Three Degrees Help Drive Antibiotic Decision in Cellulitis

Three Degrees Help Drive Antibiotics in Cellulitis

By: M. ALEXANDER OTTO, Family Practice News Digital Network

SAN FRANCISCO – A greater than 3° C difference in skin temperature between affected and unaffected limbs in cellulitis – measured using inexpensive, handheld, infrared laser thermometers – was found to signal the need for hospital admission for intravenous antibiotics.

Skin temperature changes in cellulitis had never been quantified, said Dr. Michael Montalto. "We’ve never had a concept in absolute terms of the differences we feel as clinicians every day. [Our study gives] an idea of the kind of scale that might cause you to think the patient needs to have an admission for IV therapy. At least in our study, if the temperature difference [between the affected and unaffected limb] was above 3 °C, those people were getting IV therapy," he said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Of 63 cellulitis patients who were admitted to the hospital for intravenous antibiotic therapy, lesions were on average 3.4 °C warmer (95% confidence interval, 3.0-3.9) than the corresponding location on the unaffected limb. The difference dropped to an average 2.1° C warmer (95% CI, 1.7-2.6) at discharge after a mean stay of 5 days, the investigators found.

Patients in the study, who were 50 years old on average, had mostly lower-limb cellulitis; just over half were men. Nurses took the limb temperatures to keep researchers blinded to the results until the study’s end. Skin temperatures did not correlate with blood pressure, core temperature, or other variables.

Dr. Montalto and his colleagues found that the warmest point on limbs affected by cellulitis dropped from an average of 34.4 °C on the day of admission for intravenous antibiotics to 32° C when patients were well enough to be discharged on oral antibiotics, a statistically significant difference (95% CI, 1.9-3.0).

Furthermore, the results also suggested a role for laser thermometers – which can cost less than $50 at electronic stores and until now have been used mostly for industrial purposes – to measure severity and treatment response in cellulitis, said Dr. Montalto, a hospitalist at Epworth Hospital and Royal Melbourne Hospital. The devices emit two beams that are focused into one dot on the skin, at which point the temperature is read from a screen. The process is quick and painless.

The thermometers are "another tool to use for tricky patients when you are wondering whether or not they are getting better," he said. Current measures – white cell counts, erythema, fever, and skin color, among others – are not specific enough, he said.

The next step in the project is to see if skin temperature helps identify the causative organism in cellulitis, which remains unknown in many cases. Methicillin-resistant Staphylococcus aureus (MRSA) cellulitis, for instance, may project a higher temperature than other types of cellulitis.

"We often have people presenting from nursing homes who don’t have a wound. They just have a big, fat, painful, red leg with nothing to swab. You’ve got no way of determining what the organism is except trial and error. If we could show that the temperature profile helps with that," and, thus, appropriate antibiotic selection, it would be a significant advance, Dr. Montalto said at the meeting, which was sponsored by the American Society for Microbiology.

True to the point, 12 patients (19%) had positive swabs in the study, mostly for staphylococci, but a few MRSA and gram-negative bacteria also showed up.

Dr. Montalto said that he had no relevant financial disclosures.

Family Practice News

AKI in a Hospitalized Patient with Cellulitis.

Oct 2012

Perazella MA.

Source

Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.

Abstract

Acute Kidney Injury

AKI occurs commonly in hospitalized patients with multiple comorbidities. In this Attending Rounds, a woman with AKI in the setting of an infection, use of antibiotics and other medications, bacteremia, and hypotension is considered. Such patients lead to a broad differential diagnosis for AKI including prerenal AKI, acute tubular injury/acute tubular necrosis, infection-related GN, and drug-induced acute interstitial nephritis. The roles of an accurate history, physical examination, laboratory data, and kidney biopsy are highlighted in establishing the correct diagnosis in such patients.

Full text article: CJASN

A rare case of orbital cellulitis followed by therapeutic(orthodontic) extraction.

Sept 2011

Srinivasa Prasad B, Govardhan T.

