[Skip to Content]

Quiz

Dermatology

Fever, Hypotension, and a Worsening Necrotic Wound

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: March 21, 2022

JAMA Clinical Challenge

Article Information and Disclosures

Danielle M. Peterson, MD¹;

William E. Damsky, MD, PhD^1,2;

Matthew D. Vesely, MD, PhD¹

Author Affiliations

¹Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
²Department of Pathology, Yale School of Medicine, New Haven, Connecticut

Read article on JAMA Network

Read Case Take Quiz Answer

On the day of giving birth via a normal vaginal delivery, a healthy woman in her 20s developed painful swelling on her right thigh, at the site of a methergine injection administered 1 day prior. Despite 3 days of treatment with an oral antibiotic (cefalexin), her thigh pain and swelling did not improve, and she was readmitted to the hospital and intravenous clindamycin was started. Wound cultures and blood cultures obtained during incision and drainage performed on hospital day 1 were negative for bacterial, mycobacterial, and fungal organisms. The following day, her temperature was 39.4 °C (102.9 °F), blood pressure was 86/42 mm Hg, and heart rate was 131/min. She was transferred to the intensive care unit for presumed septic shock, and her antibiotics were changed to vancomycin and meropenem. Surgical debridement of the right thigh was performed on hospital day 3.

Take Quiz

Please finish quiz first before checking answer.

On the day of giving birth via a normal vaginal delivery, a healthy woman in her 20s developed painful swelling on her right thigh, at the site of a methergine injection administered 1 day prior. Despite 3 days of treatment with an oral antibiotic (cefalexin), her thigh pain and swelling did not improve, and she was readmitted to the hospital and intravenous clindamycin was started. Wound cultures and blood cultures obtained during incision and drainage performed on hospital day 1 were negative for bacterial, mycobacterial, and fungal organisms. The following day, her temperature was 39.4 °C (102.9 °F), blood pressure was 86/42 mm Hg, and heart rate was 131/min. She was transferred to the intensive care unit for presumed septic shock, and her antibiotics were changed to vancomycin and meropenem. Surgical debridement of the right thigh was performed on hospital day 3.

Sign in to take quiz and track your certificates

Buy This Activity

Article Information

Corresponding Author: Matthew D. Vesely, MD, PhD, Department of Dermatology, Yale School of Medicine, 333 Cedar St, PO Box 208059, New Haven, CT 06510 (matthew.vesely@yale.edu).

Published Online: March 21, 2022. doi:10.1001/jama.2022.2806

Conflict of Interest Disclosures: Dr Vesely reported that his spouse is an employee of Regeneron Pharmaceuticals. Dr Damsky reported serving as a consultant for Pfizer, Eli Lilly, and TWi Biotechnology; receiving research funding from Pfizer; and receiving licensing fees from MilliporeSigma. No other disclosures were reported.

Funding/Support: Dr Vesely is supported by a Dermatology Foundation Career Development Award, the Melanoma Research Alliance, and the National Center for Advancing Translational Sciences (KL2 TR001862). Dr Damsky is supported by the National Institute of Allergy and Infectious Diseases (K08AI159229).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient for providing permission to share her information.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.