Soft Tissue & Bone Infections

Case 1:

A 38 year old man (?) named Chewbacca presents to your office. You note that he is extremely hairy, with what appears to be fur covering his entire body; he also speaks in a language you cannot find on your translator iPad. His vital signs and CBC are within normal limits. He gestures to an area of his body that he recently shaved on his right arm, and you note ~4 small boils (about 0.5 cm in size) scattered within a mildly erythematous region of skin. What is your next step?

a.       Obtain an XR of the right arm.

b.       Prescribe doxycycline to cover community-acquired MRSA.

c.       I&D the boils and recommend keeping the area clean and dry.

d.       Prescribe cephalexin and doxycycline for both streptococcal and MRSA coverage.

Explanation:

Chewbacca has unfortunately developed purulent cellulitis and he should be treated empirically for CA-MRSA. Although combination therapy (option D) is often given, this is of unclear benefit; just break it down into two categories: purulent and nonpurulent cellulitis. For purulent cellulitis, empirically cover for MRSA alone and for nonpurulent cellulitis, cover Strep spp. alone!

In this case, Chewbacca likely has furuncles, which are infections of the hair follicle that extend into the dermis and subcutaneous tissues. Furuncles are often a common presentation of community-acquired MRSA (especially given the history that he recently shaved). I&D alone, without antibiotic therapy, would suffice if he only had a few abscesses <2 cm in size. Imaging for cellulitis is generally only used if the diagnosis is unclear, or if there is concern for a foreign body or deep tissue involvement.