Thursday, November 17, 2011

A High School Wrestler with a Skin Infection


I walked into the urgent care exam room to find a 17 year old teen-ager sitting on the exam table.  He and his dad were there together.
I introduced myself and then asked how could I help.
“Something’s here on my leg I need  taken care of,” the adolescent replied.
“Hmm, okay, let me take a look.”
With that the tall strapping 165 pounder, muscular physique adolescent dressed in a muscle t-shirt and rather loose fitting but long nylon shorts, pulled up one of his legs to his shorts, to show me the skin on the lateral side of his right leg.  He had several abrasions surrounded by erythema (redness).  I felt his skin and it was warm to almost hot to my touch. 
“When did this happen?”
“Two day ago,” Doug replied.  “I had a match after school, I’m a wrestler you see, and it took a while for me to pin my opponent, but I did!  I didn’t notice anything until that night when I was home doing my homework and my leg started to itch right where this redness is.  That’s when I noticed I had probably gotten some, what do you call it, ‘mat burn’ I think on me?” 
“Okay, so what did you do?”
“Nothing, I had already taken my shower at school after my match, so I tried not to itch it, finished my homework and went to bed.”
“And what happened the next morning, which was yesterday?”
“I woke up and saw what I thought was ‘mat burn’ was worse, it still itched somewhat but the whole area was larger.  I washed it off with soap and cool water thinking that would help and went to school.  During school I noticed that it was beginning to bother me, it was tender to touch, so at wrestling practice last night I showed it to my coach.  He sent me home and told me to be seen by a doctor, he thought it was infected.”

This patient is showing typical signs of community acquired methicillin resistant staphylococcus aureus (CA-MRSA).  The skin typically harbors at least two bacteria, both of which are staphylococcus, one is called staphylococcus aureus and the other is called staphylococcus epidermis.  In the past several years the staphylococcus aureus strain has become more and more resistant to antibiotics. 

Due to this resistance, it is now harder to treat staphylococcus aureus infections with the run of the mill antibiotics.  Many of the staphylococcus aureus strains are showing they don’t respond to oxacillin (penicillins) and they are called MRSA.  MRSA infections are then split into two categories, based on whether the MRSA was acquired in the hospital or in the community, hence CA-MRSA or HA-MRSA. 

“Okay, so did you go in and get seen by a physician yesterday after school?”
“No, I waited until after dinner to show it to my dad here and he said,” changing his voice inflection to resonate with a bass tone closer to his father’s voice, ‘first thing in the morning you’re going into be seen, you understand me son?  That’s nothing to fool around with!”  Dropping the bass voice, and returning to his tenor voice, Doug then said, “so that’s why I’m here.”  After he said this, Doug turned his head to look at his dad with a smirk.  His father grinned back at him. 
“Okay, well Doug you have cellulitis of your right lateral thigh, which in English means you have a skin infection.  Seeing that you are a wrestler you most likely have what we call community acquired methicillin resistant staphylococcus aureus or MRSA.  It’s typically now found in locker rooms, athletic clubs, on wrestling mats, soccer players, etc.  Almost any place where there is a chance to acquire a breakage in your skin followed by introduction of skin bacteria.  And that’s what has happened to you.”
“So what do I do about it?”
“I’m going to have to put you on antibiotics, are you allergic to sulfa drugs?”
“What’s that?”
“Sulfa is a substance found in may drugs, such as sulfasalazine, Bactrim, some diurectic medications, etc.  Do you have any allergies to medications?”
Doug looked at his dad, who nodded no. 
“Okay well then seeing that you most likely have MRSA there is one drug that you can take orally which will take care of it and that is Bactrim.  You will have to take it twice a day for 10 days.  Before you leave here I’m going to mark the outside areas of your cellulitis, in other words where you redness stops.  I want you in 24 hours to look at the pen markings and make sure that the redness has not gone beyond them, instead the redness is smaller.  If the redness has gone beyond the pen markings then you have to come back in here and be seen again, we’ll have to switch you to a different antibiotic or a combination of antibiotics, understood?”
“Yeah, I guess so.”

