Sonography First for Subcutaneous Abscess and Cellulitis Evaluation

1. Address correspondence to Michael Blaivas, MD, Department of Emergency Medicine, Northside Hospital Forsyth, 1200 Northside Forsyth Dr, Cumming, GA 30040-1147 USA. E-mail:mike@blaivas.org

Sonography is an ideal imaging modality for evaluation of pathologic soft tissue conditions. High resolution and the ability to perform dynamic testing such as compressing structures allow for accurate differentiation between potentially confusing physical findings. Traditionally, clinicians assumed that any area of the skin that was erythematous and showed swelling potentially harbored an abscess. Incision and drainage has long been the standard of care in such cases and was often used as a diagnostic procedure. However, studies have confirmed anecdotal clinical evidence that the physical examination is often incorrect. In fact, not only was incision and drainage being performed unnecessarily, in some cases, needed procedures were missed after failure to recognize the presence of an abscess. With the recent spread of sonography into clinical practice, multiple descriptions of point-of-care sonography use in suspected soft tissue infections have been published. Some have even noted that blind incision and drainage, once thought to be harmless, could lead to serious potential complications because not all red swollen structures should be cut with a scalpel. This article reviews clinical scenarios in which point-of-care soft tissue sonography is useful in suspected skin infections and describes pathologic findings and commonly accepted scanning approaches.

Complete Text Article

aium

Presentation and management of pediatric orbital cellulitis.

Fall 2011

Fanella S, Singer A, Embree J.

Source

Section of Infectious Disease, Department of Pediatrics

Abstract

BACKGROUND:

Orbital cellulitis is a serious, vision-threatening infection.

OBJECTIVE:

To review the epidemiology and clinical data of pediatric orbital cellulitis in Manitoba.

METHODS:

A 12-year retrospective review was conducted of all children (younger than 18 years of age) with orbital cellulitisadmitted to Manitoba's only tertiary pediatric centre. Admission rates for orbital cellulitis were compared over three distinct time periods, based on licensure and funding levels of the heptavalent pneumococcal conjugate vaccine (PCV7) in Manitoba.

RESULTS:

Thirty-eight patients with orbital cellulitis were identified. Of these, 11% were of Aboriginal ethnicity in contrast with 30% to 40% of children who were admitted for other respiratory illnesses. Subperiosteal abscesses occurred in 31.5%. Only eight patients (21%) required surgery. Follow-up imaging after presentation usually did not indicate a need for subsequent surgical drainage. 

The mean number of orbital cellulitis cases per 1000 admissions for the following periods - before PCV7 licensure, after licensure and before full provincial funding, and after licensure and full funding - were 0.39, 0.53 and 0.90, respectively. No significant difference was noted among any of the periods as PCV7 coverage increased.

CONCLUSIONS:

The rate of subperiosteal abscesses was lower than other reports. This may be due to the median age at presentation. In contrast to admissions for most other respiratory infections at the Winnipeg Children's Hospital (Winnipeg, Manitoba), Aboriginal ethnicity was uncommon. Surprisingly, rates of admissions for orbital cellulitis appeared to show an increasing trend with increasing access to PCV7 in Manitoba, although overall the number of cases was very small. Studies into the changing microbiology of orbital cellulitis and sinusitis are warranted.

PubMed

Recurrent cellulitis with benzathine penicillin prophylaxis is associated with diabetes and psoriasis.

Sept 24, 2012

Karppelin M, Siljander T, Huhtala H, Aromaa A, Vuopio J, Hannula-Jouppi K, Kere J, Syrjänen J.

Source

Department of Internal Medicine, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland, matti.karppelin@uta.fi.

Abstract

Risk factors for recurrent cellulitis were assessed in a case-control study including 398 patients receiving prophylactic treatment with benzathine penicillin and 8,005 controls derived from a national population-based health survey. In the multivariate analysis, psoriasis [odds ratio (OR) 3.69], other chronic dermatoses (OR 4.14), diabetes (OR 1.65), increasing body mass index (OR 1.17), increasing age (OR 1.06) and history of previous tonsillectomy (OR 6.82) were independently associated with recurrent cellulitis. Forty percent of the patients reported a cellulitis recurrence, despite ongoing benzathine penicillin prophylaxis. The role of previous tonsillectomy in recurrent cellulitis needs further evaluation.

PubMed

Unrecognized bladder perforation leading to severe progressive cellulitis and candidal infection.

Mar Apr 2012

Fenderson JL, Washington BB, Hampton BS, Myers D.

