A 23-year-old male with no significant medical history submitted a Health Services Request form for a “bump in his armpit that hurts and is not going away” last evening. He wrote that his cellmate says it is a keloid that looks infected. The request was triaged and Mr. Dukes was scheduled for Nursing Sick Call the next morning
Mr. Dukes arrived stating that he has a small, scar-like bump in his armpit for a while, but about 6 days ago it looked like a pimple had developed in it. It has continued to grow and become extremely painful. Last night he had slight chills and thought he had a fever, but did not see medical to get his temperature checked at that time. He states today the pain is 9/10, and is more like a stinging, burning pain that travels into his left inner elbow with any movement of his left upper extremity. He denied numbness or tingling of the left hand and fingers.
His cell-mate gave him some ibuprofen last night which he stated did not help the pain at all. He stated that about six months ago, before incarceration, he did have some smaller lesions, also in the left axilla, but they were not as “bulging” and definitely not as painful as this is. He states that he did not seek treatment because they basically went back to normal “on their own.” However, it looked like the scarring area had become thicker and in general, “worse.” When questioned further, he disclosed that he has had similar lesions on and off for many years. He did state that it seems like every time he has an episode when they got worse, the scarring part gets bigger. He states that he is having no itchiness or rash overall, as one would find if he had a sensitivity to the laundry or bathing soap.
The patient’s Review of Systems (ROS) is positive for subjective fever, chills, fatigue, and insomnia for one day due to painful left axilla. ROS is also positive for a painful, erythematous mass in his left axilla, he states for six days; with pain extending to the elbow, but does not travel to left hand or fingers. His ROS is negative for unintentional weight loss, weakness, numbness, tingling, and paralysis of his left upper extremity.
No known drug allergies; no known food allergies.
No medications routinely
Ibuprofen, two 200 mg tablets PO taken one time last night for left axillary pain
Vitals: 100.7°F, P 88, R 14, BP 128/72, HT: 5’9”, WT: 176 lbs, BMI: 26
General: A well-nourished young adult male of stated age, sitting on the examination table in slight discomfort. A&O ×4.
Skin, Hair, and Nails: Deeply seated, cord-like nodular lesion, elongated, 4 cm × 1 cm left axillary mass that is erythematous, tender, and swollen, extending distally to left anterior chest. Mass is slightly fluctuant at its center with multiple pointing white heads, diffusely warm. The skin surrounding the mass is slightly hard to palpation. No lacerations, open lesions, or drainage. No skin lesions or lacerations on any other area of the patient’s body (per his report and physical inspection).
Neck: Full Range of Motion, cervical and tonsillar lymphadenopathy, L +3, R +1
Lungs: Clear to auscultation bilaterally, without adventitious sounds.
Heart: S1, S2 RRR without murmurs, rubs, or gallops.
Musculoskeletal: Full Range of Motion of right upper extremity. Decreased Range of Motion left shoulder, eliciting severe pain with left upper extremity extension overhead with external rotation. Full Range of Motion left elbow, wrist, hand, and fingers.
Peripheral Vascular: Extremities warm throughout, BUE and BLE pulses 2+ and symmetric. capillary refill brisk, less than 2 seconds throughout. Upper and lower distal extremities without edema. No varicosities noted.
Neurologic: Cranial nerves II to XII grossly intact. Upper and lower extremity sensation intact to light and sharp touch. Muscle bulk, tone, 5/5 strength symmetric throughout.
Correctional Nurse Actions
Conduct the initial assessment for Mr. Dukes and explain the referral process. Due to the fever, significant pain with arm movement, and the generally remarkable presentation of the lesion under his left arm that actually extended to the left chest region, the Correctional Nurse contacted the provider, who ordered that Mr. Dukes be scheduled for Provider Sick Call that afternoon.
Differential Diagnoses for MR. DUKES
•Left axillary folliculitis is a consideration, except that the presentation of folliculitis is more papular and pustular, with each papule or pustule found around a single hair shaft, making this a less likely diagnosis for Mr. Dukes. Folliculitis is typically itchy and tender.
•Left axillary hidradenitis suppurativa is highly likely here. The patient’s clinical presentation of the elongated, cord-like mass that was painful to the touch is suggestive, as is the fact that this has occurred before, but not to this scale.
•Contact dermatitis, a hypersensitivity reaction to new colognes, perfumes, deodorants, soaps, detergents, clothing, and jewelry is unlikely as the condition is restricted to Mr. Dukes’ left axilla, although he is in a new environment with potentially different soap and laundry supplies used to wash his clothing.
•Hodgkin lymphoma is a lymphoid tumor that may arise from infection such as Epstein–Barr virus, and chronic inflammation. Low-grade lymphomas are slowly progressive and painless, usually noticed first as a skin lesion and lymphadenopathy. The incidence is higher in males than in females, and the typical peak age is 15 to 34 years. Mr. Dukes’ acute onset and pain make this an unlikely diagnosis.
