Derma Case: 37-year-old Man with Fever and Arm Pain

by Stephen Holt, MD, MS

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    00:02 Today, we're gonna talk about bacterial skin and soft tissue infections.

    00:06 As we do, let's start with a case.

    00:08 This is a 37-year old man with a history of opioid use disorder and injection drug use who presents with fever and arm pain.

    00:16 He reports that he uses about 15 bags of heroine a day and often "sterilizes" his needles by licking them before injecting.

    00:24 3 days ago, he noted pain, redness and swelling in his right forearm.

    00:28 Overnight, he noted progression of the redness and he developed fevers and chills leading him to present to the hospital.

    00:35 He has no other past medical history.

    00:37 He takes no medications, no recent travel and no history of blood clots.

    00:42 He does smoke about 10 cigarettes a day but does not drink alcohol.

    00:45 Family history is non-contributory.

    00:47 And review of systems reveals no dyspnea, no joint pain, and no nausea.

    00:54 Moving on to the physical exam, he is febrile to 38.5 degrees celsius.

    00:59 Heart rate's 92, blood pressure's okay.

    01:01 Head, neck exam: normal sclerae, no lymphadenopathy.

    01:04 Cardiopulmonary exam is benign, importantly, there's no murmurs.

    01:08 His abdomen is soft, nontender and nondistended.

    01:12 Examining his extremities, we see multiple track marks in the antecubital fossa bilaterally.

    01:18 There's an ill-defined 6x4 cm patch of erythema, warmth induration, mild tenderness in the right foream distal to the antecubital fossa with central puncture wound and equivocal central fluctuants There's a small amount of purulent fluid expressed when applying pressure to that area.

    01:37 There is on exam, an epitrochlear lymph node.

    01:40 There's no proximal erythema or crepitus He has no pain with elbow range of motion, and there's no axillary lymphadenopathy.

    01:47 In addition, you don't detect any palpable cords.

    01:51 Shown here on the right, is a representative picture of this patient absent the aforementioned track marks.

    01:57 Okay, with that case presentation, what's our most likely diagnosis? Let's start with the top.

    02:03 Erysipelas.

    02:04 So erysipelas is usually caused by Strep. pyogenes.

    02:08 And patients with this diagnosis tend to present more acutely and may progress very rapidly over the span of 12-24 hours.

    02:15 Our patient's story was really over 2-3 day period.

    02:18 Importantly, erysipelas si non-purulent.

    02:21 It only involves the upper layers of the dermis and the superficial lymphatics Our patient seems to have some evidence of purulence by pushing on the area and some pus was coming out.

    02:31 In addition, more often than not, erysipelas is on the face, oftentimes in children.

    02:35 And there's a clear demarcation between the involved and uninvolved areas with a raised, advancing border.

    02:42 There's not a subtle, blurred distinction between the infected lesion and the non-infected skin.

    02:48 So I think we can safely take erysipelas off of our list.

    02:52 Next up is cellulitis.

    02:54 And when you're thinking about cellulitis, you should also be aware of certain risk factors.

    02:58 The first of which is any break in the skin.

    03:00 Our patient is using injection drugs so he's frequently having breaks in the skin.

    03:04 Another common one would be tinea pedis, which you'll often see in diabetes.

    03:08 Diabetes in its own right, even without tinea pedis is a risk factor for getting cellulitis, as is venous stasis due to the interruption of lymphatic flow and HIV because it's an immunocompromised state.

    03:21 Our patient has some suspicion of a collection or an abscess deep to the superficial findings, which is something that we would definitely see with cellulitis particularly if it's caused by community acquired MRSA.

    03:33 Next up, speaking of severe infections, is necrotizing fasciitis Now patients with nec fasc, which is the most severe skin and soft tissue infection, will oftentimes have tenderness and pain out of proportion to the exam initially.

    03:47 Unfortunately, eventually as the disease progresses and you have progressive necrosis, they may actually have a diminished sensation to pain.

    03:55 You're looking at edema beyond the borders of the erythema.

    03:58 You may have crepitus due to the gas gangrene and bullae may form as well.

    04:02 Now for necrotizing fasciitis, patients will almost always have some risk factor, with diabetes, HIV or perhaps being immunocompromised by immunosuppresant medications.

    04:12 We're not getting that story from him so I think we can safely x that one out too.

    04:19 Septic thrombophlebitis needs to be considered and needs to be excluded in anyone with injection drug use who has fevers, swelling and redness.

    04:27 So I have to keep that one on our list for now.

    04:31 And lastly, impetigo.

    04:33 Let's talk about that one in a little bit more detail.

    04:36 So impetigo is a bacterial infection most often caused by staph and strep organisms, and there's a good picture of it shown here.

