A strange ulcer.

Case Presentation

A 13-year-old girl presented with a 3 cm deep necrotic wound on her lower back [Figure 1]. One week before observation, she had begun to complain of flu-like symptoms and achiness. Three days before observation, she was falling in and out of consciousness. When her condition worsened, she was rushed to the emergency room. A lumbar puncture was performed, meningococcal meningitis was diagnosed and she was transferred to the Infectious Disease Ward of our hospital to start antibiotic therapy.

Figure 1

Our patient presenting with a 3 cm deep necrotic wound on her lower back

Her medical history was unremarkable. She was otherwise healthy and had never suffered from allergies.

Patch tests performed with 1%, 5%, and 10% PVP-I in Vaseline resulted negative. Circulating IgE levels were within normal limits.

The cutaneous lesion was treated with topical antibiotics (mupirocin cream) and clostridiopeptidase A ointment. At the third week follow-up, the lesions had healed with minimal reliquates.

Question

What is the diagnosis?

Answer

Chemical burn caused by polyvinylpyrrolidone- iodine (PVP-I).

Discussion

Iodine preparations are antibacterial/antiseptic agents which have been used worldwide since the 1800's for their potent germicidal activity, relatively low irritancy and toxicity, and low cost.[1] The antimicrobial action is due to the iodination and oxidation of the membranes and cytoplasm of infective agents by free iodine molecules. Although generally well tolerated, PVP-I can cause primary irritant contact dermatitis and allergic contact dermatitis.[23] More severe reactions, such as chemical burns, have been described after repeated or prolonged exposure especially in pediatric or atopic patients with more delicate and vulnerable skin.[45] In our case, the patient was not atopic and the exposure was neither prolonged nor repeated. The area of iodine staining corresponded exactly with the area of the ulcer. This was an important factor supporting the diagnosis of povidone iodine-induced burn. As previously reported, skin irritation and maceration associated with pressure factors may also have contributed. Previously described burns occurred most frequently on the buttocks in patients placed in the lithotomic position, while undergoing gynecological or urological operations, and on the extremities in those undergoing orthopedic operations.

Given the widespread use of PVP-I, physicians need to be aware of this rare but possible adverse reaction.