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A Case of Ecthyma Gangrenosum Caused by MRSA FREE TO VIEW

Manveen Dassan, MD; Humera Kausar, MD; Pavan Irukulla, MBBS; Yizhak Kupfer, MD; Chanaka Seneviratne, MD
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Maimonides Medical Center, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):280A. doi:10.1378/chest.2238464
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SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Ecthyma Gangrenosum (EG) is a well-known skin lesion that has been associated with extensive pseudomonal infection. We report a case of EG that was caused by systemic infection with MRSA

CASE PRESENTATION: A 41 year old previously healthy male presented with severe weight loss and decreased appetite. His workup led to a new diagnosis of pre B cell lymphoblastic leukemia. The patient was subsequently started on an appropriate chemotherapeutic regimen. On day 10 of treatment, he developed neutropenic septic shock and required vasopressors. At this point, the patient developed a new skin lesion, described as a dark, 5x5 mm non-blanching macule. The patient was started on broad spectrum antibiotics including Vancomycin. One day later, blood cultures and fluid aspirated from the lesion grew MRSA sensitive to Vancomycin. Treatment with Vancomycin continued for the following two weeks. The patient’s blood pressure normalized by day 6 and subsequent blood cultures from day 4 onward remained negative.

DISCUSSION: EG is classically described as maculopapular hemorrhagic bullae which progress to ulcerated punched out lesions, typically covered in black/gray eschar and surrounded by erythematous halos1. Though commonly associated with pseudomonas aeruginosa infection3, many other organisms, including viral and fungal, have been implicated2. EG can cause both bacteremia and localized infections. From greatest to least, the areas affected are gluteal/perineal, extremities, face and body3. Localized EG is usually caused by an infection at a site of previous trauma2. The prognosis depends upon a number of factors, though the bacteremic form carries a higher mortality2. Neutropenia, immunocompromised states, coexisting infections, and inadequate antibiotic treatment have all been associated with worse outcomes2. Early empiric antibiotic therapy is the mainstay of treatment for EG1. Typical treatment regimens include coverage with an anti-pseudomonal penicillin or carbapenem, in addition to an aminoglycoside or fluoroquinolone2. This case demonstrates that EG can be caused by overwhelming MRSA infection. Despite the patient’s neutropenic state, he responded well to Vancomycin and was able to be discharged home.

CONCLUSIONS: MRSA is a rare cause of EG. Initial empiric antibiotic therapy for EG should be a regimen which includes both anti-pseudomonal and MRSA agents. Early appropriate antibiotics are associated with improved survival.

Reference #1: Greene SL, Su WP, Muller SA.Ecthyma gangrenosum:report of clinical, histopathologic and bacteriologic aspects of eight cases. J Am Acad Dermatol.1984;11:781-7

Reference #2: Weiel JJ, Zhang CZ, Smith JA, et al. Clinicopathologic aspects of ecthyma gangrenosum in pediatric patients: A case series and review of the literature. J Clin Anat Pathol.2013;1:1-5

Reference #3: Son, Young Min et al. “Ecthyma Gangrenosum:A Rare Cutaneous Manifestation Caused by Stenotrophomonas Maltophilia in a Leukemic Patient.” Annals of Dermatology 21.4 (2009): 389-392. PMC. Web.5 Mar.2015.

DISCLOSURE: The following authors have nothing to disclose: Manveen Dassan, Humera Kausar, Pavan Irukulla, Yizhak Kupfer, Chanaka Seneviratne

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