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Another Dimension
Jet-Black Eschar
Suggested citation for this article: Gilsdorf
JR. Jet-black eschar. Emerg Infect Dis [serial online] 2002 Aug [date
cited];8. Available from: URL: http://www.cdc.gov/ncidod/EID/vol8no8/02-0171.htm
At first glance, the baby appeared healthy. She was pudgy, pink-cheeked
and impeccably clean, and rested quietly in the mother’s arms—until we
disturbed her; then she cried with the weary wail of an infant hurting
for days.
“This one came first,” said the mother, pointing to a quarter-sized red,
swollen nodule to the right of the baby’s spine. Embedded in its center
was a jet-black eschar the size of a pea. I prodded the edge of the nodule;
the baby curled her legs, buried her head in the mother’s shirt, and screamed.
“There are more,” continued the mother, a pretty young woman with an anxious
expression, pointing at the other nodules—one on the occiput, one on the
labia majora, one on the left upper chest. Two of these also had black
eschars.
Our first questions were routine and probably anticipated by the mother:
When did the fever start? How high had the fever been? When did the lumps
appear? What medicines had the baby received? The mother carefully answered
each question, underscoring her responses with layers of detail, struggling
to remain composed. As she spoke, each word, each gesture, each facial
expression carried an air of earnestness, reinforcing her belief that
the answers would help make the baby well again. While the mother gently
rocked back and forth in the examining-room chair, the infant clung to
her chest as fiercely as a wide-eyed baby lemur clings to his mother’s
furry belly.
The questions that followed were more circumspect and, to the mother,
probably puzzling and far removed from the immediate problem of her feverish
baby with the lumps. Still, she answered each one completely, dragging
information out of her memory as if it were buried treasure. How much
did the baby weigh at birth? What was her medical history? Had anyone
at home been ill? Where had she traveled?
We were ready to zero in on possible diagnoses. The next set of questions
must have seemed truly absurd to the mother. Another person, one not so
engrossed in the well-being of the baby, might have thought our inquiries
weird or intrusive, or even trivial or irrelevant. Do you have any spiders
at your house? Have you seen bugs crawling on the baby? Has she been in
a hot tub? Are you and the baby’s father blood relatives (first or second
cousins)? How old was the baby when the umbilical cord fell off?
Then, I reached for the bioterrorism protocol from the state health department,
which prompted a new set of questions. Has the baby been in contact with
imported rugs or animal hides? Has she been in contact with anyone who
works on a ranch or with livestock? And finally the question we didn’t
ask until last winter: Has the baby been in contact with anyone (grandparents,
family friends, babysitters) who works at a mail-sorting facility? The
mother’s face tensed with bewilderment and disbelief. But, again, she
answered carefully and thoughtfully, persevering as we filed through our
differential diagnoses.
A biopsy of the neck nodule was sent for culture and histologic testing.
The baby was admitted to the pediatric ward and was started on piperacillin/tazobactam
and gentamicin treatment. The next day, the pathology report came back.
The lesion was consistent with ecthyma gangrenosum. Large numbers of bacilli
were observed, none with the morphologic features of anthrax. The culture
report confirmed Pseudomonas aeruginosa.
Janet R. Gilsdorf
Ann Arbor, Michigan
Dr. Gilsdorf is professor of pediatrics at the Medical School and professor
of epidemiology at the School of Public Health, University of Michigan,
and director, Pediatric Infectious Diseases, C.S. Mott Children’s Hospital,
Ann Arbor, Michigan. Her research laboratory studies both the molecular
epidemiology of Hemophilus influenzae colonization and disease
and the pathogenic factors of H. influenzae, focusing on identifying
virulence genes associated with acute otitis media and on defining the
structural, functional, and immunologic parameters of adherence pili.
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