|Year : 2014 | Volume
| Issue : 2 | Page : 93-95
Burning sensation, oozing, and bleeding: A unique finding of septicemia with skin erosion
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Web Publication||29-Dec-2014|
Chandra Sekhar Sirka
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha - 751 019
Source of Support: None, Conflict of Interest: None
Septicemia is an inflammatory host response to infection, which rapidly progresses to multiorgan failure and may develop skin lesions. The skin lesions of septicemia often present as purpura, purpura fulminans, and bleeding from erosion. However, there is a paucity of literature describing the features of septicemia both on the intact and eroded skin. The diagnosis of septicemia by identifying its features on the skin is very important for a dermatologist. This case report describes the dermatological changes of septicemia on the eroded skin of pemphigus vulgaris under treatment.
Keywords: Bleeding, burning sensation, erosion, oozing, septicemia
|How to cite this article:|
Sirka CS. Burning sensation, oozing, and bleeding: A unique finding of septicemia with skin erosion. Int J Adv Med Health Res 2014;1:93-5
| Introduction|| |
The general perception is that patients admitted to skin ward have large area of skin erosion and the skin disease usually take a long time to heal. All these factors combined can increase the risk of infection and septicemia. 
The diagnosis of septicemia is mostly high index of suspicion from the systemic clinical feature supported by isolation and/or demonstration of the organism and from serum biomarkers. But the confirmation test is usually delayed because the isolation of organism is time consuming.
The dermatologists commonly make diagnosis from morphology of lesion and history and rarely require investigations for confirmation. However, the skin findings of septicemia are inconsistent and not diagnostic.
The pathogenesis of skin lesions in septicemia was postulated to be vascular occlusion or infarction. But, recent biopsy finding from the purpuric lesions of septicemia demonstrated necrosis and bacterial colonization in the vessel wall. 
The most published literatures on septicemia have described the skin findings on the intact skin. ,, To the best of the author's knowledge, there is only one case report describing the feature of septicemia on the eroded skin.  In this case report of septicemia, various skin findings and management have been reported.
| Case report|| |
A 42-year-old male, follow-up case of pemphigus vulgaris, was admitted to the skin ward with <10% body surface erosion. He was on oral medications like prednisolone (10 mg OD) and cyclophosphamide (50 mg OD) for 4 months. He was admitted to the skin ward with a diagnosis of pemphigus vulgaris. The patient developed high-grade fever (temperature ranged 101-104°F), with rigor, chill, burning sensation, and tenderness on the few erosions of pemphigus vulgaris on the next day. Clinical examination revealed no pus or erythema around the erosions. Based on the tenderness and burning sensation on the erosion, he was suspected of having secondary infection. The blood sample and skin swab were sent for total leukocyte count (TLC), differential count (DC), and culture sensitivity. On the same day in the afternoon, he developed disorientation, decreased urination, tachypnea, tachycardia, increased oozing, spotty hemorrhage, and frank bleeding from the erosions of pemphigus vulgaris present on both frictional and non-frictional sites [Figure 1], [Figure 2] and [Figure 3]. The examination of bleeding erosions did not reveal any obvious ulceration or necrosis on the surface. The uninvolved skin looked normal. At this point, he was suspected of having a septicemia with disseminated intravascular coagulation (DIC), and the blood sample was sent for TLC, DC, platelet count, prothrombin time (PT), partial thromboplastin time (PTT), plasma fibrinogen, culture sensitivity, random blood sugar, and serum sodium, potassium, and calcium. Cyclophosphamide was discontinued. Prednisolone was continued in the same dose and empirical IV linezolid (600 mg BD) was added along with supportive therapy. The blood investigation revealed the following: TLC 14,500 cells/mm 3 , neutrophils 80%, platelets 100,000 cells/mm 3 , random blood sugar 86 mg/dl (normal 75-110), sodium 125 mEq/l (normal 136-145), potassium 4.00 mEq/l (normal 3.5-5.1), and calcium 8.50 mg/dl (normal 8.8-10.6). Staphylococcus aureus sensitive to linezolid was isolated from both blood and erosions. The investigation did not reveal any evidence of DIC in the patient. The symptoms of fever, burning sensation, tenderness, oozing, bleeding from erosion, and disorientation improved over 3-4 h after the administration of IV linezolid. The IV linezolid was continued up to 7 days. The repeat hematologyl and culture reports from erosion and blood on day 12 did not reveal any abnormal result. The dose of prednisolone was increased to 30 mg (OD) on day 15. The skin erosions of pemphigus vulgaris started healing after 2 weeks of increasing the dose of steroid. There was no recurrence of fever, burning sensation, tenderness, oozing, bleeding from erosion, and disorientation till the fourth week.
|Figure 1: Erosion showing hemorrhagic crust and clotted blood on the erosion|
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| Discussion|| |
The worldwide incidence of septicemia in the skin ward ranges from 4.65 to 55.2%. , The increased incidence is attributed to increased area of skin erosion, corticosteroid, and immunosuppressant use and pronged hospitalization of these patients. 
Septicemia is an inflammatory host response to infection, characterized by fever, altered bowel and bladder habits, tachypnea, altered consciousness and presence of organism in the blood.
The commonly used approach to diagnose infection and septicemia in patients with extensive skin erosion in most centers is by obtaining repeated culture from the eroded surface, the blood and studying the serological biomarkers. However, there is no consensus on the frequency of performing these tests. So, there is an urgent need to recognize the early signs and symptoms of septicemia for further investigation and treatment.
The skin findings in septicemia are purpura, purpura fulminans, and bleeding from the eroded skin. ,, However, the occurrence of these skin lesions is rare and nonspecific. ,,,
The first report of septicemia with findings on the eroded skin was on pemphigus vulgaris.  But the authors did not evaluate these patients for DIC, so the cause of bleeding could not be ascertained. The present case of pemphigus vulgaris with septicemia without DIC had fever, burning sensation, tenderness, oozing, and bleeding from erosions, which is similar to the previously reported cases. 
Frank bleeding from the erosion in the absence of purpuric spots on the intact skin in the present case could be due to the direct entry of S. aureus through the eroded surface into the circulation by causing necrosis of the vessel wall at the site of entry. 
In the clinical setting, differentiating frank bleeding of septicemia from DIC and coagulopathy disorder may be difficult, but the normal levels of platelet count, PT, PTT, and plasma fibrinogen D-dimer in blood and the absence of bleeding or purpura on the uninvolved skin help in differentiating septicemia from DIC and coagulopathy disorder. 
Hence, from this present case, it was concluded that dermatologists must think of septicemia when cases with pemphigus vulgaris and existing skin erosion suddenly develop burning sensation, tenderness followed by increased oozing, hemorrhagic spots, and frank bleeding and they should be subjected to appropriate investigation and treatment.
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[Figure 1], [Figure 2], [Figure 3]