Anais a n a I s harris 14 07 897 21 year old lady investigations blood cultures negative eosinase normal alp 177 when previously 80 back in june 2025 crp 15 urea normal ast normal fibrinogen 4.5 but remainder of coag screen normal full blood count normal neutrophils normal and white cell counts normal venous blood gas ph 7.4 sodium a 129 lactate nought 0.8 wound swab from 01/21/2026 moderate growth of staphylococcus aureus open brackets abnormal close brackets susceptible to clarithromycin doxycycline flucloxacillin and penicillin note global pain to the left knee in the december after slipping the night before very tender to the proximal tibia to exclude a fracture had a knee x-ray which demonstrated a small knee joint effusion however no lipohemarthrosis and no acute bony injury and just do is the bed ready it's ready and we've printed off but it's okay oh fine well can see you covered there is it on null 3 no it's waiting room waiting room oh well in that case yeah do mind if we have a chat and then I'll leave my social worker yeah thank you if you had a pet I thought you'd fit you in it that's quite nice but it's just another chair another place have a seat wherever you'd like I'm rob I'm 1 of the medical registrars I use this massage roller business how are you sorry I'm sorry pain deep deep yes been in those chairs doing the long haul flights all night not so sore so both people are tested I've been reading your gp record it sounds like it's been going on for months it's been through november exactly and it started after you wore crocs at work and had more thermal socks at the same time you worked as a carer don't you that right that's what I think I have a conversation but I was getting swelling in my legs so so it started with swelling yeah it started with swelling in my legs go down at night don't I I I just thought it was and how swollen were you feet well it wasn't really my legs and then I had done a 12 hour shift to come home and I had like a rash on the top of my foot mhmm which I thought could be like a heat rash where I've been walking around I've been going to the doctors no I called 111 actually because it was on the weekend I said on that phone call that it was cellulitis right the gp has I mean I mean in theory you can but we don't believe that you can do know what mean they were just consistently it's not this apparently they they believe that it's contact dermatitis yeah that's what the dermatologist thinks for making it the patients yeah and what do you think about that I don't believe it is why is that because it's nowhere else on my body mhmm but you don't wear crocs anywhere else on your body no I know but I've worn crocs way before november really fine fine I've worn it for years last of sorry the chest degenerates are unsuspended on yeah I've I've had them for years not no problems no problems no I've worn them with socks without socks mhmm everything it's like the only thing I could think of that it could have been it's not in a sock distribution is it it's in a shoe distribution it's exactly where your crocs sit isn't it now when you put your croc on it's almost gone isn't it like it's that exact distribution do you what I mean but then also the thermal socks came up to here oh really fine they're like ankle socks yeah it wasn't like a hive it could have been either of them but like I said I've worn crocs for years so it's 6 7 years yeah it's just very weird how it would only start in november and then tell me about the knee pain that you had I saw that you came to you came to see us with pain in your knee that gave way after you slipped is that right yeah I've got a bad knee on the on the left yeah not on both sides just gone right up the left yeah and that started after you fell over after I twisted I just had a number oh fine I didn't see that yeah cool fine we can have a look at that can't we because you had a small it's usually a bit of swelling in the joint when you had your x-ray back in november was just looking at the pictures yeah was when this swelling in the knee and the feet start at the same time or no there's this 1 has been swollen for a while like this knee like here but the doctors won't do anything about it they said that and it's almost like because it your knee because your knee's cap is here isn't it yeah so it's there's your kneecap but you feel like it's here on this yeah it's it's mainly the left this 1 here yeah that 1 mhmm which a lot yeah but it just says like doctor just said it's just a normal part of your body so it doesn't matter right okay you know I mean the doctors have I I don't even see me on the phone I think 1 month not at 1 time and that was 2 weeks ago I see lots of messages on your gp record with them telling me to call 1 month that's not a good sign they've been very reassuring to do it yeah sorry this do that don't come and see us send us pictures so you'd 1 1 1 say go to your gp and then gp say phone 111 then you you just have a conversation back and say go to the hospital I know I came to the hospital I've been to the hospital for 3 times and do you have any rashes anywhere else in your body it's not like I suppose in a fist I didn't know that's normal for you and that's abnormal for you yeah this has come out in the last these yeah this rashes start the last like week week mhmm I would have a rash that cough and go away but then this rash has just stayed it's like an itchy rash yeah okay itchy and you're and you're itching and taping the tops off them a little bit is that is that what they are yeah yeah that's fine I'm just I'm just interested whether they're ulcerating by themselves or not personally that's okay I'm terrible for itching as well so you've got a side effect all right so they're raised and it's in the spot where you would itch over your elbows isn't it the rest of the stuff on your forearms they're not clearly ulcerating but how about this 1 do you think you've itched that 1 or do you think that's ulcerated by itself I mean I could have I don't you have it's mainly around your elbows you have been scratching so I can't to replace it keep telling you for it it's it doesn't look like a psoriasis or anything else that can affect the joints certainly and how do you feel in yourself do you feel ill yeah I feel quite ill my nose in what way do you feel ill I feel really tired mhmm don't know if you're sleeping for a night but yesterday I couldn't remember my training oh yeah time mhmm I can't remember that you're on the same thing no like I'm just too asleep and they're just sort of hot 1 minute get hot and then