Yesterday's Morning Report was on cellulitis and mimickers.
One key point made was the distinction between cellulitis and erysipelas, which is an infection of the superficial skin layers caused by beta-hemolytic streptococci. Unlike cellulitis, the borders of erysipeloid areas are very well demarcated.
From a previous morning report on cellulitis:
Predisposing factors: saphenous vein harvesting, venous insufficiency, mastectomy with lymph node dissection, liposuction, "skin popping" in IVDU
Source: portal of entry in skin (e.g. tinea pedis, ulcer)- by far most common; other possibilities include osteomyelitis, bacteremia.
Unusual sources: seawater (vibrio vulnificus), fresh water (aeromonas hydrophilia), fish (strep iniae)
Micro:
80% gram +ve (staph, strep), 20% gram -ve. Aspirates/swabs are not indicated (unless ulcer)
Broader coverage may be indicated in pts with DM2.
Blood cultures are indicated in lymphedema, buccal, periorbital, water exposure, chills or fever. Otherwise, bacteremia is rare (less than 4%).
Empiric treatment: Cefazolin or cephalexin. Other possibilities: cloxacillin, clindamycin, penicillin, amoxicillin-clavulin. May want broader coverage (e.g. gram -ve coverage) in diabetics
Ancillary measures: Elevation, immobilization. Interdigital dermatophytic infections should be treated (e.g. clotrimazole and miconazole), terbinafine, etc
Click here for a review of cellulitis from NEJM
Important Conditions that Masquerade as Cellulitis:
Infectious:
- Necrotising fasciitis/ Clostridial myonecrosis
Non-infectious:
- Just plain edema with or without changes of chronic venous stasis- highly probable if bilateral
- Lymphedema
- Lipodermatosclerosis (in patients with chronic venous stasis) fibrosing panniculitis characterized by advanced hyperpigmentation and induration involving most of the leg circumferentially.
- Superficial thrombophlebitis/DVT
- Contact dermatitis
- Systemic drug reaction
- Gout: in addition to arthritis, often have overlying skin induration and involvement of tendons
- Sweet's syndrome: acute febrile neutrophilic dermatosis associated with AML
- Well's syndrome aka eosinophilic cellulitis: urticarial lesions, transient systemic eosinphilia.
Click here for a great Annals review of diseases that masquerade as cellulitis.
Predisposing factors: saphenous vein harvesting, venous insufficiency, mastectomy with lymph node dissection, liposuction, "skin popping" in IVDU
Source: portal of entry in skin (e.g. tinea pedis, ulcer)- by far most common; other possibilities include osteomyelitis, bacteremia.
Unusual sources: seawater (vibrio vulnificus), fresh water (aeromonas hydrophilia), fish (strep iniae)
Micro:
80% gram +ve (staph, strep), 20% gram -ve. Aspirates/swabs are not indicated (unless ulcer)
Broader coverage may be indicated in pts with DM2.
Blood cultures are indicated in lymphedema, buccal, periorbital, water exposure, chills or fever. Otherwise, bacteremia is rare (less than 4%).
Empiric treatment: Cefazolin or cephalexin. Other possibilities: cloxacillin, clindamycin, penicillin, amoxicillin-clavulin. May want broader coverage (e.g. gram -ve coverage) in diabetics
Ancillary measures: Elevation, immobilization. Interdigital dermatophytic infections should be treated (e.g. clotrimazole and miconazole), terbinafine, etc
Click here for a review of cellulitis from NEJM
Important Conditions that Masquerade as Cellulitis:
Infectious:
- Necrotising fasciitis/ Clostridial myonecrosis
Non-infectious:
- Just plain edema with or without changes of chronic venous stasis- highly probable if bilateral
- Lymphedema
- Lipodermatosclerosis (in patients with chronic venous stasis) fibrosing panniculitis characterized by advanced hyperpigmentation and induration involving most of the leg circumferentially.
- Superficial thrombophlebitis/DVT
- Contact dermatitis
- Systemic drug reaction
- Gout: in addition to arthritis, often have overlying skin induration and involvement of tendons
- Sweet's syndrome: acute febrile neutrophilic dermatosis associated with AML
- Well's syndrome aka eosinophilic cellulitis: urticarial lesions, transient systemic eosinphilia.
Click here for a great Annals review of diseases that masquerade as cellulitis.
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