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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thick&#44; non-septate hyaline hyphae&#44; branching at a right angle&#46; Direct examination&#46; KOH 20&#37; and Parker&#39;s ink&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma Gangrenosum &#40;EG&#41; was once considered pathognomonic for sepsis caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; other agents have been described in oncohaematological patients&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Skin biopsies are often not performed&#44; and treatment is usually empirical&#46; This report describes three cases of neutropenic patients with EG who underwent skin biopsy with direct examination&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patient 1&#58; Male&#44; 36 years old&#44; with acute lymphoblastic leukemia&#44; presented with febrile neutropenia &#40;FN&#41; during chemotherapy&#44; and treatment with cefepime was started&#46; After ten days&#44; he once again had a fever&#44; with the appearance of erythematous lesions with a necrotic center on the face and chest&#46; He had neutropenia &#40;10&#47;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;24&#44;000&#47; mm<span class="elsevierStyleSup">3</span>&#41;&#46; Blood cultures and a skin biopsy were collected&#44; and liposomal amphotericin B and voriconazole were started&#46; Direct examination identified septate hyaline hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which were later also detected in the histopathological examination&#46; <span class="elsevierStyleItalic">Fusarium spp</span>&#46; was identified in blood and skin cultures&#46; The patient did not survive depicting of the treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Patient 2&#58; Male&#44; 47 years old&#44; had FN during chemotherapy for acute myeloid leukemia&#44; and treatment with cefepime was started&#46; After fourteen days&#44; he once again had a fever&#44; with the appearance of a single erythematous lesion with a necrotic center&#44; on the chest &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; He had neutropenia &#40;40&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;44&#44;000&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41;&#46; Blood cultures and a skin biopsy were collected&#46; Direct examination revealed non-septate hyaline hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; which were later seen in the histopathological examination&#46; Antifungal treatment with liposomal amphotericin B was started&#46; Subsequently&#44; <span class="elsevierStyleItalic">Syncephalastrum spp</span>&#46; was identified in the skin culture&#46; The patient remained afebrile&#44; with neutrophilic recovery&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Patient 3&#58; Male&#44; 36 years old&#44; had FN during chemotherapy for acute myeloid leukemia&#44; and treatment with cefepime was started&#46; After four days&#44; he had a fever&#44; and arterial hypotension&#44; with the appearance of an erythematous lesion with a necrotic center on the back region&#46; Antibiotic therapy was expanded to include polymyxin B&#44; amikacin&#44; and meropenem&#46; He had neutropenia &#40;170&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;2&#44;000&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41;&#46; A skin biopsy was collected&#44; and a direct examination identified the presence of gram-negative rods&#46; No specimen was sent for histopathological examination&#46; Subsequently&#44; multidrug-resistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> was identified in the skin and blood cultures&#46; The antimicrobial regimen was maintained until a clinical resolution was attained&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The present report describes three cases of neutropenic patients who developed EG&#46; All had a similar clinical presentation&#44; with fever recurrence and the appearance of lesions during antibiotic therapy&#46; In the first patient&#44; direct examination suggested the diagnosis of fusariosis&#44; directing the combined antifungal treatment&#46; The cause of death was attributed to the absence of immune reconstitution&#46; In the second patient&#44; the direct examination suggested the diagnosis of mucormycosis&#44; directing the change of the antifungal agent for liposomal amphotericin B&#46; In the third patient&#44; the direct examination suggested the diagnosis of bacterial sepsis&#44; directing the expansion of the antibiotic regimen without the association of antifungal agents&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Typically&#44; the EG agent is identified in blood and skin cultures&#46; However&#44; as these results are not promptly available&#44; the treatment is usually the empirical expansion of the anti-infective regimen&#46; The disadvantages of this approach are exposure to toxic drugs and increased costs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The skin biopsy is a safe procedure in thrombocytopenic patients&#46;<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&#44; which later confirmed what had already been detected&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; we suggest performing an early skin biopsy with direct examination in neutropenic patients with EG&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Yung Gonzaga&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Thiago Jeunon&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Jorge Machado&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Marcio Nucci&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</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&#46;</p></span></span>"
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Case Letter
Ecthyma gangrenosum in neutropenic patients and the importance of an early skin biopsy for direct examination
Yung Gonzagaa,
Autor para correspondência
yungbmg@hotmail.com

Corresponding author.
