Forum for Clinical and Surgical Oral Pathology

Case BBOPF 07-1 - Episode II

The Rest of the Story

This patient had a staphylococcal infection of his inferior lip. One can see some evidence of pustules in the first set of photos taken on the "Friday afternoon". These are highly suggestive, but not, pathognomonic of Staph. There are other signs and symptoms, discussed below.

The patient had apparently manipulated a small furuncle and it expanded rapidly into his lip. Rapidly spreading staphylococcal infections into soft tissue are often contained by the staph toxins. In contrast, rapidly spreading streptococcal infections are often not contained and can race across the face (erysipelas), down the neck, through the orbit, or down the parapharyngeal tissues. As most know, most, but not all, morbidity from staphylococcus is due to toxins, naturally produced poisons. Staph in the blood stream can be deadly, and can cause severe endocarditis and literally "burn out" a heart valve quickly. These type of infections are common in intravenous drug abusers, who often have resistant strains of the organism and are best admitted to the hospital if they have an abscess. That was not the issue in the present case.

On taking a full history, this patient had recently traveled to India, which was irrelevant to his present illness. There are various parasites and venoms that could have caused his lip swelling, but there was too much time elapsed from his travel to the present situation for them to be likely.

Although this was originally thought to be a herpes simplex infection of the lips (herpes labialis - "cold sore(s)"), there was no antecedent infection with the virus, typical lesions, and none of the usual signs and symptoms of viral illness. Initial herpes infections are often intra-oral and quite impressive. The thought of the original clinician was a good one, but not the correct one. If this was herpes simplex, the treatment would have been adequate, but it would be unlikely for the lip to have swelled as shown in the photos.

Angioneurotic edema is another consideration, but the appearance was not typical of this condition. The lips often seem "blown up" as if a balloon injected with air, and the lips are usually both, and symmetrically affected.

The fever and pattern of lymph nodes were suggestive of bacterial infection, and fit the likely diagnosis. While consistent, they are not unique to it.

Rapidly spreading, or enlarging, bacterial infections often do not produce culturable material. Until an abscess forms and localizes, cutting into the tissue is usually non-productive. Culturing the surface yields mixed flora and contaminants. Thus, at this stage, until and if an abscess formed, trying to obtain organisms would not be indicated.

The "golden crusts" of staph were seen in the initial photographs (slightly above the eschar where the patient had bled when the lip cracked). These were a "tip off" that staph was present as the infecting organism. Staph toxins also produce a "scalded skin" type of appearance, with some fluid under the epidermis. He had some indications of this, but the finding was not as impressive as in its usual appearance on the palms and soles.

The common approach to antibiotic therapy for staphylococcal infections which may be contaminated with streptococci is to use a broad spectrum agent such as cefazolin i.v. and/or cephalexin p.o. as first line agents. It would be equally appropriate to use amoxicillin/clavulanate as a p.o. agent. There are many other choices but it is important to select an antibiotic with good staphylococcal coverage. One must also be aware of resistant strains of staphylococci which are increasing in the community and in the hospital. So-called MRSA or Methacillin Resistant Staph Aureus is being seen more and more, and often i.v. vancomycin is required to contain it. There are also now vancomycin resistant strains, so this drug should not be used indiscriminately. Both doxycycline and TMP/SX (Bactrim or Septra) are reasonable agents for some staph, but resistance can occur quickly.

My diagnosis was thus Staphylococcal infection of the lip, likely Staph aureus. The patient was given iv. Cefazolin 2 gm, initially, and then high does cephalexin 1gm every 6 hrs for a day, followed by 500 mg every 6 hrs. He was also placed on a short course of prednisone to relieve the swelling in his lip, and pain medication.

Since Staphylococcal infections block lymphatics and cause swelling, it is important to dilate the arterial tree to make sure that antibiotics flow into the area. That was another reason for using steroids as an adjunct to the management. Gentle warm packs were encouraged, despite the swelling, to dilate the vasculature for the reasons given. A bland diet was prescribed. He was also given petrolatum to put on his very dry lips.

The patient had quick relief from his swelling, within 24 hours, and at follow-up the next day his lip was about 50% of the initial size. He also felt much better. By three days later (Monday) his lip was nearly back to normal size. He had put a bandage on it to "hide" his ugly lip, and when he stripped off the adhesive bandage his lip swelled back a little. The second set of photographs show this time frame. He reported that two days after initiating therapy there was a "good deal" of exudate from the cracked lips. This was sero-sanguinous in nature. Thus no true abscess ever formed and no area was available to incise and drain. He continued to return to normal appearance, and by a week later the entire matter had resolved.

Had the patient had a persistent fever over 101 F, any signs of a heart murmur, or failed to respond, he would have been admitted to the hospital. As demonstrated, out-patient management of a case such as this is possible, but the patient must be closely followed.

Whether this is a "medical" or "dental" case is subject to debate, dental practice acts notwithstanding. If one elects to manage such a case and it "goes sour", one must be in a position to defend the approach, care and management. Staph strains can be deadly organisms and I've seen the damage they can do enough times to be vigilant and respectful of their power.

I submitted this case since it was one of the more ebullient, non-traumatic lip enlargements I've ever seen.

I hope you found it both interesting and educational.

Cordially,

Robert S. Baratz, MD, PhD, DDS
Boston University School of Medicine
Department of Medicine
Quincy Medical Center
Departments of Medicine and Surgery

Images

(Click for a larger version)

(Click for a larger version)

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).