Acute myeloid leukaemia presenting with ecthyma gangrenosum as the first manifestation: A case report.

RATIONALE: Ecthyma gangrenosum (EG) is an uncommon cutaneous infection usually associated with Pseudomonas aeruginosa bacteremia in immunocompromised patients, particularly those with underlying malignant diseases. Despite its rarity, especially in immunocompetent or nondiagnosed immunodeficiency patients, EG can present as the first manifestation of an underlying immunosuppression. PATIENT CONCERNS: A 42-year-old Japanese man was admitted to our hospital with a 3-day history of a painless red macule on his right forearm and fever. DIAGNOSES: Blood culture on admission revealed the presence of Pseudomonas aeruginosa, whereas pus culture of the skin lesion showed Pseudomonas aeruginosa and methicillin-susceptible Staphylococcus aureus positivity. INTERVENTIONS: Additional bone marrow aspirate examination and immunophenotyping were performed to confirm the diagnosis of acute promyelocytic leukaemia with PML-retinoic acid alpha receptor. OUTCOMES: The patient was successfully treated with a 14-day course of antibiotics, and no evidence of relapse was noted. The patient achieved complete remission after treatment for acute promyelocytic leukaemia. LESSONS: It should be kept in mind that EG is an important cutaneous infection that is typically associated with P aeruginosa bacteremia and the presence of underlying immunodeficiency, such as acute leukaemia.

[Recurrent postpartum pyoderma gangrenosum and fatal cardiomyopathy]. / Pyoderma gangrenosum récidivant du post-partum et cardiomyopathie fatale.

BACKGROUND: We report a case of recurrent post-partum pyoderma gangrenosum (PG) complicated by post-partum cardiomyopathy (PPCM). PATIENTS AND METHODS: A 23-year-old woman presented with a previous medical history of aseptic abscess of the left breast in her fourth pregnancy, which developed after surgical drainage of an inflammatory ulceration treated by atraumatic topical care. During her fifth pregnancy, the patient presented a large and painful ulceration in relation to the scar of the Caesarean section, despite the introduction of broad-spectrum antibiotic therapy. Bacteriological samples were negative. Histological examination militated in favor of PG. One week after initiation of corticosteroid therapy, the patient suddenly showed signs of heart failure. Based on trans-thoracic echocardiography PPCM was diagnosed, and the outcome was fatal. DISCUSSION: This observation raises the question of the relationship between PG and pregnancy and describes the association of PG and PPCM. PG occurs rarely during pregnancy and it may be induced by the rise in G-CSF levels found in pregnant women. The association with PPCM seen in our patient could have been due to the development of an anti-angiogenic climate at the end of pregnancy, together with inflammatory myocardial aggression linked to the PG.

Non-pseudomonal ecthyma gangrenosum caused by methicillin-resistant Staphylococcus aureus (MRSA) in a chronic alcoholic patient.

We report for the first time a case of non-pseudomonal ecthyma gangrenosum (EG) caused by methicillin-resistant Staphylococcus aureus in a chronic alcoholic without an associated immunocompromised state or disease. EG is an infection of the skin, commonly associated with Pseudomonas aeruginosa bacteraemia, though other organisms are also known to be causally related. It usually occurs in patients who are terminally ill and the immunocompromised. In our case, chronic alcoholism with suppression of innate immunity may have led to the development of the condition.

Ecthyma gangrenosum in a 3-month-old, previously healthy infant: A Case Report.