Concerns over CA-MRSA:
There are many risk factors for CA-MRSA which include: 1) skin trauma, 2) crowding, 3) skin to skin contact, 4) sharing personal items such as razors, towels, etc, 5) frequent exposure to antimicrobial agents, 6) challenges in personal hygiene.

Nowadays, 61% of all skin and soft tissue infections are being caused by CA-MRSA.  So now in the out-patient clinics we are dealing with a resistant skin bacteria that if left untreated can continue to cause damage and eventually can invade the system. 

I went ahead and took his past medical history (seasonal allergies), family history (only positive for heart disease in his grandparents), medication history (zyrtec for his allergies).  After that I did his physical exam and besides a low grade fever, the only positive portion of it was the erythema on his right lateral thigh.  It measured about 8 inches in length by 3” in diameter.  The area was mildly swollen, tender to touch, and had increased warmth. 
“Okay, I’m going to mark your thigh here with my pen and remember what I said, if this isn’t better by tomorrow you come right back in, alright?”
With that his dad said emphatically, “I’ll see to it that he comes back in, if it’s worse.”
“Alright then, here’s your prescription for the Bactrim, take it twice a day, no fail.  If you have any nausea from it eat yogurt once a day.  Also make sure to keep this area nice and clean by taking a daily shower and using antibacterial soap.”
“What about my wrestling, I have a match next Thursday night?”
“Thanks for reminding me, that’s off, you’re not going to be able to play in that match.  If this clears up you can go back to playing after you finish your antibiotics, and your skin is back to its normal color.  And that’s another thing, let your coach know that you have this infection, tell him he needs to tell your team mates in case they come down with it from having contact with the wrestling mat.  Tell your coach that he is going to have to apply a bleach solution to the mat and let it dry before anyone else gets on it again.  Can you do that for your team mates?”
“Sure,” Doug replied rather flatly.  “But you don’t underestand,” he said emphatically, “I have to play in the match next Thursday, if I’m going to divisionals.”
Doug’s dad immediately interjected, “Doug, we’ll just have to talk to your coach, there has to be some other players who haven’t been able to play in every match up to divisionals.  I’ll go with you to talk to your coach on Monday, okay?”
“Alright, Dad,” Doug said, not really believing it would work.  Doug turned his attention back to me. 
“Okay, well then take your antibiotics, I wish you well and good luck with the rest of your wrestling season.”
 “Okay Doug, let’s go, we’ll stop by the pharmacy on the way home,” his dad said pleased that the problem wasn’t anything worse.
Doug didn’t appear the following day in clinic, so I assume that the Bactrim was working and he was getting better with each successive day.

 If a patient has methicillin sensitive staphylococcus aureus (MSSA) then they can be treated with penicillins, such as amoxil, augmentin, dicloxacillin, keflex, etc.  But if the patient has MRSA then our choices of antibiotics is smaller with our armormentarium being only Bactrim (a sulfa drug), clindamycin, tetracyclines or fluoroquinolones (Cipro, which we don’t use in a pediatric setting). 

Had Doug come back the following day, I would have added in clindamycin to the Bactrim.  If this had not worked then he probably would have to have been be switched over to an intravenous antibiotic.   I was glad that the Bactrim had worked for him. 


2 comments:

  1. so for MRSA you don't need to do any sort of strip test or culture to verify that it is actually the culprit?

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  2. thanks, Jeff for the question. To answer your question, clinicians assume based on patient's history, how they acquired the infection, the prevalence of community acquired MRSA (>60% of skin infections) that we are most likely dealing with CA-MRSA and treat the patient as such. Hence we don't do bacterial cultures on the patient. If they were to be hospitalized, cultures are indeed done.
    Thanks for reading and posting your comment. -sharon

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