Case Presentation: Mr. A is a 53-year-old male who presented with a painful thigh. The patient was released from prison one week prior and had been living under a bridge next to a creek ever since. On the day of admission, Mr. A decided to bathed himself in the creek. As he was wading through water up to his knees, he felt a sharp pain on his left thigh and immediately suspected he was bitten by a snake. Upon exiting, he slipped on wet rocks, resulting in numerous extremity abrasions. Shortly thereafter, his left medial thigh became red, swollen and extremely painful, prompting him to call 911.Upon presentation, Mr. A was hypotensive, tachycardic, but afebrile. His left thigh was erythematous and swollen, and he had a notable left dorsal foot erythematous pustule. Admission laboratories revealed acute thrombocytopenia, an elevated INR, transaminitis with an elevated alkaline phosphatase, and mild rhabdomyolysis. The emergency department suspected snake envenomation, and the patient was initiated on CroFab, in addition to broad-spectrum antibiotics. Upon transfer to the medicine service, admission blood cultures grew Plesiomonas shigelloides, and a skin scraping from the left foot pustule obtained the following day grew Aeromonas hydrophila. Work-up of Mr. A’s liver injury and coagulopathy revealed elevated Factor VIII levels and hepatitis B-related cirrhosis with portal hypertension. His hospitalization was complicated by progressive skin and soft tissue infections of the left foot and right finger that required surgical debridement and grew methicillin-susceptible S. Aureus. Mr. A slowly improved on antibiotic therapy and was discharged after 16 days.
Discussion: Chronic liver disease (CLD) complicated by a skin and soft tissue infection (SSTI) is commonly encountered by hospitalists. Differentiating this condition from snakebite envenomation is challenging yet important as treatments for each are vastly different. Following a typical Crotalinae (pit viper) snakebite, fang marks should be evident and accompanied by adjacent pain, swelling, and ecchymosis. Envenomation can also result in shock, acute disseminated intravascular coagulopathy, and rhabdomyolysis. In this case, nearly all of these findings were present. However, the patient never visualized the snake, and there were no clear bite marks on his thigh. Furthermore, clinical evidence of hepatitis B-related cirrhosis and an elevated Factor VIII level suggested a most likely diagnosis of CLD with an associated coagulopathy complicated by a severe SSTI from freshwater aquatic bacteria. CLD patients are at an increased risk for developing rapidly progressive SSTIs, especially following inoculation from traumatic aquatic injury. While snakebite envenomation can certainly occur and suspicion necessitates a thorough evaluation, CLD patients should always be covered with broad-spectrum antibiotics when presenting with skin and soft tissue complaints following freshwater environment exposure.
Conclusions: Aquatic environments can be hazardous. Snakebite envenomation can result in a presentation similar to CLD, and a thorough work-up is necessary to ensure accurate diagnosis and treatment. Atypical bacteria also thrive in these habitats, and hospitalists should utilize broad-spectrum antibiotics accordingly, especially in CLD patients who are at high risk for life-threatening SSTIs.