Limb Salvage Using Negative Pressure Wound Therapy and Split-Thickness Skin Grafting for Polymicrobial Ecthyma Gangrenosum in a Patient With Acute Lymphoblastic Leukemia: A Case Report

Ecthyma gangrenosum (EG) is a rare and potentially life-threatening cutaneous infection predominantly affecting profoundly immunocompromised patients.Although classically associated with Pseudomonas (P.) aeruginosa, polymicrobial infections may occur and can result in extensive tissue necrosis and limbthreatening defects.Reconstruction in severely immunocompromised patients is particularly challenging when exposed tendons are present.We present the case of a 32-year-old woman with relapsed B-cell acute lymphoblastic leukemia undergoing re-induction chemotherapy who developed profound neutropenia and rapidly progressive necrosis of the left dorsal hand and forearm following low-energy blunt trauma.The lesion evolved from a post-traumatic hematoma into a 20 × 8 cm full-thickness necrotic defect.Tissue cultures demonstrated polymicrobial infection with P. aeruginosa, Acinetobacter baumannii complex, Stenotrophomonas maltophilia, and extended-spectrum β-lactamase-producing Escherichia coli.Histopathology revealed full-thickness necrosis, dermal vascular thrombosis, and abundant intravascular Gram-negative bacilli, consistent with EG.Management included hematologic optimization, serial surgical debridement, targeted antimicrobial therapy, and negative pressure wound therapy at -125 mmHg.The extensor tendon paratenon was carefully preserved.After 14 days of negative pressure wound therapy and recovery of the absolute neutrophil count to 3.93 × 10³/µL, a healthy granulation bed developed, and definitive coverage was achieved with a split-thickness skin graft harvested from the ipsilateral thigh.Graft take exceeded 95%, with preservation of distal perfusion, sensation, and upper-extremity function.This case demonstrates that extensive polymicrobial EG can be successfully managed with a staged limb-salvage strategy integrating aggressive infection control, negative-pressure wound therapy, hematologic recovery, and delayed skin grafting.Notably, preserving the extensor tendon paratenon can enable successful split-thickness skin grafting in select patients with tendon exposure, thereby avoiding the morbidity of flap reconstruction.