Hand rash after a minor cut at work
A 58-year-old woman comes to the clinic for a painful rash on her right hand that has been slowly worsening over the past week. She works part-time at a supermarket deli counter and recalls a minor cut on her index finger from the meat slicer about 10 days ago. The rash began around the cut and has slowly expanded. She has tried applying triple antibiotic ointment without improvement. Her medical history includes hypertension and GERD. On examination, there is a 4-cm, violaceous, slightly edematous plaque on the dorsum of her right hand and index finger. The lesion has a sharply demarcated, raised border. It is tender to palpation, and the patient reports a burning sensation. There is no fluctuance, drainage, or lymphangitis. Temperature is 37.1°C (98.8°F), blood pressure is 134/82 mmHg, pulse is 76/min, and respirations are 14/min. Laboratory studies show a white blood cell count of 8,200/mm³. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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A
Explanation
Clinical Pearl:
Erysipeloid is an occupational skin infection caused by Erysipelothrix rhusiopathiae, typically seen in individuals handling meat or fish. It presents as a characteristic violaceous plaque with a sharply raised border, and penicillin or amoxicillin is the treatment of choice.
Explanation:
This patient's presentation, including the violaceous skin plaque with a sharply demarcated border on her hand following a minor cut while handling deli meat, is characteristic of erysipeloid. Erysipeloid is caused by Erysipelothrix rhusiopathiae, an organism for which oral amoxicillin or penicillin is the treatment of choice according to infectious disease society guidance. Oral trimethoprim-sulfamethoxazole is used for suspected community-acquired MRSA, but the indolent course, lack of purulence, and specific occupational exposure make erysipeloid more likely; E. rhusiopathiae is also intrinsically resistant to sulfonamides. Oral doxycycline would be appropriate for infections related to saltwater exposure, such as from Vibrio species, which is not suggested by the patient's history. Wound cultures are low yield for erysipeloid as the organism is difficult to isolate from the skin surface, and treatment should not be delayed pending results. Hospital admission and intravenous vancomycin are unnecessary as the patient is afebrile, hemodynamically stable, and has a localized infection.
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