cellulitis_erysipelas
CELLULITIS/ERYSIPELAS
Cellulitis is a spreading bacterial skin infection that infects deeply involving the subcutaneous tissues.
It typically occurs in areas where the skin integrity has been compromised.
It may also result from blood-borne spread of infection to the skin and subcutaneous tissues.
It is commonly caused by beta-hemolytic streptococci and Staphylococcus aureus.
Erysipelas is a type of cellulitis with margins that are sharply demarcated, involves the epidermis and superficial lymphatics.
Onset of symptoms is acute whereas cellulitis has an indolent course.
It is more commonly caused by beta-hemolytic streptococci.

Diagnosis

  • Diagnosis is usually made by clinical presentation with or without Gram stain and culture
  • On evaluation, location and extent of edema, erythema, warmth, and tenderness are noted so that resolution or progression may be monitored in detail
    • Examine for bullae, crepitus, fluctuance, necrosis, purpura, and systemic signs (eg tachycardia, hypotension)

Classification

Cellulitis

Uncomplicated

  • Area involved is erythematous, warm to the touch, swollen and is distinguished from erysipelas by non-elevated,ill-defined margins
  • Primarily involves the subcutaneous tissues and dermis 
  • Patients are usually asymptomatic & without comorbidity

Complicated

  • Cellulitis in diabetes mellitus (DM) patients including diabetic leg ulcer
  • Presence of comorbidities or vascular compromise (eg peripheral vascular disease, chronic venous insufficiency, morbid obesity); if necessary, patients are hospitalized to stabilize comorbid condition
  • Presence of significant systemic symptoms: Acute confusion, tachycardia, tachypnea, hypotension
  • Signs of potentially severe deep soft-tissue infection: violaceous bullae, cutaneous hemorrhage, skin sloughing, gas in the tissue; surgical debridement of affected area may be required

Purulent

  • Presence of purulent exudate or drainage without a drainable abscess

Nonpurulent

  • Absence of purulent exudate or drainage and no abscess

Recurrent

  • Cellulitis occurring 3-4 times/year even with pharmacological prophylaxis and control of predisposing factors

Laboratory Tests

Gram Stain, Culture & Sensitivity

  • Lesion Culture
    •  Cultures of aspirate, biopsy and blood specimens in adults without comorbid conditions yield low results and are generally not indicated
    • Essential only for those with history of malignancy, systemic complications (eg pyrexia, hypotension), predisposing factors (ie immersion injury, animal bites, neutropenia)
    • Fine-needle aspiration of closed lesions give positive results approximately 30% of the time
    • This technique may be useful when unusual pathogens are suspected (eg immunocompromised patients), when fluctuant areas are detected or when initial antimicrobial therapy failed
    • If a specimen can be taken from the site of origin of the cellulitis, positive culture can be obtained in about 1/3 of the patients
  • Blood cultures (BC)
    • Useful only in patients with significant leukocytosis, severe systemic symptoms, underlying comorbidities, cellulitis complicating lymphedema, buccal or periorbital cellulitis, persistent/recurrent cellulitis, certain exposures (water- related injury or animal bites), and in the elderly or immunocompromised patient

Imaging

  • Unnecessary in most cases
  • Computed tomography (CT) or magnetic resonance imaging (MRI) for suspected necrotizing fasciitis
  • Radiographic exams may be used to rule out osteomyelitis
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