Abstract

We report a rare case of orbital cellulitis occurring secondary to a dental infection followed by therapeutic (orthodontic) extraction. A 16 year old female patient presented to the dental office with a left orbital proptosis for the past 4 days. PNS view, CT scan revealed an abscess in relation to medial, lateral superior inferior walls of the orbit associated with naso ethmoidal and left maxillary sinus. Through nasal endoscopy, middle meatus antrostomy and ethmoidectomy was performed for the drainage of pus from the orbit, ethmoid and maxillary sinus under general anesthesia. Immediately regression of orbital swelling was noticed. Eyeball movements improved. Epiphora reduced and proptosis declined. With the advent of higher antibiotics, orbital infection rarely occurs secondary to dental causes except in a very few cases. Complete elimination of pus from orbital cavity, para nasal air sinuses and appropriate antibiotic coverage at the earliest forms the mainstay of treatment. The nasal endoscopic approach with orbital decompression is the most acceptable atrumatic, cosmetic and functional procedure.

NCBI/NIH

Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis.

Oct 2012

Jones H, Trinidade A, Jaberoo MC, Lyons M.

Source

Department of Otolaryngology, The Lister Hospital, Stevenage, UK.

Abstract

Background: Subclinical infection of the sinuses can result in delayed diagnosis and unusual presenting complications. 

Case report: This paper describes the case of a 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis. 

Results: Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery. 

Conclusion: Serious sinusitis complications still occur, and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality.

PubMed

A rare case of endogenous Streptococcus group C endophthalmitis associated with cellulitis

Sept 2011

A Ebneter,^1,* L Goold,¹ and J S Gilhotra¹

Sir,

Group C Streptococci are part of the human flora¹ and rarely cause opportunistic infections. Here we report a case of endophthalmitis presumably caused by a cellulitis of the arm.

Case Report:

A 59-year-old woman with non-insulin-dependent diabetes mellitus had been given an influenza vaccination into her left arm with chronic lymph oedema. Two days later she developed painful swelling of the arm. Another 24h later she noticed decreased visual acuity of the right eye and pain. On presentation, the patient was febrile and a cellulitis involving the entire left arm with marked swelling was present. Systemic therapy with penicillin 2.4g every 4h and flucloxacillin 1g every 6h had already been started. The visual acuity was hand movements. The cornea showed mild exposure keratopathy due to a lagophthalmos of 2mm secondary to a pre-existing facial nerve palsy. The pupil was mid-dilated and non-reactive. A hypopyon was present and visualization of the posterior segment was not possible owing to dense vitritis. Vitreous and anterior chamber taps were done and ceftazidime (2.25mg/0.1ml) and vancomycin (1mg/0.1ml) were injected intravitreally. Gram staining of the aqueous tap featured Gram-positive cocci growing in chains, which were later identified as group C Streptococci. The B-scan showed an attached retina and dense vitreous debris. Blood cultures (taken after commencement of systemic antibiotics) did not grow any microorganisms. One day later the visual acuity further deteriorated to perception of light. Owing to corneal stromal opacity it was not possible to safely perform a vitrectomy. Topical prednisolone hourly and 50mg oral prednisone were added to the antibiotic treatment. Despite three more intravitreal injections of antibiotics over the following 10 days there was no improvement. Surgery involving keratoprosthesis, lensectomy, and vitrectomy was now offered to the patient, who declined this approach. The eye eventually became phthisical.

Comment:

Streptococcal endophthalmitis is exogenous in the vast majority of cases and is caused by organisms from the viridians group (50%), followed by Enterococcus (27%), Streptococcus pneumoniae (12.5%), and beta-haemolytic Streptococci (10.5%).² Endogenous Streptococcalendophthalmitis is uncommon, and we could only find two case reports in which group C Streptococcus was the causative microorganism.^3, 4 Our case highlights the importance of early recognition and the poor prognosis of endogenous Streptococcal endophthalmitis.

NIH

Acetaminophen-induced cellulitis-like fixed drug eruption.

Mar 2011

Fathallah N, Ben Salem C, Slim R, Boussofara L, Ghariani N, Bouraoui K.

Source

Department of Clinical Pharmacology, Faculty of Medicine of Sousse, Sousse, Tunisia.

Abstract

Acetaminophen is a widely used analgesic drug. Its adverse reactions are rare but severe. An 89-year-old man developed an indurated edematous and erythematous plaque on his left arm 1 day after acetaminophen ingestion. Cellulitis was suspected and antibiotic therapy was started but there was no improvement of the rash; there was a spectacular extension of the lesion with occurrence of flaccid vesicles and blisters in the affected sites. The diagnosis of generalized-bullous-fixed drug eruption induced by acetaminophen was considered especially with a reported history of a previous milder reaction occurring in the same site. Acetaminophen was withdrawn and the rash improved significantly. According to the Naranjo probability scale, the eruption experienced by the patient was probably due to acetaminophen. Clinicians should be aware of the ability of acetaminophen to induce fixed drug eruption that may clinically take several aspects and may be misdiagnosed.

