Ecthyma gangrenosum in pediatrics JUAN ROJAS (1) JUAN LOPEZ (2) YULY MUÑOZ (2) GUILLERMO GONZALEZ (3) Pediatric Infectious Diseases Fellowship Program. University El Bosque/ University Libre sectional Cali. Colombia, South America. Physician. University Libre sectional Cali, Colombia, South America. Pediatric dermatologist. Club Noel Children´s Hospital. University Libre sectional Cali, Colombia, South America. r

Introduction Etiology Clinical Manifestations Histologic findings Differential diagnosis Treatment

Introduction Ecthyma gangrenosum (EG) is a rare infection of the skin Lesion caused by P. aeruginosa Other types of bacteria: S. aureus or beta hemolytic group Often associated: Primary and secondary immunodeficiency Qualitative and quantitative neutrophil defects Infectio 2013;17(1):43–47 Acta Pædiatrica 2015; 104:134–138

Introduction Mortality: 40%-75% of immunologically compromised individuals Characterized by black eschars on an erythematous base Diagnosis: Symptoms Cultures and skin biopsies Infectio 2013;17(1):43–47 Acta Pædiatrica 2015; 104:134–138

Pediatric Dermatology 2013; 30 (6): 1-2 Etiology The most common pathogen: P. aeruginosa A. hydrophila, S. aureus, S. marcescens, E. coli, K. pneumoniae, N. meningitidis, V. vulnificus, B. cepacia Fungi: Fusarium sp, Candida sp, Mucor and Aspergillus sp caused by P. aeruginosa, but can also be caused by a number of pathogens such as Aeromonas hydrophila, Staphylococcus aureus, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Neisseria meningitidis, Vibrio vulnificus, Burkholderia cepacia; and fungi such as Fusarium sp, Candida sp, Mucor and Aspergillus sp Acta Pædiatrica 2015; 104:134–138 Pediatric Dermatology 2013; 30 (6): 1-2

Clinical Manifestations Hemorrhagic bullae or necrotic ulcers that have progressed from painless macules or papules Often the presenting lesion will exhibit an erythematous halo Depending on the extent of infection and immune status: The patient may also be febrile with other constitutional symptoms Dermatology Online Journal 2012; 18 (3): 3

Treatment: acyclovir, clindamycin and cefepime Clinical case Girl: 5 years old Initially presented chickenpox and then infection with S. aureus EG Treatment: acyclovir, clindamycin and cefepime A, B, C, D: Erosions and deep ulcers, with serous and hematic crusts, necrotic background Infectio 2013;17(1):43–47

A, B, C: erythematous papules and macules with irregular borders Infectio 2013;17(1):43–47

Exudating deep, blackish eschar surrounded by extended ulceration and erythema Arch Dis Child 2015;100:54–56

Necrotic skin lesion with surrounding erythema and dilated veins Arch Dis Child Fetal Neonatal 2011; 96 (4): 1

Erythema, nodules, bulla, and ulcers with necrosis on the right femoribus internus Pediatric Dermatology 2011; 28 (2): 1-3

Initial presentation Wound at 2 months Pediatric Dermatology 2013; 30 (6): 1-2

Dermatology Online Journal 2012; 18 (3): 3 Histologic findings Necrotizing vasculitis in which the media and adventitia of the vascular wall are invaded, but the intima is spared Singapore Med J. 2006; 47: 1080 Dermatology Online Journal 2012; 18 (3): 3 Infectio 2013;17(1):43–47

Differential diagnosis Bacterial cellulitis Insect bites In the early, hyperaemic phase Deep group α β-haemolytic Streptococci impetigo Burns In the late, eschar-necrotising phase Arch Dis Child 2015;100:54–56

Pediatric Dermatology 2011; 28 (2): 1-3 Treatment Empirical antimicrobial therapy: Anti-Pseudomonal penicillins and aminoglycosides Adjusted on the basis of culture results Should be started Pediatric Dermatology 2011; 28 (2): 1-3 Arch Dis Child 2015;100:54–56 Acta Pædiatrica 2015; 104:134–138

Pediatric Dermatology 2011; 28 (2): 1-3 Treatment Debridement Assessment of immune function Full blood count and peripheral blood smear HIV serology Immunoglobulin levels Neutrophil function tests Pediatric Dermatology 2011; 28 (2): 1-3 Arch Dis Child 2015;100:54–56 Acta Pædiatrica 2015; 104:134–138