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

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

  • Institutional reporting systems discourage clinical honesty

    Jenny Shields, PhD
  • How doctors can turn criticism into collaboration

    Mary Remón, LCPC
  • Nurse-initiated protocols for sepsis: a strategic imperative for patient care and hospital operations

    Rhonda Collins, DNP, RN
  • How molecular discoveries are transforming preeclampsia prediction and care

    Thomas McElrath, MD, PhD and Kara Rood, MD
  • How neuroplasticity offers hope for complex PTSD

    Hannah Holmes
  • New treatments for enlarged prostate offer faster relief with fewer side effects

    Martina Ambardjieva, MD, PhD
  • Most Popular

  • Past Week

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Why rigorous training is vital for today’s surgeons

      Philip Alford, MD | Physician
    • Why telling kids to eat less and move more fails to address obesity

      Callia Georgoulis | Conditions
    • The hidden reason your vacations never feel like enough

      Kent DeLay, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • The hidden reason your vacations never feel like enough

      Kent DeLay, MD | Physician
    • Confronting the return of measles and vaccine misinformation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Institutional reporting systems discourage clinical honesty

      Jenny Shields, PhD | Conditions
    • How doctors can turn criticism into collaboration

      Mary Remón, LCPC | Conditions
    • Building trust in dyad leadership partnerships

      Amir Atabeygi, MD, MHA and Christina Mitchell, MHA | Physician
    • The hidden moral injury behind value-based health care

      Jonathan Bushman, DO | Physician

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

  • Most Popular

  • Past Week

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Why rigorous training is vital for today’s surgeons

      Philip Alford, MD | Physician
    • Why telling kids to eat less and move more fails to address obesity

      Callia Georgoulis | Conditions
    • The hidden reason your vacations never feel like enough

      Kent DeLay, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • The hidden reason your vacations never feel like enough

      Kent DeLay, MD | Physician
    • Confronting the return of measles and vaccine misinformation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Institutional reporting systems discourage clinical honesty

      Jenny Shields, PhD | Conditions
    • How doctors can turn criticism into collaboration

      Mary Remón, LCPC | Conditions
    • Building trust in dyad leadership partnerships

      Amir Atabeygi, MD, MHA and Christina Mitchell, MHA | Physician
    • The hidden moral injury behind value-based health care

      Jonathan Bushman, DO | Physician

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...