22-Year-Old Male with Suspected Staphylococcal Skin and Soft Tissue Infection

Case at a Glance

A 22-year-old male presents with a non-healing traumatic wound on his arm and secondary lesions in bilateral axillae following recent shaving, concerning for staphylococcal skin and soft tissue infection.

Patient's Story

The patient reports sustaining a significant contusion to his forearm over one week prior, which resulted in an open wound. Despite time for natural healing, the wound has shown minimal improvement and remains symptomatic. He describes the formation of a scab that is associated with mild to moderate pain. Additionally, he reports the recent appearance of similar painful, scabbed lesions in both axillary regions, which coincided with recent shaving of the area. Concerned about the lack of healing and spread of lesions, he sought medical attention.

Initial Assessment

Physical examination revealed a traumatic wound on the forearm with scab formation and surrounding inflammation. Multiple similar lesions were noted in bilateral axillary regions with characteristics consistent with secondary bacterial infection. The patient appeared otherwise well with no systemic signs of infection documented at the time of evaluation.

The Diagnostic Journey

The patient presented to urgent care for evaluation of his non-healing wound and new lesions. Clinical assessment suggested a bacterial skin and soft tissue infection, with the pattern and appearance raising suspicion for staphylococcal etiology. The temporal relationship between shaving and axillary lesion development, combined with the primary traumatic wound, supported the diagnosis of secondary bacterial infection with possible auto-inoculation.

Final Diagnosis

Suspected staphylococcal skin and soft tissue infection with primary focus at traumatic forearm wound and secondary lesions in bilateral axillae, likely related to folliculitis post-shaving with bacterial spread.

Treatment Plan

Empirical antibiotic therapy was initiated to target suspected staphylococcal infection. Patient was provided with wound care instructions including proper cleaning and dressing techniques. Education was given regarding hygiene practices, particularly related to shaving and wound care to prevent further spread or recurrence.

Outcome and Follow-up

Patient was advised to monitor for signs of clinical improvement with antibiotic therapy and to return for follow-up if symptoms worsen or fail to improve within the expected timeframe. Instructions were given to watch for signs of systemic infection or complications requiring immediate medical attention.