinum and subcutaneous emphysema. Foreign body aspiration leading to the occurrence of pneumomediastinum in a child with asthma may go unnoticed and be wrongly attributed to asthma, which leads to delayed diagnosis as well as to life-threatening and long-term complications.Case presentationWe describe a case of a 6-year-old Moroccan boy with asthma who was admitted to our emergency department for acute dyspnea and persistent dry cough. The patient was initially treated as having acute asthma exacerbation. Owing to insufficient clinical and radiographic improvement with asthma treatment, a rigid bronchoscopy under general anesthesia was performed. A pumpkin seed was removed from the left main bronchus. Clinical and radiographic improvement was achieved after foreign body extraction.ConclusionsThis case emphasizes that the possibility of foreign body aspiration should always and carefully be considered by the emergency physician when faced with a child with asthma presenting with pneumomediastinum and subcutaneous emphysema as an important differential diagnosis even in the absence of a history of foreign body aspiration.

Case of a floating right atrial thrombus successfully treated with fibrinolysis

Mobile right atrial thrombi are at high risk of causing massive pulmonary embolism and are a medical emergency. This type of thrombus is identified in about 4-18% of pulmonary embolism cases. The presence of a free-floating embolic mass in right atrial or ventricle is often mortal: the death rate can reach 27%. Although surgery is commonly indicated, fibrinolysis is a therapeutic alternative. Here, a 58-year-old man presented to the emergency department for acute dyspnea associated with a painful right leg. Initial exams showed a shunt effect on blood gases with increased brain natriuretic peptide. Transthoracic echography (TTE) found a free-floating thrombus in the right atrium with signs of pulmonary hypertension and right ventricular dysfunction. Bilateral pulmonary embolism was confirmed by computed tomography angiography. Because there were signs of acute cor pulmonale and no contraindications, treatment with systemic fibrinolysis was decided. The treatment was delivered in intensive care unit and a cardiac surgical team was available. Subsequent clinical improvement was observed. TTE follow up at 12 hours revealed complete thrombus dissolution. There were no complications, in particular no hemorrhage. The patient was discharged after eleven days. At 6 months of follow-up, outcomes with oral anticoagulation therapy were satisfactory. Scintigraphy found good symmetrical perfusion of both lungs with stackable ventilation. TTE at 1 year showed preserved left and right ventricular function with no sign of pulmonary arterial hypertension and no thrombus recurrence. Systemic fibrinolysis appears to be a good alternative to surgery in this case.

Acute dyspnea in Emergency Department: point of care ultrasound in the diagnosis of atrial sarcoma

We describe a rare case of a 65-year-old patient presented to Emergency Department for acute dyspnea. Traditional diagnostic work-up was done and the emergency physician promptly performed a bedside point-of-care ultrasound. A giant mass in the left atrium was detected with impairing of mitral valve function. The patient was then sent to cardiac surgery department with a final diagnosis of high-grade cardiac sarcoma.

A lung ultrasound score for early triage of elderly patients with acute dyspnea.

Lung ultrasound has value in diagnosing dyspnea. The main objective of this study was to evaluate the accuracy of a modified lung ultrasound (MLUS) score to predict the severity of acute dyspnea in elderly patients. This was an observational single-centre study including patients over age 64 admitted to the emergency department for acute dyspnea with hypoxia. Participants had an early lung ultrasound performed by a dedicated emergency physician, followed by the usual care by a team blinded to the lung ultrasound results. Patients were allocated by disposition to either a critical care (CC) group (patients who needed admission to the intensive care unit [ICU] and/or who died within 48 h) or a standard care group. Among 137 patients analysed (mean age 79 ± 13 years, 74 [54%] women), 43 (31%) were categorized into the CC group. The time taken to obtain the MLUS was 30 ± 22 min. The area under the receiver operating characteristic curve of the MLUS for predicting the CC group was 0.97 (0.92-0.99; p &lt; 0.01) with a cut-off set strictly above 17 for 93% sensitivity (81-99), 99% specificity (94-100), a positive predictive value of 98% (87-100), a negative predictive value of 97% (91-99), a positive likelihood ratio of 86, a negative likelihood ratio of 0.07, and a diagnostic accuracy of 97% (93-99). In a multivariate analysis, the MLUS was the only independent associated factor for the CC group. An early lung ultrasound score can predict the need for ICU admission and/or death within 48 hours in elderly dyspneic patients.

Diagnostic and prognostic value of plasma volume status at emergency department admission in dyspneic patients: results from the PARADISE cohort.

