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BryanK
08-23-2017, 11:37
Good afternoon all,

I have a friend who has been laid up in the hospital for a few days now, and they have no idea what has caused this blistering(all on same arm), her symptoms, or how to treat it(from what she's told me). They've ruled out bug bites.

I'm just trying to help a friend with any leads that she could pass onto her physicians. I've attached photos, and her current condition is:

104 degree fever that hasn't broken
Redness all over the body
Dehydrated
Chronic headaches/migraines


I really appreciate any help with this. Thank you for reading.

PedOncoDoc
08-23-2017, 11:53
Any new exposures/medicines/supplements/etc?

BryanK
08-23-2017, 12:06
I will ask, but to be clear, do you mean while she has been admitted, or prior to? Thank you for the reply

PedOncoDoc
08-23-2017, 12:13
I will ask, but to be clear, do you mean while she has been admitted, or prior to? Thank you for the reply

Prior to the admission.

Trapper John
08-23-2017, 14:36
Doesn't look like a systemic allergic reaction to me. Looks more like a local reaction to a bite, sting, or contact to an allergen that has become infected and may be going systemic. Suspect Streptococcus. I would imagine the primary care facility will get a culture/sensitivity, thoroughly wash, debride the infection, bandage, and start her on some broad spectrum antibiotic (fluroquinolone like ciprofloxacin) until lab results indicate otherwise.

BryanK
08-23-2017, 14:39
Prior to the admission.

She's been resting, so no definitive answer on that just yet. Her fiance let me know that her swelling has worsened, fever slightly lower, and has been in multiple antibiotics thusfar. I doubt I'll be privy to the dosages and types of antibiotics however.

BryanK
08-23-2017, 14:43
Doesn't look like a systemic allergic reaction to me. Looks more like a local reaction to a bite, sting, or contact to an allergen that has become infected and may be going systemic. Suspect Streptococcus. I would imagine the primary care facility will get a culture/sensitivity, thoroughly wash, debride the infection, bandage, and start her on some broad spectrum antibiotic (fluroquinolone like ciprofloxacin) until lab results indicate otherwise.

She initially suspected a bite, but they have ruled that out somehow. She's on a variety of antibiotics, but the swelling has worsened. They have not given her or her fiancÚ any answers as of yet.

This is day 3 of her hospital stay.

Trapper John
08-23-2017, 14:56
She initially suspected a bite, but they have ruled that out somehow. She's on a variety of antibiotics, but the swelling has worsened. They have not given her or her fiancÚ any answers as of yet.

This is day 3 of her hospital stay.

Three days!! Variety of antibiotics!! Still has a low-grade fever!! Now ya got my attention.

What hospital is this? Did they get a culture & sensitivity to determine bacteria type and sensitivity to antibiotics? I am concerned about an antibiotic resistant strain. I am thinking that someone else may need to be brought in on this one. A local bacterial infection that is refractory to treatment for 3 days bothers me a lot.

PedOncoDoc
08-23-2017, 14:59
Staph and Strep skin infections are certainly is on the differential, as is Stevens Johnson Syndrome, hence my question about new medications and other exposures.

Trapper John
08-23-2017, 15:03
Staph and Strep skin infections are certainly is on the differential, as is Stevens Johnson Syndrome, hence my question about new medications and other exposures.

Now I got to go look that one up! Thanks a lot Doc. :D

Oh and on another subject I will be contacting you in a few week regarding GVHD.

Be well.

Old Dog New Trick
08-23-2017, 15:04
MRSA

The initial presentation of MRSA is small red bumps that resemble pimples, spider bites, or boils; they may be accompanied by fever and, occasionally, rashes. Within a few days, the bumps become larger and more painful; they eventually open into deep, pus-filled boils About 75 percent of CA-MRSA infections are localized to skin and soft tissue and usually can be treated effectively.

Trapper John
08-23-2017, 15:08
MRSA

The initial presentation of MRSA is small red bumps that resemble pimples, spider bites, or boils; they may be accompanied by fever and, occasionally, rashes. Within a few days, the bumps become larger and more painful; they eventually open into deep, pus-filled boils About 75 percent of CA-MRSA infections are localized to skin and soft tissue and usually can be treated effectively.

