Journal Club

Arianna Betancourt Botell, MD

Medical Intern
12/08/2021
 Presentation of case
• A 22-year-old man was admitted due to pain and rapidly spreading
erythema of the left hand.
• The patient had been well until the day of admission, when he awoke
with pain and swelling of the left hand that involved the DIJ of the
second finger and the PIJ of the fourth finger.
• Over a period of several hours, the pain progressed and bullae began to
form. He began to have pain with movement of the second and fourth
fingers, and the bullae turned dark purple; these changes prompted the
patient to present to the emergency department the hospital.
• In the emergency department, he reported pain of the left hand that
worsened with movement of the second and fourth fingers.
• There was no lethargy, fatigue, headache, dyspnea, cough, or pain
elsewhere.
• The patient had no notable medical history and had been well before the
day of presentation.
PATIENT MEDICAL HISTORY

4-days before Day before

presentation presentation

Recently He received He kneaded the

begun the deer hide, hide with his hands
practicing he scraped and massaged into
taxidermy as a the skin and it a mixture of deer
new hobby. fur to remove brain and tap water
numerous that had been pre-
AGE: 22 ticks pared the day
GENDER: Male before and left to
stand overnight. He
ALLERGIES: NKDA
did not wear
MEDICATIONS: None protective clothing
or gloves
 PHYSICAL EXAMINATION
Vital signs
• T: 38.6°C

• BP: 126/63 mm Hg

• HR: 101 bpm

• RR: 18 bpm

• SatO2: 100% while he

was breathing ambient air.

• There were two violaceous, tender bullae on the dorsal aspect of the left hand

• In addition, nontender, streaking erythema spreading across the dorsal aspect of the
left hand, the volar aspect of the left forearm, and the medial aspect of the left upper
arm into the axilla. There was no axillary lymphadenopathy.
Laboratory Data
 Imaging study
CT-scan with IV contrast
of the left hand

• Focal soft-tissue swelling overlying

the distal interphalangeal joint of
the second finger and the proximal
interphalangeal joint of the fourth
finger on the dorsal aspect of the
left hand.
• There was no evidence of osseous
erosion, periosteal reaction,
fracture, joint effusion, fluid
collection, or subcutaneous air. The
left forearm had a normal
appearance on imaging.
 Management
● Patient was admitted to the hospital
● Intravenous fluid, ceftriaxone, and vancomycin were administered
● Consultants from:

○ orthopedic hand service

○ Dermatology

○ infectious diseases evaluated the patient

● A diagnostic test was performed.

DIFFERENTIAL
DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS

Skin and Soft-Tissue Infections

• Beta-hemolytic streptococcus, especially group A streptococcus (Strep- tococcus
pyogenes): is the most common cause of cellulitis, and blistering and
lymphangitis may occur.

• Staphylococcus aureus can cause cellulitis, but a purulent infection of the skin
and soft tis- sue usually develops.
 DIFFERENTIAL DIAGNOSIS
Plague
• Yersinia pestis
• handling of infected animal tissue
(bubonic or septicemic plague)
• can be found in deer, it is more
commonly associated with other
animals
• Incubation period 2-6 days, which
is compatible with the time course
in this case
• can result in papules, ulcers, and
eschars at flea-bite inoculation
sites
Brucellosis
• Brucella abortus is well described in deer, risk
in hunters.
• Skin contact with infected animal tissue.
• Incubation period 2-4 weeks, but it is possible
for the disease to manifest in 5 days.
• Although skin findings can develop, they are
relatively uncommon and typically diffuse.
• Rashes; papulonodular or maculopapular or
may resemble erythema nodosum.
 DIFFERENTIAL DIAGNOSIS
Tularemia Orf
• Francisella tularensis.
• Known as contagious ecthymas.
• Contact with infected animal tissue.
• The orf virus is in the parapoxvirus genus.
• sometimes referred to as rabbit fever.
• Contact with animals directly or with contaminated
• In patients who have the
equipment.
ulceroglandular form of tularemia, a
• >sheep or goats than deer.
skin ulcer is present, along with a
• Incubation period of 3-7 days.
swollen lymph node.
• Initially manifests as a small papule and then
• usually have a systemic illness.
progresses through stages involving the
development of a hemorrhagic bulla or pustule.
• Low-grade fever and lymphangitis.
 DIFFERENTIAL DIAGNOSIS
Anthrax

• Bacillus anthracis. Cutaneous anthrax

• Handling of infected animal products (deer-hide).
• The spores can be found in soil, and hoofed animals, including deer, are most likely to host the
organism.
• rare in the US, and a vaccine is available for use in livestock.
• Sxs 1-7 days after exposure, initially with a painless papule, which progresses to a vesicle and
subsequently erodes to a painless ulcer with an eschar.
• Extensive edema (edema toxin), lymphangitis and systemic symptoms may occur.
 Erysipelothrix rhusiopathiae Infection
• localized cutaneous disease known as erysipeloid
(most in fingers after occupational exposure to
animals.
• )
• Handle fresh or frozen fish or crabs; slaughter-house
workers, butchers, and farmers are also at risk
• Characterized by fever, arthritis, and skin
Erysipeloid manifest as:
abnormalities.
o Cellulitis 2-7 days after exposure.
o Violaceous and well-defined lesions are
typical, and vesicles may develop.
o Early pain and localized swelling without
pitting edema are thought to be • Systemic symptoms are relatively
characteristic clinical manifestations. uncommon with localized erysipeloid, but
o Lymphangitis and regional fever may occur.
lymphadenopathy may occur. • Other infectious syndromes: diffuse
cutaneous form, bacteremia with possible
seeding of distant sites, or endocarditis.
DIAGNOSIS

Cutaneous bacterial infection.

Erysipeloid due to Erysipelothrix

rhusiopathiae infection.
 Follow-up
● After the initiation of antimicrobial therapy, the patient’s condition improved during the
hospitalization, and he was discharged on hospital day 6.
● He had increased mobility of the second and fourth fingers, recession of the lymphangitic
streaking, and no further fevers.
● After the culture results were received, the antimicrobial regimen was changed. The
preferred agent for the treatment of E. rhusiopathiae infection is penicillin or a cephalosporin;
the organism is intrinsically resistant to vancomycin.
● Antibiotic therapy was administered for a total of 14 days.
● On his final day of therapy, the patient was seen in the orthopedic surgery clinic for the
removal of sutures from the punch biopsy. At that time, his lesions had nearly healed. The full
range of motion had returned to his hand and fingers, and the infection appeared to have
resolved.
 REFERENCES

● N Engl J Med 2021; 385:2078-2086

DOI: 10.1056/NEJMcpc2107357