A 25-year-old man with no past medical history presented to the emergency department with bilateral hand pain. This was his third ED presentation. During his second visit, at an outside facility, he was diagnosed with cellulitis and prescribed doxycycline. Despite taking antibiotics for two days, the pain and swelling continued to worsen, particularly in the left third digit. Symptoms initially began six days prior to presentation, when he noticed a small, raised lesion to the palm of his right hand. Several days later, he observed swelling and redness to the dorsum of his left hand and middle finger. He also began having pain in his right thumb while reporting decreased range of motion in both wrists and hands. The patient reported having subjective fever five days prior and left knee pain two days prior. He denied history of trauma. The patient worked as a waiter in a restaurant and had no history of IV drug use but acknowledged intermittent use of cocaine and alcohol. The patient denied recent unprotected intercourse. He also denied dysuria, penile discharge, or genital lesions.
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Objectively, the patient presented afebrile, with a heart rate of 105 bpm and blood pressure of 139/88. On exam, his left hand had dorsal erythema and edema. His middle finger was held in flexion, swollen, tender to palpation, and painful with passive extension. The patient had limited active range of motion of the left wrist and middle digit with flexion. On the right hand, the patient had a 2 mm brown pustule on his palm. The right thumb was held in flexion with diffuse edema and had limited active range of motion due to pain. His left knee did not have any overlying skin changes or large effusions and had full range of motion without pain.
Soft tissue point-of-care ultrasound (POCUS) revealed fluid surrounding the flexor sheath at the left middle finger and also in the right thumb (see Figure 1). Laboratory was notable for a leukocytosis to 18.6, a C-reactive protein of 124.6, and an erythrocyte sedimentation rate of 50. Other basic laboratory results were normal. X-rays of the bilateral hands and left knee were unremarkable. Urine DNA amplification for gonorrhea and chlamydia were sent to lab.