by LISA SANDERS, M.D.
The 73-year-old man looked up at the clear summer sky — the morning was nearly gone. He had finished mowing the main part of his lawn and was trimming the edges near the shrubbery with the weed wacker. He wanted to finish before the sun and heat made the work too hard. Suddenly he felt a sharp sting on the lower part of his shin. He glanced down at his bare leg. Nothing there. He still had the hedges to trim, so he kept working. He quickly finished the needed pruning, then moved on to the inside tasks he had planned.
It was late afternoon when the man called it a day and went to clean up before joining his family for dinner. Only in the shower did he take a good look at his leg. He found a distinct puncture mark where he had felt the sting, but it was just a dot — no big deal. Two days later, though, he noticed that the dot was now surrounded by a faint circle of red. He showed it to his wife, and she was concerned. She suggested he use an antibiotic ointment. She had some Neosporin on hand, and he applied it generously. Then he called to make an appointment with his doctor at the Hospital of St. Raphael’s Adult Primary Care Center in New Haven, Conn., just in case that wasn’t enough.
The next morning, he was glad he did. The circle of red was much bigger — about the size of a quarter — and a lot darker. And it was starting to hurt.
His usual doctor wasn’t available, so he had made his appointment with the advanced-practice nurse, Jana Young. She listened to the man’s story and his wife’s concerns as she looked at the red ring on his leg. It was slightly raised, with a clearing directly around the healing puncture site. When she touched the wound, it was tender, and the skin felt thickened and lumpy. There was no discharge, no crusting, no pus. It didn’t look like an infection. In fact, it didn’t look like anything she’d seen before. She brought in a colleague, an internist in the practice. He wasn’t sure what it was, either.
This probably isn’t an infection, Young told the man. It’s probably just the normal course of whatever kind of bite you got. But just in case she was wrong and the site was developing an infection, she marked the outer border of the lesion with a permanent marker and told the man to start taking an antibiotic called cephalexin, which she would call in to his pharmacy, if the red spread outside the line.
A Growing Red Blotch
At home the man tried not to worry, but the rash seemed to get larger and redder right in front of his eyes. The next day, he thought it was bad enough to start the antibiotics. He took the medication for the next three days. Nothing changed. The red circle continued to slowly spread outward. So five days after his first appointment, the man was back at his doctor’s office.
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