Ecthyma gangrenosum in pediatrics JUAN ROJAS 1 JUAN

Introduction Etiology Clinical Manifestations Histologic findings Differential Treatment diagnosis

Introduction Ecthyma gangrenosum (EG) is a rare infection of the skin Lesion caused by

Introduction Mortality: 40%-75% of immunologically compromised individuals Characterized by black eschars on an erythematous

Etiology The most common pathogen: P. aeruginosa A. hydrophila, S. aureus, S. marcescens, E.

Clinical Manifestations Hemorrhagic bullae or necrotic ulcers that have progressed from painless macules or

Clinical case Girl: 5 years old Initially presented chickenpox and then infection with S.

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

Exudating deep, blackish eschar surrounded by extended ulceration and erythema Arch Dis Child 2015;

Necrotic skin lesion with surrounding erythema and dilated veins Arch Dis Child Fetal Neonatal

Erythema, nodules, bulla, and ulcers with necrosis on the right femoribus internus Pediatric Dermatology

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

Histologic findings Necrotizing vasculitis in which the media and adventitia of the vascular wall

Differential diagnosis Bacterial Insect In cellulitis bites the early, hyperaemic phase Deep group α

Treatment ü Empirical antimicrobial therapy: ü Anti-Pseudomonal penicillins ü and aminoglycosides ü Adjusted Should

Treatment ü Debridement ü Assessment of immune function ü Full blood count and peripheral

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

Introduction Etiology Clinical Manifestations Histologic findings Differential Treatment diagnosis

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

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 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

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

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 Insect In cellulitis bites 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

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

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