Ecthyma gangrenosum: Difference between revisions
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Name = Ecthyma gangrenosum | |
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'''Ecthyma gangrenosum''' is a type of skin lesion characterized by vesicles or [[Blister|blisters]] which rapidly evolve into [[Cutaneous condition|pustules]] and [[Necrosis|necrotic]] [[Ulcer|ulcers]] with undermined [https://medical-dictionary.thefreedictionary.com/tender tender] [[Erythema|erythematous]] border. "[https://medical-dictionary.thefreedictionary.com/ecthyma Ecthyma]" means a pus forming infection of the skin with an ulcer, "gangrenosum" means the gangrene or necrosis. It is the [[pathognomonic]] of ''Pseudomonas aeruginosa'' bacteremia. ''Pseudomonas aeruginosa'' is a gram negative, aerobic, coccobacillus bacterium. <ref>{{Cite journal|last=Koo|first=Su Han|last2=Lee|first2=Joon Ho|last3=Shin|first3=Heakyeong|last4=Lee|first4=Jong Im|date=2012-11-14|title=Ecthyma Gangrenosum in a Previously Healthy Infant|url=http://e-aps.org/journal/view.php?doi=10.5999/aps.2012.39.6.673|journal=Archives of Plastic Surgery|language=English|volume=39|issue=6|doi=10.5999/aps.2012.39.6.673|issn=2234-6163}}</ref> |
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DiseasesDB = 29391 | |
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eMedicineSubj = derm | |
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eMedicineTopic = 539 | |
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'''Ecthyma gangrenosum''' is an infection of the [[skin]] typically caused by ''[[Pseudomonas aeruginosa]]''.<ref name="Medscape">{{cite web |url= https://emedicine.medscape.com/article/1053997-overview#showall|title= Ecthyma gangrenosum: Overview|last= Kingsberry|first= Mina|date= 13 July 2017|website= Medscape|publisher= |access-date= 20 November 2017|quote=}}</ref><ref name="Biscaye">{{cite journal |last1= Biscaye|first1= Stephanie|last2= Demoncy|first2= Diane|last3=Afanetti|first3=Mickael|last4=Dupont|first4=Audrey|last5=Haas|first5=Herve|last6=Tran|first6=Antoine|date= 2017|title= Ecthyma gangrenosum, a skin manifestation of Pseudomonas aeruginosa sepsis in a previously healthy child|url= https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266152/pdf/medi-96-e5507.pdf|journal= Medicine|volume= 96|issue= |pages= |doi= 10.1097/MD.0000000000005507|access-date= 20 November 2017}}</ref> It usually occurs in systemically ill or immunocompromised patients such as those with [[neutropenia]].<ref name="Biscaye"/> Ecythyma gangrenosum is almost always a sign of Pseudomonal sepsis, but other [[Gram-negative bacteria]] including [[Proteus (bacterium)|Proteus]] species and [[E coli]], as well as [[MRSA]], may cause similar presentations.<ref name="Medscape"/> |
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This type of skin lesion was first described in association with ''Pseudomonas aeruginosa'' by L. Barker in 1897.<ref name=":0">{{Cite journal|last=Vaiman|first=M.|last2=Lazarovitch|first2=T.|last3=Heller|first3=L.|last4=Lotan|first4=G.|date=2015-04-01|title=Ecthyma gangrenosum and ecthyma-like lesions: review article|url=https://link.springer.com/article/10.1007/s10096-014-2277-6|journal=European Journal of Clinical Microbiology & Infectious Diseases|language=en|volume=34|issue=4|pages=633–639|doi=10.1007/s10096-014-2277-6|issn=0934-9723}}</ref> It was given the name "'''ecthyma gangrenosum'''" by Hitschmann and Kreibich. <ref name=":1">{{Cite web|url=Kingsberry, M. (2017). Ecthyma gangrenosum: Overview. Medscape. Retrieved from https://emedicine.medscape.com/article/1053997-overview#showall|title=Ecthyma gangrenosum: Overview|last=Kingsberry|first=M|date=2017|website=Medscape|archive-url=|archive-date=|dead-url=|access-date=}}</ref> |
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== Presentation == |
