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Ecthyma Gangrenosum

Ecthyma gangrenosum is a medical condition in which the skin becomes infected with pseudomonas aeruginosa. The people who are most at risk of developing this skin condition are those who are critically ill or those whose immune system is severely compromised. In many of these patients, this condition is a sign of generalized infection in the body (with the same pathological agent). Ecthyma gangrenosum is mainly characterized by the appearance of lesions in the skin in the form of vesicles or pustules. These tend to be hemorrhagic and they quickly progress to necrotic ulcers.

This condition occurs when the skin no longer represents a defensive barrier and the bacteria easily disseminate into the body. What happens is that pseudomonas aeruginosa enters the body and affects the arteries and veins in the skin, causing their walls to be inflamed and quickly leading to necrosis. The affectation of the blood vessels leads to secondary necrosis in the other layers of the skin, contributing to the aggravation of the disease. This condition has a high mortality rate, especially if emergency medical treatment is not administered. There is no prevalence whereas the gender is concerned and, when it comes to age, it seems that children and the elderly are the most affected (as their immune system does not function properly).

Symptoms of Ecthyma Gangrenosum

These are the most common symptoms of ecthyma gangrenosum:

Prodromal symptoms (precede the appearance of lesions on the skin: Diarrhea (in children) and Fever
First lesions are macules and pustules
These lesions are painless and they have a red surrounding border
As the lesions progress, they form a hemorrhagic center (bulla)
The lesions evolve into necrotic ulcers
The transformation from the initial lesion to the necrotic ulcer can undergo in a matter of hours
Single or multiple lesions are present on the skin
Areas that are most affected: anal, genital and axillary
Any other part of the body can be affected, especially if there is a generalized infection with pseudomonas aeruginosa
Other areas that can be affected include:
- Gluteal region
- Perineal region
- Upper or inferior limb extremities
- Trunk
- Face – In rare cases – bilateral periorbital lesions
Lesions heal with the formation of scars

What are the Causes of Ecthyma Gangrenosum?

These are the most common causes that lead to the appearance of ecthyma gangrenosum:

Infection with pseudomonas aeruginosa
Other bacterial/fungal infections
Gram positive bacteria
- Staphylococcus aureus
- Streptococcus pyogenes
Gram negative bacteria
- Escherichia coli
- Klebsiella pneumoniae
- Neisseria gonorrhoeae
- Aeromonas hydrophila
- Yersinia pestis
Fungal infection
- Candida albicans
- Aspergillus fumigatus
- Fusarium solani
Infection with the herpes simplex virus

Diagnosis

These are the most common methods used for the diagnosis of ecthyma gangrenosum:

Gram stain
- A sample is taken from the center of the lesion
Blood culture
- Blood is drawn before starting the treatment with antibiotics
- The best period for a blood culture is when the patient runs a high fever (sign of powerful infection in the body, the bacteria is rapidly disseminated)
Skin biopsy
- This is performed for differential diagnosis, so as to rule other possible causes that leads to the appearance of this medical condition
- Vascular necrosis is identified through this method
Tissue culture
- This is performed in order to clearly identify the bacteria, fungi or virus causing the infection on the skin
- Includes the sensitivity tests
Urine culture
- Identify rests of infectious agents
Differential diagnosis
- Cutaneous anthrax
- Aspergillosis
- Ecthyma
- Pyoderma gangrenosum
- Septic emboli
Imaging (MRI) can also be used for the diagnosis of ecthyma gangrenosum

Treatment

These are the most common courses of treatment undertaken for ecthyma gangrenosum:

Antibiotic therapy

Antibiotics need to be administered rapidly and in correspondence with the bacterial agent causing the infection
The most recommended antibiotics are:
- Penicillin that works against pseudomonas aeruginosa
- Aminoglycosides
- Fluoroquinolones
- Cephalosporin (third generation)
In order to obtain the best results, two antibiotics can be recommended at the same time

Surgical debridement

This is recommended in cases when the patients do not respond to the antibiotic therapy
The procedure is necessary to stop the spreading of the necrotic ulcers

Other treatments include:

Administration of granulocyte-macrophage colony-stimulating factor – Aids with the recovery process
In case of fungal infection
- Anti-fungal treatment
- Systemic medication against the most common fungi
The treatment is only administered after the result of the blood cultures arrives. It is important to know the kind of pathogen that is causing the infection in order to administer the right treatment.
Poor prognosis is considered to be in the following cases:
- Multiple necrotic ulcers present on the skin, spreading continuously
- Delayed treatment with antibiotics
- High count of bacteria in the blood
- Generalized sepsis with pseudomonas aeruginosa