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Louise Kenny: It’s a mystery

21 Sep, 09 | by julietwalker

One of the most exciting aspects of working here is the opportunity to have a good rummage among the rarities of diagnoses that I learnt about for the MRCP.  There have been a few cases now, which have rung a big bell in my head, related to conditions which I never thought to save space for in my brain, as they seemed so obscure and unlikely. 

It’s not all bizarre trios of symptoms which can only be a syndrome diagnosed 8 times since discovered. There have also been the routine admissions and outpatient complaints of COPD, Asthma, minor trauma and all over body pain.  However there does seem to be a little more of the exotic.

Of course, here in Santiago, diagnosis and treatment is often dependent solely on clinical findings, which is excellent for honing clinical skills for spotting signs, but makes any weird and wonderful findings less official.  We can run a variety of blood tests and x-rays within working hours, and can send blood or patients off to the city for more complex images or analysis. 

There is even talk of genotyping an infant with ambiguous genitalia. We’re eagerly awaiting USS confirmation, after which we’ll scratch our heads and wonder what to do next. 

The one thing I have noticed is missing is the routine swabbing and culture of wounds or infection sites.  I saw an acute hot, red, swollen knee in the ER recently, and being unable to run any tests whatsoever, simply started IV antibiotics – A microbiologist’s worst nightmare!

Apologies for those non-medics who may find these images gruesome, look away now, but we all here thought this was an interesting case worth sharing.

desquamation of feet

desquamation of hands

spontaneous ulcer to left upper arm

A 38 year old male who presented initially with sudden onset pain, and went on to rapidly, over days, develop an ulcerating, sloughy, necrotic sore of the left upper arm.  He denied any injury, insect bite or sting and also had no past medical history.  He was afebrile, with stable observations.  Apart from intense pain in his left arm, and desquamation of his hands and feet which occurred approximately 4 days after the wound appeared, he reported no other systemic symptoms.

I have seen desquamation a couple of times, but never to this extent, which is perhaps indicative of the late presentation here in comparison to back home.   

We treated this patient with broad-spectrum antibiotics and surgical debridement at the nearest surgical department.

Many thanks to the Gateshead outreach service for their suggestions regarding dressings.

I saw the patient today in clinic – it has now been 3 weeks since the onset, and things are looking a little better, although, due to limited investigation, we still have no diagnosis!

I’m going to leave this blog open; I’d be interested to see what people think of the history and photos. Any suggestions? (The patient has given his consent for me to share his details.)

Louise Kenny has completed F2 year in the Northern deanery and is now working in Guatemala

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  • Dr John Corish

    I fail to see where the mystery lies. It’s a clearcut case of necrotising fasciitis. Was the patient an IV drug user?

  • Susheel Kapoor

    Dear Louise,

    It does convincingly look to be a case of fasciitis. Also you could have investigated the patient for diabetes mellitus; as it could be a factor leading to the causation of this condition. You may lookup the emedicine site for further details of the condition.

    BW,

    Dr Susheel Kapoor

  • Louise kenny

    Thanks Dr Corish,
    No, he is not an IVDU. Necrotising fasciitis is indeed our working diagnosis, however this patient looked remarkably well with no signs or symptoms of systemic toxicity.
    At the time this man presented to A+E, the lesion had been present for 8 days with desquamation for 4 days. He stated that while initially it had developed rapidly, it had not increased in size for 3-4 days (with no antimicrobial treatment). The lesion remained vascular, with healthy surrounding tissue.
    I have only seen one case in the past so I shouldn’t assume, but I would have expected systemic signs with necrotizing fasciitis, especially with the extent of the skin lesion. The case I have seen in the past was a female, who presented with rapid deterioration to septic shock despite minimal skin signs who then later progressed to show similar lesions.
    Does necrotizing fasciitis not usually follow a more progressive, and aggressive pattern, or have you seen a case like this?

  • Dr John Corish

    Dr. Kenny, thank you for the extra information. Necrotising fasciitis may be subacute. Desquamation is a non-specific sign seen in many diseases. Here is a case that seems to have many similarities to yours: http://www.cmej.org.za/index.php/cmej/article/viewFile/581/392

  • Louise Kenny

    Thats a very useful and relevent case review.
    The patient returned to clinic today, with very little improvement from the previous week, but also no deterioration of either the lesion or his general health.
    The lesion has begun to develop granulation tissue.
    Many thanks again

  • matthew kennedy

    He’d be dead if it was necrotising fasciitis surely. The elbow wound looks to have very healthy, granulating edges. The feet look nice and pink as well and it’s one poor soul who synchronously develops nec fasc at 5 different sites. Is a systemic cause not the more likely explanation. Any dermatologists out there with any bright ideas?

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