P3.109: Rural Dominican Republic Clinic Case Report: 14 Year-Old Male Patient with a Lateral Malleolar Ulcer and Chest Abscess Secondary to Spider Bite

Introduction: Skin infections are a common presentation of illness particularly in impoverished global communities where sanitary conditions are poor and residents lack readily accessible antimicrobial agents. The presence of a chest abscess in conjunction with an extremity infection is an uncommon presentation. In this case, a patient being treated at a rural clinic in the Dominican Republic presented with a lower extremity skin wound and complaints of chest pain.

Case Description: The patient was a 14 year-old male patient of Haitian-Creole ethnicity. His presenting symptoms included difficulty walking, and weight-bearing issues of the left leg, and right lateral chest pain. History of present illness included a report of a presumed tarantula bite approximately two weeks prior. On exam, the patient was tachycardic, diaphoretic, and demonstrated a large soft tissue ulcer on the lateral malleolus. The ulcer (seen in Figure 1) had clean margins, was approximately 5cm in diameter, and was limited to the soft tissue. Portable ultrasound of the right lateral chest was completed and a complex abscess was visualized. Using sterile technique, a small incision was completed and approximately 200cc of purulent fluid was expressed from the wound. The lateral malleolus was irrigated with 2L of pressured bottled water and wrapped in sterile bandage. The patient and a neighbor, who was present during the visit were instructed to leave the chest incision open/uncovered overnight. He received a 3-week course of metronidazole and cephalexin and instructions to return the following day. The next day, the patient reported significantly improved pain and presented with normal vital signs. He was instructed to complete the entire course of antibiotics and seek medical attention with any recurrence of fevers or diaphoresis.

Discussion: Typically a tarantula bite causes localized inflammation and pain and rarely progresses to the severity seen in this patient. The suspected etiology of this case is that the bite led to a bacterial-driven soft tissue infection with subsequent seeding and development into a chest wall abscess. This presentation was worsened by poor sanitation practices and home environment. Due to the language barrier and lack of a parent or guardian present, it was difficult to elicit what exactly had resulted in this patient developing such a severe presentation.

Conclusion: This case highlights the importance of having access to multidisciplinary clinical management resources in rural, global communities. This clinic was run by international and local physicians and the management was led by a pediatric infectious physician with extensive global health experience. Due to the appropriate drainage procedure completed by the emergency medicine trained physicians and the selection of appropriate antibiotic coverage by the infectious disease specialist, this patient was able to have a dramatic improvement within 24 hours of treatment.