Cases and Research Letters
Facial Ecthyma Gangrenosum in 2 Preterm Neonates
Ectima gangrenoso facial en dos recién nacidos pretérmino
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Serrano-Martín, J. del Boz, M. Chaffanel-Peláez, A. Vera-Casaño" "autores" => array:4 [ 0 => array:3 [ "nombre" => "M.M." "apellidos" => "Serrano-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "J." "apellidos" => "del Boz" "email" => array:1 [ 0 => "mmarser@live.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Chaffanel-Peláez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Vera-Casaño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Regional Universitario Carlos Haya, Málaga, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Regional Universitario Carlos Haya, Málaga, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ectima gangrenoso facial en dos recién nacidos pretérmino" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 951 "Tamanyo" => 164939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1. Necrotic ulcers in the right nasal cavity and on the upper lip, right cheek, and tongue.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma gangrenosum (EG) is a bacterial skin infection generally caused by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, although it may also be caused by other organisms.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It commonly appears in the context of <span class="elsevierStyleItalic">P aeruginosa</span> sepsis, but the skin is occasionally the primary focus.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">EG usually appears in immunocompromised patients. The characteristic clinical presentation is an erythematous macule that develops into a hemorrhagic vesicle and finally a necrotic ulcer.</p><p id="par0015" class="elsevierStylePara elsevierViewall">EG should be considered in the differential diagnosis of ulcerous skin lesions in preterm patients because a rapid diagnosis permits early treatment and thus reduces the high mortality associated with <span class="elsevierStyleItalic">P aeruginosa</span> sepsis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report on 2 cases of EG in newborn infants. The first patient was a first-born twin girl delivered by caesarean section at 30 weeks’ gestation due to maternal preeclampsia. On the fifth day of life neutropenia with respiratory worsening was detected and antibiotic treatment with vancomycin and amikacin was started due to suspected sepsis. On the eighth day 2 erythematous lesions appeared in the nasal area and on the right cheek. After 24 hours they developed into necrotic ulcers with a base covered by whitish slough and abundant yellowish secretion. Similar lesions were also seen on the hard palate and tongue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Blood and samples from the lesions were taken for culture and topical gentamicin was added to the treatment because of suspected bacterial skin infection.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Two days later, the patient showed clinical deterioration consistent with sepsis and the cultures were found to be positive for <span class="elsevierStyleItalic">P aeruginosa</span>. Meropenem was added to the treatment regimen and the patient progressed favorably. The skin lesions resolved, leaving serious aesthetic sequelae with a loss of substance in the nasal septum and columella.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The second case involved a second-born female triplet delivered by caesarean section at 27 weeks’ gestation. On the second day of life neutropenia was detected, requiring treatment with a colony-stimulating factor. However, on the next day the infant began to show signs of sepsis that coincided with the appearance of a nasal ulcer with whitish slough at the base and abundant yellowish exudate. Based on the suspicion of EG and <span class="elsevierStyleItalic">P aeruginosa</span> sepsis, meropenem and amikacin were administered. Despite these measures, the patient died at 4 days of life. Cultures of blood and samples taken from the ulcer were positive for <span class="elsevierStyleItalic">P aeruginosa</span>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The incidence of EG in patients with <span class="elsevierStyleItalic">P aeruginosa</span> bacteremia is between 1% and 3%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">P aeruginosa</span> causes up to 5.7% of nosocomial sepsis cases in premature newborns, but few cases involving EG have been described.