Case Letter
Ecthyma gangrenosum and severe transitory neutropenia in an immunocompetent girl
Pablo Vargas-Mora
, Santiago García, Ligia Aranibar, Fernando Valenzuela
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Department of Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile
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0 ] "pt" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta – Caso clínico</span>" "titulo" => "Ectima gangrenoso e neutropenia transitória grave em criança imunocompetente" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "668" "paginaFinal" => "669" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 750 "Tamanyo" => 59397 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bolha hemorrágica na vulva com dois dias de evolução.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pablo Vargas‐Mora, Santiago García, Ligia Aranibar, Fernando Valenzuela" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pablo" "apellidos" => "Vargas‐Mora" ] 1 => array:2 [ "nombre" => "Santiago" "apellidos" => "García" ] 2 => array:2 [ "nombre" => "Ligia" "apellidos" => "Aranibar" ] 3 => array:2 [ "nombre" => "Fernando" "apellidos" => "Valenzuela" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059620301859" "doi" => "10.1016/j.abd.2020.03.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301859?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302599?idApp=UINPBA00008Z" "url" => 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Atrophic epidermis can be seen with moderate spongiosis and a central area with marked pallor due to the presence of apoptotic keratinocytes of vacuolated appearance below a more superficial layer of extensive hyperkeratosis and parakeratosis, producing a “tricolor flag” appearance (Hematoxylin & eosin, ×20).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inés Gracia-Darder, Daniel Ramos, Julián Boix-Vilanova, Ana Francisca Bauzá-Alonso" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Inés" "apellidos" => "Gracia-Darder" ] 1 => array:2 [ "nombre" => "Daniel" "apellidos" => "Ramos" ] 2 => array:2 [ "nombre" => "Julián" "apellidos" => "Boix-Vilanova" ] 3 => array:2 [ "nombre" => "Ana Francisca" "apellidos" => "Bauzá-Alonso" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220302575" "doi" => "10.1016/j.abdp.2020.02.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302575?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301847?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301847/v2_202011080908/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Letter</span>" "titulo" => "Ecthyma gangrenosum and severe transitory neutropenia in an immunocompetent girl" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "668" "paginaFinal" => "669" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pablo Vargas-Mora, Santiago García, Ligia Aranibar, Fernando Valenzuela" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Pablo" "apellidos" => "Vargas-Mora" "email" => array:1 [ 0 => "pablovargas.med@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Santiago" "apellidos" => "García" ] 2 => array:2 [ "nombre" => "Ligia" "apellidos" => "Aranibar" ] 3 => array:2 [ "nombre" => "Fernando" "apellidos" => "Valenzuela" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Faculty of Medicine, University of Chile, Santiago, Chile" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 750 "Tamanyo" => 58061 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hemorrhagic blister on vulva, two days of evolution.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma gangrenosum (EG) is a rare cutaneous lesion, principally caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, through either primary infection or hematogenous spread. Other pathogenic agents responsible have also been described, such as <span class="elsevierStyleItalic">Aeromonas hydrophila</span>, <span class="elsevierStyleItalic">Staphylococcus aureus</span>, and <span class="elsevierStyleItalic">Aspergillus</span> spp., among others.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It generally develops in patients with sepsis or immunosuppression, in a context of hematological malignancies or immunosuppressive therapy. It presents with erythematous/violaceous or hemorrhagic lesions that evolve into a central necrotic ulcer with an erythematous halo, preferentially situated on the buttocks and legs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This report presents the case of a previously healthy baby girl with genital EG and the subsequent development of a severe transitory neutropenia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A previously healthy 17-month-old girl presented with a hemorrhagic blister on the left side of her vulva. It had started seven days before, with perilesional erythema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) that progressively developed ulceration and edema. There was no fever or other systemic symptoms. She was treated with oral cefpodoxime and clindamycin. As there was no improvement after 72 hours, she was hospitalized and referred to dermatology. On physical examination, the patient was in good general condition with stable hemodynamics and no fever. She had a skin ulcer on the left labia majora with a maximum diameter of 1.7 cm and well-defined borders. There was fibrin at its base, much swelling, and perilesional induration, sensitive to the touch (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A hemogram was carried out which showed 5,840 leucocytes/mm<span class="elsevierStyleSup">3</span>, an absolute neutrophil count (ANC) of 876 mm<span class="elsevierStyleSup">3</span>, and C-reactive protein of 33 mg/dL. Polymerase chain reaction (PCR) tests of the lesion for herpes simplex viruses 1 and 2, cytomegalovirus, varicella-zoster virus, and the Epstein-Barr virus were all negative. Blood, fungal, and mycobacteria cultures were all negative, but a culture