Cellulitis
PGI Borlagdan, Marilet T.
ARMMC
Objectives
●
●
Present a case of cellulitis.
Discuss
the
etiology,
risk
pathophysiology, management,
prognosis of cellulitis.
factors,
evaluation,
complications, and
TABLE OF CONTENTS
I.
Case Vignette
VI.
II
Salient Features
VII.
Course in the ward
Discussion
Etiology, risk factors,
pathophysiology
evaluation,
III.
Differential Diagnoses
VIII.
IV.
Admitting Impression
IX.
Complications, Prognosis, &
Patient Education
V.
Management at the ER
IX.
References
Management
I. CASE VIGNETTE
GENERAL DATA:
●
●
●
●
●
●
M.J.
63/M
May 19, 1959
Married
Islam
Banaba, San Mateo, Rizal
I. CASE VIGNETTE
CHIEF COMPLAINT:
Swelling of the left leg and foot
HISTORY OF PRESENT ILLNESS
●
●
●
11 MONTHS PTC
●
(+) tenderness and swelling of left leg
(+) undocumented fever
(-) DOB/chest pain/abdominal pain/changes in urination or bowel
movement
Sought consult at a local hospital in Oriental Mindoro → admitted
for 1 week, managed as a case of Cellulitis → improved
●
●
●
2 WEEKS PTC
●
●
1 WEEK PTC
(+) tenderness and swelling of left foot
(+) undocumented fever
(-) DOB/chest pain/abdominal pain/changes in urination or bowel
movement
No medications taken
No consult done
●
●
●
●
●
●
●
FEW HRS PTC
(+) tenderness and swelling of left foot
(+) undocumented fever
(+) extension of swelling up to the left leg
(+) difficulty walking
(-) DOB/chest pain/abdominal pain/changes in urination or bowel
movement
Took Etoricoxib (Arcoxia) 90 mg → partial relief
No consult done
(+) persistence of symptoms → ER consult
I. CASE VIGNETTE
PAST MEDICAL HISTORY:
●
●
●
(+) Hypertension x 30 years
○ Usual BP: 120-130/80 mmHg
S/p CABG (2004, Philippine Heart Center)
Current medications:
○
○
○
○
●
●
●
Valsartan 160 mg OD
Amlodipine 10 mg OD
Clopidogrel 75 mg OD
ISMN 60 mg OD
(+) Drug Allergy: Penicillin
(-) DM, BA, PTB, liver/kidney disease
Fully vaccinated with Moderna
○
Booster: Pfizer
I. CASE VIGNETTE
FAMILY HISTORY:
●
●
●
(+) HTN - maternal
(+) DM - paternal
(-) BA, kidney/liver disease, cancer,
allergies
PERSONAL AND SOCIAL HISTORY:
●
●
●
●
●
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use
Denies history of STI
Retired budget analyst
I. CASE VIGNETTE
REVIEW OF SYSTEMS
General: (-) changes in weight, (-) loss of appetite
HEENT: (-) headache, (-) blurring of vision, (-) ptosis, (-) loss of hearing, (-) tinnitus, (-)
aural discharge, (-) dysphagia, (-) hoarseness of voice, (-) neck rigidity, (-) lymph gland
enlargement
Respiratory: (-) DOB, (-) SOB, (-) cough, (-) colds
Cardiovascular: (-) chest pain, (-) orthopnea, (-) palpitations
Gastrointestinal: (-) vomiting, (-) abdominal pain, (-) constipation, (-) diarrhea
I. CASE VIGNETTE
REVIEW OF SYSTEMS
Genitourinary: (-) dysuria, (-) urgency, (-) nocturia, (-) hematuria
Musculoskeletal: (+) joint pain, (-) muscle cramps, (-) muscle weakness
Neurologic: (-) aphasia, (-) numbness, (-) loss of sensation, (-) tremors, (-) dizziness
Endocrine: (-) cold/heat intolerance, (-) polyphagia, (-) polydipsia
Psychiatric: (-) anxiety, (-) depression
PHYSICAL EXAMINATION
Vital signs
BP: 110/70 mmHg
HR: 80 bpm
RR: 19 cpm
General Survey
Awake, conscious, coherent, not in cardiorespiratory distress
HEENT
Anicteric sclerae, pink palpebral conjunctiva, no ear and nose