RATIONALE: Ecthyma gangrenosum (EG) is an aggressive cutaneous disease caused by local or systemic infection with Pseudomonas aeruginosa. EG is characterized by cutaneous manifestations ranging from nodule and papule, to necrotic ulceration with surrounding erythema, especially with black eschar or central crust. EG presents with characteristic skin lesions which is important to establish diagnosis of sepsis caused by P aeruginosa, a serious condition that can be treated efficiently if diagnosed early. PATIENT CONCERNS: A 3-month-old female infant was presented with characteristic skin lesions of EG and developed sepsis 3 days later. DIAGNOSES: Ecthyma gangrenosum and sepsis caused by Pseudomonas aeruginosa. INTERVENTIONS: Meropenem was used in combination with ceftazidime at first and excision of necrotic skin lesions was performed later. OUTCOMES: Cure. LESSONS: Early recognition of EG plays an important role in providing appropriate empiric antibiotic treatment at early stage of sepsis, and improves the prognosis. Surgical excision may be helpful if no improvement was achieved via antibiotic treatment.

PYODERMA GANGRENOSUM IN BURNED PATIENT - CASE REPORT.

INTRODUCTION: Pyoderma gangrenosum is a rare, chronic, destructive, ulcerating skin disease of uncertain etiology. It develops most frequently in patients between 25-45 years of age and affects both sexes equally. CASE REPORT: We present a case of pyoderma gangrenosum in a young female patient who sustained a burn injury of 40% total body surface area. She underwent four operations. She developed a wound infection and urinary infection during her hospital stay. By the end of hospitalization, the papules followed with coalesce of ulcerations formed on the previously epithelized areas of her legs. The patient complained of the intensive pain localized on these surfaces. Since pyoderma gangrenosum was suspected, a dermatologist was included in treatment. Therapy was initiated (methylprednisolone 60 mg per day intravenously) with gradual reduction of the dosage. The patient was discharged from hospital two weeks later with almost fully complete cicatrization and epithelization. CONCLUSION: Pyoderma gangrenosum is still difficult to be diagnosed in the absence of specific and sensitive diagnostic methods; however, it is crucial to be suspected as early as possible and to start treatment immediately. Multidisciplinary approach is essential for ontimal results.

Pyoderma gangrenosum: a misdiagnosis.

Pyoderma gangrenosum is an inflammatory disease of unknown etiology, commonly mistaken for an infection. Here, we report the case of a 55-year-old woman with an infectious process that was initially misdiagnosed as pyoderma gangrenosum and treated accordingly. We also discuss the criteria and the methods available to diagnose infections and pyoderma gangrenosum correctly.

Pyoderma gangrenosum-like ulcer caused by Helicobacter cinaedi in a patient with x-linked agammaglobulinaemia.

Cutaneous lesions of the legs have been linked to Helicobacter species in a number of patients with X-linked agammaglobulinaemia (XLA), a primary immunodeficiency. We describe a 26-year-old patient with XLA, who was referred with an extensive skin ulcer that enlarged gradually over the course of 7 years. The ulcer resembled pyoderma gangrenosum (PG), and extended from below the knee to the ankle. The man (who has sex with men) was negative for human immunodeficiency virus. Helicobacter cinaedi was identified by 16S ribosomal (r)DNA PCR analysis from a biopsy of the lesion. This fastidious organism has been implicated previously in causing unexplained skin macules in one other patient with XLA. We suggest that early consideration of infection with Helicobacter species in immunocompromised patients who present with unexplained cutaneous lesions is important, as a prolonged antibiotic course can lead to clinical improvement.

Feasibility of conservative medical treatment for pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a chronic skin disease with an incidence of 3-10 per million, and it is often associated with underlying systemic disease. A case of PG of the left leg successfully treated with local debridement and advanced and compression dressings, without systemic treatment is reported. Progression and healing of the ulcer was incredibly rapid. The treatment of PG usually consists of systemic administration of corticosteroids. But wherever the administration of systemic immunosuppressive therapy is impractical, a topical treatment can be used. This type of treatment does not represent a mere palliative, but could be significant for healing, as in the case of our patient.

Ecthyma gangrenosum secondary to Staphylococcus aureus in an infant with transient neutropenia.