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Ecthyma gangrenosum presents as a round or oval [[lesion]], 1.0 to 15 cm in diameter{{citation needed|date=November 2017}}, with a halo of [[erythema]].<ref name="Medscape"/> Lesions begin as painless [[macule]]s that evolve to become [[pustule|pustular]], [[Cutaneous condition#Nodule|nodular]], [[Bulla (dermatology)|bullous]], or haemorrhagic [[Vesicle (dermatology)|vesicular]]<ref name="Medscape"/><ref name="Biscaye"/><ref name="Acta">{{cite journal |last1= Vaiman|first1= Michael|last2= Lasarovitch|first2= Tsilia|last3=Heller|first3=Lior|last4=Lotan|first4=Gad|date= 2015|title= Ecthyma gangrenosum versus ecthyma-like lesions: should we separate these conditions?|url= https://s3-eu-west-1.amazonaws.com/thejournalhub/10.15570/actaapa.2015.18/actaapa.2015.18.pdf|journal= Acta Dermatovenerologica|volume= 24|issue= |pages= 69-72|doi= 10.15570/actaapa.2015.18|access-date= 20 November 2017}}</ref> Advanced lesions contain a [[necrotic]] center and an [[eschar]] with a surrounding erythematous edge<ref name="Medscape"/><ref name="Biscaye"/>, representing where the organism invaded [[blood vessel]]s and caused [[infarction]]s{{citation needed|date=November 2017}}. An early lesion may mature into a necrotic ulcer within 12 hours.<ref name="Medscape"/><ref name="Biscaye"/><ref name="Acta"/> These ulcerative lesions are single or multiple and heal with [[scar]] formation.{{citation needed|date=November 2017}} |
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It mostly occurs in patients with underlying immunocompromised conditions (e.g. [[Malignancy]]). Although most cases are found in ''Pseudomonas aeruginosa'' infection, there are recent reports of this skin lesion associated with other microorganisms, such as ''Escherichia coli, Citrobacter freundii, Klebsiella pneumonia'', various other Pseudomonas species, and ''Morganella morganii.''<ref name=":0" /> |
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== Pathophysiology == |
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The lesion is caused by perivascular invasion of bacteria in the dermis and subcutaneous tissue.<ref name="Medscape"/> The mechanism of tissue destruction is ''Pseudomonas'' [[protease]] and endotoxin A.<ref name="Varghese">{{cite journal |last1= Varghese|first1= George|last2= Eapen|first2= Pushpa|last3=Abraham|first3=Susanne|date= 2011|title= Ecthyma gangrenosum of a single limb|url= https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190474/|journal= Indian Journal of Critical Care Medicine|volume= 15|issue= 3|pages= 188-189|doi= 10.4103/0972-5229.84898|access-date= 20 November 2017}}</ref> The latter is similar to ''[[Corynebacterium diphtheriae]]'' toxin that inactivates [[elongation factor 2]] (thus inhibiting protein synthesis), [[elastase]] (an enzyme which degrades [[elastin]] in the blood vessel walls), [[phospholipase C]] (which degrades [[phospholipid]]s in cell membranes), and [[pyocyanin]] (which generates [[reactive oxygen species]] and can colour the pus in a wound [[blue]]){{citation needed|date=November 2017}}. |
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== |
== Mechanism == |
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{{Infobox disease||Name=Ecthyma gangrenosum|Image=|Caption=|DiseasesDB=29391|ICD10=|ICD9=|ICDO=|OMIM=|MedlinePlus=|eMedicineSubj=derm|eMedicineTopic=539|MeshID=}} |
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* [[Ecthyma]] |
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The organism enters directly through the breakdown of mechanical defense barriers such as [[Mucous membrane|mucosa]] or skin. Immunocompromised conditions make the patient more susceptible to this infection and [[Sepsis|septicemia]]. <ref name=":1" />In case of septicemia, the bacteria reaches the skin via the bloodstream. Defective [[Humoral immunity|humoral]] or [[Cell-mediated immunity|cellular immune system]] increases the risk because the organism is not able to be cleared from the bloodstream. The main mechanism of the organism that is causing the typical skin lesions is the invasion of the organism into the arteries and veins in the [[dermis]] and subcutaneous tissues of the skin. This [https://medical-dictionary.thefreedictionary.com/perivascular perivascular] invasion leads to nodular formation, ulceration, vasculitis and necrosis due to impaired blood supply. Perivascular involvement is achieved by direct entry of bacteria through the skin or [[Bacteremia|hematogenous]] spreading in case of sepsis. <ref name=":1" /> |
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== Symptoms == |
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The primary skin lesion usually starts with a [[macule]] that is painless, round and erythematous. Then, it develops into a pustule, and then a [[Bulla|bullae]] with central hemorrhagic focus. The bullae progresses into an ulcer which extends laterally. Finally it becomes a gangrenous ulcer with central black [[eschar]] surrounded by erythematous halo. <ref name=":1" /> |
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<references /> |
