A 53 year old male presented to the Newport Emergency Department complaining of worsening pain and redness to the anterior shin of the right leg. He had scratched his leg 6 days ago while working in his garden. The next morning, when he noted the leg to be getting more painful and red, he went to an urgent care center and was diagnosed with cellulitis. He was started on Keflex 500 milligrams BID, which he has been taking regularly but he reports the redness has been spreading and the pain had remained stable. He denies fevers, numbness, tingling, or weakness in the leg.

On exam, there is a 6 x 10 cm area of erythema and exquisite tenderness to palpation in the anterior, lower right leg. No appreciable swelling. There is a 3 cm linear scratch in the center of the erythema. The patient was afebrile with normal vital signs. Basic labs were drawn and were unremarkable with a white count of 8.3.

The patient has obviously failed this course of oral antibiotics. What would you do?

Switch to Bactrim or Clindamycin to increase MRSA coverage? Admit for IV antibiotics?

Before making this decision, however, we needed to consider the question of why the patient wasn’t responding to the Keflex. Given the size of the scratch on his leg and the fact that this was caused by something from his garden, we needed to consider the possibility of a retained foreign body. You would expect that if there was retained foreign material, it might be wood and would not show up on X-ray. A bedside soft tissue ultrasound in two planes was performed and the images are shown below.

Time to go fishing... 

The patient was treated with a dose of Clindamycin and given his overall well appearance with no fevers and normal white, he was discharged home on Clindamycin. 

Faculty Reviewer: Dr. Kristina McAteer