Eosinophilic cellulitis (wells' syndrome) in association with angioimmunoblastic lymphadenopathy.

Eosinophilic cellulitis (wells' syndrome) in association with angioimmunoblastic lymphadenopathy.
Acta Derm Venereol. 2007

Renner R, Kauer F, Treudler R, Niederwieser D, Simon JC.
Department of Dermato-Venereology and Allergology, University of Leipzig.

Eosinophilic cellulitis (Wells' syndrome) is an uncommon inflammatory disease with clinical polymorphism. It is often associated with infectious, allergic or myeloproliferative diseases; however, the exact aetiology is unknown. This report describes a rare case of eosinophilic cellulitis in association with angioimmunoblastic lymphadenopathy. The typical skin findings of Wells' syndrome disappeared completely following chemotherapy and autologous stem cell transplantation.

Acta Dermato-Venereologica

Management of cellulitis in a pediatric emergency department.

Management of cellulitis in a pediatric emergency department.

Pediatr Emerg Care. 2007 Nov
Khangura S, Wallace J, Kissoon N, Kodeeswaran T.
Division of Emergency Medicine, Departments of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.

OBJECTIVES: (1) To determine antibiotic choices, route of administration, and outcomes of children treated as outpatients with noncomplicated, nonfacial cellulitis at a tertiary care center. (2) To determine the number of visits and time spent in the emergency department (ED) for treatment.

DESIGN: A descriptive case-control study.

SETTING: A tertiary care pediatric ED at an academic medical center.

METHODS: Medical records of all otherwise healthy children (aged 1-16 yrs) presenting with noncomplicated, nonfacial cellulitis over a 3-year period (January 1, 2001-December 31, 2003) were reviewed. Data extracted included the following: demographics; clinical presentation; laboratory and microbiology results; management, including choice, dose, and route of antibiotic(s); treatment failures; and time spent in the ED.

INTERVENTIONS: None.

MAIN RESULTS: Two hundred sixty-nine patients met the inclusion criteria, and their charts were selected for review. The oral antibiotic most often prescribed was cephalexin (N = 105). Treatment failure occurred in 10 (8.9%) of the cases. The intravenous antibiotic most often prescribed was cefazolin (N = 124; 39 received cefazolin alone, and 85 received cefazolin and probenecid). The cefazolin-only group had 12 (31%) treatment failures, whereas the cefazolin and probenecid group had 7 (8.1%) treatment failures. More time in the ED (521 +/- 287 minutes) and more visits (3.4 +/- 2.8) were seen in the intravenous group as compared with the oral group (time in ED, 164 +/- 139 minutes; visits, 1.4 +/- 1).

CONCLUSIONS: Noncomplicated, nonfacial cellulitis is most commonly treated using first-generation cephalosporins. Treatment with oral antibiotics was effective and required fewer visits and less time in the ED compared with intravenous treatment. Twice-daily cefazolin and probenecid was associated with less treatment failures and admissions than cefazolin alone and may represent a reasonable alternative for children with nonfacial cellulitis requiring intravenous antibiotics.

Pediatric Emergency Care - Lippincott, Williams and Wilkins

Cellulitis revealing a cryptococcosis-related immune reconstitution inflammatory syndrome in a renal allograft recipient.

Cellulitis revealing a cryptococcosis-related immune reconstitution inflammatory syndrome in a renal allograft recipient.
Am J Transplant. 2007 Dec

Lanternier F, Chandesris MO, Poirée S, Bougnoux ME, Mechai F, Mamzer-Bruneel MF, Viard JP, Galmiche-Rolland L, Lecuit M, Lortholary O.

Service des Maladies Infectieuses et Tropicales Hôpital Necker-Enfants Malades, Université Paris V Centre d'Infectiologie Necker-Pasteur, Paris, Cedex 15, France.

Corresponding author: Olivier Lortholary, olivier.lortholary@nck.aphp.fr

Immune reconstitution inflammatory syndrome (IRIS) has rarely been described in the course of disseminated cryptococcosis in solid organ transplant recipients. We report here the case of a renal transplant recipient who developed severe cellulitis in the context of Cryptococcus neoformans-associated IRIS while undergoing reduction of his immunosuppressive therapy. IRIS appeared concomitantly with a dramatic increase of blood CD4+ T cells (94-460/mm(3)) and required the administration of a short-term steroid therapy to resolve.

