Letter to the Editor
Ecthyma gangrenosum in a renal transplant recipient
Ectima gangrenoso en paciente portadora de trasplante renal
Begoña Santos, Marta Sanz, Almudena Nuñez, Lech Onofre Mayor, Borja Quiroga
Corresponding author
Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, Spain
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gangrenosum in a renal transplant recipient" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "573" "paginaFinal" => "574" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Begoña Santos, Marta Sanz, Almudena Nuñez, Lech Onofre Mayor, Borja Quiroga" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Begoña" "apellidos" => "Santos" ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "Sanz" ] 2 => array:2 [ "nombre" => "Almudena" "apellidos" => "Nuñez" ] 3 => array:2 [ "nombre" => "Lech Onofre" "apellidos" => "Mayor" ] 4 => array:4 [ "nombre" => "Borja" "apellidos" => "Quiroga" "email" => array:1 [ 0 => "borjaqg@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ectima gangrenoso en paciente portadora de trasplante renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 743 "Ancho" => 990 "Tamanyo" => 102192 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous lesions on the arm (A) and on the back of the leg (B), corresponding to ecthyma gangrenosum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ecthyma gangrenosum is a skin lesion usually produced by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, resulting from infection of a hair follicle or from systemic infection usually in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> It is a rare disease with high rate of morbidity and mortality. The lesions begin as erythematous macules, which later develop into haematic papules or vesicles that rupture, thus producing necrotic ulcers. An early diagnosis and antibiotic treatment are essential to improve the prognosis of the disease. Here we present a case of a renal transplant patient on dual immunosuppressive therapy, who had ecthyma gangrenosum caused by <span class="elsevierStyleItalic">P. aeruginosa</span>, 3 years after the renal transplant, with a good response to antibiotic treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This case involves a 63-year-old female patient, with hypertension, type 2 diabetes and a kidney transplant from a cadaver donor 3 years earlier; she attended the emergency room for a two day history of generalised skin lesions, fever and sore throat. Relevant history included a post-transplant intestinal ischaemia resolved with intestinal resection. She is currently being treated with mycophenolate mofetil (MMF) and tacrolimus.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On arrival she had a temperature of 38<span class="elsevierStyleHsp" style=""></span>°C, blood pressure of 126/75<span class="elsevierStyleHsp" style=""></span>mmHg and heart rate of 81<span class="elsevierStyleHsp" style=""></span>bpm. On physical examination there were painful vesicular-bullous skin lesions of haemorrhagic content on the right leg, abdomen and left arm, about 3–25<span class="elsevierStyleHsp" style=""></span>mm in diameter, and punctate erythematous lesions on the nasolabial folds and tongue blisters, and on the oral mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The laboratory tests showed haemoglobin 11.3<span class="elsevierStyleHsp" style=""></span>g/dL, platelets 210,000, leukocytes 1780 (neutrophils 11.2%, lymphocytes 23% and monocytes 60.7%), glucose 140<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine 1.95<span class="elsevierStyleHsp" style=""></span>mg/dL (baseline 1<span class="elsevierStyleHsp" style=""></span>mg/dL), urea 93<span class="elsevierStyleHsp" style=""></span>mg/dL, potassium 3.31<span class="elsevierStyleHsp" style=""></span>mEq/L, procalcitonin 1.1<span class="elsevierStyleHsp" style=""></span>ng/ml, CRP 6.30<span class="elsevierStyleHsp" style=""></span>mg/dL, pH in venous blood gases 7.39, <span class="elsevierStyleSmallCaps">l</span>-lactate 2<span class="elsevierStyleHsp" style=""></span>mmol/l. In the preceding days she had received empirical antibiotic therapy with amoxicillin-clavulanic acid for a sore throat.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Suspecting ecthyma gangrenosum, the patient was admitted and placed on broad-spectrum antibiotics (daptomycin, ceftazidime and Meropenem<span class="elsevierStyleSup">®</span>) after obtaining blood cultures, a wound culture and a biopsy of the lesion in Dermatology. Also, immunosuppression was reduced with a temporary suspension of MMF. During admission, the patient progressed favourably, and the skin lesion cultures were positive for <span class="elsevierStyleItalic">P. aeruginosa</span>; the daptomycin was stopped after determining sensitivity by an antibiogram (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In addition to antibiotic therapy, one of the bullous lesions was drained, and copper sulfate and silver sulfadiazine were applied topically. After 7 days of treatment, the lesions improved and the lab test results normalised (Cr 0.79<span class="elsevierStyleHsp" style=""></span>mg/dL and leukocytes 3,000<span class="elsevierStyleHsp" style=""></span>μ/l), and so the patient was discharged. In follow-up, and after completing 3 weeks of antibiotic therapy, the patient's symptoms resolved completely.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We therefore report here an exceptional case of ecthyma gangrenosum in a patient with a renal graft that functioned for 3 years, with a positive outcome after treatment, despite the initial condition of neutropenia and immunosuppression.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are few data on ecthyma gangrenosum published to date, with the majority of them concerning patients with haematological diseases in paediatric or immunosuppressed patients.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> As for kidney transplant patients, 3 cases have been reported so far.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4–6</span></a> In all 3 cases the outcome has been favourable, after targeted antibiotic treatment, whether or not combined with debridement of the lesions,. In one of these cases the initial evolution was torpid, with septic shock, and required admission to the intensive care unit and repeated surgical debridement. The patient improved thereafter.