And that is EXACTLY what is #1 on my DDx!

BryanK
08-23-2017, 15:25
Three days!! Variety of antibiotics!! Still has a low-grade fever!! Now ya got my attention.

What hospital is this? Did they get a culture & sensitivity to determine bacteria type and sensitivity to antibiotics? I am concerned about an antibiotic resistant strain. I am thinking that someone else may need to be brought in on this one. A local bacterial infection that is refractory to treatment for 3 days bothers me a lot.

I'm unsure of the tests she's had thus far, and I think she's probably unsure also unfortunately.

She's at Howard County General Hospital (Maryland), which is a branch of Johns Hopkins. If anyone could figure this thing out I'd think it'd be them, but they have me wondering now.

MRSA

The initial presentation of MRSA is small red bumps that resemble pimples, spider bites, or boils; they may be accompanied by fever and, occasionally, rashes. Within a few days, the bumps become larger and more painful; they eventually open into deep, pus-filled boils About 75 percent of CA-MRSA infections are localized to skin and soft tissue and usually can be treated effectively.

I appreciate the insight, it certainly appears to be the case.

Trapper John
08-23-2017, 15:32
BryanK- She is fortunate that she has you for a patient advocate. Being affiliated with JH then you should be pushing for their infectious disease specialists to weigh in on this ASAP. Don't f' around with this and be an a'hole if you need to. Old Dog is right on this one, I'll bet money on it!

Good luck and be persistent.

BryanK
08-23-2017, 16:15
BryanK- She is fortunate that she has you for a patient advocate. Being affiliated with JH then you should be pushing for their infectious disease specialists to weigh in on this ASAP. Don't f' around with this and be an a'hole if you need to. Old Dog is right on this one, I'll bet money on it!

Good luck and be persistent.

Thank you sir. She has in fact seen the IDS, and still no word on a diagnosis. I understand it takes time, I just didn't figure it took that long to nail down.

Old Dog New Trick
08-23-2017, 16:16
Just a hunch. WAG

She work in healthcare, hospice or recently work out at a gym?

PedOncoDoc
08-23-2017, 17:02
Thank you sir. She has in fact seen the IDS, and still no word on a diagnosis. I understand it takes time, I just didn't figure it took that long to nail down.

There is a big difference between being at an academic center-affiliated hospital and being at said academic center.

Cultures do take time to grow, but draining/scraping of one of the bullae (large blisters) as shown in your picture should help with the diagnosis.

Staph or strep skin infection and subsequent exotoxin effects could certainly lead to her clinical picture and is more likely than SJS (Stevens-Johnson), but I had assumed (mea culpa!) the docs are working her up for the more common things and you were asking because the process has progressed despite a few days of assessments and intervention which would make for a need to think outside the box.

PedOncoDoc
08-23-2017, 17:04
Just a hunch. WAG

She work in healthcare, hospice or recently work out at a gym?

That thought process for risk of MRSA is outdated - a large portion of the community at large is colonized with MRSA now, so one does not need any of those risk factors in order to be at risk for MRSA infection.

Trapper John
08-23-2017, 19:09
That thought process for risk of MRSA is outdated - a large portion of the community at large is colonized with MRSA now, so one does not need any of those risk factors in order to be at risk for MRSA infection.

Thanks for posting that, I was going to make the same point. CA-MRSA is now endemic.

Trapper John
08-23-2017, 19:13
There is a big difference between being at an academic center-affiliated hospital and being at said academic center.

Cultures do take time to grow, but draining/scraping of one of the bullae (large blisters) as shown in your picture should help with the diagnosis.

Staph or strep skin infection and subsequent exotoxin effects could certainly lead to her clinical picture and is more likely than SJS (Stevens-Johnson), but I had assumed (mea culpa!) the docs are working her up for the more common things and you were asking because the process has progressed despite a few days of assessments and intervention which would make for a need to think outside the box.

Excellent points Doc! Unfortunately, finding someone that can think outside the box is becoming an endangered species. But on the bright side, at lease she is not in a VA hospital. ;)

Old Dog New Trick
08-23-2017, 19:18
That thought process for risk of MRSA is outdated - a large portion of the community at large is colonized with MRSA now, so one does not need any of those risk factors in order to be at risk for MRSA infection.

