Enterococcal Infection-Provoked Generalized Pustular Psoriasis in the Absence of Preexisting Psoriasis: A Novel Case Report

A 50-year-old female with a history of cervical cancer, chemoradiation-induced arteritis, peripheral vascular disease, and multiple vascular surgeries presented for an extensive pruritic and painful rash on her abdomen, trunk, and extremities. A physical exam revealed well-defined, thick plaques with silvery and micaceous scales on her right lower leg, left knee, stomach, back, groin, bilateral elbows, distal dorsal fingertips, and dorsal hands. Her right-side axillary femoral bypass site had an exposed polytetrafluoroethylene (PTFE) graft with purulent malodorous discharge. The laboratory work-up showed elevations in acute inflammatory markers, hypoalbuminemia, hypoproteinemia, and hypocalcemia. Skin biopsy revealed mounds of parakeratosis with intracorneal neutrophilic aggregates, large intraepidermal aggregates of neutrophils, and exocytosis of neutrophils into the epidermis with stuffing of the dermal papilla. Wound cultures from the right groin fold were positive for Enterococcus faecium and E. faecalis. Due to the characteristic findings of the rash and biopsy results, a diagnosis of generalized pustular psoriasis (GPP) secondary to enterococci infection was made. To our knowledge, this is the first reported case of GPP caused by Enterococci spp. infection.