•Non-Hodgkin lymphoma is the fifth most common cancer in the United States, typical age of diagnosis is 65 to 74 years of age, although 16% of those afflicted are under the age of 35 years. It presents as palpable, painless, bulky lymphadenopathy in the axilla, cervical or inguinal areas. This is an unlikely diagnosis given the patient’s presentation and pain.
Most Likely Diagnosis
Left axillary Hidradenitis Suppurative. Because of the multiple pimple-like follicular occlusions in combination with the very inflamed nodules that merge into a painful, rope-like mass, this is the most likely diagnosis for Mr. Dukes.
Pathophysiology of Hidradenitis Suppurative
Hidradenitis Suppurativa is a clinical diagnosis. Largely considered a disorder of apocrine-bearing skin at the epithelial level of the terminal follicle, this condition tends to be progressive, chronic, and disabling. Although its exact etiology is unknown, it produces a range of symptoms, including mucopurulent drainage from abscesses, fistulas, sinus tracts, and scarring. It is a recurring condition with insidious onset, occurring typically in otherwise healthy adolescents and adults. Comparisons are often made with acne vulgaris due to the inflamed, occluded comedones; however, Hidradenitis Suppurative has not been found to demonstrate an increase in sebaceous activity. The axilla and groin are the two most commonly affected areas. No laboratory and/or imaging tests are necessary for the diagnosis. Pathological examination of Hidradenitis Suppurative specimens may indicate follicular plugging accompanied by fibroplasia and a mixed inflammatory cell infiltrate.
There are some possible exacerbation factors (comorbidities and lifestyle risk factors) associated with Hidradenitis Suppurative. These include obesity, smoking, Diabetes Mellitus, and hyperlipidemia.
The most commonly isolated bacteria are staphylococcus aureus, coagulase-negative staphylococci, and anaerobic streptococci.
Wound culture, left axilla abscess, exudate from pointing white heads
A tetanus immunization was given prior to patient discharge from the clinic, and Doxycycline was ordered presumptively, with the first dose administered before he left Provider Sick Call.
Mr. Duke was sent to the dermatologist in the community on an urgent basis the following morning. The dermatologist performed local incision and drainage of the abscess, taking great care to break open loculations and fistulas that trapped additional purulent debris. When these occluded comedones were deroofed, copious thick, mucopurulent, malodorous exudate was expressed. Loculations were broken up to further release deeply seated abscess pockets in need of drainage. This axillary mass had multiple tracts. Once drained, the abscess cavity was irrigated with normal saline and packed with gauze to allow healing via secondary intention.
The dermatologist scheduled a follow-up visit in two days for a wound check and repacking. After that, nursing at the facility conducted the daily wound care, including daily vital sign checks.
Mr. Dukes was scheduled for a Provider Sick Call follow-up in one week, and was instructed to contact healthcare staff immediately for any worsening of symptoms. In addition, he was told that he would be seen for wound care daily.
Topical clindamycin 1% or oral tetracycline is the first-line medical treatment for mild to moderate Hidradenitis Suppurative and Mr. Dukes was prescribed Doxycycline 100 mg PO BID for 14 days. Due to the pain from the procedure and the wound care/packing he required, for the first week he was ordered Tylenol#3 BID, and then was changed to Tylenol.
Mr. Dukes tolerated his procedures as well as could be expected, as this is a very painful condition. In addition, incision and drainage is generally a painful procedure, and Mr. Dukes had a moderate area addressed. The required wound care and the repeated wound packings that had to be done daily are also quite painful. Mr. Dukes was compliant with all appointments with nursing staff and the provider, and his infection ultimately cleared, although the fibroplasia in his axilla did become larger.
What is Hidradenitis Suppurative?
The need for antibiotics and instructions to take them for the full course.
The use of narcotic pain medication
Treatment plan, including the frequency of the dressing changes he can expect.
Hygiene while healing and after.
The importance of contacting medical immediately if he experiences fever, chills or a worsening of the pain.
Alikhan A, Lynch PJ, Eisen DB.(2009). Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 60(4):539–561. doi:10.1016/j.jaad.2008.11.911
Jovanovic M, Kihiczak G, Schwartz RA. (2019). Hidradenitis suppurativa. Medscape. https://emedicine.medscape.com/article/1073117-overview
Lash BW, Wolfe Z, Argiris A. (2018) Hodgkin lymphoma. Medscape. https://emedicine.medscape.com/article/201886-overview
Michel C, DiBianco JM, Sabarwal V, et al.(2019). The treatment of genitoperineal hidradenitis suppurativa: a review of the literature. Urology, 124:1–5. doi:10.1016/j.urology.2018.10.013
Papadakis MA, McPhee SJ, Rabow MW.(2018). Furunculosis and carbuncles. In: Current Medical Diagnosis and Treatment. 75th ed. McGraw-Hill Education, 158–159. ISBN 978-1-25-986148-2
Vinjamaram S, Estrada-Garcia DA.(2019). Non-Hodgkin lymphoma. Medscape. https://emedicine.medscape.com/article/203399-overview
Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clincal and bedside skills. Springer Publishing Company. Kindle edition.
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