International Journal of Infectious Diseases 15 (2011) e289e290

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Case Report

Atypical nodular panniculitis

Damien Picard a,*, Julie de Quatrebarbes a, Isabelle Gueit b, Pascal Joly a
a
b

Department of Dermatology, Rouen University Hospital, 1 rue de Germont, F 76031 Rouen Cedex, France
Department of Infectious Diseases, Rouen University Hospital, University of Rouen, France

A R T I C L E I N F O

S U M M A R Y

Article history:
Received 11 August 2010
Accepted 20 December 2010

Suppurative panniculitis usually occurs among immunocompromised patients and can be caused by
opportunistic pathogens or by secondary infectious lesions in the context of septicemia. Herein we
report the case of an 82-year-old woman with multiple red nodules on the leg caused by Pseudomonas
aeruginosa, not related to a blood disseminated infection. The present case represents an unusual
presentation of indolent suppurative panniculitis caused by P. aeruginosa.
2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Corresponding Editor: William Cameron,

Ottawa, Canada
Keywords:
Panniculitis
Pseudomonas aeruginosa

Introduction
Pseudomonas aeruginosa is often recognized as an opportunistic
pathogen in hospitalized and debilitated patients, causing primary
bacteremia or septicemia, endocarditis, pneumonia, abscesses, and
wound infections. Cutaneous manifestations associated with P.
aeruginosa can present as non-severe infections such as folliculitis or
severe infections such as ecthyma gangrenosum in the context of
septicemia. Indolent infectious nodules are frequent in immunocompromised patients, usually involving fungi, parasites, or slowgrowing bacteria. We describe herein an unusual clinical indolent
presentation of a disseminated cutaneous infection by P. aeruginosa.
Case report
An 82-year-old female patient was referred for a 1-week history
of nodules on her right leg. Her previous medical history included:
diabetes mellitus, hypercholesterolemia, high blood pressure,
coronary artery disease, atrial brillation, stage IV arteriosclerosis
obliterans according to the LericheFontaine classication that had
required a prosthetic crossover femoropopliteal bypass 3 months
earlier, chronic renal insufciency (diabetic nephropathy and
hypertensive nephroangiosclerosis), and a hysterectomy for
uterine neoplasia. On presentation, the patient had no fever and
was hemodynamically stable. Clinical examination showed
multiple painful redpurple nodules on the right leg and an
inguinal lymphadenopathy (Figure 1). The patient also had an
arterial ulcer on the external side of the right foot; distal pulses

* Corresponding author. Tel.: +33 2 32 88 68 41; fax: +33 2 32 88 88 55.

E-mail address: damien.picard@chu-rouen.fr (D. Picard).

were present. Vessel auscultation did not show any murmur.

Cardiac examination revealed a mitral valve insufciency.
The erythrocyte sedimentation rate was 84 mm/1st h and Creactive protein was elevated at 168 mg/l; the neutrophil count
was normal (4.9  109/l). A skin biopsy showed an abscess
formation with numerous neutrophils and Gram-negative bacilli.
Blood cultures were negative. P. aeruginosa was isolated from a
culture of skin biopsies harvested from two different sites. Cultures
for mycobacteria and fungi were negative. P. aeruginosa had been
isolated 3 months earlier from the ulcer. Interestingly, the
antibiogram proles of the P. aeruginosa isolated from the ulcer
and from the two abscesses were identical, showing sensitivity to
ticarcillin, piperacillin, and ciprooxacin. An arterial echo-Doppler
showed no evidence of thrombosis of the arterial prosthesis.
Magnetic resonance imaging (MRI) of the right leg did not show
prosthesis infection, but did reveal numerous subcutaneous
abscesses (Figure 2). Transesophageal echocardiography did not
show endocarditis. A peripheral blood lymphocyte subpopulation
count showed a low number of B-lymphocytes: 44  106/l. The
immunoglobulin G (IgG) plasma level was normal at 10.4 g/l
(normal 6.712.7 g/l), whereas the immunoglobulin M (IgM)
plasma level was low: 0.48 g/l (normal 0.552.1 g/l). The patient
was initially treated for 14 days with intravenous piperacillin (6 g/
day) and ciprooxacin (750 mg/day) adapted to the renal
insufciency and then piperacillin was administered for 30 days.
The nodules slowly healed, although some became ulcerated.
There was complete remission after 45 days.
Discussion
Infectious nodular panniculitis usually occurs among immunocompromised patients. Infectious agents involved can be bacteria,

1201-9712/$36.00 see front matter 2011 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijid.2010.12.007

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D. Picard et al. / International Journal of Infectious Diseases 15 (2011) e289e290

Figure 1. Multiple red nodules on the right leg.

had no systemic symptoms such as fever or bacteremia. It is likely

that the portal of entry of the infection was the leg ulcer since P.
aeruginosa with the same antibiogram prole was evidenced on
the ulcer 3 months earlier. Diabetes mellitus and immunodeciency parameters such as B lymphopenia and the low plasma IgM
level, related to the advanced age of the patient, might have
favored the cutaneous infection. Three mechanisms for infection
could be considered in the present case: (1) multiple direct
inoculations through skin punctures due to insulin injections,
unlikely given the localization of the abscesses on the leg; (2)
bloodstream dissemination, is also unlikely given the absence of
bacteremia and systemic symptoms; (3) lymphangitic spread,
which appears more likely due to the sporotrichoid-like dissemination.
Our case report is reminiscent of some cases of ecthyma
gangrenosum without bacteremia that have been reported in the
literature in immunocompromised patients.5 However, almost all
these patients had neutropenia and most often presented with a
solitary lesion that was not consistent with a disseminated
infection.
Skin infections secondary to Gram-negative organisms are
uncommon and usually involve immunocompromised patients. P.
aeruginosa is mainly responsible for localized skin infections or
severe disseminated infections associated with this patient
population. P. aeruginosa can also be responsible for subacute
and loco-regional disseminated infections without systemic
symptoms.
Funding
No funding source.
Conict of interest
No conict of interest to declare.
Acknowledgements

Figure 2. MRI of the leg showing subcutaneous nodules (arrows).

fungi, and parasites. Clinical cases such as this one, with

sporotrichoid dissemination, usually involve mycobacteria, sporotrichosis, nocardiosis, and leishmaniosis, but do not commonly
involve Gram-negative bacteria such as P. aeruginosa.
Cutaneous infections due to P. aeruginosa can encompass a
clinical spectrum ranging from non-severe infections such as
folliculitis to severe disorders such as ecthyma gangrenosum or
infectious cellulitis. Cutaneous abscesses due to P. aeruginosa have
mainly been observed in immunocompromised patients with
septicemia.14 These severe infections are completely different
from the chronic and indolent course observed in our patient who

The authors thank Richard Medeiros, Rouen University Hospital, medical editor, for editing the manuscript.
References
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