deformity/tenderness, no cervical lymphadenopathies
Respiratory
Symmetrical chest expansion, clear breath sounds, no chest
retractions
Temp: 37.9°C
SpO2: 98% at room air
PHYSICAL EXAMINATION
Cardiovascular
Adynamic precordium, normal rate, regular rhythm, no murmur, no
heaves, no thrills
Abdominal
Soft, non-tender, normoactive bowel sounds, no palpable mass
Neurological
●
●
●
GCS 15 (E4V5M6)
Oriented to person, place, time
No motor or sensory deficIt
PHYSICAL EXAMINATION
CRANIAL NERVES
●
●
●
●
●
●
●
●
●
I: no anosmia
II: pupils 2-3 mm equally reactive to light , normal direct and consensual pupillary reflex,
good accommodation and convergence in near reaction
III, IV, VI: extraocular muscles intact
V: no facial sensory deficit, good bite strength
VII: able to wrinkle forehead, raise eyebrow, puff cheeks, whistle and show teeth, normal
taste perception
VIII: normal hearing acuity
IX X : with gag reflex, soft palate rises on phonation, uvula midline on phonation
XI: able to shrug shoulder against resistance, can turn face against resistance
XII: tongue midline
PHYSICAL EXAMINATION
Extremities
(+) swelling of LEFT leg and foot,
poorly demarcated, erythematous,
warm
to
touch,
tender
on
palpation,
nonpurulent,
with
flaking of skin
(+) tophi, bilateral foot
(+) areas of hyperpigmentation,
bilateral foot
(-) blisters
(-) insect bites
(-) puncture wound
(-) scaling/maceration on interdigital
clefts of toes
II. SALIENT FEATURES
Subjectives
●
●
●
●
●
●
●
(+) tenderness of left leg and foot
(+) undocumented fever
(+) difficulty walking
(+) history of cellulitis
(+) hypertensive for 30 years
(+) history of CABG (2004, PHC)
(+) allergy to drug: penicillin
Objectives
●
●
●
●
(+) febrile (37.9°C)
(+) swelling of LEFT leg and foot, poorly
demarcated, erythematous, warm to touch,
tender on palpation, nonpurulent, with
flaking of skin
(+) tophi, bilateral foot
(+) areas of hyperpigmentation, bilateral
foot
III.
DIFFERENTIAL
DIAGNOSES
DDX 1: Erysipelas
Rule in
●
●
●
●
(+) fever
(+) swelling of left foot and leg
(+) erythema
(+) tender
Rule out
●
●
●
●
(-) bright red erythema
(-) elevation of the affected area
(-) well-demarcated borders
(-) burning sensation at the affected
area
DDX 2: Stasis Dermatitis
Rule in
●
●
●
●
●
●
(+) swelling of left foot and leg
(+) erythema
(+) tender
(+) hyperpigmentation
(+) hypertension
(+) history of CABG
Rule out
●
●
●
●
(-) pruritus
(-) lichenification
(-) weeping erosions
Usually affects both legs
DDX 3: Contact Dermatitis
Rule in
●
●
●
(+) swelling of left foot and leg
(+) erythema
(+) tender
Rule out
●
●
●
(-) pruritic
(-) recent exposure to known
allergens
(-) burning/stinging sensation
III. ADMITTING IMPRESSION:
CELLULITIS, LEFT LEG AND
FOOT; HASCVD CAD S/P
CABG (PHC, 2004)
IV. MANAGEMENT AT THE ER
●
●
Medication given:
○ Paracetamol 300 mg TIV
Diagnostics:
○
○
○
○
○
○
○
○
CBG: 130 mg/dl
CBC
BUN, Crea, SGOT, SGPT, Na, K, procalcitonin
Chest x-ray
X-ray of left leg and foot
ECG
RT PCR
Blood CS x 2 sites- requested however not done
CBC(10/16/22)
Procalcitonin (10/16/22)
Blood chemistry (10/16/22)
ECG (10/16/22)
Interpretation: Normal sinus rhythm, low QRS voltage
Heart rate is 75 bpm
Regular sinus rhythm
Normal axis deviation
No ST elevation
Chest x-ray (10/16/22)
A: Trachea is at midline.
