Case of deep dissecting hematoma resulting in sepsis due to Pseudomonas aeruginosa infection.

Dear Editor,

Deep dissecting hematoma (DDH) is a severe manifestation of dermatoporosis.1 DDH represents a massive bleeding event in the deep soft tissue, most often due to minimal trauma.2 Because DDH begins as a painful swelling lesion, similar to severe infectious diseases including cellulitis and necrotizing fasciitis, previous reports have emphasized differentiating between DDH and infectious diseases.2 However, involvement of both diseases has not previously been reported. We encountered a case of DDH infected by Pseudomonas aeruginosa, eventually resulting in septic shock.

A 78‐year‐old Japanese woman was referred to us with a 1‐day history of increased weakness, impaired consciousness and painful swelling in the right lower leg. The patient had been taking prednisolone at 20 mg/day and azathioprine at 100 mg/day for idiopathic interstitial pneumonia and antineutrophil cytoplasmic antibody‐associated vasculitis for 6 years, and edoxaban tosilate hydrate at 15 mg/day for pulmonary embolism and deep vein thrombosis. The patient had fallen to the floor and suffered bruising of the right lower leg 9 days before the first visit. Physical examination revealed: axillary temperature, 37.9°C; systolic/diastolic blood pressure, 78/62 mmHg; heart rate, 139 beats/min; and a painful, fluctuating, purpuric, nodular lesion measuring 10 cm × 8 cm in size, accompanied by erythema on the right lower leg (Fig. 1a). Blood testing revealed: white blood cell count, 2000/μL; C‐reactive protein, 36.7 mg/dL; and estimated glomerular filtration rate, 42 mL/min per 1.73 m2. Contrast‐enhanced computed tomography of the lower leg revealed a heterogeneously enhancing nodular lesion (Fig. 1b), suggesting hematoma located from superficial to deep soft tissue. The examination of the lung revealed a reticular shadow predominantly in the lower lung field, which is characteristic in idiopathic interstitial pneumonia but not in bacterial pneumonia. Bacteriological examination detected P. aeruginosa in both the hematoma and in the blood, but the examination failed to detect the bacteria in the urine. The examination showed nearly identical susceptibility to various types of antibiotics between P. aeruginosa from hematoma and those from blood (Table S1). Sepsis due to DDH infected by P. aeruginosa was diagnosed. The hematoma was debrided, then the infection was treated by systemic administration of piperacillin and tazobactam of 13.5 mg/day for 22 days. The therapy was effective, although antibiotic de‐escalation should have been considered after the detection of P. aeruginosa.

Figure 1

(a) Clinical findings. Painful, fluctuating, purpuric, nodular lesion approximately 10 cm × 8 cm in size, accompanied by erythema on the right lower leg. (b) Images of contrast‐enhanced computed tomography. Hematoma visualized as a heterogeneously enhanced area is indicated by white arrowheads.

Because early clinical manifestations of DDH can be similar to severe infectious disease, DDH should be carefully distinguished from infectious diseases.2 On the other hand, DDH tends to occur in patients who take corticosteroids for a long period and/or old age, both of which can lead to blood vessel fragility and immunocompromised conditions. Additionally, the anticoagulant agent of edoxaban tosilate hydrate can cause or exacerbate hematoma in this case. As shown in this report, DDH and bacterial infection can occur together because systemic administration of corticosteroid for a long period and aging are risk factors for both infection and DDH. Dermatologists should be aware of this possibility and carefully diagnose painful swelling lesions in the extremities.

Conflict of Interest

None declared.

Table S1. Susceptibility to various types of antibiotics.

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