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Localized swelling, erythema after puncture wound in 8-year-old male
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As we move into the summer months, it might be good to look at a common summertime problem, puncture wounds to the foot.
Figure 1. Stock tank where cattle drink.
Source: Brien JH
A previously healthy 8-year-old male was admitted to the pediatric ward for management of severe cellulitis of the left foot. Three days earlier, the patient was running barefoot in a wet, muddy area around a stock tank — a pond of water on a cattle ranch from which the cattle drink (Figure 1) — near his home. These small bodies of standing water may contain fish, frogs and other aquatic life, and routinely contain feces from the cattle as well as birds and other animals that may drink from this water source.
The patient apparently stepped on something at the water’s edge that punctured his left foot in the space between the fourth and fifth toes as it swung forward. It was unclear what that object may have been, as nothing was sticking out of the puncture site at that time. The next day, there was some localized swelling and erythema of the foot, and he was taken to an urgent care clinic where apparently some drainage was seen, and he was prescribed Keflex (oral cephalexin, Shionogi) capsules, without a culture being obtained. However, the patient did not take the cephalexin because he could not swallow the capsules.
Figure 2. Erythematous, swollen left foot.
Source:Goad RN
Figure 3. MRI shows cellulitis and pocket of fluid.
Source:Goad RN
The next day he was taken to his primary provider, where the doctor prescribed clindamycin suspension. However, the patient balked at the taste of the clindamycin, taking only one dose, and was admitted the next day with worsening cellulitis for IV antimicrobial therapy.
His past medical history is that of a healthy 8-year-old male with no significant medical or surgical problems. His immunizations are thought to be up-to-date, but documentation was not available. He will enter the third grade in the fall, and the school screening of immunizations has never been questioned.
On examination, his vital signs are normal, and he appears to be a healthy male with an erythematous, swollen left foot (Figure 2), with a bloody discharge from the space between the fourth and fifth toes (note that he coincidentally has a large wart on the dorsum of the foot).
Admitting lab tests included a normal CBC and erythrocyte sedimentation rate, with a C-reactive protein level of 16.6 (0-3); while the culture taken at the second visit is pending, the Gram stain revealed mixed gram-positive cocci and gram-negative rods. Plain radiographs were normal, and the MRI (Figure 3) reveals the cellulitis and a pocket of fluid. The patient is scheduled to go to the OR for debridement and drainage.
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Case Discussion
Empiric antimicrobial therapy is frequently debatable, with multiple acceptable choices. Of the choices from which to pick, board exam questions will usually give one “best answer” — that’s the case here. In my opinion, the best choice pending culture results would be (A) IV gentamicin plus clindamycin. One has to consider the circumstances of a puncture wound while running in an outdoor area where there is a high chance of contamination with cattle feces mixed with pond water as well as the foot itself, which can be colonized with a variety of Gram-negative and Gram-positive organisms, both aerobic and anaerobic.
Figure 4. Puncture wound between fourth and fifth toes.
Source: Goad RN
Figure 5. Remaining debris removed from the wound.
Source: Goad RN
In the operating room, the surgeon entered in the space between the fourth and fifth toes (Figure 4) and encountered more pus and debris, including some material that appeared to be a small wooden stick that was in four pieces (Figure 5). Also, the large wart was removed.
The culture taken in the OR grew both Klebsiella pneumoniae and Edwardsiella tarda. Edwardsiella, a Gram-negative facultative rod, was named as a pathogen at the Walter Reed Army Institute of Research, but had been recognized for years as a normal commensal in the intestines of various species, including cattle, and prefers a water environment when it is found outside these land-dwelling animals. Therefore, stock tanks, and the ground surrounding them, are commonly heavily contaminated with cattle feces, so it is no surprise that this organism is recovered in this type of infection.
Both organisms were sensitive to all the antimicrobials tested, including cephalexin, and after 4 days of IV therapy with gentamicin and ceftriaxone, the patient was discharged on oral cephalexin suspension, which actually is not bad-tasting, with good results (Figure 6). Also, cephalexin capsules are a bit too large for most 8-year-old children to swallow. However, in spite of both organisms being sensitive to the cephalexin, it would not have resolved the infection anyway without removing the foreign body. It turned out that cephalexin was an appropriate choice, but initially I probably would have empirically added something like clindamycin, for broader coverage of such an infection. I also would have cultured the exudate at the earliest opportunity, especially in a complicated foot infection.
Figure 6. Recuperation of puncture wound.
Source: Goad RN
With regard to the tetanus question, my advice would be to use both tetanus immune globulin and toxoid (B) due to the high risk of exposure and lack of immunization documentation. I can think of nothing more tetanus-prone than a puncture wound contaminated with cow feces. However, a call to the school nurse might resolve the question, but in the summertime, that may not be so easy, and time to make a decision is important. I discussed the tetanus question regarding prophylaxis in the February and May 2014 columns; please refer to those columns for more details.
Figure 7. Previous case of puncture wound in which an infection failed to improve or relapsed.
Source: Goad RN
Figure 8. Despite parental assurance of splinter removal, a piece was later found.
Source: Goad RN
Most of us will eventually encounter a child who impales a splinter into their foot. I have seen this on several occasions where parents were positive that the splinter was removed, only to find out when the infection fails to improve, or relapses, that a piece remained (Figures 7 and 8). Physicians should always be suspicious of a retained foreign body in this setting. An ultrasound will usually detect a piece of wood, which is most likely, where a plain radiograph will typically not see it. Lastly, advise your little patients to keep their shoes on when running around outdoors.
I want to thank Richard N. Goad, DPM, for his pictures and assistance with this case, as well as rancher (and brother-in-law) Allen Wiese of Calvert, Texas, for his help and allowing me to take the pictures of the stock tanks.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.