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JAMA Surgery Clinical Challenge
July 2017

An Uncommon Occupational Lesion

Author Affiliations
  • 1Department of Otorhinolaryngology–Head and Neck Surgery, Institut Claudius Regaud, Institut Universitaire du Cancer, Toulouse, France
  • 2Dermatologist–Oncology and Clinical Research Units, Institut Claudius Regaud, Institut Universitaire du Cancer, Toulouse, France
  • 3Orthopedic and Plastic Department, Clinique Médipole Garonne, Toulouse, France
JAMA Surg. 2017;152(7):703-704. doi:10.1001/jamasurg.2017.0844

A 35-year-old white head and neck surgeon with an unremarkable medical history was referred to the Surgical Emergency Department for a phlegmon of the flexor tendon sheath of the right hand. The lesion progressively developed several days after an unintentional exposure to blood with a blade used to drain an abscess of the oral cavity. The patient presented a deep wound induced by the bistoury piercing of the index finger pulp of the right hand, with a disrupted epidermal barrier. Both the patient who was operated on and the surgeon were negative for human immunodeficiency virus and hepatitis B/C virus testing. A soft tissue abscess of the digit appeared 7 days after the initial trauma. Antibiotic therapy combining amoxicillin and clavulanate was started, without any significant improvement. Surgery was performed urgently, with excision of the wound entrance and washing of the flexor tendon sheath. Bacteriological swabs were performed in the same time. An antibiotic regimen with amoxicillin/clavulanate was prescribed. Forty-eight hours after surgery, pustules appeared. Further drainage and washing of the sheath were repeated (Figure, A). The bacteriological samples were found to be sterile. The surgeon was hospitalized for infusions combining piperacillin/tazobactam and teicoplanine, carried out over 72 hours. An oral antibiotic regimen with amoxicillin/clavulanate (3 g every 24 hours) was prescribed for 10 additional days. The lesions completely resolved within 2 weeks. One year later, the surgeon presented with prodromal burning pain of the same index finger, and a similar soft tissue abscess recurred after 48 hours at the same site of the original lesion with a small painful vesicle progressively developed (Figure, B).

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