A 14-year-old boy with ecthyma gangrenosum (page 1/3)
Prepared by.... Thidarat Weerasetsiri, M.D.
Thanyawee Puthanakit, M.D
Patient: A 14 years old boy, Lampang province
CC : Prolonged fever for 3 weeks
Present Illness:
3 wk PTA : He developed low grade fever and anemia without other associated symptoms.
1 day PTA: He developed petechiae hemorrhage over trunk and extremities
Past History: No underlying disease, no drug allergy
Physical examination:
 

GA: A boy, alert, moderate pale, no jaundice
V/S: BT 38.7 C, PR 100/min, RR 20/min, BP 110/70mmHg, Body weight and height : within normal range
HEENT: mild pale conjuntivae, no icteric sclera
LN: small cervical nodes 0.5 cm. in diameter, no axillary and inguinal lymphadenopathy
Heart: regular rhythm, normal S1 S2, no murmur
Lungs: normal breath sound, no adventitious sound
Abdomen: soft, liver: not palpable, spleen: not palpable
Skin: generalized petechiae hemorrhage at trunk and extremities

Laboratory investigations:
CBC: Hb 7.7 g/dl, Hct 22%, WBC 5,720 cell/cumm.(PMN 8%, Lymp 31%, Mo 2% Myeloblast 59%), Platelet 47,000/cumm.
Bone marrow aspiration: Hypercellularity marrow, 90% of cells are myeloblasts, Auer rods are seen
Diagnosis: Acute myeloblastic leukemia (AML) M2
Treatment: Chemotherapy (Siriraj protocol 3) was initiated on the 2nd day of admission.
Progression in hospital (Figure1and Table 1)
During the 1st- 4th week of admission:
  The patient had low grade fever ( peak of 38 C) with neutropenia, therefore he was empirically treated with intravenous cefotaxime and gentamicin. He remained febrile despite empirical antibiotics treatment. The antibiotics were changed to intravenous cefoxitin and amikacin.
During the 5th week of admission:
  The patient developed high intermittent fever, range from 39 C to 40 C. The hemoculture for bacteria and fungus were negative. The antibiotics were changed to intravenous cefpirome and amikacin. He had prolonged neutropenia with absolute neutrophil count 0, therefore G-CSF was added in the treatment regimen.
During the 6th-7th week of admission:
 

The patient remained febrile and had profound neutropenia. The treatment has changed to intravenous imipenem, amikacin and amphotericin B.
Figure 1 Progression in hospital
 
During the 8th week of admission
> He developed multiple, painful erythematous papules over trunk and extremities. The lesions changed to pustular lesions on erythematous base, and then papular lesions with central necrosis at face, trunk and extremities (Fig 2, 3).
> He also developed dyspnea with chest pain. The physical examination revealed decreased breath sound at left lower lung field.
Figure 2
Figure 3

What is your differential diagnosis and management?

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