Dissecting Cellulitis Treated with the Long-Pulsed Nd:YAG Laser.

Dissecting Cellulitis Treated with the Long-Pulsed Nd:YAG Laser.

Dermatol Surg. 2006 Aug;32(8):1039-44

School of Medicine, Department of Dermatology, Wayne State University, Detroit, Michigan.

Dissecting cellulitis is a chronic inflammatory scalp condition characterized by pustular nodules, sinus tract formation, and resultant cicatricial alopecia. Current treatments are of limited efficacy.

This report explored treating dissecting cellulitis with the long-pulsed Nd:YAG laser to determine the capabilities and limitations of this modality with respect to: (1) reducing pus formation; (2) enabling the termination of systemic treatments; (3) investigating the side-effect profile including dyspigmentation and scarring alopecia; and (4) terminating the disease process. This observational study followed four patients with long-standing dissecting cellulitis through consecutive treatments with the long-pulsed Nd:YAG laser without epidermal cooling.

One year after initiating laser treatment, patients achieved decreased pus formation, a reduced reliance on systemic treatments, and a controlled or terminated disease process without dyspigmentation. Three patients had regrowth of terminal hairs in treatment sites. The long-pulsed Nd:YAG laser is effective in attenuating the progression of dissecting cellulitis without appreciable adverse cutaneous side effects. This is a pilot study, and more patients must be treated in other trials to verify these findings.

Brett D. Krasner, MD, Fasahat H. Hamzavi, MD, George J. Murakawa, MD, PhD, and Iltefat H. Hamzavi, MD, have indicated no significant interest with commercial supporters.

PMID: 16918566 [PubMed - in process]

A Case of Facial Cellulitis and Necrotizing Lymphadenitis due to Cowpox Virus Infection.

A Case of Facial Cellulitis and Necrotizing Lymphadenitis due to Cowpox Virus Infection.

Clin Infect Dis. 2006 Sep 15;43(6):737-42. Epub 2006 Aug 10

Pahlitzsch R,
Hammarin AL,
Widell A.

Department of Otolaryngology, Blekinge County Hospital, Karlskrona, Sweden. roland.pahlitzsch@ltblekinge.se.

We describe a patient with facial cellulitis/erysipelas due to cowpox virus inoculation in the respiratory epithelium of the nose. A cytopathic agent was isolated in cell culture, and the diagnosis of cowpox was confirmed by electron microscopy and polymerase chain reaction.

The most likely source of infection was exposure to the family cats. In addition to the severe edematous cellulitis of the face, the clinical course was dominated by several areas of subcutaneous, necrotizing lymphadenitis, from one of which a huge abscess formed that had to be incised. Hyperbaric oxygen treatment was provided to prevent development of dermal necrosis.

The healing process in the numerous areas of lymphadenitis was markedly protracted, and 1 persisting node (which yielded positive results on polymerase chain reaction) had to be excised 2 years after onset of disease.

This is the first reported case of inoculation of cowpox virus in the respiratory mucosa of the nose. It resulted in a clinical course totally different than that for inoculation in the skin. We also present a short review of findings on orthopoxvirus infection that focuses on the chain of transmission.

PMID: 16912948 [PubMed - in process]

[Human cowpox/catpox infection. A potentially unrecognized disease]

Steinborn A,
Essbauer S,
Marsch WCh.
Universitatsklinik und Poliklinik fur Dermatologie und Venerologie, Martin-Luther-Universitat Halle-Wittenberg, Halle (Saale).

HISTORY AND ADMISSION FINDINGS:

A 36-year-old woman initially noticed a red spot, about pea-sized, with a central pimple over the right eyebrow and a swollen submandibular lymph node. A pressure-sensitive, 4 cm large, node developed out of this small spot, with a central, black, tightly-adhering crust bearing several varioliform vesicles around its edge. In addition to swelling of the right half of the face, the patient had a fever up to 39.5 degrees C, general malaise, nausea and vomiting. Various antibiotics were ineffective. The woman was hospitalized with a diagnosis of facial erysipelas. She owned a cat which had developed a purulent nodule on a forepaw a few days before onset of the patient's disease.

