Ecthyma gangrenosum without pseudomonas septicemia in a kidney transplant recipient

We report a case of ecthyma gangrenosum (EG) without septicemia in a renal transplant recipient who presented with a 1-month history of painful ulcers, vesicles and bullae on the face and extremities. Histopathological findings revealed subepidermal bullae covered by a necrotic epidermis containing an infiltrate of a moderate number of lymphocytes, neutrophils and necrotic collagen. Many dilated and congested capillaries were also present due to thrombi beneath the bullae, with alteration of collagen fibers through the superficial to middle dermis with some infiltrate. A culture from the ulcers revealed the presence of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus, whereas the results of repeated blood cultures were negative. The ulcers were completely cured by early appropriate i.v. antibiotic therapy with granulocyte colony-stimulating factor, without progression to EG with septicemia. An immunocompromised state due to immunosuppressive drugs, in addition to diabetes mellitus, hypogammaglobulinemia and hypoproteinemia, may have caused the EG and herpes zoster may have exacerbated the condition.