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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 13 | 14 | 27 |
| 2024 Octubre | 100 | 65 | 165 |
| 2024 Septiembre | 98 | 45 | 143 |
| 2024 Agosto | 158 | 74 | 232 |
| 2024 Julio | 97 | 56 | 153 |
| 2024 Junio | 113 | 69 | 182 |
| 2024 Mayo | 101 | 70 | 171 |
| 2024 Abril | 84 | 24 | 108 |
| 2024 Marzo | 98 | 35 | 133 |
| 2024 Febrero | 79 | 33 | 112 |
| 2024 Enero | 92 | 48 | 140 |
| 2023 Diciembre | 83 | 22 | 105 |
| 2023 Noviembre | 108 | 29 | 137 |
| 2023 Octubre | 70 | 35 | 105 |
| 2023 Septiembre | 89 | 37 | 126 |
| 2023 Agosto | 80 | 27 | 107 |
| 2023 Julio | 62 | 55 | 117 |
| 2023 Junio | 72 | 25 | 97 |
| 2023 Mayo | 65 | 41 | 106 |
| 2023 Abril | 80 | 31 | 111 |
| 2023 Marzo | 60 | 40 | 100 |
| 2023 Febrero | 46 | 46 | 92 |
| 2023 Enero | 56 | 34 | 90 |
| 2022 Diciembre | 53 | 37 | 90 |
| 2022 Noviembre | 59 | 36 | 95 |
| 2022 Octubre | 38 | 33 | 71 |
| 2022 Septiembre | 34 | 32 | 66 |
| 2022 Agosto | 33 | 39 | 72 |
| 2022 Julio | 36 | 34 | 70 |
| 2022 Junio | 16 | 32 | 48 |
| 2022 Mayo | 71 | 41 | 112 |
| 2022 Abril | 100 | 54 | 154 |
| 2022 Marzo | 91 | 77 | 168 |
| 2022 Febrero | 79 | 40 | 119 |
| 2022 Enero | 63 | 45 | 108 |
| 2021 Diciembre | 46 | 52 | 98 |
| 2021 Noviembre | 57 | 50 | 107 |
| 2021 Octubre | 62 | 52 | 114 |
| 2021 Septiembre | 57 | 44 | 101 |
| 2021 Agosto | 52 | 41 | 93 |
| 2021 Julio | 51 | 27 | 78 |
| 2021 Junio | 46 | 37 | 83 |
| 2021 Mayo | 43 | 33 | 76 |
| 2021 Abril | 110 | 44 | 154 |
| 2021 Marzo | 137 | 35 | 172 |
| 2021 Febrero | 84 | 19 | 103 |
| 2021 Enero | 46 | 25 | 71 |
| 2020 Diciembre | 68 | 21 | 89 |
| 2020 Noviembre | 40 | 7 | 47 |
| 2020 Octubre | 34 | 4 | 38 |
| 2020 Septiembre | 44 | 10 | 54 |
| 2020 Agosto | 21 | 23 | 44 |
| 2020 Julio | 32 | 14 | 46 |
| 2020 Junio | 33 | 31 | 64 |
| 2020 Mayo | 31 | 23 | 54 |
| 2020 Abril | 29 | 20 | 49 |
| 2020 Marzo | 26 | 23 | 49 |
| 2020 Febrero | 2 | 10 | 12 |
| 2020 Enero | 4 | 8 | 12 |
| 2019 Diciembre | 6 | 5 | 11 |
| 2019 Noviembre | 4 | 4 | 8 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 0 | 8 | 8 |
| 2019 Agosto | 6 | 7 | 13 |
| 2019 Julio | 4 | 8 | 12 |
| 2019 Junio | 5 | 12 | 17 |
| 2019 Mayo | 5 | 17 | 22 |
| 2019 Abril | 2 | 14 | 16 |
| 2019 Marzo | 2 | 10 | 12 |