LABORATORY TEST:

ESR and CRP were moderately elevated, no leukocytosis and blood cultures were sterile. Wound smears showed colonization with Klebsiella pneumoniae and Enterobacter cloacae.

DIAGNOSIS, TREATMENT AND COURSE:

The patient's general condition improved under initially calculated antibiotic dosages, which was later adapted to the measured resistance. The black-crusted nodes became larger, however, and incision was performed on the 8 th day after hospitalization, under the suspicion of fluctuation. However, no pus was removed, but there was massive inflammatory infiltration of the soft tissue. Examination of samples of skin and part of the crust revealed orthopox virus (cowpox virus). Spontaneous healing followed within 3 weeks, leaving only a small scar.

CONCLUSIONS:

This was a cowpox virus in the sense of a zoonosis transmitted by the cat. In Germany, now that smallpox has been eradicated, the clinical presentation of infections with the orthopox virus, which are closely related to variola virus, are too little recognized. Atopic and immunocompromised patients are at risk of a cutaneous dissemination with a more severe course of the infectious illness; even a lethal outcome has been reported in Germany.

PMID: 12649797 [PubMed - indexed for MEDLINE]

[Cowpox virus infection in a child]

April 2004

[Article in French]
Heilbronner C,
Harzic M,
Ferchal F,
Pothier A,
Charara O,
Beal G,
Bellaiche M,
Lesca C,
Foucaud P.
Service de pediatrie, hopital Andre-Mignot, centre hospitalier de Versailles, 177, rue de Versailles, 78157 Le-Chesnay, France. cheilb@yahoo.com

Although human cowpox virus infection is rare nowadays, an animal reservoir of this virus still exists. The general course of cowpox virus infections is usually benign but the diagnosis is difficult and often late.

CASE REPORT: An 11-year-old boy, owner of two cats, presented with an infected sacral wound lesion associated with fever and lymph nodes. The wound became necrotic and other cutaneous and mucous membrane lesions developed secondarily. Blood tests did not show hyperleukocytosis or a systemic inflammatory response. Concurrently one of the cats was examined by a veterinary because of multifocal cutaneous lesions. Evocative skin biopsy specimens from the animal and, secondarily from the patient, allowed the identification of orthopoxvirus. Evolution was slowly favourable under symptomatic treatment.

CONCLUSION: Poxviruses are responsible for many animal and human diseases, the most famous of them being smallpox which today is considered eradicated. Vaccination against smallpox is no longer performed since 1977. Whether the arrest of vaccinations against smallpox may induce the apparition of other poxviruses infections or alter their clinical expression is an open question.]

PMID: 15051092 [PubMed - indexed for MEDLINE]

Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study.

Recurrence of lymphoedema-associated cellulitis (erysipelas) under prophylactic antibiotherapy: a retrospective cohort study.

Vignes S,
Dupuy A.

Department of Lymphology, Hopital Cognacq-Jay, Paris, France.

Aim: To identify the predictors of successful antibiotic prophylactic treatment using benzathin-penicillin G to prevent recurrence of erysipelas in patients with secondary upper limb lymphoedema. A retrospective cohort study.

Patients with secondary arm lymphoedema were recruited in a single lymphology unit between 1990 and 2003. All patients had had at least three recurrences of erysipelas. Patients were given 2.4 MU benzathin-penicillin G intramuscularly at 14-day intervals. For each patient, the following data were recorded: characteristics of breast cancer treatment (type of surgery, radiotherapy, hormone therapy), number of erysipelas recurrences before inclusion, patient characteristics including body mass index (BMI) and lymphoedema volume at inclusion.

