Case 1

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Case 1

• 71 y.o. WF with diverticulosis admitted 2/12/01
  for L sided abdominal phlegmon (presented with
  colonic obstruction)
  
• 2/14 underwent sigmoid colectomy, small bowel
  resection anastomosis, ID of abscess, and
  colostomy
  
• stormy hospital course complicated by

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History

• 2/17 re-exploratory laparotomy
• respiratory failure prolonged intubation, s/p
  bronchoscopy, (-) cultures
  
• heart failure with EF 25 with pleural effusion
  ? thoracentesis ? pneumothorax (twice) ? chest
  tube placements

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History

• MSSA bacteremia with sepsis ARF, treated with
  vanc/imipenem ? was on CVVHD pressors,
  eventually resolved
  
• several episodes of bradyarrhythmias and
  asystolic episodes x 7 10 days pacer
  implanted 3/27/01
  
• ? UTI (foul-smelling urine) treated with
  fluconazole x 10 days

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History

• 4/4 developed fever
• lines changed over wire
• clinda/cipro started, cefepime next day
• catheter tip cultures 2/2 blood cultures grew
  Enterobacter aerogenes E. coli
  
• urine culture grew E. cloacae E. coli
• afebrile on 4/6, antibiotics d/ced

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History

• 4/10 patient hypotensive, started on pressors
• clinda/cipro restarted
• 2/2 cultures grew Enterobacter aerogenes
• catheter tip cultures pending
• ID consult called
• Where is the infection coming from?

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History

• Past Medical History
• Diverticulosis
• Asthma
• Engelmanns disease
• Hiatal hernia
• Family History
• Engelmanns disease
• () CA

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History

• Social History
• Lives in Eden
• No ETOH/tobacco use
• Medications
• Cipro/clinda
• Prevacid, pressors, etc.
• Allergies PCN sulfa

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PE

• Elderly WF, minimally responsive
• Tm 100.2 BP 120/60 HR 93
• pale conjunctivae, () tracheostomy, R IJ TLC, no
  conjunctival hemorrhage
  
• Lungs with bilateral rhonchi, L chest tube
• S1, S2 faint, () pacer L SC area
• Abdominal incision well-healed, () colostomy

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PE

• cool extremities, 2 edema
• () erythematous macular rash over volar/medial
  surface L arm, warm to touch, () blisters over
  distal medial forearm
  
• R great toe L 5th toe necrotic
• L knee with effusion

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Labs

• WBC 23.5
• HgB 7.1
• Plt 57
• BUN/Creatinine 68/1.1
• 4/10 tracheal aspirate culture S. aureus
• 4/10 2/2 BCs with E. aerogenes GPC
• 4/12 catheter tip culture pending

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Labs

• Head CT () CVA

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• ID recommendations
• stop clindamycin, continue ciprofloxacin
• add vancomycin imipenem
• ? TEE, rule out endocarditis/pacer infection
• vesicle unroofed, fluid sent for viral culture
• IV acyclovir started for shingles
• GPC identified as coag-negative staph

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Case 2

• 45 y.o. WM readmitted 4/12/01 for pain and
  lesions over distal L thumb
  
• initially admitted 3/1/01 3/7/01 for severe
  ascending lymphangitis and cellulitis over L
  thumb
  
• working with a metal pipe late Feb. 2001 when he
  noted a metal sliver embedded in L thumb, removed
  with pocketknife

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History

• thereafter noticed progressive ascending redness
  and pain over L thumb, wrist, and forearm,
  accompanied by fever and chills, worsening pain
  and swelling that same evening
• went to OSH, transferred to WFUBMC and had I D
  done x 2, all cultures (-)
  
• treated with clindamycin/gatifloxacin

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History

• finished 3 week course of IV Clindamycin po
  gatifloxacin, got better
  
• started feeling worse few days off abx more
  redness over thumb, and noted some blisters
  over incision site and area proximal to nailbed

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History

• local MD restarted clinda/gati, without relief
• c/o worsening pain/discomfort and swelling
• bone scan done at OSH, ? bone involvement
• admitted by Ortho 4/12/01

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History

• Past Medical History
• Osteoarthritis
• GERD
• () PPD, completed treatment for latent TB
  infection
  
• Family History
• HTN

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History

• Social History
• married, lives with wife
• works in correctional facility as foreman in auto
  shop, teaching skills to inmates
  
• (-) ETOH, tobacco
• Medications
• Vioxx, Prevacid, clindamycin IV, etc.
• Allergies ? rash to Unasyn

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PE

• Middle aged, overweight WM, NAD
• T 97.5 BP - 151/84 HR 59
• non-toxic appearing
• Lungs clear, S1, S2
• exam pertinent for L thumb, purplish distal
  phalanx, with swelling, tender

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Labs

• ASO from previous hospitalization normal
• all cultures last admission (-)
• WBC 5.6
• 59 segs, 31 lymphocytes, 9 monocytes
• HgB 15.0
• Plt 147

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What to do next?

