A 38-year-old male presents 8 days after being stung in the left foot while surfing. He reports the sudden onset of sharp pain while walking in the ocean. He was seen initially in the emergency department. The puncture wound on his left foot was anesthetized, explored, and irrigated. No X-ray was obtained, no foreign body was discovered, and he was discharged home.
Two days ago, he noticed worsening heat, itchiness, swelling, and skin changes (red bumps and patches extending from the foot up to the lower calf) in his left foot. His current pain is rated 3/10 and localized to the left foot. The patient is able to walk and bear weight. He has been taking ibuprofen for pain control and is not taking antibiotics. He denies fevers, but reports fatigue and feels more cold than usual.
General:
- Alert and cooperative
Extremity:
- A puncture wound on the left foot, at base of hallux, appears clean and without obvious retained foreign body (FB).
- The entire left foot is swollen to a greater size than the right, is warm to the touch, neurovascularly intact, and without significant tenderness.
- Urticaria and blanching erythema are extending from the left foot to the lower calf.
- Dorsalis pedis (DP) pulse is 2+ on the left foot, and compartments are soft.
The rest of the exam is unremarkable.
An approximately 5 x 0.2 cm dense cylindrical structure projects over the forefoot as seen on the AP radiograph, extending from the base of the second metatarsal to the soft tissue between the first and second metatarsal. Swelling is most pronounced at the dorsum of the foot. There is no evident acute displaced fracture.
Stingray stinger
A dense cylindrical structure within the forefoot is concerning for a retained foreign body, specifically a stingray stinger in the context of the reported history. Soft tissue swelling is most pronounced at the dorsum of the foot. The patient was evaluated by orthopedic surgery and scheduled for an outpatient operating room case the next day. He was discharged on oral levofloxacin after treatment in ED with intravenous ceftriaxone and doxycycline.
Take-Home Points
- Strongly consider performing an X-ray to evaluate for a retained foreign body in puncture wounds as they can appear benign on the surface.
- For saltwater injuries secondary to stingrays, it is important to cover for vibrio vulnificus with a third-generation cephalosporin and a tetracycline (e.g., ceftriaxone and doxycycline) or a fluoroquinolone.
- Initial treatment for pain at the time of initial stingray injury involves hot-water immersion.
- Hodge D. Bites and stings. In: Textbook of Pediatric Emergency Medicine, 6th ed, Fleisher GR, Ludwig S (Eds), Lippincott, Williams, and Wilkins, Philadelphia 2010. p.671
- Clark RF, Girard RH, Rao D, et al. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. J Emerg Med 2007; 33:33. PMID: 17630073
- Jang HC, Choi SM, Kim HK, et al. In vivo efficacy of the combination of ciprofloxacin and cefotaxime against Vibrio vulnificus sepsis. PLoS One 2014; 9:e101118. PMCID: PMC4076242
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