Massive Pulsatile Hemorrhage From Medial Palpebral Artery Erosion in Eyelid Ecthyma Gangrenosum.

We report the case of a 58-year-old previously healthy male who presented with sudden-onset massive pulsatile hemorrhage from the left medial eyelid, 1 week after apparent healing of a necrotic eyelid ulcer that had been treated empirically with intravenous piperacillin-tazobactam, teicoplanin, and clindamycin without surgical debridement. Emergency exploration identified active arterial bleeding, presumed to originate from the medial palpebral artery, at the site of the healed ulcer. Hemostasis was achieved with electrocauterization and suturing. Culture from the affected site grew Pseudomonas aeruginosa, whereas blood cultures were negative, and imaging showed no evidence of deep tissue or orbital spread. The patient continued to improve under broad-spectrum antimicrobial therapy and was discharged with satisfactory healing. This case illustrates that delayed arterial erosion and massive pulsatile hemorrhage may occur after apparent clinical resolution of periocular ecthyma gangrenosum, even in the absence of bacteremia or known immunosuppression. Ecthyma gangrenosum should be considered in the differential diagnosis of necrotizing periocular infections, particularly when P. aeruginosa is isolated and imaging does not support deep fascial or orbital involvement.