On exam, he had an indurated 7x5cm tender, erythematous swelling with mild fluctuance overlying the R inguinal fold. There was no crepitus or discernible pulsatility. All distal pulses were 2+. Genital exam was normal. Proximity to femoral vessels was presumed, so bedside ultrasound was performed prior to planned incision and drainage of the abscess.
Here the collection looks nice and abscess-y. There is layering internal debris, irregular cavity contour, even some overlying subcutaneous edema (cobblestoning) consistent with cellulitis. No soft tissue gas.
The velocity is set low here, but there seems to be some pulsatile flow at the edge of the abscess cavity. Given that the femoral vessels were not clearly distinguished, I&D was deferred and CT abdomen and pelvis with IV contrast was ordered for anatomic detail.
Radiology Attending #1, calling with critical findings on CT: This is weird. It could be a lymph node or an abscess or a vascular lesion. [Thanks] Might be some kind of vascular thing? But it’s not necrotizing fasciitis. Get a formal ultrasound so I can really see. And also, there’s cellulitis.
Vascular Surgery: Well, I see what they mean about “involving adjacent vessels,” but I don’t know that means this is *vascular,* you know? Did anybody think about cancer? This could be cancer. Let me call you when the ultrasound is back.
Vascular Surgery: Actually, get an MRI. Then we’ll know for sure.
Radiology Attending #1: This venous ultrasound shows a partially thrombosed pseudoaneurysm.
Vascular Surgery, immediately followed by radiologist #1: No, no, I know you specifically asked, and I know I *said* order a venous ultrasound but I meant an arterial study.
Radiology Attending #1: OK, I mean it this time. Mystery solved on this arterial study. This is definitely a pseudoaneurysm. And cellulitis. Thank you for your patience.
Vascular Surgery: Well. That’s not good.
Radiology Attending #2, MRI: This is a phlegmon and not a pseudoaneurysm. But yes, cellulitis.
To be fair, on a bad day, this could be cancer.
Vascular Surgery: I told you!
Emergency Medicine: Well, I already started some antibiotics. Anybody mind if I just stick around in the chat and read all the messages but don’t contribute anything else?
Hospital Medicine has entered the chat: This is probably some sort of STD
General Surgery: Thank you for this interesting consult, but I’m not cutting into that. By the way, since you asked me, it looks like a *vascular* lesion
Vascular Surgery: I can hear you. I’m standing right here. I’m still not cutting into that.
General Surgery: OK, let IR do it.
[Interventional] Radiology Attending #3: Thank you for this interesting consult for this pleasant young man with arterio-venous-pseudoaneurysm-cellulitis-abscess-phlegmon. I have reviewed the pertinent images and I don’t see anything to biopsy or drain here.
P.S I think this might be a lymph node or other "mass." Did anybody consider cancer? You see, what I mean is, I’m not cutting into that.
Hospital Medicine Guys, this could still be an STD. Not HIV or LGV or syphilis though. Those tests are negative. Maybe TB? In the groin. Let’s do some new antibiotics.
Infectious Disease has entered the chat: O wow, not COVID. Um, probably cat scratch disease?
Patient: Well this has been fun. You guys wanna give me a call when you come up with something?
All: YES! END (not really)
Please don’t cut into an "abscess" anywhere before doing a quick bedside ultrasound. People can sometimes have weird things on their insides, and you could set off bleeding that you can’t control, inoculate bacteremia, disseminate TB, create a fistula, biopsy a thyroid, mutilate a kerion, or start spreading cancer. Oh, you were hoping I’d tell you what it is? Still working on it.
This case made me think of a poem my parents used to make me read as a child. You probably know it. The one about 6 blind men meeting an elephant, which ends:
Each in his own opinion Exceeding stiff and strong, Though each was partly in the right, And all were in the wrong!
Tricia A. Smith, MD, MPH
Assistant Professor
Department of Emergency Medicine
Emory University School of Medicine
Attending Physician
Emory University Hospital
April 2021