Bilateral Ankle Inflammation in a 34-Year-Old Male: Diagnostic Challenge

Case at a Glance

A 34-year-old male office worker presented with bilateral ankle erythema, swelling, and systemic symptoms initially diagnosed as cellulitis, but showed poor response to penicillin therapy with worsening bilateral involvement.

Patient's Story

The patient, a sedentary office manager with obesity (BMI 37.6), presented with a 1.5-week history of bilateral ankle symptoms. He reported initial onset of unexplained fever 3 weeks prior that resolved spontaneously. Subsequently developed bilateral ankle erythema, intense warmth, mild edema, and significant Achilles tendon stiffness. Associated symptoms included recurrent fever, flu-like symptoms, and generalized joint aches. The patient noted that fever responded temporarily to acetaminophen but returned cyclically with profuse sweating.

Initial Assessment

Primary care physician diagnosed cellulitis of the right lower extremity based on clinical presentation of erythema and warmth. Patient was prescribed a 7-day course of penicillin V, along with diclofenac 50mg and acetaminophen for symptomatic relief. Initial improvement was noted mid-treatment with patient able to work with legs elevated.

The Diagnostic Journey

Despite antibiotic therapy, patient experienced significant symptom recurrence over the weekend with worsening bilateral ankle involvement, persistent fever, and increased pain. The bilateral nature of the condition, poor response to penicillin, and systemic symptoms raised questions about the initial cellulitis diagnosis. Differential considerations included stasis dermatitis with secondary infection, erythema nodosum, or other inflammatory conditions.

Final Diagnosis

Pending further evaluation - Initial diagnosis of cellulitis questioned due to bilateral presentation and treatment failure

Treatment Plan

Patient scheduled for follow-up evaluation to reassess diagnosis. Considerations for alternative antibiotic therapy based on local resistance patterns, additional diagnostic testing, and evaluation for underlying inflammatory or venous conditions. Symptomatic management with acetaminophen and anti-inflammatory medications continued.

Outcome and Follow-up

Patient remains symptomatic at completion of initial antibiotic course with bilateral ankle involvement and recurrent fever. Follow-up appointment scheduled for diagnostic reassessment and potential treatment modification.