Sunday, April 29, 2007

Facial Cellulitis by Pseudomonas aeruginosa

Facial Cellulitis by Pseudomonas aeruginosa

from Cancer Control: Journal of the Moffitt Cancer Center
Causes of Head and Neck Lesions During Neutropenia
Orbital Cellulitis

Orbital cellulitis is most commonly caused by Staphylococcusaureus, Streptococcus sp, and anaerobic bacteria. In children,Haemophilus influenzae type B was the most common cause of head and neck cellulitis.[9] With theH. influenzae type B vaccination,non-type B H. influenzae is now more common. In addition to these pathogens, P. aeruginosacan cause orbital cellulitis. In cancer patients, especially those with lymphoma or leukemia, Aspergillussinusitis spreading to the orbit is the most common organism associated with orbital cellulitis.[10] Other predisposing factors include surgery, trauma, pre-existing ocular disease, and immunosuppressive therapy.[11] Affected patients usually present with acute onset of unilateral periorbital pain, redness, edema,warmth, and tenderness. This life-threatening infection should be treated promptly and aggressively with anti-staphylococcal and two antipseudomonal antibiotics,[12] and amphotericin B or a lipid formulation of amphotericin B if fungal sinusitis is suspected.

Lingual Cellulitis

Lingual cellulitis is extremely rare.[13] If it occurs in neutropenic patients, the inflammation and associated swelling of the soft tissue can advance quickly. Prompt surgical and medical management are required to prevent local progression.This has been reported in profoundly neutropenic patients with acute myeloblastic leukemia.[13] It may occur after minor local trauma,followed by infections with organisms colonizing the mouth.Anaerobic streptococci and pseudomonas have been isolated from blood cultures.


Tonsillitis in the setting of neutropeniais most commonly caused by anaerobic bacteria such as Capnocytophagaochracea and Fusobacteriumsp. Usually, this entity is diagnosed only when blood cultures are positive because anaerobic cultures of the oropharynx cannot be obtained without a tissue biopsy. The treatment of choice is a penicillin-containing antibiotic orclindamycin.

Cryptococcus neoformans usually causes chronic meningitis or pneumonia, or it can be completely asymptomatic early in the course.[14] One case of cryptococcal tonsillitis in a patient with chronic lymphocytic leukemia was reported.[15] He presented with left tonsillar enlargement without exudate. Blood cultures and excisional biopsy of the involved tonsil revealed the presence of C.neoformans. He was successfully treated with amphotericin B and flucytosine for 6 weeks.

Malignant Otitis

ExternaMalignant otitis externa is a serious, locally invasive Pseudomonasinfection that typically occurs in elderly diabetic patients.[16,17] Severe otalgia is the usual presenting complaint. Purulent drainage and granulation tissue in the external auditory canal are usually found on examination.Local cellulitis and bone destruction are best documented by computed tomography scan or magnetic resonance imaging techniques.Malignant otitis externa has been reported in three severely neutropenic children with acute lymphoblastic leukemia who were receiving induction chemotherapy.[18] All of them presented with pain, extensive soft-tissue involvement, and profound discharge.External ear canal cultures showed prolific growth of P. aeruginosaand S. aureus. They we retreated with a 2-week regimen of intravenous antibiotics and regular suctioning and washing of the canal to remove debris and necrotic tissue. Although rare, externalotitis with local extension into the mastoid due to Aspergillus infection can occur in patients with prolonged neutropenia.

Ramsay Hunt Syndrome

Ramsay Hunt syndrome is caused by reactivation of the latent varicella-zoster virus infection harbored in the geniculate ganglion.[19] It is most common in immunocompromised patients, usually presenting with vesicles over the pinna and external auditory meatus, facial nerve palsy, and auditory involvement(tinnitus, vertigo, and deafness).It has been reported recently in a patient with malignant granulosa cell tumor of the ovary who developed Ramsay Hunt syndrome following aggressive chemotherapy.[20] She presented with classical symptoms and signs. Tzanck smear from the vesicular lesions showed acantholytic and inflammatory cells with an occasional binucleated pattern suggesting herpes zoster virus.She was treated with high-dose acyclovir.Skin lesions and pain rapidly resolved, but facial paralysis persisted partially. Risk factors for reactivation varicella infection include radiation therapy, chemotherapy,and corticosteroid use as well as the underlying malignancy.