Source

Department of Obstetrics and Gynecology, Women & Infants' Hospital of Rhode Island, Providence, RI, USA. jfenderson@wihri.org

Abstract

BACKGROUND:

Retropubic midurethral slings are a minimally invasive surgical procedure used in the treatment of stress urinary incontinence and are typically associated with high cure rates and low complication rates. Bladder perforation is a known intraoperative complication that, if left unrecognized, can have significant morbidity.

CASE:

A 47-year-old underwent a retropubic midurethral sling, anterior colporrhaphy, and cystoscopy. She developed a suprapubic wound cellulitis that progressed to involve the right trunk and flank as well as persistent fever for more than 48 hours despite broad-spectrum antibiotics. Upon return to the operating room, the patient was found to have an unrecognized bladder perforation with mesh in the bladder. Wound culture was remarkable for Candida parapsilosis and Escherichia coli.

CONCLUSION:

Unrecognized bladder perforation and nonbacterial causes of infection should be considered in patients with severe progressing cellulitis despite broad-spectrum antibiotic coverage after retropubic midurethral sling placement.

Wolters Kluwer

Life-threatening Escherichia coli cellulitis in patients with haematological malignancies.

Sept 2012

Sunder S, Haguenoer E, Bouvet D, Lissandre S, Bree A, Perrotin D, Helloin E, Lanotte P, Schouler C, Guillon A.

Source

1Service de Médecine Interne et Maladies Infectieuses, CHRU de Tours, France.

Abstract

Cellulitis due to Escherichia coli is rare and usually secondary to a cutaneous portal of entry. Skin and soft tissue infections (SSTI) secondary to E. coli bacteraemia have been reported exclusively in immunodeficient patients. Here, we report two cases of serious cellulitis secondary to E. coli bacteraemia in patients with haematological malignancies. Both isolated strains belonged to phylogenetic group B2 and harboured some of the main virulence factor genes commonly found in extra-intestinal pathogenic E. coli (ExPEC), including neuC, iro and fimH. Cellulitis due to E. coli seems to be linked to the immunocompromised status of patients rather than to a highly virulent clone. Nevertheless, some of the virulence factors appear to be important because both isolates belong to phylogenetic group B2. This aetiology should be considered in SSTI in patients with haematological malignancies.

Full Text Article

Journal of Medical Microbiology

An interesting case of empedobacter brevis bacteremia after right knee cellulitis.

June 2012

Raman S, Shaaban H, Sensakovic JW, Perez G.

Sir,

A 65-year-old obese white female, with a medical history significant of hypertension, degenerative joint disease, chronic obstructive pulmonary disease, Brown-Séquard syndrome with right lower extremity weakness, a right total knee replacement 6 weeks prior to admission, presented to the Emergency Room with right knee cellulitis and discharged home on cephalexin. On the following morning, she returned to the hospital after a fall at home resulted in a laceration in her right knee with serosanguineous drainage.

On initial examination, patient was afebrile with temperature of 98, blood pressure 120/56, respiratory rate 18 and heart rate 63. On physical exam, her right knee was swollen, red and tender to touch, with a sutured lacerated wound oozing serosanguineous drainage. Laboratory workup, which included complete blood count, serum chemistry, urine analysis and culture, were negative. Magnetic resonance imaging (MRI) showed a fractured right patella. Blood culture drawn 2 days prior from her first ER visit came positive for a gram negative bacteria, identified as Empedobacter brevis. The microbiology was sensitive to most of the antibiotics. She was treated with Levaquin for 10 days and that resulted in negative blood cultures and clinical response.

Empedobacter brevis formerly known as Flavobacterium brevis are gram-negative, and short nonmotile rods, which are widely distributed in the environment both in soil and water. They are also found in plants, raw meat products, and in hospital environments, which could lead to rare nosocomial infections. They are obligate aerobes, which form a yellow colony when grown on the solid medium. These bacteria are also known to be oxidase-negative, catalase-negative, and phosphatase-positive. 

Therapies with β-lactam antibiotics should be used with caution as β-lactamase gene blaEBR-1 has been associated with E. brevis, which has been shown to reduce susceptibility to extended spectrum cephalosporins and carbapenems.In our patient, the primary source of infection was not found but the source could have been; (a) her fall with laceration of knee; (b) solutions used to irrigate her knee in the ER; and (c) improper sterilization of the instruments used to suture the alteration.

Flavobacteriaceae family known as yellow colony forming bacteria was divided based on their genetic variation into Flavobacterium, Chryseobaterium, Myroides, and Empedobacter with Empedobacter brevis as a separate genetic variant. To our knowledge, there have been only three reported cases of Empedobacter brevis infection. 

