[Differential diagnosis of "sterile" phlegmonous hand infections].
BACKGROUND
Bacterial infections represent a large proportion of emergencies in hand surgery. In some cases, pyoderma gangrenosum and mycobacterial infection may present with the same symptoms of swelling, pain, and purulent secretion. In these cases, operative treatment would be harmful. Therefore two cases-pyoderma gangrenosum and tuberculosis-are presented here in relation to common bacterial hand infection.


METHODS
Using two case reports of diseases that only rarely affect the hands, their relevance to differential diagnosis is shown with reference to the literature.


RESULTS
In both cases, we found clinical symptoms of bacterial hand infection with negative bacterial smear tests. After several debridements, pyoderma gangrenosum of the dorsum of the hand was diagnosed in one patient after pyodermiform lesions at the thigh and the nasal septum were detected and pre-existing colitis ulcerosa was taken into consideration. Corticoid therapy induced complete remission. The second patient with similar clinical symptoms had been operated on at another hospital several times before being transferred to our institution. The presumptive diagnosis of pyoderma gangrenosum was made, and under treatment with prednisone the symptoms quickly improved. After 2 weeks, the wound conditions and the patient's condition rapidly worsened. Following amputation at the upper arm level, the patient died of septic multiple organ failure. Autopsy studies revealed tuberculous sepsis originating from the hand.


CONCLUSIONS
Patient history should be evaluated carefully because of its value to correct diagnosis. In case of negative smear tests, especially from immunocompromised, elderly patients and in patients with a history of pulmonary tuberculosis, Ziehl-Neelsen staining should be obtained. In case of multilocular affection or pre-existing chronic inflammatory bowel disease, the presumptive diagnosis of pyoderma gangrenosum can be confirmed by biopsies from the lesions margin. In both cases, unnecessary traumatizing operations could thus be avoided and treatment optimized.
Universitätsklinik für Plastische Chirurgie und Schwerbrandverletzte, Handchirurgiezentrum, Operatives Referenzzentrum für Gliedmassentumoren, BG-Kliniken Bergmannsheil-Bochum, Ruhr-Universität Bochum. adrien.daigeler@rub.de
A
A
Daigeler
M
M
Lehnhardt
M
M
Helwing
L
L
Steinstraesser
H-H
HH
Homann
H-U
HU
Steinau
D
D
Druecke
D000328:Adult; D000368:Aged; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000097:blood; D001424:Bacterial Infections / Q000175:diagnosis* / Q000601:surgery; D002481:Cellulitis / Q000175:diagnosis* / Q000601:surgery; D003646:Debridement; D003937:Diagnosis, Differential; D016267:External Fixators; D017809:Fatal Outcome; D005260:Female; D006225:Hand / Q000601:surgery; D006801:Humans; D010020:Osteonecrosis / Q000175:diagnosis / Q000601:surgery; D017511:Pyoderma Gangrenosum / Q000175:diagnosis* / Q000601:surgery; D013524:Surgical Flaps; D014391:Tuberculosis, Miliary / Q000175:diagnosis* / Q000601:surgery; D014955:Wrist Joint / Q000601:surgery
D019268:Antibodies, Antineutrophil Cytoplasmic