An ‘old-fashioned’ clinical sign

Abstract

Case presentation A 69-year-old man presented to the emergency department in February 2009 with a 2-day history of fevers and a swelling on his anterior chest wall at the site of a previously removed, infected, aorto-bifemoral Dacron graft. Examination revealed the mass to be fluctuant, erythematous and tender associated with a temperature of 38 C. Physical examination was otherwise unremarkable. The patient had a history of severe peripheral vascular disease, with an axillo-bifemoral graft constructed in September 2008. This failed to provide adequate perfusion with resultant pain and gangrene leading to a left above-knee amputation. He was readmitted in December 2008 with a discharging abscess from the axillary end of the graft. Cultures yielded MRSA. Despite teicoplanin and doxycycline, as per microbiological sensitivities, his clinical condition and his inflammatory markers failed to respond. MRI of the chest showed pus tracking along the failed graft, which was subsequently removed. Following this procedure, he recovered well and was discharged before Christmas of the same year. At outpatient review he was well with no fevers and an apparently unrelated complaint of back pain. Shortly after his second admission the patient described increasing severe back pain, since that Christmas, which he had been treating with simple analgesics and a hot-water bottle, consistent with the observation of erythema ab igne seen over the lumbar area. Neurological examination was normal.