Transcript ID Case Conference 10-10-07

“I think something bit me.”
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
4/16/08
CC: Arm pain
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27 yo CM remote history of substance abuse
presented to OSH with R arm swelling. 6 days PTA
he had been helping his brother move a woodpile.
After he carried the logs from one side of the yard
to the other he noticed a sore spot on the inside of
his right elbow.
He had seen spiders on the logs and recently killed
some brown spiders in his house, so concluded he
had been bit by a spider.
The sore spot became more swollen and red over
the next few days. The area became more firm
and tender then started to darken in color.
HPI (cont)
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One day PTA the patient was seen at his primary
care physician’s office for severe pain and swelling.
He was prescribed levofloxacin and instructed to go
to the ED if his symptoms got worse.
The patient went home from the doctor’s office
planning to refill the prescription in the morning.
That night at midnight he presented to his local ED
for severe pain and redness in his arm.
He states his arm was “so swollen it felt like it was
gonna pop open.” It was “so dark it looked like a
hunk of meat.” He said the wound “smelled like
rotting meat.”
HPI (cont)
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The ER MD called a surgical consult to
assess for necrotizing fasciitis. The
surgeons Recommended transfer to UNC.
Called the UNC ID fellow and requested a
transfer.
Per physician – redness was previously all
below the elbow, since the patient had been
in the ED (3 hours) it had extended
superiorly towards his bicep.
HPI (cont)
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The patient was started on imipenum,
clindamycin, and vancomycin and
transported to UNC.
From departure of OSH to arrival at
UNC ED the patient reports the
redness has decreased. Prior marker
line approximately 2cm from current
errythematous border
PMH
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Face and head trauma (2000) - the
patient had been battered,
experienced multiple facial lacerations
but no LOC.
h/o Anxiety and depression previously treated with lexapro
Medications
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Prior to hospitalization - None
Allergies - NKDA
History (cont)
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Social History: tob 2 pacs a day for 10 years
ETOH 2 drinks /week h/o cocaine, XTC, mj
use in the distant past. The patient
adamantly denies using any IV drugs
recently, denies any HIV risk factors. His last
HIV test was 2 years ago and was negative.
No pets
Lives near Fayetteville, NC
Family History: DM - uncles.
HTN - father
Physical Exam
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154/89 - 76 - 15 - 36.2
INAD, resting comfortably. EOMI, PERRLA, nonicteric
no e/e on OP. no JVDLymph Nodes no LAD appreciated in
cervical, supraclavicular, or inguinal regions
RRR no murmurs CTAB no rash or lesions other than RUE
a&ox3, pleasant and cooperative
soft NT nabs, no HSM LUE and BLE have no c/c/e
RUE with approx 2cm area of dark discoloration, exquisite
tenderness, and purulent drainage on the medial aspect of the
R anticubital fossa. there is surrounding edema, minimal
induration. The errythema is approximately 5cm receeded
from the marker line labelled 4/11/04 0445am.
Neurological no focal defecits, sensation intact
Radiology
Radiology
CT with contrast
CT with contrast
CT with contrast
CT with contrast
CT with contrast
CT with contrast
CT with contrast
CT with contrast
CT without contrast
CT without contrast
CT without contrast
CT without contrast
CT without contrast
CT without contrast
CT without contrast
Discussion
Further Diagnostic Tests
Operative Report
a small cavity in the subcutaneous
area of the antecubital fossa that did
involve the defect into the fascia, but
there was no deep collection of pus,
dead muscle or deeper involvement.
There was a small amount of necrotic
skin and subcutaneous tissue, all of
which was debrided away.
Hospital Course
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Diagnosed with streptococcus
anginosus cellulitis with fascial defect
s/p debriedment
Did well clinically, no further fevers,
WBC remained normal. 4 days of IV
therapy then d/ced on
amoxicillin/clavulanate to follow up
with ortho and ID
DDx of blackened eschar
lesion
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Cutaneous anthrax
lesions
Brown recluse spider
bite
Rickettsial pox
Cutaneous
leishmaniasis
Varicella zoster
Herpes simplex
Staphylococcal or
streptococcal cellulitis
Ecthyma gangrenosum
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Ulceroglandular
tularemia
Plague
Eczema
Typhus
Glanders
Rat-bite fever
Aspergillosis
Mucormycosis
Leprosy
Vaccinia
Spider Bite?
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Brown Recluse is often
blamed for necrotic
lesions
In North Carolina this is
fairly unlikely
Literature looking at the
falsely high incidence of
“spider bites”
Brown Recluse photo: R. Bessin, University of Kentucky Entomology.
Distribution map from R. Vetter, Univ. Calif. Riverside
Spider Survey
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Vetter et al. survey of a
Kansas home using glue
boards
Found 2055 confirmed
Loxosceles reclusa from
June-Nov 2001
No bites to family of four
living in the home during
that time
Brown Recluse Bite vs
Bacterial Infection
Images from University of Kentucky Dept of Entomology.
References
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Uptodate.com 4/15/08
Mandell’s Principles and Practices of Infectious Disease, 5th Ed.
Majeski, J. Necrotizing fasciitis developing from a brown recluse spider bite.
Am Surg 2001; 67:188.
Wright, SW, Wrenn, KD, Murray, L, et al. Clinical presentation and outcome of
brown recluse spider bites. Ann Emerg Med 1997; 30:28.
Anderson, PC. Spider bites in the United States. Dermatol Clin 1997; 15:307.
Williams, ST, Khare, VK, Johnson, GA, et al. Severe intravascular hemolysis
associated with brown recluse spider envenomation: A report of two cases
and review of the literature. Am J Clin Pathol 1995; 104:463.
Vetter, R. Identifying and misidentifying the brown recluse spider. Dermatol
Online J 1999; 5:7.
Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders
(Araneae: Sicariidae) and no envenomations in a Kansas home: implications
for bite diagnoses in non-endemic areas. J Med Entomol 2002; 39:948-951.
Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown recluse
spider bites (loxoscelism) greatly outnumber actual verifications of the spider
in four western American states. Toxicon 2003; 42:413-418.