Niels_Olson:
This rash began after he fell and hit his cheek on the couch 27 Dec 07, then did the same thing one week later, about 2 Jan 08.
Niels_Olson:
16 Jan 08
Niels_Olson:
21 Jan 08 survey. This & next 8 photos. This is ~ 1 day after starting augmentin. Over next few days a diffuse, blanching, erythematous, maculopapular rash would develop. D/c'd augmentin. This is when the lesion on the back of his knee would develop.
Niels_Olson:
21 Jan 08. Vomiting. Urgent care doc started augmentin. GI symptoms resolved the next morning. There's a bit of cracker in the corner of his mouth. Not pus.
Niels_Olson:
21 Jan 08
Niels_Olson:
Right cheek, 21 Jan 08
Niels_Olson:
Right post-auricular & anterior SCM region, 21 Jan 08
Niels_Olson:
Chest -- 21 Jan 08
Niels_Olson:
Left wrist, 21 Jan 08
Niels_Olson:
Closeup of wrist. Without scale it does look like Molluscum, but it's much smaller and he had had and cleared MC in the previous summer. This evolved over the next few days to become a much more eczemeatous, macular, flat, blanching, diffuse rash.
Niels_Olson:
Last of the 21 Jan 08 survey
Niels_Olson:
The only photo from February, it's Mardi Gras. Nothing for two weeks after Altabax. then 10d cefalexin, then 2d sertaconazole, then 12d Bactrim then 2d bacitracin. Looks like 15 Jan 08 or 9 Mar 08 photos. To zoom, click in, then "ALL SIZES".
Niels_Olson:
9 Mar 08. On 15 Mar 08, after 12d Bactrim, 2d bacitracin. On 17 March, gave dermatologist a table of all antibiotics, dates & doses given. D/c'd bacitracin; started topical hydrocortisone. We knew it would get better or worse.
Niels_Olson:
I presented this table of drug doses and dates to the dermatologist and his resident on 17 Mar 08. After looking at this and his cheek, we agreed to try a mild topical steroid for a few days. We knew it would get better or worse.
Niels_Olson:
21 Mar 08. It got worse. Indurated. Many people would express pus from it this day. Me, my wife, the ER docs, the ward docs, the ENTs (at least two of each). Total, maybe a CC or 2. Also had purulent lacrimal discharge, thus ENT, and a noncontrast CT.
Niels_Olson:
Demonstrating extent of induration just before going to ER. IV Clinda and Vanc started shortly after arrival.
Niels_Olson:
New petechial spot on neck just before going to ER. No palpable LAD.
Niels_Olson:
Contralateral popliteal fossa lesion that appeared with Augmentin rash in February, which has also not resolved
Niels_Olson:
Evening of 22 Mar 08, posterolateral light. IV Clinda and Vanc x 24 hrs. Still indurated, but palpably less so. Increasing exfoliation. Warm compresses as possible.
Niels_Olson:
Evening of 22 Mar 08, anterior light
Niels_Olson:
Morning of 23 Mar 08. ENT decided to no I&D.
Niels_Olson:
Evening of 23 Mar 08. Clinda & Vanc x 48 hrs. No induration. More exfoliation. Tolerated PO Clinda, but only got 2/3 of dose b/c the remainder got spilled in a fumble. Resumed IV Clinda & Vanc.
Niels_Olson:
24 Mar 08. Black scab in the middle came off w/ soaking, but min Δ. No induration. Vanc & Clinda x 72h. Clinda PO. Trying fluocinolone on knee to eval for eczema.
Niels_Olson:
25 Mar 08. Culture grew MSSA. D/c'd home. Plan: 1) PO Clinda Q8 x 10d (Clinda total = 14d). 2) Derm added fluorocinolone. Will start that after 2d, so we have some data on removing vanc. Not weeping, taken in bath. Diarrhea x3.
Niels_Olson:
University Hospital Antibiogram based on 2007 data
Niels_Olson:
Tulane Hospital Antibiogram based on July - December 2007 data. Compared to University Hospital, note the greater number of acinitobacter infections. The outbreak actually peaked in February 2008.
Niels_Olson:
26 Mar 08. Day 5 of Clinda, 9 left. Lesion is ~1 cm in front of focal plane, therefore a large circle of confusion (<30 micrometers at image plane) obscures detail of somewhat more particulated surface, but the lesion is still the best it's looked.
Niels_Olson:
27 Mar 08. Day 6 of Clinda, 8 left. This afternoon he started to itch, which is new, so we started putting Alta lotion (petrolatum, paraffin, PVP eicosene copolymer, recommended by Dr Boh)
Niels_Olson:
28 Mar 08. 2-3 mm honey crust in center (detail in next pic). Day 7 Clinda, 7 left. Had planned to start steroid today. Pic taken at 77°F, 5 to 7° warmer than other pics. Also played outside in sun all afternoon. Just flushed?
Niels_Olson:
28 Mar 08. Detail. Honey crusted area is slightly out of focus. It's a orange upside-down U just right of center. Click into picture page and mouse over and it'll be highlighted by a square.
