RESUMO
A 51-year-old male with profound and prolonged neutropenia 12 days after receiving chemotherapy for an acute myeloid leukemia developed a nodular, erythematous lesion with a necrotic center on the base of the neck, associated with fever, chills, and myalgia. An invasive fungal infection was diagnosed after growth of Candia tropicalis in blood cultures. He evolved with multiple reddish papular lesions concentrated mainly on the trunk, although they also spread to the extremities. The most common skin lesions of disseminated candidiasis are erythematous-violaceous papules with vesicular centers, which, in some cases, can progress to necrosis. Other forms of cutaneous presentation of invasive candidiasis are ecthyma gangrenosum-like lesions, hemorrhagic plaques or bullae, rash resembling folliculitis, and subcutaneous nodules.
Un varón de 51 años que se encontraba con neutropenia profunda y prolongada luego de 12 días del inicio de su quimioterapia por una leucemia mieloide aguda desarrolló una lesión nodular, eritematosa y con centro necrótico en la base del cuello, asociada a fiebre, escalofríos y mialgias. Se diagnosticó infección fúngica invasiva luego del desarrollo de Candia tropicalis en los hemocultivos. Evolucionó con múltiples lesiones papulares rojizas concentradas principalmente en el tronco, aunque también extendidas a las extremidades. Las lesiones cutáneas más frecuentes de la candidiasis diseminada son pápulas eritematosas-violáceas con centros vesiculares, que, en algunos casos, pueden evolucionar a necrosis. Otras formas de presentación cutánea de la candidiasis invasiva son lesiones similares a ectima gangrenoso, placas o bullas hemorrágicas, erupción que resembla foliculitis, y nódulos subcutáneos.
Assuntos
Candidíase Invasiva , Ectima , Leucemia Mieloide Aguda , Masculino , Humanos , Pessoa de Meia-Idade , Pele/patologia , Candidíase Invasiva/complicações , Candidíase Invasiva/patologia , Ectima/complicações , Ectima/patologia , Leucemia Mieloide Aguda/complicações , Leucemia Mieloide Aguda/tratamento farmacológicoAssuntos
Ectima Contagioso , Ectima , Vírus do Orf , Animais , Ectima Contagioso/diagnóstico , Humanos , OvinosAssuntos
Ectima/imunologia , Doenças da Imunodeficiência Primária/diagnóstico , Infecções por Pseudomonas/imunologia , Pseudomonas aeruginosa/isolamento & purificação , Sepse/imunologia , Pele/patologia , Ectima/diagnóstico , Ectima/patologia , Evolução Fatal , Gangrena , Humanos , Lactente , Quinases Associadas a Receptores de Interleucina-1 , Masculino , Doenças da Imunodeficiência Primária/complicações , Infecções por Pseudomonas/diagnóstico , Infecções por Pseudomonas/patologia , Sepse/diagnóstico , Sepse/patologia , Pele/imunologia , Pele/microbiologiaRESUMO
BACKGROUND: Ecthyma gangrenosum (EG) is a cutaneous infectious disease characterized by eschar-like skin ulcers typically caused by Pseudomonas aeruginosa. Here, we report a case of relapsing EG in a patient who had returned from a trip to Colombia, thus establishing EG as an important differential diagnosis of tropical diseases, and demonstrating that even long-term antibiotic treatment can result in only partial remission of EG. CASE PRESENTATION: A 77-year-old man with underlying chronic lymphocytic leukemia (CLL) on ibrutinib treatment was admitted because of a superinfected mosquito bite on the left ear and multiple partially necrotic skin lesions disseminated all over the entire body five days after returning from a trip to Colombia. The initial clinical suspicion of a tropical disease (leishmaniosis, systemic mycosis, or others) could not be confirmed. During the diagnostic workup, microbiological cultures of the skin biopsies and bronchoalveolar lavage revealed Pseudomonas aeruginosa, leading to a diagnosis of EG. Initial antibiotic treatment resulted in partial remission. However, the patient had to be re-admitted due to a relapse 3-4 weeks after the first episode. Finally, the patient was successfully treated with a combined approach consisting of antibiotics, recurrent surgical incisions, and administration of immunoglobulins. CONCLUSIONS: In conclusion, EG should be considered as a differential diagnosis in immunosuppressed patients presenting with eschar-like skin ulcers. A combined treatment approach seems to be the best choice to achieve clinical cure and avoid relapse.
