Case study: Boy, aged 10 years, has painful nodules on his feet
Medical advice was sought on the fifth day of symptoms, and by this time, the child was improving clinically.
Image credit: Author provided
Image credit: Author provided
Summary of presenting symptoms
A boy aged 10 years presented to the outpatient office with a history of painful nodules on the plantar surface of his bilateral feet 8 to 10 hours after spending time in a hot tub. He was unable to bear weight or put on socks and shoes due to his pain. The photos were taken soon after the painful and red papules appeared. The lesions affected the whole plantar aspect of both feet. Over the following 4 days, the nodules became less painful and red.
Medical advice was sought on the fifth day of symptoms, and by this time, the child was improving clinically. He was stable with subcutaneous, mildly painful, fleshy nodules mostly populating the medial arch of the foot. His remaining clinical examination results were within a normal range. Further questioning of the child’s mother revealed that other children exposed to the hot tub experienced painful feet but without lesions.
CASE OVERVIEW
Due to the patient’s improving symptoms and the self-limiting nature of the illness, no tests or labs were ordered as the child was not acutely ill. No peer consultations or specialists were utilized (Table).
Discussion related to possible diagnosis
The term Pseudomonas hot-foot syndrome (suppurative panniculitis) was coined after an outbreak affected 40 children who swam in a public wading pool with an abrasive, grit floor covering.1 After wading in the pool, these children exhibited intensely painful, red nodules, causing the inability to bear weight.
The presentation varies and may include diffuse erythema of the soles, fever, malaise, and nausea.1,2 Symptoms may be seen along with hot-tub folliculitis and may include surfaces like the hands, buttocks, and more. Some literature suggests lesion location may be based upon contact with the hot tub’s or pool’s abrasive surface, paired with increased mechanical stress from how children typically play or wade in pools.3 Biopsies have revealed intense perivascular, interstitial, and periadnexal infiltration of neutrophils extending to subcutaneous fat. Blood work results are usually normal, and no sepsis has been reported.1
P aeruginosa isan opportunistic, human pathogen that thrives in warm, humid swimming pools.6 Many local outbreaks of otitis externa, folliculitis, urinary tract infections, and respiratory infections have been caused by P aeruginosa isolated from pools, pool toys, pool surfaces, and pool plumbing. Additionally, several studies have isolated P aeruginosa from subcutaneous nodules of affected children.1,4,5
It is hypothesized that repeated trauma caused by a rough pool surface led to inoculation of the skin surface by P aeruginosa.1,6-8 Outbreaks mostly occurred in children due to thin corneum stratum offering no resistance to bacterial entry compared with adults’ thick skin.
Final diagnosis, treatment and prognosis, and follow-up
The diagnosis of suppurative panniculitis was made in the outpatient office. The compelling factor for the diagnosis was the history of the child wading in a hot tub, the characteristic hallmark of painful cutaneous nodules over the plantar surface of the feet, and similar symptoms experienced by other children who used the same hot tub. The child has a good prognosis; there was no follow-up, and his family was educated to have the hot tub checked and properly treated before using it again.
The nodules resolve with or without treatment within 1 to 14 days, with 88% resolving in 7 days. Many patients have been treated with antibiotics, oral steroids, and analgesics. Typically, treatment is not necessary because it is a self-limiting and self-resolving disorder.
Outbreaks of hot-foot syndrome by P aeruginosa indicate the potential presence of a public health hazard that can be prevented by adequate chlorination, less abrasive pool floors, and routine cleaning with detergents or disinfectants rated effective against P aeruginosa.
Table. Differential Diagnosis
References:
1. Fiorillo L, Zucker M, Sawyer D, Lin AN. The Pseudomonas hot-foot syndrome. N Engl J Med. 2001;345(5):335-338. doi:10.1056/NEJM200108023450504
2. Skar G, Simonsen KA. Painful foot nodules and rash in a teenager. J Pediatric Infect Dis Soc. 2017;6(2):211-213. doi:10.1093/jpids/pix002
3. Michl RK, Rusche T, Grimm S, Limpert E, Beck JF, Dost A. Outbreak of hot-foot syndrome – caused by Pseudomonas aeruginosa. Klin Padiatr. 2012;224(4):252-255. doi:10.1055/s-0031-1297949
4. Rasmussen JE, Graves WH 3rd. Pseudomonas aeruginosa, hot tubs, and skin infections. Am J Dis Child. 1982;136(6):553-554. doi:10.1001/archpedi.1982.03970420077018
5. Yu Y, Cheng AS, Wang L, Dunne WM, Bayliss SJ. Hot tub folliculitis or hot hand-foot syndrome caused by Pseudomonas aeruginosa. J Am Acad Dermatol. 2007;57(4):596-600. doi:10.1016/j.jaad.2007.04.004
6. Schets FM, van den Berg HH, Baan R, Lynch G, de Roda Husman AM. Pseudomonas aeruginosa on vinyl-canvas inflatables and foam teaching aids in swimming pools. J Water Health. 2014;12(4):772-781. doi:10.2166/wh.2014.066
7. Barradah RK. Pseudomonas-contaminated pool triggering an episode of idiopathic palmoplantar hidradenitis. Case Rep Dermatol. 2021;13(2):411-416. doi:10.1159/000516355
8. Cutrone M, Valerio E, Grimalt R. Pool palms: a case report. Dermatol Case Rep. 2019;4(2):154.
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