An Infant with Measles Developed Ecthyma Gangrenosum Caused by Coagulase-Negative Staphylococcus: A Rare Case Report from Somalia

Introduction

Ecthyma gangrenosum is an uncommon cutaneous lesion caused by the aerobic gram-negative opportunistic bacterial pathogen Pseudomonas aeruginosa. Sepsis is not a frequent consequence in patients without bacteremia. Patients with impaired immune systems are more frequently impacted.¹ Despite being the most frequent causal agent, Pseudomonas aeruginosa is not the only bacteria that has been involved.² Other types of bacteria may also be implicated in the etiology of EG: cocci bacteria, both gram-positive and gram-negative.³

This illness often affects the extremities, gluteal, and perineal areas, and it has been linked to fatal septicaemic infections and high mortality.⁴ We report a case of ecthyma gangrenosum in an infant after a measles infection.

Case Presentation

A 10-month-old male infant was brought into the pediatrics unit with a 10-day history of high-grade fever and generalized body rashes without any prior vaccination history.

At the time of admission, the patient had a high fever of about 40.3°C and appeared conscious. Physical examination revealed several skin lesions that were in various stages of development and appeared as nodules with a central crust and round, ulcerated, necrotic papules.

The face, chest, and upper extremities were all affected by the lesions (Figure 1). After obtaining samples of the patient’s blood, cerebrospinal fluid, and skin lesion (pustule), an empiric course of intravenous Clindamycin (10 mg/kg per day) and Ceftriaxone (50 mg/kg per day) was started.

Figure 1 Ecthyma gangrenosum ulcers in the face, chest, and upper extremities.

Laboratory tests showed CRP 25 mg/l, LDH 579 U/L, WBC 15.06 × 1000/mm3, HGB 8.4 g/dl, and absolute neutrophils 1930/mm3 (12.8%), PLT 323 × 1000/mm3.

Coagulase-negative Staphylococcus was found in the tissues that were taken from the lesion, supporting the diagnosis of ecthyma gangrenosum.

Coagulase-negative Staphylococcus aureus, an isolated strain, was susceptible to vancomycin, quinupristin, daptomycin, and vancomycin (Table 1). According to the drug susceptibility test results, intravenous Vancomycin (20 mg/kg per dose, 3 times daily) should be started. Coagulase-negative Staphylococcus aureus was eliminated as a result of this defervescence. The necrotic lesion was surgically removed from the patient. Twenty days after the treatment, the patient made a complete recovery. The lesions significantly improved. The necrotic lesion was surgically removed from the patient, and there was no sign of recurrence or new lesions. Lesions were seen on subsequent visits.

Table 1 The Cultured Organism’s Antibiotic Sensitivity

Discussion

Ecthyma gangrenosum (EG) is a well-known cutaneous infection that is mostly linked to bacteremia caused by Pseudomonas aeruginosa. The etiopathogenesis of EG has also been linked to various pathogens, including Candida sp., Escherichia coli, Citrobacter sp., Klebsiella sp., Staphylococcus aureus, and Streptococcus pyogenes.⁵

Although the gluteal or perineal region is the most typical location for EG lesions (57%), other unusual locations can also be affected, including the extremities, trunk, face, and very infrequently the periorbital region.⁴

Our patient had lesions that appeared as nodules with a central crust and round, ulcerated, necrotic papules. The left forehead, left side of the chest, and area next to the breasts were all affected by the lesions.

Pseudomonas aeruginosa is the most frequently linked bacterium in the pathogenesis of EG. Staphylococcus aureus,^6,7 and gram-negative cocci such as Neisseria gonorrhea⁸ or gram-negative bacteria such as E. coli may also be involved.⁹ In our patient, the causative organism is coagulase-negative Staphylococcus, which is a gram-positive bacteria. In 2023, according to our knowledge, there is one case report of EG caused by coagulase-negative Staphylococcus, especially Staphylococcus lentus.⁵

Patients with cancer, hypogammaglobulinemia, steroid therapy, immunodeficiency, particularly neutropenia, and malignancies are at a higher risk of contracting this infection.¹⁰ In immunocompromised patients, the death rate from EG varies from 38% to 96%, while in nonbacteremic patients, it is 16%. Although neutropenia is the most common risk factor for EG.¹¹

Viral diseases like measles have the ability to directly or indirectly inhibit bone marrow granulocytosis. Neutropenia can range greatly in severity, from moderate to severe.¹² Our patient had a history of measles, which led to neutropenia before developing EG

The management of ecthyma gangrenosum requires early identification and antimicrobial treatment. A better prognosis is linked to a lack of bacteremia.

To stop the spread of infection and septicemia, surgical drainage of small abscesses and debridement of all necrotizing tissues may be required.¹³ In nonsepticemic cases, the death rate is typically around 15%. However, in septicemic patients, the rate is incredibly varied and can reach up to 96%.¹⁴ Thus, the potential application of the right treatment and identification of the lesions can be essential to their survival. The lesions significantly improved. The necrotic lesion was surgically removed from the patient, and there was no sign of recurrence or new lesions. Lesions were seen on subsequent visits.