CASE REPORT

A rare case of ecthyma gangrenosum associatedwith methicillin-resistant Staphylococcus aureus infection

Patompong Ungprasert • Nitipong Permpalung •

Pongsathorn Kue-A-Pai • Nischala Ammannagari •

Daych Chongnarungsin

Received: 30 August 2012 / Accepted: 27 September 2012 / Published online: 12 October 2012

� Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2012

Abstract Ecthyma gangrenosum (EG) is a well-recog-

nized dermatological condition caused by gram-negative

bacillary infection, particularly Pseudomonas aeruginosa.

Association with gram-positive cocci is very rarely repor-

ted in the literature. To the best of our knowledge, we

describe the third case of EG caused by methicillin-resis-

tant Staphylococcus aureus in a patient with AIDS who

presented with multiple typical necrotic lesions.

Keywords Ecthyma gangrenosum � Methicillin-resistant

Staphylococcus aureus � Pseudomonas aeruginosa �Necrotizing vasculitis

Introduction

Ecthyma gangrenosum (EG), a necrotizing vasculitis, is a

well-recognized dermatological manifestation of gram-

negative bacillary infection, particularly pseudomonal

sepsis. It is typically found in immunocompromised

patients. EG as a result of a gram-positive infection is

extremely rare. We report a case of a 40-year-old white

man with acquired immunodeficiency syndrome (AIDS)

who presented to our hospital with multiple painful

necrotic skin lesions. Wound cultures grew methicillin-

resistant Staphylococcus aureus (MRSA). To the best of

our knowledge, this is the third reported case of EG asso-

ciated with MRSA.

Case report

A 40-year-old Caucasian gentleman presented to our

emergency department with multiple painful skin lesions

involving his trunk and lower extremities. He initially

presented to our emergency department 2 weeks previously

with a painful lump in the right side of his neck. He was

diagnosed with subcutaneous abscess. He underwent inci-

sion and a drainage procedure revealing 2 ml frank pus that

subsequently grew MRSA. He was prescribed a 10-day

course of oral cephalexin. However, he stopped taking the

antibiotic after 3 days as the pain resolved. A few days

later, he started noticing erythematous skin rash on his chin

that spread to his torso and lower extremities. His rash

gradually progressed to large bullae that became necrotic.

He had been diagnosed with AIDS 15 years earlier with

very poor compliance to antiretroviral therapy. He was lost

to follow-up and did not take any medications for 1 year.

However, he had recently returned to see his infectious

disease physician 6 weeks ago. His CD4 count at that time

was 4 cells/mm3. His antiretroviral medicines, with pro-

phylactic trimethoprim/sulfamethoxazole and azithromy-

cin, were restarted, but again he failed to take his

medications regularly.

Physical examination revealed blood pressure of

125/60 mmHg, heart rate of 86 beats/min, and temperature of

37.4 �C. Cardiovascular and respiratory examination was

unremarkable. Skin examination revealed multiple deep,

punched-out ulcerations with erythematous halo in the ante-

rior aspect over his torso and both lower extremities (Fig. 1).

Laboratory findings were significant for hemoglobin of

P. Ungprasert (&) � N. Permpalung � P. Kue-A-Pai �N. Ammannagari � D. Chongnarungsin

Department of Internal Medicine, Bassett Medical Center

and Columbia University College of Physicians and Surgeons,

Cooperstown, NY 13326, USA

e-mail: patompong.ungprasert@bassett.org

123

J Infect Chemother (2013) 19:761–763

DOI 10.1007/s10156-012-0498-0

15.1 g/dl, leukocyte count of 4.1 9 103/ll, neutrophils of

61 %, and platelet count of 153 9 103/ll. Erythrocyte sedi-

mentation rate was 62 mm/h. His chest X-ray and transtho-

racic echocardiogram were unremarkable. Two sets of blood

cultures, obtained before administration of antibiotics,

showed no growth. Superficial wound swabs for Gram’s stain

and culture, which were obtained from lesions in his torso and

both lower extremities, did not reveal any organisms. He was

diagnosed with ecthyma gangrenosum (EG), and vancomycin

was immediately started after obtaining the cultures. He was

evaluated by a dermatologist on the following day, who

agreed with the diagnosis of ecthyma gangrenosum. He

responded well to the antibiotic. His erythematous halo slowly

disappeared, and his punched-out ulcers became shallower

with granulation tissue over the 10-day course of his hospi-

talization. He was discharged home with a 1-month course of

oral linezolid. Unfortunately, again, he did not return to our

institute for a follow-up visit.

