A Landscaper's Nodular Skin Lesions and Painful, Swollen Joints

A 32-year-old man from northern Mexico who worked as a landscaper presented to the emergency department with a 4-month history of increasing pain and swelling of his left wrist and fingers as well as raised nodular lesions on the dorsum of his hand. 

History. Two months earlier, the patient experienced a traumatic laceration to the dorsum on the left hand from a piece of wood while working with soil. He developed an ulcerative lesion at the base of the thumb, which healed during next few weeks with only local wound care (soap, water, and bandages). He denied fever, chills, night sweats, or weight loss. There was no history of ethanol use, chronic diseases, or known immunodeficiency.

He was afebrile, and his physical examination was unremarkable except for the left upper extremity, which showed swelling of the left hand and wrist with some mild erythema, but no increased warmth. The dorsum of the left hand showed multiple round nodular lesions with central umbilication (Figure 1). Motion of the left wrist was limited by pain and flexion and extension of the fingers were limited by swelling. There was no lymphadenopathy detected.

Figure 1. Dorsal aspect of left hand and wrist showing extensive swelling and nodular umbilicated cutaneous lesions.

Complete blood count and chemistry profile were unremarkable. The patient had an elevated Erythrocyte sedimentation rate (ESR) of 46 mm/hour (normal ESR level, < 20 mm/hour) and an elevated C-reactive protein (CRP) of 2.4 mg/dL (normal CRP level, < 0.5 mg/dL; Table 1).

Plain radiographs showed lytic lesions of the metacarpals and the trapezium with a displaced fracture and collapse of the trapezium along with diffuse soft tissue swelling of the wrist (Figure 2). His chest radiograph, which was performed to evaluate any potential disseminated diseases, was unremarkable.

Figure 2. Plain radiograph of the left hand showing lytic lesions of metacarpals and the trapezium with a displaced fracture and collapse of the trapezium along with diffuse soft tissue swelling about the wrist (red arrow).

Magnetic resonance imaging (MRI) demonstrated chronic osteomyelitis of multiple bones of the hand and wrist, septic arthritis of multiple hand and wrist joints, pathologic fracture of the trapezium, subcutaneous abscesses at the dorsal and palmar aspects of the wrist and hand, myositis, small intramuscular abscesses, and tenosynovitis (Figure 3).

Figure 3. MRI axial view of the left wrist showing bony destruction and soft tissue infection at the base of the metacarpals (blue arrow).

The patient was taken to the operating room for extensive debridement. Thick inflammatory tissue with very amorphous tissue described as “adipose-like,” but darker than normal adipose, was encountered. There was no frank purulence.

Table 1. Diagnostic workup   

Several intraoperative cultures were positive for an unusual organism (Figures 4 and 5).

Figure 4. Blood agar plat showing chalky-white fluffy colonies.

Figure 5. Gram stain showing filamentous gram-positive organisms.