A 43 y.o. opiod user comes in with a painful heel after stepping on a nail on a railroad track.
What would you do?
the patient is incidentally COVID +
Our patient had a skin abscess caused by staph aureus with cellulitis extending to the knee. Bullous disease in staph is thought to be produced by an epidermolytic toxin produced by Staph aureus. Phage type 71. Other infections are known to cause blisters as well. Bullous impetigo is an infection caused by staph aureus although it has been reported with strep pyogenes . Viral infections causing blistering are herpes simplex, chicken pox and shingles: which are caused by varicella zoster virus . Cocksackie virus can also cause blistering.
cocksackie blisters on the palate
Later symptoms of necrotizing fasciitis can also cause blisters. In necrotizing fasciitis there is a rapidly progressive infection of the fascia that cause extensive necrosis of the subcutaneous tissue relatively sparing the muscle and skin. Since it affects deep fascia it can present as just redness . Pain out of proportion to the physical examine is often seen. As overlying skin is deprived of its blood supply skin necrosis ensues and hemorrhagic bullae form.
Our patient was taken to the OR and an 8cm abscess was drained. The overlying skin was necrotic and plans were made for a skin graft at a later date.
The pt left four days after I+D and had returned to the ED once for a dressing change.
Ho, K , Yap N, Lateef F. Necrotizing fasciitis: how reliable are the cutaneous signs? J Emerg Trauma Shock 2017 Oct –Dec 10(4):205-210.
Helsing P, Gaustad P. bullous impetigo cased by group A streptococci. A cas report. Acta Derm Venereol. 1992;72(1):50-1.
Lin J, Wu C,Hsia S, ChiuC. Bullous impetigo: arare presentation in fulminant streptococcal toxic shock syndrome. Pediatr Emerg Care. 2007 May :23(5):318-20.
after 4 days of clinda and debridement