Discussion

Ecthyma gangrenosum is an uncommon dermatological

manifestation characterized by round, indurated ulcers with

a central necrotic black eschar and surrounding erythema

[1]. The exact pathogenesis is not well understood. How-

ever, it is believed to be a result of bacterial invasion into

the walls of small dermal vessels, leading to infarction and

necrosis of overlying dermal and subdermal tissue [2]. It is

classically associated with pseudomonal infection though a

wide range of gram-negative bacteria (including Aeromo-

nas hydrophila, Klebsiella pneumoniae, Serratia marces-

cens, Xanthomonas maltophilia, Morganella morganii,

Escherichia coli, and Citrobacter freundii), which have

also been reported as causative agents [3]. Association with

gram-positive coccal infection is very rarely described in

the literature. Nakai et al. [4] reported the first case of EG

that was associated with MRSA and Pseudomonas aeru-

ginosa wound infection in a kidney transplant recipient in

2008. Sen et al. [5] subsequently reported another case of

EG associated with MRSA bacteremia in a patient who was

intubated for acute exacerbation of chronic obstructive

pulmonary disorder (COPD). To the best of our knowledge,

with the limitation of no histological evaluation or tissue

culture, this is the third reported adult case of EG associ-

ated with MRSA.

EG typically occurs in immunocompromised individu-

als, most commonly in patients with neutropenia or

malignancy [1]. Although relatively infrequent, EG has

also been described in patients with AIDS. Interestingly, a

portion of patients who had EG as a result of immunode-

ficiency from AIDS did not have neutropenia, similar to

our patient [6].

In conclusion, EG is seen in immunocompromised

patients, including patients with AIDS. Although classi-

cally described as a manifestation of gram-negative bac-

terial infection, the possibility of gram-positive coccal

infection should not be overlooked. Thus, the choice of

initial antibiotic should be made on a case-by-case basis.

Conflict of interest We do not have any financial or nonfinancial

potential conflicts of interest.

References

1. Greene SL, Su WP, Muller SA. Ecthyma gangrenosum: report of

clinical and bacteriologic aspects of eight cases. J Am Acad

Dermatol. 1984;11:781–7.

Fig. 1 Multiple round and indurated ulcers of varying sizes

(5–50 mm) with central necrotic tissue and surrounding erythema

are seen on the torso (a) and lower extremities (b)

762 J Infect Chemother (2013) 19:761–763

123

2. Walls AC, Frangos JE, Goralnick E. Ecthyma gangrenosum in a

67-year-old man with chronic lymphocytic leukemia. J Emerg

Med. 2012;43:339–41.

3. Reich HL, Fadeyi DW, Naik NS, Honig PJ, Yan AC. Nonpseud-

omonal ecthyma gangrenosum. J Am Acad Dermatol. 2004;

50:S114–7.

4. Nakai N, Takenaka H, Kishimoto S. Ecthyma gangrenosum

without pseudomonas septicemia in a kidney transplant recipient.

J Dermatol. 2008;35:585–9.

5. Sen H, Inangil G, Sahin L, Dere K, Ozkan S, Dagli G. Ecthyma-

gangrenosum-like lesions associated with methicillin-resistant

Staphylococcus aureus infection. Int J Infect Dis. 2009;13:e173–5.

6. Khan MO, Montecalvo MA, Davis I, Wormser GP. Ecthyma

gangrenosum in patients with acquired immunodeficiency syn-

drome. Cutis. 2000;66:121–3.

J Infect Chemother (2013) 19:761–763 763

123