Ipoh, Malaysia
The patient is a 50-yr-old man with a history of swelling of
the right leg for 2 months. He noted that the right foot was swollen initially
and a few weeks later the swelling has progressed to the right leg. Over the past week the swelling has
progressed to the right thigh. The swelling was mildly painful but overall the
past week the swelling has progressed a lot.
The swelling was so severe that he was unable to wear his normal shoe.
He has a history of hypertension and a history of “stroke” where he lost his
consciousness and was told by his doctor he suffered from a minor stroke. He was treated as cellulitis by his doctor
with penicillin but did not improve. In
fact he had developed a generalised maculopapular eruptions over the
trunk a week after starting on IV penicillin.
O/E: Shows a severe unilateral swelling of the right leg
extending from the foot to the thigh.
There was superficial erythema, desquamation with small blisters. The affected
areas are well-demarcated especially on
right thigh. The leg swelling was indurated and
mildly pitting. The measured circumference of the right leg at mid-calf level was 51 cm compared with the corresponding left leg of 39 cm. His right inguinal nodes were markedly enlarged. Rest of
exam was unremarkable.
Images:
Differential Diagnosis
1. Erysipelas right leg
2. Filariasis
3. Deep vein thrombosis
Lab:
Hb 13.5 gm%, TWBC 17,900 (N87%, L10%, E0.1%, B1% M2%) ESR 79mm/hr Biochemistry unremarkable. Culture from the right leg grew Staphylococcal aureus. Doppler ultrasound right leg did not show any
evidence of deep vein thrombosis but enlarged right inguinal nodes.
He was advised to stop penicillin and started on IV moxifloxacin 400mg od, IV hydrocortisone 200mg qid, and wet compress. Blood was sent for microfilaria (x3) which was negative.
Follow-up Photo after 5 days of IV moxifloxacin and IV hydrocortisone.
0
Marked improvement after 5 days of IV moxifloxacin and IV hydrocortisone. There is a 5 cm reduction in the circumference of the right call. The patient would be scheduled for a MRI lower pelvis/right thigh soon, but he has refused since he is feeling so much better.
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Your thoughts will be appreciated.
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