The outcome studied was the occurrence of erysipelas on the affected arm under antibiotic prophylactic treatment. With a 4.2-year median follow-up from the onset of antibiotic prophylactic treatment, 23 of 48 women experienced recurrence of erysipelas. The median duration of erysipelas recurrence-free period under this treatment was 2.7 years. The estimated rate of recurrence was 26%[95% confidence interval (CI) 13-38%] at 1 year and 36% (95% CI 22-50%) at 2 years. No patient stopped the treatment because of side-effects.

No predictive factor of erysipelas recurrence under antibiotic prophylactic treatment was identified. Antibiotic prophylaxis using benzathin-penicillin is a well-tolerated treatment of erysipelas recurrence in patients with upper limb lymphoedema secondary to breast cancer. The rate of erysipelas recurrence was 26% at 1 year in patients who had a history of at least one erysipelas. We did not find any predictor of erysipelas recurrence.

PMID: 16898904 [PubMed - in process]

Delayed Breast Cellulitis Following Breast Conserving Therapy for Stage 1 and 2 Breast Carcinoma.

Delayed Breast Cellulitis Following Breast Conserving Therapy for Stage 1 and 2 Breast Carcinoma.

Sub-category: Breast Cancer

Category: Breast Cancer

Meeting: 2000 ASCO Annual Meeting

Abstract No: 532

Citation: Proc Am Soc Clin Oncol 19: 2000 (abstr 532)
Author(s): Douglas Zippel, Moshe Papa, Gur Ben-Ari

Abstract

The advent of breast conserving surgery in appropriate breast tumors has allowed an adequate therapeutic advantage while at the same time ensuring a better cosmetic result along with a shorter hospital stay. Overall, breast conservation is well tolerated. One complication, which has been increasingly reported , is delayed breast cellulits (DBC) in the treated breast. This cellulitis can often be mistakenly interpreted as an aggressive early recurrence in the breast, thus presenting both surgeon and oncologist with a difficult diagnostic dilemma. The cellulits is to be distinguished from a post lumpectomy wound infection which can occur in the immediate post operative period. DBC appears several months after the surgical procedure, and is characterized by pain, erythema and edema in the affected breast, mimicking inflammatory carcinoma. There may be associated systemic symptoms such as chills, fever and leukocytosis. We present 16 cases of DBC from a population of 360 women undergoing breast conserving therapy for stage 1 and 2 breast cancer. The location of the primary tumor in all these patients was the upper outer quadrant or tail of the breast. There were no medial or inferior tumors. All patients underwent radiotherapy to the affected breast. 13 patients underwent axillary dissection, 9 node positive and 4 node negative. The mean number of lymph nodes removed was 16. All patients underwent FNA aspiration of the affected area, and fluid was sent for cytology and culture. There where no recurrent carcinomas found, and all cultures were negative. Treatment consisted mainly of symptomatic relief with NSAID drugs. The mean time to resolution of symptoms was 7.5 months. The manifestation of DBC is not uncommon in woman after lumpectomy and radiation therapy. It is probably a result of the disruption of lymphatic channels after surgery, coupled with some element of tissue damage secondary to radiation. The surgical oncologist should be aware of this particular entity, and while recurrent carcinoma should be considered and ruled out, the most appropriate therapy for such cases is symptomatic relief and encouragement, for the entity is usually self limiting.

American Society of Clinical Oncology

* * * *

Related Discussion from National Lymphedema Network

Oct-Dec 2005 Kathleen D. Francis, MD

Q: I had a lumpectomy for breast cancer 8 months ago followed by chemotherapy and radiation. Recently I developed redness, soreness and swelling of the breast, but otherwise have been feeling well. Is this an infection?

A: There are several diagnostic considerations in evaluating someone with the symptoms you describe. The main things that need to be ruled out include infection, inflammatory reaction to surgery and radiation, or a form of breast cancer called inflammatory breast carcinoma.

