DESTIN, FLA. Don't be afraid to treat infections empirically in patients in whom you have no definitive diagnosis, if you have considered the differential diagnoses and have ruled out more ominous conditions, Dr. Bari Cunningham said.
"It's okayand at times, necessaryto treat empirically," said Dr. Cunningham at a meeting sponsored by the Alabama Dermatology Society.
She described the case of a gardener who presented with what appeared to be severe acne on his back. Various acne washes and medications failed to resolve the acne.
The patient's job involved carrying burlap sacks of branches and sticks; he typically carried the bags over his shoulders and slung across his back, said Dr. Cunningham, who assumed the "acne" was actually some kind of inoculation injury.
Various diagnoses were considered, including mycetoma, sporotrichosis, deep fungal infection, and foreign body reactions. Various studies showed granulomas and suppurative inflammation, but they were negative for these differential diagnoses.
Without a diagnosis, Dr. Cunningham, a pediatric dermatologist at the University of California, San Diego, decided to treat empirically after the patient returned complaining of tenderness and extensive drainage from the lesions. The patient was successfully treated with trimethoprim/sulfamethoxazole, clarithromycin, and ciprofloxacin.
"He ultimately completely cleared," she said. The outcome underscores the fact that it is, indeed, okay to treat empirically.
"I really, in retrospect, should have started him right away and not made him wait 4 or 5 months," she said. "I had the pathologyI had everything. There was no reason why I shouldn't have just treated empirically right off the bat."