Photo Quiz: Subcutaneous Infection in an Immunocompetent Patient Handling a Wooden Wheelbarrow.

Abstract

A 44-year-old male presented to the emergency department with injury to his right hand. Five days prior, he had been lifting a wheelbarrow out of his truck and punctured his right hand. The patient reported removing several splinters from the palmar surface of his right thumb and right index finger. The following day, the area was swollen, and pus was expressed from the puncture wound. He denied fever, chills, and restricted range of movement. He had not traveled outside the United States and had no animal contact. In the emergency department, on examination, the hand was swollen and sore, and pus was expressed. His temperature was 36.4°C, his pulse was 68 beats per minute, his blood pressure was 144/96 mm Hg, and his respiratory rate and oxygen saturation were within normal limits. Radiographs were negative for a metallic foreign body or fracture. In the emergency department, a booster dose for Tdap was administered, and he was started on oral antibiotic cephalexin at 500 mg/day for 10 days. He was discharged home in stable condition. He returned 20 days after the initial presentation with a complaint of worsening pain, although the swelling and redness had improved. Grayscale and color Doppler ultrasonography demonstrated 2 linear echogenic foci, consistent with wooden splinters within the soft tissues of the right thumb. One of these foreign bodies measured 1.0 cm in length, and the other measured approximately 2.8 cm in length. There was edema surrounding these echogenic structures approximately 0.5 cm deep to the skin surface. Surgical intervention was performed, the wooden splinters were removed, and purulent material was obtained and sent to the microbiology department for aerobic, anaerobic, and fungal cultures. The patient was started on oral doxycycline at 100 mg/day for 10 days and cefazolin and amoxicillin-clavulanate at 875 to 125 mg/day for 7 days. He was instructed to soak the hand in warm water and keep it clean and dry. Our patient received no antifungal therapy during the hospital course and was lost to follow-up later. Gram staining from the wound showed rare Gram-positive bacilli. The anaerobic culture from the wound grew rare Clostridium bifermentans, and aerobic culture was finalized with no growth. Culture on Sabouraud dextrose agar grew a few colonies after 7 days of incubation at 30°C. A subculture of the original plate is shown in Fig. 1A and B. A lactophenol cotton blue stain of the colony is represented in Fig. 1C and D.