Two Cases of Progressive Erythematous Lesions of the Upper Extremity
A generally healthy 39-year-old male presented to his local emergency department with a progressively enlarging area of erythema on his left upper extremity for three days. The patient worked at a water treatment plant and was reaching to grab something while working in a water tower when he saw a "brown spider with thin legs” bite him on the left arm. He stated he immediately knocked the spider away and was not able to find it for identification. The patient admitted to some chills, but no fevers, nausea, vomiting, or diarrhea. The remainder of the review of systems was negative. The patient had no prior medical history and took no medications.
Physical exam revealed a localized area of erythematous tissue at the site of the bite on the left forearm, with central necrosis and a well-demarcated border. The size of the lesion was approximately 3.5 x 3.5 cm (Figure 1).
He was treated with IV ampicillin/sulbactam and underwent a surgical debridement of the area. He required a skin graft at the site and subsequently did well in follow up.
A 44-year-old male truck driver presented to the emergency department with a skin lesion on his arm for four days. He notes the lesion appeared after waking from sleep. The lesion progressively got larger over the past three days. The patient stated he drives and delivers freight to the entire east coast of the United States and sleeps in his truck frequently. The lesion described in this case is similar to the case above.
The patient denied any fevers, chills, nausea, vomiting. He denied any significant past medical history. He took no chronic medications. The remainder of his review of systems was negative.
On physical exam, the lesion was approximately 1.5 x 1.5 cm (Figures 2 and 3).
He was advised by the emergency department physician that he should have intravenous antibiotic therapy, but due to his employment, he stated could not stay for IV antibiotics or admission. He, therefore, was started on oral doxycycline (>95% bioequivalency to IV formulation of doxycycline) and discharged to have a followup in 24 hours. The patient was advised to go to the nearest emergency department on his travels at any time for any worsening, progression, fevers, etc.