Ecthyma Gangrenosum In a new born child

Introduction

Ecthyma gangrenosum is one of the mos serious of specific cutaneous infection caused b) Pseudomonas aeruginosa. It occurs as a result o bacteremia or following a primary cutaneow lesions.[1] Less common organisms causing it are Pseudomonas cepacae[2], S aureus, E coli, klebsiella, N. meningitidis, aspergillus species, aeromonas species. Lesions occur due tc bacteremia leading to disseminated infective vasculitis characterized by erythematous macules, papules or nodules with a central hemorrhagic vesicle or bulla which ruptures leaving behind c punched out indurated ulcer surrounded by raisec edematous edges with central necrosis and eschai formation.[4] Such cases respond well to intravenous anti-pseudomonas therapy.[4],[5] Prognosis depend: on underlying condition, it is generally good it patients with burn, UTI with pseudomonas infection but worse in those with underlying malignancy and with poor immunity.

We report a rare cases of ecthymc gangrenosum in a new born child with eye involvement, who responded poorly to anti pseudomonas treatment.

Case Report

A 11/2 -month - old male child presented with solid, red raised lesions, red flat skin lesions, ulcerative lesions all over the body 10 days after birth.

Red flat skin lesions first developed over inner canthus of right eye which became solid, ruptured to form an ulcer within 3-4 days. Similar lesions developed over right nostril, abdomen, gluteal region and left lower leg. Lesions were associated with yellowish discharge.

Small red raised solid lesions also developed over the trunk and abdomen. There was no history of fever, burns or drug intake, no history of umbilical sepsis, catheterization or immunodeficiency. The examination of skin revealed widespread multiple erythematous macules and papules over abdomen, well defined punched out indurated ulcers with raised erythematous, edematous border with central blackish hemorrhagic eschar over right eye inner canthus, left nostril, gluteal region and right lower leg. Right eye showed conjunctival congestion and corneal ulcer. Systemic examination revealed distended abdomen with everted umbilicus and hepatomegaly. Investigations revealed CBC-WNL except TLC-125,000 / cmm, peripheral smear-showed toxic granules, gram stain showed GNR. Blood culture and pus culture from the lesion near right eye yielded growth of Pseudomonas aeruginosa. Diagnosis of ecthyma gangrenosum was made on clinical and bacteriological examination.

Child was put on topical and systemic antipseudomonas antibiotics.

Systemic treatment in the form of injection vancomycin 25 mg i.v bd x 10 days, injection metrogyl 20 mg i.v. 6′h hourly x 8 day, injection zidime 25 mg i.v. x 10 days, injection pipracil 350 mg i.v. 8th hourly x 8 days, injection amikacin 26 mg i.v. bd x 10 days were also administered. Surgical debridement of ulcer was also done.

Discussion

Ecthyma gangrenosum usually responds well to systemic i.v. antipseudomonas treatement.[4],[5] But prognosis depends upon the underlying condition. In our patient no underlying cause for extensive disseminated bacterial vasculitis was found. Even after 3 weeks treatment with antipseudomonas antibiotics clinical improvement was not satisfactory.

We are reporting this case because of its 1) Rare presentation in new born period, 2) Eye involvement in the form of conjunctival congestion and corneal ulceration due to pseudomonas bacteremia, and 3) Poor response to systemic i.v antipseudomonas treatment.