This 17-year-old presented with multiple boils in the perineum and under breast and skin folds. The lesions produced a malodorous discharge (which caused problems with peer acceptance at school) and were increasing in size. Oral antibiotics had not helped. The patient was admitted for intravenous antibiotic therapy.
This patient has experienced previous similar episodes, in which lesions were largely confined to the perineum. Other areas are now involved, and the outbreaks have been occurring with increasing frequency.
Earlier outbreaks were treated with a short course of antibiotics, which afforded temporary relief. Some lesions were incised and drained.
Obese patient; body mass index, 52.2 (above the 95th percentile). Nodulocystic swellings 1 to 1.5 cm in diameter in the perineum, axilla, and under mammary folds and skin folds on the back. Some swellings drained yellowish, foul-smelling purulent discharge, which was collected for culture. Hypertrophic granulation tissue was noted in some of the draining lesions. The patient had hyperpigmented areas and scars from surgery and old healed lesions.
White blood cell count: 9400/µL, with 76% neutrophils, 21% lymphocytes, and 3% monocytes. Hemoglobin, 11.3 g/dL, with evidence of microcytic, hypochromic anemia. Serum electrolyte values, normal. Random blood glucose, 139 mg/dL. Serum levels of free insulin, 174 µIU/mL; total insulin, 284 µIU/mL; free testosterone, 0.55 ng/dL. Bioavailable testosterone levels elevated at 13.5 ng/dL. Insulin antibodies not detected. Normal levels of thyroid hormones, free thyroid-stimulating hormone, sex hormone-binding globulin, cortisol, dehydroepiandrosterone sulfate, follicle-stimulating hormone, somatomedin C, and serum albumin.
Culture grew a few coagulase-negative staphylococci and Corynebacterium species. A staphylococcal survey of the patient was negative, as were results of a urine pregnancy test.
WHAT'S YOUR DIAGNOSIS?
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