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Question 22#

A 40-year-old woman cut her finger while cooking in her kitchen. Two days later she became rapidly ill with fever and shaking chills. Her hand became painful and mildly erythematous. Later that evening her condition deteriorated as the erythema progressed and the hand became a dusky red. Bullae and decreased sensation to touch developed over the involved hand. What is the most important next step in the management of this patient?

A) Surgical consultation and exploration of the wound
B) Treatment with clindamycin for mixed aerobic-anaerobic infection
C) Treatment with penicillin for clostridial infection
D) Vancomycin to cover community-acquired methicillin-resistant Staphylococcus
E) Evaluation for acute osteomyelitis

Correct Answer is A


The striking features of this infection are its rapid onset and progression to a cellulitis characterized by dusky dark red erythema, bullae formation, and anesthesia over the area. The patient is acutely ill with fever, tachycardia, and other evidence of SIRS (systemic inflammatory response syndrome). These are clues to necrotizing fasciitis, a rapidly spreading deep soft tissue infection. The organism, usually S pyogenes, reaches the deep fascia from the site of penetrating trauma. Prompt surgical exploration down to fascia or muscle may be lifesaving. Necrotic tissue is Gram stained and cultured—streptococci, staphylococci, mixed anaerobic infection, or clostridia are all possible pathogens. Antibiotics to cover these organisms are important but not as important as prompt surgical debridement. Acute osteomyelitis is considered when cellulitis does not respond to antibiotic therapy, but would not present with this rapidity.