The Challenge: Can you figure out what is wrong with a young woman who develops an unsightly rash on her arm that seems to have spread to her boyfriend?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try to solve a medical mystery. Below you will find the story of a 29-year-old physician who gets what looks like a simple mosquito bite. Over the course of several weeks the bite gets big and red and very ugly. When a similar rash appears on her boyfriend’s belly, the physician finally consults with another physician for help.
I will provide you the information the patient provided to her doctor, who was then able to figure out the diagnosis. The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a really cool case.
A Repulsive Rash
“Wow! That looks awful!” the young woman exclaimed as she caught sight of the ugly round hole in her friend’s arm. “Have you seen a doctor about that?”
The woman with the rash, a 29-year-old resident in emergency medicine, smiled, a little embarrassed. “As soon as I get a little time off,” she assured her friend, carefully adjusting her sleeve so that the sore was covered. It wasn’t painful, but it sure was hideous.
It hadn’t started out looking like that. She had gotten a few mosquito bites on her arm early that summer, when she and her boyfriend had been on vacation in Brazil. The bites had all gotten better except for this one.
At first it didn’t look special. It was just a small bump, a little pinker than her usual skin tone. After a couple of weeks it got redder and a scab formed over it, as if she had scratched at it – though she didn’t think she had, since it hadn’t really itched. And it just stayed that way for weeks, through the month of July and the first couple of weeks of August. Just a red bump covered with a tiny scab.
When the scab fell off she could see that beneath it the skin had opened up. Initially it was a small opening, maybe the size of a dull pencil point. It was weird. What kind of bite does that? she wondered.
A Workplace Hazard?
Over the next couple of weeks the sore got redder and it began to ooze a clear liquid that dried into this weird crusty scab. It definitely looked infected. Could she have picked up something in the E.R.?
Heaven knows she saw all kinds of terrible bugs at work. And though she did her best to protect herself — washing her hands countless times in every shift, wearing gloves and even a face shield when appropriate — she knew that catching something a patient has is one of the risks of the job. She cleaned the lesion daily and coated it in a topical antibiotic regularly.
Then her boyfriend got it. That was really upsetting.
One Rash, Then Two
The couple had gone to see some of the World Cup in Brazil that summer, catching a few games first in Manaus, then in Brasilia. In between games they had spent a couple of days in the jungle. She had come home after that to go back to work, but he stayed on another couple of weeks to see the games in Rio de Janeiro.
The night he got back, as he got ready for bed, his doctor-girlfriend noticed a couple of big scrapes on his abdomen. “What happened there?,” she asked. It was nothing, he told her. A souvenir of an otherwise perfect day swimming at the beach in Rio. He had a close encounter with some rocks. But it didn’t hurt anymore and they were healing pretty nicely, he added. She agreed and the two didn’t think much about it. At least not for a while.
A couple of weeks later she noticed that one of the scrapes on her boyfriend’s stomach was healing nicely, but the other was red and was oozing a bit. Was it infected?
It was fine when he first got home, so it wasn’t likely something he had picked up from the rock or coral he had scraped against. And she also had this funny sore on her arm that was also a little red and oozy. No, it was much more likely that whatever she had on her arm, he now had on his belly. She felt awful. First she got something – who knows what, or from whom – and now she had passed it on.
Trying Antibiotics
She suggested that he put the same antibiotic ointment on his wound that she was using on hers. She also told him he should consider seeing a doctor.
Maybe, he agreed, in the kind of noncommittal tone that suggested he probably would not. The topical antibiotic was no big deal, but seeing a doctor was a hassle. Mostly he worked from their apartment in New Haven, but once or twice a week he commuted to his office in Boston, where his days were busy and long. His health insurance was there and it was was where he was supposed to get care. Plus, he was a healthy young guy, and he didn’t have a primary care doctor. So seeing a doctor seemed like a lot of work for something that would probably get better on its own.
The girlfriend heard his objections and didn’t say anything, but she wasn’t sure how fast his wound was going to get better. Her own sore, though smaller than his, had been festering for over six weeks and seemed to be getting worse, and she herself hadn’t consulted a doctor.
Over the next couple of weeks, his scrape followed the same pattern as hers, going from bad to worse to awful. It still didn’t hurt, but it looked disgusting. The skin where the scrape had been was now red, open and inflamed, covered with these strange bumps. The whole thing oozed this disgusting pus-like liquid.
Pictures of the wound on the doctor’s arm and the matching one on her boyfriend’s abdomen:
Seeing a Doctor, at Last
When her boyfriend noticed that his sore was getting larger than the original scrape, he finally agreed to see a doctor. He went to a local walk-in clinic in Boston, and the doctor there started him on an oral antibiotic.
Back in Connecticut, his girlfriend started herself on the same med. But a week of antibiotics did nothing. Their sores just got bigger and uglier.
At work, it was easy for the young resident to forget about her own wound. All the E.R. doctors-in-training wore surgical scrubs at work, and the sleeves covered the painless lesion. So she often forgot it was there until she saw it in the mirror.
But her friend’s horrified reaction reminded her how strange and awful the sore was. Her friend, also an emergency room resident, had never seen anything like it and – other than the lesion on her boyfriend’s belly – neither had she. Could they have picked something up on their visit to Brazil?
The timing made that less likely: These sores appeared weeks after getting home. Plus they had gone with four other people — her boyfriend’s family — and none of them had anything like this. So it was probably something they had picked up in the States. But what? She wasn’t sure.
She finally called a primary care physician, Dr. David Antonetti, in New Haven and made an appointment.
An Unusual Lesion
“That’s not good,” Dr. Antonetti said when the young woman showed him the sore on her arm. He had never met the young woman before, but on first impression she seemed quite healthy.
Other than this ugly lesion, she had no medical problems and took no medications. She didn’t smoke or drink and, over all, said she felt perfectly fine, not sick at all. And the sore wasn’t painful; it wasn’t even itchy. She had no fever, and none of her glands in her neck or under her arms had been swollen.
She told the doctor about how her boyfriend had gotten the same kind of rash after she had and that they had both been on antibiotics without any improvement.
A Physical Exam
Dr. Antonetti examined the young woman carefully. On her upper arm was a nickle-sized sore. The top layers of skin were gone, leaving an ulcer 2 to 3 millimeters deep that was covered in a thin layer of pus. The skin around the edge of the wound was unnaturally thick and created a kind of lip. It wasn’t red; it wasn’t hot; it was just open and ugly.
Another strange thing: Above the sore itself, Dr. Antonetti could feel — but not see — a bumpy line of firm flesh under the skin, leading away from the wound. Other than this, her exam was normal.
This definitely looks infected, the doctor agreed. He understood why she had started herself on the antibiotics. Maybe it didn’t work because the bug was resistant to it.
He carefully collected some of the discharge on a sterile swab. He’d send that for culture, and he started the patient on a medication that would work against MRSA, a common cause of skin infections that is resistant to most antibiotics, including the one the young doctor had prescribed for herself.
Still, he didn’t really think it was MRSA, he told the patient. He had seen a lot of skin infections, including a lot of MRSA infections, but he had never seen anything that looked like this. He had an idea of what it might be, but he wanted her to be seen by a specialist in infectious diseases to get a definitive diagnosis.
You can see Dr. Antonetti’s note here:
Solving the Mystery
Dr. Antonetti had figured out what was causing this young woman’s rash — and that of her boyfriend. Can you?
Rules and Regulations: Post your diagnosis and any questions you may have in the Comments section. The correct answer will appear on Friday on Well. The first person to answer will receive a copy of my book and that warm, wonderful feeling you get from solving a mystery. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.