“I think something bit me.”

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I think something bit I think something bit me.” me.” Gretchen Shaughnessy, MD Gretchen Shaughnessy, MD Clinical Fellow Clinical Fellow Dept of Infectious Diseases Dept of Infectious Diseases 4/16/08 4/16/08

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“I think something bit me.”. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases 4/16/08. CC: Arm pain. - PowerPoint PPT Presentation

Transcript of “I think something bit me.”

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““I think something bit I think something bit me.”me.”

Gretchen Shaughnessy, MDGretchen Shaughnessy, MDClinical FellowClinical FellowDept of Infectious DiseasesDept of Infectious Diseases4/16/084/16/08

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CC: Arm painCC: Arm pain

27 yo CM remote history of substance abuse 27 yo CM remote history of substance abuse presented to OSH with R arm swelling. 6 days presented to OSH with R arm swelling. 6 days PTA he had been helping his brother move a PTA he had been helping his brother move a woodpile. After he carried the logs from one woodpile. After he carried the logs from one side of the yard to the other he noticed a sore side of the yard to the other he noticed a sore spot on the inside of his right elbow.spot on the inside of his right elbow.

He had seen spiders on the logs and recently He had seen spiders on the logs and recently killed some brown spiders in his house, so killed some brown spiders in his house, so concluded he had been bit by a spider.concluded he had been bit by a spider.

The sore spot became more swollen and red The sore spot became more swollen and red over the next few days. The area became over the next few days. The area became more firm and tender then started to darken in more firm and tender then started to darken in color. color.

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HPI (cont)HPI (cont)

One day PTA the patient was seen at his One day PTA the patient was seen at his primary care physician’s office for severe pain primary care physician’s office for severe pain and swelling. He was prescribed levofloxacin and swelling. He was prescribed levofloxacin and instructed to go to the ED if his symptoms and instructed to go to the ED if his symptoms got worse.got worse.

The patient went home from the doctor’s The patient went home from the doctor’s office planning to refill the prescription in the office planning to refill the prescription in the morning. That night at midnight he presented morning. That night at midnight he presented to his local ED for severe pain and redness in to his local ED for severe pain and redness in his arm.his arm.

He states his arm was “so swollen it felt like it He states his arm was “so swollen it felt like it was gonna pop open.” It was “so dark it was gonna pop open.” It was “so dark it looked like a hunk of meat.” He said the looked like a hunk of meat.” He said the wound “smelled like rotting meat.”wound “smelled like rotting meat.”

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HPI (cont)HPI (cont)

The ER MD called a surgical consult to The ER MD called a surgical consult to assess for necrotizing fasciitis. The assess for necrotizing fasciitis. The surgeons Recommended transfer to surgeons Recommended transfer to UNC. Called the UNC ID fellow and UNC. Called the UNC ID fellow and requested a transfer. requested a transfer.

Per physician – redness was previously Per physician – redness was previously all below the elbow, since the patient all below the elbow, since the patient had been in the ED (3 hours) it had had been in the ED (3 hours) it had extended superiorly towards his bicep.extended superiorly towards his bicep.

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HPI (cont)HPI (cont)

The patient was started on The patient was started on imipenum, clindamycin, and imipenum, clindamycin, and vancomycin and transported to UNC.vancomycin and transported to UNC.

From departure of OSH to arrival at From departure of OSH to arrival at UNC ED the patient reports the UNC ED the patient reports the redness has decreased. Prior redness has decreased. Prior marker line approximately 2cm from marker line approximately 2cm from current errythematous bordercurrent errythematous border

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PMHPMH

Face and head trauma (2000) - Face and head trauma (2000) - the patient had been battered, the patient had been battered, experienced multiple facial experienced multiple facial lacerations but no LOC.lacerations but no LOC.

h/o Anxiety and depression - h/o Anxiety and depression - previously treated with lexapropreviously treated with lexapro

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MedicationsMedications

Prior to hospitalization - NonePrior to hospitalization - None Allergies - NKDAAllergies - NKDA

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History (cont)History (cont)

Social History: tob 2 pacs a day for 10 Social History: tob 2 pacs a day for 10 years years ETOH 2 drinks /week h/o cocaine, XTC, ETOH 2 drinks /week h/o cocaine, XTC, mj use in the distant past. The patient mj use in the distant past. The patient adamantly denies using any IV drugs adamantly denies using any IV drugs recently, denies any HIV risk factors. His recently, denies any HIV risk factors. His last HIV test was 2 years ago and was last HIV test was 2 years ago and was negative.negative.

No petsNo pets Lives near Fayetteville, NCLives near Fayetteville, NC Family History: DM - uncles. Family History: DM - uncles.

HTN - father HTN - father

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Physical ExamPhysical Exam

154/89 - 76 - 15 - 36.2154/89 - 76 - 15 - 36.2 INAD, resting comfortably. EOMI, PERRLA, nonictericINAD, resting comfortably. EOMI, PERRLA, nonicteric no e/e on OP. no JVDLymph Nodes no LAD appreciated no e/e on OP. no JVDLymph Nodes no LAD appreciated

in cervical, supraclavicular, or inguinal regionsin cervical, supraclavicular, or inguinal regions RRR no murmurs CTAB no rash or lesions other than RUERRR no murmurs CTAB no rash or lesions other than RUE a&ox3, pleasant and cooperativea&ox3, pleasant and cooperative soft NT nabs, no HSM LUE and BLE have no c/c/esoft NT nabs, no HSM LUE and BLE have no c/c/e RUE with approx 2cm area of dark discoloration, RUE with approx 2cm area of dark discoloration,

exquisite tenderness, and purulent drainage on the exquisite tenderness, and purulent drainage on the medial aspect of the R anticubital fossa. there is medial aspect of the R anticubital fossa. there is surrounding edema, minimal induration. The errythema surrounding edema, minimal induration. The errythema is approximately 5cm receeded from the marker line is approximately 5cm receeded from the marker line labelled 4/11/04 0445am.labelled 4/11/04 0445am.

