Introduction: Ecthyma gangrenosum (EG) is a cutaneous manifestation resulting from bacteremia, associated with high mortality, especially in immunocompromised patients, those with a primary skin lesion, or individuals with an immature immune system, such as premature neonates.
Case Description: We report an extremely premature male neonate, small for gestational age, born via uncomplicated vaginal delivery to a primigravida mother with an untreated urinary tract infection and vaginosis. At birth, the neonate presented with respiratory distress requiring positive pressure ventilation, supplemental oxygen, and intravenous dextrose. He was referred to the Neonatal Intensive Care Unit due to perinatal risk factors and initiated on first-line antibiotic therapy (ampicillin and gentamicin). Early during admission, hyperpigmented macules appeared on the abdomen and left thigh. Blood cultures were negative. The neonate’s condition progressed unfavorably, necessitating advanced supportive measures. (image)
Discussion: Pseudomonas aeruginosa infections are more frequent in immunocompromised patients, particularly in extremely premature neonates. The rapid evolution of erythematous macules into papules, vesicles, and necrotic ulcers with a central black eschar suggests infection by this pathogen. Initial antibiotic therapy in this case included vancomycin and amikacin. While aminoglycosides are part of recommended regimens, literature indicates that optimal management of septic EG should include an antipseudomonal β-lactam (piperacillin-tazobactam, ceftazidime, or meropenem) in combination with an aminoglycoside for improved outcomes.
Conclusion: Early recognition of cutaneous lesions by healthcare providers is critical. Prompt initiation of appropriate antibiotic therapy, even without microbiological confirmation, can improve clinical outcomes and reduce mortality in EG.
