Atypical Wounds Q&A
1. A patient has a diabetic wound that probes to the bone. ESR -103, CRP - 6. An X-ray suggests changes of periosteal elevation and sclerosis suggestive of osteomyelitis. Which of the following would you do next?
A. radionuclide bone scan
B. MRI of right foot
C. start six weeks of IV antibiotics
D. obtain a bone biopsy for culture prior to antibiotics
E. culture the drainage prior to antibiotics
2. A 32-year-old male who works as a field worker in the U.S. and resides in Mexico developed small sinus lesions on the left foot three years ago and now has developed multiple recurrent sinuses on that foot. The patient took multiple courses of antibiotics from Mexico. He presents to the wound clinic with a completely deformed left foot, swollen with multiple sinus lesions with purulent drainage as seen in the photo. Gram stain shows Gram positive nonspore-forming anaerobic bacilli with sulphur granules. What is the diagnosis?
B. skin abscess because of drug use
C. Charcot foot arthropathy
3. A 32-year-old woman is evaluated for a five-day history of nodules over her lower extremities, which happened after she visited a local spa that used whirlpool foot baths. She reports shaving her legs with a razor before her visit. Tissue culture grows a mycobacterial species within five days. Which of the following is the most likely cause of the infection?
A. Mycobacterium marinum
B. Mycobacterium ulcerans
C. Mycobacterium fortuitum
D. Mycobacterium avium complex
4. A 70-year-old female with a history of Type 2 DM, ESRD, on hemodialysis, presents with an extremely painful wound on her leg, which started as small darkened area that progressively increased in size with worsening pain. What is the diagnosis?
A. spider bite
B. pyoderma gangrenosum
D. calcinosis cutis
5. A 65-year-old HIV-positive patient with recurrent hidradenitis suppurativa lesions on both buttocks now presents with fungating growth as seen on the picture. What is the diagnosis?
A. basal cell cancer
B. squamous cell cancer
C. Kaposi sarcoma
D. fungal infection
- D — The patient with osteomyelitis should get a bone biopsy and culture before being subjected to six weeks of IV antibiotics. There was a huge discrepancy in the patient with open wounds with osteo between swab culture and bone culture.2 Also probe to bone sign is more specific for diagnosis of osteomyelitis than any other radiological study.1 In patients with clinical sign of probe to bone and X-ray positive for osteo, the next best test is to do a bone biopsy.
- A — This patient has actinomycosis. Actinomycosis israelii is Gram-positive, nonspore-forming anaerobic bacilli.3 The treatment is surgical excision and antibiotics for six months. Ampicillin is the drug of choice.
- C — Mycobacterium fortuitum furunculosis is a well- described skin infection in patients who obtain pedicures at nail salons that use contaminated whirlpool footbaths. M. fortuitum, M. chelonae or M. abscessus are rapid- growing mycobacteria, and culture grows in less than seven days. All other mycobacteria listed in question are slow-growing organisms.
- C — The patient with long-standing ESRD who is on hemodialysis develops dysfunctional calcium and phosphorus balance leading to calciphylaxis. A patient with calciphylaxis has a high risk of mortality, with 60 to 80 percent of patients dying within six months of diagnosis. The patient usually develops sudden superficial skin necrosis followed by painful, pruritic, violaceous skin discoloration in livedo reticularis pattern with black eschar. Biopsy shows metastatic calcification within the lumen of arterial vessels.5
- B— This patient with hidradenitis suppurativa now has fungating growth, patient’s ulcers has transformed into malignancy, and most common malignant transformation in chronic ulcer is squamous cell cancer.6
Meta-Analysis of DX tests for DM Osteo- (9 Studies: 1,054 patients). Infect Dis. 2008; 47:519-27.
Senneville E, Melliez H, Beltrand E, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis. 2006; 42:57-62.
Bettesworth J, Gill K, Shah J. Primary actinomycosis of the foot: A case report and literature review. JACCWS. 2009 July; 1(3):95-100.
Wentworth AB, et al, Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980–2009: A population–based study. Mayo Clin Proc. 2013 Jan; 88(1):38-45.
Rose EA. Evolution of treatment strategies for calciphylaxis. Am J Nephrol. 2011; 34(5):460-7.
Alam M, Ratner D. Cutaneous squamous cell carcinoma. NEJM. 2001 Mar 29; 344(13):975-83.