A 36-year-old white woman sought care at our outpatient clinic for 2 days of right forearm and hand redness, swelling, and severe pain at a previous intravenous (IV) catheter site. The patient had received intramuscular antibiotics for culture-positive streptococcal pharyngitis 2 weeks earlier, and then IV fluids and steroids due to poor oral intake from odynophagia.
She indicated that since the time of the pharyngitis diagnosis, she’d had a persistent fever. At our clinic, she was given a diagnosis of cellulitis and started on a course of oral cephalexin.
Three days later, she returned. She had a temperature of 100°F and her right forearm and wrist were exquisitely sensitive to touch over a warm and indurated violaceous rash with pseudovesicles over the most edematous portions (FIGURE 1). This rash extended onto her right hand and proximal phalanges. Her fingers hurt when she moved them; sensation and pulses were intact.
Her left wrist was now mildly swollen, with associated warmth and erythema, but no vesicles. Her left ankle was also warm, erythematous, and moderately swollen with significant tenderness to palpation. She had a few scattered nodular, erythematous lesions on her upper right arm and chest.
We (RW and VK) admitted the patient and started her on IV vancomycin and clindamycin to treat presumed refractory cellulitis. On Day 2 she hadn’t improved, so we added gatifloxacin for gram-negative coverage. On Day 3, her lesions worsened, so we transferred her to a higher-level facility.
FIGURE 1
Worsening lesions
The patient’s right forearm and wrist were exquisitely sensitive to touch over the rash, with pseudovesicles. Ink markings denote original boundaries of the lesion.
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