Supplementary Material for: Ecthyma Gangrenosum of Fungal Origin: a Case Report

Introduction: Ecthyma gangrenosum (EG) is usually a dermatologic manifestation of a Pseudomonas aeruginosa infection in an immunocompromised individual but may sometimes be caused by other bacteria or fungi in an immunocompromised or non-immunocompromised individual.
Case presentation: A 75-year-old woman with a history of high blood pressure and sequels of ischemic cerebral infarction presented with a 5-day history of general malaise, cough with yellow sputum, and respiratory distress. The patient had pale mucous membranes, temperature of 38.5°C, tachycardia, normal blood pressure, SaO2 of 85%, intercostal retractions, and severe bronchospasm upon hospital admission. No skin lesions were seen. The patient was admitted to the intensive care unit (ICU) because of her critical condition and was supported with invasive mechanical ventilation. Her blood count showed 8,100 leukocytes/mm3, neutrophils 79%, hemoglobin 10.1 g/dL, creatinine 1.1 mg/dL, and c-reactive protein 328 mg/dL. Arterial blood gases showed metabolic acidosis and moderate hypoxemia. The initial report of blood and urine cultures was negative for bacteria, and positive for influenza A H1N1. The patient was treated with oseltamivir and intravenous methylprednisolone for acute respiratory distress syndrome associated with the viral infection that occurred. Subsequently, ulcerated lesions with erythematous border and necrotic center were seen in the anterior region of the chest and abdomen, from where Candida metapsilosis was isolated. EG was reported in this patient, who was also immunocompromised because of steroid use, had a prolonged stay in the ICU and received broad-spectrum antibiotics. Fungemia and urinary infection due to different fungi were also found.
Conclusion: It is worth mentioning that EG can be caused by germs other than Pseudomonas aeruginosa and fungal infections should not be ruled out.

引言：坏疽性臁疮（Ecthyma gangrenosum, EG）通常是免疫功能低下个体感染铜绿假单胞菌（Pseudomonas aeruginosa）的皮肤表现，但有时也可由免疫功能低下或免疫功能正常个体的其他细菌或真菌引发。

病例报告：1例75岁女性患者，有高血压病史及缺血性脑梗死后遗症，因全身不适、咳黄痰、呼吸困难症状持续5天就诊。入院时患者黏膜苍白，体温38.5℃，心动过速，血压正常，动脉血氧饱和度（SaO2）85%，存在肋间肌回缩，且伴严重支气管痉挛。入院初期未发现皮肤病变。患者因病情危重收入重症监护病房（intensive care unit, ICU），并接受有创机械通气支持。血常规检查显示白细胞计数8100/mm³，中性粒细胞占比79%，血红蛋白10.1g/dL，肌酐1.1mg/dL，C反应蛋白328mg/dL。动脉血气分析提示代谢性酸中毒及中度低氧血症。初始血培养及尿培养结果显示细菌阴性，甲型流感病毒H1N1阳性。患者因此次病毒性感染相关急性呼吸窘迫综合征，接受了奥司他韦及静脉注射甲泼尼龙治疗。后续在患者胸腹部前部可见边界发红、中心坏死的溃疡性皮损，从该皮损处分离出近平滑假丝酵母菌（Candida metapsilosis）。该患者被诊断为坏疽性臁疮，其因使用糖皮质激素而处于免疫抑制状态，在重症监护病房停留时间较长，并接受了广谱抗生素治疗。同时还检出了真菌血症及由不同真菌引发的尿路感染。

结论：值得注意的是，坏疽性臁疮可由铜绿假单胞菌以外的病原体引发，不应排除真菌感染的可能。