Update: A 39-Year-Old Man With a Skin Infection

In a Clinical Crossroads article published in January 2008,¹ Robert C. Moellering, MD, discussed Mr M, a 39-year-old man with episodes of skin infections on his thigh and his left index finger. In the article, Dr Moellering discussed the nature of Mr M's index finger infection, the options for treatment, and the likelihood of recurrence. Mr M had no history of trauma or exposure to a pathogen, had fairly severe pain, was afebrile, and had significant lymphangitic streaking. Based on these symptoms, Dr Moellering identified a streptococcus or a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain as likely culprits and recommended treating with antibiotics to cover both S aureus and Streptococcus pyogenes. He suggested that following Mr M's drainage and intravenous antibiotics, he be discharged taking oral antimicrobial therapy to complete the course. Because Mr M had only had 1 serious infection, Dr Moellering was not concerned that Mr M had an underlying immunodeficiency and, thus, did not recommend workup; Dr Moellering also did not recommend any ongoing prevention or prophylaxis to prevent future infections because of the lack of evidence that such treatment would be efficacious.

I’ve had 3 subsequent infections since the MRSA in my finger. Two were on the side of my torso, close to my ribs, and 1 of them required—I forget the technical term—squeezing the infection out. I made 3 trips to the doctor, during which they placed a wick and performed lacerations. The other one was minor. It swelled and it hurt to touch, but I didn't touch it and it sort of went away.

The third infection occurred this weekend. I hit my finger on a lane line in a swimming pool and must have created a small cut. It swelled up significantly and was very painful. I almost went to the emergency department for this infection, but then on Sunday evening, without prompting or touching, it started to ooze pus out of my thumb. Having had experience with this sort of thing, I helped it along and squeezed the pus out myself. I then put a wick into the small incision where the pus came out and my finger feels 100 times better today. I never actually went to the doctor, but I have been using antibacterial soap since I discovered it, a recommendation I received when I got the infection on my abdomen. Nevertheless, frankly, once I have the infection, I’ve got the infection, and I’ve just got to ride it out.

The infections usually last for 3 to 4 days. Typically, when I start to see an infection, I put a circle around the spot with a ballpoint pen to track its growth. If it seems to improve on its own, I won't go to the doctor, but if I start to see green slime, like I saw when I had MRSA, I’ll probably go to the doctor. In general, I try to avoid going to the doctor about these infections. I have a real fear of doctors digging into my skin and cutting. With this last infection, I was pretty lucky because it sort of fixed itself. I was pretty sure the doctors would have cut my thumb and given me antibiotics if I had gone in and that would have been very painful. Instead, I just pressed and squeezed it myself.

Because the first infection on my torso was diagnosed as a “Staph” infection, I took antibiotics, but it was nothing like the inpatient intravenous antibiotics I received for MRSA over the course of a week. I did not take antibiotics for either of the other infections.

I’m starting to think that my frequency at swimming pools is a factor. I must be susceptible to the bacteria in the pools. Or, as my doctor suggested at my last visit, it may just be in me.

It is clear that Mr M's problems with staphylococcal infections have not been eliminated and it is likely that the recurrent infections he describes are due to CA-MRSA. Recurrences and intrafamilial transmission of such infections are being increasingly noted.^{2 - 3} Although in some instances this may be the result of persistent nasal or oropharyngeal colonization with MRSA, the incidence of such colonization remains much lower for CA-MRSA than for methicillin-susceptible staphylococci.⁴ Direct person-to-person spread, spread from colonized fomites, and even spread from pets and companion animals may contribute to recurrence of these infections.⁵ It seems unlikely that Mr M's swimming pool is the source of these infections. At this stage, it would be useful for him to see an infectious diseases specialist to try to determine the source and work out a program for prevention of his infections.

Finally, as with many of the CA-MRSA skin infections seen in the United States, the patient's abscesses respond reasonably well to local measures. Unfortunately, however, this is not always the case, and serious, life-threatening complications may be seen in a small number of such cases.