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the general population EG is most frequently located in the anogenital region, on the extremities, and on the trunk, but rarely on the face or neck.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> By contrast, most of the cases of preterm EG in the literature involve the face. This characteristic formed the basis for the term <span class="elsevierStyleItalic">noma neonatorum</span>, coined by Ghosal et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> because of the clinical similarity between this type of EG and noma (cancrum oris),<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> a disease that is predominantly caused by <span class="elsevierStyleItalic">Fusobacterium necrophorum</span> and <span class="elsevierStyleItalic">Prevotella intermedia</span><a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> and described in children aged 2 years and older and adults living in unsanitary conditions. Freeman et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> later included these cases of noma neonatorum in the description of EG because of their common etiologic pathogen, <span class="elsevierStyleItalic">P aeruginosa</span>, which is practically inexistent in classic noma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis of EG, while mainly clinical, must be confirmed by cultures taken from the lesions and, in most cases, a <span class="elsevierStyleItalic">P aeruginosa</span>–positive blood culture. These analyses allow EG to be distinguished from other types of lesions in the differential diagnosis, such as deep mycosis or lesions caused by anaerobic pathogens. The main goal of treatment is to resolve the underlying bacteremia, which affects prognosis, and should include synergistic antibiotics generally consisting of an aminoglycoside and an antipseudomonal β-lactam. The lesion should be treated with topical antibiotics and mechanical or chemical debridement.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, EG must be included in the differential diagnosis of ulcerous lesions in preterm patients, especially in cases with associated neutropenia, bearing in mind the tendency for these lesions to appear on the face. Rapid identification can allow for early and adequate antibiotic treatment and reduce the high mortality associated with <span class="elsevierStyleItalic">P aeruginosa</span> sepsis, especially in lesions that appear days before clinical sepsis as described in the first of these 2 patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Serrano-Martín MM, del Boz J, Chaffanel-Peláez M, Vera-Casaño A. Ectima gangrenoso facial en dos recién nacidos pretérmino. Actas Dermosifiliogr. 2012;103:637-638.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 951 "Tamanyo" => 164939 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1. Necrotic ulcers in the right nasal cavity and on the upper lip, right cheek, and tongue.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonpseudomonal ecthyma gangrenosum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 14 | 28 |
| 2024 October | 100 | 65 | 165 |
| 2024 September | 98 | 45 | 143 |
| 2024 August | 158 | 74 | 232 |
| 2024 July | 97 | 56 | 153 |
| 2024 June | 113 | 69 | 182 |
| 2024 May | 101 | 70 | 171 |
| 2024 April | 84 | 24 | 108 |
| 2024 March | 98 | 35 | 133 |
| 2024 February | 79 | 33 | 112 |
| 2024 January | 92 | 48 | 140 |
| 2023 December | 83 | 22 | 105 |
| 2023 November | 108 | 29 | 137 |
