Molly, a 39-year-old woman, presented at a neighborhood free clinic complaining of fever, chills and a large ulceration on her right upper arm. Molly is well known to the staff as a frequent visitor with a history of I.V. drug use. After waiting for about 3 hours, she was shown to an examination room.

Molly's fever at that time was 38.9oC, her breathing and pulse were normal and her blood pressure was 140/90 mm Hg. The right upper arm carried a foul smelling, necrotic abscess about 4 cm in diameter. Draining pus was noted from the ulcer.

Draining ulcer - right upper arm

Crepitation from below the elbow and the whole upper arm was noted and an X-ray and a CT scan of the arm were ordered.

X-ray and CT-scan reveal extensive gas in the soft tissues from the elbow to the shoulder of the right arm.

Exudate from the abscess was collected, Gram stained and submitted for microbiological workup. Blood was drawn for analysis as well. Gram stains showed a mixture of Gram+ rods and Gram+ cocci. There were at least two different sizes of cells seen among the cocci.

Meanwhile the abscess was drained and the whole area was surgically debrided. While awaiting culture results the patient was begun on penicillin and gentamicin.

Results from the hematology lab included:

hematocrit, 27%

hemoglobin, 8.2g/dL

leukocyte count 18,000 / mm3 with

88% segmented neutrophils
7% band forms
3% lymphocytes
2% monocytes

Cultures grew four different bacterial species:

Group F streptococci
Clostridium clostridiforme
Staphylococcus aureus
Anaerobic streptococci

In light of culture results, a cephalosporin was substituted for the penicillin. Molly was admitted to a local hospital. Her condition improved and she was discharged 5 days later. She will continue to visit the clinic every other day for the next two weeks to complete a course of antibiotics and to check on the resolution of the abscess. Attempts were made during the hospital stay to arrange for drug counseling and to locate a treatment program for Molly. Plans for follow-up through the clinic were put in place.