Ecthyma gangrenosum Due to Escherichia coli Bacteremia in a Patient with Acute Myeloid Leukemia: A Case Report and a Literature Review About E. coli-Induced Ecthyma gangrenosum

AUTHORS

Mohammadreza Salehi 1 , Ramezanali Sharifian 2 , Alireza Shafiy Almasian 2 , Seyed Ali Dehghan Manshadi 1 , Arash Seifi 1 , Ailar Ahangari 1 , *

1 Department of Infectious Diseases and Tropical Medicine, Tehran University of Medical Sciences, Tehran, Iran

2 Hematology and Oncology Department, Tehran University of Medical Sciences, Tehran, Iran

How to Cite: Salehi M, Sharifian R, Shafiy Almasian A, Dehghan Manshadi S A, Seifi A, et al. Ecthyma gangrenosum Due to Escherichia coli Bacteremia in a Patient with Acute Myeloid Leukemia: A Case Report and a Literature Review About E. coli-Induced Ecthyma gangrenosum, Arch Clin Infect Dis. Online ahead of Print ; 14(3):e66413. doi: 10.5812/archcid.66413.

ARTICLE INFORMATION

Archives of Clinical Infectious Diseases: 14 (3); e66413
Published Online: June 8, 2019
Article Type: Case Report
Received: January 17, 2018
Revised: March 15, 2019
Accepted: May 19, 2019
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Abstract

Introduction: Ecthyma gangrenosum is a skin lesion presenting invasive infection in the skin, which is commonly caused by Pseudomonas. Pathogenesis is mostly attributed to the microbial invasion in cutaneous tissues caused by the microorganism. One of the important, but rare causes of Ecthyma gangrenosum after Pseudomonas is Escherichia coli.

Case Presentation: A 45-year-old woman known as a case with acute myeloid leukemia who went into remission due to chemotherapy. After chemotherapy, she was febrile and septic. A physical examination revealed an erythematous round lesion (3 × 3 cm) that had developed on the posterior aspect of the right thigh with central bolus necrosis. E. coli was detected based on both blood cultures.

Conclusions: Ecthyma gangrenosum is mostly seen in patients with severe immunodeficiency such as aplastic anemia, hematologic malignancies, especially patients with leukemia after chemotherapy and also in HIV patients. So far, in 11 patients reported in the literature, at least 8 cases are reported lesions on the lower limb, which is the most probable anatomic area for E. coli-induced Ecthyma gangrenosum. The E. coli-induced Ecthyma gangrenosum is a rare infectious lesion that is particularly seen in patients with a malignancy history, and lower extremity lesions should be considered.

Keywords

Ecthyma gangrenosum Escherichia coli Leukemia

Copyright © 2019, Archives of Clinical Infectious Diseases. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Ecthyma gangrenosum is a skin lesion presenting an invasive infection in the skin that commonly caused by Pseudomonas. Also, these lesions may rarely present in patients without bacteremia (1, 2). They usually show themselves as one or several macular lesions or papules with a red and inflamed area and then change into a hemorrhagic bulla and finally become necrotic (1, 3). The first case of Ecthyma gangrenosum was explained in 1987 and first named in 1930. Pathogenesis is mostly microbial invasion in cutaneous tissues caused by microorganism produced bacteremia. That microorganism is usually a Gram-negative and mostly Pseudomonas, which infiltrates through perivascular area. In case of no bacteremia, mostly cutaneous infiltration of microorganism is known as the cause (2). Although Ecthyma gangrenosum was pathognomonic for Pseudomonas-induced septicemia in the past, today other kinds of microorganisms, including a variety of bacteria and fungi and viruses are known as the triggering factor. One of the important, but rare causes of Ecthyma gangrenosum after Pseudomonas is E. coli, which can be as a result of bacteremia, cellulitis, and urinary tract infection (2, 4). E. coli-induced soft tissue infections are rare and are usually seen in patients with severe immunodeficiency (5).

2. Case Presentation

A 45-year-old woman known as the case of acute myeloid leukemia (AML-M5) who went into remission due to chemotherapy with 7-3 regimen (7 days cytarabine and 3 days daunorubicin). On the 21st day after chemotherapy, she was febrile and septic. A physical examination revealed an erythematous round lesion (3 × 3 cm) that had developed on the posterior aspect of the right thigh with central bolus necrosis (Figure 1). Absolute neutrophil count (ANC) was fewer than 200 cell/mm3 at that time. Sepsis work-up included 2 sets of blood culture for 30 minutes. Then imipenem, vancomycin, and amphotericin B started. After 48 hours, E. coli detection on both blood cultures that were sensitive to imipenem and amikacin. Vancomycin and amphotericin B were stopped and amikacin added to imipenem. Systemic symptoms subsided after a few days and Ecthyma gangernusom completely improved 2 weeks later.

Erythematous round lesion with central bolus necrosis
Figure 1. Erythematous round lesion with central bolus necrosis

3. Discussion

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 ReportYearNumber of CasePresenting SitePreceding BacteremiaUnderlying Disease
Anderson (7)19791Left nostrilnoGastroenteritis
Rajan (8)19821Upper extremity and lower extremityyesAlcoholic cirrhosis
Edelstein and Cutting (9)19863Lower extremity and perianal skinYesLung cancer
Fuchshuber et al. (10)19981Lower extremityYesMultiple myeloma
Patel et al. (2)20091Upper extremityYesAML
Gomes et al. (11)20121Lower extremityYesNo
Pathak et al. (1)20131Lower extremityYesNo
Mouna et al. (3)20151Lower extremityNoNo
Salehi20181Lower extremityYesAML

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.

Footnotes

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