Systemic congestion, evaluated by estimated plasma volume status (ePVS), is associated with in-hospital mortality in acute heart failure (AHF). However, the diagnostic and prognostic value of ePVS in patients with acute dyspnea has been insufficiently studied. To assess the association between the first ePVS calculated from blood samples on admission in the emergency department (ED) and discharge diagnosis of AHF and in-hospital mortality in patients admitted for acute dyspnea. The study included 1369 patients admitted for dyspnea in the ED in 2015. ePVS was calculated from hematocrit and hemoglobin values at admission. Comparisons of baseline characteristics according to ePVS tertiles were carried out and then associations between ePVS and the two outcomes "AHF diagnosis" and "intra-hospital mortality" were assessed using a logistic regression model. 36.6% had a BNP > 400pg/mL and median ePVS was 4.58 dL/g [3.96-5.55]. Overall in-hospital mortality was 11.1% (n = 149). In multivariable analysis, the third ePVS tertile (> 5.12 dL/g) had a significantly increased risk of having AHF (OR = 1.64 [1.16-2.33], p = 0.005). In-hospital mortality rose across ePVS tertiles (8.4-13.8% p < 0.01). ePVS greater than the first or second tertile threshold (respectively, 4.17 dL/g and 5.12 dL/g) were both significantly associated with a higher risk of in-hospital mortality (OR for 2nd/3rd tertile = 2.06 [1.25-3.38], p = 0.004 and OR for 3rd tertile = 1.54 [1.01-2.36], p = 0.04). Higher ePVS values determined from first blood sample at admission are associated with a higher probability of AHF and in-hospital mortality in patients admitted in the ED for acute dyspnea.

Acute cardiac dyspnea in the emergency department: diagnostic value of N-terminal prohormone of brain natriuretic peptide and galectin-3.

ObjectiveThis study was performed to determine whether a dual-biomarker approach using N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and galectin-3 optimizes the diagnosis and risk stratification of acute cardiac dyspnea. Atypical clinical manifestations and overlapping pathologies require objective and effective diagnostic methods to avoid treatment delays.MethodsThis prospective observational study included 208 patients who presented to the emergency department for acute dyspnea. NT-proBNP and galectin-3 were measured upon admission. The patients were divided into two groups according to the etiology of their clinical manifestations: cardiac and non-cardiac dyspnea. The patients’ New York Heart Association functional class, left ventricular ejection fraction, and discharge status were assessed.ResultsDiagnostic criteria for acute heart failure were fulfilled in 61.1% of the patients. NT-proBNP and galectin-3 were strongly and significantly correlated. Receiver operating characteristic analysis revealed similar areas under the curve for both markers in the entire group of patients as well as in the high-risk subsets of patients.ConclusionsThe diagnostic performance of NT-proBNP and galectin-3 is comparable for both the total population and high-risk subsets. Galectin-3 adds diagnostic value to the conventional NT-proBNP in patients with acute cardiac dyspnea, and its utility is of major interest in uncertain clinical situations.

Soluble CD146, a new endothelial biomarker of acutely decompensated heart failure

BackgroundThe present study involved both human cohorts and animal experiments to explore the performance of soluble CD146 (sCD146), a marker of endothelial function, as a diagnostic marker of acutely decompensated heart failure (ADHF), to determine the influence of patients' characteristics on that performance and to explore the potential application of CD146 in the pathophysiology of ADHF. Methods and resultsNT-proBNP and sCD146 were measured in three hundred ninety-one patients admitted to the emergency department for acute dyspnea. ROC curve analysis demonstrated that AUCs for ADHF diagnosis in dyspneic patients were 0.86 (95% CI: 0.82–0.90) for sCD146 and 0.90 (95% CI: 0.86–0.92) for NT-proBNP. Subgroup analyses demonstrated that adding sCD146 to NT-proBNP improved the diagnostic performance for patients lying in the gray zone of NT-proBNP (p=0.02) and could be especially useful for ruling-out ADHF. An experimental model of ADHF in rats using thoracic aortic constriction suggests that CD146 is expressed in the intima of large arteries and associated with both left ventricular function and organ congestion. ConclusionssCD146, a marker of endothelial function, seems to be as powerful as NT-proBNP is used to detect the cardiac origin of an acute dyspnea. The combination of sCD146 and NT-proBNP may have better performance than NT-proBNP used alone in particular for patients underlying in the “gray” zone and could therefore be an improved option for ruling-out ADHF. Both experimental and human data suggest that CD146 is related to systolic left ventricular function and to organ congestion.

N-terminal proB-type natriuretic peptide testing: practical diagnostic value in a emergency department

