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Summertime sighting: Painful swelling, erythema around the ankle
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A previously healthy 13-year-old male experienced sudden-onset of some painful swelling with erythema about the left ankle. He denied any trauma, or stings, but has had common summertime insect bites with some scratching.
By the next day, the problem had worsened, and when his lower leg continued to swell with some streaking up his leg, the patient was taken to the local ED where he received some intramuscular Rocephin (ceftriaxone, Hoffmann-La Roche) and referred for admission.
His past medical history is unremarkable, and his immunizations are up-to-date. He denies any injury and has had no sick contacts.
Figure 1. Diffuse erythema and swelling about the ankle.
Source: Brien JH
Figure 2. Irregular erythematous marks on the medial aspect of the leg.
Source: Brien JH
On examination, the patient had fever and some diffuse erythema and swelling about the ankle with some irregular erythematous marks up the medial aspect of the leg (Figures 1-2). There were a couple of small fluid-filled lesions on his ankle that were unroofed and sent for culture; empiric treatment was started with Rocephin and clindamycin.
Case Discussion
This is a fairly typical example of group A streptococcus (S. pyogenes) cellulitis with lymphangitis (D). Just about any organism can cause this, but group A streptococcus (GAS) is the most common, and it frequently finds its way onto the boards. Even though I have no data to support it, I feel like we have been seeing more of this condition in the last 10 to 15 years than in years past — or at least I have.
Figure 3.
Source: Brien JH
Figure 4.
Source: Brien JH
I featured a similar case in the September 2013 column (Figures 3-4), and among the more than 300 columns written since 1987, that is the only other time this condition has been featured. As shown in these cases, a common finding with GAS cellulitis is blistering (Figure 5). S. aureus is a common cause of injury-related foot or leg infections, but the infection tends to remain localized around the site of injury (Figure 6). One also can see blistering with S. aureus infections, but they are usually superficial, like bullous impetigo. S. aureus infections are also a bit slower developing — usually greater than 48 hours to come to attention — whereas group A strep infections develop rapidly, often within 24 hours. Therefore, empiric treatment should cover for GAS as well as S. aureus, and some experts would recommend using something for gram-negative organisms pending culture and sensitivities, especially if the infection originates from the foot.
Figure 5. Blistering.
Source: Brien JH
Figure 6. Injury-related foot infection.
Source: Brien JH
Puncture wound cellulitis of the foot is frequently caused by P. aeruginosa, classically associated with puncturing through sneakers (Figure 7), which was featured in the April 2004 column. It would be very unusual for this infection to result in rapidly progressive lymphangitis up the leg. The same can be said of E. coli. Again, if the history included a puncture wound of the foot, perhaps an empiric anti-Pseudomonas antimicrobial agent used should be used, such as gentamicin.
Figure 7. Puncture wound.
Source: Brien JH
Figure 8. Rapidly progressive lymphangitis.
Source: Brien JH
Lastly, as noted, GAS infections can result in rapidly progressive lymphangitis (Figures 8-10) within 36 hours after a minor injury to the finger. However, in the summertime, a little-recognized entity is superficial lymphangitis from an arthropod sting (Figure 11, from Michael W. Cater, MD).
Figure 9. Rapidly progressive lymphangitis.
Source: Brien JH
Figure 10. Rapidly progressive lymphangitis.
Source: Brien JH
The patient did well on Rocephin plus clindamycin and when the culture revealed the GAS, treatment was changed to penicillin G to finish a 4-day hospital course, then discharged on oral penicillin VK for another week, and did well.
Figure 11. Superfi cial lymphangitis from an arthropod sting.
Source: Cater MW
- Reference for Figure 11:
- Marque M, et al. Dermatology. 2008;doi:10.1159/000149822.
- 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.