Skin biopsy provided an elusive diagnosis and evidence that the patient had likely omitted important information during medical interviews. A 43-year-old man with a history of alcohol and opioid use was admitted to the inpatient ward from the infectious disease clinic. For 2 weeks, he had experienced recurrent, painful skin nodules that expressed bloody, purulent fluid. These were associated with fever and chills but no joint pain. He reported no allergies, recent travel, tick bites, or new medications.
Presentation
The patient was a groundskeeper at a golf course near the North Carolina coastline. He had intermittent episodes of similar skin eruptions over the previous several years. Multiple superficial wound cultures had been performed during this time, showing colonization with different microorganisms, including Candida albicans and coagulase-negative Staphylococcus species. Approximately 1 year earlier, a blood culture was positive for Pantoea species. When past skin biopsies revealed fungal yeast forms, he was treated with itraconazole without clinical improvement. Before admission, he had been on a 6-month course of alternating trimethoprim/sulfamethoxazole and doxycycline, taking each drug for 2 months at a time, with no clinical response. He denied recurrent childhood infections or chronic immunosuppressive therapy.
Twelve years before, the patient underwent spinal fusion for a golfing injury. A spinal abscess populated with methicillin-resistant Staphylococcus aureus complicated recovery. An extensive intravenous antibiotic course was administered in conjunction with negative pressure wound therapy and opioid analgesia. He developed a severe oral opioid dependence, progressing to a point that he spent much of his salary on illegally purchased opioids. His dependence led to the end of his marriage and his golfing career.
Five years before admission, the patient entered a drug rehabilitation program and began treatment with buprenorphine/naloxone. His therapy was subsequently transitioned to sublingual buprenorphine 8 mg 3 times daily. He denied using alcohol or illicit drugs, including intravenous substances, since that time.
Assessment
A physical examination, including a general musculoskeletal examination, showed a well-maintained man in no acute distress. His lungs were clear, and his heart sounds were normal. Multiple subcutaneous nodules were distributed on the bilateral upper and lower extremities, sparing the back, trunk, and feet (Figure 1). The nodules, pustular with an erythematous base, looked to be at different stages of healing. Lesions on the lower extremities were fluctuant.
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-Ankeet S. Bhatt, MD, Scott Perkins, BS, Elizabeth McKinnon, MD, John R. Perfect, MD
This article originally appeared in the January 2017 issue of The American Journal of Medicine.