Ecthyma gangrenosum is classically a cutaneous manifestation of a pseudomonal septicemia that presents in a patient with an immunodeficiency or hematologic malignancy. We describe a previously healthy 8-month-old girl who developed transient neutropenia and characteristic ecthyma gangrenosum lesions secondary to methicillin-resistant Staphylococcus aureus. This unique presentation of methicillin-resistant Staphylococcus aureus ecthyma gangrenosum emphasizes the importance of broad empiric coverage and early culturing for microorganism and susceptibilities in any patient presenting with ecthyma gangrenosum.

Pyoderma gangrenosum requiring inpatient management: a report of 26 cases with follow up.

We present a case series of inpatients with pyoderma gangrenosum (PG), an ulcerative neutrophilic skin condition of unknown aetiology. Twenty-six patients were admitted with PG, nine men and 17 women. At the time of the chart review, seven patients (26.9%) had died. Patients had a mean of 2.0 active ulcerative lesions and 22 patients' ulcers (84.6%) were on the lower limb. Systemic diseases were coexistent in 15 patients (57.7%), the most common being rheumatoid arthritis (19.2%). Thirty-eight wound cultures were taken and were positive for Staphylococcus aureus in 22 cases (57.8%) and Pseudomonas aeruginosa in 20 (52.6%). After prednisolone, cyclosporin was the next most commonly prescribed systemic therapy (34.6%). Surgical debridement was undertaken in seven cases (26.9%) and two patients had skin grafts. Upon discharge from hospital, 21 patients' ulcers (80.8%) had improved. At 6 months 50% showed complete ulcer healing. Our results highlight the potential severity of PG requiring hospital admission, the need for aggressive therapy and the overall high associated morbidity and mortality.

Coexistence of fatal disseminated invasive aspergillosis and pyoderma gangrenosum: a case report.

OBJECTIVE: To report an unusual case of disseminated aspergillosis involving the lymph nodes, lungs, and skin in a patient with pyoderma gangrenosum (PG) and myelodysplastic syndrome (MDS). CASE PRESENTATION AND INTERVENTION: A 46-year-old man presented with productive cough of 2 weeks' duration. Besides, several painless, fixed lymph nodes were palpated at his left neck. He had PG and MDS diagnosed in June 2004 with regular use of oral dapsone and prednisolone. His skin lesions healed with scar formation and no purulent discharge. A computed tomography scan of the head, neck and chest showed bilateral lung consolidation and abscesses at the left neck, right upper lung and right pleura. The neck abscess culture grew Aspergillus species. Dark reddish macules developed over the right arm, chest and abdominal wall, and the left lower limb 2 weeks after initiation of amphotericin B. The histology of the right arm skin biopsy showed invasive aspergillosis. Caspofungin was started then for suspicion of poor response to amphotericin B. He expired despite 35 days of antifungal therapy. CONCLUSION: This report highlights the rarity of coexistence of disseminated aspergillosis and PG, and should alert physicians to the possibility of invasive fungal infection superimposed on a chronic skin lesion.

Treatment of postsurgical pyoderma gangrenosum with a high-potency topical steroid.

Pyoderma gangrenosum is a rare disease characterized by chronic, nonhealing, noninfectious ulcers that can become exacerbated by trauma or manipulation, including surgical treatment. We describe the case of a 30-year-old woman who presented with a large ulcer at the site of an excisional cervical lymph node biopsy; she also had a smaller ulcer at the site of an earlier biopsy that had been previously well healed. The ulcers persisted despite local care, and the larger ulcer was exacerbated by surgical debridement. Histopathology revealed the presence of intense neutrophilic infiltrates with sterile microabscesses-a finding consistent with pyoderma gangrenosum. With 9 weeks of treatment with a high-potency topical steroid, both ulcers gradually healed.

Pyoderma gangrenosum-like ulcer in a patient with X-linked agammaglobulinemia: identification of Helicobacter bilis by mass spectrometry analysis.

