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Ecthyma Gangrenosum in a Neonate Case Report

Article · October 2020

DOI: 10.4103/ijpd.IJPD_132_19

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Bishnupriya Sahoo Himani Bhasin

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Case Report

Ecthyma Gangrenosum in a Neonate

Abstract Bishnupriya Sahoo,

Ecthyma gangrenosum (EG) is pathognomonic of invasive Pseudomonas infection or septicemia. It Himani Bhasin1,
is characterized by pustules that rapidly evolve into hemorrhagic blister with central necrosis with Shikhar Ganjoo2,
the surrounding erythema. It is more often seen in immunocompromised patients but can be seen
in healthy neonate also. We report the case of a 4‑day‑old neonate presenting with Pseudomonas Pankaj Abrol
bacteremia and EG. Departments of Pediatrics and
2
Dermatology, Shree Guru
Keywords: Ecthyma gangrenosum, eschar, necrotic ulcer, Pseudomonas Gobind Singh Tricentenary
Medical College and Hospital,
Gurugram, Haryana,
1
Department of Pediatrics,
Introduction On examination, the baby was of term
North Delhi Municipal
gestational age, weighing 2480 g. The baby Corporation Medical College,
Ecthyma gangrenosum (EG) is a
was lethargic, hyperthemic (core temperature Delhi, India
well‑known cutaneous manifestation of
101°F), tachypneic (respiratory rate 64/min),
severe, invasive infection by Pseudomonas
and not accepting feeds. Bilateral inguinal
aeruginosa. The characteristic lesions of
region showed multiple, well‑defined,
EG are hemorrhagic pustules that evolve
punched‑out gangrenous ulcers with raised
into necrotic punched‑out gangrenous
erythematous borders and central black
ulcers with black–gray eschar. It is
eschar. The largest lesion was seen at the left
usually seen in immunocompromised and
groin measuring 3 cm × 2 cm, erythematous
critically ill patients. However, there are
and necrotic with central eschar. Similar
isolated reports of its occurrence in normal
lesions were present over the abdomen and
healthy individuals.[1‑3] Here, we report the
face. Induration was present around the
development of EG in a normal neonate.
umbilicus [Figures 1a,b, 2 and 3].
Case Report On investigation, hemoglobin was
A 4‑day‑old  term male neonate with a 18.2 g/dl and total leukocyte count was
birth weight of 2.6 kg, delivered through 20,000/mm3, with absolute neutrophil
normal vaginal delivery, presented with count of 9200/mm3 and thrombocytopenia
the complaints of multiple skin lesions that (platelets = 45000/mm3). Peripheral smear
began on the 2nd postnatal day, associated showed toxic granulations and band
Submitted: 04‑Jan‑2020
with fever and decreased oral acceptance forms. Quantitative C‑reactive protein was
Revised: 05‑Feb‑2020
since the 3rd day of life. Initially, red macules 68 mg/L. 15–20 red blood cells/high‑power
Accepted: 06‑May‑2020
developed over the inguinal and perineal field were seen in the suprapubic
Published: 30-Sep-2020
region with subsequent ulceration over the urine sample. Coagulation profile was
next 3–4 days. Similar lesions developed on deranged (international normalized
the abdomen, face, and left eyelid. ratio – 1.7). Chest radiography, TORCH Address for correspondence:
profile, and cerebrospinal fluid examination Dr. Himani Bhasin,
The skin lesions were associated with were normal. HIV infection was ruled out Department of Pediatrics, North
continuous low‑grade fever and lethargy. by enzyme‑linked immunosorbent assay Delhi Municipal Corporation
There was a history of redness around the Medical College, Delhi, India.
testing of both parents. E‑mail: himani.bhasin@yahoo.
umbilicus without any discharge. There co.in
was no history of burns, drug intake, Neonate blood culture grew P. aeruginosa.
catheterization, or diarrhea. The mother However, culture and Gram staining of
was admitted in the intensive care unit discharge from skin lesions did not grow Access this article online
for puerperal sepsis and had urinary tract any organism. Urine culture was sterile.
Website: www.ijpd.in
infection. Based on the history suggestive of sepsis,
typical skin lesions, and blood culture DOI: 10.4103/ijpd.IJPD_132_19

growing P. aeruginosa, the diagnosis of Quick Response Code:

This is an open access journal, and articles are
distributed under the terms of the Creative Commons EG associated with Pseudomonas infection
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are How to cite this article: Sahoo B, Bhasin H,
licensed under the identical terms. Ganjoo S, Abrol P. Ecthyma gangrenosum in a
For reprints contact: [email protected] neonate. Indian J Paediatr Dermatol 2020;21:313-5.

