A Fatal Case of "Bullous Erysipelas-like" Pseudomonas Vasculitis

Abstract

Erysipelas is a generally benign superficial bacterial skin infection, and its bullous form constitutes a rare and more severe variant. We describe the first and fatal case of "bullous erysipelas-like" septic vasculitis due to Pseudomonas bacteremi. A 69-year-old Chinese man presenting with diarrhea and septic shock initially began to rapidly develop sharply defined erythematous plaques with non-hemorrhagic bullae over his lower limbs. Culture of the aspirate from the bullae was positive for Pseudomonas aeruginosa. This was also consistent with his blood cultures showing Pseudomonas bacteremia. Histology of the skin lesion showed microthrombi and neutrophilic infiltrates in blood vessels with Gram-negative bacilli extruding from the vessel walls, characteristic of septic vasculitis. The bullous erysipelas-like lesions seen in this patient represents a rare manifestation of both septic vasculitis and Pseudomonas infection.

Keywords: Bullous erysipelas; leukocytoclastic vasculitis; septic vasculitis.

Figure 1

(a) Initial sharply defined areas of erythema with early bullae formation (b) Progression of erythema with extension of bullae

Figure 2

(a) There is subepidermal blistering with partial necrosis of the epidermis (H and E stain, Magnification: x200) (b) The underlying superficial dermis reveals blood vessels occluded by fibrin microthrombi (H and E stain; Magnification: x100) (c) Septic vasculitis - A blood vessel in the deep dermis shows neutrophilic infiltrate and fibrinoid necrosis of vessel wall (H and E, Magnification: x400) (d) Gram-negative bacilli can be seen extruding from the blood vessel wall (arrows) (H and E stain; Magnification x600)