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The lesion may be single or multiple. They are most commonly seen in [[perineum]] and under arm pit. However, it can occur in any part of the body.<ref name=":1" /> |
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[[Category:Bacterium-related cutaneous conditions]] |
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== Diagnosis == |
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{{Cutaneous-infection-stub}} |
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Diagnosis is made by clinical [[observation]] and the following tests. |
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(1) [[Gram stain]] of the fluid from pustules or bullae, and tissue swab. |
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(2) Blood culture |
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(3) Urine culture |
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(4) Skin biopsy |
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(5) Tissue culture |
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[[Magnetic resonance imaging]] can be done in case of '''ecthyma gangrenosum''' of [[Anatomical terms of location|plantar]] foot to differentiate from [[necrotizing fasciitis]].<ref name=":1" /> |
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== Causes and prevention == |
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The main organism associated with '''ecthyma gangrenosum''' is ''Pseudomonas aeruginosa''. However, multi-bacterial cases are reported as well. Prevention measures include practicing proper hygiene, educating the immunocompromised patients for awareness to avoid possible conditions and seek timely medical treatment. <ref name=":1" /> |
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== Treatments and prognosis == |
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Treatments involve antibiotics that cover for ''Pseudomonas aeruginosa''. [[Antipseudomonal penicillins]], [[Aminoglycoside|aminoglycosides]], [[Quinolone antibiotic|fluoroquinolones]], third generation [[Cephalosporin|cephalosporins]] or [[aztreonam]] can be given. Usually, the antibiotics are changed according to the culture and sensitivity result. <ref name=":1" />In patients with very low white blood cell counts, [[Granulocyte-macrophage colony-stimulating factor]] may be given. Depending on the causal agents, antivirals or antifungals can be added.<ref name=":1" /> |
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Surgery will be needed if there is extensive necrosis and not responding to medical trea.tments. |
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== Recent research == |
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A recent retrospective study of all cases of '''Ecthyma gangrenosum''' from 2004-2010 in a university hospital in Mexico shows that [[neutropenia]] in immunocompromised patients is the most common risk factor for '''ecthyma gangrenosum'''. <ref>{{Cite journal|last=Martínez-Longoria|first=César Adrián|last2=Rosales-Solis|first2=Gloria María|last3=Ocampo-Garza|first3=Jorge|last4=Guerrero-González|first4=Guillermo Antonio|last5=Ocampo-Candiani|first5=Jorge|last6=Martínez-Longoria|first6=César Adrián|last7=Rosales-Solis|first7=Gloria María|last8=Ocampo-Garza|first8=Jorge|last9=Guerrero-González|first9=Guillermo Antonio|date=October 2017|title=Ecthyma gangrenosum: a report of eight cases|url=http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0365-05962017000500698&lng=en&nrm=iso&tlng=en|journal=Anais Brasileiros de Dermatologia|volume=92|issue=5|pages=698–700|doi=10.1590/abd1806-4841.20175580|issn=0365-0596}}</ref> |
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== References == |
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Revision as of 04:23, 13 December 2017
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Ecthyma gangrenosum is a type of skin lesion characterized by vesicles or blisters which rapidly evolve into pustules and necrotic ulcers with undermined tender erythematous border. "Ecthyma" means a pus forming infection of the skin with an ulcer, "gangrenosum" means the gangrene or necrosis. It is the pathognomonic of Pseudomonas aeruginosa bacteremia. Pseudomonas aeruginosa is a gram negative, aerobic, coccobacillus bacterium. [1]
This type of skin lesion was first described in association with Pseudomonas aeruginosa by L. Barker in 1897.[2] It was given the name "ecthyma gangrenosum" by Hitschmann and Kreibich. [3]
