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Hand ulceration
A 45-year-old man presented to a south Texas emergency department with a red, tender, edematous left hand. Earlier that day, he had been working in an oil field when his hand suddenly began to hurt.
On physical exam, puncture wounds were visible at the metacarpophalangeal joint of the thumb and the interphalangeal joint, dorsal aspect; the area was surrounded by necrotic black tissue (FIGURE). Additionally, erythema with extensive edema extended distally to the proximal interphalangeal joints of each digit. Upon palpation, the area was warm, firm, and tender, with the edema tracking proximally to his mid-forearm.
The patient had a temperature of 99.5 °F; his other vital signs were normal. His past medical history included hypertension.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Dx: Cellulitis, compartment syndrome by scorpion sting
Based on the necrotic puncture wounds, unilateral distribution of the swelling, and the patient’s acknowledgement that he’d seen a scorpion in his work environment prior to symptom onset, he was given a diagnosis of cellulitis with secondary compartment syndrome following a scorpion sting.
A geographic problem
In the United States, there are approximately 17,000 reported cases of scorpion stings every year, with fewer than 11 related deaths reported between 1999 and 2014.1 These cases tend to follow a geographic distribution along the American Southwest, with the highest incidence occurring in Arizona, followed by Texas; the majority of cases occur during the summer months.1
The most clinically relevant scorpion in the United States is the Centruroides sculpturatus, also known as the Arizona bark scorpion.2Centruroides spp can be recognized by a slender, yellow to light brown or tan body measuring 1.3 cm to 7.6 cm in length. There is a tubercule at the base of the stringer, a defining characteristic of the species.3
Urgent care is necessary for more severe symptoms
The most common complaint following a scorpion sting tends to be pain (88.7%), followed by numbness, edema, and erythema.1 Other signs and symptoms include muscle spasms, hypertension, and salivation. Symptoms can persist for 10 to 48 hours. Cardiovascular collapse and disseminated intravascular coagulation are 2 potentially fatal complications of a scorpion sting.
The diagnosis is made clinically based on history and physical exam findings; a complete blood count, coagulation panel, and creatine kinase and amylase/lipase bloodwork may be ordered to assess for end-organ complications. Local serious complications, such as compartment syndrome, should be urgently referred for surgical management.
Continue to: Signs of compartment syndrome...
Signs of compartment syndrome include tense, swollen compartments and pain with passive stretching of muscles within the compartment. Rapid progression of symptoms, as seen in this case, is also a red flag.
Differential diagnosis includes necrotizing fasciitis
The differential diagnosis includes uncomplicated cellulitis, as well as necrotizing fasciitis and methicillin-resistant Staphylococcus aureus (MRSA) cellulitis.
Necrotizing fasciitis. The lack of subcutaneous crackles and pain that is out of proportion to touch, as well as relatively normal vital signs, ruled out a diagnosis of necrotizing fasciitis in this case.
Community-acquired MRSA is seen with purulent cellulitis. However, this patient had no purulent discharge.
Antivenom is only needed for severe cases
Treatment is primarily supportive; all patients should have the wound thoroughly cleaned, and pain can be controlled using nonsteroidal anti-inflammatory drugs or opioid therapy.2 Tetanus prophylaxis should be given. The Centruroides antivenom, Anascorp, should be considered for patients with severe symptoms, including loss of muscle control, roving or abnormal eye movements, slurred speech, respiratory distress, excessive salivation, frothing at the mouth, and vomiting.4 In most cases, local poison control centers should be consulted for advice on management and to answer questions about antivenom availability.
Our patient was admitted to the hospital and an urgent surgery consult was obtained. The surgeon performed a fasciotomy to treat the compartment syndrome, and the patient survived without loss of his hand or arm.
1. Kang AM, Brooks DE. Nationwide scorpion exposures reported to US poison control centers from 2005 to 2015. J Med Toxicol. 2017;13:158-165. doi: 10.1007/s13181-016-0594-0
2. Barish RA, Arnold T. Scorpion Stings. Merck Manual. Updated April 2020. Accessed June 26, 2021. https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/scorpion-stings
3. González-Santillán E, Possani LD. North American scorpion species of public health importance with reappraisal of historical epidemiology. Acta Trop. 2018;187:264-274. doi: 10.1016/j.actatropica.2018.08.002
4. Anascorp. Package insert. Accredo Health Group, Inc; 2011.
A 45-year-old man presented to a south Texas emergency department with a red, tender, edematous left hand. Earlier that day, he had been working in an oil field when his hand suddenly began to hurt.
