Ecthyma Gangrenosum Secondary to Pseudomonal Sepsis Complicated by Acute Respiratory Distress Syndrome Following Craniotomy for Resection of a Metastasis

Ecthyma gangrenosum is a rare physical exam finding pathognomonic for severe bacteremia and typically associated with pseudomonal sepsis. The characteristic skin lesions appear as ring-shaped hemorrhagic pustules that evolve into necrotic ulcers. In the present case, a 62-year-old woman with a pulmonary adenocarcinoma treated with surgical resection and adjuvant chemotherapy developed three symptomatic brain masses. The lesions were presumed metastatic and initially treated with stereotactic radiosurgery; however, follow-up imaging identified treatment failure of a cerebellar lesion, and the patient was subsequently taken to surgery on an elective basis for suboccipital craniotomy and tumor resection. Although her initial postoperative course was unremarkable, on postoperative day two, she experienced a rapidly progressive neurologic and hemodynamic decline. During this period, numerous ring-shaped, necrotic cutaneous lesions rapidly appeared, consistent with ecthyma gangrenosum. In spite of multi-modality critical care treatment and resuscitation, including milrinone, multiple vasopressors, anti-pseudomonal antibiotics, and prone positioning, the patient progressed to cardiorespiratory failure and died.