Tuesday, February 27, 2007

Risk factors for recurrent lower extremity cellulitis in a U.S. Veterans Medical Center population.

Risk factors for recurrent lower extremity cellulitis in a U.S. Veterans Medical Center population.
Am J Med Sci. 2006 Dec

Lewis SD,
Peter GS,
Gomez-Marin O,
Bisno AL.
University of Miami Miller School of Medicine, Miami Veterans Affairs Medical Center, Miami, Florida 33125, USA.

BACKGROUND: Despite the frequency of recurrent acute cellulitis of the lower extremities, factors associated with this infection have not been previously assessed in a case-control study among patients admitted to U.S. hospitals.

METHODS: We compared the clinical characteristics of 47 patients with those of 94 age- and sex-matched control subjects admitted to the Miami Veterans Affairs Medical Center.

RESULTS: In a multivariate analysis, two physical factors, lower extremity edema and body mass index, one behavioral factor, smoking, and one demographic factor, homelessness, were significantly and independently associated with recurrent cellulitis. The latter two factors have not previously been reported to be independently associated with cellulitis.

CONCLUSIONS: Our results suggest that increased emphasis on weight loss, smoking cessation, and improved foot hygiene in the homeless might decrease recurrences of lower extremity cellulitis.

PMID: 17170620 [PubMed - indexed for MEDLINE]

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Tuesday, February 20, 2007

Severe pseudo-preseptal cellulitis following sub-Tenon carboplatin injection for intraocular retinoblastoma.

Severe pseudo-preseptal cellulitis following sub-Tenon carboplatin injection for intraocular retinoblastoma.

J AAPOS. 2007 Feb 14

Kiratli H,
Kocabeyoglu S,
Bilgic S.

Hacettepe University School of Medicine, Department of Ophthalmology, Ankara, Turkey.

Sub-Tenon or subconjunctival administration of carboplatin is used to consolidate tumor regression by achieving high intraocular concentrations, without incurring systemic toxicity, in selected patients with intraocular retinoblastoma. Mild transient periocular edema is a common side effect of this treatment. We describe four patients with severe local soft-tissue toxic reaction mimicking preseptal cellulitis following subtenon carboplatin injections. The development of this complication after injecting through the inferior conjunctiva and unexpectedly severe signs are the unusual features of these patients. We did not encounter this complication after injections through the superior conjunctiva in 22 other patients using the same technique and identical drug dosage.

PMID: 17306997 [PubMed - as supplied by publisher]

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Wednesday, February 14, 2007

Orbital cellulitis following implantation of aqueous drainage devices.

Orbital cellulitis following implantation of aqueous drainage devices.

Eur J Ophthalmol. 2007 Jan-Feb

Chaudry IA,
Shamsi FA,
Morales J.
Oculoplastic and Orbit Divisio, King Khaled Eye Specialist Hospital, Riyadh - Saudi Arabia.

PURPOSE. Orbital cellulitis (OC) as a complication of implanted aqueous drainage devices (ADD) for glaucoma is an uncommon phenomenon. The authors report two cases of infectious OC in patients with a history of congenital glaucoma and placement of ADD.

METHODS. Clinical records of two patients with ADD who subsequently developed OC were reviewed for presenting symptoms, signs, medical and surgical management, and final outcome.

RESULTS. In the first case, an 11-year-old girl was found to have evidence of OC 9 days after the implantation of a Krupin-Denver valve. In the second case, a 14-month-old girl presented with similar findings 8 months following the implantation of an Ahmed valve. In both cases, ultrasonography demonstrated evidence of orbital inflammation and in one patient computed tomography scan was consistent with OC. In both cases, prompt institution of systemic antibiotics resulted in resolution of the clinical signs. In the first case, diagnosis was made early and the patient was promptly treated with systemic antibiotics, resulting in resolution of her symptoms without the need for implant removal. Because of the delayed presentation in the second case, an infected implant had to be removed to achieve resolution in addition to aggressive with antibiotics treatment.

CONCLUSIONS. Although rare, infectious OC may occur following implantation of ADD. Early recognition and intervention may be required to achieve resolution of the infection.

PMID: 17294397 [PubMed - in process]

Friday, February 09, 2007

Thigh Cellulitis

Thigh cellulitis: atypical presentation of intra-abdominal infection

Ann Fr Anesth Reanim. 2001 Nov

Tramoni G,
Mohammedi I,
Peguet O,
Petit P.

Service de reanimation polyvalente, pavillon G, hopital Edouard-Herriot, place d'Arsonval, 69003 Lyon, France.

