OK, I haven't been a nurse forever, but it sure feels like it. Especially when a new resident comes to me complaining about a "rash" she's had for over a year despite multiple trips to her primary care physician, a pharmacy's worth of ointments and pills and anti-itch creams, and now a referral to a dermatologist whom she can't even get in to see until May. She even saw her PCP last Tuesday, and he apparently told her she has to "live with it" till she can get in to the skin doc.
I took one look at it and went She has, literally, at least fifty "spider-bite" lesions in various stages all over her legs, arms, back, and abdomen. Several of them have yellowish exudate and look infected, while others are obviously older and have the characteristic reddish-black craters in the middle..........and if it's not MRSA, I'll eat my nursing cap!! This poor woman is 96 years old, still fairly sharp mentally but she's no bigger than a minute.........what I don't understand is why her PCP hasn't been able to diagnose it when I, a 'mere' nurse, can glance at it and know immediately what it is. I've seen way too much of this stuff not to recognize it; heck, I've had a couple of bouts with MRSA myself. How could an MD NOT catch this??
Luckily, the PCP was receptive to my urgent fax describing my findings ("please schedule an appointment ASAP"), but MRSA is so prevalent in the community now, it blows my mind that a medical doctor can miss it. So now I wonder: is it common for physicians not to recognize this infection? And if so, does this mean that community-based nurses need to start stripping new move-ins down to their skivvies and doing complete skin examinations?
I already know the answer to that last question........but I'm still shocked. And after fifteen years in health care, I'd thought I was pretty much un-shockable.:uhoh21:
Specializes in LTC, assisted living, med-surg, psych.
That's what I think happened. I don't think she had MRSA to start with either, but she's got it now. Orders came in today for ABX and follow-up next week.
"Healing is problematic in some patients. Until recently, we did not fully understand that venom factors can remain in bite lesions for a relatively long time or that a bite we are treating is actually a recurrence rather than the initial lesion. (29) In patients with more severe bites, eschar may take months to develop and the skin may take several months more to heal. (1) These wounds may progress to significant tissue loss and spreading of ulcerations.
Delayedwound healing can occur despite appropriate medical treatment. (29) Why bites do not promptly heal is not clear, but the persistence of venom in the wound or the generation of secondary inflammatory mediators may play a role. In one study of brown recluse spider bites, Rees et al reported that some patients who had received skin grafts experienced repeated graft rejections for no obvious reason. (29) Eventually, the authors realized that these patients had developed pyoderma gangrenosum. Our patient 2 developed contact dermatitis, which manifested as several satellite lesions on the face, neck, and arm. Although the diagnosis of pyoderma gangrenosum was not made in this patient, the persistent presence of venom or secondary inflammatory mediators may have provoked the dermatitis that she did develop. Pyoderma gangrenosum as a complication of brown recluse spider bites appears to be associated with predisposing factors such as surgery near the time of the bite or a personal or family history of rheumatoid arthritis, ulcerative colitis, or Crohn's disease. (1)
Recurrent lesions may arise months after the bite and in adjacent areas. (29) Hoover et al advocated life-long follow-up at 6-month intervals in such patients to look for the development of squamous cell carcinoma. (30) Because the clinical course of healing is so difficult to predict with any brown recluse spider bite, reconstruction should not be attempted until healing is complete.
1. This and other similar published articles like this one clearly indicate recurring and difficult lesions are present in pt's who have encountered documentedand confirmed Brown Recluse spider bites. (Translation: Not misdiagnosed or suspected MRSA cases.)
2. There doesn't appear to be any specific information which firmly suggests that you can tell the "visual differences" between MRSA or Spider Bites nor is the specific "length of time" lesions present themselves on the body alone can be in anyway considered as a main contributing conclusion diagnostic factor.
3. We must keep an open mind that there are quite literally 100's of other types of non infectious skin abnormalities that can equally present, visually appear and symptomatically seem like an MRSA or Spider Bite has occurred. (Lyme's disease comes to mind)
I'm not claiming to be an expert on the subject of spider bites vs. MRSA lesions however, I admit sometimes a little independent and somewhat interesting research on the subject does somehow make the proverbial noggin tick a little bit faster in the race doesn't it? :)
That's what I think happened. I don't think she had MRSA to start with either, but she's got it now. Orders came in today for ABX and follow-up next week.
Good catch then. Easy to overlook a developing abscess in skin that is already diseased.
Especially when a new resident comes to me complaining about a "rash" she's had for over a year despite multiple trips to her primary care physician, a pharmacy's worth of ointments and pills and anti-itch creams, and now a referral to a dermatologist whom she can't even get in to see until May. She even saw her PCP last Tuesday, and he apparently told her she has to "live with it" till she can get in to the skin doc.
She has, literally, at least fifty "spider-bite" lesions in various stages all over her legs, arms, back, and abdomen. Several of them have yellowish exudate and look infected, while others are obviously older and have the characteristic reddish-black craters in the middle..........and if it's not MRSA, I'll eat my nursing cap!! This poor woman is 96 years old, still fairly sharp mentally but she's no bigger than a minute.........what I don't understand is why her PCP hasn't been able to diagnose it when I, a 'mere' nurse, can glance at it and know immediately what it is. I've seen way too much of this stuff not to recognize it; heck, I've had a couple of bouts with MRSA myself. How could an MD NOT catch this??
VivaLasViejas, ASN, RN
22 Articles; 9,996 Posts
That's what I think happened. I don't think she had MRSA to start with either, but she's got it now. Orders came in today for ABX and follow-up next week.