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Therefore it seems that starting treatment early with broad-spectrum antibiotics (which especially covers <span class="elsevierStyleItalic">P. aeruginosa</span>) when these lesions are suspected, as well as granulocyte-colony stimulating factor and surgery if necessary, affects how the condition, which is potentially fatal, develops.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">An association between neutropenia and increased mortality has been documented in patients with ecthyma gangrenosum, with neutropenia being one of the main factors for poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> In a series of 43 cases of immunocompetent paediatric patients who developed sepsis due to <span class="elsevierStyleItalic">P. aeruginosa</span>, 9 out of 10 patients who died had presented with leukopenia at the onset of symptoms.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> It is noteworthy that in reviewing cases in the immunocompetent general population, the evolution of the disease is more torpid, with increased mortality in patients with a renal transplant on immunosuppressive therapy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, the clinical suspicion of ecthyma gangrenosum in patients with a renal transplant and suggestive lesions requires an initial aggressive approach with broad-spectrum antibiotics, granulocyte-colony stimulating factor and surgical debridement, if necessary, in order to avoid major life-threatening complications.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any funding to complete this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Santos B, Sanz M, Nuñez A, Mayor LO, Quiroga B. Ectima gangrenoso en paciente portadora de trasplante renal. Nefrologia. 2016;36:573–574.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 743 "Ancho" => 990 "Tamanyo" => 102192 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous lesions on the arm (A) and on the back of the leg (B), corresponding to ecthyma gangrenosum.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MIC: minimum inhibitory concentration.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MIC (mg/l) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Piperacillin/tazobactam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceftazidime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aztreonam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Imipenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gentamicin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tobramycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amikacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ciprofloxacin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensitive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">≤0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1299530.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Antibiograms of wound exudate.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Étiologie de l’ecthyma gangréneux (quatre cas)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. 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| Year/Month | Html | Total | |
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| 2024 November | 8 | 3 | 11 |
| 2024 October | 152 | 62 | 214 |
| 2024 September | 134 | 44 | 178 |
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| 2024 April | 98 | 40 | 138 |
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| 2024 February | 154 | 32 | 186 |
| 2024 January | 175 | 26 | 201 |
| 2023 December | 224 | 42 | 266 |
| 2023 November | 225 | 49 | 274 |
| 2023 October | 253 | 23 | 276 |
| 2023 September | 240 | 35 | 275 |
| 2023 August | 207 | 22 | 229 |
| 2023 July | 234 | 45 | 279 |
| 2023 June | 231 | 27 | 258 |
| 2023 May | 285 | 51 | 336 |
| 2023 April | 204 | 26 | 230 |
| 2023 March | 230 | 25 | 255 |
| 2023 February | 141 | 33 | 174 |
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| 2022 December | 141 | 36 | 177 |
| 2022 November | 127 | 32 | 159 |
| 2022 October | 146 | 49 | 195 |
| 2022 September | 129 | 38 | 167 |
| 2022 August | 129 | 47 | 176 |
| 2022 July | 118 | 39 | 157 |
| 2022 June | 121 | 36 | 157 |
| 2022 May | 149 | 35 | 184 |
| 2022 April | 172 | 59 | 231 |
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| 2021 December | 178 | 67 | 245 |
| 2021 November | 138 | 60 | 198 |
| 2021 October | 174 | 45 | 219 |
| 2021 September | 122 | 31 | 153 |
| 2021 August | 119 | 38 | 157 |
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| 2021 May | 181 | 41 | 222 |
| 2021 April | 403 | 88 | 491 |
| 2021 March | 199 | 38 | 237 |
| 2021 February | 152 | 20 | 172 |
| 2021 January | 162 | 26 | 188 |
| 2020 December | 173 | 18 | 191 |
| 2020 November | 171 | 27 | 198 |
| 2020 October | 96 | 24 | 120 |
| 2020 September | 158 | 27 | 185 |
| 2020 August | 97 | 14 | 111 |
| 2020 July | 98 | 12 | 110 |
| 2020 June | 101 | 10 | 111 |
| 2020 May | 82 | 16 | 98 |
| 2020 April | 86 | 20 | 106 |
| 2020 March | 96 | 13 | 109 |
| 2020 February | 102 | 23 | 125 |
| 2020 January | 189 | 17 | 206 |
| 2019 December | 176 | 23 | 199 |
| 2019 November | 154 | 24 | 178 |
| 2019 October | 163 | 8 | 171 |
| 2019 September | 142 | 21 | 163 |
| 2019 August | 89 | 17 | 106 |
| 2019 July | 99 | 23 | 122 |
| 2019 June | 74 | 18 | 92 |
| 2019 May | 98 | 20 | 118 |
| 2019 April | 131 | 38 | 169 |
| 2019 March | 87 | 18 | 105 |
| 2019 February | 72 | 22 | 94 |
| 2019 January | 64 | 20 | 84 |
| 2018 December | 197 | 42 | 239 |
| 2018 November | 218 | 14 | 232 |
| 2018 October | 275 | 17 | 292 |
| 2018 September | 318 | 11 | 329 |
| 2018 August | 105 | 15 | 120 |
| 2018 July | 94 | 16 | 110 |
| 2018 June | 84 | 10 | 94 |
| 2018 May | 115 | 17 | 132 |
| 2018 April | 165 | 9 | 174 |
| 2018 March | 149 | 5 | 154 |
| 2018 February | 185 | 8 | 193 |
| 2018 January | 183 | 8 | 191 |
| 2017 December | 136 | 5 | 141 |
| 2017 November | 108 | 13 | 121 |
| 2017 October | 58 | 5 | 63 |
| 2017 September | 67 | 11 | 78 |
| 2017 August | 51 | 4 | 55 |
| 2017 July | 44 | 6 | 50 |
| 2017 June | 43 | 18 | 61 |
| 2017 May | 54 | 7 | 61 |
| 2017 April | 46 | 14 | 60 |
| 2017 March | 46 | 38 | 84 |
| 2017 February | 53 | 7 | 60 |
| 2017 January | 45 | 16 | 61 |
| 2016 December | 16 | 3 | 19 |
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