Mysteriously puffy hand: puffy hand syndrome
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The present case has been reported in BMJ.

A 59-year-old man with a history of intravenous drug use (DU) presented with a 3-day history of right-hand swelling, redness, warmth and pain. Physical examination was notable for a tensely oedematous hand with non-pitting oedema, warmth, blanching erythema and decreased range of motion.

He was empirically started on intravenous vancomycin for presumed skin and soft-tissue infection (SSTI). The patient was afebrile and studies including C reactive protein, leucocyte count and blood cultures were normal. An ultrasound study did not reveal any deep vein thrombosis. X-rays showed no fracture, foreign bodies or gas formation. There was no improvement after 48hours of antibiotic therapy. MRI of the hand showed diffuse myositis of the intrinsic hand muscles and surrounding skin oedema.

Initially, he denied intravenous drug use into his arms, however, on further questioning, the patient admitted to injecting methamphetamine. Although he denied recent use, urine toxicology was positive for amphetamines. He had previously been taking buprenorphine through addiction clinic, but denied injecting it into his hands.

Given the lack of serum inflammatory/infectious markers, lack of clinical improvement on antibiotics, the diagnosis of puffy hand syndrome was made. Oedema, erythema and pain improved after 48hours of upper extremity elevation in a Murphy sling and resolved completely after 96hours.

Learning points:-
• Common causes of a single swollen extremity includes skin and soft-tissue infection, trauma and deep vein thrombosis and must be considered especially in patients with history of intravenous drug use (DU), however, puffy hand syndrome is a lesser-known complication of intravenous DU that may present similarly.

• Pathophysiology of puffy hand syndrome involves sclerosis and damage of veins and lymphatic vessels after repeated drug injections, leading to lymphoedema.

• Although puffy hand syndrome has not been specifically studied, treatments such as compression bandaging, compression and physical therapy used for lymphoedema may be beneficial.

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