Blackwell Synergy

Defining Cellulitis

Defining Cellulitis

Skinmed. 2007 Nov-Dec

Lawrence Charles Parish, MD; Joseph A. Witkowski, MD

Exactly what does cellulitis mean? How many consultation requests state that the patient has cellulitis, when, in fact, it was stasis dermatitis from which the patient suffered? Leider and Rosenblum, 1 considered the 20th-century lexicographers for dermatology, wrote:

Cellulitis literally means inflammation (-itis) of the little cells (cellul-). What is really meant, of course, is diffuse inflammation of parenchyma without necrosis or sharp localization of pus.

The definition given by the Microsoft Word dictionary is less precise but more limiting as describing cellulitis as “infection and inflammation of the tissues beneath the skin.”We have traditionally considered cellulitis to be inflammation in the dermis with both redness and induration present. No purulent opening can be seen; when there is a portal for pus, a furuncle or boil would be the diagnosis.

Cellulitis and Erysipelas

The terms cellulitis and erysipelas connote a diffusely spreading bacterial infection, excluding such walled-off lesions as the abscess, furuncle, and carbuncle (ie, not a boil). The pathology of erysipelas ( Figure 1 ) should be limited to the upper portions of the dermis, while cellulitis ( Figure 2 , Figure 3 ) seeks the lower portions of the dermis and the subcutaneous tissue. Because the clinical pictures often blend, many Northern European physicians use the term erysipelas to include both erysipelas and cellulitis. Unfortunately, both terms get bantered about in the United States, creating a continuing state of confusion. There seems to be a movement to discard the concept of erysipelas entirely. 2–5

Both conditions represent the results of pyogenic infections due to such bacterium as β-hemolytic streptococcus, group A, B, C, or G. Sometimes Staphyloccocus aureus is implicated in cellulitis, while Haemophilus influenzae type b can cause childhood cellulitis. Rarer causes of cellulitis include Aeromonas hydrophila, 6 Vibrio alginolyticus, 7 and Pasteurella multocida. 8 Erysipelas, once called phlegmona diffusa, and cellulitis can develop due to Pseudomonas aeruginosa, Streptococcus pneumoniae, Serratia marcescens, 9 and Campylobacter jejuni, particularly in immunocompromised patients.

Clinical manifestations can include tenderness and malaise with the addition of chills and/or fever. There can be induration and pitting edema as a result of the rapid spread of the infection. Lymphangitis may also appear in the vicinity of the erythema. Chronic attacks of cellulitis may lead to elephantiasis. 10

Dissecting cellulitis, also known by the more cumbersome term perifollicutis capitis abscedens et suffodiens ( Figure 4 ), only partially meets the criteria for cellulitis. While there is induration, erythema, and edema, there are also accompanying pustular openings and subsequent crusting.

Nonbacterial Cellulitis

If the definition of cellulitis denotes bacterial origin, then several diseases are as misnamed as is pyogenic granuloma, which has no overt bacterial origin. These include recurrent preseptal cellulitis, which appears to be a factitial entity not due to bacteria, and breast cellulitis, also called isolated erythema of the breast, that does not have a bacterial cause. 11 Cervical carcinoma may metastasize to the skin, producing red induration, at which point it is termed cellulitis-like cutaneous metastasis. To add to the confusion, eosinophilic cellulitis, also called Wells syndrome, has a cellulitic component without bacteria being involved 12 ; sometimes a viral etiology is even suggested.

Unnecessary Confusion

A clinical presentation of erythema and induration may be found in both stasis dermatitis, for example, and cellulitis. Because these signs are present, this does not make the cutaneous findings of venous insufficiency an infectious disease. Similarly, oozing and crusting superimposed on dusky, erythematous skin suggest bacterial superinfection, but they do not create the picture of cellulitis ( Figure 5 ).

Conclusions

Cellulitis is a specific sign with recognized etiologies. The word should not have its meaning diluted by extensions of its definition, nor should cellulitis be used inappropriately.

Clinical manifestations can include tenderness and malaise with the addition of chills and/or fever. There can be induration and pitting edema as a result of the rapid spread of the infection. Lymphangitis may also appear in the vicinity of the erythema. Chronic attacks of cellulitis may lead to elephantiasis. 10

Dissecting cellulitis, also known by the more cumbersome term perifollicutis capitis abscedens et suffodiens ( Figure 4 ), only partially meets the criteria for cellulitis. While there is induration, erythema, and edema, there are also accompanying pustular openings and subsequent crusting.

