Photo Rounds

Nodule on gardener’s hand

A 75-year-old woman presented to Dermatology with a 4-week history of a pink fluctuant nodule between the metacarpophalangeal joints of her ring and middle fingers. She denied any pain or fever and thought that she might have gotten a splinter while working in the garden.

What’s your diagnosis?


 

References

Nodule on gardener’s hand

Using an 18-gauge needle, a simple incision and drainage was performed, and copious turbid and bloody material was expressed and cultured for aerobic and acid-fast bacteria, as well as fungus. The patient was started on trimethoprim sulfamethoxazole DS twice daily while cultures and sensitivities were pending. Cultures grew Staphylococcus lugdunensis, a coagulase-negative staph species known to cause a range of infections from simple skin infections to bacteremia and endocarditis.1 If the drainage had been viscous and clear to blood-tinged, that would have been more consistent with a ganglion cyst. Lack of drainage would have prompted a small punch biopsy to exclude a tumor.

Fortunately, S lugdunensis is often broadly sensitive to antibiotics, although treatment choices should follow antibiotic sensitivity testing. Any signs of systemic illness should be worked up with blood cultures and consideration of endocarditis or involvement of an implant. Penicillin is recommended as a first line systemic agent if sensitivities support this, and for abscesses, incision and drainage is recommended. The length of treatment for skin infections is generally 1 to 2 weeks, guided by response to therapy.

This patient’s nodule resolved following the incision and drainage and 7 days of therapy with trimethoprim sulfamethoxazole DS.

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Recommended Reading

Topical treatment options for acne continue to expand
MDedge Family Medicine
Long-term maintenance required in melasma patients
MDedge Family Medicine
Scar overgrowth
MDedge Family Medicine
Berdazimer gel under review at FDA for treating molluscum contagiosum
MDedge Family Medicine
Do collagen supplements benefit the skin?
MDedge Family Medicine