Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 20-year-old male college student with a superficial skin infection

mksap
Conditions
July 15, 2017
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 20-year-old male college student on the wrestling team is evaluated for a superficial skin infection. He has a history of several episodes of folliculitis and furunculosis over the past year that has required systemic treatment. His recurrent infections were treated with various oral antibiotics, including cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. He currently takes no medications, has no drug allergies, and is otherwise in good health.

On physical examination, vital signs are normal. There are multiple, scattered erythematous papulopustules and nodules on the buttocks and upper thighs, some with a collarette of scale. He has no background erythema or lymphadenopathy. The remainder of the physical examination is unremarkable.

Which of the following is the most appropriate next step in management?

A. Culture a pustule
B. Perform a Tzanck smear
C. Start linezolid
D. Start vancomycin

MKSAP Answer and Critique

The correct answer is A. Culture a pustule.

The most appropriate first step in management is to culture a pustule to identify the causative organism prior to institution of antibiotic therapy. Bacterial skin infections are most commonly caused by Staphylococcus and Streptococcus spp. and may present in a variety of ways. This patient has recurrent folliculitis and furunculosis but is otherwise healthy. The history of recurrent infections and being part of a wrestling team would suggest that infection may be secondary to community-acquired methicillin-resistant Staphylococcus aureus (MRSA). Community-acquired MRSA, defined as MRSA infections that occurs in the absence of health care exposure, tends to have enhanced virulence compared with other strains and is currently the most common organism causing skin infection requiring medical therapy. However, because of the recurrent nature of the patient’s skin infections and his exposure to previous courses of antibiotics, a culture to identify the causative organism and its susceptibility pattern would be the most appropriate next step to guide further management.

In addition to systemic therapy, topical antibiotic therapies, including benzoyl peroxide wash, chlorhexidine, or topical mupirocin, can be used. Bleach baths may be a treatment option (put 1/4 to 1/2 cup of common liquid bleach into the bath water to create a chlorinated bath), which decreases colonization of S. aureus).

A Tzanck smear can be performed if a herpes simplex virus or varicella infection is suspected. Both infections can occur in wrestlers but would typically present as painful vesicles or punched-out erosions as opposed to furuncles or folliculitis.

Linezolid is effective against many strains of MRSA and streptococci. However, its use should be limited to patients with a documented infection who have not benefitted from sensitive antibiotics because of potential toxicities or cost. Oral cephalexin (or other cephalosporins or penicillins) should not be used because these antibiotics would not be effective against MRSA if used empirically. In addition, antimicrobial therapy in this patient would more appropriately be guided by culture and sensitivity results.

Parenteral therapy for skin and soft-tissue infections should be considered in patients with extensive involvement, in patients with evidence of systemic involvement, or patients who are immunocompromised. Although vancomycin is effective against possible MRSA, parenteral therapy would not be appropriate in a stable, otherwise healthy man without any signs of systemic infection, particularly without a confirmed MRSA infection.

Key Point

  • In managing a superficial skin infection, a culture of the pustule is important to determine both the causative organism and the antibiotic susceptibility pattern.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

The real reason we think plastic surgery is just boob jobs and tummy tucks

July 14, 2017 Kevin 0
…
Next

Go ahead and call me bossy. Bossy saves lives.

July 15, 2017 Kevin 1
…

ADVERTISEMENT

Tagged as: Infectious Disease

Post navigation

< Previous Post
The real reason we think plastic surgery is just boob jobs and tummy tucks
Next Post >
Go ahead and call me bossy. Bossy saves lives.

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • For medical students: 20 pearls to honor every clinical rotation

    Ton La, Jr., MD, JD
  • Skin-in-the-game doesn’t have to be scary

    Ronald Dixon, MD
  • The fight to save Howard University College of Medicine

    Vicky Li and Naveen Balakrishnan

More in Conditions

  • Finding healing in narrative medicine: When words replace silence

    Michele Luckenbaugh
  • Why coaching is not a substitute for psychotherapy

    Maire Daugharty, MD
  • Why doctors stay silent about preventable harm

    Jenny Shields, PhD
  • Why gambling addiction is America’s next health crisis

    Safina Adatia, MD
  • How robotics are reshaping the future of vascular procedures

    David Fischel
  • How the shingles vaccine could help prevent dementia

    Marc Arginteanu, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...