Nonbacterial Cellulitis

If the definition of cellulitis denotes bacterial origin, then several diseases are as misnamed as is pyogenic granuloma, which has no overt bacterial origin. These include recurrent preseptal cellulitis, which appears to be a factitial entity not due to bacteria, and breast cellulitis, also called isolated erythema of the breast, that does not have a bacterial cause. 11 Cervical carcinoma may metastasize to the skin, producing red induration, at which point it is termed cellulitis-like cutaneous metastasis. To add to the confusion, eosinophilic cellulitis, also called Wells syndrome, has a cellulitic component without bacteria being involved 12 ; sometimes a viral etiology is even suggested.

Unnecessary Confusion

A clinical presentation of erythema and induration may be found in both stasis dermatitis, for example, and cellulitis. Because these signs are present, this does not make the cutaneous findings of venous insufficiency an infectious disease. Similarly, oozing and crusting superimposed on dusky, erythematous skin suggest bacterial superinfection, but they do not create the picture of cellulitis ( Figure 5 ).

Conclusions

Cellulitis is a specific sign with recognized etiologies. The word should not have its meaning diluted by extensions of its definition, nor should cellulitis be used inappropriately.

References

1 Leider M, Rosenblum M. A Dictionary of Dermatological Words, Terms and Phrases. New York, NY: McGraw-Hill; 1968.
2 Grosshans EM. The red face: erysipelas. Clin Dermatol. 1993;11:307–313.
3 Lazzarini L, Conti E, Tositti G, et al. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. 2005;51:383–389.
4 Parish LC, Jungkind DL. Systemic antimicrobial therapy for skin and skin structure infections: comparison of fleroxacin and ceftazidime. Am J Med. 1993;94:166S–173S.
5 Witkowski JA, Parish LC. Bacterial skin infections: management of common streptococcal and stapylococcal lesions. Postgrad Med. 1982;72:166–168, 171–173, 176–178 passim.
6 Mathur MN, Patrick WG, Unsworth IP, et al. Cellulitis owing to Aeromonas hydrophilia: treatment with hyperbaric oxygen. Aust N Z J Surg. 1995;65:367–369.
7 Lee SY, Chuang YC, Young CD. Extensive cellulitis with septic shock caused by Vibrio vulnificus infection-a case report with review of literature. Kansenshogaku Zasshi. 1991;65:1484–1487.
8 Bradaric N, Milas I, Luksic B, et al. Erysipelas-like cellulitis with Pasteurella multocida bacteremia after a cat bite. Croat Med J. 2000;41:446–449.
9 Bornstein PF, Ditto AM, Noskin GA. Serratia marcescens cellulitis in a patient on hemodialysis. Am J Nephrol. 1992;12:374–376.
10 Bonnetblanc JM, Bedane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4:157–163.
11 Miller SR, Mondry T, Reed JS, et al. Delayed cellulitis associated with conservative therapy for breast cancer. J Surg Oncol. 1998;67:242–245.
12 Chung CL, Cusack CA. Wells syndrome: an enigmatic and therapeutically challenging disease. J Drugs Dermatol. 2006;5:908–911.

SKINmed: Dermatology for the Clinician. 6;6:261-263 (November/December 2007)

LeJacq

Epidural empyema secondary to orbital cellulitis: A case report

Epidural empyema secondary to orbital cellulitis: A case report

Eur J Ophthalmol. 2007 Sep-Oct

Brijlal Meena MK, Sharma P.
A-3 Mother Teresa Nagar, S.M.S Hospital, Jaipur - India.

PURPOSE. To report a case of epidural empyema, a rare complication of orbital cellulitis, underlining the importance of early diagnosis and appropriate therapy to avoid severe complications often associated with this disease.

METHODS. The treatment was initiated with extended spectrum antibiotics such as third generation cephalosporins along with aminoglycoside or metronidazole for anaerobes.

RESULTS. The patient responded well and was asymptomatic after 15 days. Radiologic investigations (computed tomography/magnetic resonance imaging) should be done on an emergency basis. Treatment should be aggressive with parenteral use of extended spectrum antibiotics. The role of steroid is when proptosis is causing lagophthalmos with exposure keratitis and/or optic nerve compression. Judicious surgical intervention can be life saving in this emergency. Peribulbar antibiotic injection has no role in the therapy.

CONCLUSIONS. The authors present a unique case of epidural empyema secondary to orbital cellulitis associated with an episode of epileptic seizure.

