Working Diagnosis:
1. Scorpion envenomation; 2. Reactive tenosynovitis of posterior tibialis tendon and flexor digitorum longus tendons

Treatment:
After review of xray, Ultrasound, and MRI images with patient, a repeat history was obtained looking for potential sources of cellulitis. After further questioning he did report a scorpion colony found on his property. He did recall a scorpion sting prior to departing on his trip but patient initially reported and associated symptoms with his exercise routine. Patient given intramuscular ceftriaxone and oral dicloxacillin for possible cellulitis. After three days there was no improvement though there was a decrease in WBC count to 8.4. The patient was then given a one week course of oral glucocorticoid.

Outcome:
After 1 week of oral steroid treatment pain and swelling completely resolved.

Author's Comments:
Worldwide, there are an estimated 1 million scorpion stings reported annually and 3,000 deaths attributed to the envenomation. Most scorpion stings present similarly to this case with severe localized pain, edema, paresthesias, and muscle fasiculations. However, also similar to this case, sting sites can be hard to identify due to the very small size. In more severe cases, patients can have severe systemic effects to the sympathetic, parasympathetic, and neuromuscular systems. In these instances cardiac arrhythmias and uncoordinated neuromuscular activity can result. Ultimately, this can lead to respiratory failure, coma, and death. Due to the various species of scorpions worldwide, treatment is different in each area of the world but administration of targeted antivenom can help.

Editor's Comments:
This case demonstrates the importance of digging deeper into the patient history especially when expected appropriate management is failing. Insect stings/bites can themselves lead to large erythematous localized reactions. Bees, wasps, fireants, and pus caterpillars just to name a few can lead to localized reactions. These bites/stings also allow for a break in the skin that can lead to the introduction of bacteria in addition to an allergic response. Digging deeper into patient history and knowing endemic animal and insect species can be helpful in making this type of diagnosis.

References:
(1) Isbister GK, Bawaskar HS. Scorpion envenomation. N Engl J Med. 2014 Jul 31;371(5):457-63. doi: 10.1056/NEJMra1401108

(2) Rodrigo C, Gnanathasan A. Management of scorpion envenoming: a systematic review and meta-analysis of controlled clinical trials. Syst Rev. 2017 Apr 8;6(1):74. doi: 10.1186/s13643-017-0469-8.

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