In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 918 - 27th December Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
Submitted Date :
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F69. Has CLL. Scalp vesicles Rx’d by GP as Zoster but developed large unilateral area of black ulcerated scalp. Swabs growing pseudomonas.

Case posted by Dr. Richard Carr.


User Feedback


Guest Juan Carlos Garcés, Ecuador

Posted

You are not, Dr Carr, happy holidays

Ectima?

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Eman El-Nabarawy

Posted

Necrotizing fasciitis in HZ lesions in immunocompromized patient, severe HZ infection in immunocompromized patient,or leukemic infiltrate in HZ lesions with secondary vasculitis.

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Dr. Mona Abdel-Halim

Posted

Echthyma gangrenosum. Pseudomonus is on the top list of causative organisms but candida can also cause EG like picture. Pseudomonas is gram negative and does not look like the organism appearing in this gram stain. I believe what I am seeing in the gram stain is budding yeasts and few hyphae, indicating candida which can be stained by gram. Aspergillus, and Fusarium species, and Zygomycetes can also cause EG like picture but they do not stain with gram. The other yeasts that can stain with gram are the cryptococci, but they produce different clinical and pathological picture.

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Robledo F. Rocha

Posted

I’m working too, Dr. Carr!
I think this is solitary ecthyma gangrenosum.

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Mark A. Hurt MD

Posted

I'm working, too!

As I understand it, the differential diagnosis includes:

Cutaneous anthrax
Dermatologic Manifestations of Aspergillosis
Ecthyma gangrenosum
Pyoderma gangrenosum
Septic emboli due to other infectious agents

So, it would be good to know if anything else is growing.

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Dr. Richard Carr

Posted

This was a dramatic clinicopathological case (to end the year).There were 3 separate biopsies over a 6 week period (about half of one side of the scalp was involved by an extensive black ulcer). Pseudomonas grew repeatedly and finally (much later) some aspergillus (I assumed a red herring). I did not see any organisms on any of the stains on any of the biopsies (although you might imagine some rods on the Gram). Thromboembolic was considered but no other clin-path evidence for this. I looked for giant cell arteritis and could find no evidence for that. I did consider lymphoma but did not persue that route as I felt this was an infection. We sent a block to Dr Kutzner (sincere thanks) for PCR which was negative for HZV and positive for pseudomonas (not aspergillus). She started to improve steadily and dramatically after being given intra-venous immunoglobulins. Final diagnosis: Pseudomonas ecthyma gangrenosum (uncertain if preceded by Zoster). Thank you for your excellent comments today and my very best wishes to all for the new year!!

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