Derma Case: 57-year-old Man with Right Facial Swelling

by Stephen Holt, MD, MS

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    00:01 Before we close, I just wanna review another case very briefly to highlight another one of the diagnoses that was on our list.

    00:08 So, this is the 57-year old man with a history of uncontrolled diabetes mellitus who presents with right facial swelling shown here.

    00:17 He states he picked out a pimple on his nose yesterday morning and over the next 36 hours he's developed redness and swelling to his right side of his face, associated with fevers and chills, denies any new medications, no recent travel or history of prior blood clots.

    00:33 Social, family history is non-contributory.

    00:35 doesn't have any dyspnea, no eye symptoms though I'm sure that right eye is a little bit tricky to open.

    00:40 He's febrile to 102F, a little borderline tachycardic, blood pressure's okay.

    00:46 and he has a well-demarcated, raised erythematous rash involving the entire right cheek with warmth and tenderness.

    00:54 There is no periorbital swelling, and no fluctuants.

    00:59 Highlighting the key fetaures here - he's got diabetes, he's much more likely to have a significant infection, the facial swelling, the rapid time course over 36 hours with fevers and chills, constitutional symptoms It's well demarcated without any fluctuants.

    01:13 This is a good example of erysipelas and I just want you guys to be able to recognize that.

    01:17 Again with erysipelas in a person who has systemic symptoms and immunocompromised, you should get by with intravenous antibiotics particularly 3rd generation cephalosporins- ceftriaxone, or you can use cefazolin.

    01:29 With a milder infection you could probably get by with oral penicillin or amoxicillin.

    01:34 Okay, let's review a few key points about bacterial, skin and soft tissue infections.

    01:40 First off, the most common bugs: absolutely a Staph aureus and beta-hemolytic strep.

    01:45 Remember to look for certain risk factors: immunocompromised patients, those with any evidence of skin breakdown and venous stasis.

    01:54 Next up, when you're doing your examination, look for discreet borders which may suggest erysipelas.

    01:59 Look for systemic symptoms, which may indicate bacteremia.

    02:02 And look for fluctuants which may mean that you've got an abscess that's gonna require incision and drainage.

    02:08 Don't forget about those hematogenous and immune-mediated complications that can ensue.

    02:13 And when you're thinking about treatment, you want oral or IV antibiotics that are directed against staph and strep.

    02:18 If you're worried about MRSA, don't forget to add the vanco(mycin).

    About the Lecture

    The lecture Derma Case: 57-year-old Man with Right Facial Swelling by Stephen Holt, MD, MS is from the course Skin Infections.

    Included Quiz Questions

    1. Staphylococcus aureus
    2. Escherichia coli
    3. Pseudomonas aeruginosa
    4. Clostridium perfringens
    5. Staphylococcus epidermidis

    Author of lecture Derma Case: 57-year-old Man with Right Facial Swelling

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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