B: No active lung infiltrates seen. Pulmonary
vascular markings are within normal limits.
Pleura is not visible.
C: Heart is not enlarged. Aorta is partially
calcified.
D: Diaphragm is intact. Right diaphragm is
higher than the left. Costophrenic angles are
clearly visible.
E: Note of sternotomy wires. Visualized osseous
structures are unremarkable.
Impression: Atheromatous aorta.
Left leg APL (10/16/22)
●
●
●
No
demonstrable
fracture
or
dislocation in the radiographs taken.
Soft tissue swelling is noted in the
distal leg.
Included joint spaces appear intact.
Left foot APO (10/16/22)
●
●
●
Cortical erosions are seen in the head of first and
2nd metatarsal heads and bases of 1st and 2nd
proximal phalanges.
Subtle soft tissue hyperdensity is noted along
metacarpophalangeal joint of 1st digit. Consider
gouty arthritis.
Included joint spaces and soft tissue outlines
appear intact.
Admitting orders (10/16/22):
●
●
●
●
●
●
●
IVF: PNSS 1L x 80 cc/hr
Low salt low fat diet
Diagnostics:
○
Awaiting RT PCR
○
For blood CS x 2 sites
○
For procalcitonin
○
For AV duplex scan of lower extremities
○
For FBS, LP
Medications:
○
Clindamycin 600 mg IV q6
○
Omeprazole 40 mg/tab OD
○
Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
○
Tramadol 50 mg IV q8 PRN for pain
○
Valsartan 160 mg/tab OD
○
Amlodipine 10 mg/tab OD
○
Clopidogrel 75 mg/tab OD
○
ISMN 60 mg/tab OD
WOF: fever, DOB, chest pain
VS q4
Monitor I & O q shift
V. COURSE IN THE WARD
1ST HOSPITAL DAY
S:
(-) fever
(-) DOB
(-) chest pain
(-) abdominal pain
(-) changes in
urination/bowel movement
O:
BP: 110/80 mmHg
HR: 89 bpm
RR: 18 cpm
Temp: 36.6
Awake, conscious, not in cardiorespiratory distress
Anicteric sclerae, pink palpebral conjunctiva, no
cervical lymphadenopathies
Symmetric chest expansion, clear breath sounds, no
chest retractions
Adynamic precordium, no murmur
Soft, nontender abdomen
(+) Swelling of left leg and foot, warm to touch,
erythematous, minimal pain on movement
(+) Tophi on both feet
A:
Cellulitis,
left
leg
and
foot,
non-purulent skin and soft tissue
infection, moderate; Transaminitis;
HASCVD CAD s/p CABG (PHC, 2004)
P:
IVF: PNSS 1L X 80 cc/hr
Diet: Low salt, low fat diet
Dx: For FBS, lipid profile, AV duplex scan, blood CS
1.
Clindamycin 600 mg IV Q6 (D1)
2.
Omeprazole 40 mg/tab OD
3.
Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
4.
Tramadol 50 mg IV q8 PRN for pain
5.
Valsartan 160 mg/tab OD
6.
Amlodipine 10 mg/tab OD
7.
Clopidogrel 75 mg/tab OD
8.
ISMN 60 mg/tab OD
Monitor VS Q4
Monitor I & O q shift
WOF: DOB, desaturation, fever, hypotension
BLOOD CHEM (10/17/22)
2ND HOSPITAL DAY
S:
(-) fever
(-) DOB
(-) chest pain
(-) abdominal pain
(-) changes in
urination/bowel movement
O:
BP: 100/80 mmHg
HR: 90 bpm
RR: 18 cpm
Temp: 36.0
Awake, conscious, not in cardiorespiratory distress
Anicteric sclerae, pink palpebral conjunctiva, no cervical
lymphadenopathies
Symmetric chest expansion, clear breath sounds, no chest
retractions
Adynamic precordium, no murmur
Soft, nontender abdomen
(+) Decreased swelling of left leg and foot, warm to
touch, erythematous, minimal pain on movement
(+) Tophi on both feet
A:
Cellulitis,
left
leg
and
foot,
non-purulent,
moderate;
Transaminitis; HASCVD CAD s/p CABG
(PHC, 2004)
P:
IVF: PNSS 1L x 80 cc/hr
Diet: Law salt, low fat diet
Dx: For CBC PC, BUN, Crea, SGOT, SGPT, Na, K Cl, still for
AV Duplex Scan, Awaiting blood CS
1.
