Burning sensation, oozing, and bleeding: A unique finding of septicemia with skin erosion
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||29-Dec-2014|
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha - 751 019
Source of Support: None, Conflict of Interest: None
Septicemia is an inflammatory host response to infection, which rapidly progresses to multiorgan failure and may develop skin lesions. The skin lesions of septicemia often present as purpura, purpura fulminans, and bleeding from erosion. However, there is a paucity of literature describing the features of septicemia both on the intact and eroded skin. The diagnosis of septicemia by identifying its features on the skin is very important for a dermatologist. This case report describes the dermatological changes of septicemia on the eroded skin of pemphigus vulgaris under treatment.
A 42-year-old male, follow-up case of pemphigus vulgaris, was admitted to the skin ward with <10% body surface erosion. He was on oral medications like prednisolone (10 mg OD) and cyclophosphamide (50 mg OD) for 4 months. He was admitted to the skin ward with a diagnosis of pemphigus vulgaris. The patient developed high-grade fever (temperature ranged 101-104°F), with rigor, chill, burning sensation, and tenderness on the few erosions of pemphigus vulgaris on the next day. Clinical examination revealed no pus or erythema around the erosions. Based on the tenderness and burning sensation on the erosion, he was suspected of having secondary infection. The blood sample and skin swab were sent for total leukocyte count (TLC), differential count (DC), and culture sensitivity. On the same day in the afternoon, he developed disorientation, decreased urination, tachypnea, tachycardia, increased oozing, spotty hemorrhage, and frank bleeding from the erosions of pemphigus vulgaris present on both frictional and non-frictional sites [Figure 1], [Figure 2] and [Figure 3]. The examination of bleeding erosions did not reveal any obvious ulceration or necrosis on the surface. The uninvolved skin looked normal. At this point, he was suspected of having a septicemia with disseminated intravascular coagulation (DIC), and the blood sample was sent for TLC, DC, platelet count, prothrombin time (PT), partial thromboplastin time (PTT), plasma fibrinogen, culture sensitivity, random blood sugar, and serum sodium, potassium, and calcium. Cyclophosphamide was discontinued. Prednisolone was continued in the same dose and empirical IV linezolid (600 mg BD) was added along with supportive therapy. The blood investigation revealed the following: TLC 14,500 cells/mm 3 , neutrophils 80%, platelets 100,000 cells/mm 3 , random blood sugar 86 mg/dl (normal 75-110), sodium 125 mEq/l (normal 136-145), potassium 4.00 mEq/l (normal 3.5-5.1), and calcium 8.50 mg/dl (normal 8.8-10.6). Staphylococcus aureus sensitive to linezolid was isolated from both blood and erosions. The investigation did not reveal any evidence of DIC in the patient. The symptoms of fever, burning sensation, tenderness, oozing, bleeding from erosion, and disorientation improved over 3-4 h after the administration of IV linezolid. The IV linezolid was continued up to 7 days. The repeat hematologyl and culture reports from erosion and blood on day 12 did not reveal any abnormal result. The dose of prednisolone was increased to 30 mg (OD) on day 15. The skin erosions of pemphigus vulgaris started healing after 2 weeks of increasing the dose of steroid. There was no recurrence of fever, burning sensation, tenderness, oozing, bleeding from erosion, and disorientation till the fourth week.
Septicemia is an inflammatory host response to infection, characterized by fever, altered bowel and bladder habits, tachypnea, altered consciousness and presence of organism in the blood.
The commonly used approach to diagnose infection and septicemia in patients with extensive skin erosion in most centers is by obtaining repeated culture from the eroded surface, the blood and studying the serological biomarkers. However, there is no consensus on the frequency of performing these tests. So, there is an urgent need to recognize the early signs and symptoms of septicemia for further investigation and treatment.
Hence, from this present case, it was concluded that dermatologists must think of septicemia when cases with pemphigus vulgaris and existing skin erosion suddenly develop burning sensation, tenderness followed by increased oozing, hemorrhagic spots, and frank bleeding and they should be subjected to appropriate investigation and treatment.
Jessop S, McKenzie R, Milne J, Rapp S, Sobey G. Pattern of admissions to a tertiary dermatology unit in South Africa. Int J Dermatol 2002;41:568-70.
Lerolle N, Carlotti A, Melican K, Aubey F, Pierrot M, Diehl JL, et al
. Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans. Am J Respir Crit Care Med 2013;188:684-92.
Fitzgerald CJ, Pranikoff TV, Ross GA, Mou S, Givner LB, Shetty AK. Purpura fulminans caused by community-associated methicillin-resistant Staphylococcus aureus. Am J Emerg Med 2012;30:1013.e1-1013.e4.
Satoskar AA, Molenda M, Scipio P, Shim R, Zirwas M, Variath RS, et al
. Henoch-Schönlein purpura-like presentation in IgA-dominant Staphylococcus infection-associated glomerulonephritis - a diagnostic pitfall. Clin Nephrol 2013;79:302-12.
Chalmers E, Cooper P, Forman K, Grimley C, Khair K, Minford A, et al
. Purpura fulminans: Recognition, diagnosis and management. Arch Dis Child 2011;96:1066-71.
Sirka CS, Nanda M, Majumdar SK. Staphylococcal sepsis presenting as oozing and bleeding from erosion: An unusual presentation. Indian Journal of Research and Reports in Medical Sciences 2013;3:41-4.
Asati DP, Sharma VK, Khandpur S, Khilnani GC, Kapil A. Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi. Indian J Dermatol Venereol Leprol 2011;77:141-7.
Thomas M, Peter JV, Williams A, Job V, George R. Systemic inflammatory response syndrome in diseases of the skin. Postgrad Med J 2010;86:83-8.
Zumelzu C, Alexandre M, Blom A, Levy A, Laroche L, Caux F. Unilateral purpura of a limb revealing a periprosthetic abscess in an HIV-infected patient. Ann Dermatol Venereol 2011;138:748-52.
Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999;341:586-92.