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3-year-old female presents with lesion that doubles in size
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A previously healthy 3-year-old female presented with a sore on her right proximal posterior thigh that began about 6 days earlier. Her mother noted that it began as a smaller abrasion, which was thought to be a result of an abrasion injury that may have happened while riding a lawn mower a few days earlier. She reported no fever, and the child was otherwise well. The lesion was seen the next day in a local ER, diagnosed as impetigo, and treated with “triple-antibiotic” cream. Within a couple of days, the lesion appeared to essentially double in size, measuring 6 cm by 2 to 3 cm, with an overlying flaccid blister (Figure 1). At this point, she was taken back to the ER, where a brown recluse spider bite was diagnosed and treated with topical mupirocin. She was seen again the next day by her primary, at which time a swab of the moist, raw lesion was sent for culture and Gram stain, revealing Gram-positive cocci. Treatment was started with trimethoprim-sulfamethoxazole (TMP/SMX). The culture grew methicillin-sensitive Staphylococcus aureus (MSSA), and it was also sensitive to TMP/SMX.
At the time of her visit today (day #6), the lesion is found to be dry and roughly the same dimensions as noted above (Figure 2).
What’s your diagnosis?
A. Abrasion injury with secondary bullous cellulitis
B. Burn injury
C. Resistant bacterial cellulitis
D. Varicella-zoster (shingles)
Sometimes, cases are not very straightforward, as in this case. However, of the choices listed, this case is most consistent with A — an injury, followed by secondary cellulitis due to MSSA that happened to be an epidermolytic toxin-producing strain, essentially resulting in a giant bullous impetigo-like lesion with cellulitis.
A preceding injury was observed, followed by a progressive increase in lesion size consistent with spreading infection, and flaccid, overlying blister skin that resolved on appropriate antimicrobial therapy (topical and systemic).
A brown recluse spider bite is relatively uncommon and often unrecognized when it occurs. If the spider is seen, one might notice the violin-shape marking on the posterior thorax (Figure 3, courtesy of Jill Murphy). The bite may sting or may not be felt at all. Following the bite, a slowly developing blistering/ulcerative lesion is noted with necrosis. These lesions can be relatively small or fairly large. There is no known effective therapy except to follow for the possibility of secondary bacterial infection. Numerous pictures can be found on the internet.
Burn injuries are obviously painful and usually do not occur without knowing it. They usually do not appear as an abrasion, but perhaps the initial appearance was misrepresented by the historian. Usually, a blister follows fairly soon after the initial thermal injury. Otherwise, it could be difficult to tell the difference.
Varicella-zoster, or shingles, is a rash caused by reactivated varicella-zoster virus (chickenpox virus). The rash usually follows a characteristic dermatomal pattern and appears in most cases as mixed papulovesicular lesions on erythematous bases, but there can be areas where there is such confluence that large areas of crusting can be seen. Occasionally, dark, necrotic-appearing areas, especially in immunocompromised patients, may also be seen (Figure 4).
- 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.
Columnist comment: I would like to thank Dr. Goddy T. Corpuz for contributing to this interesting case. My term for the diagnosis was “Giant bullous impetigo with cellulitis.” Since I have never seen anything quite like this before, I just made up that term. Perhaps we can call it “GBIC syndrome,” or better yet, use the eponym, “Brien syndrome.” Speaking of making up disease names, I counted approximately 560 medical eponyms. A medical eponym is a person, place or thing after whom (or which) the condition is named, and if named after a person, it is generally considered a great honor. However, some of those 560-ish eponyms were promoted by those eponymizing (another made-up term) themselves. However, self-eponymizing is widely considered in bad taste. We could perhaps use Dr. Corpuz’s name (Corpuz syndrome), since he took the pictures and referred the patient. But perhaps GBIC syndrome would look better for coding purposes, and we would not have to remember Dr. Corpuz’s name. Then, in case we ever see something like this again, we will know GBIC is the code to use because, after all, that is what’s important. Otherwise, if you cannot code it, you cannot get proper RVU credit, which seems to be the most important thing in our little pus-filled world these days.
That being said, I plan to retire from practice at the end of July this year. However, I will plan to continue writing this column for the foreseeable future. I may run out of clinical material in a few years, so I will continue to need more reader-contributions, such as this case, to keep it going longer.
Enjoy the spring weather, and get ready for snake bites, sunburns, accidents, enteroviruses and mosquitoes.