of the lesion tested positive for <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>. An immunological study was made for lymphocytic sub-populations, IgA-IgM-IgG immunoglobulins, neutrophil oxidative burst test, anti-neutrophil antibodies, VDRL, and HIV. All these were negative, thus eliminating the possibility of associated immunodeficiency. After treatment with intravenous ceftazidime and amikacin for six days there was a favorable evolution, so it was decided to discharge her and provide oral ciprofloxacin for 14 days. This resulted in the complete resolution of the lesion. At an outpatient checkup 72 hours after the discharge, the hemogram showed 4,800 leucocytes/mm<span class="elsevierStyleSup">3</span> and an ANC of 96 mm<span class="elsevierStyleSup">3</span>, which improved spontaneously after two weeks and showed no relapse after six months on follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">EG is a rare disease in healthy pediatric patients with no associated sepsis. It generally reveals a primary sub-clinical immunodeficiency and so it is essential to carry out a complete immunological study on all such patients. Its mortality is high, over 90% where there is sepsis and 15% in the case of local infection, where neutropenia is the most important factor for prognosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a> In the literature there are few cases of EG in previously healthy patients; the present authors found only six which showed severe neutropenia (< 500 mm<span class="elsevierStyleSup">3</span>) after the initiation of the clinical condition, as in this report. However, all these cases showed an associated etiological factor (respiratory infections, infantile benign neutropenia, and hypogammaglobulinemia).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Leucopenia induced by fluoroquinolones has been described. This tends to be mild to moderate, being reported in less than 0.2% of the cases, mainly in adults with co-morbidities.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the present case normalization of the hemogram occurred at the end of the second week of oral ciprofloxacin, so this cause is not very probable. Also, it has been suggested that <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> might cause a transitory neutropenia mediated by a toxin that could inhibit the migration of neutrophils to the affected areas and also reduce the number of neutrophils in the blood.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This case is reported due to the exceptional manifestation of severe neutropenia after EG in an immunocompetent patient.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors' contributions</span><p id="par0025" class="elsevierStylePara elsevierViewall">Pablo Vargas-Mora: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Santiago García: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ligia Aranibar: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Fernando Valenzuela: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "Reference" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-11-12" "fechaAceptado" => "2020-03-05" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Vargas-Mora P, García S, Aranibar L, Valenzuela F. Ecthyma gangrenosum and severe transitory neutropenia in an immunocompetent girl. An Bras Dermatol. 2020; 95. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.abd.2020.03.009">https://doi.org/10.1016/j.abd.2020.03.009</span></p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology, Faculty of Medicine, University of Chile. Santiago, Chile.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 750 "Tamanyo" => 58061 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hemorrhagic blister on vulva, two days of evolution.</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" => 994 "Ancho" => 750 "Tamanyo" => 76676 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin ulcer in labia majora, seven days of evolution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Reference" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "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. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 17 | 10 | 27 |
| 2024 Outubro | 92 | 86 | 178 |
| 2024 Setembro | 130 | 80 | 210 |
| 2024 Agosto | 186 | 98 | 284 |
| 2024 Julho | 139 | 120 | 259 |
| 2024 Junho | 117 | 77 | 194 |
| 2024 Maio | 92 | 66 | 158 |
| 2024 Abril | 138 | 82 | 220 |
| 2024 Março | 99 | 58 | 157 |
| 2024 Fevereiro | 98 | 83 | 181 |
| 2024 Janeiro | 55 | 45 | 100 |
| 2023 Dezembro | 57 | 63 | 120 |
| 2023 Novembro | 67 | 71 | 138 |
| 2023 Outubro | 49 | 72 | 121 |
| 2023 Setembro | 59 | 71 | 130 |
| 2023 Agosto | 53 | 49 | 102 |
| 2023 Julho | 46 | 37 | 83 |
| 2023 Junho | 49 | 33 | 82 |
| 2023 Maio | 39 | 23 | 62 |
| 2023 Abril | 20 | 19 | 39 |
| 2023 Março | 41 | 30 | 71 |
| 2023 Fevereiro | 31 | 35 | 66 |
| 2023 Janeiro | 27 | 19 | 46 |
| 2022 Dezembro | 28 | 21 | 49 |
| 2022 Novembro | 49 | 47 | 96 |
| 2022 Outubro | 49 | 47 | 96 |
| 2022 Setembro | 43 | 67 | 110 |
| 2022 Agosto | 40 | 39 | 79 |
| 2022 Julho | 34 | 47 | 81 |
| 2022 Junho | 30 | 51 | 81 |
| 2022 Maio | 36 | 60 | 96 |
| 2022 Abril | 48 | 57 | 105 |
| 2022 Março | 42 | 64 | 106 |
| 2022 Fevereiro | 33 | 39 | 72 |
| 2022 Janeiro | 43 | 73 | 116 |
| 2021 Dezembro | 41 | 62 | 103 |
| 2021 Novembro | 44 | 57 | 101 |
| 2021 Outubro | 44 | 63 | 107 |
| 2021 Setembro | 26 | 36 | 62 |
| 2021 Agosto | 38 | 51 | 89 |
| 2021 Julho | 32 | 39 | 71 |
| 2021 Junho | 48 | 54 | 102 |
| 2021 Maio | 72 | 87 | 159 |
| 2021 Abril | 124 | 264 | 388 |
| 2021 Março | 56 | 74 | 130 |
| 2021 Fevereiro | 16 | 21 | 37 |
| 2021 Janeiro | 21 | 17 | 38 |
| 2020 Dezembro | 15 | 18 | 33 |
| 2020 Novembro | 23 | 17 | 40 |
| 2020 Outubro | 21 | 10 | 31 |
| 2020 Setembro | 17 | 10 | 27 |
| 2020 Agosto | 10 | 12 | 22 |
| 2020 Julho | 4 | 6 | 10 |
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