questions 2

Cellulitis

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Topic updated on 09/03/17 11:11pm

Snapshot
  • A 60-year-old man with a past medical history of diabetes and hypertension presents with swelling in his right leg after he scraped his calf on the corner edge of his coffee table. On physical exam, there is a poorly demarcated 10 cm red and tender plaque on his right calf. Some parts resemble an orange peel. There is a superficial scrape in the middle of the plaque. He is sent home on oral antibiotics.
Introduction
  • Clinical definition
    • painful bacterial infection involving the deeper dermis and subcutaneous tissues
      • often from Streptococcal spp. or, less commonly, S. aureus
    • from superficial involvement of skin to deep
      • impetigo (very superficial skin infection)
      • erysipelas (upper dermis and cutaneous lymphatics)
      • cellulitis (deeper dermis and subcutaneous tissues)
  • Epidemiology
    • incidence
      • 48 per 1000 person-years
    • risk factors
      • skin ulcers
      • tinea pedis
      • intravenous drug use
      • venous insufficiency
      • diabetes
      • lymphedema
      • pre-existing skin injury
  • Etiology
    • streptococcus species
    • S. aureus
  • Pathogenesis
    • pre-existing injury in skin can act as entry portal for bacteria
  • Prognosis
    • recurrence
Presentation
  • Symptoms
    • painful and tense skin
  • Physical exam
    • fever
    • diffuse inflammation of affected area
      • poorly demarcated
      • red
      • warm
      • tender
      • dimpling around hair follicles resembling orange peel (peau d’orange)
    • may have purulence
Evaluation
  • Labs
    • tissue cultures
      • may aid diagnosis and guide treatment
    • blood cultures
      • if cellulitis is purulent
  • Diagnosed clinically
Differential
  • Erysipelas
    • more superficial involvement of skin and soft tissues
    • there is often an overlap and may not be distinguished clinically from erysipelas
Treatment
  • Medical
    • oral antibiotics
      • indications
        • for mild cases of cellulitis
      • drugs
        • penicillin
        • dicloxacllin
        • cephalexin
        • clindamycin
          • for suspected methicillin-resistant S. aureus
    • IV antibiotics
      • indications
        • for cellulitis with signs of systemic infection
          • e.g., positive blood cultures
      • drugs
        • penicillin
        • cefazolin
        • ceftriaxone
        • clindamycin
Complications
  • Skin abscess formation
    • more common in IV drug users
  • Lymphedema
    • due to lymphatic damage caused by infection
    • may be permanent
  • Sepsis


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Qbank (2 Questions)

TAG
(M3.DM.2) A 34-year-old male is seen by his primary care physician for a swollen and slightly red lower leg as demonstrated in Figure A. His physician prescribes him 2 weeks of oral antibiotics and tells the patient to return if he doesn't see any resolution in 1-2 weeks. Four days later, the patient shows up in the emergency room for a "swollen and red" leg as seen in Figure B. The patient states that he has been compliant in taking his antibiotics but that his nausea and fevers are really his main issues. He denies any acute injury to his leg, and the area of erythema and edema are not tender to palpation. He has full range of motion about his ankle and toes and endorses sensation distally. He has palpable dorsalis pedis and posterior tibial pulses. What should be the next step in this patient's care and why? Topic Review Topic
FIGURES: A   B        

1. Hospital admission for IV antibiotics because of lack of response to oral antibiotics within 24-48 hrs
2. Hospital admission for IV antibiotics because of risk of compartment syndrome
3. Outpatient treatment with broader spetrum oral antibiotic since current antibiotic regimen is not working
4. Outpatient treatment with same antibiotic as not enough sufficient time was given for antibiotic to work
5. Outpatient treatment with IV antibiotics with a peripherally inserted central catheter (PICC)

PREFERRED RESPONSE ▶
TAG
(M2.DM.1) A 23-year-old previously healthy female not currently taking any medications presents to the emergency department with complaints of chills, malaise, and pain in her left lower extremity. She reports feeling "off" for the last 24 hours, but wanted to complete the 7 hour drive home from her recent hiking trip.

Vital signs are as follows: temperature of 101.8F (38.8C), heart rate of 95 bpm, blood pressure of 125/70 mmHg, and respiratory rate of 11 resp/min.

Physical exam findings are shown in Figure A. You also note a large, poorly-healed blister on the left great toe.

While waiting for labs to return, the patient spikes a fever to 103F (39.4C) and begins to feel confused. Along with IV fluids, which of the following is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. IV heparin
2. IV penicillin G
3. IV cefazolin
4. IV caspofungin
5. Oral vancomycin

PREFERRED RESPONSE ▶


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