title: Gangrenous cellulitis associated with gram-negative bacilli in pancytopenic patients: dilemma with respect to effective therapy.
abstract: BACKGROUND
  Gangrenous (necrotizing) cellulitis is a progressive bacterial infection of skin and soft tissue; the infection can spread into subcutaneous tissue with involvement of superficial and deep fascia (necrotizing fasciitis). We describe two pancytopenic patients with polymicrobial gram-negative bacteremia and fulminating gangrenous cellulitis.
  
  
  METHODS
  Pseudomonas aeruginosa was isolated from a localized hemorrhagic area of the face in one patient. The chronology of infection in these two patients is documented in a series of dramatic color photographs. Despite appropriate antibiotic therapy, the infections progressed relentlessly and both patients died.
  
  
  CONCLUSIONS
  We discuss the dilemma of establishing the correct diagnosis prior to the appearance of the characteristic cutaneous manifestations of hemorrhagic necrosis and gangrene. Once the diagnosis is established, surgical excision is universally recommended. Unfortunately, bleeding diatheses in pancytopenic patients with co-existing coagulation deficiencies pose logistic obstacles in urgent, real-life situations. The timing and conditions for surgery need to be elucidated in these patients. An approach to this infection is proposed. The utility of frozen-section biopsy of the involved tissue and computed tomographic scans of the involved area remains to be evaluated.
authors.affiliation: Department of Medicine, University of Pittsburgh, Pennsylvania 15261.
authors.forename: S
authors.initials: S
authors.lastname: Kusne
authors.forename: D E
authors.initials: DE
authors.lastname: Eibling
authors.forename: V L
authors.initials: VL
authors.lastname: Yu
authors.forename: D
authors.initials: D
authors.lastname: Fitz
authors.forename: J T
authors.initials: JT
authors.lastname: Johnson
authors.forename: L E
authors.initials: LE
authors.lastname: Kahl
authors.forename: L D
authors.initials: LD
authors.lastname: Ellis
mesh_terms: D000328:Adult; D001171:Arthritis, Juvenile / Q000150:complications; D002481:Cellulitis / Q000209:etiology / Q000382:microbiology / Q000628:therapy*; D005260:Female; D005734:Gangrene / Q000209:etiology / Q000382:microbiology / Q000628:therapy*; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D006801:Humans; D015470:Leukemia, Myeloid, Acute / Q000150:complications; D008875:Middle Aged; D009336:Necrosis; D010198:Pancytopenia / Q000150:complications*; D011552:Pseudomonas Infections / Q000150:complications* / Q000175:diagnosis / Q000628:therapy