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BACKGROUND
A 47-year-old woman presents to her primary care physician with a several-year history of chronic skin infections and painful, 1- to 3-mm red pustules in her groin. Many of the pustules have broken and are draining a foul-smelling, puslike fluid mixed with blood. The patient reports that these lesions almost always begin as firm bumps that are not painful, but they eventually break open. The patient has been seriously uncomfortable with this for over a year and a half and has had episodic abscess formation in the involved area for many years.
She had seen physicians for the same problem and had been prescribed oral and topical antibiotics. The nodules seemed to improve when she was taking the antibiotics, but nothing has stopped the recurrences or cured the condition. Any contact with the affected area increases the irritation and pain. The patient has felt socially uncomfortable because of the strong, offensive smell, and her pain has caused her to substantially reduce her activity level.
The patient’s medical history is significant for morbid obesity, which had led her to seek gastric bypass surgery. The inflammation and pain in her groin worsened after she had lost over 100 lb. Now, many of the eruptions occur in the fold under her pannus. She reports no fever and no exposure to new chemical agents, detergents, or cleaning agents.
On physical examination, her vital signs are a temperature of 98.6°F, a heart rate of 88 beats per minute, and a blood pressure of 132/65 mm Hg. The patient has a nontoxic appearance and normal findings on cardiovascular examination. Clinically significant lymphadenopathy is absent, even in the inguinal area and in the armpits. She has numerous draining lesions in various stages of eruption; those in the groin and perineal regions are tender to palpation. Evidence of coalescence of some of the lesions and a spreading redness in the inguinal area are observed.
The patient's complete blood count shows the following values: WBC count of 8.6 X 109/L, hemoglobin (Hb) 8 g/L, hematocrit (Hct) 0.259 (25.9%), platelets 361 X 109/L.
What is the diagnosis? Why is the patient experiencing what appears to be recurring infections? |
Hint
Recurrent painful discharging nodules. |
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Authors: |
Anusuya Mokashi, Medical Student, New York Medical College, Valhalla
Jane A. Petro, MD, Chief of Plastic Surgery, Northern Westchester Hospital, Professor of Surgery, New York Medical College, Valhalla |
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eMedicine
Editor:
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Rick Kulkarni, MD, Attending Physician, Director of Informatics, Department of Emergency Medicine, Olive View - UCLA Medical Center, Assistant Professor of Medicine, David Geffen School of Medicine at UCLA |
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