A 9-year-old male with swollen lymph node and lesion near his eye

Issue: March 2011

A 9-year-old male presented to his primary provider with a mildly swollen right pre-auricular lymph node and a pimple-like lesion just lateral to his right eye. It was initially thought to be an insect bite, and he was treated with a first-generation cephalosporin. During the next 3 weeks, despite a second course of oral antimicrobial therapy with clindamycin, supplemented with topical antibiotic ointment (mupirocin), the lesion grew larger, ulcerated and developed numerous satellite lesions. He was admitted to the hospital for more aggressive therapy and diagnostic investigation.

He denied any injury to the area, recent travel, unusual animal or insect exposure. His past medical history was positive for mild intermittent asthma and the usual childhood minor illnesses. He also had a mild infection with methicillin-resistant Staphylococcus aureus of his left arm 3 months earlier, and a “fever blister” on his lower lip 1 month earlier. Otherwise, he is a healthy male with immunizations up to date.

James H. Brien

Examination revealed a healthy appearing male with an ulcerative lesion just lateral to his right eye on a narrow erythematous base, with an impetiginous-appearing crust and numerous satellite papulopustular lesions, as shown in Figures 1 and 2. His eye exam is normal, and except for mild swelling of the right pre-auricular lymph node, the rest of his examination is normal.

Lab tests include bacterial culture, Gram stain, fungal stain and culture, acid-fast stain and culture and herpes and varicella zoster polymerase chain reaction (PCR). All stains are negative; the cultures and PCRs are pending.

What’s Your Diagnosis?

A. Cutaneous herpes

B. MRSA impetigo

C. Mycobacterium marinum

D. Sporotrichosis


Figures 1-2: An ulcerative lesion just lateral to the patient’s right eye on a narrow erythematous base, with an impetiginous-appearing crust and numerous satellite papulopustular lesions.

The answer turned out to be lymphocutaneous sporotrichosis (D), but it was not proved until after further empiric therapy with acyclovir for possible herpes and antistaphylococcal antibiotics for possible MRSA. I will have to admit that when I first saw this patient upon admission to the hospital, I thought for sure that this was going to turn out to be an unusual case of cutaneous herpes or shingles. I held on to that thought, even after the PCRs returned negative. Then I thought it might be a case of herpes with secondary S. aureus infection, such as that shown in Figures 3 and 4, a case I saw many years ago of culture-proven cutaneous herpes simplex virus infection with secondary S. aureus infection. Both organisms were obtained from the fluid sterilely obtained from the intact blister at the inferior part of the lesion. As that case demonstrated, sometimes these combined infections can take on an unusual appearance. However, all bacterial cultures were ultimately negative and PCRs for herpes simplex and zoster were negative, as were PCRs for atypical mycobacteria. Repeated fungal cultures performed eventually revealed 1+ Sporothrix schenckii about 1 month after initial presentation for admission. Having no evidence of disseminated disease, he was then treated with a 6-month course of itraconazole, the drug of choice, at a dose of 5 to 10 mg/kg/day divided into two doses, with good resolution. An alternative and much less expensive treatment option is the time-honored saturated solution of potassium iodide (SSKI).


Figures 3-4: Herpes with secondary Staphylococcus aureus infection. Images: Brien JH

For this infection to have occurred, there must have been some minor scratch or other break in the skin that went unnoticed, providing the port of entry for the fungus. Regardless of how it got there, the patient responded well to the treatment, as shown in Figures 5, 6 and 7. Figure 5 was at discharge from the hospital a few days after those shown in Figures 1 and 2. Figure 6 is about 1 month later, when treatment was begun, and Figure 7 was a couple of months after the end of therapy, showing near normalization of the area, with only minor scarring.

Figure 5: A few days after beginning treatment.

Figure 6: About 1 month after treatment initiation.

Figure 7: About 2 months after the end of therapy, showing near normalization of the area, with only minor scarring.

Mycobacterium marinum also occurs after injury to the skin in contaminated, non-chlorinated water, allowing the entry of the organism, resulting in a chronic sore that may closely resemble sporotrichosis, usually on the extremity, as shown in Figure 8. It is usually self-limited in immunocompetent patients, but it can be treated with clarithromycin, doxycycline, trimethoprim-sulfamethoxazole or rifampin plus ethambutol for 4 to 6 weeks.

Figure 8: A chronic sore caused by Mycobacterium marinum, which can closely resemble sporotrichosis.

Cutaneous herpes simplex or zoster about the eye may look almost exactly as it did in this patient, as shown on the patient in Figure 9. There’s certainly enough similarity that most patients will be empirically treated for herpes until the diagnosis is clear.

Figure 9: Cutaneous herpes simplex or zoster.

Lastly, soft tissue S. aureus infections, including MRSA, can take different forms. A focal infection may look similar to the lesion shown in this patient, as shown in Figure 10 (the leg of a patient with an MRSA infection). However, it does not progress to a chronic ulcer and should have responded to the antimicrobial therapy given.

Figure 10: Soft tissue MRSA infections can take different forms, including a focal infection seen in this photo.

Columnist Comments

It’s always humbling to be wrong. I ought to know, being one of the most humbled people still practicing. With this patient, I was too slow to let go of the idea that this must be herpes. But, looking back on it, had I looked closer, I would have noticed that there never were any true vesicles, just these pseudovesicle-like papules. Also, if this were herpes, the appearance would imply an active infection and the PCR should have been positive if properly sampled. The first negative should have made me pay more attention to other possibilities, but when all the stains and cultures for bacteria, acid-fast and fungal organisms came back negative, I felt we were just not obtaining good enough samples. Fortunately, through the persistence of my partner and Head of our Pediatric Infectious Diseases Section, Dr. Manju Gaglani, a specimen finally grew the organism. She got the patient on proper treatment, and he continues to do well.

So, if something does not quite fit, back up, look again (closer) and don’t get stuck.

James H. Brien, DO, is Vice Chair for Education at The Children’s Hospital at Scott and White and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbrien@aol.com.

Disclosure: Dr. Brien reports no relevant financial disclosures.