UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Case Authors: Robin P. Gehris, MD, Drazen Jukic, MD
NOVEMBER 2003 CASE OF THE MONTH
CLINICAL FINDINGS
CLINICAL HISTORY:A previously healthy 6-year-old white male presented with a 2-month history of a lesion on the left wrist. By the parents’ report, the lesion had initially resembled an insect bite; however it progressed to become tender, indurated, and to develop a central crusted area with purulent discharge and an expanding margin of erythema. He was seen by his pediatrician and treated for a presumed bacterial infection with a course of Amoxicillin. He was then seen by a separate pediatrician and treated with a full course of Amoxicillin/ Clavulanate, followed by Cephalexin for a presumed spider bite with secondary bacterial infection. Despite three courses of antibiotics, the lesion continued to enlarge and discharge purulent material.
A full review of systems was positive only for pruritus at the site of the lesion, but no other systemic complaints; specifically the patient denied fever, malaise, weight loss, night sweats, lymphadenopathy or joint paints. No other family members had any systemic complaints or similar rashes.
One week prior to the onset of his rash, the patient had vacationed at the beach in North Carolina, where he swam in the ocean, played on the beach and purchased a hermit crab. There was no specific history of insect or spider bites or trauma to the left wrist. Prior to this, the patient routinely spent several days a week in a home daycare center, where he used a large wading pool which was reportedly cleaned each night with Clorox bleach.
PHYSICAL EXAMINATION:
The patient was afebrile, well-appearing and in no acute distress. His left dorsolateral wrist had a 3 x 1 cm well-demarcated, erythematous, indurated plaque with central crust. With firm pressure, a small amount of purulent material was able to be expressed from the center of the lesion. There was no associated lymphadenopathy or “sporotrichoid” spread of the lesion onto the left arm.
Gram stain was negative for WBCs
or organisms. Tissue cultures were negative for anaerobic organisms or fungus.
acid fast bacilli.
Two 4-mm punch biopsies
were performed: one in formalin for H&E and one in sterile saline for culture.
Empiric treatment was initiated with oral Clarithromycin
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