Acute Bilateral Parotitis

Acute bacterial parotitis typically occurs in elderly, dehydrated,intubated, or postoperative patients.The most common pathogen associated with acute parotitisis S. aureus, followed by viridans streptococci.[21] However, acute parotitis resulting from anaerobes,enteric Gram-negative bacilli, and P.aeruginosa has also been documented.[22,23] Patients usually present with pain, swelling, and dysphagia.On examination,symptoms include tense swelling over the parotid area, tenderness, and pain on opening the mouth. In cancer patients, the occurrence of acute bilateral parotitis may not be related to an infectious agent but can be caused by chemotherapy.Chemotherapy-induced acute parotitis occurred in three patients with acute myeloid or lymphoblastic leukemia who were being treated with L-asparaginase, daunorubicin,or cytarabine.[24-26] The parotitis persisted throughout chemotherapy administration and resolved promptly upon discontinuation of the drugs.

Leukemic Infiltration

Cutaneous involvement in certain types of leukemia is not uncommon. An unusual case of leukemic infiltration of the skin secondary to acute myeloblastic leukemia mimicking cellulitis has been reported.[27] The patient presented with bilateral periorbitaledema and erythema clinically simulating infectious periorbital cellulitis.Pathologic evidence of polymorphonuclear leukocyte infiltrate in the dermis suggested the presence of pyoderma gangrenosum, a condition that has been shown to coexist with leukemic infiltration.[28]


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Wednesday, April 25, 2007

Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times?

Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times?
J Wound Care. 2007 Apr

Johnson S,
Leak K,
Singh S,
Tan P,
Pillay W,
Cuschieri RJ,
Mostyn E.
Department of Vascular Surgery, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster Royal Infirmary, UK.

OBJECTIVE: This single-centre non-blind randomised controlled trial aimed to compare clinical outcomes in terms of recovery time of standard treatment of lower limb cellulitis versus standard treatment combined with cycloidal vibration (Vibro-Pulse) therapy.

METHOD: Thirty-six patients (18 per group) with lower limb cellulitis were randomised to receive either standard treatment (intravenous or oral antibiotic therapy) and bed rest or standard treatment combined with cycloidal vibration treatment three times per day, 30 minutes per treatment. The outcome measure was the daily amount of reduction in erythema/cellulitis and oedema reduction against time for up to seven days of treatment and the resources required.

RESULTS: There was a clinically significant difference between the two groups, with 66% of the study group fully recovering within the seven days compared with 11% of the control group.

CONCLUSION: Cycloidal vibration combined with standard therapy can significantly reduce cellulitis treatment time. This can reduce both hospital bed days and the resources required.

PMID: 17444382 [PubMed - in process]

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Friday, April 20, 2007

Paediatric periorbital cellulitis and its management.

Paediatric periorbital cellulitis and its management.

Rhinology. 2007 Mar

Beech T,
Robinson A,
McDermott AL,
Sinha A.

Otolaryngology Department, City Hospital, Dudley Road, Birmingham, United Kingdom.

TOPIC: Periorbital cellulitis is often difficult to distinguish from orbital cellulitis, which is a rare but potentially fatal disease. There are only a few small studies in the literature and we aim to look at an ideal way of managing periorbital cellulitis in a paediatric population using our department's experience.

MATERIALS AND METHODS: Retrospective analysis of case notes and computer records of children attending our hospital with periorbital cellulitis over 26 month period.