| 2023 October | 70 | 35 | 105 |
| 2023 September | 89 | 37 | 126 |
| 2023 August | 80 | 27 | 107 |
| 2023 July | 62 | 55 | 117 |
| 2023 June | 72 | 25 | 97 |
| 2023 May | 65 | 41 | 106 |
| 2023 April | 80 | 31 | 111 |
| 2023 March | 60 | 40 | 100 |
| 2023 February | 46 | 46 | 92 |
| 2023 January | 56 | 34 | 90 |
| 2022 December | 53 | 37 | 90 |
| 2022 November | 59 | 36 | 95 |
| 2022 October | 38 | 33 | 71 |
| 2022 September | 34 | 32 | 66 |
| 2022 August | 33 | 39 | 72 |
| 2022 July | 36 | 34 | 70 |
| 2022 June | 16 | 32 | 48 |
| 2022 May | 71 | 41 | 112 |
| 2022 April | 100 | 54 | 154 |
| 2022 March | 91 | 77 | 168 |
| 2022 February | 79 | 40 | 119 |
| 2022 January | 63 | 45 | 108 |
| 2021 December | 46 | 52 | 98 |
| 2021 November | 57 | 50 | 107 |
| 2021 October | 62 | 52 | 114 |
| 2021 September | 57 | 44 | 101 |
| 2021 August | 52 | 41 | 93 |
| 2021 July | 51 | 27 | 78 |
| 2021 June | 46 | 37 | 83 |
| 2021 May | 43 | 33 | 76 |
| 2021 April | 110 | 44 | 154 |
| 2021 March | 137 | 35 | 172 |
| 2021 February | 84 | 19 | 103 |
| 2021 January | 46 | 25 | 71 |
| 2020 December | 68 | 21 | 89 |
| 2020 November | 40 | 7 | 47 |
| 2020 October | 34 | 4 | 38 |
| 2020 September | 44 | 10 | 54 |
| 2020 August | 21 | 23 | 44 |
| 2020 July | 32 | 14 | 46 |
| 2020 June | 33 | 31 | 64 |
| 2020 May | 31 | 23 | 54 |
| 2020 April | 29 | 20 | 49 |
| 2020 March | 26 | 23 | 49 |
| 2020 February | 2 | 10 | 12 |
| 2020 January | 4 | 8 | 12 |
| 2019 December | 6 | 5 | 11 |
| 2019 November | 4 | 4 | 8 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 0 | 8 | 8 |
| 2019 August | 6 | 7 | 13 |
| 2019 July | 4 | 8 | 12 |
| 2019 June | 5 | 12 | 17 |
| 2019 May | 5 | 17 | 22 |
| 2019 April | 2 | 14 | 16 |
| 2019 March | 2 | 10 | 12 |
| 2019 February | 0 | 6 | 6 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 2 | 0 | 2 |
| 2018 August | 0 | 2 | 2 |
| 2018 July | 0 | 1 | 1 |
| 2018 June | 0 | 4 | 4 |
| 2018 May | 0 | 6 | 6 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 52 | 7 | 59 |
| 2018 January | 46 | 7 | 53 |
| 2017 December | 65 | 5 | 70 |
| 2017 November | 46 | 11 | 57 |
| 2017 October | 41 | 6 | 47 |
| 2017 September | 64 | 10 | 74 |
| 2017 August | 63 | 14 | 77 |
| 2017 July | 38 | 9 | 47 |
| 2017 June | 68 | 40 | 108 |
| 2017 May | 60 | 8 | 68 |
| 2017 April | 60 | 6 | 66 |
| 2017 March | 50 | 20 | 70 |
| 2017 February | 39 | 8 | 47 |
| 2017 January | 34 | 19 | 53 |
| 2016 December | 48 | 7 | 55 |
| 2016 November | 74 | 9 | 83 |
| 2016 October | 78 | 23 | 101 |
| 2016 September | 139 | 11 | 150 |
| 2016 August | 96 | 10 | 106 |
| 2016 July | 47 | 14 | 61 |
| 2016 June | 12 | 18 | 30 |
| 2016 May | 7 | 14 | 21 |
| 2016 April | 6 | 10 | 16 |
| 2016 March | 9 | 7 | 16 |
| 2016 February | 6 | 2 | 8 |
| 2016 January | 7 | 13 | 20 |
| 2015 December | 4 | 1 | 5 |
| 2015 November | 8 | 8 | 16 |
| 2015 October | 13 | 6 | 19 |
| 2015 September | 6 | 3 | 9 |
| 2015 August | 13 | 2 | 15 |
| 2015 July | 113 | 11 | 124 |
| 2015 June | 77 | 13 | 90 |
| 2015 May | 94 | 14 | 108 |
| 2015 April | 86 | 13 | 99 |
| 2015 March | 76 | 6 | 82 |
| 2015 February | 67 | 13 | 80 |
| 2015 January | 70 | 14 | 84 |
| 2014 December | 79 | 12 | 91 |
| 2014 November | 63 | 9 | 72 |
| 2014 October | 89 | 22 | 111 |
| 2014 September | 63 | 18 | 81 |
| 2014 August | 31 | 3 | 34 |
| 2014 July | 26 | 5 | 31 |
| 2014 June | 40 | 4 | 44 |
| 2014 May | 43 | 9 | 52 |
| 2014 April | 44 | 8 | 52 |
| 2014 March | 43 | 11 | 54 |
| 2014 February | 42 | 6 | 48 |
| 2014 January | 35 | 11 | 46 |
| 2013 December | 39 | 8 | 47 |
| 2013 November | 27 | 9 | 36 |
| 2013 October | 39 | 7 | 46 |
| 2013 September | 34 | 18 | 52 |
| 2013 August | 14 | 14 | 28 |
| 2013 July | 13 | 19 | 32 |
| 2013 June | 15 | 20 | 35 |
| 2013 May | 19 | 11 | 30 |
| 2013 April | 10 | 19 | 29 |
| 2013 March | 20 | 26 | 46 |
| 2013 February | 46 | 7 | 53 |
| 2013 January | 43 | 6 | 49 |
| 2012 December | 22 | 5 | 27 |
| 2012 November | 1 | 1 | 2 |
| 2012 October | 0 | 3 | 3 |
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