Ecthyma gangrenosum ina new born child

Introduction

Ecthyma gangrenosum is one of the most serious of specific cutaneous infection caused by Pseudomonas aeruginosa. It occurs as a result of bacteraemia or following a primary cutaneous lesion.[1] Less common organisms causing it are Pseudomonas cepacae,[2] s. aureus, E coli, klebsiella, N. meningitidis, aspergillus species, aeromonas species. Lesions occur due to bacteremia leading to disseminated infective vasculitis characterized by erythematous maculas, papules or nodules with a central hemorrhagic vesicle or bulla which ruptures leaving behind a punched out indurated ulcer surrounded by raised edamatous edges with central necrosis and eschar formation.[4] Such cases respond well to intravenous anti-pseudomonas theraphy.[4],[5] Prognosis depends on underlying condition, it is generally good in patients with burn, UTI with pseudomonas infection but worse in those with underlying malignancy and with poor immunity.

We report a rare case of ecthyma gangrenosum in a new born child with eye involvement, which has not been reported earlier who responded poorly to anti-pseudomonas treatment to highlight the poor prognosis in new born.

Case Report

A 11/2-months-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 lesion 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 expect TLC - 125,000/cmm, peripheral smear-showed toxic granules, gram stain showed GNR. Blood culture and pus culture from the lesion near right eye - positive for pseudomonas aeruginosa. Diagnosis of ecthyma gangrenosum was made on clinical and bacteriological examination.

Child was put on topical and systemic antipseudomonas antibiotics and topical eiprofloxacin and gentamicin eye drops.

Systemic treatment in the form of injection vancomycin 25 mg i.v bd x 10 days, injection metrogyl 20 mg i.v 6th hourly x 8 day, injection zidime 25 mg i.v x 10 days, injection pipracil 350 mg i.v 8th and hourly x 8 day, were given injection amikacin 26 mg i.v bd x 10 days.

Surgical debridement of ulcer was also done.

Discussion

Ecthyma gangrenosum usually respond 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. 3) poor response to systemic i.v antipseudomonas treatment.