Case Letter
Ecthyma gangrenosum in neutropenic patients and the importance of an early skin biopsy for direct examination
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Marcio Nucci" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Yung" "apellidos" => "Gonzaga" "email" => array:1 [ 0 => "yungbmg@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Thiago" "apellidos" => "Jeunon" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Jorge" "apellidos" => "Machado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Marcio" "apellidos" => "Nucci" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Private clinic, Rio de Janeiro, RJ, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 576 "Ancho" => 900 "Tamanyo" => 73951 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thick, non-septate hyaline hyphae, branching at a right angle. Direct examination. KOH 20% and Parker's ink.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma Gangrenosum (EG) was once considered pathognomonic for sepsis caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, other agents have been described in oncohaematological patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Skin biopsies are often not performed, and treatment is usually empirical. This report describes three cases of neutropenic patients with EG who underwent skin biopsy with direct examination.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patient 1: Male, 36 years old, with acute lymphoblastic leukemia, presented with febrile neutropenia (FN) during chemotherapy, and treatment with cefepime was started. After ten days, he once again had a fever, with the appearance of erythematous lesions with a necrotic center on the face and chest. He had neutropenia (10/mm<span class="elsevierStyleSup">3</span>) and thrombocytopenia (24,000/ mm<span class="elsevierStyleSup">3</span>). Blood cultures and a skin biopsy were collected, and liposomal amphotericin B and voriconazole were started. Direct examination identified septate hyaline hyphae (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which were later also detected in the histopathological examination. <span class="elsevierStyleItalic">Fusarium spp</span>. was identified in blood and skin cultures. The patient did not survive depicting of the treatment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Patient 2: Male, 47 years old, had FN during chemotherapy for acute myeloid leukemia, and treatment with cefepime was started. After fourteen days, he once again had a fever, with the appearance of a single erythematous lesion with a necrotic center, on the chest (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). He had neutropenia (40/ mm<span class="elsevierStyleSup">3</span>) and thrombocytopenia (44,000/ mm<span class="elsevierStyleSup">3</span>). Blood cultures and a skin biopsy were collected. Direct examination revealed non-septate hyaline hyphae (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which were later seen in the histopathological examination. Antifungal treatment with liposomal amphotericin B was started. Subsequently, <span class="elsevierStyleItalic">Syncephalastrum spp</span>. was identified in the skin culture. The patient remained afebrile, with neutrophilic recovery.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Patient 3: Male, 36 years old, had FN during chemotherapy for acute myeloid leukemia, and treatment with cefepime was started. After four days, he had a fever, and arterial hypotension, with the appearance of an erythematous lesion with a necrotic center on the back region. Antibiotic therapy was expanded to include polymyxin B, amikacin, and meropenem. He had neutropenia (170/ mm<span class="elsevierStyleSup">3</span>) and thrombocytopenia (2,000/ mm<span class="elsevierStyleSup">3</span>). A skin biopsy was collected, and a direct examination identified the presence of gram-negative rods. No specimen was sent for histopathological examination. Subsequently, multidrug-resistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> was identified in the skin and blood cultures. The antimicrobial regimen was maintained until a clinical resolution was attained.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The present report describes three cases of neutropenic patients who developed EG. All had a similar clinical presentation, with fever recurrence and the appearance of lesions during antibiotic therapy. In the first patient, direct examination suggested the diagnosis of fusariosis, directing the combined antifungal treatment. The cause of death was attributed to the absence of immune reconstitution. In the second patient, the direct examination suggested the diagnosis of mucormycosis, directing the change of the antifungal agent for liposomal amphotericin B. In the third patient, the direct examination suggested the diagnosis of bacterial sepsis, directing the expansion of the antibiotic regimen without the association of antifungal agents.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Typically, the EG agent is identified in blood and skin cultures. However, as these results are not promptly available, the treatment is usually the empirical expansion of the anti-infective regimen. The disadvantages of this approach are exposure to toxic drugs and increased costs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The skin biopsy is a safe procedure in thrombocytopenic patients.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Direct examination helped to identify the agent before the results of cultures were obtained, which later confirmed what had already been detected.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary, we suggest performing an early skin biopsy with direct examination in neutropenic patients with EG.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Yung Gonzaga: Approval of the final version of the manuscript; critical review of the literature; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript; drafting and editing of the manuscript; statistical analysis; design and planning of the study.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Thiago Jeunon: Approval of the final version of the manuscript; critical review of the literature; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript; drafting and editing of the manuscript; statistical analysis; design and planning of the study.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Jorge Machado: Approval of the final version of the manuscript; critical review of the literature; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript; drafting and editing of the manuscript; statistical analysis; design and planning of the study.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Marcio Nucci: Approval of the final version of the manuscript; critical review of the literature; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript; drafting and editing of the manuscript; statistical analysis; design and planning of the study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-14" "fechaAceptado" => "2020-11-11" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1193 "Ancho" => 750 "Tamanyo" => 167263 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Septate hyaline hyphae with branching at an acute angle. Direct examination, KOH 20%, ×40.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 672 "Ancho" => 900 "Tamanyo" => 92308 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Single erythematous lesion with necrotic center in the anterior thoracic region, close to the Hickman catheter.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 576 "Ancho" => 900 "Tamanyo" => 73951 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thick, non-septate hyaline hyphae, branching at a right angle. 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"fecha" => "1970" "volumen" => "57" "paginaInicial" => "34" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5445814" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecthyma gangrenosum and ecthyma-like lesions: review article" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Vaiman" 1 => "T. Lazarovitch" 2 => "L. Heller" 3 => "G. Lotan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Clin Microbiol Infec Dis." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 27 | 8 | 35 |
| 2024 October | 135 | 76 | 211 |
| 2024 September | 174 | 94 | 268 |
| 2024 August | 173 | 127 | 300 |
| 2024 July | 173 | 117 | 290 |
| 2024 June | 140 | 103 | 243 |
| 2024 May | 96 | 60 | 156 |
| 2024 April | 137 | 93 | 230 |
| 2024 March | 63 | 66 | 129 |
| 2024 February | 85 | 85 | 170 |
| 2024 January | 80 | 75 | 155 |
| 2023 December | 70 | 50 | 120 |
| 2023 November | 77 | 98 | 175 |
| 2023 October | 77 | 69 | 146 |
| 2023 September | 75 | 85 | 160 |
| 2023 August | 57 | 39 | 96 |
| 2023 July | 77 | 37 | 114 |
| 2023 June | 61 | 43 | 104 |
| 2023 May | 58 | 24 | 82 |
| 2023 April | 42 | 24 | 66 |
| 2023 March | 66 | 48 | 114 |
| 2023 February | 56 | 34 | 90 |
| 2023 January | 50 | 36 | 86 |
| 2022 December | 42 | 30 | 72 |
| 2022 November | 71 | 61 | 132 |
| 2022 October | 82 | 67 | 149 |
| 2022 September | 55 | 65 | 120 |
| 2022 August | 69 | 56 | 125 |
| 2022 July | 86 | 77 | 163 |
| 2022 June | 38 | 41 | 79 |
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