I realize that but if those factors are present (e.g., gym) then a place may be identified for follow up notification.

Yep, MRSA and MSSA are now like getting chlamydia from a whore house, all's you have to do is walk in the door.

Whatever this lady has I hope the hospital identifies it and begins the proper treatment.

PedOncoDoc
08-24-2017, 08:19
Yep, MRSA and MSSA are now like getting chlamydia from a whore house, all's you have to do is walk in the door.

Will just have to take your word on that one. :D

Any additional follow up now that a day has passed?

BryanK
08-24-2017, 10:26
I haven't heard from her or her fiancÚ today, but it's still kind of early. As of my last post, no new news regarding what this is. I will update as soon as I know something.

Thank you for the assistance gentlemen, I really appreciate it.

PedOncoDoc
08-24-2017, 11:03
I haven't heard from her or her fiancÚ today, but it's still kind of early. As of my last post, no new news regarding what this is. I will update as soon as I know something.

Thank you for the assistance gentlemen, I really appreciate it.

So long as she is not clinically deteriorating, some times a bit of watchful waiting provides clarity.

BryanK
08-25-2017, 04:37
They reversed their decision regarding whether the initial cause was a bite of some sort. The final verdict is cellulitis caused by tampering with the bite site(unknown critter). It seems they have found the right antibiotic, and she's been fever-free for almost 24 hours. Is it normal to rule out a bug bite, then reverse that decision 4 days later?

Regardless, I'm just glad she's on the other side of this now. Over 3 days with a fever orbiting at 104 without relief has to take a toll on the body. Thank you for your concerns and assistance, and hopefully this thread can be used for future situations like this. :lifter

Old Dog New Trick
08-25-2017, 05:32
Fantastic, good news this morning.

Reversing course is only a part of "practicing medicine."

PedOncoDoc
08-25-2017, 08:15
They reversed their decision regarding whether the initial cause was a bite of some sort. The final verdict is cellulitis caused by tampering with the bite site(unknown critter). It seems they have found the right antibiotic, and she's been fever-free for almost 24 hours. Is it normal to rule out a bug bite, then reverse that decision 4 days later?

Regardless, I'm just glad she's on the other side of this now. Over 3 days with a fever orbiting at 104 without relief has to take a toll on the body. Thank you for your concerns and assistance, and hopefully this thread can be used for future situations like this. :lifter

Glad things are getting better. It doesn't have to be an insect bite - any injury to the skin can be a potential site of infection, and can be difficult to attribute the potential opportunity for infection in hindsight.

Trapper John
08-25-2017, 14:36
Glad to hear what is potentially a good outcome!

Firelord
08-27-2017, 10:17
That looks like a condition my son suffered from when he was a toddler. We took him to an emergency room at a hospital in Atlanta but they couldn't diagnose and/or treat the condition. They recommended Shriners next door. They were able to diagnose the issue in a matter of a few hours - The ER doctor stated he had seen it once before - The slang term for the condition was "Scalded Skin Syndrome"; basically a type of staph infection caused by a spider bite - never did find the location of the bite though.

PedOncoDoc
08-27-2017, 11:25
That looks like a condition my son suffered from when he was a toddler. We took him to an emergency room at a hospital in Atlanta but they couldn't diagnose and/or treat the condition. They recommended Shriners next door. They were able to diagnose the issue in a matter of a few hours - The ER doctor stated he had seen it once before - The slang term for the condition was "Scalded Skin Syndrome"; basically a type of staph infection caused by a spider bite - never did find the location of the bite though.

Staph Scalded Skin is not caused by a spider bite - again, it's typically related to a staph infection (commonly of the skin) and a result of the toxins released by the bacteria.

Odd Job
08-30-2017, 12:36
I saw a patient with a blister just like that on her leg. She reported having being "bitten" by a small slow-flying insect which she described as a small black fly. The bite took place around 15:00 in the Regent's Park in London. I saw a 1" blister on this young lady's leg by 17:00 in the urgent care center.
When I saw the patient again at 18:00 the blister was three times the size, with a very tight skin. It looked like a bad burn.

I never did find out what insect it was, but the diagnosis was a local reaction to some kind of foreign matter injected or transferred to the patient by this insect.