Purpose: N-terminal proBNP (NT-proBNP) testing has been proposed as a part of the evaluation of patients with dyspnea in Emergency Department (ED). Observational studies demonstrated that NT-proBNP improved diagnosis and reduced costs. Nevertheless, recent randomized studies failed to confirm the utility of this laboratory test in ED. We sought to evaluate the diagnostic impact of NT-proBNP measurement in patients presenting with acute dyspnea in ED, taking into account clinical and chest x-ray results routinely obtained. Methods: We enrolled 498 consecutive patients presented at our ED for dyspnea (male/female 248/250; mean±SD age 77.3±12) with a single NT-proBNP determination (Elecsys Roche Diagnostics, cutoff: 450 ng/L) at admission. For each patient enrolled, a score was calculated by evaluating the presence or absence of six clinical and radiological findings, such as: 1) history of heart failure; 2) history of ischemic cardiomyopathy; 3) pulmonary rales; 4) leg edema; 5) chest x-ray cardiac enlargement; 6) chest x-ray pulmonary congestion. According to the clinical and radiological score, the patients were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. On a second time two cardiologists, rather than knowledge of the results of NT-proBNP, reviewed all other clinical data and made the final diagnosis. Results: NT-proBNP mediane value was 2445 ng/L (lower quartile 631 and upper quartile 5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score, and 0.936 for the two in combination (logistic model). The likelihood ratio positive (LR+) was not determinable in the group A, 1.63 in the group B and 1.22 in the group C. The LR- was 1.26 in the group A, 0.16 in the group B and 0.05 in the group C In the B- group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions: NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. In patients presenting to an ED with acute dyspnea classifiable in the low or high probability groups this marker keeps its strong discriminating power, but gives poor additional information to clinical standard evaluation. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

High NT-probnp and Procalcitonin Level Can Predict the Poor Prognosis of Acute Dyspneic Patients

Acute decompensated heart failure is the main cause of acute dyspnea in emergency department and the infection is the main cause of acute decompensate heart failure. NT-proBNP is an independent predictor of high left ventricular end-diastolic pressure and correlate to NYHA classification and the severity of the heart failure. Procalcitonin (PCT) is potentially biomarker of the state of bacterial infection and has excellent specificity and positive predictive value on the disgnosis of ongoing and potentially severe systemic infection.

Diagnostic value of N-terminal ProB-Type Natriuretic Peptide in Emergency Department: Analysis by subgroups

Objectives. Our aim was to evaluate the diagnostic impact of N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement in patients presenting with acute dyspnea in Emergency Department (ED), taking into account clinical and chest x-ray results routinely obtained. Methods. This was a prospective observational study. Four hundred eighty-eight consecutive subjects evaluated for dyspnea in a metropolitan 600 beds hospital ED, entered into the final data analysis. According to a clinical and radiological score, the patients enrolled were divided in three groups: low (A-group), intermediate (B-group), and high (C-group) probability of heart failure. Results. NT-proBNP median value was 2445 ng/L (Inter Quartile Range 631-5847 ng/L), and the area under the receiver-operating characteristic curves (AUC) was 0.854 for NT-proBNP, 0.921 for clinical/radiological score and 0.936 for the two in combination (logistic model). In the B-group (intermediate) NT-proBNP test added correct diagnostic information in 126 subjects with HF and in 53 subjects without a final diagnosis of HF. In A- and C-group NT-proBNP test added correct diagnostic information in 1 patient. Conclusions. NT-proBNP did not substantially enhance diagnostic accuracy in all patients with shortness of breath in ED. However, in patients with not conclusive clinical and radiological results NT-proBNP determinations improved the percentage of correct diagnosis.

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED

ObjectiveThis study was designed to determine whether the mainstream end-tidal carbon dioxide (ETCO2) measurement can accurately predict the partial arterial carbon dioxide (Paco2) level of patients presented to emergency department (ED) with acute dyspnea. MethodsThis prospective, observational study was conducted at a university hospital ED, which serves more than 110 000 patients annually. Nonintubated adult patients presented with acute dyspnea who required arterial blood gas analysis were recruited in the study for a 6-month period between January and July 2010. Patients were asked to breathe through an airway adapter attached to the mainstream capnometer. Arterial blood gas samples were obtained simultaneously. ResultsWe included 162 patients during the study period. The mean ETCO2 level was 39.47 ± 10.84 mm Hg (minimum, 19 mm Hg; maximum, 82 mm Hg), and mean Paco2 level was 38.95 ± 12.27 mm Hg (minimum, 16 mm Hg; maximum, 94 mm Hg). There was a positive, strong, statistically significant correlation between ETCO2 and Paco2 (r = 0.911, P < .001). The Bland-Altman plot shows the mean bias ± SD between ETCO2 and Paco2 as 0.5 ± 5 mm Hg (95% confidence interval, −1.3165-0.2680) and the limits of agreement as −10.5 and +9.5 mm Hg. Eighty percent (n = 129) of the ETCO2 measurements were between the range of ±5 mm Hg. ConclusionMainstream ETCO2 measurement accurately predicts the arterial Paco2 of patients presented to ED with acute dyspnea. Further studies comparing mainstream and sidestream methods in these patients are required.

Ecthyma-gangrenosum-like lesions associated with methicillin-resistant Staphylococcus aureus infection

Ecthyma gangrenosum (EG) manifests as a skin lesion and is commonly associated with Pseudomonas aeruginosa septicemia in immunocompromised patients. Other viral, fungal and bacterial agents can also cause EG. The first clinical observation is grouped vesicles with surrounding erythema. Within a few days, they evolve into a gangrenous ulcer with a black/gray eschar surrounded by an erythematous halo. Herein, we present a patient with chronic obstructive pulmonary disease who developed EG-like lesions due to methicillin-resistant Staphylococcus aureus infection while he was in the intensive care unit.