Cutaneous botryomycosis mimicking ecthyma gangrenosum in a patient treated with ibrutinib
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LETTER TO THE EDITOR
Cutaneous botryomycosis mimicking ecthyma gangrenosum in a patient treated with ibrutinib Ana Pulido-Pérez 1 & Marta Bergón-Sendín 1 & Ana Mateos-Mayo 1 & Verónica Parra-Blanco 2 & Ricardo Suárez-Fernández 1 & Fernando Carretero-López 3 Received: 8 September 2020 / Accepted: 3 October 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, Botryomycosis represents a rare form of skin infection that occurs most frequently in immunosuppressed individuals. The term derives from the Greek botrys (bunch of grapes, due to the similarity of the granules of pus to this picture) and myces (fungus), given the misconception of its fungal etiology [1]. Its peculiar clinical and histopathological characteristics make it different from other pyoderma in terms of treatment and prognosis. In patients with hematological malignancies, botryomycosis is an exceptional pathology due to its low incidence [2]. So far, no cases have been described in patients treated with Bruton tyrosine kinase inhibitors. A 73-year-old man, treated with ibrutinib 420 mg/24 h for chronic lymphocytic leukemia, was evaluated for a painful lesion in his left arm that had started 7 days earlier. He described itch in the previous weeks for which he had applied a home-grown Aloe vera plant directly to the skin. Physical examination showed excoriations and a necrotic lesion on the left arm that exuded scarce material (Fig. 1a). He also complained of associated fever of 38 °C for 3 days. A skin biopsy was performed, and histopathological study revealed a dermal inflammatory infiltrate composed of lymphocytes, neutrophils, and histiocytes. In the deep dermis, there were also groups of granular elements, basophils, surrounded by an amorphous and
* Ana Pulido-Pérez [email protected] 1
Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007 Madrid, Spain
2
Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
3
Department of Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
eosinophilic material and histiocytes in its periphery, which constituted the image of the Splendore-Hoeppli phenomenon (Fig. 1b). Methicillin-sensitive Staphylococcus aureus was isolated from skin biopsy and the purulent drainage. Pseudomonas aeruginosa was isolated from blood cultures but not from skin biopsy or pus. A total body CT scan ruled out the presence of visceral masses or abscesses. Initial empirical treatment with piperacillintazobactam was initiated and later continued with levofloxacin and surgical debridement. Botryomycosis is a chronic, suppurative infection that can affect the skin or internal organs. Its main etiological agents are Staphylococcus aureus and Pseudomonas aeruginosa [2]. Most of the published cases correspond to cutaneous forms, with direct inoculation of bacteria after a trauma or incision on the skin. Clinically, it may appear as subcutaneous nodules, ulcers, or fistulas that drain a purulent, gra
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