you freeze it yeah or your face is burning and your hands are like ice mhmm and this is all since october november november yeah swelling was october november but the rest of it mhmm let's see what this looks like then so you saw someone to get this mri of your knee yeah yesterday who did you oh when you came in to have the mri did you see some did you see a a consultant like an orthopedic consultant or something about it yeah not yesterday it was I haven't seen him from the mri I seen him from clinic that's who I am I didn't think did I I don't think I can only see the 1 x-ray that you had at newton but I think no is that right was it here I think it was here might be here sorry it might be a bit of mess in that I'll go back up no if you're usually in your joint it's still waiting to be reported by the radiologist so we I this is my interpretation I can't see any infection the swelling is that it hurts yeah it's like around the side mhmm around the right yeah on the in the aspect of it behind the back of it as well seen here but it because there's nothing there yeah blood vessels and subcutaneous stuff there's nothing there's no collection of fluid but where you describe the swelling is may is just maybe we caught it in our mri but it shouldn't be gotcha fine and any and any ulcers any other places any more of this rash anything in your genitals or in your mouth no nothing like that not that I've no okay and have you had any eye symptoms any problems with seeing and you work as a carer of you know old people's home or yeah I've a retirement be awful I couldn't do it is it a nice retirement home yeah it is it's quite nice and do you you guys live together I take it yeah yeah fine and do you live in a house or flat a house in a house fine and anyone else in the house any kids any cats no kids just my mom and my school and the cat you tell me about the cat how long have you had the cat for I don't know about that and how long have you been living with the cat does it start at the same time as the cat half yeah so yeah fine okay so certainly so from my perspective I'm not a skin specialist I'm a medical specialist I guess I'm I'm interested as to whether there could be something linking the knee and the feet together but the rash that I see here doesn't look like a kind of rash that does link the knee and the feet together and it's in a complex thing I think that the dermatologist has seen pictures of this and felt that it was in keeping with the contact dermatitis and it does look infected because we can see that you had infection on your previous swabs which showed the growth of staphylococcus aureus and you've got raised inflammatory markers in your blood your crp is not fit so I suspect you feel crap because you've got in inflamed skin yeah which I think is because of contact dermatitis certainly I don't think I think based on what we see well see let's what the have you seen what the dermatologist said no haven't they've seen the pictures of your feet but they haven't met you but they've met your pictures of feet do know what I mean and they've spoken to your gp they've seen my feet they've seen your feet so this is the dermatology consultant dear doctor harris thank you for your advice request on this 20 21 year book which is you I understand the inflammation on the top of the feet started 3 months ago the images are most in keeping with an contact dermatitis due to the very sharp cut off between the abnormal and normal skin + the associated symmetry an additional photo of an area of a limb shows some patchy dermatitis which often becomes more widespread after superficial infection of an area of dermatitis elsewhere in terms of immediate treatment I'd suggest complete some of antibiotics I would recommend potent topical steroid once a day for 3 weeks did you have that yeah and it made my feet worse way them worse yeah and my feet literally out sort of bright red and turned into but then what but the skin was forming again not like it is now where it's breaking down it wasn't it wasn't swollen anymore it was swelling more and then it was cracked bleeding pussing I and it says usually contact dermatitis on the feet is related to leather products especially worn without socks is that something you do no it says crocs and trainers are very unlikely to cause any kind of reaction so it's all very strange isn't it yeah alright so you tried how long did try the steroids for 2 days and then on top it would my toes I didn't mhmm using the cream and then after you all the bottom my toes split open is it still split open now somewhere so yeah it's just it done it to all my toes after using it mhmm I've tried I tried the cream twice I tried it but just wash it put the cream on for a day or 2 mhmm and then told me to wash it with dermal 500 yeah your best fine but you can wash it you can go dietary dermal 500 yeah dermal and then good serious great fine and looking at your tests your the swab that we sent from the january 23 has come back showing a growth of a bug that normally exists on the skin however this growth is abnormally high and so it does look infected so what what should we do today what would you like to do in months to to form so I I don't think it's gonna take it's not gonna be something I can fix instantaneously unfortunately what's reassuring is that your observations from overnight are fine you've not had any fevers or anything like that that we've documented which is obviously good and your markers of infection and inflammation are not ridiculously raised I think we should I shall add on some tests to make sure this isn't something weird and wonderful sometimes you can get strange reactions to other infections in your body which can inflame the soles of your feet usually it's only the soles and doesn't affect the top but it's worth making sure that hasn't got have you had any urine infections or had bits lately or anything like that no nothing like that so I guess it's worth aliyah's test or not have them on board on they're gonna be sending away to the lab in bristol because they're complicated things that I'm testing for so they're unlikely to did I ask the dermatologist to see you in their clinic because they talked about they said if it gets better then that would be great but if not well I had a letter that had come through I need to see her more quickly yes yeah fine okay well I can ask them to see I can send them a letter as well or I can ask them to see you urgently in 1 because this is clearly affecting you a lot isn't it and and I think I think that based on what they say I think it