A Healthy 2-Year-Old Child with a Round Black Skin Lesion
A
healthy 2-year-old female presented with a round,
non-tender skin lesion on her buttock, its center black
and ulcerated, its margins red. It began as a small
black spot a week before and subsequently enlarged and ulcerated, without blister formation, reaching the size and
shape shown in the Figure.
The patient was afebrile, without systemic signs or symptoms. Her blood tests, including complete blood count (peripheral leukocyte count of 10.3 109/L with 3 109/L
neutrophils, 6.1 109/L lymphocytes, 0.9 109/L monocytes, and 0.3 109/L eosinophils), C-reactive protein, and
erythrocyte sedimentation rate were unremarkable. The child
had no history of recent viral illness or prolonged water exposure (eg, whirlpool, pool with protracted wet diaper, bath
tub, or bath sponge). She came in contact with horses and
chickens at her grandfather’s farm.
Cutaneous anthrax was suggested. A skin-punch biopsy
was taken from the lesion and demonstrated fibrin and mixed
inflammatory cells with a necrotic area and neutrophils in the
connective tissue. The culture revealed Pseudomonas aeruginosa. These findings are consistent with a diagnosis of Ecthyma gangrenosum.
Ecthyma gangrenosum is a cutaneous manifestation of severe, invasive infection by Pseudomonas aeruginosa, usually
seen in immunocompromised and critically ill patients.1
Very few cases have been seen in healthy children presenting
with this lesion.2,3 One review of Ecthyma gangrenosum
cases in previously healthy children found that most either
had previously undetected immunodeficiencies or transient
risk factors (including viral infections and antimicrobial
treatment) predisposing them to the development of such infection.4-6 Pseudomonas skin infection are also known to occur in individuals after use of hot-tubs, whirlpools, water
slides, and swimming pools. A previous report of two healthy
children with invasive Pseudomonas infection linked their infection to prolonged bathing.3
Current literature recommends prompt treatment with
systemic antibiotic therapy, with Pseudomonas coverage,
once Ecthyma gangrenosum is suspected, based on clinical
appearance.4 If the lesion fails to respond to antimicrobials,
surgical debridement may be required.7,8 Isolated Ecthyma
Figure. Round, non-tender skin lesion on 2-year-old female
buttock. Note the black ulcerated center of the lesion and its
red margins.
gangrenosum has an estimated mortality of up to 25%—
a rate that is greatly increased by concomitant sepsis.7
In our case, spontaneous recovery was observed prior to
the pathologic and microbiologic diagnosis, and the lesion
completely resolved within 3 weeks without treatment. Two
years since presentation, our patient has encountered no immunologic or other health problems. n
Hammam Ghanaiem, MD
Pediatric Department
Hadassah-Hebrew University Medical Center
Ein Kerem, Jerusalem, Israel
Dan Engelhard, MD
Pediatric Department
Hadassah-Hebrew University Medical Center
Ein Kerem, Jerusalem, Israel
School of Primary Health Care
Monash University, Melbourne, Australia
References available at www.jpeds.com
J Pediatr 2013;-:1.
0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc.
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.04.038
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References
1. Mina Yassaee SBE, Ravi Ubriani, William D James. Ecthyma gangrenosum. In: Elston DM, ed. Medscape. Available at: http://emedicine.
medscape.com/article/1053997-overview. Accessed November 13, 2012.
2. Athappan G, Unnikrishnan A, Chandraprakasam S. Ecthyma gangrenosum: presentation in a normal neonate. Dermatol Online J 2008;14:17.
3. Meislich D, Long SS. Invasive Pseudomonas infection in two healthy children following prolonged bathing. Am J Dis Child 1993;147:18-20.
4. Zomorrodi A, Wald ER. Ecthyma gangrenosum: considerations in a previously healthy child. Pediatr Infect Dis J 2002;21:1161-4.
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Vol. -, No. 5. Martin-Ancel A, Borque C, del Castillo F. Pseudomonas sepsis in children without previous medical problems. Pediatr Infect Dis J 1993;12:
258-60.
6. Chusid MJ, Hillmann SM. Community-acquired Pseudomonas sepsis in
previously healthy infants. Pediatr Infect Dis J 1987;6:681-4.
7. Craigie RJ, Ahmed S, Mullassery D, Panarese A, Caswell M, Kenny SE. A
spot that can kill. Lancet 2007;369:1540.
8. Khalil BA, Baillie CT, Kenny SE, Lamont GL, Turnock RR,
Pizer BL, et al. Surgical strategies in the management of Ecthyma
gangrenosum in pediatric oncology patients. Pediatr Surg Int
2008;24:793-7.
Ghanaiem and Engelhard