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.

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FIGURE 1


FIGURE 1

Question

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.

Discussion

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 mschade@pennstatehealth.psu.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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.

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