J Pediatr Infect Dis 2015; 10(02): 059-062
DOI: 10.1055/s-0035-1564069
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Eschar or Ecthyma or Both?

S. Arunachalam
1   Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore, Singapore
,
K.C. Thoon
2   Infectious Disease Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
3   YLL School of Medicine and Duke-NUS Graduate School of Medicine, National University of Singapore, Singapore, Singapore
,
N. Nagarajan
4   Paediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
,
J.Y. Pan
5   National Skin Centre, Singapore, Singapore
› Author Affiliations
Further Information

Publication History

10 April 2015

27 July 2015

Publication Date:
14 September 2015 (online)

Abstract

We report a case of scrub typhus with coexistent Pseudomonas aeruginosa skin infection in the same patient. A 6-year-old Chinese boy presented with 5 days of fever, 2 days of right thigh swelling, and an insect bite mark over the swelling. A full blood count had been performed prior to hospital consultation, and showed neutropenia and thrombocytopenia. Initial clinical examination revealed a tender erythematous induration with a central punctum on his right thigh, which progressed to form a rolled-up papule with black central necrosis. The clinical suspicion was of an eschar, although ecthyma gangrenosum could not be ruled out. He had recently returned from a recreational trip in the United States 3 weeks earlier, and had travelled to Wisconsin and Las Vegas. He was treated initially for right thigh cellulitis with parenteral ampicillin and cloxacillin, but after infectious disease consultation, he was commenced on intravenous ciprofloxacin. A wound culture grew P. aeruginosa, while rickettsial serology was positive for Orientia tsutsugamushi. He responded clinically to ciprofloxacin and was discharged well, and an outpatient review showed significant improvement of his cutaneous lesion.

 
  • References

  • 1 Zomorrodi A, Wald ER. Ecthyma gangrenosum: considerations in a previously healthy child. Pediatr Infect Dis J 2002; 21 (12) 1161-1164
  • 2 Chan YH, Chong CY, Puthucheary J, Loh TF. Ecthyma gangrenosum: a manifestation of Pseudomonas sepsis in three paediatric patients. Singapore Med J 2006; 47 (12) 1080-1083
  • 3 Ishikawa T, Sakurai Y, Tanaka M , et al. Ecthyma gangrenosum-like lesions in a healthy child after infection treated with antibiotics. Pediatr Dermatol 2005; 22 (5) 453-456
  • 4 Altemeier WA, Todd JC, Inge WW. Gram-negative septicemia: a growing threat. Ann Surg 1967; 166 (4) 530-542
  • 5 Huminer D, Siegman-Igra Y, Morduchowicz G, Pitlik SD. Ecthyma gangrenosum without bacteremia. Report of six cases and review of the literature. Arch Intern Med 1987; 147 (2) 299-301
  • 6 Kingsberry MY. Ecthyma Gangrenosum. updated September 12, 2014. Available at http://emedicine.medscape.com/article/1053997-clinical#b4 . Accessed on June 1, 2013
  • 7 Reich HL, Williams Fadeyi D, Naik NS, Honig PJ, Yan AC. Nonpseudomonal ecthyma gangrenosum. J Am Acad Dermatol 2004; 50 (5, Suppl): S114-S117
  • 8 Reller ME, Dumler JS. Scrub Typhus (Orientia tsutsugamushi). In: Kliegman RM, Stanton BF, GemeIII JWS, Schor NF, Behrman RE, editors. Kliegman: Nelson Textbook of Pediatrics. Nineteenth ed. Philadelphia, PA: Saunders, An Imprint of Elsevier; 2011: 1045-1046
  • 9 Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J 2003; 22 (4) 341-345
  • 10 Kim DM, Park CJ, Lim SC, Park KH, Jang WJ, Lee SH. Diagnosis of scrub typhus by immunohistochemical staining of Orientia tsutsugamushi in cutaneous lesions. Am J Clin Pathol 2008; 130 (4) 543-551
  • 11 Silpapojakul K, Chupuppakarn S, Yuthasompob S , et al. Scrub and murine typhus in children with obscure fever in the tropics. Pediatr Infect Dis J 1991; 10 (3) 200-203
  • 12 Brown GW, Shirai A, Jegathesan M , et al. Febrile illness in Malaysia—an analysis of 1,629 hospitalized patients. Am J Trop Med Hyg 1984; 33 (2) 311-315
  • 13 Blacksell SD, Bryant NJ, Paris DH, Doust JA, Sakoda Y, Day NP. Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: a lack of consensus leads to a lot of confusion. Clin Infect Dis 2007; 44 (3) 391-401
  • 14 Lee KY, Lee HS, Hong JH, Hur JK, Whang KT ; Rkyung-YL. Roxithromycin treatment of scrub typhus (tsutsugamushi disease) in children. Pediatr Infect Dis J 2003; 22 (2) 130-133
  • 15 Watt G, Kantipong P, Jongsakul K, Watcharapichat P, Phulsuksombati D, Strickman D. Doxycycline and rifampicin for mild scrub-typhus infections in northern Thailand: a randomised trial. Lancet 2000; 356 (9235) 1057-1061
  • 16 Rolain JM, Maurin M, Vestris G, Raoult D. In vitro susceptibilities of 27 rickettsiae to 13 antimicrobials. Antimicrob Agents Chemother 1998; 42 (7) 1537-1541