On physical exam, puncture wounds were visible at the metacarpophalangeal joint of the thumb and the interphalangeal joint, dorsal aspect; the area was surrounded by necrotic black tissue (FIGURE). Additionally, erythema with extensive edema extended distally to the proximal interphalangeal joints of each digit. Upon palpation, the area was warm, firm, and tender, with the edema tracking proximally to his mid-forearm.
The patient had a temperature of 99.5 °F; his other vital signs were normal. His past medical history included hypertension.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Dx: Cellulitis, compartment syndrome by scorpion sting
Based on the necrotic puncture wounds, unilateral distribution of the swelling, and the patient’s acknowledgement that he’d seen a scorpion in his work environment prior to symptom onset, he was given a diagnosis of cellulitis with secondary compartment syndrome following a scorpion sting.
A geographic problem
In the United States, there are approximately 17,000 reported cases of scorpion stings every year, with fewer than 11 related deaths reported between 1999 and 2014.1 These cases tend to follow a geographic distribution along the American Southwest, with the highest incidence occurring in Arizona, followed by Texas; the majority of cases occur during the summer months.1
The most clinically relevant scorpion in the United States is the Centruroides sculpturatus, also known as the Arizona bark scorpion.2Centruroides spp can be recognized by a slender, yellow to light brown or tan body measuring 1.3 cm to 7.6 cm in length. There is a tubercule at the base of the stringer, a defining characteristic of the species.3
Urgent care is necessary for more severe symptoms
The most common complaint following a scorpion sting tends to be pain (88.7%), followed by numbness, edema, and erythema.1 Other signs and symptoms include muscle spasms, hypertension, and salivation. Symptoms can persist for 10 to 48 hours. Cardiovascular collapse and disseminated intravascular coagulation are 2 potentially fatal complications of a scorpion sting.
The diagnosis is made clinically based on history and physical exam findings; a complete blood count, coagulation panel, and creatine kinase and amylase/lipase bloodwork may be ordered to assess for end-organ complications. Local serious complications, such as compartment syndrome, should be urgently referred for surgical management.
Continue to: Signs of compartment syndrome...
Signs of compartment syndrome include tense, swollen compartments and pain with passive stretching of muscles within the compartment. Rapid progression of symptoms, as seen in this case, is also a red flag.
Differential diagnosis includes necrotizing fasciitis
The differential diagnosis includes uncomplicated cellulitis, as well as necrotizing fasciitis and methicillin-resistant Staphylococcus aureus (MRSA) cellulitis.
Necrotizing fasciitis. The lack of subcutaneous crackles and pain that is out of proportion to touch, as well as relatively normal vital signs, ruled out a diagnosis of necrotizing fasciitis in this case.
Community-acquired MRSA is seen with purulent cellulitis. However, this patient had no purulent discharge.
Antivenom is only needed for severe cases
Treatment is primarily supportive; all patients should have the wound thoroughly cleaned, and pain can be controlled using nonsteroidal anti-inflammatory drugs or opioid therapy.2 Tetanus prophylaxis should be given. The Centruroides antivenom, Anascorp, should be considered for patients with severe symptoms, including loss of muscle control, roving or abnormal eye movements, slurred speech, respiratory distress, excessive salivation, frothing at the mouth, and vomiting.4 In most cases, local poison control centers should be consulted for advice on management and to answer questions about antivenom availability.
Our patient was admitted to the hospital and an urgent surgery consult was obtained. The surgeon performed a fasciotomy to treat the compartment syndrome, and the patient survived without loss of his hand or arm.
A 45-year-old man presented to a south Texas emergency department with a red, tender, edematous left hand. Earlier that day, he had been working in an oil field when his hand suddenly began to hurt.
On physical exam, puncture wounds were visible at the metacarpophalangeal joint of the thumb and the interphalangeal joint, dorsal aspect; the area was surrounded by necrotic black tissue (FIGURE). Additionally, erythema with extensive edema extended distally to the proximal interphalangeal joints of each digit. Upon palpation, the area was warm, firm, and tender, with the edema tracking proximally to his mid-forearm.