Assuntos
Ectima/diagnóstico , Úlcera Cutânea/diagnóstico , Adenina/análogos & derivados , Adenina/uso terapêutico , Administração Intravenosa , Idoso , Antibacterianos/uso terapêutico , Líquido da Lavagem Broncoalveolar/microbiologia , Colômbia , Diagnóstico Diferencial , Ectima/tratamento farmacológico , Ectima/microbiologia , Ectima/cirurgia , Humanos , Hospedeiro Imunocomprometido , Imunoglobulinas/uso terapêutico , Leucemia Linfocítica Crônica de Células B/tratamento farmacológico , Leucemia Linfocítica Crônica de Células B/patologia , Masculino , Piperidinas/uso terapêutico , Pseudomonas aeruginosa/isolamento & purificação , Úlcera Cutânea/microbiologia , Úlcera Cutânea/cirurgiaRESUMO
El ectima gangrenoso es un trastorno infeccioso infrecuente clásicamente relacionado a bacteriemia, descrito principalmente en poblaciones inmunodeprimidas. El agente más comúnmente relacionado es Pseudomonas aeruginosa, sin embargo, se han descrito otras etiologías bacterianas, hongos filamentosos y levaduras. Su patogénesis está dada por la invasión de la pared de los vasos sanguíneos, causando trombosis arterial y venosa, desencadenando necrosis de epidermis y tejidos subdérmicos. Clínicamente, se manifiesta como máculas, vesículas o pústulas hemorrágicas que evolucionan a úlceras de superficie necrótica rodeadas por un halo eritematoso característico, habitualmente en un contexto clínico de sepsis. El diagnóstico de este cuadro es clínico, sin embargo, el estudio microbiológico es clave en la identificación del agente etiológico y un posterior tratamiento dirigido. En su manejo es esencial una alta sospecha clínica y el inicio de tratamiento antibiótico en forma precoz. La duración del tratamiento es variable y en algunos casos debe asociarse a debridación quirúrgica. El pronóstico es variable dependiendo de múltiples factores: estado inmunológico, agente etiológico, presencia de sepsis y el tiempo de inicio de tratamiento.(AU)
Ecthyma gangrenosum is an infrequent infectious disorder classically related to bacteremia, described mainly in immunosuppressed populations. The most related agent is Pseudomonas aeruginosa, however other bacterial etiologies, filamentous fungi and yeasts have been described. Its pathogenesis is given by the invasion of the blood vessel wall, causing arterial and venous thrombosis, triggering necrosis of epidermis and subdermal tissues. Clinically, it manifests as hemorrhagic macules, vesicles or pustules that evolve into ulcers with a necrotic surface surrounded by a characteristic erythematous halo, usually in a clinical setting of sepsis. The diagnosis of this condition is clinical, however the microbiological study is key in the identification of the etiological agent and a subsequent directed treatment. In its management, a high clinical suspicion and an early start of antibiotic treatment are essential. The duration of treatment is variable and in some cases it must be associated with surgical debridement. The prognosis is variable depending on multiple factors: immunological status, etiological agent, presence of sepsis and time of initiation of treatment.(AU)
Assuntos
Humanos , Infecções por Pseudomonas/microbiologia , Sepse , Ectima/diagnóstico , Prognóstico , Ectima/etiologia , Ectima/tratamento farmacológicoAssuntos
Humanos , Feminino , Infecções por Pseudomonas , Ectima/diagnóstico , Neutropenia , Pseudomonas aeruginosaRESUMO
Abstract The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term "necrotizing soft tissue infections". Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.
Assuntos
Humanos , Infecções Bacterianas , Infecções Estafilocócicas , Infecções dos Tecidos Moles , Fasciite Necrosante , Ectima , Staphylococcus aureus Resistente à Meticilina , AntibacterianosAssuntos
Ectima , Neutropenia , Infecções por Pseudomonas , Ectima/diagnóstico , Feminino , Humanos , Pseudomonas aeruginosaRESUMO
The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term "necrotizing soft tissue infections". Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.
