Skin Lesions, Weight Loss, and Facial Swelling After a Hand Injury (2024)

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Yuriko f*ckuta

Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine

Houston, Texas

USA

Correspondence: Y. f*ckuta, Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, 7200 Cambridge St, Suite 8B, Houston, TX 77030 (yuriko.f*ckuta@bcm.edu)

https://orcid.org/0000-0003-3560-4018

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Cindy Qinyang Wu

Department of Medicine, Baylor College of Medicine

Houston, Texas

USA

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Todd Michael Lasco

Department of Pathology, Baylor St. Luke‘s Medical Center

Houston, Texas

USA

Department of Pathology & Immunology, Baylor College of Medicine

Houston, Texas

USA

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Abdul Hafeez Diwan

Department of Pathology & Immunology, Baylor College of Medicine

Houston, Texas

USA

Department of Dermatology, Baylor College of Medicine

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A 51-year-old male with no medical history, developed vesicles on his left wrist several days after he cut the back of his left hand while cleaning his sister's porch in East Texas. The porch was infested with dirt and cat feces. The bleeding stopped easily and he did not seek medical attention at that point. The left wrist lesions began as fluid-filled vesicles, ruptured spontaneously, and left scars. There was mild itchiness but no pain. The skin lesions progressed to involve his chest, right wrist, and sporadic lesions on his lower extremities and face despite over-the-counter topical creams and multiple courses of oral antibiotics, including trimethoprim-sulfamethoxazole and doxycycline over 1 year. He did endorse fatigue and a 30-pound weight loss. He did not have respiratory symptoms, fever, or joint pain. He worked as a long-distance truck driver, frequenting California and southwest Texas, and enjoyed outdoor activities like hiking and hunting before his symptoms began. He developed progressive facial swelling, which prompted him to go to an outside hospital. Oral prednisone was started because of concern for angioedema, then he was transferred to our hospital for further evaluation. On admission, he appeared well, and his vital signs were within normal limits. Physical examination findings included multiple ulcerating nodular lesions on his right upper chest (Figure 1), and bilateral wrists, left outer nare, and smaller lesions scattered across his lower extremities. Some of the lesions were crusted or partially covered with dry eschar. There was no active drainage or tenderness. He also had mild bilateral periorbital and facial edema. The examination was otherwise normal. The white blood cell count was 12.6 K/µL (reference range 3.5–10.5 K/µL for men) with an 85% neutrophilic predominance. Liver function testing and other routine laboratory tests were normal. Human immune deficiency-1 antigen and antibody testing (4^th-generation human immunodeficiency virus assay) was nonreactive. Serum cortisol was undetectable. Computed tomography scans of the chest, abdomen, and pelvis revealed diffuse enlargement of the bilateral adrenal glands (right: 4.9 × 3.2 cm, left 6.0 × 4.1 cm) (Figure 2) and enlarged anterior mediastinal lymph node measuring 1.4 × 1.2 cm.

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