The initial clinical presentation of intraabdominal disease can be an extraabdominal location. We report three cases of patients admitted to our intensive care unit because of a severe soft tissue infection of the lower extremity. Systematic research of the primitive source by using computed tomography (CT) scan allows us to find perforation of the gastrointestinal tract. Despite an unusual presentation, a high index of suspicion for lower intestine perforation must always be considered in face of a patient presenting with a spontaneous thigh cellulitis. Immediate radical debridement, appropriate antibiotics, and intensive care support are critical to control these life-threatening infections.

PMID: 11759323 [PubMed - indexed for MEDLINE]

Related Article:

Necrotizing soft tissue infection of the thigh: consider an abdominal cause.

Nijhof HW,
Steenvoorde P,
Bonsing BA,
Hartgrink HH.

Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. h.w.nijhof@lumc.nl

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved.

METHODS: Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance.

RESULTS: Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus.

CONCLUSIONS: High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.

Springer Link

Related Article:

Cellulitis of the right thigh, with gas.

J R Soc Med. 2003 Nov

Departments of General Surgery, Medicine, and Radiology, Glan Clwyd Hospital, Rhyl, North Wales LL18 5UJ, UK.

Cellulitis involving the lower limb is a common cause of admission to hospital. In instances where cellulitis affects the thigh and groin region, anorectal causes should be sought.


A woman of 69 was admitted after four weeks of rigors, low backache and anorexia. In addition her right hip had been painful for three weeks. There had been no change of bowel habit or abdominal pain. Three days before admission she had been started on trimethoprim by her general practitioner for a possible urinary tract infection. The medical history included hypertension, a pleomorphic salivary gland adenoma (excised one year previously) and rheumatoid arthritis. She was taking co-codamol, lansoprazole, lisinopril and prednisolone (15 mg once daily); she had recently stopped taking methotrexate.

On examination she was pyrexial (temperature 38.4°C) and mildly jaundiced. Her abdomen was soft and non-tender, but the right thigh was erythematous, warm and swollen on the anteromedial aspect from just below the inguinal ligament to the mid thigh. Haemoglobin was 11.5g/dL, white cell count 18.0 x 109/L, bilirubin 41 µmol/L. Cellulitis was diagnosed and she was started on intravenous benzylpenicillin 1.2 g four times daily and flucloxacillin 1 g four times daily. After 48 hours the thigh was slightly less erythematous but the fever persisted. Blood cultures were negative as were antistreptolysin titres. The treatment was changed to intravenous metronidazole 500 mg three times daily and clindamycin 600 mg four times daily and hyperbaric oxygen. After a further three days the cellulitis had spread over the whole thigh, her temperature was 39°C and there was evidence of an underlying soft tissue collection with crepitus. An ultrasound scan revealed gas in the soft tissues from the thigh to the ankle, confirmed by a plain X-ray. On clinical examination of the abdomen and perineum there was still no evident septic focus. Drainage of the thigh abscess yielded a large volume of foul smelling gas and pus, and the incision was extended from the groin to the knee. Most of the pus was subcutaneous; a small amount extended between the muscle groups but there was no evidence of myonecrosis. A tract was seen to be extending extraperitoneally up the femoral canal, with pus coming from above. A drain was placed up the femoral canal and the thigh wound was left open. On culture the pus gave a mixed growth of coliforms, anaerobic flora, streptococcus species and Pseudomonas aeruginosa. A CT scan showed extensive diverticular disease and a gas collection in the region of the right femoral canal closely related to a loop of bowel (Figure 1). At this stage faeces began to emerge from the thigh wound. At laparotomy there was a perforated diverticular mass in the right iliac fossa which had tracked down the femoral canal without contamination of the peritoneal cavity. A Hartmann's procedure was performed, with resection of about 15 cm of diseased sigmoid colon. After sixteen days she underwent debridement of the right thigh wound which was then closed with deep tension sutures. A lymphocutaneous fistula developed but this settled spontaneously. Five months later the colostomy was reversed without complications.


A possible cause of the gas tracking in the soft tissue was necrotizing fasciitis. However, no debridement of necrotic tissue was necessary during the initial procedure; moreover, necrotizing fasciitis is usually associated with a thin brown exudate rather than a large amount of frank pus.
1 A largebowel origin is more likely, and the perforation might have occurred several weeks earlier, with partial walling off in the right iliac fossa. The patient was insistent about her lack of gastrointestinal symptoms, but the manifestations could have been limited by the steroid she was taking.