PMID: 17932865 [PubMed - in process]

All About Cellulitis- The Skin Infection

All About Cellulitis- The Skin Infection

C.D. Mohatta
October 24, 2007

Cellulitis - Overview

Cellulitis is a bacterial infection of the skin. Cellulitis generally affects only one limb, but can also affect other parts of the body. The skin may become red, swell, warm and have other clinical features. Cellulitis may create complications if left untreated. Therefore it is necessary, that we find out more about what is cellulitis.

Cellulitis Symptoms

Cellulitis commonly affects one limb. The skin appears red with swelling and blisters may form. The affected limb becomes tender. There is a feeling of warmth on the affected site. Abscesses may also form on the affected site and the lymph glands may swell to drain the infection. Fever may also develop with cellulitis.

Cellulitis Causes

A bacterial infection causes cellulitis. Streptococcus pyogenes causes most of the cellulitis. Staphylococcus aureus also causes many cases of cellulitis. These are bacteria that attack the skin and cause inflammation and swelling.

The bacteria normally cause more trouble to those, who are weak and vulnerable for various reasons. Diabetics have lesser immunity than others. Diabetics may form chronic ulcers of the feet and these ulcers are vulnerable to bacteria entry.

Some people may be on immune suppressant drugs for some diseases. Their immune system gets suppressed and bacteria can easily flourish if they find an entry in such people. Many diseases such as AIDS, etc. also suppress the immunity and make the person more vulnerable to bacterial attack. I

If you have a healthy immune system, your body can easily fight the bacterial infection. As your defense becomes weak, the bacteria find it easy to attack you. The same is true with aged people, because their blood circulation becomes poor and the body is unable to send the required number of white blood cells to all parts of the body.

If you have chronic problems such as athlete's feet, bacteria find it easy to enter the body via the cracked and peeling skin.

Complications

The face and lower legs are common places affected by cellulitis, but note that any part of the body can get affected. Many complications may arise with cellulitis.
If the infection enters the deeper layers of the body issue, it can cause serious complications. Once the bacteria enter the deeper layers, it spreads rapidly in the body. By entering the blood stream and the lymph nodes, the bacteria causes big harm to the body. The major complications of unchecked cellulitis can be meningitis (if cellulitis is on the face), sepsis, gangrene, etc.

Cellulitis treatment

Topical and oral antibiotics are commonly used to treat the early cases of cellulitis at home. If the infection is severe, hospitalization is recommended and intravenous antibiotics are administered.

For further advice, consult your doctor.

Precautions:

If you are susceptible to frequent cellulitis or are immune depressed, take care to prevent it.

Treat fungal infections immediately.

Protect yourself from the smallest skin injury by wearing protective clothing and shoes.

Moisturize the skin regularly so that it does not crack.

For further advice, consult your doctor.

American Chronicle

Dacryocystitis presenting as post-septal cellulitis: a case report.

Dacryocystitis presenting as post-septal cellulitis: a case report.

J Med Case Reports. 2007 Sep

Scott E Henney,1,3 Mike J Brookes,1 Kevin Clifford,2 and Anirvan Banerjee1
1ENT Department, James Cook University Hospital, Marton Road, Middlesbrough, UK
2Radiology Department, James Cook University Hospital, Marton Road, Middlesbrough, UK
350 Lyndon Road, Sutton Coldfield, West Midlands, WS9 0RJ. UK
Corresponding author.

Scott E Henney: scott.henney@doctors.org.uk
Mike J Brookes: mikebrookes@physiobase.com
Kevin Clifford: kevin.clifford@stees.nhs.uk
Anirvan Banerjee: Anirvan.Banerjee@stees.nhs.uk

Abstract

Dacryocystitis is relatively common, the majority of patients present with pre-septal cellulitis and not an orbital abscess due to anatomical barriers. The authors report a case of dacryocystitis presenting as post-septal cellulitis in a postmenopausal lady with an underlying malignancy. Following antibiotic therapy and elective dacryocystorhinostomy the patient is still under follow-up, and has no further recurrence of symptoms. Orbital abscess in postmenopausal women presenting with dacryocystitis should be considered, as prompt recognition and early surgical intervention is required to prevent visual loss.

Background

Dacryocystitis is associated with pyrexia and severe erythematous swelling around the nasal aspect of the lower lid. The majority of patients with dacryocystitis present with pre-septal cellulitis and not an orbital abscess. Orbital abscess formation and can lead to vision loss therefore requires emergency surgical drainage.
Case Presentation

A 50-year-old woman was referred to the Ear Nose and Throat department with a two day history of a painful swollen right eye. She was an in-patient awaiting wide local excision and axillary node clearance with post-operative chemotherapy for receptor-negative carcinoma of the breast.

