Advertisement

Skin Infections

  • Nancy RihanaEmail author
  • Mindy Sampson
Chapter

Abstract

Cutaneous infections are common in immunocompromised patients. Neutropenia predisposes patients to fungal, bacterial and viral infections. Antibacterial antifungal and antiviral prophylaxis have caused a significant reduction in some of these infections.

There are two main types of cutaneous infections : primary cutaneous infections and cutaneous manifestations of a disseminated infection. In the latter, skin lesions may be the window to disseminated bloodstream infection and the first and only evidence of a disseminated life threatening infection.

The diagnosis may be at your fingertips; therefore a thorough skin exam is the clue. However, it’s also important to know the characteristic lesions associated with different infections. It will help expedite diagnosis so appropriate treatment is initiated promptly in neutropenic patients, which can be lifesaving.

In a retrospective study of 43 neutropenic febrile patients with cutaneous lesions, fungal infections were the most frequent, and nodular lesions on the lower extremities were the most prevalent (Naorungroj and Aiempanakit, J Am Acad Dermatol 74:AB166, 2016).

Skin biopsy for pathological study and culture remains the gold standard and should be obtained early to confirm the suspected diagnosis. In these immunocompromised patients the inflammatory response is altered by either the primary disease or its treatment. Therefore, routine pathogens may present in an atypical fashion, with diminished or absent induration, erythema, or pustulation in response to bacterial resulting cutaneous infection without typical cellulitis (Urabe, Clin Infect Dis 39:S53–S55, 2004). Skin lesions are evaluated not only by morphology, but also in the context of the clinical setting and biopsy result. The skin biopsy is inexpensive, relatively noninvasive and without contraindication, and may avoid the need for more invasive procedures such an open lung biopsy (Grossman, et al., Cutaneous manifestations of infection in the immunocompromised host. Springer Science+Business Media, LLC, New York, 2012).

In addition to antimicrobial therapy, surgery should not be postponed in the face of progressive skin and soft tissue infection in this population (Brzozowski and Ross, J Hand Surg Br 22:679–680, 1997).

Keywords

Ecthyma gangrenosum Bullous cellulitis Fulminant necrotizing infections Spontaneous clostridial myonecrosis Purplish discoloration Crepitation Necrotizing enterocolitis Subcutaneous nodules Disseminated cutaneous mycobacterium knife-cut sign Herpetic whitlow Disseminated HZ 

