case_images: PMC11814207_01
case_images: Ecthyma gangrenosum rash on left hand on day 3.
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case_images: PMC11814207_01_fped-13-1449357-g001.jpg
case_images: F1
case_images: The patient's examination on presentation was notable for a Glasgow Coma Scale (GCS) score of 13, fever, hypotension, otorrhea, and a necrotic rash on his trunk, genitals, face, and extremities (Figure 1).
case_images: Full-body MRI, sagittal, STIR showing 9 mm STIR hyperintense expansile pontine mass on day 13.
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case_images: PMC11814207_01_fped-13-1449357-g002.jpg
case_images: F2
case_images: Given the patient's high risk for occult infection and lack of localizing symptoms, on day 13, a whole-body magnetic resonance imaging (MRI) was completed that revealed a 9 mm expansile, short tau inversion recovery (STIR) hyperintense lesion in the pons along with diffuse skin micro-abscesses consistent with EG (Figure 2).
case_images: (A) Brain MRI: T2 post-contrast axial Fluid-attenuated inversion recovery (FLAIR) showing a 10 mm x 9 mm x 9 mm abscess in right paramedian pons on day 14. (B) Brain MRI: T2 post-contrast sagittal FLAIR showing a 10 mm x 9 mm x 9 mm abscess in R paramedian pons on day 14.
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case_images: PMC11814207_01_fped-13-1449357-g003.jpg
case_images: F3
case_images: Follow-up dedicated brain MRI showed a 10 mm lesion involving the right paramedian pons with peripheral ring enhancement and a central area of restricted diffusion, consistent with an abscess (Figures 3A, B).
case_images: (A) Brain MRI: T2 post-contrast axial FLAIR showing a 5 mm x 3 mm abscess in right paramedian pons on day 69. (B) Brain MRI: T1 post-contrast sagittal MPRAGE showing a 5 mm x 3 mm abscess in R paramedian pons on day 69.
case_images: fped-13-1449357-g004.jpg
case_images: PMC11814207_01_fped-13-1449357-g004.jpg
case_images: F4
case_images: MRI examination showed a decreased size of the pontine lesion to 6 mm in its greatest dimension and near resolution of the central diffusion restriction. MRI on day 69 of the clinical course showed mild residual signal changes and enhancement (Figures 4A,B).