Ecthyma gangrenosum is specific skin lesion, which is usually accompanied by Pseudomonas septicemia and rarely can be seen with other microorganisms such as Streptococcus, Aeromonas hydrophila, Staphylococcus aureus, Serratia marcescens, Pseudomonas maltophilia, Citrobacter freundii, E. coli, Candida albicans, Aspergillus, and Mucor species (3). In a review done by Vaiman et al. (4), 197 patients suffering from Ecthyma gangrenosum infection were studied between 1975 to 2014. In this study, they found out that in 123 patients, Pseudomonas caused 73.65% and other agents caused 17.35% and the remaining 9% was induced by fungal agents.
Ecthyma gangrenosum is mostly seen in patients with severe immunodeficiency, including Agammaglobulinemia, aplastic anemia, hematologic malignancies, especially patients with leukemia after chemotherapy, and also in HIV patients. However, it was also reported in patients without defect in the immune system (2-4). Ecthyma gangrenosum is usually diagnosed based on the patient’s history, underlying diseases, blood culture, and tissue culture. Early recognition and rapid antibiotic therapy for these lesions are very important in decreasing the mortality rate (2).
Nowadays, general infections caused by E. coli are of the important problems in patients with hematological malignancies, especially after chemotherapy, which is usually followed by bad prognoses (5). Cellulitis and different types of soft tissue infections caused by E. coli, are rare and usually need background risk factors such as reduced number or dysfunction of neutrophils (6). The first E. coli-induced Ecthyma gangrenosum was reported in 1979 in a 1-year-old baby with cellulitis on the left nostril without bacteremia and E. coli was isolated from the lesion and the nose (2, 5).
In a literature review by Patel et al. (2) in 2009, which was published in Cutis journal, there was 7 cases of Ecthyma gangrenosum caused by E. coli, and the first E. coli-induced Ecthyma gangrenosum was reported in a patient suffering from AML. We reported the second Ecthyma gangrenosum case that caused by E. coli in a woman who was an AML patient. Based on a search of the literature using PubMed/MEDLINE for EG/E. coli, until Nov. 24th in 2017, we have added 5 new cases to the table designed in Patel et al.’s article (Table 1) (2). So far, in 11 patients reported in the literature, at least 8 cases reported lesions on the lower limb, which seems is the most probable anatomic area for E. coli-induced Ecthyma gangrenosum.
Table 1.
Ecthyma gangrenosum Caused by Escherichia coli; Reports in the Literature (2)
Case Report | Year | Number of Case | Presenting Site | Preceding Bacteremia | Underlying Disease |
---|
Anderson (7) | 1979 | 1 | Left nostril | no | Gastroenteritis |
Rajan (8) | 1982 | 1 | Upper extremity and lower extremity | yes | Alcoholic cirrhosis |
Edelstein and Cutting (9) | 1986 | 3 | Lower extremity and perianal skin | Yes | Lung cancer |
Fuchshuber et al. (10) | 1998 | 1 | Lower extremity | Yes | Multiple myeloma |
Patel et al. (2) | 2009 | 1 | Upper extremity | Yes | AML |
Gomes et al. (11) | 2012 | 1 | Lower extremity | Yes | No |
Pathak et al. (1) | 2013 | 1 | Lower extremity | Yes | No |
Mouna et al. (3) | 2015 | 1 | Lower extremity | No | No |
Salehi | 2018 | 1 | Lower extremity | Yes | AML |
Abbreviation: AML, acute myeloid leukemia.
About 81.8% of the patients equal to 9 out of 11 reported E. coli-induced bacteremia accompanying their disease, which reminds the importance of sending blood culture in patients with Ecthyma gangrenosum. In our case, the isolated E. coli was an extended spectrum β lactamase (ESBL) producer, which is an enzyme providing resistance to most beta-lactam antibiotics and makes the treatment more difficult. Given underlying diseases, 6 of the patients (54.4%) had a history of malignancy (3 pulmonary cancers, 2 AML, and 1 Multiple Myeloma), 3 patients (27.2 %) had no specific previous disease, 1 patient had cirrhosis, and 1 patient had Gastroenteritis. It seems the malignancy history is the most important risk factor in developing E. coli-induced Ecthyma gangrenosum.
3.1. Conclusions
Although E. coli-induced Ecthyma gangrenosum is a rare infectious lesion, especially in patients with a malignancy history, lower extremity lesions should be considered carefully. In these patients sending blood culture, antibiogram, and rapid appropriate antibiotic therapy can be effective in adopting good management and saving patients’ lives.
LEAVE A COMMENT HERE: