Cellulitis Disease

BASICS

DESCRIPTION

An acute, spreading infection of the dermis and subcutaneous tissue. Several entities are recognized:

Cellulitis of the extremities - characterized by an expanding, red, swollen, tender or painful plaque with an indefinite border that may cover a wide area
Recurrent cellulitis of the leg after saphenous venectomy - patients have an acute onset of swelling, erythema of the legs arising months to years after coronary artery bypass. (Surgery using lower extremity veins for bypass grafts.)
Dissecting cellulitis of the scalp - recurrent painful, fluctuant dermal and subcutaneous nodules
Facial cellulitis in adults - a rare event. Patients usually develop pharyngitis, followed by high fever, rapidly progressive anterior neck swelling, tenderness and erythema associated with dysphagia
Facial cellulitis in children - potentially serious. Swelling and erythema of the cheek develop rapidly, usually unilateral.
Perianal cellulitis - bright perianal erythema extending from the anal verge approximately 2 to 3 cm onto the surrounding perianal skin
Pseudomonas cellulitis - may be a localized phenomenon or it may occur during pseudomonas septicemia
System(s) affected: Skin/Exocrine
Genetics: No known genetic pattern
Incidence/Prevalence in USA: Unknown
Predominant age:
- Perianal cellulitis - principally in children
- Facial cellulitis - in adults, usually older than 50 years. In children, between 6 months and three years.
Predominant sex: Male = Female (perianal cellulitis more common in boys)

SIGNS AND SYMPTOMS

General
- Local tenderness
- Pain
- Erythema
- Malaise
- Fever, chills
- Involved area is red, hot, and swollen
- Borders of the area are not elevated and not demarcated
- Regional lymphadenopathy is common
Recurrent cellulitis
- Same as above
- Edema
- High fever, chills and toxicity
Dissecting cellulitis of the scalp
- Purulent drainage from burrowing interconnecting abscesses
Facial cellulitis in adults
- Malaise
- Anorexia
- Vomiting
- Itching
- Burning
- Dysplasia
- Anterior neck swelling
Facial cellulitis in children
- Irritability
- Upper respiratory tract infection symptoms
Perianal cellulitis
- Intense perianal erythema
- Pain on defecation
- Blood streaked stools
- Perianal pruritus

CAUSES

By site
- Cellulitis of the extremities: Group A streptococcus, Staphylococcus aureus
- Recurrent cellulitis of the leg: Non-group A beta hemolytic Streptococci (group C,G,B)
- Dissecting cellulitis of the scalp: Staphylococcus aureus
- Facial cellulitis in adults: H. influenzae type B
- Facial cellulitis in children: H. influenzae type B, over 3 years with portal of entry: staphylococcal and streptococcal
- Synergetic necrotizing cellulitis: Mixed aerobic-anaerobic flora
- Intravenous drug use: Staphylococcus aureus, Streptococci, Enterobacteriaceae, Pseudomonas, Fungi
- Synergetic necrotizing cellulitis: Mixed aerobic-anaerobic flora
Specific diseases
- Diabetes mellitus: Staphylococcus aureus, Streptococci, Enterobacteriaceae, Anaerobes
- Human bites: Eikenella corrodens
- Animal bites (cat and dog): Staphylococci, Pasteurella multocida
Patient groups
- Neonates: Group B streptococcus
- Immunocompromised
  - Bacteria (Serratia, Proteus and other Enterobacteriaceae)
  - Fungi (Cryptococcus neoformans)
  - Atypical mycobacterium
- Children with nephrotic syndrome: E. coli
- Environmental and occupational exposures
  - Erysipelothrix rhusiopathiae
  - Vibrio species
  - Aeromonas hydrophilia
Rare causes
- Anaerobic
- Clostridium perfringens (gas forming cellulitis)
- Tuberculosis
- Syphilitic gumma
- Fungal: Mucormycosis, Aspergillosis

RISK FACTORS

General
- Previous trauma (laceration, puncture, human or animal bite)
- Underlying skin lesion (furuncle, ulcer)
- Surgical wound
- Recurrent cellulitis
- Post coronary artery bypass in patients whose saphenous veins have been removed
- Lower extremity lymphedema secondary to a. radical pelvic surgery b. radiation therapy c. neoplastic involvement of pelvic lymph nodes
- Mastectomy
- Diabetes mellitus
- Intravenous drug use
- Immunocompromised host
- Burns
- Environmental and occupational factors

DIAGNOSIS

LABORATORY

Aspirates from the point of maximum inflammation. Yield a 45% positive culture rate as compared to a 5% from leading edge culture.
Blood cultures - potential pathogens isolated in 25% of patients
Mild leucocytosis with a left shift
A mildly elevated sedimentation rate
CBC

Drugs that may alter lab results: Previous antibiotic therapy may alter the results
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Biopsy of skin shows marked infiltration of the dermis with eosinophils and inflammatory changes

SPECIAL TESTS

Serial serological testing with antistreptolysin O, anti-deoxyribonuclease B, and anti-hyaluronidase tests may be successful in diagnosing cellulitis caused by group A, C, or G hemolytic streptococci
Sinus drainage and culture of aspirate

IMAGING

Gas forming cellulitis
- Plain x-rays show gas bubbles in the soft tissue
- CT shows gas and myonecrosis

DIAGNOSTIC PROCEDURES

Skin biopsy
Lumbar puncture should be considered for all children with H. influenzae type B cellulitis

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient for mild cases, inpatient for severe infections

GENERAL MEASURES

Immobilization and elevation of the involved limb to reduce swelling may be needed in H. influenzae type B
Sterile saline dressings to decrease local pain
Moist heat to localize the infection
Cool Burrow's compresses for pain relief

SURGICAL MEASURES

Debridement for gas/purulent collections
Intubation or tracheotomy may be needed for cellulitis of the head or neck
Wide filleting incision in necrotizing cellulitis

ACTIVITY

Ambulatory in mild infection; bedrest in severe infection

DIET

Regular diet

PATIENT EDUCATION

Good skin hygiene
Avoid skin traumas
Report early skin changes to physician

FOLLOW UP

PREVENTION/AVOIDANCE

Treatment of tinea pedis with antifungal (such as clotrimazole) will prevent recurrent cellulitis of the legs in patients who have had coronary bypass
Avoid trauma
Avoid swimming in fresh water or salt water in the presence of skin abrasion
Avoid human or animal bite
Support stocking with peripheral edema
Good skin hygiene
For recurrent cellulitis - prophylactic penicillin G (250-500 mg po bid)
H. influenzae cellulitis - ´rifampin´ prophylaxis for entire family of index case or in day-care classroom in which one or two children exposed. Dosage: 20 mg/kg/day (maximum: 600 mg/day) for 4 days.

POSSIBLE COMPLICATIONS

Bacteremia
Local abscesses
Super infection with gram negative organisms
Lymphangitis especially in recurrent cellulitis
Thrombophlebitis of lower extremities in older patients
Dissecting cellulitis of the scalp - scarring; alopecia
Facial cellulitis in children - meningitis in 8% of patients
Gas forming cellulitis - gangrene; amputation; 25% mortality

EXPECTED COURSE AND PROGNOSIS

With adequate antibiotic treatment, outlook is good

MISCELLANEOUS

ASSOCIATED CONDITIONS

Facial cellulitis in children
- Upper respiratory tract infection
- Unilateral or bilateral otitis media in 68% of patients
- Meningitis in 8% of patients
Perianal cellulitis
- Pharyngitis may precede the infection
Frontal sinus in adult
- Subacute bacterial endocarditis
- Scarlet fever
- Vaccinia
- Herpes simplex
- Herpes zoster

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: In cellulitis of lower extremities, patients are more prone to develop thrombophlebitis
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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