In persons who have had surgery and irradiation to the breast, lymphatic pathways in the breast presumably have been damaged or impaired. This can result in inefficient drainage of fluid and proteins from the breast, and also decreases the body's immune response in that area. Both of these processes lead to an increased risk of infection, or cellulitis, of the breast.
Cellulitis is an acute inflammation of skin and subcutaneous fat often associated with fever and other systemic symptoms such as tiredness and nausea. The infective organism in the vast majority of cases is presumed to be non-group A streptococcus, but in more than 80% of cases, no bacterial pathogen is ever isolated in the tissue or blood cultures. Infective cellulitis usually responds rapidly to a penicillin or erythromycin, although other antibiotics also may be effective.
In one study, the most important risk factor for the development of breast cellulitis was lymphedema of the breast. Other factors included seroma aspiration or drainage of a hematoma following breast surgery, and a larger volume of breast tissue removed in a lumpectomy.
Cellulitis can also occur in persons who do not have lymphedema or any risk of lymphedema. However, inflammatory and systemic symptoms in persons with lymphedema who develop cellulitis may take longer to resolve than in persons who do not have lymphedema. It is postulated that in persons with lymphedema or who are at risk for lymphedema, the toxins released by bacteria that have been killed by antibiotics or immune responses are not removed efficiently and these toxins set up a persistent local inflammatory response. This may also explain why the bacterial pathogen is infrequently isolated from patients with cellulitis-it may be the inflammatory response to the bacterial toxins rather than proliferation of the bacteria itself that is causing most of the symptoms.

Another consideration in evaluating redness, soreness, and edema of the breast occurring after treatment for the breast cancer is what may be described as non-infective inflammation. In these cases, the symptoms are similar to cellulitis, but are not accompanied by fever or systemic complaints and the onset of the symptoms is often more gradual. For instance, an inflammatory reaction can occur following radiation to the breast and may last for many months. One study referred to an entity called "delayed breast cellulitis" (using the term to mean inflammation rather than infection) in which pain, redness, and skin edema of the breast occurred between 4-15 months after lumpectomy without systemic symptoms, with negative tissue and blood cultures, and with negative biopsies for recurrent cancer. The majority of patients recovered without antibiotic treatment, but the mean time to resolution of symptoms was 7 months.

Because it can be very difficult to distinguish acute infection from the inflammation, the term acute inflammatory episode (AIE) is becoming more common to describe these episodes.

Lastly, breast inflammation and edema that is unresponsive to antibiotic therapy raises the possibility of inflammatory breast cancer, a diffuse neoplastic process that involves the skin lymphatics. Since mammography can be difficult to interpret in this situation, patients may require fine needle aspiration or core biopsy to rule out cancer.

As you can see, evaluation of the symptoms you describe can be a complicated process. In any case of new onset breast redness, soreness and edema, it is important to have medical evaluation to arrive at a proper diagnosis and institute appropriate treatment when needed.

Profile of neck cellulitis - Clinician's dilemma

Profile of neck cellulitis - Clinician's dilemma

Ravikumar A, Ezhilarasu PDepartment of ENT & head and neck surgery, SRMC & RI (DU), Porur, Chennai – 600 116, India

Correspondence Address:Ravikumar A Department of ENT & head and neck surgery, SRMC & RI (DU), Porur, Chennai – 600 116 India
ezhilarasup@yahoo.com

Abstract

Cellulitis neck may be the only presenting feature of an underlying disease in the upper aerodigestive tract. Inflammation in the head and neck region spreads through potential neck spaces to the surface by direct extension or by lymphatic spread. Four cases of cellulitis neck who presented in the emergency department and progressed with variable clinical course are reported in this paper. After initial treatment with parenteral broad spectrum antibiotics, investigations revealed underlying disease and appropriate treatment was instituted. The importance of detailed clinical examination, investigations and key management protocols are highlighted.