RESULTS: Thirty-four patients met the criteria. Sixteen patients had reduced visual acuity, proptosis or ophthalmoplegia. Twenty-three had white cell count checked, 14 were raised and 7 of these had an operation. Eleven had blood cultures checked and all were negative. Seven had other cultures taken, Streptococcus milleri was the predominant organism isolated. Sixteen were CT scanned, 14 showed significant sinus disease. All patients were treated with intravenous antibiotics and ten required operative intervention. Two patients developed lateral orbital collections requiring further surgery.

CONCLUSIONS: Although relatively rare, periorbital cellulitis can be dangerous and it is essential for it to be treated seriously. A multidisciplinary approach is needed in managing children with this condition, with a good history and full blood count assisting in assessing severity, but a CT scan of the patient's sinuses is essential to differentiate from orbital cellulitis.

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Monday, April 16, 2007

A predictive model of recurrent lower extremity cellulitis in a population-based cohort.

A predictive model of recurrent lower extremity cellulitis in a population-based cohort.
Arch Intern Med. 2007 Apr

McNamara DR,
Tleyjeh IM,
Berbari EF,
Lahr BD,
Martinez J,
Mirzoyev SA,
Baddour LM.
Department of Medicine, College of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

BACKGROUND: Cellulitis is common and recurs in some patients. The study described herein derived a predictive model for the recurrence of lower extremity cellulitis in a population-based cohort.

METHODS: We conducted a retrospective, population-based cohort study using the Rochester Epidemiology Project. We reviewed the medical records of Olmsted County, Minnesota, residents with lower extremity cellulitis occurring from January 1, 1999, to June 30, 2000. Univariate and multivariate Cox proportional hazards analyses were performed to evaluate risk factors in patients who experienced recurrent lower extremity cellulitis within 2 years. A predictive model was developed to estimate risk of recurrence based on a score of risk factors identified by multivariate analysis.

RESULTS: A total of 209 episodes met the definition of lower extremity cellulitis. Thirty-five patients (16.7%) experienced recurrence within 2 years. Multivariate analysis identified tibial area involvement, prior malignancy, and dermatitis affecting the ipsilateral limb as independent risk factors for recurrence, with hazard ratios of 5.02, 3.87, and 2.99 (P<.01), respectively. A score calculated from these variables (a count of 0, 1, 2, or 3) was developed to measure risk of recurrence. Based on the predictive model, the estimated probability of recurrence (95% confidence interval [CI]) within 2 years was 5.0% (95% CI, 1.6%-8.2%), 17.3% (95% CI, 11.1%-23.0%), 50.6% (95% CI, 34.2%-63.0%), or 92.8% (95% CI, 51.9%-98.9%) for a score of 0, 1, 2 or 3, respectively.

CONCLUSIONS: We derived a model including tibial area involvement, history of cancer, and dermatitis to predict recurrence of lower extremity cellulitis. Potential interventions can be incorporated into treatment to diminish the proclivity for recurrence in high-risk patients.

Archives of Internal Medicine

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Monday, April 09, 2007

Lower limb cellulitis: features associated with length of hospital stay

Lower limb cellulitis: features associated with length of hospital stay

J Infect. 2006 Jan
Morpeth SC,
Chambers ST,
Gallagher K,
Frampton C,
Pithie AD.
Department of Infectious Diseases, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand.

AIMS: This study aimed to identify features associated with length of hospital stay (LOHS), length of intravenous antibiotic therapy (LIVAT) and six-week outcomes for patients with lower limb cellulitis, and to test the Eron/Passos classification of cellulitis in the New Zealand system.

METHODS: Eighty-five variables were collected prospectively from a cohort of 51 inpatients admitted to Christchurch hospital. The primary end-point for analysis was LOHS. LIVAT and six-week outcomes were secondary end-points.