Assuntos
Dermatopatias Bacterianas , Antibacterianos , Ectima , Fasciite Necrosante , Humanos , Staphylococcus aureus Resistente à Meticilina , Infecções dos Tecidos Moles , Infecções EstafilocócicasAssuntos
Ectima/etiologia , Neoplasias do Mediastino/diagnóstico por imagem , Doenças Nasais/etiologia , Infecções Oportunistas/etiologia , Pneumonia Bacteriana/diagnóstico por imagem , Infecções por Pseudomonas/diagnóstico por imagem , Sarcoma Sinovial/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Idoso , Colite Ulcerativa/complicações , Colite Ulcerativa/tratamento farmacológico , Ectima/patologia , Evolução Fatal , Gangrena , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Masculino , Neoplasias do Mediastino/complicações , Mesalamina/efeitos adversos , Mesalamina/uso terapêutico , Necrose , Doenças Nasais/microbiologia , Doenças Nasais/patologia , Infecções Oportunistas/microbiologia , Infecções Oportunistas/patologia , Pneumonia Bacteriana/etiologia , Infecções por Pseudomonas/etiologia , Infecções por Pseudomonas/patologia , Sarcoma Sinovial/complicações , Choque Séptico/etiologiaRESUMO
Ecthyma gangrenosum is a rare skin infection classically associated with Pseudomonas aeruginosa. We performed a retrospective study of all cases diagnosed with ecthyma gangrenosum from 2004-2010 in a university hospital in Mexico (8 cases, 5 female patients and 3 male patients, ages between 4 months and 2 years). The most common risk factor for ecthyma gangrenosum is neutropenia in immunocompromised patients. In previously healthy patients, immunological evaluation is important to rule out underlying immunodeficiency. Ecthyma gangrenosum in healthy patients has a high mortality rate and early diagnosis and aggressive antibiotic treatment is imperative as it can improve patients' prognosis.
Assuntos
Ectima/microbiologia , Gangrena/microbiologia , Infecções por Pseudomonas/complicações , Pseudomonas aeruginosa/isolamento & purificação , Pré-Escolar , Ectima/tratamento farmacológico , Feminino , Gangrena/tratamento farmacológico , Humanos , Lactente , Masculino , Estudos RetrospectivosRESUMO
Abstract: Ecthyma gangrenosum is a rare skin infection classically associated with Pseudomonas aeruginosa. We performed a retrospective study of all cases diagnosed with ecthyma gangrenosum from 2004-2010 in a university hospital in Mexico (8 cases, 5 female patients and 3 male patients, ages between 4 months and 2 years). The most common risk factor for ecthyma gangrenosum is neutropenia in immunocompromised patients. In previously healthy patients, immunological evaluation is important to rule out underlying immunodeficiency. Ecthyma gangrenosum in healthy patients has a high mortality rate and early diagnosis and aggressive antibiotic treatment is imperative as it can improve patients' prognosis.
Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Pseudomonas aeruginosa/isolamento & purificação , Infecções por Pseudomonas/complicações , Ectima/microbiologia , Gangrena/microbiologia , Estudos Retrospectivos , Ectima/tratamento farmacológico , Gangrena/tratamento farmacológicoRESUMO
Abstract Ecthyma gangrenosum is an uncommon dermatological manifestation characterized by round, indurated ulcers with a central necrotic black eschar and surrounding erythema. This report describes the case of a 5-year-old girl, affected by acute lymphocytic leukemia, presenting with a black eschar on her right thigh. Such lesions should always be correctly identified to avoid potentially fatal bacteraemia. Furthermore, because of its similar clinical presentation, cutaneous anthrax must be ruled out.
Assuntos
Humanos , Feminino , Pré-Escolar , Infecções por Pseudomonas/microbiologia , Úlcera Cutânea/microbiologia , Ectima/microbiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Pseudomonas aeruginosa , Infecções por Pseudomonas/patologia , Úlcera Cutânea/patologia , Ectima/patologiaRESUMO
Ecthyma gangrenosum is an uncommon necrotizing vasculitis, in most cases secondary to sepsis by Pseudo-mona aeruginosa in immunocompromised patients. However, there have been several reports of ecthyma gangre-nosum caused by other infectious etiologies. We report an unusual case of ecthyma gangrenosum associated with methicillin-resistant Staphylococcus aureus infection in a patient without the classic immunological risk factors described in the literature.
