31 March 2009

That's Just Bizarre

A 88 year old male with a history of steroid-dependent COPD and steroid-induced diabetes sustained a small cut on the palm of his left hand.   This was a 1cm puncture wound inflicted with a kitchen knife while washing dishes.   It was a minor cut, the bleeding controlled easily (despite the fact that he was on warfarin) and he did not seek medical attention immediately.  Three days later, he presented to his primary care doctor because his wrist and arm were swelling up; he was sent to the ER for assessment.

On exam, the patient had subcutaneous emphysema on the dorsum of the hand and circumferentially all the way from the wrist to the shoulder.   There was no erythema, tenderness, or fluctuance.   The wound was clean and dry without evidence of infection.  There was no pain with range of motion at any joint, and the compartments were soft (indeed, squishy).   The patient was afebrile and well-appearing, and the white count was normal.  An MRI of the extremity was obtained:

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Uploaded with plasq's Skitch!


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Uploaded with plasq's Skitch!


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Uploaded with plasq's Skitch!

I apologize for the poor resolution -- for some reason I could not download the nice high-res images.   The black spots under the skin, between muscle groups, and (weirdly) around the bones is air.  According to the radiologist, there was no evidence of fasciitis, or any other inflammatory/infectious process.

A general surgeon, a hand surgeon, and an internist spent a while puzzling over this with me.   The big concern was that gas in the soft tissues is the hallmark of certain very bad infections -- think gangrene and the so-called flesh-eating bacteria, which are terribly life-threatening.   The patient didn't look infected, but being diabetic and on steroids and nearly 90, they sometimes don't show you the evidence of infection.   The MRI was more definitive that it was probably not infected, but if not, then how the hell did all that air get up there?

Ultimately, we played safe, admitted him for IV antibiotics and observation.   My theory was that the cut on the palm was acting as a sort of ball-valve mechanism where each time he opened and closed his hand, he pumped a little more air into the palm, which then tracked up the arm as more and more air got insufflated.  

People are weird.

7 comments:

  1. wow... that's really, really interesting. thanks for sharing!

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  2. Thanks for posting this cool case! Just learned something new...

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  3. Why would the PCP send him to the ER (ED) for evaluation? Sounds like a direct admission with a surgical consultation. Maybe even a (gasp) phone call to the surgeon on call.

    Oh wait, the PCP probably doesn't admit anymore and sends all acute cases to the ER (ED)>

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  4. Did you consider the possibility of the guy himself blowing air into the cut? We once had a woman in the ER who had free air in her abdomen and was almost on the operating table when she admitted her friend used to "blow" on her vagina. Quite bizarre.

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  5. I am surprised you got an MRI (we can't often get them from the ER). I would have just started the ABX and called the surgeon in.
    Still, that is very bizarre.

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  6. Fab images. Very cool case. The weirdness continues.

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