References

  1. 1.
    Kryeziu E, Kryeziu K, Bajraktari G, Abazi M, Zylfiu B, Rudhani I, Sh S, Ukimeri A, Brovina A, Sh D, Telaku S. Ecthyma gangrenosum in a patient with acute leukemia. Med Arh. 2010;64(6):373–4.PubMedGoogle Scholar
  2. 2.
    Brady GP, Bolivar R, Fainstein V, et al. Infections caused by Pseudomonas aeruginosa. Rev Infect Dis. 1983;5:279–313.CrossRefGoogle Scholar
  3. 3.
    Grossman ME, Fox LP, Kovarik C, Rosenbach M. Cutaneous manifestations of infection in the immunocompromised host. 2nd ed. New York: Springer Science+Business Media, LLC; 2012.  https://doi.org/10.1007/978-1-4419-1578-8.CrossRefGoogle Scholar
  4. 4.
    Bodey GP. Dermatologic manifestations of infections in neutropenic patients. Infect Dis Clin N Am. 1994;8(3):655–75. Review.Google Scholar
  5. 5.
    Mull JD, Callahan WS. The role of the elastase of Pseudomonas aeruginosa in experimental infection. Exp Mol Pathol. 1995;4:567–75.CrossRefGoogle Scholar
  6. 6.
    Brzozowski D, Ross DC. Upper limb Escherichia coli cellulitis in the immunocompromised. J Hand Surg Br. 1997;22(5):679–80.PubMedCrossRefGoogle Scholar
  7. 7.
    Livingston W, Grossman ME, Garvey G. Hemorrhagic bullae in association with Enterobacter cloacae septicemia. J Am Acad Dermatol. 1992;27:637–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Chapman RA, Van Slyck EJ, Madhavan T. Skin lesions associated with E. coli sepsis in a patient with acute leukemia. Henry Ford Hosp Med J. 1980;28(1):47–8.PubMedGoogle Scholar
  9. 9.
    Grant MD, Horowitz HI, Lorian V. Gangrenous ulcer and septicemia due to citrobacter. N Engl J Med. 1969;280(23):1286–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Gössl M, Eggebrecht H. Necrotizing skin ulceration in antibiotic-induced agranulocytosis. Mayo Clin Proc. 2006;81(12):1527.PubMedCrossRefGoogle Scholar
  11. 11.
    Sakhnini E, Weissmann A, Oren I. Fulminant Stenotrophomonas maltophilia soft tissue infection in immunocompromised patients: an outbreak transmitted via tap water. Am J Med Sci. 2002;323(5):269–72.PubMedCrossRefGoogle Scholar
  12. 12.
    Harris RL, Faintein V, Elting L, et al. Bacteremia caused by Aeromonas species hospitalized cancer patients. Rev Infect Dis. 1985;7:314–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Klastersky J. Infections in immunocompromised patients. I. Pathogenesis, etiology, and diagnosis. Clin Ther. 1985;8(1):90–9.PubMedGoogle Scholar
  14. 14.
    Cone LA, Dreisbach L, Potts BE, Comess BE, Burleigh WA. Fatal Bacillus cereus endocarditis masquerading as an anthrax-like infection in a patient with acute lymphoblastic leukemia: case report. J Heart Valve Dis. 2005;14(1):37–9.PubMedGoogle Scholar
  15. 15.
    Mori T, Tokuhira M, Takae Y, et al. Successful non-surgical treatment of brain abscess and necrotizing fasciitis caused by Bacillus cereus. Intern Med. 2002;41(8):671–3.PubMedCrossRefGoogle Scholar
  16. 16.
    Groschel D, Burgess MA, Bodey GP. Gas gangrene-like infection with Bacillus cereus in a lymphoma patient. Cancer. 1976;37:988–91.PubMedCrossRefGoogle Scholar
  17. 17.
    Bodey GP, Rodriguez S, Fainstein V, et al. Clostridial bacteremia in cancer patients. Cancer. 1991;67:1928–42.PubMedCrossRefGoogle Scholar
  18. 18.
    Hopkins DG, Kushner JP. Clostridial species in the pathogenesis of necrotizing enterocolitis in patients with neutropenia. Am J Hematol. 1983;14:289–95.PubMedCrossRefGoogle Scholar
  19. 19.
    Van der Lelie H, Leverstein-Van Hall M, Mertens M, et al. Corynebacterium CDC group JK (Corynebacterium jeikeium) sepsis in haematological patients: a report of three cases and a systematic literature review. Scand J Infect Dis. 1995;27(6):581–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Olson JM, Nguyen VQ, Yoo J, Kuechle MK. Cutaneous manifestations of Corynebacterium jeikeium sepsis. Int J Dermatol. 2009;48(8):886–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Elting LS, Bodey GP, Keefe BH. Septicemia and shock syndrome due to viridans streptococci: a case – control study of predisposing factors. Clin Infect Dis. 1992;14:1201–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Van Ingen J. Diagnosis of nontuberculous mycobacterial infections. Semin Respir Crit Care Med. 2013;34(pg):103–9.PubMedGoogle Scholar
  23. 23.
    Roukens AH, Mendels EJ, Verbeet NL, Borne PA v d, Nicolae-Cristea AR, Bentvelsen RG, van Doorn R, de Boer MG. Disseminated cutaneous Mycobacterium chelonae infection in a patient with acute myeloid leukemia. Open Forum Infect Dis. 2014;1(3):ofu103.  https://doi.org/10.1093/ofid/ofu103.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    McWhinney PH, Yates M, Prentice HG, et al. Infection caused by Mycobacterium chelonae: a diagnostic and therapeutic problem in the neutropenic patient, Clin Infect Dis, 1992, vol. 14(pg. 1208–1212).PubMedCrossRefGoogle Scholar