BACKGROUND: Pyoderma gangrenosum-like ulcers and cellulitis of the lower extremities associated with recurrent fevers in patients with X-linked (Bruton) agammaglobulinemia have been reported to be caused by Helicobacter bilis (formerly classified as Flexispira rappini and then Helicobacter strain flexispira taxon 8). Consistent themes in these reports are the difficulty in recovering this organism in blood and wound cultures and in maintaining isolates in vitro. We confirmed the presence of this organism in a patient's culture by using a novel application of gene amplification polymerase chain reaction and electrospray ionization time-of-flight mass spectrometry. OBSERVATION: An adolescent boy with X-linked agammaglobulinemia presented with indurated plaques and a chronic leg ulcer whose origin was strongly suspected to be an H bilis organism. Histologic analysis demonstrated positive Warthin-Starry staining of curvilinear rods, which grew in culture but failed to grow when subcultured. They could not be identified by conventional techniques. A combination of gene amplification by polymerase chain reaction and electrospray ionization time-of-flight mass spectrometry confirmed the identity of this organism. CONCLUSIONS: This novel technology was useful in the identification of a difficult-to-grow Helicobacter organism, the cause of pyoderma gangrenosum-like leg ulcers in patients with X-linked agammaglobulinemia. Correct identification of this organism as the cause of pyoderma gangrenosum-like ulcers in patients with X-linked agammaglobulinemia is of great importance for the early initiation of appropriate and curative antibiotic therapy.

Pyoderma gangrenosum on the breast: a case presentation and review of the published work.

We present a case of pyoderma gangrenosum localized on the breast, without a preceding surgical intervention and associated systemic disorder. The ulcer had rapidly developed and covered a large portion of the breast. The patient responded well to systemic steroids and salicylazosulfapyridine and the ulcer completely healed with scarring after 3 months of treatment. Pyoderma gangrenosum rarely involves the breasts. A published work survey disclosed only 31 reported cases up to date. In most of these cases the lesions were related to previous surgical interventions, probably as the result of a pathergy phenomenon. The main differential diagnoses were skin and soft tissue infections including necrotizing fasciitis, and malignant neoplasms. Negative initial wound cultures and the relative sparing of nipple/areola complex helped to eliminate these disorders. Though an unusual site for pyoderma gangrenosum, lesions on the breast showed the characteristic clinical features of the disease. The types of associated disorders were also similar to those of the cases with classical pyoderma gangrenosum. As most of the lesions healed with significant scarring, early recognition and treatment of pyoderma gangrenosum located on the breast is important to prevent serious physical and psychological morbidity.

Aeromonas hydrophila ecthyma gangrenosum without bacteraemia in a diabetic man: the first case report in Italy.

Ecthyma gangrenosum is a well recognized cutaneous manifestation of severe, invasive infection by Pseudomonas aeruginosa usually in immunocompromised and critically ill patients. This type of infection is usually fatal. Aeromonas infection is infrequently reported as the cause of ecthyma gangrenosum. Here we show the first case described in Italy of Aeromonas hydrophila ecthyma gangrenosum in the lower extremities in an immunocompetent diabetic without bacteraemia. A 63-year-old obese diabetic male was admitted with an ulcer on his left leg, oedema, pain and fever. Throughout his hospitalization blood cultures remained sterile, but a culture of A. hydrophila was isolated following punctures from typical leg pseudomonal-ecthyma gangrenosum lesions developed after admission. The patient, questioned again, stated that a few days before he had worked in a well near his house without taking precautions. We conclude that early diagnosis and suitable antibiotic therapy are important for the management of ecthyma gangrenosum. The typical presentation of soft tissue infection of A. hydrophila should mimic a Gram-positive infection, which may result in a delay in administration of appropriate antibiotics. Moreover, A. hydrophila should be considered a possible agent for non-pseudomonal ecthyma gangrenosum in a diabetic man with negative blood cultures, in presence of anamnestical risk factors.