Cellulitis in childhood invasive pneumococcal disease: A population-based study.

Cellulitis in childhood invasive pneumococcal disease: A population-based study.

Gubbay JB, McIntyre PB, Gilmour RE.

National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, The Children's Hospital at Westmead and the University of Sydney, Sydney, New South Wales, Australia.

Aim:

There are few detailed data on the age-specific incidence and clinical pattern of pneumococcal cellulitis in children. We conducted a retrospective review of cellulitis as a subset of prospectively collected laboratory-identified invasive pneumococcal disease (IPD) and performed a systematic review of published literature.

Methods:

Prospective laboratory surveillance in urban regions of New South Wales, Australia, 1 June 1997-31 December 2001. Medical notes reviewed for each identified case and defined literature search strategy applied.

Results:

There were 1067 cases of IPD in children aged 0-17 years; 38 (3.3%) were cellulitis (32 periorbital, 6 buccal). Compared with other types of IPD, a greater proportion of cellulitis cases occur in children <2 p =" 0.004)" p =" 0.06).">

Conclusion:

Cellulitis is an uncommon focus in IPD in children, and is almost always facial. Most cases occur under 2 years of age, are seldom associated with meningitis or other complications, and are frequently not recognised on admission.

PMID: 16737477 [PubMed - as supplied by publisher]

........

Additional Studies:

Pneumococcal Facial Cellulitis in Children

Bacteremic pneumococcal cellulitis compared with bacteremic cellulitis caused by Staphylococcus aureus and Streptococcus pyogenes.

Periorbital cellulitis with breast cancer

Roger J G Stevens, MB MSc, Jennifer E Rusby, MA MRCS, and Michael D Graham, MChir FRCS

Department of Surgery, Dorset County Hospital, Dorchester Dorset DT1 2JY, UK

Correspondence to: Mr Michael D Graham E-mail: rjgs@doctors.org.UK

Periorbital cellulitis is a condition frequently referred to general physicians rather than ophthalmologists. It can be caused by malignant disease.
Case History

A woman of 50 reported two months of left facial swelling associated with pain and paraesthesia. She had diabetes and was on anticoagulants after a complicated lower limb arterial reconstruction for peripheral vascular disease. Two days before admission she had felt generally unwell and developed periorbital cellulitis and fever with poor glycaemic control.

Her temperature was 38°C, she had a sinus tachycardia of 120 beats per minute and a random blood glucose was 17 mmol/L. Periorbital swelling and erythema extending to the left side of her face was consistent with periorbital cellulitis. An incidental finding on examination was a 6 × 10 cm hard mass in the upper outer quadrant of the right breast with associated axillary lymphadenopathy and a left pleural effusion. C-reactive protein was 173 mg/L and she was hyponatraemic (sodium 125 mmol/L) and hypocalcaemic (calcium 1.97 mmol/L). Alkaline phosphatase was raised at 373 IuL. A chest radiograph confirmed a left pleural effusion. She was treated empirically with broad-spectrum intravenous antibiotics and chloramphenicol eye drops.

A CT scan of the brain and orbits (Figure 1) showed a large space-occupying lesion centred on the greater wing of the left sphenoid bone and increased attenuation of the soft tissues around the left eye consistent with periorbital cellulitis. A neurosurgical opinion was sought but biopsy of the lesion was considered inappropriate since this would have required complex surgery and would not have changed the management. Mammography revealed a 5 cm mass in the upper outer quadrant of the right breast, graded M5 with multiple satellite lesions and a 2 cm mass in the axillary tail. A core biopsy showed this to be an invasive ductal carcinoma, graded B5b. Oestrogen and progesterone receptor status was strongly positive. A technetium-99m whole body bone scan demonstrated increased uptake not only in the left sphenoid but also in several areas of the vertebral column and in the right sacroiliac joint, consistent with further metastases.

The cellulitis resolved with antibiotics. Current treatment is tamoxifen 20 mg once a day and the patient is being considered for primary palliative chemotherapy with or without local radiotherapy.