First, a case series of an outbreak of endophthalmitissecondary to possible contamination, second, a case of anaphylactoid purpura that was treated with minocycline, and third, a case of meningitis in a canine. This is the first case of Empedobacter brevis bacteremia in a human adult that has ever been reported in the medical literature.

PubMed - Journal of Global Infectious Diseases

Recurrent cellulitis due to Helicobacter cinaedi after chemotherapy for malignant lymphoma.

June 2012

Ishizawa J, Mori T, Tsukada Y, Matsuki E, Yokoyama K, Shimizu T, Sugita K, Murata M, Iwata S, Okamoto S.

Source

Division of Hematology, Department of Medicine, Keio University School of Medicine, Central Clinical Laboratory, Keio University Hospital.

Abstract

A 62-year-old man with diffuse large B-cell lymphoma received five courses of R-CHOP chemotherapy. The patient developedcellulitis in the bilateral lower extremities without fever, and blood culture yielded Helicobacter cinaedi after five-day culture. Although the response to tazobactam/piperacillin (TAZ/PIPC) was prompt, cellulitis recurred immediately after discontinuation of the drug. Even after two months of treatment with PIPC plus amikacin followed by amoxicillin, it recurred again soon after stopping the antibiotics. H. cinaedi reportedly causes bacteremia and cellulitis in immunocompromised patients mostly in patients with acquired immunodeficiency syndrome. Only sporadic cases have been reported in association with hematological malignancies. Physicians should be aware of H. cinaedi as one of the causative pathogens of bacteremia and cellulitis in patients with hematological malignancies. Longer incubation period of blood culture is needed to detect the microbe and long-term use of antimicrobials is required to prevent recurrent cellulitis.

Rinsho Ketsueki

Treatment of Recalcitrant Eosinophilic Cellulitis With Adalimumab

Sept 2012

Kavita Y. Sarin, MD, PhD; David Fiorentino, MD, PhD

Arch Dermatol. 2012;148(9):990-992. doi:10.1001/archdermatol.2012.114

Eosinophilic cellulitis is a rare condition characterized by recurrent pruritic or tender skin lesions. Biopsies usually display characteristic histologic features of dermal edema, eosinophils, and flame figures (collections of degranulated eosinophilic material). Eosinophilic cellulitis typically responds well to systemic steroids. However, oral steroids may be contraindicated in some patients. In addition, long-term use of systemic steroids can lead to steroid dependence as well as adverse effects on bone density, wound healing, and metabolism. Recent evidence in mice suggests that the tumor necrosis factor (TNF) pathway may play a role in antigen-specific IgE production and eosinophil recruitment. This suggests that TNF inhibitors may have some efficacy in the treatment of eosinophilic cellulitis.

Full Text Article with Diagnostic Images:

Archives of Dermatology

Incidence of deep vein thrombosis in erysipelas or cellulitis of the lower extremities.

Aug 2012

Mortazavi M, Samiee MM, Spencer FA.

Source

Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.

Abstract

The incidence of deep vein thrombosis (DVT) in patients with erysipelas and cellulitis of the lower extremities is unknown. As such, the indication and efficacy of prophylactic anticoagulation for prevention of DVT in these patients is unclear. 

The main goal of this review is to provide an estimate of the incidence of DVT in erysipelas and cellulitis based on existing literature. A comprehensive search of the electronic sources: MEDLINE, EMBASE, CINAHL, LILAC and Cochrane without any language limitation was performed from 1950 to April 2011 for articles focused on the occurrence of DVT in cellulitis or erysipelas of the lower extremities. The selected studies were divided into two groups according to presence or absence of systematic investigation for DVT. Those studies in which the patients received prophylactic or therapeutic anticoagulants before a diagnosis of DVT were excluded. The reported incidence rate of DVT in patients with erysipelas or cellulitis of the lower extremities is highly variable, ranging from 0 to 15%.

In this review, the overall incidence rates of DVT in studies with and without systematic investigation for thromboembolism were 2.72% (95% CI: 1.71-3.75%) and 0.68% (95% CI: 0.27-1.07%), respectively. Given the low reported overall incidence of DVT, neither routine prophylactic anticoagulation nor systematic paraclinical investigation for DVT is indicated in low risk patients with erysipelas or cellulitis of the lower extremities. DVT should still be considered in patients with high pretest probability or other thromboembolic risk factors.

PubMed

Gas-Producing Cellulitis From Injection of Spot Remover Fluid

Gas-Producing Cellulitis From Injection of Spot Remover Fluid (n-Hexane).

