71-year-old female patient with a history of poorly controlled type 2 diabetes mellitus (DM-2), hypertension, stage V chronic kidney disease (CKD) on hemodialysis for arteriovenous fistula and left diabetic foot, with a previous consultation.
She was admitted to the emergency department with a two-week history of skin rashes initially on her scalp and then spread to her face and upper limbs.
Upon admission, the patient was confused, sleepy, with poor distal perfusion and tachycardia.
Vital signs were: heart rate 118 beats/min, blood pressure 112/72 mmHg and axillary temperature 37.5 °C. Physical examination showed the presence of multiple painful cervical adenopathies with erythematous base of the left cheek.
In the temporo-occipital area of the scalp there was a crusted plaque with purulent secretion of bad odor, sensitive to fixation.
In the right arm, the patient presented two folds tennis, which subsequently ulcerated, evolving with necrosis.
There was no mucosal involvement and the rest of the physical examination was normal.
Laboratory tests showed: hemoglobin 7.3 mg/dL, white blood cell count 27.500/mm3, platelet count 513.000/mm3, C-reactive protein (CRP): 78 mg/dL (normal nitrogen value bicarbonate 8.5 mg/mm), serum bicarbonate
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Ceftriaxone and intravenous clindamycin empirical antimicrobial therapy was initiated after culture.
Evaluated by infectious diseases and dermatology, antibiotic therapy was switched to piperacillin/ tazo, due to clinical suspicion of GD.
He-motives were negative.
Biopsy of a skin lesion was performed with Gram stain, culture and histopathological study.
Gram stain of the tissue showed Gram stalks and culture of the tissue was positive for Staphylococcus aureus resistant to MRSA.
The antibiogram showed sensitivity to vancomycin (minimum inhibitory concentration of 0.75 ug/mL), rifampicin and cotrimoxazole, and resistance to all β-lactams, clindamycin and ciprofloxacin.
Antibacterial treatment was adjusted by adding vancomycin i.v.
Histopathological study confirmed the diagnosis of GD, confirming a dermal and necrotizing inflammation with neutrophilic vasculitis.
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Established in a favorable way, with crusted lesions not exudates, afferent and with a decrease in inflammatory parameters.
However, during his hospital stay, he presented necrosis of the second toe of the left foot. A transmetatarsal amputation was performed due to prolonged antibiotic treatment with vancomycin and piperacillin/ta.
After one week of oral cotrimoxazole, the patient was discharged in good general condition, with fever and resolution of the skin lesions.