Examination revealed marked swelling and erythema of both upper and lower lids of the right eye. Swelling prevented complete visualisation of the pupil and cornea. There was mild proptosis and a restriction of extraocular motility. Visual acuity was measured at 6/60 on the left and 4/60 on the right. Examination of the other cranial nerves, nose, nasopharynx and neck was normal.

A computed tomography (CT) scan of the orbits and brain demonstrated a soft tissue density collection on the floor of the right orbit, elevating the inferior rectus muscle, extending posteriorly to the apex of the orbit (Fig 1). There appeared to be a more focal peripherally enhancing collection just inferior to the globe and a further enhancing collection adjacent to and within the fossa for the lacrimal sac (Fig 2). Streaky increased density was noted within the intra-coronal and extra-coronal fat, and there was right proptosis (Fig 3). The swelling extended into the soft tissues of the infra-orbital region, but there was little pre-septal soft tissue swelling (Fig 4). The para-nasal sinuses and nasal cavity appeared normal, as did the canal for the nasolacrimal duct.

The features identified on the CT scan were consistent with an inflammatory process and the enhancing rim around the fossa for the lacrimal sac was consistent with dacryocystitis.

The patient underwent drainage of orbital abscess via an orbital rim incision and the purulent material was sent for microbiological investigation. Intraoperatively, dilation of nasolacrimal sac was noted. The diagnosis of dacryocystitis with tracking posteriorly was confirmed. The purulent material cultured demonstrated a mixed growth of coliforms, sensitive to ciprofloxacin. The patient responded well to intravenous ciprofloxacin and metronidazole. She regained full extraocular motility, the proptosis resolved and her vision was 6/6 on the left and 6/12 on the right at discharge.

One month following surgery the patient presented with a red, swollen, tender right eye. A diagnosis of early recurrence of dacryocystitis was made. CT orbits was repeated, and no compressive lesion to account for her nasolacrimal duct problem was shown. This episode settled with ciprofloxacin and metronidazole. She was found to have a right nasolacrimal duct stenosis and underwent right endonasal dacryocystorhinostomy (DCR) to prevent further abscess formation. The patient is still under follow-up, and has no further recurrence of symptoms.

Discussion

Dacryocystitis is associated with pyrexia and severe erythematous swelling around the nasal aspect of the lower lid [7]. The majority of patients with dacryocystitis present with pre-septal cellulitis and not an orbital abscess. The reason for this seems to be the insertion of the orbital septum on the posterior orbital crest preventing extension to the orbit [4]. Other anatomical barriers exist, including lacrimal fascia, medial canthal ligament and obicularis muscle [6]. Once these barriers have been breached orbital abscess formation is unimpeded and can lead to vision loss, requiring surgical drainage. Post-septal cellulitis is more commonly associated with congenital dacryocystitis as the orbital septum is poorly formed in infants. There are only a few documented cases of post-septal spread in adults [1-6].

Dacryocystitis is relatively common in the general population, with the majority of cases seen in the first and fifth decade of life, especially in postmenopausal women (70–83% of cases) and those with poor hygiene [7]. The prevalence of dacryocystitis in the postmenopausal population may be due to changes in the size of the nasolacrimal duct anatomy. Groessl et al demonstrated that women have significantly smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct [9]. Moreover, there were changes noted in the antero-posterior dimensions of the bony nasolacrimal canal coinciding with the osteoporotic disease process occurring in middle-aged females [9]. Hormonal changes, which produce a generalised de-epithelialisation, may cause a de-epithelialisation in the lacrimal sac and duct, resulting in an already narrowed canal becoming blocked [7].

Underlying malignancy may also impair inflammatory and immunological responses to infection. Obstruction of the nasolacrimal duct due to metastatic spread has been reported with primary sites from the breast and prostate, but is an extremely rare phenomenon and there was no evidence that this occurred in this case [10].

Conclusion

Orbital complications of dacryocystitis are rare because of the septum and other anatomical barriers. In postmenopausal women, the osteoporotic process causes changes in the dimensions of the bony nasolacrimal canal, and hormonal changes may cause desquamation and consequently blocking of the canal. The possibility of an orbital abscess in postmenopausal women presenting with dacryocystitis should be considered, as prompt recognition and early surgical intervention is required to prevent visual loss. Elective dacryocystorhinostomy once the acute infectious phase has settled is the treatment of choice in adult patients [4,8].

Journal of Medical Case Reports