| 2019 Febrero | 0 | 6 | 6 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Agosto | 0 | 2 | 2 |
| 2018 Julio | 0 | 1 | 1 |
| 2018 Junio | 0 | 4 | 4 |
| 2018 Mayo | 0 | 6 | 6 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 52 | 7 | 59 |
| 2018 Enero | 46 | 7 | 53 |
| 2017 Diciembre | 65 | 5 | 70 |
| 2017 Noviembre | 46 | 11 | 57 |
| 2017 Octubre | 41 | 6 | 47 |
| 2017 Septiembre | 64 | 10 | 74 |
| 2017 Agosto | 63 | 14 | 77 |
| 2017 Julio | 38 | 9 | 47 |
| 2017 Junio | 68 | 40 | 108 |
| 2017 Mayo | 60 | 8 | 68 |
| 2017 Abril | 60 | 6 | 66 |
| 2017 Marzo | 50 | 20 | 70 |
| 2017 Febrero | 39 | 8 | 47 |
| 2017 Enero | 34 | 19 | 53 |
| 2016 Diciembre | 48 | 7 | 55 |
| 2016 Noviembre | 74 | 9 | 83 |
| 2016 Octubre | 78 | 23 | 101 |
| 2016 Septiembre | 139 | 11 | 150 |
| 2016 Agosto | 96 | 10 | 106 |
| 2016 Julio | 47 | 14 | 61 |
| 2016 Junio | 12 | 18 | 30 |
| 2016 Mayo | 7 | 14 | 21 |
| 2016 Abril | 6 | 10 | 16 |
| 2016 Marzo | 9 | 7 | 16 |
| 2016 Febrero | 6 | 2 | 8 |
| 2016 Enero | 7 | 13 | 20 |
| 2015 Diciembre | 4 | 1 | 5 |
| 2015 Noviembre | 8 | 8 | 16 |
| 2015 Octubre | 13 | 6 | 19 |
| 2015 Septiembre | 6 | 3 | 9 |
| 2015 Agosto | 13 | 2 | 15 |
| 2015 Julio | 113 | 11 | 124 |
| 2015 Junio | 77 | 13 | 90 |
| 2015 Mayo | 94 | 14 | 108 |
| 2015 Abril | 86 | 13 | 99 |
| 2015 Marzo | 76 | 6 | 82 |
| 2015 Febrero | 67 | 13 | 80 |
| 2015 Enero | 70 | 14 | 84 |
| 2014 Diciembre | 79 | 12 | 91 |
| 2014 Noviembre | 63 | 9 | 72 |
| 2014 Octubre | 89 | 22 | 111 |
| 2014 Septiembre | 63 | 18 | 81 |
| 2014 Agosto | 31 | 3 | 34 |
| 2014 Julio | 26 | 5 | 31 |
| 2014 Junio | 40 | 4 | 44 |
| 2014 Mayo | 43 | 9 | 52 |
| 2014 Abril | 44 | 8 | 52 |
| 2014 Marzo | 43 | 11 | 54 |
| 2014 Febrero | 42 | 6 | 48 |
| 2014 Enero | 35 | 11 | 46 |
| 2013 Diciembre | 39 | 8 | 47 |
| 2013 Noviembre | 27 | 9 | 36 |
| 2013 Octubre | 39 | 7 | 46 |
| 2013 Septiembre | 34 | 18 | 52 |
| 2013 Agosto | 14 | 14 | 28 |
| 2013 Julio | 13 | 19 | 32 |
| 2013 Junio | 15 | 20 | 35 |
| 2013 Mayo | 19 | 11 | 30 |
| 2013 Abril | 10 | 19 | 29 |
| 2013 Marzo | 20 | 26 | 46 |
| 2013 Febrero | 46 | 7 | 53 |
| 2013 Enero | 43 | 6 | 49 |
| 2012 Diciembre | 22 | 5 | 27 |
| 2012 Noviembre | 1 | 1 | 2 |
| 2012 Octubre | 0 | 3 | 3 |
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