  25. 25.
    Roukens AH, Mendels EJ, Verbeet NL, et al. Disseminated cutaneous mycobacterium chelonae infection in a patient with acute myeloid leukemia. Open Forum Infect Dis. 2014;1(3):ofu103.  https://doi.org/10.1093/ofid/ofu103. Published 2014 Nov 26.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Doucette K, Fishman JA. Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant patients. Clin Infect Dis. 2004;38:1428–39.PubMedCrossRefGoogle Scholar
  27. 27.
    Doutre MS, Beylot C, Mougein J, et al. Cutaneous infection caused by Mycobacterium malmoense in a patient with myelodysplastic syndrome. J R Soc Med. 1993;86:110–1.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Naorungroj S, Aiempanakit K. A study of cutaneous manifestations among febrile neutropenic patients: a five-year retrospective review in a single tertiary university hospital in Southern Thailand. J Am Acad Dermatol. 74(5):AB166.  https://doi.org/10.1016/j.jaad.2016.02.653.
  29. 29.
    Feld R, Evans WK, DeBoer G. Herpes zoster in patients with small-cell carcimona of the lung receiving combined modality treatment. Ann Intern Med. 1980;93:282–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Mays SR, Bogle MA, Bodey GP. Cutaneous fungal infections in the oncology patient: recognition and management. Am J Clin Dermatol. 2006;7(1):31–43.PubMedCrossRefGoogle Scholar
  31. 31.
    Pappas PG, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1–50.PubMedCrossRefGoogle Scholar
  32. 32.
    Horn DL, et al. Epidemiology and outcomes of candidemia in 2019 patients: data from the prospective antifungal therapy alliance registry. Clin Infect Dis. 2009;48(12):1695–703.PubMedCrossRefGoogle Scholar
  33. 33.
    Sipsas NV, et al. Candidemia in patients with hematologic malignancies in the era of new antifungal agents (2001–2007): stable incidence but changing epidemiology of a still frequently lethal infection. Cancer. 2009;115(20):4745–52.PubMedCrossRefGoogle Scholar
  34. 34.
    Guarana M, Nucci M. Acute disseminated candidiasis with skin lesions: a systematic review. Clin Microbiol Infect. 2018;24(3):246–50.PubMedCrossRefGoogle Scholar
  35. 35.
    Chen LY, et al. Associated clinical characteristics of patients with candidemia among different Candida species. J Microbiol Immunol Infect. 2013;46(6):463–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Nucci M, Anaissie E. Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis. 2002;35(8):909–20.PubMedCrossRefGoogle Scholar
  37. 37.
    Nucci M, Anaissie E. Fusarium infections in immunocompromised patients. Clin Microbiol Rev. 2007;20(4):695–704.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Hay RJ. Fusarium infections of the skin. Curr Opin Infect Dis. 2007;20(2):115–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Hayashida MZ, et al. Disseminated fusariosis with cutaneous involvement in hematologic malignancies: report of six cases with high mortality rate. An Bras Dermatol. 2018;93(5):726–9.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Gilbert DN, et al., editors. The Sanford guide to antimicrobial therapy 2018. Sperryville: Antimicrobial Therapy, Inc; 2018.Google Scholar
  41. 41.
    Bernardeschi C, et al. Cutaneous invasive aspergillosis: retrospective multicenter study of the French invasive-aspergillosis registry and literature review. Medicine (Baltimore). 2015;94(26):e1018.CrossRefGoogle Scholar
  42. 42.
    Patterson TF, et al. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine (Baltimore). 2000;79(4):250–60.CrossRefGoogle Scholar
  43. 43.
    Branscomb R. An overview of mucormycosis. Lab Med. 2002;33(6):453–5.CrossRefGoogle Scholar
  44. 44.
    Patterson TF, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1–e60.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Petrikkos G, et al. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis. 2012;54(Suppl 1):S23–34.PubMedCrossRefGoogle Scholar
  46. 46.
    Roden MM, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634–53.PubMedCrossRefGoogle Scholar
  47. 47.
    Ingram CW, et al. Disseminated zygomycosis: report of four cases and review. Rev Infect Dis. 1989;11(5):741–54.PubMedCrossRefGoogle Scholar
  48. 48.
    Sun HY, Singh N. Mucormycosis: its contemporary face and management strategies. Lancet Infect Dis. 2011;11(4):301–11.PubMedCrossRefGoogle Scholar
  49. 49.
    Chang P, Rodas C. Skin lesions in histoplasmosis. Clin Dermatol. 2012;30(6):592–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Lemos LB, Baliga M, Guo M. Blastomycosis: the great pretender can also be an opportunist. Initial clinical diagnosis and underlying diseases in 123 patients. Ann Diagn Pathol. 2002;6(3):194–203.PubMedCrossRefGoogle Scholar
  51. 51.
