Ecthyma-like Lesions Research Articles

Necrotic ulcers in an immunocompromised patient

A 68-year-old man presented to dermatology clinic with extensive ulcers for one-week duration. Patient had underlying uncontrolled Type II Diabetes Mellitus and pemphigus foliaceous. His medications were metformin 1 g twice daily, prednisolone 30 mg daily and azathioprine 50 mg daily. He denied fever, prior trauma or insect bites. On examination, there were multiple necrotic ulcers of varying sizes present on the anterior trunk and extensors of left knee (Fig. 1A & B). Some of the lesions were exudative with serous discharge. The surrounding skin was erythematous. Blood investigation revealed leucocytosis at 15,000 cells per cubic millimetre and a raised C-Reactive Protein (CRP) at 8 mg/dL. Patient was empirically started on intravenous piperacillin-tazobactam 4.5 g thrice daily to cover for bacterial skin infection. Four days later, swab from the lesion yielded Pseudomonas Aeruginosa with sensitivity towards ceftazidime. Blood culture revealed no growth. Antibiotic therapy was changed to intravenous ceftazidime 1 g thrice daily. Surgical debridement of the necrotic patches was done twice, followed by bactigrass and duoderm dressing. After 1 week of therapy, patient remained well with no new ulcers formed. Inflammatory markers such as total white cell counts and CRP have normalised too. Hence, he was discharged home. What is the diagnosis? Ecthyma gangrenosum. Ecthyma gangrenosum (EG) is a haemorrhagic and necrosing vasculitis of the small vessels, commonly associated with Pseudomonas Aeruginosa [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar]. Risk factors include neutropenia, malignancies, immunosuppressive treatments and diabetes mellitus. [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar, [2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] EG presents with painless erythematous macules, with or without vesicles. Within 12–24 h, the lesions become indurated with haemorrhagic blisters. Finally, deep-necrotic ulcers with a grey-black eschar formed with a surrounding erythematous halo. [[2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] Most common affected sites are perineal (57%), distal extremities (30%), facial and truncal (12%)[[2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar]. Clinical assessment is sufficed to diagnose EG. Culture from tissue or swab of lesion may identify the causative pathogen. [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar, [2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] Blood culture is recommended if bacteraemia is suspected. [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar] Empirical treatment with anti-pseudomonal antibiotic is recommended if the diagnosis of EG is suspected. [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar, [2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] Once the causative organism and its sensitivity are identified, targeted therapy of a single antimicrobial agent is administered until improvement of lesions is observed. Surgical debridement is indicated in extensive cutaneous lesions, abscess or non-responsive to medical therapy alone. [[1]Vaiman M. et al.Ecthyma gangrenosum and ecthyma-like lesions: review article.Eur J Clin Microbiol Infect Dis. 2015; 34: 633-639https://doi.org/10.1007/s10096-014-2277-6Crossref PubMed Scopus (112) Google Scholar, [2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] This case emphasizes the need to recognise EG and deliver suitable treatment early. Delay in diagnosis may result in fatal outcome as the mortality rate ranges from 38% to 77%. [[2]Bettens S. et al.Ecthyma gangrenosum in a non-neutropaenic, elderly patient: case report and review of the literature.Acta Clin Belg. 2008; 63: 394-397https://doi.org/10.1179/acb.2008.081Crossref PubMed Scopus (18) Google Scholar] Informed consent of the patient has been obtained to publish his case and images in the manuscript. The authors declare that they have no competing interests.