is a contact dermatitis but I don't I think it is still slightly unexplained as to why it didn't get better with steroids than they suggested it's worth excluding some other more systemic things especially given you've got that slight rash on your arms as well I'll hand on some tests to look for that where are your parents from wales no 1 from turkey mediterranean no sometimes there's a weird vasculitis that affects people from but that's fine good so what shall we do today so we we should get you some antibiotics to treat the infection in the feet does she make me feel poorly 2 different had so far iv ones yeah use some flucloxacillin probably we could get you some tablets of those to get it out of here and then I mean I had them before it didn't clear it up what did you have flucloxacillin yeah mhmm fine and then you've had an iv dose of flucloxacillin now yeah the bug that we cultured is in theory susceptible to all of these antibiotics so why why don't we try something different why don't you have some which is what we'd use as a second line agent at home have you fine that's what I tried and it got worse fine okay yeah so you've tried fluvoxamine you've tried clarithromycin yeah and in what in what way did it get worse on the clarithromycin I just felt with clariant I guess we're throwing treatments at you aren't we but I don't think anything's gonna make it better immediately do you know what I mean no yeah I understand that maybe maybe persevering with some of these is gonna be the right I know I know it's easy for me to say without the painful swollen feet but like as I say it's been going on since november it's what 3 months now 4 months yeah and to expect that 1 day 2 days of steroid is gonna make it magically better may be a bit ambitious is it supposed to make it work I don't know it's yeah so I was struggling just to even and so what things have you got at home you've got some dermal have you got some steroids at home do you wanna try this the topical steroids again and persevere with them maybe after treating for an infection in the feet first yeah other than other than treating you for an infection and looking for anything systemic I'm not sure what I'm going to add unfortunately on saturday morning we don't have dermatologists in the hospital all the time you know I'm I'm the closest you're going to get to a dermatology specialist in this hospital at this time so the yeah the best I'm gonna be able to do is make sure you're not going to die which you're not which is good obviously and try and get you some treatment for an infection and suggest trying the steroids again after you treat had the treatment for an infection we should send another swab today and see what's happening in the feet but I don't know and it'll help with swelling in your leg in the leg and the feet in the leg and the feet I think the swelling is because your body's reacting to this inflamed tissue your body's driving lymphatics and white blood cells to this area to heal it up and that swells your feet up and what about the swelling is it the swelling that's uncomfortable the fact that your skin is cracked and painful when you do that at work the swelling you'd make it better for you the infection more than others or not the infection is equally sensitive to all of those antibiotics so we've tried different classes of antibiotics so you haven't had this class of antibiotics yet doxycycline sometimes it can cause skin reactions in the arms if you're exposed to them not this time what were you gonna say sarah we usually think about those because they induce the enzymes in the liver clarithromycin but doxycycline doesn't seem to do that so much and then we'll be good to see what your knee mri shows from my perspective it looks fine I can't see what the I can't see the the lump that you described on the mri of your knee however the specialist will look at it specialist radiologist will look at it and tell us what they think is going on with you knee in over the next few days and then I'll speak to the dermatologist and ask them to see you in their clinic that sound alright yeah cool I'll go and do those things for you and then we can try and get you out of check that sound alright yeah cool any questions anything I forgot no I think that's they probably want to move you to our amu waiting room but I can catch up with you there no trouble that sound alright so on examination obese papular rash to bilateral forearms with areas of excoriation on bilateral elbows but no ulceration or clear vasculitic component to rash legs left anterior tibia complains of swelling in this site however nothing palpable and nothing seen on mri most likely to be lipoma or adiposity bilateral feet erythematous in the pattern of shoes with clear demarcation between normal and abnormal skin evidence of superficial skin breakdown with islands of superficial skin surrounded by areas of erythema on the soles of the feet cracking to the web spaces and toes with thickened skin on the on the plantar aspect bilaterally plan wound swab of bilateral feet to guide sensitivities course of doxycycline for 1 week to treat for infection subsequent use of steroid already has a supply at home from gp urgent outpatient referral to dermatology which I will complete home today add on blood tests to exclude vasculitis as a potential cause of rash however feels very unlikely given pattern and distribution of rash without any systemic symptoms and then dermatology referral dear dermatology, <\n> I'd be very grateful for your urgent review of this 21 year old lady with bilateral rash to her feet in the pattern of a shoe full stop <\n\n> She has been experiencing this rash since november 2025 and this has been discussed with your team who advised this was most likely to be a contact dermatitis and advised steroids and dermal she's used these however has not had any benefit from the steroids and found that her skin became thicker and more swollen with use of steroid she's had multiple course of antibiotics to treat for superimposed infection of this site and I've treated her again for it today full stop <\n\n> She's had multiple attendances to the emergency department as well as her gp with these symptoms which are significantly affecting her every day full stop <\n\n> She works as a carer and so is unable and then is unable to work due to these symptoms and the pain in her feet I'd be very grateful for your urgent review in clinic and I passed you already have some photos from the previous referral from her gp 1 and add to the plan analgesia some codeine to take away