Keywords: Cellulitis neck; dysphagia; parapharyngeal space; parenteral antibiotics; phonation; transglottic tumour

Case Resport

Case 1
A 50-year-old male patient presented with swelling in the anterior aspect of the neck with restricted mouth opening and dysphagia for 2 days without any difficulty in breathing and change of voice. He was a diabetic on irregular treatment. He was a smoker for past 6 years. Examination showed diffuse cellulitis of left side of neck. Examination of oral cavity, Pharynx and larynx was not possible, because of trismus. Blood examination showed polymorpho nuclear leucocytosis. X-ray neck lateral view showed widened prevertebral shadow from C4 to C6. Meanwhile parenteral broad spectrum antimicrobial therapy was started. The neck swelling decreased in size and the inter incisor distance improved after 2 days of treatment. Videolaryngoscopy revealed an ulceroproliferative growth covered with slough involving the lingual surface of epiglottis, vallecula, extending down into medial wall of left pyriform fossa with fixity of left hemilarynx. Right pyriform fossa was free. Both arytenoids were grossly edematous and the ventricular bands were found hypertrophied with fullness of the left ventricle. Right vocal cord was mobile and no phonatory gap was observed. X-ray chest revealed no abnormality. Direct laryngoscopy and biopsy under local anaesthesia was done. Histopathological examination revealed moderately differentiated squamous cell carcinoma. The case was diagnosed as carcinoma larynx (transglottic) stage III (T3, N0 and M0). Radical radiotherapy was offered as the treatment, after the patient refused surgery. He is on regular follow up.

Case 2
A 52-year-old male patient presented with swelling of the left side of the neck with restricted mouth opening and dysphagia for 3 days without any breathing difficulty and voice change. He was nondiabetic. He was a smoker for past 25 years. Examination showed tender diffuse swelling in the left lateral aspect of the neck. Examination of oral cavity, pharynx and larynx was not possible because of trimus. Blood investigation showed increased neutrophil count. X-ray neck lateral view showed widened prevertebral soft tissue shadow from C4 to C6. Meanwhile parenteral broad spectrum antibiotics was started. The neck swelling decreased in size to a hard nontender 5 ´ 4 cm left submandibular lymphnode. The inter incisor distance improved after 2 days of treatment. Video laryngoscopy did not reveal any lesion in oral cavity, oropharynx or larynx. USG neck revealed mixed echogenic lesion measuring 5.2 x 4.2 cm predominantly solid, located in the left submandibular region. Few cystic spaces/areas of necrosis were noted within. FNAC of the node showed secondary deposits of squamous cell carcinoma. Panendoscopy did not reveal any primary. The case was diagnosed as secondaries neck with occult primary. He was treated with wide field radiotherapy covering possible primary sites and neck with good response. He is on regular follow up.

Case 3
A 58 years male patient presented with diffuse swelling in the left side of the neck, restricted neck movements and minimal voice change for 5 days. He gave history of recurrent respiratory tract infection. Examination showed diffuse tender swelling in the left lateral aspect of the neck. Oral cavity, pharynx were normal. Video Laryngoscopy revealed sluggishly moving left vocal cord. There was incomplete compensation by the right vocal cord on phonation. Parenteral broad spectrum antibiotics reduced the neck cellulitis, revealed three discrete mobile firm nontender lymphnodes around 2.5 cm each in the left side of the neck including one in the posterior triangle and two in the level III region. X-ray chest revealed increased broncho - pulmonary markings. Sputum AFB and mantoux were positive. FNAC of the node showed caseating necrosis. The case was diagnosed as laryngeal tuberculosis and tuberculous cervical lymphadenitis. Patient was treated with antitubercular drugs with good response. He is on regular follow up.

Case 4
A 55-year-old male patient presented with swelling in the left side of neck with fever for 3 days. Patient was hospitalized. Neck examination showed diffuse and tender swelling in the left lateral aspect of the neck. Examination of oral cavity revealed no abnormalities and indirect laryngoscopy showed fullness in the left lateral pharyngeal wall. Rest of the larynx was normal. Blood investigations showed increased neutrophil count. X-ray neck lateral view showed widening of prevertebral shadows from C4 to C6. USG neck showed echogenic shadows in the left side of neck. Patient was diagnosed as left parapharyngeal abscess. Under all aseptic precautions the left parapharyngeal abscess was drained and parenteral broad spectrum antimicrobial therapy started. Patient was treated conservatively thereafter and he recovered completely.