Neurological no focal defecits, sensation intactNeurological no focal defecits, sensation intact

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RadiologyRadiology

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RadiologyRadiology

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CT with contrast

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CT with contrast

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CT with contrast

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CT with contrast

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CT with contrast

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CT with contrast

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CT with contrast

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CT with contrast

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CT without contrast

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CT without contrast

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CT without contrast

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CT without contrast

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CT without contrast

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CT without contrast

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CT without contrast

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Discussion

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Further Diagnostic Further Diagnostic TestsTests

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Operative ReportOperative Report

a small cavity in the subcutaneous a small cavity in the subcutaneous area of the antecubital fossa that area of the antecubital fossa that did involve the defect into the did involve the defect into the fascia, but there was no deep fascia, but there was no deep collection of pus, dead muscle or collection of pus, dead muscle or deeper involvement. There was a deeper involvement. There was a small amount of necrotic skin and small amount of necrotic skin and subcutaneous tissue, all of which subcutaneous tissue, all of which was debrided away. was debrided away.

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Hospital CourseHospital Course

Diagnosed with streptococcus Diagnosed with streptococcus anginosus cellulitis with fascial anginosus cellulitis with fascial defect s/p debriedmentdefect s/p debriedment

Did well clinically, no further Did well clinically, no further fevers, WBC remained normal. 4 fevers, WBC remained normal. 4 days of IV therapy then d/ced on days of IV therapy then d/ced on amoxicillin/clavulanate to follow amoxicillin/clavulanate to follow up with ortho and IDup with ortho and ID

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DDx of blackened DDx of blackened eschar lesioneschar lesion Cutaneous anthrax Cutaneous anthrax

lesionslesions Brown recluse spider Brown recluse spider

bite bite Rickettsial pox Rickettsial pox Cutaneous Cutaneous

leishmaniasis leishmaniasis Varicella zoster Varicella zoster Herpes simplex Herpes simplex Staphylococcal or Staphylococcal or

streptococcal cellulitis streptococcal cellulitis Ecthyma Ecthyma

gangrenosumgangrenosum

Ulceroglandular Ulceroglandular tularemia tularemia

Plague Plague Eczema Eczema Typhus Typhus Glanders Glanders Rat-bite fever Rat-bite fever Aspergillosis Aspergillosis Mucormycosis Mucormycosis Leprosy Leprosy Vaccinia Vaccinia

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Spider Bite?Spider Bite?

Brown Recluse is Brown Recluse is often blamed for often blamed for necrotic lesionsnecrotic lesions

In North Carolina this In North Carolina this is fairly unlikelyis fairly unlikely

Literature looking at Literature looking at the falsely high the falsely high incidence of “spider incidence of “spider bites”bites”

Brown Recluse photo: R. Bessin, University of Kentucky Entomology.

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Distribution map from R. Vetter, Univ. Calif. Riverside

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Spider SurveySpider Survey

Vetter et al. survey of Vetter et al. survey of a Kansas home using a Kansas home using glue boardsglue boards

Found 2055 confirmed Found 2055 confirmed Loxosceles reclusaLoxosceles reclusa from June-Nov 2001from June-Nov 2001

No bites to family of No bites to family of four living in the home four living in the home during that timeduring that time

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Brown Recluse Bite vs Brown Recluse Bite vs Bacterial InfectionBacterial Infection

Images from University of Kentucky Dept of Entomology.

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ReferencesReferences

Uptodate.com 4/15/08Uptodate.com 4/15/08 Mandell’s Principles and Practices of Infectious Disease, 5Mandell’s Principles and Practices of Infectious Disease, 5thth Ed. Ed. Majeski, J. Necrotizing fasciitis developing from a brown recluse spider Majeski, J. Necrotizing fasciitis developing from a brown recluse spider

bite. Am Surg 2001; 67:188. bite. Am Surg 2001; 67:188. Wright, SW, Wrenn, KD, Murray, L, et al. Clinical presentation and Wright, SW, Wrenn, KD, Murray, L, et al. Clinical presentation and

outcome of brown recluse spider bites. Ann Emerg Med 1997; 30:28.outcome of brown recluse spider bites. Ann Emerg Med 1997; 30:28. Anderson, PC. Spider bites in the United States. Dermatol Clin 1997; Anderson, PC. Spider bites in the United States. Dermatol Clin 1997;

15:307. 15:307. Williams, ST, Khare, VK, Johnson, GA, et al. Severe intravascular Williams, ST, Khare, VK, Johnson, GA, et al. Severe intravascular

hemolysis associated with brown recluse spider envenomation: A report hemolysis associated with brown recluse spider envenomation: A report of two cases and review of the literature. Am J Clin Pathol 1995; 104:463. of two cases and review of the literature. Am J Clin Pathol 1995; 104:463.

Vetter, R. Identifying and misidentifying the brown recluse spider. Vetter, R. Identifying and misidentifying the brown recluse spider. Dermatol Online J 1999; 5:7. Dermatol Online J 1999; 5:7.

Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in non-endemic areas. J Med Entomol implications for bite diagnoses in non-endemic areas. J Med Entomol 2002; 39:948-951.2002; 39:948-951.

Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown recluse spider bites (loxoscelism) greatly outnumber actual verifications recluse spider bites (loxoscelism) greatly outnumber actual verifications of the spider in four western American states. Toxicon 2003; 42:413-418.of the spider in four western American states. Toxicon 2003; 42:413-418.