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16-year-old male athlete presents with skin sores on lower extremities
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A previously healthy 16-year-old male presented with a 2-month history of some skin sores on the lower aspects of both lower extremities. These lesions were accompanied by mild discomfort but no fever or other medical complaints. There had been numerous visits to providers, and several courses of oral antimicrobials were given, as well as topical mupirocin; all without benefit. No other medications had been used.
The patient participates in various school-sponsored athletic events, and he noted that these lesions had begun around the time of starting athletic training for football. There had been no travel, animal contact or significant insect exposure. He adamantly denies any trauma to either leg, including shaving of the ankles (a practice many athletes use before taping ankles for support). These lesions went through cycles that began with the development of nodular lesions and progressed to pustules with some drainage of material, followed by scabbing. During this 2-month course, his evaluations included multiple stains and cultures, including common bacterial, fungal and acid-fast bacilli, none of which were positive.
Ultimately, the patient was admitted to the hospital for IV antibiotics with clindamycin plus Zosyn (piperacillin-tazobactam, Pfizer) and further evaluation. His vital signs were normal, and his exam revealed a big, athletic-appearing 16-year-old male, with the chief complaint being the only abnormal finding. Both lower extremities were involved with these lesions, from about the mid-calf to the ankle (Figures 1 to 3). Purulent material could be easily expressed with gentle pressure (Figure 4). Stains and cultures as noted above were repeated in the hospital, and again with negative results. Screening blood tests and plain radiographs, as well as MRI imaging of both legs, were all normal. Dermatology performed a biopsy, which is pending.
What’s your diagnosis?
A. Recurrent folliculitis
B. Sporotrichosis
C. Resistant bacterial cellulitis
D. Panniculitis
The biopsy results revealed granulomatous inflammatory changes and abscesses, most consistent with the nodular-type of panniculitis, erythema induratum (choice D). This is an uncommon condition that most frequently involves the calves of afflicted patients. It is characterized by inflammation of the subcutaneous fat with several subtypes. A form of panniculitis, lipodermatosclerosis, is occasionally seen as a complication of morbid obesity (Figure 5) and is associated with venous insufficiency. In addition to obesity, panniculitis has occasionally been associated with various systemic diseases, such as tuberculosis, HIV infection and other infections. The patient who presented was not obese, although he was somewhat large, and he had no associated underlying disease or infection. Trauma can also be the cause, and even though he denied trauma to either leg, sometimes trauma can be sustained on the football field that may go unnoticed.
This case highlights the importance of early biopsy of mysterious problems that seem to be eluding diagnosis. Sometimes, we get stuck in a narrow-minded diagnostic rut, and before we know it, a great deal of time has gone by, waiting for things to get better. A condition may have an “infectious appearance” and it would just seem intuitive that if common stains and cultures are negative and an appropriate antimicrobial agent does not help, then maybe it is not an infection. Not all suppurative-looking lesions are infectious. However, for those that are infectious with purulent drainage, recovery of the causative agent is usually not difficult.
Recurrent folliculitis would be expected to be much less severe and easily managed. This is usually due to Staphylococcus aureus and aggravated by microtrauma of the follicles by shaving or other repetitive activities, such as chronic rubbing caused by wearing tight pants. Simply discontinuing the damage-causing activity will usually resolve the problem.
Sporotrichosis is a fungal infection that typically involves the skin, resulting in a chronic ulcer at the inoculation site that could possibly spread to one of the regional lymph nodes (lymphocutaneous sporotrichosis). Purulent material may or may not be present. There may or may not be a history of working in a rose garden, as the books imply. A fungal culture or biopsy of the lesion itself or possibly the involved lymph node will usually provide the answer. It would not likely involve such a large area, on both legs.
Resistant bacterial cellulitis would be one of the early thoughts of a lesion with purulent drainage that is not responsive to the usual antimicrobial agents. However, when stains and cultures are negative and there is no response to empiric antimicrobial agents over a reasonable period, this diagnosis should be abandoned and biopsy pursued; 2 months is a bit long.
Disclosure: Brien reports no relevant financial disclosures.