begins as a simple abscess or benign infection that quickly spreads, espe-
cially in an immunocompromised patient, often a diabetic male. If not
promptly diagnosed, it can lead to end-artery thrombosis in the subcuta-
neous tissue and widespread necrosis. Treatment includes aggressive fluid
resuscitation; broad-spectrum antibiotics to cover gram-positive, gram-
negative, and anaerobic bacteria; wide surgical debridement; and, possibly,
hyperbaric oxygen therapy.
(a)Epididymitis is a bacterial infection of the epididymis, with a grad-
ual onset of lower abdominal or testicular pain. The involvement in this
case is far more extensive and the crepitus and widespread discoloration
indicate a more virulent infection. (c)Scrotal edema can be idiopathic, but
usually occurs secondary to an insect or human bite. Scrotal edema associ-
ated with penile edema may be seen in older men in conjunction with
lower extremity edema in fluid overload states (eg, congestive heart fail-
ure). (d)Paraphimosis is the inability to reduce the proximal foreskin over
the glans penis (the foreskin becomes “stuck” behind the glans penis). It may
lead to decreased arterial flow and eventual gangrene. (e)Testicular torsion
is the twisting of a testicle on its root that usually occurs during strenuous
activity or following trauma, but can occasionally occur during sleep. It is
most common in infants and young adults.
171.The answer is d.(Rosen, pp 1588-1591.)Septic arthritisis an infec-
tion of a joint space, most commonly the knee, followed by the hip, shoul-
der, and wrist. Patient’s present with a warm, tender, erythematous,
swollen joint and pain with passive range of motion. Fever and chills are
common.Arthrocentesisis diagnostic with joint fluid demonstrating a
WBC count > 50,000/μL with > 75% granulocytes. Staphylococcus aureus
remains the predominant pathogen for all age groups. In young adults
gonococcal septic arthritis is common. Patients with septic arthritis should
receive a first dose of antibiotics in the ED prior to admission. If a coinci-
dent cellulitis is present over the involved joint, arthrocentesis may need to
be delayed.
(a)Plain radiographs should be obtained to identify any underlying
osteomyelitis or joint disease, but are often negative. Preexisting arthritis
(osteoarthritis or rheumatoid arthritis), immunocompromised states (alco-
holism, diabetes, or cancer), and risky sexual behavior are risk factors for
the development of septic arthritis. (b)MRI plays no role in the diagnosis
of septic arthritis, but may be useful in other musculoskeletal injuries
involving the knee. (c)The ESR and C-reactive protein are often elevated
Fever Answers 193