Ecthyma gangrenosum caused by Achromobacter xylosoxidans bacteremia

A 73-year-old woman with ovarian cancer undergoing chemotherapy presented with a three-day history of fever, vomiting, and confusion. She did not have a central venous access port. Physical examination revealed somnolence without meningeal irritation signs. A dry lesion located on the right forearm (Figure 1) was the only identifiable infectious focus. Neutropenia was not present. Blood and urine specimens were collected for culture, and piperacillin-tazobactam (3x4.5 g/day) was initiated. Urine culture yielded negative results, while two peripheral blood cultures grew Achromobacter xylosoxidans. Despite systemic antibiotic therapy, the patient succumbed to sepsis-related complications on the 5^th day of hospitalization. The cultured microorganism was sensitive to piperacillin-tazobactam. Histologic examination confirmed Ecthyma gangrenosum (EG).

EG, a cutaneous infection, commonly affects immunocompromised patients with fulminant bacteremia. Dr. Lewellys Barker first described EG as a manifestation of Pseudomonas aeruginosa in 1897¹. While P. aeruginosa remains the most commonly identified and implicated pathogen in EG, other microorganisms can also contribute to its etiology². The primary site of EG is usually in the axillary and anogenital regions; however, cases with localized involvement of the arms, legs, trunk, and face have been documented in the literature^1,2. EG has a poor prognosis, especially in neutropenic immunocompromised patients¹. A. xylosoxidans bloodstream infections have been successfully treated with antibiotics like ceftazidime, piperacillin-tazobactam, carbapenems, and trimethoprim-sulfamethoxazole³.

FIGURE 1:
Gangrenous ulcer with black eschar on the forearm.

This report presents a case of EG, a potentially fatal disease, and highlights the importance of prompt skin biopsies and microbiologic cultures for early diagnosis and treatment.

ACKNOWLEDGMENTS

None.

REFERENCES

• ¹
  Shah M, Crane JS. Ecthyma Gangrenosum. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. [Internet]. Access date:15 January 2023. Avaliable from: Avaliable from: https://www.ncbi.nlm.nih.gov/books/NBK534777/
  » https://www.ncbi.nlm.nih.gov/books/NBK534777/
• ²
  Gargouri L, Maaloul I, Kamoun T, Maalej B, Safi F, Majdoub I, Hachicha M, Mahfoudh A. Ecthyma gangrenosum: A manifestation of community-acquired Pseudomonas aeruginosa septicemia in three infants. Arch Pediatr. 2015;22(6):616-20. Available from: https://doi.org/10.1016/j.arcped.2015.03.006
  » https://doi.org/10.1016/j.arcped.2015.03.006
• ³
  Legrand C, Anaissie E. Bacteremia due to Achromobacter xylosoxidans in patients with cancer. Clin Infect Dis. 1992;14(2):479-84. Available from: https://doi.org/10.1093/clinids/14.2.479
  » https://doi.org/10.1093/clinids/14.2.479

• Financial Support: None.

Publication Dates

• Publication in this collection
  24 July 2023
• Date of issue
  2023