August 2012

Omori N, Mitsukawa N, Kubota Y, Satoh K.

Source

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.

Abstract

BACKGROUND:

Subcutaneous administration of hydrocarbons, categorized according to their toxicological profiles, is rare compared to oral, inhalational, and cutaneous routes of exposure. Furthermore, injection of n-hexane in humans has not been described.

OBJECTIVES:

This report demonstrates a singular case of subcutaneous administration of n-hexane.

CASE REPORT:

A 21-year-old man presented to the Emergency Department (ED) 7 h after injecting his left antecubital fossa with approximately 5 cc of spot remover fluid, which contained more than 95% n-hexane, in a suicide attempt. There was redness in the left forearm, but no apparent swelling was observed. He was administered tetanus prophylaxis and discharged with follow-up. However, the patient returned to the ED 14 h later, complaining of progression of the swelling around the injection site extending to the axilla. Significant volume of air in the soft tissue of the affected extremity was noted on both the radiograph and computed tomography scan; therefore, an immediate extensive incision and debridement of the diseased limb was performed. The postoperative course was uneventful, and a complete resolution of emphysema without any functional deficits was obtained for 5 months of follow-up.

CONCLUSION:

In patients suffering from n-hexane injection, initial physical examination findings may not be apparent. Thus, the patient must be monitored closely for evidence of a spread of subcutaneous gas with elevation and immobilization. If increase in tissue pressure or spread of gas is not prevented, as in our case, immediate incision and removal of the toxic substances should be planned.

Elsevier

Neonatal cellulitis caused by group B Streptococcus.

August 2012

[Article in French]

Breinig S, Roques-Gineste M, Marcoux MO, Bloom MC.

Source

Service de réanimation pédiatrique, hôpital des enfants, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France.

Abstract

Dermohypodermitis (cellulitis) in newborn infants and in infants aged up to 3 months is uncommon and often not typical. Because group B Streptococcus is known to induce rapid life-threatening complications, early diagnosis leading to emergency treatment is of utmost importance. We report on the case of a 14-day-old girl, initially admitted for viral bronchiolitis with suspected bacterial pulmonary infection, in the absence of any cutaneous injury. The disease actually wascellulitis of the face, caused by group B Streptococcus. The baby presented with a severe septic clinical condition. Early treatment with antibiotics (intravenous amoxicillin for 10 days) allowed a favorable course, with rapid control of the sepsis and regression of the submandibular tumefaction.

Full Text Article

Elsevier

Cellulitis--epidemiological and clinical characteristics.

2012

Hadzovic-Cengic M, Sejtarija-Memisevic A, Koluder-Cimic N, Lukovac E, Mehanic S, Hadzic A, Hasimbegovic-lbrahimovic S.

Source

Clinic for Infectious Diseases, Clinical Center of University of Sarajevo, Bosnia and Herzegovina. melica74@gmail.com

Abstract

INTRODUCTION: 

Cellulitis is acute skin infection and/or infection of subcutaneous tissue, mostly caused by Streptococcus pyogenes and Staphylococcus aureus. Clinical preview is usually obvious and enough for diagnosis. Tretment is antimicrobial therapy. In recurrent cases a prophylaxis is very often needed.

OBJECTIVES:

Analysis some of the epidemiological and clinical characteristics of cellulitis.

PATIENTS AND METHODS:

Retrospective analysis of medical documentation of patients with clinical preview of cellulitiswho were hospitalized in Clinic for infective diseases of Clinical Center of University of Sarajevo in last three years.

RESULTS:

In period of three years 123 patients were hospitalized with clinical preview of cellulitis in the broadest sense of the word. In 123 of cellulitises, 35/123 (28.45%) were erisipelases-superficial type and 88/123 (71,55%) were deep cellulitises. Men were more affected 56,09%, average of age was 50.22 years. Before hospitalization patients had ambulance treatment in average of 5.12 days, and hospitalization was long in average of 13.33 days. Risk factors wich contributes to the disease were found in 71.54% of cases. Due to localisation, skin disorders on lower limb were the most frequent 71.56%,cellulitis of upper limb were found in 12.19%, head and/or neck in 13.08%, trunk in 3.25%. Repetition of disease were found in 4.8% in patients wtih risk factors. Bacteremic isolats were confirmed in 27.64% of cases. In all patients empirical antibiotic treatment were started, in the 62.60% the first choice of medicine was antibiotic from the group of lincosamides.

CONCLUSION:

Cellulitis is very serious disease that can be prevented.

PubMed