Assuntos
Ectima/microbiologia , Ectima/patologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/patologia , Idoso , Biópsia , Ectima/tratamento farmacológico , Epiderme/microbiologia , Epiderme/patologia , Feminino , Gangrena , Humanos , Imunocompetência , Fatores de Risco , Infecções Estafilocócicas/tratamento farmacológicoAssuntos
Antibacterianos/uso terapêutico , Doenças Transmitidas por Carrapatos/diagnóstico , Tularemia/diagnóstico , Adolescente , Diagnóstico Diferencial , Ectima/diagnóstico , Feminino , Francisella tularensis , Humanos , Pele/microbiologia , Doenças Transmitidas por Carrapatos/tratamento farmacológico , Tularemia/tratamento farmacológicoRESUMO
El ectima gangrenoso es una vasculitis necrosante poco frecuente, en la mayoría de los casos secundaria a sepsis por Pseudomonas aeruginosa en pacientes inmunocomprometidos. Sin embargo, existen reportes de ectima gangrenoso secundarios a otras etiologías infecciosas. Presentamos un caso de ectima gangrenoso asociado a una infección por Staphylococcus aureus resistente a meticilina en una paciente sin los factores de riesgo clásicos de inmunosupresión que se describen en la literatura médica.
Ecthyma gangrenosum is an uncommon necrotizing vasculitis, in most cases secondary to sepsis by Pseudo-mona aeruginosa in immunocompromised patients. However, there have been several reports of ecthyma gangre-nosum caused by other infectious etiologies. We report an unusual case of ecthyma gangrenosum associated with methicillin-resistant Staphylococcus aureus infection in a patient without the classic immunological risk factors described in the literature.
Assuntos
Humanos , Feminino , Idoso , Infecções Estafilocócicas/patologia , Ectima/microbiologia , Ectima/patologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/tratamento farmacológico , Biópsia , Fatores de Risco , Ectima/tratamento farmacológico , Epiderme/microbiologia , Epiderme/patologia , Gangrena , ImunocompetênciaRESUMO
La otitis externa maligna es considerada una infección invasiva del conducto auditivo externo, infrecuente y sumamente agresiva, que llega, en ocasiones, a comprometer la base del cráneo. Se presenta habitualmente en inmunocomprometidos, incluidos aquellos con infección por VIH. El ectima gangrenoso es una infección cutánea localizada, inusual, causada, en la mayoría de los casos por Pseudomonas aeruginosa, con compromiso multisistémico y evolución tórpida. La asociación entre ambas entidades es aún más rara. A continuación, presentamos el caso de una mujer de 37 años, con el antecedente principal de infección por VIH desde hace 10 años, adherente al tratamiento antirretroviral y, a pesar de mantener una adecuada respuesta inmunológica y virológica, se presenta a la urgencia de nuestro hospital en shock séptico por otitis externa maligna, con ectima gangrenoso y posible síndrome hemofagocítico como complicación, aislándose Pseudomonas aeruginosa como agente causal.
Malignant otitis externa is an aggressive, infrequent and invasive infection of the external auditory canal. In some cases it leads to skull base compromise, particularly in immunocompromised individuals, including HIV-positive patients. Ecthyma gangrenosum is an unusual, localized cutaneous infection, caused mostly by Pseudomonas aeruginosa, with systemic compromise and a torpid evolution. An association between these 2 entities is even more rare. We present the case of a 37-year old woman with a history of 10 years’ HIV infection and good adherence to antiretroviral therapy. Although she had an adequate immunological and virological response, she presented at our emergency department in septic shock due to malignant otitis externa with ecthyma gangrenosum and possible haemophagocytic syndrome as a complication, with Pseudomonas aeruginosa determined to be the causative agent.
Assuntos
Humanos , Feminino , Adulto , Otite Externa , HIV , Ectima , Otorrinolaringopatias , Pseudomonas aeruginosa , Terapia Antirretroviral de Alta Atividade , Linfo-Histiocitose Hemofagocítica , GangrenaRESUMO
We present the case of a 1-year-old healthy boy who was taking oral antibiotics for an otitis media and then developed an erythematous penile lesion that rapidly became ulcerated. He was admitted to the hospital for further diagnostic studies and intravenous therapy, and his wound culture grew Pseudomonas aeruginosa, consistent with the diagnosis of ecthyma gangrenosum. Serial blood counts also demonstrated a progressive neutropenia, and an immunodeficiency evaluation resulted in the diagnosis of autoimmune neutropenia of childhood. This case illustrates the importance of culturing wounds and the need for clinicians to recognize the characteristic features of ecthyma gangrenosum, to initiate appropriate antipseudomonal antibiotic therapy empirically, and to evaluate for a possible immunodeficiency, even in the apparently healthy child.