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POSTPARTUM ECTHYMA GANGRENOSUM

PUNAM M SATPUTE*, SNEHA D SHIRODKAR**,MANJIRI NADKARNI***, VR BADHWAR****
*Lecturer; **Professor; ***Resident; ****Head of Department, Department of Obstetrics and Gynaecology, Lokmanya Tilak Municipal General Hospital and Medical College, Sion, Mumbai.

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A gangrenous lesion on the hypertrophied breast in the postpartum period arouses concern both, to the patient and her obstetrician. Ecthyma gangrenosum is the cutaneous manifestation of an underlying pseudomonas septicaemia or an immuno compromised state, in the form of a vesiculoeruptive haemorrhagic ulcer. Reported here is an interesting case of Ecthyma gangrenosum occurring in a postpartum patient, on a lactating breast with early septicaemia, that responded well to timely antibiotic therapy.

INTRODUCTION

Pregnancy is a period of profound temporary changes and the cutaneous tissue is affected in a wide spectrum. Apart from physiological changes due to the hormonal influences, the obstetrician should be well versed with pathological lesions associated with pregnancy. Ecthyma Gangrenosum is one such lesion that heralds an underlying systemic infection and is curable with timely appropriate antibiotic therapy.

CASE REPORT

An antenatally unregistered, 25 years old primipara, delivered 6 days ago at home, c/o gradual onset distension and pain in abdomen since delivery with sudden postpartum enlargement of right breast and an erythematous ulcer since 2 days preventing her to feed her baby. Tetanus immunization taken with local general practitioner, both antepartum and intrapartum courses were uneventful, delivery conducted by a local dai.

O/E, she was afebrile, had tachycardia upto 110 beats/minute. Her right breast was hypertrophied than the left side and the areola was surrounded by a massive nontender ulcerative crater, purple black in colour, with punched out haemorrhagic edges on the lower side, (Fig. 1), with a few haemorrhagic vesicles, some of which had ruptured (Fig. 2). The right areola and nipple was normal. Left breast was lactating and normal. P/A - uterus had involuted well, nontender, soft gaseous distension of abdomen with hypoactive bowel sounds noted.

Fig 1 : Ecthyma Gangrenosum of (R) breast with punched out margins at lower end and discolouration of breast

Fig 2 : Close view depicting the ruptured vesicles seen scattered around the Ecthyma Gangrenosum, solitary lesion.

P/S and P/V revealed vagina covered with a few yellowish purulent flakes, cervix discoloured bluish black, no foul odoured discharge from cervix or vagina and a nontender postpartum uterus with normal adnexae.

Investigations showed Hb - 9 gm%, WBC 4200 mm3 withneutropenia, RBS - 30 mg%, VDRL and HIV -ve, LFT and RFT - WNL, coagulation profile WNL except platelet count of 85,000. X-Ray chest showed a mild (R) pleural effusion. X-Ray abdomen showed insignificant airfluid levels. USG - mild hepatomegaly and minimal fluid in abdomen. Vaginal culture showed pseudomonas predominance sensitive to amikacin. FNAC of breast-neutrophilic infiltration of the benign ductal cells with Gram-ve bacilli. Surgical opinion was for conservative management and dermatological opinion confirmed Ecthyma Gangrenosum.

Patient was conservatively managed in a head high position to facilitate drainage of vaginal secretions and parenteral antibiotic (Ceftriaxone and Amikacin) started immediately on admission, continued for 10 days. Daily with clinical monitoring for overt signs of septicaemia, her neutropenia improved on 8th day of admission when WBC count increased from 4200 to 7600 mm3, with resolution of pleural effusion and purulent vaginal flakes by the 10th day. EG also showed signs of healing especially at ulcer edges by a weeks time with complete disappearance of vesicles. Patient went home on 16th day on request and resumed breast feeding in a month from the (R) breast. Baby and mother followed up once after 2 months were healthy and normal.

DISCUSSION

Ecthyma Gangrenosum is extensive cutaneous necrosis. [1] Its occurrence in a postpartum patient is rare, as it usually affects debilitated leukaemics, burns patients and the immuno compromised. Pregnancy itself is a period of immuno suppression and delivery conducted under improper asepsis can facilitate this infection. It is known to affect the apocrine glands hence seen on extremities, anogenital areas and on the buttocks, [2] however a lactating mammary gland is an unusual target. EG is pathognomonic of a pseudomonas aeruginosa infection that manifests first as haemorrhagic vesicles which break down to form ulcers with necrotic gangrenous bases and elevated haemorrhagic borders. [3] Subcutaneous nodules are also seen occasionally. The vesicular fluid harbours gram negative bacilli with neutrophils. Histologically ulcers show necrotizing vasculitis with neutrophilic infiltration. Extensive bacillary infiltration of the adventitia and media of the blood vessels sparing the intima confirms that the bacilli invade the vessel wall and spread along the surface of the vessels to the dermis below. [4] Subcutaneous nodules are the result of cellulitis to the bacillary load, and septic emboli may be evident at the capillary level in severe cases.

Timely diagnosis and appropriate therapy with antipseudomonal action (penicillins, quinolones, aminoglycosides, higher generation cephalosporins) should be started immediately without delay, as in our case for quick kill of bacillary load. Hence choose a wise broad spectrum antibiotic initially rather than await a culture report. Improvement in neutropenia heralds responsiveness to therapy. Parenteral drugs are recommended especially in the immunocompromised.

Greene et al described factors causing a poor prognosis in Ecthyma [5] , which are,

1. Multiple ulcers.

2. Delay in diagnosis and initiation of appropriate antibiotic therapy.

3. Huge bacillary load.

4. Neutropenia not resolved in 8 days of therapy.

5. Repeated instrumentation or catheterization.

ACKNOWLEDGEMENTS

We express our gratitude to HOD Dermatology LTMGH, Dr. H Jerajani for assistance in the case.

REFERENCES

1.Berger, Raza Ali. Timothy, Atlas of infections of the skin, Churchill Livingstone. 207.

2.Feingold David, Arndt Kenneth. Cutaneous Medicine and Surgery, WB Sounders. Vol. 2 : 945.

3.Fernandes Armida, Valia RG. Textbook and Atlas of Dermatology IADVL Bhalani. Vol. I : 107.

4.Lucas Sebastian, David Elder. Lever’s Histopathology 8th Edition Lippincott Raven. 465.

5.Andrews, Harry Arbold. Disease of the skin, clinical Dermatology 8th Edition. Saunders. 289.

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