RESULTS: On univariate analysis use of diuretics, living alone, cellulitis acuity, a creatinine concentration of >0.1 mmol/l, poor mobility, pulse >90 bpm, age >70 years, oedema extent, chronic oedema, ulceration, neutrophil count >10x10(9)/l, erythema area >1000 cm2 and haemoglobin concentration less than normal were significantly (P= or <0.05) or ="3">7 days was associated with use of diuretics, living alone, age >70 years, more oedema, erythema area >1000 cm2, haemoglobin less than normal, ulceration, creatinine >0.1 mmol/l and poor mobility. The presence of a discharge was associated with LIVAT. Multivariate analysis accounted for 48% of the variance in LOHS and 16% for LIVAT. Use of diuretics, neutrophil count >10x10(9)/l and oedema score were independently associated with LOHS, with oedema score associated with short stay and diuretic use with long stay. The Eron/Passos system was not helpful so a new scoring system was devised which successfully classified patients into length of stay groups.

CONCLUSIONS: The clinical features analysed accounted for half of the variance in LOHS. An important reason may be physician discretion. If so, our scoring system based on these results could be used in a clinical pathway to improve patient care. This tool would need to be evaluated prospectively.

Science Direct

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Edema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg

Edema/Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: a series with community follow-up.
Br J Dermatol. 2006 Nov


Cox NH.
Dermatology Department, Cumberland Infirmary, Carlisle CA2 7HY, UK.

BACKGROUND: Cellulitis of the lower leg is a common problem with considerable morbidity. Risk factors are well identified but the relationship between consequences of cellulitis and further episodes is less well understood.

OBJECTIVES: To review risk factors, treatment and complications in patients with lower leg cellulitis, to determine the frequency of long-term complications and of further episodes, and any relationship between them, and to consider the likely impact of preventive strategies based on these results.

METHODS: Patients with ascending, presumed streptococcal, cellulitis of the lower leg were identified retrospectively from hospital coding. Hospital records, together with questionnaires to both general practitioners and patients, were used to record subsequent complications and identifiable risk factors for further episodes.

RESULTS: Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated (P <>

CONCLUSIONS: This study demonstrates that the true frequency of postcellulitic oedema, as well as that of further episodes, is probably underestimated. Furthermore, there is a strong association between these factors, each of which is both a risk factor for, and a consequence of, each other, and for which intervention (reduction of oedema or more prolonged antibiotic therapy) may reduce the risk of recurrent infection. By contrast, self-reporting of toeweb maceration is low, so attempts to reduce the risk of recurrent cellulitis by treatment of tinea pedis or bacterial intertrigo may fail.

Blackwell Synergy

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Thursday, April 05, 2007

Cervicofacial cellulitis revealing cutaneous lymphomas

Cervicofacial cellulitis revealing cutaneous lymphomas
Rev Stomatol Chir Maxillofac. 2007 Mar 29

Benbouzid MA,
Bencheikh R,
Benhammou A,
El Edghiri H,
Boulaich M,
Essakali L,
Kzadri M.
Service d'ORL et de chirurgie maxillofaciale, hopital des specialites, CHU Rabat-Sale, Maroc.

INTRODUCTION: The cervicofacial localization of cutaneous lymphomas is rare. These lymphomas usually present as a long-lasting and treatment-refractory papule or nodule. Lymphomas can also be revealed by cervicofacial cellulitis.

CASES: We report 2 cases of cervicofacial cellulitis revealing a cutaneous lymphoma. The diagnosis was proved by multiple biopsies, performed because there was no clinical improvement in spite of an aggressive and adequate antibiotherapy. Our 2 patients were treated by radio and chemotherapy.

DISCUSSION: Cutaneous lymphomas are lymphocytic proliferations stemming from cutaneous lymphoid tissue, without nodal, medullary, or visceral localization. Their clinical presentation is quite polymorphic, and cellulitis is one of the modes of revelation, especially forehead and neck localization. They have no portal of entry and are resistant to treatment. The diagnosis relies on histology, and biopsies must be performed if there is a suspicion of lymphoma. The treatment is radio and chemotherapy, and the evolution depends on the tumoral stage.

PMID: 17399753 [PubMed - as supplied by publisher]

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