Clinicopathological Features of Contagious Ecthyma-Like Lesions in a Dog

Background: Contagious ecthyma or orf is a poxviral disease of goat and sheep, with incidental infection appearing in humans, cows, camels, and many wild ruminants, and very rarely in dogs. Case description: In the present paper was described gross morphology and histopathology of contagious ecthyma in a dog with a large ulcerated cutaneous mass in the neck (under the collar) which was managed by local surgery. Clinical findings: The mass was solitary, soft, well circumscribed and grey to brown color. Cut surfaces of the mass contained discrete, round without any lobulation and liquefied foci in the centers. Histologically, there were vacuolar degeneration of keratinocytes in the stratum spinosum, marked epidermal proliferation associated with deep epidermal pegs and dermal papilla, and accumulation of scale-crust with ortho- and parakeratotic hyperkeratosis. Dermal lesions included superficial edema, marked capillary dilation, and an influx of neutrophils, followed by a marked accumulation of lymphocytes. It is guessed that the dog was fed with infected carcass. Clinical relevance: As regards the virus has zoonotic potential, it should be given more attention.

Mucormycosis in the post renal transplant surgical scar

Cutaneous mucormycosis is a rare entity related to kidney transplantation, which usually presents with ecthyma-like lesions and black necrotic cellulitis. Cutaneous mucormycosis should be considered in the differential diagnosis when a kidney transplant recipient develops erythema nodosum-like lesions with panniculitis or discharging sinus.We report an unusual case of primary cutaneous mucormycosis in a post-renal transplant patient, presenting as pus discharging sinus from the surgical incision site.

Ecthyma gangrenosum and ecthyma-like lesions: review article.

The generally accepted definition of ecthyma gangrenosum (EG) states that this condition is pathognomonic of Pseudomonas septicemia (Pseudomonas aeruginosa) and that it should usually be seen in immunocompromised patients, particularly those with underlying malignant disease. The cases described in the literature present a somewhat different picture. Our objective was to analyze this controversy. The review analyzes 167 cases of EG that were described in the literature from 1975 to 2014. All articles on EG cases with EG-specific tissue defect that had signs of general and/or local infection and skin necrosis were included and analyzed, whatever the etiology detected. Necrotic lesions of the skin diagnosed as EG have various microbiological etiology, can occur in immunocompetent or even healthy persons, and are not necessarily connected with septicemia. In published cases, P. aeruginosa was detected in 123 cases (73.65%); of them, there were only 72 cases (58.5%) with sepsis. Other bacterial etiology was detected in 29 cases (17.35%) and fungi were detected in 15 cases (9%). While the clinical picture of the disease and the treatment strategy remain the same, there is no need to invent two separate definitions for Pseudomonas and non-Pseudomonas cases. We suggest accepting a broader definition of EG.

Experimental parapoxvirus infection (contagious ecthyma) in semi-domesticated reindeer (Rangifer tarandus tarandus)

Contagious ecthyma (contagious pustular dermatitis, orf) occurs world-wide in sheep and goats and is caused by orf virus (genus Parapoxvirus, family Poxviridae). Contagious ecthyma outbreaks have been described in semi-domesticated reindeer (Rangifer tarandus tarandus) in Sweden, Finland and Norway, occasionally with high mortality. Fourteen one-year-old reindeer were corralled in mid-April. One week after arrival, two animals received a commercial live orf virus vaccine for sheep (Scabivax®) on scarified skin of the medial thigh. Four weeks later, the two vaccinated and six additional animals were inoculated in scarified oral mucosa with parapoxvirus obtained from reindeer with clinical contagious ecthyma. The remaining six reindeer were kept as sentinels, sharing feed and water with the inoculated animals. A small whitish lesion appeared on the inoculation site and the labial skin-mucosa junction of three animals five days post inoculation (p.i.). Twelve days p.i., typical ecthyma lesions were visible on the inoculation site in six of eight animals, including both vaccinees. Four inoculated animals (including both vaccinees) and one sentinel seroconverted 12 days p.i., and five animals (including one sentinel) seroconverted 20 days p.i. No contagious ecthyma-like lesions were detected in the sentinels. All animals were euthanized at 26–29 days p.i. Histological examination of lesions showed proliferative dermatitis with epidermal hyperplasia, hyperkeratosis, intra-epithelial pustules and ulcers. Orf virus DNA was detected in mandibular lymph nodes, tonsils and mucosal lesions of four animals, including one sentinel, which showed that virus transmission took place. The commercial orf virus vaccine may be difficult to administer due to the need for close-cropping and its zoonotic nature, and did not indicate significant protection, although the latter has to be verified with a larger number of animals.

