Photograph Quiz

Development of a Rash Later on Hot Tub Utilize

Am Fam Medico. 2015 Sep 1;92(five):387-388.

A man presented with a rash that appeared 1 to 2 days afterward he used a hot tub. He adult chills and a fever of 102°F (39°C) the 24-hour interval subsequently the rash appeared. The rash continued to spread and the fever persisted even though he had been taking oral trimethoprim/sulfamethoxazole for two days.

Physical test revealed four or five superficial, tender, isolated, painful, erythematous nodules in bilateral axilla that were fluctuant and 0.5 to 1 cm in size (Effigy 1). Incision and drainage produced a pocket-sized amount of thick, purulent exudate from each nodule. The erythematous nodules on his abdomen were i to 3 mm in size and were not fluctuant. At that place was a pustule with surrounding erythema on his right calf.

Effigy 1.

Question

Based on the patient'south history and physical examination findings, which one of the following infections is the most likely diagnosis?

A. Clostridium perfringens.

B. Pseudomonas aeruginosa.

C. Staphylococcus aureus.

D. Streptococcus pyogenes.

Discussion

The answer is B: P. aeruginosa. The contempo utilize of a hot tub preceding a painful superficial rash is the key feature suggesting P. aeruginosa infection. P. aeruginosa can live freely in the environment and is found in natural water sources, such as lakes and rivers. Information technology rarely affects drinking water but may colonize in plumbing fixtures on biofilms. P. aeruginosa is oft found in hot tubs, likely because of the college temperature and aeration of the water.1

Infection with P. aeruginosa, a gram-negative bacterium, is uncommon in immunocompetent patients. When infection does occur, the severity tin can vary. Minor peel infections include a maculopapular erythematous rash manifesting as cellulitis or cutaneous nodules. Severe infections tin can effect in tissue necrosis. In that location may exist a few to many lesions, usually located on the axilla, groin, or body.2

P. aeruginosa is periodically identified as the pathogen in otitis externa and dermatitis outbreaks that are associated with puddle or hot tub employ. Insufficient chlorine utilize and pH monitoring are usually the cause of these outbreaks.3

C. perfringens infection can cause myonecrosis, or gas gangrene. The infection is typically associated with skin trauma. The skin appears deep purplish-red and taut, and is very tender. Hemorrhagic bullae tin develop. Often, gas can be palpated in the skin as crepitus. Systemic signs of infection develop rapidly, often within 24 hours.2

S. aureus can crusade purulent material to collect in the deep dermis and subcutaneous tissue. A hair follicle is typically the entry point. When several areas of infection join, they course a carbuncle. These tracts of infection are palpable. This infection ofttimes leads to repeated development of abscesses. About xx% to 40% of the population is colonized with S. aureus, and information technology is unknown why only some of these individuals develop repeated infections.2

Due south. pyogenes typically forms a diffuse spreading superficial skin infection. It is ordinarily associated with mild trauma that is often unrecognized by the patient. The infection develops apace with spreading edema, erythema, and rut. When the infected skin is raised with a noted border of demarcation, it is known equally erysipelas. South. pyogenes infection is more mutual in older persons and children.two

Summary Table

Infection Characteristics

Clostridium perfringens

Enters at the site of skin trauma; deep purplish-cherry skin discoloration with possible bullae germination; crepitus if gas is present under the skin

Pseudomonas aeruginosa

Associated with recent hot tub or pool use; pare infection is usually superficial; located on the axilla, groin, or body

Staphylococcus aureus

Enters through a hair follicle; purulent material located in the deep dermis and subcutaneous tissue; carbuncles

Streptococcus pyogenes

Enters through minor skin trauma; more superficial infections that are raised, red, and warm to the bear upon

To see the full article, log in or buy access.

Address correspondence to Emily K. Snodgrass, Physician, at k8snodgrass@gmail.com. Reprints are non available from the author.

Writer disclosure: No relevant financial affiliations.

REFERENCES

i. Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009;201:71–115.

2. Stevens DL, Bisno AL, Chambers HF, et al.; Infectious Diseases Society of America. Practice guidelines for the diagnosis and treatment of peel and soft-tissue infections [published corrections announced in Clin Infect Dis. 2005;41(12):1830, and Clin Infect Dis. 2006;42(8):1219]. Clin Infect Dis. 2005;41(ten):1373–1406.

3. Centers for Disease Command and Prevention. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs—Colorado and Maine, 1999–2000. MMWR Morb Mortal Wkly Rep. 2000;49(48):1087–1091.

This series is coordinated past John E. Delzell, Jr., MD, MSPH, Assistant Medical Editor.

A drove of Photo Quiz published in AFP is available at https://world wide web.aafp.org/afp/photoquiz.

Previously published Photo Quizzes are now featured in a mobile app. Get more than information at https://www.aafp.org/afp/apps.

The editors of AFP welcome submissions for Photograph Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To exist considered for publication, submissions must encounter these guidelines. E-mail submissions to afpphoto@aafp.org.

Copyright © 2015 by the American Academy of Family unit Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may utilize that printout only for his or her personal, not-commercial reference. This material may not otherwise exist downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later on invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

MOST RECENT ISSUE

Feb 2022

Admission the latest event of American Family Dr.

Read the Issue


E-mail Alerts

Don't miss a single consequence. Sign upward for the free AFP e-mail tabular array of contents.

Sign Upwardly Now