It mostly occurs in patients with underlying immunocompromised conditions (e.g. Malignancy). Although most cases are found in Pseudomonas aeruginosa infection, there are recent reports of this skin lesion associated with other microorganisms, such as Escherichia coli, Citrobacter freundii, Klebsiella pneumonia, various other Pseudomonas species, and Morganella morganii.[2]
Mechanism
| Ecthyma gangrenosum |
|---|
The organism enters directly through the breakdown of mechanical defense barriers such as mucosa or skin. Immunocompromised conditions make the patient more susceptible to this infection and septicemia. [3]In case of septicemia, the bacteria reaches the skin via the bloodstream. Defective humoral or cellular immune system increases the risk because the organism is not able to be cleared from the bloodstream. The main mechanism of the organism that is causing the typical skin lesions is the invasion of the organism into the arteries and veins in the dermis and subcutaneous tissues of the skin. This perivascular invasion leads to nodular formation, ulceration, vasculitis and necrosis due to impaired blood supply. Perivascular involvement is achieved by direct entry of bacteria through the skin or hematogenous spreading in case of sepsis. [3]
Symptoms
The primary skin lesion usually starts with a macule that is painless, round and erythematous. Then, it develops into a pustule, and then a bullae with central hemorrhagic focus. The bullae progresses into an ulcer which extends laterally. Finally it becomes a gangrenous ulcer with central black eschar surrounded by erythematous halo. [3]
The lesion may be single or multiple. They are most commonly seen in perineum and under arm pit. However, it can occur in any part of the body.[3]
Diagnosis
Diagnosis is made by clinical observation and the following tests.
(1) Gram stain of the fluid from pustules or bullae, and tissue swab.
(2) Blood culture
(3) Urine culture
(4) Skin biopsy
(5) Tissue culture
Magnetic resonance imaging can be done in case of ecthyma gangrenosum of plantar foot to differentiate from necrotizing fasciitis.[3]
Causes and prevention
The main organism associated with ecthyma gangrenosum is Pseudomonas aeruginosa. However, multi-bacterial cases are reported as well. Prevention measures include practicing proper hygiene, educating the immunocompromised patients for awareness to avoid possible conditions and seek timely medical treatment. [3]
Treatments and prognosis
Treatments involve antibiotics that cover for Pseudomonas aeruginosa. Antipseudomonal penicillins, aminoglycosides, fluoroquinolones, third generation cephalosporins or aztreonam can be given. Usually, the antibiotics are changed according to the culture and sensitivity result. [3]In patients with very low white blood cell counts, Granulocyte-macrophage colony-stimulating factor may be given. Depending on the causal agents, antivirals or antifungals can be added.[3]
Surgery will be needed if there is extensive necrosis and not responding to medical trea.tments.
Recent research
A recent retrospective study of all cases of Ecthyma gangrenosum from 2004-2010 in a university hospital in Mexico shows that neutropenia in immunocompromised patients is the most common risk factor for ecthyma gangrenosum. [4]
References
- ^ Koo, Su Han; Lee, Joon Ho; Shin, Heakyeong; Lee, Jong Im (2012-11-14). "Ecthyma Gangrenosum in a Previously Healthy Infant". Archives of Plastic Surgery. 39 (6). doi:10.5999/aps.2012.39.6.673. ISSN 2234-6163.
- ^ a b Vaiman, M.; Lazarovitch, T.; Heller, L.; Lotan, G. (2015-04-01). "Ecthyma gangrenosum and ecthyma-like lesions: review article". European Journal of Clinical Microbiology & Infectious Diseases. 34 (4): 633–639. doi:10.1007/s10096-014-2277-6. ISSN 0934-9723.
- ^ a b c d e f g h i Kingsberry, M (2017). [Kingsberry, M. (2017). Ecthyma gangrenosum: Overview. Medscape. Retrieved from https://emedicine.medscape.com/article/1053997-overview#showall "Ecthyma gangrenosum: Overview"]. Medscape.
{{cite web}}: Check|url=value (help); Cite has empty unknown parameter:|dead-url=(help) - ^ Martínez-Longoria, César Adrián; Rosales-Solis, Gloria María; Ocampo-Garza, Jorge; Guerrero-González, Guillermo Antonio; Ocampo-Candiani, Jorge; Martínez-Longoria, César Adrián; Rosales-Solis, Gloria María; Ocampo-Garza, Jorge; Guerrero-González, Guillermo Antonio (October 2017). "Ecthyma gangrenosum: a report of eight cases". Anais Brasileiros de Dermatologia. 92 (5): 698–700. doi:10.1590/abd1806-4841.20175580. ISSN 0365-0596.