Skin mucormycosis presenting as an erythema-nodosum-like rash in a renal transplant recipient: a case report

IntroductionCutaneous mucormycosis is a rare entity related to kidney transplantation. It usually presents with ecthyma-like lesions and black necrotic cellulitis. We report an unusual case of primary cutaneous mucormycosis presenting as erythema-nodosum-like lesions in a woman who had received a renal transplant.Case presentationA 49-year-old woman with diabetes received a living-unrelated kidney transplant. Her clinical course was uneventful for the first six months after transplantation. She then developed multiple, painful, erythema-nodosum-like lesions on her right leg and thigh following an episode of minor trauma. Mucormycosis was diagnosed by skin biopsy. Microscopic examination also showed panniculitis. The patient was treated successfully with amphotericin B and surgical resection. To our knowledge, this is the first description of primary cutaneous mucormycosis with erythema-nodosum-like lesions and panniculitis after renal transplantation.ConclusionCutaneous mucormycosis should be considered in the differential diagnosis when a kidney transplant recipient develops erythema-nodosum-like lesions with panniculitis.

Sporotrichoid cutaneous Mycobacterium avium complex infection

Mycobacterium avium complex, a common opportunistic pathogen among patients with AIDS, usually manifests as disseminated disease involving the lung, lymph nodes, and gastrointestinal tract. Primary cutaneous infections with M avium complex are extremely rare, and most cutaneous lesions are caused by dissemination. Cutaneous manifestations thus far reported include scaling plaques, crusted ulcers, ecthyma-like lesions, verrucous ulcers, inflammatory nodules, panniculitis, pustular lesions, and draining sinuses. Localized skin involvement resembling sporotrichosis is unusual and to our knowledge has been reported only once in the English-language literature. We describe an additional case of primary cutaneous M avium complex infection manifesting as sporotrichosis-like lesions on a patient with AIDS. (J Am Acad Dermatol 2002;47:S249-50.)

Cutaneous mucormycosis with subsequent visceral dissemination in a child with neutropenia: A case report and review of the pediatric literature

Primary cutaneous mucormycosis is a rare opportunistic fungal infection that is usually limited to the skin. We describe a primary cutaneous Rhizopus infection occurring at a site occluded by a sterile adhesive dressing in which the disease was viscerally disseminated at the time fo diagnosis. Mucormycosis should be considered in all ecthyma-like lesions in immunocompromised patients. It may be rapidly diagnosed by examination of hematoxylin-eosin and PAS-stained sections of the eschar base and a culture of a leading edge tissue aspirate. We review 21 cases of primary cutaneous mucormycosis in children and compare them with the present case.

Ecthyma-like Skin Lesions Caused by Staphylococcus aureus

To the Editor. —Ecthyma gangrenosum is an uncommon but dramatic physical finding. It has been described as a classic sign ofPseudomonassepsis, but recent reports indicate that similar skin lesions may be produced byAeromonas hydrophila, lactosepositive vibrios, and perhaps other Gram-negative bacilli and fungi.1-3We would like to report the occurrence of necrotic skin lesions in two patients with systemicStaphylococcus aureusinfection. Both patients with hematologic malignant neoplasms were profoundly immunosuppressed and had skin lesions clinically indistinguishable from those described inPseudomonassepsis. Report of Cases.—Case 1. —A 68-year-old man with erythroleukemia and neutropenia was admitted to the hospital with acute onset of fever and dyspnea. Physical examination revealed a temperature of 38.9 °C, petechiae on the lower extremities, and three ecthyma-like lesions on the back and a forearm (Figure). The WBC count was 500/cu mm. Cultures of blood and skin lesions showed growth