Clindamycin 600 mg IV Q6 (D2)
2.
Omeprazole 40 mg/tab OD
3.
Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
4.
Tramadol 50 mg IV q8 PRN for pain
5.
Valsartan 160 mg/tab OD
6.
Amlodipine 10 mg/tab OD
7.
Clopidogrel 75 mg/tab OD
8.
ISMN 60 mg/tab OD
Monitor VS Q4
Monitor I & O q shift
WOF: DOB, desaturation, fever, hypotension
3RD HOSPITAL DAY
S:
(-) fever
(-) DOB
(-) chest pain
(-) abdominal pain
(-) changes in
urination/bowel movement
A:
Cellulitis,
left
leg
and
foot,
non-purulent,
moderate;
Transaminitis; HASCVD CAD s/p CABG
(PHC, 2004)
O:
BP: 120/80 mmHg
HR: 74 bpm
RR: 20 cpm
Temp: 36.2
Awake, conscious, not in cardiorespiratory distress
Anicteric sclerae, pink palpebral conjunctiva, no
cervical lymphadenopathies
Symmetric chest expansion, clear breath sounds, no
chest retractions
Adynamic precordium, no murmur
Soft, nontender abdomen
(+) Decreased swelling and tenderness of left leg
and foot, warm to touch, erythematous,
(+) Tophi on both feet
IM IDS NOTES:
●
No objection for
discharge
●
Shift
to
oral
antibiotics for 2
weeks
●
For AV Duplex
scan as OPD
●
Refer
P:
IVF: PNSS 1L x 80 cc/hr
Diet: Law salt, low fat diet
Dx: Still for CBC PC, Bun, Crea, SGOT, SGPT, Na, K, CL, For
AV Duplex Scan as OPD, Awaiting blood CS
1.
Clindamycin 600 mg IV Q6 (D3)
2.
Omeprazole 40 mg/tab OD
3.
Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
4.
Tramadol 50 mg IV q8 PRN for pain
5.
Valsartan 160 mg/tab OD
6.
Amlodipine 10 mg/tab OD
7.
Clopidogrel 75 mg/tab OD
8.
ISMN 60 mg/tab OD
Monitor VS Q4
Monitor I & O q shift
WOF: DOB, desaturation, fever, hypotension
BLOOD CHEM (10/20/22)
V. DISCUSSION
Cellulitis
●
●
●
●
Definition:
○ Acute bacterial infection causing inflammation
of the deep dermis and surrounding
subcutaneous tissue.
Characterized by:
○ Localized pain
○ Erythema
○ Swelling
○ Heat
Usually without an abscess or purulent discharge
Etiology:
○ Beta-hemolytic streptococci typically cause
cellulitis, generally group A streptococcus (i.e.,
Streptococcus
pyogenes),
followed
by
methicillin-sensitive Staphylococcus aureus.
●
Epidemiology:
○
●
Risk factors:
○
○
●
common; most often occurs in middle-aged and
older adults
Immunocompromised
host
(DM,
lymphedema, malnourished, older patients,
obese, peripheral arterial disease)
General infection risk: History of cellulitis
(highest risk factor)
Risk factors for MRSA Cellulitis:
○
○
Increased exposure to MRSA (Contact sports,
crowded living conditions, health care
workers, indigenous descent)
Increased susceptibility (Immunodeficiency,
young age)
Pathophysiology
of Cellulitis
Evaluation
●
●
●
●
●
●
Cellulitis is diagnosed clinically based on the presence of spreading
erythematous inflammation of the deep dermis and subcutaneous tissue.
Two of the four criteria (warmth, erythema, edema, or tenderness) are
required to make the diagnosis.
Its most common presentation is on the lower extremities but can affect any area
of the body.
Most often unilateral and rarely presents bilaterally
Patient's skin should be thoroughly evaluated to find the potential source for the
cellulitis by looking for microabrasions of the skin secondary to injuries, insect
bites, pressure ulcers, or injection sites.