, Thiago Jeunonb, Jorge Machadoa, Marcio Nuccic
a Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil
b Private clinic, Rio de Janeiro, RJ, Brazil
c Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma Gangrenosum &#40;EG&#41; was once considered pathognomonic for sepsis caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; other agents have been described in oncohaematological patients&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Skin biopsies are often not performed&#44; and treatment is usually empirical&#46; This report describes three cases of neutropenic patients with EG who underwent skin biopsy with direct examination&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patient 1&#58; Male&#44; 36 years old&#44; with acute lymphoblastic leukemia&#44; presented with febrile neutropenia &#40;FN&#41; during chemotherapy&#44; and treatment with cefepime was started&#46; After ten days&#44; he once again had a fever&#44; with the appearance of erythematous lesions with a necrotic center on the face and chest&#46; He had neutropenia &#40;10&#47;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;24&#44;000&#47; mm<span class="elsevierStyleSup">3</span>&#41;&#46; Blood cultures and a skin biopsy were collected&#44; and liposomal amphotericin B and voriconazole were started&#46; Direct examination identified septate hyaline hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which were later also detected in the histopathological examination&#46; <span class="elsevierStyleItalic">Fusarium spp</span>&#46; was identified in blood and skin cultures&#46; The patient did not survive depicting of the treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Patient 2&#58; Male&#44; 47 years old&#44; had FN during chemotherapy for acute myeloid leukemia&#44; and treatment with cefepime was started&#46; After fourteen days&#44; he once again had a fever&#44; with the appearance of a single erythematous lesion with a necrotic center&#44; on the chest &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; He had neutropenia &#40;40&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;44&#44;000&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41;&#46; Blood cultures and a skin biopsy were collected&#46; Direct examination revealed non-septate hyaline hyphae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; which were later seen in the histopathological examination&#46; Antifungal treatment with liposomal amphotericin B was started&#46; Subsequently&#44; <span class="elsevierStyleItalic">Syncephalastrum spp</span>&#46; was identified in the skin culture&#46; The patient remained afebrile&#44; with neutrophilic recovery&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Patient 3&#58; Male&#44; 36 years old&#44; had FN during chemotherapy for acute myeloid leukemia&#44; and treatment with cefepime was started&#46; After four days&#44; he had a fever&#44; and arterial hypotension&#44; with the appearance of an erythematous lesion with a necrotic center on the back region&#46; Antibiotic therapy was expanded to include polymyxin B&#44; amikacin&#44; and meropenem&#46; He had neutropenia &#40;170&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41; and thrombocytopenia &#40;2&#44;000&#47;&#160;mm<span class="elsevierStyleSup">3</span>&#41;&#46; A skin biopsy was collected&#44; and a direct examination identified the presence of gram-negative rods&#46; No specimen was sent for histopathological examination&#46; Subsequently&#44; multidrug-resistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> was identified in the skin and blood cultures&#46; The antimicrobial regimen was maintained until a clinical resolution was attained&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The present report describes three cases of neutropenic patients who developed EG&#46; All had a similar clinical presentation&#44; with fever recurrence and the appearance of lesions during antibiotic therapy&#46; In the first patient&#44; direct examination suggested the diagnosis of fusariosis&#44; directing the combined antifungal treatment&#46; The cause of death was attributed to the absence of immune reconstitution&#46; In the second patient&#44; the direct examination suggested the diagnosis of mucormycosis&#44; directing the change of the antifungal agent for liposomal amphotericin B&#46; In the third patient&#44; the direct examination suggested the diagnosis of bacterial sepsis&#44; directing the expansion of the antibiotic regimen without the association of antifungal agents&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Typically&#44; the EG agent is identified in blood and skin cultures&#46; However&#44; as these results are not promptly available&#44; the treatment is usually the empirical expansion of the anti-infective regimen&#46; The disadvantages of this approach are exposure to toxic drugs and increased costs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The skin biopsy is a safe procedure in thrombocytopenic patients&#46;<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&#44; which later confirmed what had already been detected&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; we suggest performing an early skin biopsy with direct examination in neutropenic patients with EG&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Yung Gonzaga&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Thiago Jeunon&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Jorge Machado&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Marcio Nucci&#58; Approval of the final version of the manuscript&#59; critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; statistical analysis&#59; design and planning of the study&#46;</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&#46;</p></span></span>"
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Informação do artigo
ISSN: 03650596
Idioma original: Inglês
DOI:10.1016/j.abd.2020.11.018
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