Although femoral hernias usually contain omentum or small bowel, occasionally they contain appendix, caecum, testicle, ovary, a Meckel's diverticulum or a caecal diverticulum.2
Previous workers have described necrotizing fasciitis of the abdominal wall secondary to a strangulated femoral hernia containing a perforated sigmoid diverticulum in the presence of a rectosigmoid cancer, though this involved the left femoral canal.
3 Necrotizing fasciitis has also been described in the abdominal wall over the right iliac fossa secondary to perforation of a sigmoid diverticulum.4 We have not found any previous report of a perforated sigmoid diverticulum presenting with cellulitis and abscess formation in the right thigh.


Nichols RL, Florman S. Clinical presentations of soft-tissue infections and surgical site infections. Clin Infect Dis 2001;33(suppl 2):84 -93[CrossRef]

Naunton-Morgan RM, Maw A. Solitary caecal diverticulum strangulated in a femoral hernia. Br J Surg1996; 83:1547[Medline]

Conn IG, Martin DL, La Ferla G. Necrotising fasciitis secondary to a strangulated femoral hernia containing a perforated sigmoid diverticulum. J R Col Surg Edinb1996; 31:91 -2

Harrison BJ. Perforated sigmoid diverticulum with necrotizing fascilitis of the abdominal wall. J R Soc Med1981; 74:625 -6[Medline]

Royal Society of Medicine

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Tuesday, February 06, 2007

Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East.

Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East.
Ophthalmology. 2007 Feb;114

Chaudhry IA,
Shamsi FA,
Elzaridi E,
Al-Rashed W,
Al-Amri A,
Al-Anezi F,
Arat YO,
Holck DE.

Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. orbitdr@hotmail.com

PURPOSE: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East.

DESIGN: Noncomparative, interventional, retrospective case series.

PARTICIPANTS: Patients diagnosed with orbital cellulitis.

METHODS: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study.

MAIN OUTCOME MEASURES: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications.

RESULTS: A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month-85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision.

CONCLUSIONS: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis.

PMID: 17270683 [PubMed - in process]

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Thursday, February 01, 2007

Feasibility study to inform the design of a UK randomised controlled trial of prophylactic antibiotics on prevention of recurrent cellulitis

Feasibility study to inform the design of a UK multi-centre randomised controlled trial of prophylactic antibiotics for the prevention of recurrent cellulitis of the leg.

Trials. 2007 Jan 26;8(1):3

Thomas KS,
Cox NH,
Shipley D,
Meredith S,
Nunn A,
Sp-Savelyich B,
Reynolds NJ,
Williams HC,
Uk Dctn UD.


BACKGROUND: This paper describes the results of a feasibility study for a randomised controlled trial (RCT).

METHODS: Twenty-nine members of the UK Dermatology Clinical Trials Network (UK DCTN) expressed an interest in recruiting for this study. Of these, 17 obtained full ethics and Research & Development (R&D) approval, and 15 successfully recruited patients into the study. A total of 70 participants with a diagnosis of cellulitis of the leg were enrolled over a 5-month period. These participants were largely recruited from medical admissions wards, although some were identified from dermatology, orthopaedic, geriatric and general surgery wards. Data were collected on patient demographics, clinical features and willingness to take part in a future RCT.

RESULTS: Despite being a relatively common condition, cellulitis patients were difficult to locate through our network of UK DCTN clinicians. This was largely because patients were rarely seen by dermatologists, and admissions were not co-ordinated centrally. In addition, the impact of the proposed exclusion criteria was high; only 26 (37%) of those enrolled in the study fulfilled all of the inclusion criteria for the subsequent RCT, and were willing to be randomised to treatment. Of the 70 participants identified during the study as having cellulitis of the leg (as confirmed by a dermatologist), only 59 (84%) had all 3 of the defining features of: i) erythema, ii) oedema, and iii) warmth with acute pain / tenderness upon examination. Twenty-two (32%) patients experienced a previous episode of cellulitis within the last 3 years. The median time to recurrence (estimated as the time since the most recent previous attack) was 205 days (95% CI 102 to 308). Service users were generally supportive of the trial, although several expressed concerns about taking antibiotics for lengthy periods, and felt that multiple morbidity / old age would limit entry into a 3-year study.

CONCLUSIONS: This pilot study has been crucial in highlighting some key issues for the conduct of a future RCT. As a result of these findings, changes have been made to i) the planned recruitment strategy, ii) the proposed inclusion criteria and ii) the definition of cellulitis for use in the future trial.