© 2020 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer - Medknow 313
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Sahoo, et al.: Ecthyma gangrenosum

b
Figure 1: (a and b) Multiple deep ulcerations with necrosis and surrounding Figure 2: Necrotic ulcer on the abdomen
halo on the perianal area and perineum

Figure 4: Healing skin lesions on the face, abdomen, and thighs during
Figure 3: Necrotic ulcer on the face
follow‑up

was made. Skin biopsy was considered for diagnostic described EG in association with Pseudomonas septicemia
confirmation, but it was deferred by the guardians. and was later given the name “ecthyma gangrenosum”
Maternal urine culture demonstrated Klebsiella, and her by Hitschmann and Kreibich.[4] Other organisms
blood culture was sterile. implicated in similar lesions include Escherichia coli,
At our hospital, on admission, the child was started Aeromonas, Citrobacter freundii, Corynebacterium
empirically on cefotaxime and amikacin. Based on pus diphtheriae, Klebsiella pneumoniae, Neisseria gonorrhoeae,
culture report, antibiotics were upgraded to meropenem and Staphylococcus  aureus, Streptococcus pyogenes, and
vancomycin. Wound dressings were done daily along with Yersinia pestis, and fungi such as Aspergillus fumigatus,
the application of local antibiotics (mupirocin) and silver Candida albicans, and herpes simplex virus.[3]
sulfadiazine. Fresh frozen plasma and platelet transfusion
Initially, the lesions begin as painless, erythematous
was given. During the course of treatment, fever subsided,
macules in the skin, which rapidly become pustular with
the lesions started healing, and no new lesions were seen
[Figure 4]. Antibiotic therapy was given for 14 days, and surrounding redness and induration. Subsequently, a
the neonate was discharged on supplements with follow‑up hemorrhagic focus appears at the center of the lesion,
ensured in the newborn high‑risk clinic after 1 week. On forming a bulla, and as the bulla spreads laterally, it
follow‑up, there was a great improvement of the skin evolves into a gangrenous ulcer with a black scab or eschar
lesions by 2 weeks and clearing by 4 weeks. surrounded by a red halo.[3,5] These lesions may be single
or multiple.
Discussion EG may appear at any site in the body, but commonly
EG is a known but uncommon skin manifestation of affected sites are anogenital area and armpits. The arms
invasive Pseudomonas infection. In 1897, Baker first and legs, trunk, and face are less often involved.[3]

314 Indian Journal of Paediatric Dermatology | Volume 21 | Issue 4 | October-December 2020

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Sahoo, et al.: Ecthyma gangrenosum

In the present case, the lesions were distributed just below be published and due efforts will be made to conceal their
the inguinal area in the medial part of the thigh, abdomen, identity, but anonymity cannot be guaranteed.
and face [Figures 1 and 2]. Financial support and sponsorship
Diagnosis is made by demonstrating the organism on Gram Nil.
stain of fluid from the central hemorrhagic pustule or blister,
blood culture, skin biopsy, or tissue cultures. If there is no Conflicts of interest
discharge, then the swab should be taken from underneath There are no conflicts of interest.
of the scab. Skin biopsy shows vascular necrosis with few
inflammatory cells and surrounding bacteria. Management References
includes administration of appropriate antibiotics. As there 1. Huminer D, Siegman‑Igra Y, Morduchowicz G, Pitlik SD.
is high likelihood of EG being associated with Pseudomonas Ecthyma gangrenosum without bacteremia. Report of
septicemia, antipseudomonal antibiotics (such as piperacillin six cases and review of the literature. Arch Intern Med
1987;147:299‑301.
tazobactam and third‑generation cephalosporins) are
2. Foca MD. Pseudomonas aeruginosa infections in the neonatal
empirically started. Subsequently, antibiotics are modified intensive care unit. Semin Perinatol 2002;26:332‑9.
as per culture reports and sensitivity of isolated organism. 3. Patel JK, Perez OA, Viera MH, Halem M, Berman B. Ecthyma
gangrenosum caused by Escherichia coli bacteremia: A case
Declaration of patient consent report and review of the literature. Cutis 2009;84:261‑7.
The authors certify that they have obtained all appropriate 4. Vaiman M, Lazarovitch T, Heller L, Lotan G. Ecthyma
gangrenosum and ecthyma‑like lesions: Review article. Eur J
patient consent forms. In the form the patient(s) has/have
Clin Microbiol Infect Dis 2015;34:633‑9.
given his/her/their consent for his/her/their images and 5. Dorff GJ, Geimer NF, Rosenthal DR, Rytel MW. Pseudomonas
other clinical information to be reported in the journal. The septicemia. Illustrated evolution of its skin lesion. Arch Intern
patients understand that their names and initials will not Med 1971;128:591‑5.

Indian Journal of Paediatric Dermatology | Volume 21 | Issue 4 | October-December 2020 315

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