Indian Journal of Dermatology

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

Aug 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

Bullous Eosinophilic Cellulitis in a Child Treated with Dapsone.

Sept 2012

Moon SH, Shin MK.

Source

Department of Dermatology, School of Medicine, Kyung Hee University, Seoul, Korea.

Abstract

Eosinophilic cellulitis, or Wells syndrome, is a rare but well-described condition in which bullous lesions are uncommon, especially in childhood. We report a case of bullous eosinophilic cellulitis recalcitrant to steroid therapy in a 9-year-old boy who was successfully treated with oral dapsone.

Wiley Online

Cellulitis: diagnosis and management.

Mar 2011

Bailey E, Kroshinsky D.

Source

Columbia University College of Physicians and Surgeons, New York, NY, USA.

Abstract

Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma. It is a common diagnosis in both inpatient and outpatient dermatology, as well as in the primary care setting. Cellulitis classically presents with erythema, swelling, warmth, and tenderness over the affected area. There are many other dermatologic diseases, which can present with similar findings, highlighting the need to consider a broad differential diagnosis. Some of the most common mimics of cellulitis include venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis. History, local characteristics of the affected area, systemic signs, laboratory tests, and, in some cases, skin biopsy can be helpful in confirming the correct diagnosis. Most patients can be treated as an outpatient with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern.

Wiley Online Library

Hypertrophic osteoarthropathy presenting as unilateral cellulitis

Hypertrophic osteoarthropathy presenting as unilateral cellulitis with successful treatment using pamidronate disodium.

Bernardo SG, Emer JJ, Burnett ME, Gordon M.

Source

Department of Dermatology, Mount Sinai School of Medicine, New York, New York.

Abstract

Hypertrophic pulmonary osteoarthropathy is a paraneoplastic syndrome seen in patients with lung cancer. This condition is characterized by the presence of digital clubbing, periosteal thickening, synovial thickening, and severe pain of the affected joints. Other syndromes exhibiting clubbing may or may not have underlying diseases causing their manifestation. 

An example is primary hypertrophic osteoarthropathy, or pachydermoperiostosis. While clubbing makes up part of the clinical picture in both hypertrophic pulmonary osteoarthropathy and hypertrophic osteoarthropathy, the latter has no underlying disease associations. Rather, primary hypertrophic osteoarthropathy is familial, idiopathic, and has a chronic course often beginning during puberty in males. 

Secondary hypertrophic osteoarthropathy is an acquired form of clubbing that is classically associated with lung disease. However, it has also been associated with diseases of the heart, liver, and intestines. In the setting of pulmonary malignancy, secondary hypertrophic osteoarthropathy is known as hypertrophic pulmonary osteoarthropathy. Hypertrophic pulmonary osteoarthropathy has a distinct constellation of clinical findings that includes intractable pain often refractory to treatments other than resolution of the underlying disease process. 

The authors herein report a case of hypertrophic pulmonary osteoarthropathy masquerading as recurrent lower extremity cellulitis with chronic hand and foot pain in the setting of pulmonary malignancy that responded dramatically to intravenous pamidronate disodium (a bisphosphonate). Given the rarity of hypertrophic osteoarthropathy associated with lung cancer and the difficulty with pain management in such circumstances, the authors present the following case in which pain was mitigated by treatment with bisphosphonate therapy.

PubMed

Posttraumatic fat necrosis presented as cellulitis of the leg.

2012

Haikin Herzberger E, Aviner S, Cherniavsky E.

Source

Department of Pediatrics, The Barzilai Medical Center, 2 Hahistadrut Street, Ashkelon 78278, Israel.

Abstract

Cellulitis, a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin, is a common lesion in children, usually responsive to systemic antibiotic therapy. However, an unusual course of healing or some nontypical features should call the treating physician to consider and investigate for other diagnoses that might prevent unnecessary treatment and alleviate parental stress. We present a case of posttraumatic fat necrosis, demonstrating some pitfalls in the process of diagnosis.

Full Text Article: Case Reports in Pediatrics