Ulcerated Skin Lesion Covered by Eschar in Young Cancer Patient
By Ted Rosen, MD
Professor of Dermatology, Baylor College of Medicine, Houston, Texas
CASE HISTORY
A 15-year-old male patient with known B-cell acute lymphoblastic leukemia (B-ALL) was seen in the emergency department with the chief complaint of a skin lesion on the right arm.
At the time of this visit he was receiving periodic intravenous chemotherapy consisting of vincristine and daunorubicin. At presentation he had a low-grade fever and a round, macular skin lesion. The latter consisted of a slightly dusky center and a peripheral non-blanching violaceous rim (Figure 1).
The emergency department made a diagnosis of “fixed drug eruption” and asked that all medications be temporarily withheld and that triamcinolone be applied to the affected area twice daily.
Unfortunately, he returned to the hospital a week later with a remarkably painless enlarged cutaneous lesion and a temperature of 102.6°F and a blood-tinged nasal discharge.
The skin lesion was now notably wider and deeper, ulcerated, and was covered by a prominent eschar (Figure 2).
The patient was started on broad spectrum antibiotics. A biopsy demonstrated a pauci-cellular necrotizing vasculitis.
What is your diagnosis?
DISCUSSION
Due to the emergence of a painless eschar in a febrile individual who was both immunocompromised (aggressive leukemia) and immunosuppressed (multiagent chemotherapy), the presumptive diagnosis of ecthyma gangrenosum was made.
This entity is usually a sign of serious blood-borne infection in an altered host. While the majority (~75%) of cases of ecthyma gangrenosum are due to Pseudomonas septicemia, it is well documented to be the result of a variety of bacterial, fungal, and viral pathogens.
In this case, radiographs of the sinuses showed fungal balls, and culture grew the zygomycete Rhizopus. A culture from the arm lesion also grew Rhizopus.
Treatment was changed to intravenous amphotericin-B.
Recommended Reading:
Ruiz-Sanchez D, Valtueña J, Garabito Solovera E, et al. Ecthyma gangrenosum, beyond Pseudomonas aeruginosa. Enferm Infecc Microbiol Clin (Engl Ed). 2021;39(10):526-527. doi:10.1016/j.eimce.2021.09.005.