Acute ecthyma gangrenosum-like lesions in a neutropenic patient with large granular lymphocyte leukemia
Creators: name: Moniyka Sachar
Publisher: name: figshare
Year: 2020
Subjects: subject: 110309 Infectious Diseases
subject: FOS: Health sciences
subject: FOS: Health sciences

description: The patient is a 69 yr old woman hx of AIHA, s/p splenectomy 1975, eczema, migraines, anxiety admitted 9/5 for several days of fever (Tmax 102.9) and chills, one week of painful left forearm and axillary lesions, and new finding of neutropenia. We were consulted for neutropenic fever (ANC 0) and lesions concerning for ecthyma gangrenosum. Her story begins 4 weeks ago, she was gardening at her home in NH, and noticed thorn pricks on her L hand which subsequently resolved. Also 4 weeks ago, she took her grandchildren to pet sheep and llamas. No other travel or sick contacts. She has a history of picking at skin lesions, and noticed 2 weeks ago new skin lesions on her left forearm/upper arm that she picked at but would not heal. She monitors her temperature daily, and 1 week ago began having fevers, chills, NS, fatigue, dairrhea, with no headache, respiratory, or urinary complaints. She did report continuous pain in the two lesions on her arm, along with two painful left axillary nodules. On exam, she has one lesiosn on her forearm and one on her upper arm, both with central purple plaque (&lt;1cm in diameter) with surrounding several cm of circular erythema, along with 2 erythematous, with a blue tinge swollen nodules in L axilla. She has excoriations on chest/dorsum of foot associated with prior pruritus, scratching, and lack of healing. Throughout her hc, her tmax is 102.9, with leukopenia as low as 1.9 with ANC of 0. Notably, prior CBC done July 10th showed normal WC 7.9, no prior hx of neutropenia. Her hemoglobin has been dropping throughout HC, from 12 on admission to 9.7 currently, pt has history of AIHA. Platelets normal. 9/5 and 9/7 bcx show NGTD, 9/6 ucx negative. CRP 181, ESR 30. CT Chest A/P without contrast notable for calcified granuloma in RML of lung, pancreatic lesion of 1.6 cm likely benign, hypoattenuating lesions in her liver likely benign, no lymphadenopathy. No prior imaging to compare. Diff dx: Given new-onset neutropenia (7/20 CBC wnml), and fever to 102.9, patient has neutropenic fever with no clear source identified. Differentials associated with her left arm/axilla lesions concerning for ecthyma gangrenosum: 1) Bacterial pathogens: P<i>seudomonas stutzeri</i>, <i>Aeromonas</i> spp, <i>Stenotrophomonas</i> spp, <i>Citrobacter</i> spp, <i>S. Pyogenes </i>and <i>S. aureus</i>, and atypical mycobacteria. P.aeurginosa is a high-risk pathogen given pt is neutropenic with ecthyma-like lesion. Stenotrophomonas and aeromonas can cause ecthyma-like lesions, but tend to be nocosomially acquired and could cause more of an infiltrate if con-commitant pneumonia. <b>9/5 bcx NGTD: no bacteremia that could contribute to ecthyma gangrenosum like lesions.</b> <b>Given patient has negative fungitell serum marker, negative AFB/calcofluor white stain of bx lesion, has multiple ecthyma-like lesions in lymphadenitis-type spread, is not ill with any other respiratory symptoms, lower likelihood of fungal, gram negative bacterial infections contributing to ecthyma-gangrenosum like lesions. Given pt has habit of scratching, possibility for MSSA superinfection resulting in these left arm lesions. Pt is already on MRSA coverage with vancomycin, day 5, and clinically improving. Will f/u on LUE skin bx culture results, and bm bx results. </b>2) Fungal infections, <i>Fusarium</i> spp have been classically associated with ecthyma gangrenosum, and possibly disseminated candidiasis. Given her cavitary lung lesion, and ecthyma-gangrenosum-like lesions, fusarium is high on the differential. Mucormycosis can present cutaneously as ecthyma-like lesions, and can be associated with spore inoculation via trauma as in this patient. Candidemia can also result in ecthyma-like lesions, and is a rare cause of neutropenic fever.<b> Serum fungitell, AFB and fungal stain of LUE skin bx negative, pending skin LUE fungal/AFB cx results. </b>3) Pathogens associated with fever/rash in immunocompromised patients (not necessarily ecthyma): Sporotrichosis is less likely given lack of nodular, linear lesions, however can cause cavitary lung lesions and would be consistent with exposure hx. Tularemia is possible given her outdoor exposure, recent visit to petting zoo, and painful adenopathy in axilla, can rarely cause cavitary lung lesions. Tick-borne diseases (rickettsia associated with central-spreading rash, tularemia associated with buboes, bartonella can be associated with pain lymphadenopathy). Candida/aspergillosis/crypto should be ruled out. Less likely to be endemic fungi, though would be consistent with calcified lung granuloma. 4) Pathogens associated with calcified granuloma include TB, histoplasma, schistosomiasis, sarcoidosis. Pt has no respiratory complaints at this time. May recommend further w/u pending skin bx and remaining infectious w/u results.