Cellulitis

PGI Borlagdan, Marilet T.

ARMMC
Objectives

● Present a case of cellulitis.

● Discuss the etiology, risk factors, evaluation,
pathophysiology, management, complications, and
prognosis of cellulitis.
TABLE OF CONTENTS

I. Case Vignette VI. Course in the ward

II Salient Features VII. Discussion

Etiology, risk factors, evaluation,
pathophysiology

III. Differential Diagnoses VIII. Management

IV. Admitting Impression IX. Complications, Prognosis, &

Patient Education

V. Management at the ER IX. References

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
● (+) tenderness and swelling of left leg
● (+) undocumented fever
11 MONTHS PTC ● (-) 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

● (+) tenderness and swelling of left foot

● (+) undocumented fever
2 WEEKS PTC ● (-) DOB/chest pain/abdominal pain/changes in urination or bowel
movement
● No medications taken
● No consult done
● (+) tenderness and swelling of left foot
● (+) undocumented fever
● (+) extension of swelling up to the left leg
1 WEEK PTC ● (+) difficulty walking
● (-) DOB/chest pain/abdominal pain/changes in urination or bowel
movement
● Took Etoricoxib (Arcoxia) 90 mg → partial relief
● No consult done

FEW HRS PTC (+) 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 Temp: 37.9°C

HR: 80 bpm SpO2: 98% at room air
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
 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 Rule out

● (+) fever ● (-) bright red erythema

● (+) swelling of left foot and leg ● (-) elevation of the affected area
● (+) erythema ● (-) well-demarcated borders
● (+) tender ● (-) burning sensation at the affected
area
 DDX 2: Stasis Dermatitis
Rule in Rule out

● (+) swelling of left foot and leg ● (-) pruritus

● (+) erythema
● (+) tender
● (+) hyperpigmentation
● (+) hypertension
● (+) history of CABG
● (-) lichenification
● (-) weeping erosions
● Usually affects both legs
 DDX 3: Contact Dermatitis

Rule in Rule out

● (+) swelling of left foot and leg ● (-) pruritic

● (+) erythema ● (-) recent exposure to known
● (+) tender 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) Left foot APO (10/16/22)

● No demonstrable fracture or ● Cortical erosions are seen in the head of first and
dislocation in the radiographs taken. 2nd metatarsal heads and bases of 1st and 2nd
● Soft tissue swelling is noted in the proximal phalanges.
distal leg. ● Subtle soft tissue hyperdensity is noted along
● Included joint spaces appear intact. 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:
A:
(-) fever
Cellulitis, left leg and foot,
(-) DOB
non-purulent skin and soft tissue
(-) chest pain
infection, moderate; Transaminitis;
(-) abdominal pain
HASCVD CAD s/p CABG (PHC, 2004)
(-) changes in
urination/bowel movement
P:
O: IVF: PNSS 1L X 80 cc/hr
BP: 110/80 mmHg HR: 89 bpm Diet: Low salt, low fat diet
RR: 18 cpm Temp: 36.6 Dx: For FBS, lipid profile, AV duplex scan, blood CS
1. Clindamycin 600 mg IV Q6 (D1)
Awake, conscious, not in cardiorespiratory distress
2. Omeprazole 40 mg/tab OD
Anicteric sclerae, pink palpebral conjunctiva, no 3. Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
cervical lymphadenopathies 4. Tramadol 50 mg IV q8 PRN for pain
Symmetric chest expansion, clear breath sounds, no 5. Valsartan 160 mg/tab OD
chest retractions 6. Amlodipine 10 mg/tab OD
Adynamic precordium, no murmur 7. Clopidogrel 75 mg/tab OD
Soft, nontender abdomen 8. ISMN 60 mg/tab OD
(+) Swelling of left leg and foot, warm to touch, Monitor VS Q4
Monitor I & O q shift
erythematous, minimal pain on movement
WOF: DOB, desaturation, fever, hypotension
(+) Tophi on both feet
BLOOD CHEM (10/17/22)
2ND HOSPITAL DAY
S:
A:
(-) fever
Cellulitis, left leg and foot,
(-) DOB
non-purulent, moderate;
(-) chest pain
Transaminitis; HASCVD CAD s/p CABG
(-) abdominal pain
(PHC, 2004)
(-) changes in
urination/bowel movement
P:
IVF: PNSS 1L x 80 cc/hr
O: Diet: Law salt, low fat diet
BP: 100/80 mmHg HR: 90 bpm Dx: For CBC PC, BUN, Crea, SGOT, SGPT, Na, K Cl, still for
RR: 18 cpm Temp: 36.0 AV Duplex Scan, Awaiting blood CS
Awake, conscious, not in cardiorespiratory distress 1. Clindamycin 600 mg IV Q6 (D2)
Anicteric sclerae, pink palpebral conjunctiva, no cervical 2. Omeprazole 40 mg/tab OD
lymphadenopathies 3. Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
Symmetric chest expansion, clear breath sounds, no chest 4. Tramadol 50 mg IV q8 PRN for pain
retractions 5. Valsartan 160 mg/tab OD
Adynamic precordium, no murmur 6. Amlodipine 10 mg/tab OD
Soft, nontender abdomen 7. Clopidogrel 75 mg/tab OD
(+) Decreased swelling of left leg and foot, warm to 8. ISMN 60 mg/tab OD
touch, erythematous, minimal pain on movement Monitor VS Q4
(+) Tophi on both feet Monitor I & O q shift
WOF: DOB, desaturation, fever, hypotension
3RD HOSPITAL DAY IM IDS NOTES:
● No objection for
discharge
S:
A: ● Shift to oral
(-) fever antibiotics for 2
Cellulitis, left leg and foot,
(-) DOB weeks
non-purulent, moderate;
(-) chest pain ● For AV Duplex
Transaminitis; HASCVD CAD s/p CABG scan as OPD
(-) abdominal pain
(PHC, 2004) ● Refer
(-) changes in
urination/bowel movement
P:
IVF: PNSS 1L x 80 cc/hr
O: Diet: Law salt, low fat diet
BP: 120/80 mmHg HR: 74 bpm Dx: Still for CBC PC, Bun, Crea, SGOT, SGPT, Na, K, CL, For
RR: 20 cpm Temp: 36.2 AV Duplex Scan as OPD, Awaiting blood CS
Awake, conscious, not in cardiorespiratory distress 1. Clindamycin 600 mg IV Q6 (D3)
Anicteric sclerae, pink palpebral conjunctiva, no 2. Omeprazole 40 mg/tab OD
cervical lymphadenopathies 3. Paracetamol 500 mg/tab q4 PRN for T>/= 37.8
Symmetric chest expansion, clear breath sounds, no 4. Tramadol 50 mg IV q8 PRN for pain
5. Valsartan 160 mg/tab OD
chest retractions
6. Amlodipine 10 mg/tab OD
Adynamic precordium, no murmur 7. Clopidogrel 75 mg/tab OD
Soft, nontender abdomen 8. ISMN 60 mg/tab OD
(+) Decreased swelling and tenderness of left leg Monitor VS Q4
and foot, warm to touch, erythematous, Monitor I & O q shift
(+) Tophi on both feet 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:
○ common; most often occurs in middle-aged and
older adults
● Risk factors:
○ 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!
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