Observation

1.We observed that these cases of cellulitis neck treated with parenteral broad spectrum antibiotics recovered very well without any major surgical intervention. However, a tracheostomy tray was kept ready by the bedside for all patients in case of stridor.

2.Because of the parenteral antibiotic therapy, the cellulitis decreased, revealing the underlying pathology. The lymphnodes in the neck, after the conservative management become prominent and FNAC of the nodes confirmed secondary deposits.

3.The neck nodes of tuberculous origin were not matted on presentation. Antituberculous therapy was instituted after the diagnosis was confirmed.

4.Routine management of parapharyngeal abscess yeilded good results.

Results

l The laryngeal tumour was confirmed to be transglottic and was moderately differentiated squamous cell carcinoma, oncologically stage III (T3, N0 and M0). The patient was offered surgery but refused. So radical radiotherapy and follow up thereafter was advised.

l The patient with secondaries neck with working diagnosis of occult primary was advised to undergo HRCT of neck with and without contrast. However, a proper diagnosis eluded us, so wide field radiotherapy was instituted as a therapeutic tool.

l The tubercular lymphadenitis patient is on regular follow up.

l The patient with parapharyngeal abscess after incision and drainage is doing well on follow up.

Discussion

Cellulitis neck could occur in superficial infection or infection from deep neck spaces. Kevin A. Shumrick and Paperella stated the spread of inflammation from deeper spaces occurs through direct extension or lymphatics in the parapharyngeal space to the surface. The cancers of the transglottic and pyriform sinus frequently invade the thyroid cartilage, cricothyroid membrane and upper cricoid cartilage to involve the extralaryngeal soft tissues. The transglottic lesion in particular may narrow the glottic opening to such degree that stridor and airway obstruction result. But in our first case, there was no stridor or change in voice because of adequate glottic chink and very good right vocal cord compensation. Despite extensive cellulitis of neck, this patient did not have any clinically positive lymphnode enlargement. Also he responded well to parenteral antibiotic therapy indicating good immune response. [3],[4],[5],[6]

In the second patient with occult primary and neck secondaries the initial presentation was probably due to the secondary periadenitis and suppuration, which leads to opening of the tissue planes in the neck mimicking cellulitis of neck. As Bruce A. Scott and Charles M. Steinberg explained,[2] the possible route of spread of infection in case of primary malignancies of upper aerodigestic tract is to permeate through the lymphatic channels (which are already open due to micrometastasis) and those involving the extralaryngeal soft tissues to the surface in the neck to present as cellulitis.

In the patient with tuberculous lymphadenitis, cellulitis of neck was due to the secondary infection and suppuration of the lymphnodes due to caseation necrosis, which was treated with parenteral antimicrobial therapy and antitubercular treatment subsequently.[3],[4],[5],[6]

As explained by DeMarie et al[4] parapharyngeal abscess occurs after the point source of infection spreads in contiguity from either the tongue, teeth, parotids, submandibular glands or tonsils which tracks down to the digastric muscle and alongside to the middle third of sternocleidomastoid to present as an abscess.

Conclusion

l All patients presenting with cellulitis neck should not be viewed as neck space infections alone.l The variability of pathological lesion beneath the cellulitis should be borne in mind.

l In advanced malignancies of larynx and hypopharynx, cellulitis of neck may be the only clinical presentation.l Dysphagia in any form should be investigated in detail.

l Timely intervention in treating such cases will prevent complications and prove to be life saving.

l Aggressive conservative treatment obviates the need for surgical intervention.

Indian Journal of Otolaryngology and Head and Neck Surgery