Comment

Orbital metastasis is well recognized by ophthalmologists, 1 but we can find no previous report of it causing periorbital cellulitis in which soft tissue inflammation is limited to the tissues anterior to the orbital septum (Figure 2). 2,3 Periorbital cellulitis is frequently associated with local trauma or with spread from upper respiratory tract infection and is common in children and in people with diabetes. 2 It usually resolves with intravenous antibiotics, but occasionally progresses posterior to the septum to become the more severe condition of orbital cellulitis3—which is occasionally due to orbital neoplasia. 4

Carcinoma of the breast is notorious for its diverse presentation. Metastases in bone and brain are common5 but the sphenoid is very seldom affected. In the largest retrospective review, of nearly 650 patients with orbital tumours, 2.5% were due to metastases, of which 75% originated from the breast, so that sphenoid metastasis from the breast accounted for just 1.8% of orbital space-occupying lesions. 1 In a subsequent review of 35 patients presenting with orbital metastasis, breast carcinoma was the primary tumour in 50% of cases, other less common sources being prostate, lung and the gastrointestinal tract. 6 In this and another series of a similar size, 7 the symptoms or signs of this metastasis were the first manifestation of the disease in about a quarter of the patients. Adults with periorbital cellulitis should always be questioned and examined for evidence of otherwise occult malignant disease. Involvement of an ophthalmologist is advisable.

References

Shields JA, Bakewell B, Augsburger JJ, Flanagan JC. Classification and incidence of space-occupying lesions of the orbit: a survey of 645 biopsies. Arch Ophthalmol 1984;102: 1606-11 [PubMed].

2.
Mawn LA, Jordan DR, Donahue SP. Preseptal and orbital cellulitis. Ophthalmol Clin N Am 2000;13: 633-41.

3.
Jackson K, Baker SR. Clinical implications of orbital cellulitis. Laryngoscope 1986;96: 568-74 [PubMed].

4.
Oh KT, Alford M, Kotula RJ, Nerad JA. Adenocarcinoma of the esophagus presenting as orbital cellulitis. Arch Ophthalmol 2000;118: 986-8 [PubMed] [Full Text].

5.
Patanaphan V, Salazar OM, Risco R. Breast cancer: metastatic patterns and their prognosis. South Med J 1988;81: 1109-12 [PubMed].

6.
Shields CL, Shields JA, Peggs M. Tumors metastatic to the orbit. Ophthal Plast Reconstr Surg 1988;4: 473-80.

7.
Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97: 620-4 [PubMed].

Journal of the Royal Society of Medicine

NEW LYMPHEDEMA PEOPLE FORUMS

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THE NEW FORUMS ARE UP AND RUNNING!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Our new forums represent a significant upgrade with many newfeatures, upgraded security and abilities. There are a number ofnew forums that we have added (including one for cancer) and many familiar ones like our children's forum, advocacy and more.

If you were a member of our old forums, we would love to have youcontinue with our family.

Please go ahead and reregister. We were hoping to automaticallytransfer membership, but that may be more problematic then we realized.

If you have never joined us there, come, share the excitement as wemove forward with the most comprehensive website on the internet forlymphedema and lymphatic conditions.

I will be working feverishly this weekend to see that all thearticles of the old forums are in place again.

In the meantime look forward to seeing everyone there!!!

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My Best to All!!!!

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Putting a damper on cellulitis

Nursing, Dec 2000 by Phillips, Lisa L

Like wildfire, this skin infection can rage out of control. Find out how to identify patients at high risk and respond appropriately.

INTACT SKIN IS AN EFFECTIVE barrier to bacteria. But when this protective barrier is breached, cellulitisnoncontagious inflammation of the skin-can result. Although often mild, cellulitis sometimes flares into a life-threatening systemic infection. In this article, I'll discuss how to care for a patient with cellulitis and what complications to watch for. First, though, let's take a closer look at the disease process.

Bad break

Any break in the skin-whether from an insect bite, intravenous (I.V.) catheter, or skin breakdown-can open the door to cellulitis by allowing bacteria into the body.

Cellulitis is most common on the face and lower legs, although other areas of the body can be involved.

The typical cause is group A Streptococcus or Staphylococcus aureus, although in infants, group B Streptococcus is the usual suspect. Other potential culprits include Aeromonas hydrophila, Escherichia coli, or fungi.

Anyone can get cellulitis, but some patients are at greater risk; for example, those with diabetes, peripheral vascular disease, immunosuppressive conditions, burns, and cardiovascular or pulmonary insufficiency. Intravenous drug use, whether medical or illicit, also heightens the risk.