Cultures of blood or cutaneous aspirates, biopsies, or swabs: not routinely
recommended
Management
Lifted from Practice Guidelines for
the Diagnosis and Management
of Skin and Soft Tissue Infections:
2014 Update by the Infectious
Diseases Society of America
Management
●
According to the IDSA Guidelines, cellulitis can be divided into 3 classifications:
○
Mild: without systemic signs of infection
■
Oral medications
●
Penicillin VK or
●
Cephalosporin or
●
Dicloxacillin or
●
Clindamycin
○
Moderate: with systemic signs of infection
■
Intravenous medications
●
Penicillin or
●
Ceftriaxone or
●
Cefazolin or
●
Clindamycin
○
Severe:
associated with penetrating trauma, evidence of MRSA infection
elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (Systemic
Inflammatory Response Syndrome)
■
Empiric treatment
●
Vancomycin PLUS Piperacillin/Tazobactam
Review: Systemic Inflammatory Response Syndrome (SIRS)
Any 2 of the criteria below:
●
Body temperature over 38 or under 36 degrees Celsius.
●
Heart rate greater than 90 beats/minute
●
Respiratory rate greater than 20 breaths/minute or partial pressure of CO2 less
than 32 mmHg
●
Leukocyte count greater than 12000 or less than 4000 /microliters or over 10%
immature forms or bands
Management
Lifted from Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014
Update by the Infectious Diseases Society of America
Management
●
●
●
●
●
The recommended duration of antimicrobial therapy: 5 days
○ should be extended if the infection has not improved within this time
period.
Elevation of the affected area and treatment of predisposing factors are
recommended .
In lower-extremity cellulitis, interdigital toe spaces should be carefully examined.
○ treating fissuring, scaling, or maceration may eradicate colonization with
pathogens and reduce the incidence of recurrent infection.
Outpatient therapy: recommended for patients who do not have SIRS, altered
mental status, or hemodynamic instability (mild nonpurulent).
Hospitalization: recommended if there is concern for a deeper or necrotizing
infection, for patients with poor adherence to therapy, for infection in a severely
immunocompromised patient, or if outpatient treatment is failing (moderate or
severe nonpurulent infection).
Complications
●
●
●
●
If the bacterial infection reaches the bloodstream, it could lead to bacteremia.
Bacteremia can be diagnosed by obtaining blood cultures in patients who exhibit
systemic symptoms. Failure to identify and treat bacteremia from cellulitis can lead to
endocarditis, an infection of the inner lining (endocardium) of the heart.
Patients who have cellulitis along with two or more SIRS criteria (fever over 100.4
degrees F, tachypnea, tachycardia, or abnormal white cell count) → sepsis.
If cellulitis moves from the deep dermis and subcutaneous tissue to the bone, it can
lead to osteomyelitis.
Cellulitis that leads to bacteremia, endocarditis, or osteomyelitis will require a longer
duration of antibiotics and possibly surgery.
Prognosis
●
●
●
●
If cellulitis is promptly identified and treated with correct antibiotics
→ improvement in signs and symptoms within 48 hours
Annual recurrence of cellulitis occurs in about 8-20% of patients
○ Overall recurrence rate as high as 49%
Prompt treatment of cuts or abrasions, proper hand hygiene, as well as effectively
treating any underlying comorbidities can prevent recurrence.
Overall, cellulitis has a good prognosis.
Patient Education
●
Advise the patient to:
○ take prescribed antibiotics as indicated
○ keep the area clean and dry
○ elevate the area above the level of their heart to reduce edema
○ maintain good hand hygiene and adequately clean any future abrasions in their
○
skin
seek consult once they notice the erythema to spread or not respond to
antibiotics, develop persistent fevers, begin developing significant bullae, or feel
the pain worsens.
References:
●
●
●
●
Harrison’s Principles of Internal Medicine, 20th edition
Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue
Infections: 2014 Update by the Infectious Diseases Society of America
Diagnosis
and
Management
of
Cellulitis.
Retrieved
from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303460/?fbclid=IwAR2PVuSCAZ
62nCbkJJblXnOf0QZgnWBjBPlWPRiHzJA6sQuEweHwQIVsuys
Centers for Disease Control and Prevention
THANK
YOU!
CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, and infographics &
images by Freepik and illustrations
Please keep this slide for attribution