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A Curious Blister in a High School Student

A Curious Blister in a High School Student

Tue, 10/01/2019 - 16:21

A 15-year-old otherwise healthy high school student presented to a primary care clinic with a lesion on his leg of 5 days’ duration (Figure 1). He reported significant pain in the area but had no other symptoms.

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Figure 1. A lesion on a boy’s leg at presentation to the primary care clinic, 5 days after its development.

History. He had been seen by an urgent care physician 2 days ago. At that time, the lesion was a large blister (Figures 2 and 3). At this visit, this blister had been drained, and the yellow fluid was sent for culture tests. Topical antibiotic therapy with mupirocin was prescribed for presumed bullous impetigo, and the patient was instructed to follow up with his primary care physician.

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Figure 2. The boy’s blister photographed on day 1, 5 days before presentation to the primary care clinic.

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Figure 3. The boy’s blister at presentation to urgent care, 3 days after development and 2 days before presentation to the primary care clinic.

At the time of his current presentation to the primary care clinic, the lesion had not improved. He reported mild to moderate pain. There had been no fever or limp. The patient’s mother was concerned that the lesion may be a result of a methicillin-resistant Staphylococcus aureus infection, because a number of his baseball teammates had similar skin lesions.

Physical examination. At presentation, the patient was well appearing, had stable vital signs, and was afebrile. Examination of the skin revealed a 10 × 4-cm erythematous lesion with central ulceration located on right medial leg, just below the knee. There was some skin necrosis noted on the edges of the ulceration. There was no induration or purulent exudate. No regional lymphangitis or lymphadenopathy were present. The remainder of the physical examination findings were otherwise unremarkable.

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