Answer VizD 1.2

VizD Winners:

Brian Kern                Marjan Siadat         Dave Mishkin

Scott Ottolini            Rob Klever

Devon Moore            Hong Chong

Richard Gordon        Allison Loynd

Answer to Case 1:2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Answers:

1. Pyogenic Flexor Tenosynovitis – inflammation of the tendon and the surrounding synovial sheath, typically results from a puncture wound

2. Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis

  • finger held in slight flexion
  • symmetric swelling of the finger (sausage digit)
  • tenderness along the flexor tenon sheath
  • pain with passive extension of the finger

3. I.V. antibiotics, immoblization, elevation.  Hand surgeon consultation within 24-hours for incision and drainage

**if there is no history of trauma in a sexually active adult, consider disseminated GC and treat empirically with ceftriaxone until culture results are available**

_____________________________________________

“Morrison’s Pouch”

Please welcome our newest contributor to Receiving…Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center.  Dr. Morrison is going to be leading the Ultrasound Section of Receiving.

If Dr Morrison cared for the patient in the clinical scenario above, an ultrasound of the finger would have been obtained to confirm the diagnosis of flexor tenosynovitis.  Included in the differential diagnosis is cellulitis and abscess of the digit without tendon involvement. (click on images to enlarge)

Normal Tendon

Finger Abscess Without Involvement of Tendon

Flexor Tenosynovitis (Fluid around tendon sheath)

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

VizD Vol 1.2

Case 1.2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Answer VizD 1.1

VizD Winners:

Dave Pheysey          Jeff McMenomy

Keenan Bora           Rob Klever

Chris Guyer            Julie Nguyen

Richard Gordon      Allison Loynd

Answer to Case 1:1

A 32-year-old man presents to your ED complaining of intense pruritis to the plantar portion of his foot.  He states that he returned from Guyana just two days earlier where he spent a week providing medical care to an indigenous community.  His sleeping quarters was close to the beach where he went on daily jogs.   On exam, you note the lesion seen below.

Questions:

1. What is the diagnosis?

2. What is the most common treatment?

3. Is the prognosis favorable or unfavorable?

Answers:

1.  Dx: Cutaneous larva migrans (CLM)

A skin disease in humans, caused by the larvae of various nematode parasites, the most common of which is Ancylostoma braziliense

These parasites are found in dog and cat feces and although they are able to infect the deeper tissues of

Life Cycle of Cutaneous larva migrans

Life Cycle of Hookworm (not CLM variety)

these animals (through to the lungs and then the intestinal tract), in humans they are only able to penetrate the outer layers of the skin and thus create the typical wormlike burrows visible underneath the skin. The parasites apparently lack the collagenase enzymes required to penetrate through the basement membrane deeper into the skin.

2.  Treatment:

CLM can be treated in a number of different ways:

  • Systemic (oral) agents include albendazole (trade name Albenza) and ivermectin (trade name Stromectol).
  • Another agent which can be applied either topically or taken by mouth is thiabendazole (trade name Mintezol), an anti-helminthic.
  • Topical freezing agents, such as ethyl chloride or liquid nitrogen, applied locally can freeze and kill the larvae (but is often a hit-or-miss proposition).

3.  Prognosis: Good.  The condition is self-limited

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

VizD Vol 1.1

Case 1:1

A 32-year-old man presents to your ED complaining of intense pruritis to the plantar portion of his foot.  He states that he returned from Guyana just two days earlier where he spent a week providing medical care to an indigenous community.  His sleeping quarters was close to the beach where he went on daily jogs.   On exam, you note the lesion seen below.

Questions:

1. What is the diagnosis?

2. What is the most common treatment?

3. Is the prognosis favorable or unfavorable?

Please click on the “comments” link or post your answer in the “reply box”.  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

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