    Miceli A, Krishnamurthy K. Blastomycosis. Treasure Island: StatPearls; 2018.Google Scholar
  52. 52.
    Wang S, et al. Dermatoscopic and clinicopathologic findings of cutaneous blastomycosis. J Am Acad Dermatol. 2015;73(5):e169–70.PubMedCrossRefGoogle Scholar
  53. 53.
    DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006;55(6):929–42; quiz 943–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Christianson JC, Engber W, Andes D. Primary cutaneous cryptococcosis in immunocompetent and immunocompromised hosts. Med Mycol. 2003;41(3):177–88.PubMedCrossRefGoogle Scholar
  55. 55.
    Perfect JR, Bicanic T. Cryptococcosis diagnosis and treatment: what do we know now. Fungal Genet Biol. 2015;78:49–54.PubMedCrossRefGoogle Scholar
  56. 56.
    Grunwald MR, McDonnell MH, Induru R, Gerber JM. Cutaneous manifestations in leukemia patients. Semin Oncol. 2016;43(3):359–65.PubMedCrossRefGoogle Scholar
  57. 57.
    Kang YS, Kim HS, Park HJ, Lee JY, Kim HO, Cho BK, et al. Clinical characteristics of 75 patients with leukemia cutis. J Korean Med Sci. 2013;28(4):614–9.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Li AW, Yin ES, Stahl M, Kim TK, Panse G, Zeidan AM, et al. The skin as a window to the blood: cutaneous manifestations of myeloid malignancies. Blood Rev. 2017;31(6):370–88.PubMedCrossRefGoogle Scholar
  59. 59.
    Benet C, Gomez A, Aguilar C, Delattre C, Vergier B, Beylot-Barry M, et al. Histologic and immunohistologic characterization of skin localization of myeloid disorders: a study of 173 cases. Am J Clin Pathol. 2011;135(2):278–90.PubMedCrossRefGoogle Scholar
  60. 60.
    Cohen PR. Sweet’s syndrome--a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;2:34.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Qiao J, Wang Y, Bai J, Wu Y, Fang H. Concurrence of Sweet’s syndrome, pathergy phenomenon and erythema nodosum-like lesions. An Bras Dermatol. 2015;90(2):237–9.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Going JJ, Going SM, Myskow MW, Beveridge GW. Sweet’s syndrome: histological and immunohistochemical study of 15 cases. J Clin Pathol. 1987;40(2):175–9.PubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Paydas S. Sweet’s syndrome: a revisit for hematologists and oncologists. Crit Rev Oncol Hematol. 2013;86(1):85–95.PubMedCrossRefGoogle Scholar
  64. 64.
    Kridin K, Cohen AD, Amber KT. Underlying systemic diseases in pyoderma Gangrenosum: a systematic review and meta-analysis. Am J Clin Dermatol. 2018;19(4):479–87.PubMedCrossRefGoogle Scholar
  65. 65.
    Braswell SF, Kostopoulos TC, Ortega-Loayza AG. Pathophysiology of pyoderma gangrenosum (PG): an updated review. J Am Acad Dermatol. 2015;73(4):691–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Su WP, Davis MD, Weenig RH, Powell FC, Perry HO. Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol. 2004;43(11):790–800.PubMedCrossRefGoogle Scholar
  67. 67.
    Crowson AN, Mihm MC Jr, Magro C. Pyoderma gangrenosum: a review. J Cutan Pathol. 2003;30(2):97–107.PubMedCrossRefGoogle Scholar
  68. 68.
    Loricera J, Calvo-Rio V, Ortiz-Sanjuan F, Gonzalez-Lopez MA, Fernandez-Llaca H, Rueda-Gotor J, et al. The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features. Medicine (Baltimore). 2013;92(6):331–43.Google Scholar
  69. 69.
    Greer JM, Longley S, Edwards NL, Elfenbein GJ, Panush RS. Vasculitis associated with malignancy. Experience with 13 patients and literature review. Medicine (Baltimore). 1988;67(4):220–30.CrossRefGoogle Scholar
  70. 70.
    Garcia-Porrua C, Gonzalez-Gay MA. Cutaneous vasculitis as a paraneoplastic syndrome in adults. Arthritis Rheum. 1998;41(6):1133–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Miliszewski MA, Kirchhof MG, Sikora S, Papp A, Dutz JP. Stevens-Johnson syndrome and toxic epidermal necrolysis: an analysis of triggers and implications for improving prevention. Am J Med. 2016;129(11):1221–5.PubMedCrossRefGoogle Scholar
  72. 72.
    Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: part I. Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. J Am Acad Dermatol. 2013;69(2):173, e1–13; quiz 85–6.PubMedCrossRefGoogle Scholar
  73. 73.
    Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600–7.PubMedCrossRefGoogle Scholar
  74. 74.
    Macdonald JB, Macdonald B, Golitz LE, LoRusso P, Sekulic A. Cutaneous adverse effects of targeted therapies: part I: inhibitors of the cellular membrane. J Am Acad Dermatol. 2015;72(2):203–18; quiz 19–20.PubMedCrossRefGoogle Scholar
  75. 75.
    Brazzelli V, Grasso V, Borroni G. Imatinib, dasatinib and nilotinib: a review of adverse cutaneous reactions with emphasis on our clinical experience. J Eur Acad Dermatol Venereol. 2013;27(12):1471–80.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.University of South FloridaTampaUSA

Personalised recommendations