A 65-year-old man presented to the emergency department (ED) with a two-week history of progressively severe pain in his right hand and difficulty moving his fingers. He reported that approximately two weeks earlier, while shoveling snow, he slipped and fell, landing on his right hand. Initially, he had no problems with his hand. He finished his shoveling and continued his normal daily activities.
Within two to three days he started to experience pain in his right hand, which grew progressively worse.
Because he did not have a primary care provider, the patient had a limited medical history. He reported having a mildly elevated prostate-specific antigen test years earlier. He underwent an appendectomy at age 15. He denied any other medical problems.
The patient was taking no medications and reported no known allergies to medications. He denied the use of tobacco, said he had one or two beers on an average day, and denied IV drug use. He was an artist and was married with one adult child. His family history was unremarkable with the exception of an alcoholic sister who died of cirrhosis at age 70.
During triage, vital signs were essentially normal: blood pressure, 142/74 mm Hg; heart rate, 78 beats/min; and respiratory rate, 20 breaths/min. The patient was afebrile at 37.2°C (98.9°F). Physical examination was remarkable for some edema and warmth of the right hand without any notable erythema. There was no evidence of any wound. Fingers all had good sensation; however, flexion of the index and long fingers elicited a significant increase in pain.
The remainder of the exam was unremarkable. The patient’s head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Eyes were anicteric, and no rhinorrhea was evident. The neck was supple without palpable lymphadenopathy. Lungs were clear to auscultation bilaterally. No wheezes, rales, or rhonchi were appreciated. The heart had a regular rate and rhythm; no murmurs, rubs, or gallups were noted. The abdomen was soft and non-tender. The extremities, except as previously stated, were normal, with good pulses, sensation, and strength.
Initially, only radiographs of the right hand were ordered (see Figures 1 and 2). These demonstrated soft tissue swelling on the dorsum of the hand, and an area of hypodensity between the first and second metacarpals. There were no fractures, dislocations, or other bone or joint abnormalities.
After a review of the radiographs, it was clear that the patient’s diagnosis was not a simple answer of hand contusion or fracture; thus, the evaluation was expanded. Vital signs were repeated three hours after triage: blood pressure, 128/74 mm Hg; heart rate, 76 beats/min; and respiration, 20 breaths/min. The patient was now febrile at 37.6°C (99.7°F). Because of his fever and the anomaly on the patient’s hand radiograph, expansion of the evaluation continued.
Laboratory studies included a complete blood count: white blood cells (WBCs), 30,700/mcL (reference range,1 4,500 to 11,000/mcL); hemoglobin, 13.3 g/dL (13.8 to 17.2 g/dL for men); hematocrit, 40.0% (41% to 50% for men); platelets, 217,000/mcL (130 to 400 x 103/mcL). Initial chemistry panel results were normal except for serum glucose, 143 mg/dL (70 to 125 mg/dL).
Liver function test results were normal except for aspartate aminotransferase, 33 U/L (reference range,1 10 to 30 U/L) and albumin, 2.5 g/dL (3.5 to 5.0 g/dL). Once WBCs were found to exceed 30,000/mcL, the search for a cause was widened once more.
The continued studies included a chest radiograph with normal results, unremarkable CT of the abdomen and pelvis with IV contrast, blood cultures, and urinalysis. The urinalysis showed: blood, moderate; protein, trace; nitrites, positive; leukocytes, large; WBCs > 50/high-power field (reference range,1 5/high-power field or less); and numerous bacteria.
The final study performed in the ED evaluation of the patient was a CT of the right hand with IV contrast (see Figure 3). It demonstrated diffuse edema and a 9.0-mm area of low attenuation with some rim enhancement. The differential for these findings includes an abscess or a foreign body; the latter was deemed unlikely in light of the patient’s physical exam. In consideration of his elevated WBC count, the high number of WBCs in his urine, the fever, and the CT results, the patient was diagnosed with an abscess in his right hand that had been seeded, it was surmised, by an occult urosepsis after his fall.
Before the patient’s admission, a hand surgeon was consulted. The surgeon agreed with the diagnosis, and the patient was taken to the operating room (OR). He had been given piperacillin/tazobactam in the ED.