| A |
DrVirgo, nyimalay, aspire, foucesed doc, toofar |
5 |
28% |
| B |
fd |
1 |
6% |
| C |
peter90036, CocaCola, khiladi, lq2006 |
4 |
22% |
| D |
vibrio, superabood, Korotkoff, Drtweetie, Markus2009, Justice, inkspot, ansalshah |
8 |
44% |
| Author | 12 Posts |
Justice
Forum Fanatic
Topics: 100
Posts: 1,897
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An 18-year-old male high school basketball player came to the emergency department in February because of a red patch on his left forearm. He had been well the day before, but woke up with a painful area measuring about 6 X 9 cm on the volar surface of the forearm. The area was tender to touch, erythematous, and raised but was not fluctuant. The emergency department physician did not believe that incision and drainage were required and prescribed warm packs to the area and a course of dicloxacillin.
The patient returns to the emergency department 2 days later. The patch is larger and more tender but is still not fluctuant. He is slightly ill but does not appear toxic and is able to go to school and attend basketball practice. The emergency department physician changes the antibiotic to cephalexin, but the patient continues to become somewhat worse over the next 2 days.
Which of the following is the most likely cause of this patient’s clinical deterioration?
A. Lyme disease
B. An abscess
C. Fasciitis
D. A β-lactam-resistant organism
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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insect / spider bite?
it might be D ... 
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| DrVirgo
Forum Hero
Topics: 1042
Posts: 3,344
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erythematous, and raised but was not fluctuant doesn't go away but becomes larger
-maybe Erethyma migrans, target rash of Lyme by ruling out the other choices... -not 100% sure.
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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i don't think EM rash is tender or raised, and should have central clearing
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| CocaCola
Forum Guru
Topics: 35
Posts: 908
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sounds like fasciitis to me...
although the existing atb provide coverage of streptococci - a very broad spectrum atb should used like pen G or a third gen cephalosporin...
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| Markus2009
Forum Senior
Topics: 9
Posts: 189
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CA-MRSA?---------->D
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| guangyu
Forum Elite
Topics: 29
Posts: 308
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A
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| Jcala
Forum Junior
Topics: 10
Posts: 44
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D
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| cool doctor
Forum Junior
Topics: 1
Posts: 219
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D
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| Justice
Forum Fanatic
Topics: 100
Posts: 1,897
|
The correct answer is D
Educational Objectives: Recall the clinical presentation of methicillin-resistant Staphylococcus aureus in the community.
The best explanation for this patient’s persistent infection is the presence of resistant bacteria, most likely community acquired methicillin-resistant Staphylococcus aureus (CAMRSA). These strains have been in circulation for a few years and differ from hospital-associated strains in several ways. Most important clinically is that they are not as broadly antibiotic resistant as the nosocomial strains and can usually be treated with a number of available oral agents. However, infections caused by CAMRSA can be very serious, and deaths have occurred in children and healthy adults from progressive infectionafter treatment is initiated. Clindamycin, tetracyclines, or trimethoprim/sulfamethoxazole is usually effective. Adding rifampin may also be helpful. When treating patients with severe infection caused by more broadly resistant CAMRSA, linezolid would be an expensive but reasonable alternative.
Persistent skin infections can be worrisome because they sometimes are an indication of more serious deep soft-tissue infections such as fasciitis or myositis. Conventional cellulitis is often a mild to moderately severe disease, depending on the underlying health of the patient. Although cellulitis can resolve without treatment, it usually improves faster with appropriate antibiotics. The rate of resolution is variable, and therapy is sometimes changed because of concerns regarding the efficacy of the initial treatment.
In this healthy young man, the skin lesion was actually progressing at a time when he was taking antibiotics. This might be explained by erythema migrans except for the time of year, the presence of pain, and the rapid progression. Lyme disease usually presents with a progressive local rash, but the time course is much slower, and lesions are typically painless. Abscesses can complicate skin infections and may not resolve without drainage (either spontaneous or surgical). However, this patient had no evidence of abscess either at the time of initial presentation or later. Fasciitis is a serious, deep soft-tissue infection that can progress rapidly. However, fasciitis most often occurs in persons who are otherwise ill or weak (for example, diabetics, geriatric patients, injection drug users). Infection caused by “flesh-eating bacteria,” such as Streptococcus pyogenes, can be severe and rapid, but should either have begun to respond to these antibiotics (all S. pyogenes strains are susceptible to penicillins and most cephalosporins) or have caused a much more toxic presentation by this time.
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| peter90036
Forum Elite
Topics: 28
Posts: 315
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watch out guys, there's another nice alternative to this enlarging spot = "normal large reaction" or something like that = big spot after insect bite, but no tenderness and not raised (iirc)
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| fd
Forum Senior
Topics: 5
Posts: 237
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Even though no fluctuation when he first came ,the fact that he didn't respond to the antibiotics given and the swelling increased shows he most probably has un abscess which has to be delt with, drained
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