• MRI (-) abscess/osteomyelitis
• started on Valtrex empirically, 1 gm TID
• streptozyme level sent
• HSV I II serology sent

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Viral Infections of the Hand

• Agents
• Herpes simplex virus I (HSV-I)
• Herpes simplex virus II (HSV-II)
• Varicella-Zoster virus (VZV)
• Poxviruses
• Coxsackieviruses
• Human Papillomavirus (HPV)

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Herpetic Whitlow

• first large series of cases by Stern in 1959
• 54 cases in Septic Hand clinic at St. Georges
  Hospital in London
  
• majority of cases were nurses working on the
  neurosurgical unit
  
• acquired infection from contaminated tracheal
  secretions from patients not known to herpetic
  infections
  
• herpetic whitlow used to describe the entity

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Herpetic Whitlow

• may be due to HSV-I or HSV-II
• among medical, paramedical or dental personnel,
  usually due to HSV-I
  
• in general population, usually due to HSV-II
• occupation hazard in medical, dental, and dental
  personnel who handle oral-tracheal secretions ?
  wear gloves!

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Herpetic Whitlow

• Gill et al, 1988 79 cases herpetic whitlow
• 69 of cases occurred on the fingers
• 21 of cases occurred on the thumb
• other areas (palm, wrist, and dorsum) can be
  affected as well
  
• at risk 2o to autoinoculation
• adults with genital herpes
• adults/children with herpetic gingivostomatitis

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Herpetic Whitlow

• usually involves only 1 digit
• intensely pruritic or painful (throbbing)
• followed by one or many deep vesicles that may
  coalesce ? clear fluid in vesicles ? may appear
  turbid or purulent later on
  
• neuralgia axillary adenopathy may occur
• left unincised, healing takes 2 3 weeks
• incision may lead to 2o infection delay healing

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Herpetic Whitlow

• incubation period after exposure to virus ranges
  between 2 14 days
  
• history of prior lesions very helpful
• pain associated with lesions usually out of
  proportion to clinical signs seen early in the
  process
  
• usually begins as tingling pulp space remains
  soft and not tense

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Herpetic Whitlow

• 30 50 of individuals with primary herpetic
  infections will develop recurrent or later
  infections recurrence with hand infections are
  less common
• patient remains infective until epidermal lesions
  are healed

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Herpetic Whitlow

• Who are at risk for recurrent infections?
• immunocompromised patients
• malnourished patients
• those with disorders causing a break in skin
  (burns, eczema, diabetics who monitor blood
  glucose)

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Herpetic Whitlow

• Treatment
• NO SURGERY!
• oral Acyclovir/Valacyclovir/Famciclovir
• when taken during prodrome, therapy can abort an
  attack
  
• topical preparations have limited clinical benefit

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Varicella-Zoster Virus

• dermatomal distribution is key to making
  diagnosis
  
• lesions can look exactly like herpes simplex
• postherpetic neuralgia pain often develops, much
  harder to treat
  
• therapy same as for HSV, except that medications
  given in higher doses

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Poxviruses

• 6 genera, 2 of which are associated with
  infections of the hand
  
• Orthopoxvirus (cowpox)
• Parapoxvirus (pseudocowpox) ORF

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Cowpox

• transmitted from infected cattle to humans
• generally limited to the hands, but may be
  transferred to the face
  
• clinically resemble small pox vaccinations but
  less erythema hemorrhage
  
• usually () lymphadenitis fever
• more severe constitutional symptoms in children

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Cowpox

• no longer present in US, ? in Britain Europe
• infection can occur humans, cattle, and domestic
  cats
  
• usually self limiting, more severe cases respond
  to treatment with anti-vaccinia Ig
  
• used to provide immunity to small pox

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Parapoxviruses

• cause pseudocowpox or milkers nodule
• cause orf
• primary a disease of sheep and goats
• first human case of transmission reported 1938
• lesions start out as erythematous papule and
  progress through a series of stages
  maculopapular ? target ? regenerative ?
  papillomatous ? regressive stage

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Parapoxviruses

• healing time ranges from 25 days 8 weeks
• can be painful or pruritic some patients develop
  lymphangitis lymphadenitis with occasional
  low-grade fever
  
• can be complicated by superficial bacterial
  infection, particularly if I Ded
  
• incidence rate as high as 4 among workers in
  meat industry in New Zealand

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Coxsackieviruses

• cause Hand, foot, mouth disease first
  epidemic described in 1958
  
• no relationship to the animal foot mouth
  disease
  
• majority seen in children under 10 years old, but
  can be seen in adults as well
  
• classically due to Coxsackie A-16 virus

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Coxsackieviruses

• early stages may have only palmar or plantar
  lesions, usually vesicular, may resemble
  herpetic infection
  
• distribution usually involves hands, palms,
  mouth, and occasionally the buttocks
  
• self-limited
• syndrome may be incomplete
• hands and feet only (11)
• mouth only (21)

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Human Papillomavirus

• causes cutaneous warts
• observed to be more common in meat and poultry
  handlers (23.1 of the time) vs nonmeat handlers
  (9.9)
  
• numerous treatment alternatives
• podophyllin solution
• cryotherapy (liquid nitrogen/dry ice/CO2)
• electrodiathermy and curettage
• laser evaporation
• acid (salicylic/urea acid) under tape occlusion