Scabies outbreaks are relatively common worldwide, particularly in communal living settings such as military barracks. The infestation is caused by the parasite Sarcoptes Scabiei and is easily treated once properly diagnosed. Classic symptoms include pruritus around the waist, wrists, and ankles.1 On physical examination, linear burrows visualized in finger web spaces is a typical finding.1 It is not uncommon, however, for scabies to present with a variety of other dermatologic manifestations, which can lead to a delayed or missed diagnosis. This case highlights a delayed diagnosis of scabies, initially presenting as urticaria in a 26-year-old active duty male living in military barracks where multiple previous outbreaks were identified. Providers should be aware of the oftentimes-elusive diagnosis of scabies and the many nonclassic dermatologic manifestations. A thorough skin examination with skin scrapings and examination of the finger web spaces should be considered in those with ambiguous skin rashes who are particularly at risk for scabies infection, such as military recruits, submariners, and other service members living in communal settings. Timely and accurate diagnosis and treatment is crucial to prevent reinfection and spread of scabies throughout these communal living settings.
A 63-year-old man presented with an expanding wound on the dorsal aspect of the left hand after striking it on a wall. He sustained a small laceration that progressively became more edematous and developed a violaceous border. He presented to the emergency department the following day and was prescribed bacitracin with no improvement in the lesion. He returned to the emergency department after the symptoms worsened and was subsequently prescribed a 10-day course of oral trimethoprim-sulfamethoxazole (1600/320 mg) twice daily. Physical examination at a follow-up visit 11 days after the initial injury revealed an expanding, 4.3×5.0-cm, ulcerated wound with surrounding erythema and serosanguineous drainage (left). He was started on a 10-day course of amoxicillin-clavulanic acid (1750/250 mg) twice daily and underwent debridement the same day. On postoperative day 2 (13 days following the onset of symptoms), the wound had not improved, and 2 new 1-cm bullae on the left first and second fingers had progressed (right). Erythrocyte sedimentation rate (33 mm/h [reference range, 0-10 mm/h]) and C-reactive protein (3.701 mg/dL [reference range, 0-0.747 mg/dL]) were elevated; however, other laboratory studies, including a complete blood cell count, were within reference range. He remained afebrile, and a review of systems was normal. Punch biopsy specimens were obtained. WHAT'S THE DIAGNOSIS? a. blastomycosislike pyoderma b. bullous cutaneous small vessel vasculitis c. Mycobacterium marinum (fish tank granuloma) d. necrotizing fasciitis e. neutrophilic dermatosis of the dorsal hands
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