Medical Case Report #1


#1

I wanted to start a series of case reports from actual medical situations encountered in the course of our duties on fire assignments. All cases will respect HIPAA regulations and permission has been given, when possible, by the patient.

Without further ado, here is case #1:

30 year old male member of an inmate crew has been working on a fire in California for several days. He reports an intensely itching rash and bumps over his hands bilaterally as well as some blistering and oozing of clear fluid. He denies poison oak exposure, fevers, and other associated symptoms. He says he has had these symptoms before. His other medical history only includes seasonal allergies. Some of the lesions appear to contain serosanguinous (bloody) fluid. See associated attached photos.

Anyone want to take a stab at a diagnosis? What’s the appropriate treatment plan?


#2


#3

Staph infection? If so, it is infectious to others, needs to be treated with antibiotics. (This is where my animal husbandry comes in handy!)


#4

Well, to me this looks like a common case of MRSA with some associated cellulitis. Being that the individual is apart of a FIRE crew (regardless of CDC or other hand crew affiliation) and subjected to poor hygiene (taking a shower and putting on the same dirty/grubby clothes afterwards does not count), poor nutrition (sack nasties and failure to hit the salad bar frequently), and fatigue, these would be contributing factors in “catching” MRSA. Further, fire crews are living in close quarters with each other, where an individual may be the host carrier for the entire crew…

I have seen several cases come through the medical trailer over the past several years, but unfortunately my recommendations to the MEDL for morning briefing discussions and safety messages usually don’t get properly understood by the masses.

The other issue with MRSA is that it is frequently undiagnosed as such and the patient is treated in camp or at a small local clinic with cleaning of the affected area, bandages, and maybe an ineffective prescription of oral Keflex.What this patient needs is an admission to a medical facility with IV antibiotics, debridement and drainage.

The case I followed up on as a safety dude was an engine operator from a federal government engine crew assigned to a large complex on the Siskiyou in 2014. Classic case of MRSA and a double whammy of ring worm. Dude was in the hurt box, but in reality, it was his own fault for not keeping himself clean and changing out his clothing every shift. I believe the IV antibiotic was vancomycin (probably spelled it wrong)

My recommendation for all is to maintain proper hydration/nutrition, change out your Nomex when you can, take showers every time you come off the line and before feeding if at all possible, and change your underwear and t shirts every day.

Be safe and pace.


#5

So that’s two votes for a bacterial skin infection. Here’s a third photo of the lesions. Will post what I believe to be the diagnosis later today.


#6

Dishydrotic eczema can have a similar appearance, can feel intensely itchy, and is usually a recurring condition. Eczema can provide entry point for subsequent infection, but the images alone don’t appear to me to clearly show an infection. I would check closely for any signs of puss, pain, warmth, etc to rule out infection, but images and described symptoms sound more like dishydrotic eczema to me.


#7

Probably way off, but looking at the little small bumps on the fingers, maybe severe poison oak reaction or some type of thistle weed reaction…


#8

I’m in agreement with @BTUFirewife. With the history of seasonal allergies it seems highly likely.


#9

My nurse wife is in agreement with both you and BTUFirewife.


#10

Maybe ?!?!? I know the answer but only because I was involved. I will let the good doctor do the explaining.


#11

BTUFirewife for the win!

This patient likely was suffering from dishydrotic eczema, which is relatively common in atopic (allergy-prone) people who use their hands in harsh conditions. It is miserably itchy and can occur on the feet as well.

The treatment is to avoid aggressive handwashing, using moisturizers when you can, as well as oral and/or topical steroids in extreme cases. This patient does not need to be demobed unless the symptoms are debilitating or unless there is a superimposed skin infection.

It doesn’t appear consistent with an infection because: The patient’s hands are not red, there is no pus, and it itches more than it hurts. The little bumps and vesicles (blisters) on the sides and dorsal aspects of the fingers are characteristic of dishydrotic eczema.

Thanks to everyone who participated and put themselves out there by taking a stab at this diagnosis. I hope this was fun and interesting and I’ll try to continue our fireline medicine case series.