The patient had a temperature of 99.5 °F; his other vital signs were normal. His past medical history included hypertension.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Dx: Cellulitis, compartment syndrome by scorpion sting
Based on the necrotic puncture wounds, unilateral distribution of the swelling, and the patient’s acknowledgement that he’d seen a scorpion in his work environment prior to symptom onset, he was given a diagnosis of cellulitis with secondary compartment syndrome following a scorpion sting.
A geographic problem
In the United States, there are approximately 17,000 reported cases of scorpion stings every year, with fewer than 11 related deaths reported between 1999 and 2014.1 These cases tend to follow a geographic distribution along the American Southwest, with the highest incidence occurring in Arizona, followed by Texas; the majority of cases occur during the summer months.1
The most clinically relevant scorpion in the United States is the Centruroides sculpturatus, also known as the Arizona bark scorpion.2Centruroides spp can be recognized by a slender, yellow to light brown or tan body measuring 1.3 cm to 7.6 cm in length. There is a tubercule at the base of the stringer, a defining characteristic of the species.3
Urgent care is necessary for more severe symptoms
The most common complaint following a scorpion sting tends to be pain (88.7%), followed by numbness, edema, and erythema.1 Other signs and symptoms include muscle spasms, hypertension, and salivation. Symptoms can persist for 10 to 48 hours. Cardiovascular collapse and disseminated intravascular coagulation are 2 potentially fatal complications of a scorpion sting.
The diagnosis is made clinically based on history and physical exam findings; a complete blood count, coagulation panel, and creatine kinase and amylase/lipase bloodwork may be ordered to assess for end-organ complications. Local serious complications, such as compartment syndrome, should be urgently referred for surgical management.
Continue to: Signs of compartment syndrome...
Signs of compartment syndrome include tense, swollen compartments and pain with passive stretching of muscles within the compartment. Rapid progression of symptoms, as seen in this case, is also a red flag.
Differential diagnosis includes necrotizing fasciitis
The differential diagnosis includes uncomplicated cellulitis, as well as necrotizing fasciitis and methicillin-resistant Staphylococcus aureus (MRSA) cellulitis.
Necrotizing fasciitis. The lack of subcutaneous crackles and pain that is out of proportion to touch, as well as relatively normal vital signs, ruled out a diagnosis of necrotizing fasciitis in this case.
Community-acquired MRSA is seen with purulent cellulitis. However, this patient had no purulent discharge.
Antivenom is only needed for severe cases
Treatment is primarily supportive; all patients should have the wound thoroughly cleaned, and pain can be controlled using nonsteroidal anti-inflammatory drugs or opioid therapy.2 Tetanus prophylaxis should be given. The Centruroides antivenom, Anascorp, should be considered for patients with severe symptoms, including loss of muscle control, roving or abnormal eye movements, slurred speech, respiratory distress, excessive salivation, frothing at the mouth, and vomiting.4 In most cases, local poison control centers should be consulted for advice on management and to answer questions about antivenom availability.
Our patient was admitted to the hospital and an urgent surgery consult was obtained. The surgeon performed a fasciotomy to treat the compartment syndrome, and the patient survived without loss of his hand or arm.
1. Kang AM, Brooks DE. Nationwide scorpion exposures reported to US poison control centers from 2005 to 2015. J Med Toxicol. 2017;13:158-165. doi: 10.1007/s13181-016-0594-0
2. Barish RA, Arnold T. Scorpion Stings. Merck Manual. Updated April 2020. Accessed June 26, 2021. https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/scorpion-stings
3. González-Santillán E, Possani LD. North American scorpion species of public health importance with reappraisal of historical epidemiology. Acta Trop. 2018;187:264-274. doi: 10.1016/j.actatropica.2018.08.002
4. Anascorp. Package insert. Accredo Health Group, Inc; 2011.
1. Kang AM, Brooks DE. Nationwide scorpion exposures reported to US poison control centers from 2005 to 2015. J Med Toxicol. 2017;13:158-165. doi: 10.1007/s13181-016-0594-0
2. Barish RA, Arnold T. Scorpion Stings. Merck Manual. Updated April 2020. Accessed June 26, 2021. https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/scorpion-stings
3. González-Santillán E, Possani LD. North American scorpion species of public health importance with reappraisal of historical epidemiology. Acta Trop. 2018;187:264-274. doi: 10.1016/j.actatropica.2018.08.002
4. Anascorp. Package insert. Accredo Health Group, Inc; 2011.