When you assess a patient with cellulitis, you'll set a skin lesion or rash that probably has distinct borders. The rash, which may appear suddenly, can spread rapidly in the first 24 hours. Warm, painful, and tender, the skin may have a glossy, stretched appearance. You may also see erythema along a vein traveling from the site toward the heart. The patient may complain of muscle aches and malaise and may have a fever and regional lymphadenopathy.

Confirming the diagnosis

The patient's history, contributing factors, and symptoms help confirm cellulitis. When the affected area is small and the patient has no risk factors for serious illness, no further workup is indicated. But in high-risk patients and those with systemic signs, prepare to conduct a more extensive investigation: Draw blood for a complete blood cell count and blood culture (to rule out systemic infection) and blood urea nitrogen and creatinine (to check that kidney function is adequate to handle antibiotic excretion).

Now to intervene

Mild cases of cellulitis can be treated on an outpatient basis with a 7- to 10-day course of oral antibiotics. Tell the patient to elevate the affected area above heart level and to apply warm, moist packs to the site every 2 to 4 hours. If symptoms persist or worsen, tell him to call his health care provider.

A patient with serious cellulitis--extremely reddened, warm, and inflamed skin; pain over the affected area; and fever-should be hospitalized and treated with LV antibiotics. Because systemic infection can develop swiftly, monitor the patient closely and administer fluids. Remember that in immunocompromised patients and those on corticosteroid therapy, the onset of sepsis can be extremely subtle. Be prepared to administer vasopressors to increase blood pressure if sepsis develops.

Because cellulitis reduces blood flow and glucose transport to the affected area, healing may be slow, so 4- to 6-week courses of therapy are common in severe cases of cellulitis. After completing the course of IN. therapy, the patient may undergo a 7- to 10-day course of oral antibiotics to continue eradicating the infection and to prevent a recurrence. High-risk patients should take oral antibiotics for 4 to 6 weeks.

During this time, the patient should continue to rest and to elevate the affected area. Tell him to see his health care provider for a follow-up exam after completing the course of oral antibiotics.

For high-risk patients, managing the disease that contributed to cellulitis is the best way to prevent a recurrence. For example, patients with diabetes should be given follow-up instruction on controlling blood glucose levels, and those with circulatory deficits should review skin and foot inspection and care. If necessary, refer the patient to home health care services for ongoing education.

Dealing with complications

High-risk patients and those who don't adhere to treatment are especially prone to complications of cellulitis. Although extreme examples, such as sepsis, meningitis, local necrosis, and gangrene, are uncommon, they can develop rapidly and be irreversible and devastating. Teach patients and their families to watch for ominous signs and symptoms, such as fever, painful or stiff neck, and discoloration of the affected area of skin, and report them to the health care provider immediately.

Patients with severe facial cellulitis (erysipelas) are at risk for developing bacterial meningitis if the infection travels to the sinuses. Teach the patient the signs and symptoms of meningitis and tell him to go to the emergency department if acute symptoms occur when his primary health care provider's office is closed.
Tissue necrosis is a risk for patients with peripheral vascular disease or diabetes. Small areas of necrosis may require surgical debridement; large areas of necrosis may lead to amputation.

Rarely, anaerobic bacteria invade the necrotic tissue and cause gas gangrene. Extensive tissue and nerve damage in an arm or leg makes amputation likely. Keeping infection in check Because of its potentially devastating consequences, give cellulitis the respect it deserves. By understanding how to douse the inflammation, you can prevent it from flaring out of control.

SELECTED REFERENCES

Holzapfel, L., et al.: "Microbiological Evaluation of Infected Wounds of the Extremities in 214 Adults," Journal of Accident and Emergency Medicine. 16(l):32-34, January 1999.

Rodriguez, J., et al.: "Incisional Cellulitis after Total Hip Replacement," Journal of Bone and Joint Surgery (British volume). 80(5):876-878, September 1998.

Schwartz, R., et al.: "Current and Future Management of Serious Skin and Skin-Structure Infections," American Journal of Medicine. 100(6A):90S-955, June 1996.

BY LISA L. PHILLIPS, RN Clinical Supervisor Crescent Healthcare, Inc. * Modesto, Calif.

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