Photo Quiz

Painful Vesicular Eruption on the Index Finger of a Butcher


Am Fam Physician. 2019 Jun 15;99(12):773-774.

A 55-year-old man presented with an erythematous, swollen, painful lesion on his finger that had developed several weeks earlier. He otherwise felt well and had not been ill. His medical history was notable for treated hepatitis C with compensated cirrhosis. He wore gloves while working as a butcher and had no recent trauma to the hand.

Physical examination revealed swelling and erythema of the right index finger, with a central cluster of ulcerated lesions (Figure 1). Plain radiography showed soft tissue swelling of the finger with no bony abnormalities. The lesion did not resolve with seven days of trimethoprim/sulfamethoxazole followed by seven days of doxycycline.

 Enlarge     Print




Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis?

A. Erysipelas.

B. Erysipeloid.

C. Herpetic whitlow.

D. Impetigo.

E. Shingles.


The answer is B: erysipeloid. This skin lesion is the most common manifestation of infection with Erysipelothrix rhusiopathiae, a gram-positive bacterium found in a wide variety of domestic and wild animals. Humans are typically exposed to the organism through their occupation, with butchers at particular risk. Infection has also been reported with activities such as fishing and crabbing and following incidental contact with animals or animal products.1,2 The organism enters the skin via abrasions, scratches, or puncture wounds, commonly on the hands.

E. rhusiopathiae causes three forms of illness: localized cellulitis (most common); advancing skin infection; and systemic infection with bacteremia, which may be complicated by endocarditis.2 This patient had a focal cellulitis.

A painful, erythematous patch develops two to seven days after infection with E. rhusiopathiae. The pain is described

Address correspondence to Meredith Schade, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Dunbar SA, Clarridge JE III. Potential errors in recognition of Erysipelothrix rhusiopathiae. J Clin Microbiol. 2000;38(3):1302–1304....

2. Reboli AC, Farrar WE. Erysipelothrix rhusiopathiae: an occupational pathogen. Clin Microbiol Rev. 1989;2(4):354–359.

3. Bystritsky R, Chambers H. Cellulitis and soft tissue infections. Ann Intern Med. 2018;168(3):ITC17–ITC32.

4. Chayavichitsilp P, Buckwalter JV, Krakowski AC, Friedlander SF. Herpes simplex. Pediatr Rev. 2009;30(4):119–129.

5. Sladden MJ, Johnston GA. Common skin infections in children. BMJ. 2004;329(7457):95–99.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of Photo Quiz published in AFP is available at

Previously published Photo Quizzes are now featured in a mobile app. Get more information at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Dec 1, 2019

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article