    04:44 Just like in this example, it's typically occuring in patients who are ages 2 to 5 years old, or in the elderly and certainly in those who are immunocompromised It starts off with just papules but then can progress into vesicles with surrounding erythema and ultimately these pustules with honey-crusted adherent fluid when they open up and they rupture.

    05:04 They're most likely to be on the face, around the lips and the mouth or on the proximal limbs.

    05:11 At times, especially if staph aureus is involved, the lesions maybe bullous and then they can ulcerate causing something called an ecthyma.

    05:18 These lesions are not itchy.

    05:20 They may rapidly progress however to a deeper infection with significant complications like lymphangitis, furunculosis, cellulitis which we've talked about before.

    05:30 and even staphylococcal scalded skin syndrome which is caused by an exfoliative toxin.

    05:35 Post-streptococcal glomerulonephritis may be a late manifestation, days to weeks after the initial infection.

    05:43 For mild forms, like the one we're seeing here, you can probably get by with just topical mupirocin but for moderate or severe cases, you're gonna want to use oral antibiotic directed against staph and strep.

    05:54 And a good example of that would be oral cephalexin or dicloxacillin.

    06:00 So let's look again at the key aspects of this case.

    06:04 So this is a 37-year old guy with opioid use disorder and injection drug use.

    06:08 That's gonna predispose him to any number of different skin and soft tissue infections but I'm most thinking about cellulitis.

    06:14 The time course being about 3 days, also goes with cellulitis rather than erysipelas which is much more of a quick presentation.

    06:22 Pain, redness, swelling - pretty typical for cellulitis.

    06:25 Fevers and chills when we see that, we worry about deeper infections and potentially bacteremia And he does not have a history of blood clots which at least is gonna steer us away a little bit from thrombophlebitis, so I do think we're gonna need some imaging just to be sure.

    06:41 Looking at our physical exam, again for some key features: He is febrile, he does have an ill-defined 6x4 cm patch Again, if we were thinking about erysipelas, there'd be a very well-demarcated border, with a little bit of bullous changes.

    06:55 There's mild tenderness in the right forearm which at least tells us he doesn't have late necrotizing fasciitis.

    07:01 He has equivocal central fluctuant which is most likely associated with some deep tissue abscess.

    07:07 An epitrochlear lymph node is comonly seen in patients who have any skin and soft tissue infection if you go looking for it.

    07:13 And importantly, there's no palpable cords to suggest thrombophlebitis.

    07:19 Here's some initial data to help us through.

    07:21 So unsurprisingly, a white count of 13.1 BMP is fine -that's reasurring.

    07:27 Liver function tests are okay.

    07:29 Blood culture is reasonable to get if a fever is present but keep in mind that it's useful in less than 10% of cases of cellulitis.

    07:37 Wound culture can be helpful if the lesion is purulent And I agree in this case, it's reasonable to consider an ultrasound in light of his history of injection drug use.

    07:47 In this case, our ultrasound says no "evidence of thrombosis" we can take that off of our list Soft tissue edema is present, that's no surprise And we find a 1x1 cm fluid collection deep to the central skin lesion.

    08:00 Whenever you have a fluid collection in the setting of cellulitis, it's probably more likely to be community acquired MRSA as the cause.

    08:07 Incidentally, a d-dimer would not be particulary useful in this case With the setting of an infection, it's most likely to be positive which could lead you down a path you don't want to go down.

    08:18 So it looks like we can officially call this bacterial purulent cellulitis likely from either staph or strep.

    About the Lecture

    The lecture Derma Case: 37-year-old Man with Fever and Arm Pain by Stephen Holt, MD, MS is from the course Skin Infections.

    Included Quiz Questions

    1. Streptococcus pyogenes
    2. Staphylococcus aureus
    3. Pseudomonas aeruginosa
    4. Staphylococcus epidermidis
    5. Vibrio vulnificus
    1. Presence of pus
    2. Well-defined margins
    3. The face is the most commonly affected part.
    4. Rapid progression
    5. Deep dermis sparing
    1. Pustules and vesicles with an overlying honey-colored crust
    2. A tender, erythematous, cord-like skin lesion
    3. Scaly, ill-defined papules over the flexural surfaces
    4. Fluid-filled vesicles overlying an erythematous base at the vermilion line
    5. Maculopapular skin lesions all over the body
    1. Necrotizing fasciitis
    2. Cellulitis
    3. Erysipelas
    4. Septic thrombophlebitis
    5. Impetigo

    Author of lecture Derma Case: 37-year-old Man with Fever and Arm Pain

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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    Wow, very impressive!
    By Olivier S. on 10. September 2020 for Derma Case: 37-year-old Man with Fever and Arm Pain

    I really appreciate the way Dr Holt structures his courses. The clinical scenario are not only there to help understand the different pathology, but it also give key relevant information to help with the differential.