Swollen leg II: Cellulitis

Published on 02/04/2015 by admin

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217 Swollen leg II

Cellulitis

Instruction

Look at this patient’s leg.

Salient features

History

• History of fever and chills

• Diabetes

• Animal (or human!) bites

• Exposure to seawater (Vibrio vulnificus), fresh water (Aeromonas hydrophila) or aquacultured fish (Streptococcus iniae).

Examination

• Red, inflamed leg with a definite demarcation of erythematous area (Fig. 217.1)

• Oedema

• Increased temperature

• Crepitus: crepitant cellulitis is produced by either Clostridia sp. or non-spore-forming anaerobes (Bacteroides spp, peptostreptococci and peptococci).

image

Fig. 217.1 Cellulitis.

(With permission from Habif 2009.)

Proceed as follows:

• Examine the peripheral pulses.

• Look for varicose veins (varicose eczema should be considered in the differential diagnosis of cellulites of the leg, BMJ 1999;318:1672–3).

• Look for superficial ulcers.

Diagnosis

This patient has cellulitis of the leg (lesion) caused by pyogenic bacterial infection (aetiology) and the leg is acutely swollen and painful (functional status).

Remember: Cellulitis is a clinical diagnosis; it is a deep, subcutaneous infection characterized by warmth, swelling, tenderness and erythema and may be accompanied by lymphatic streaking. Pruritus is absent (unlike in contact dermatitis).

Questions

How would you manage such a patient?

• Cultures of aspirates and lesions

• Blood cultures: bacteraemia is uncommon in cellulitis but blood cultures are useful in those with lymphoedema

• Radiology: plain film radiography or CT is useful when accompanying osteomyelitis is suspected. Gallium-67 scintillography may aid in the detection of cellulitis superimposed on recently increasing, chronic lymphoedema of a limb

• Intravenous antibiotics: because most cases of cellulitis are caused by streptococci and Staphylococcus aureus, beta-lactam antibiotics with activity against penicillinase-producing S. aureus are the usual drugs of choice. Flucloxacillin can be used until microbe is identified

• Pain relief and pyretics

• Surgical referral

• Experimental: granulocyte-colony stimulating factor (G-CSF), particularly in diabetics.

What are the causes of bilateral swollen legs?

• Cardiac failure

• Renal failure

• Hypoproteinaemia (from cirrhosis or nephrotic syndrome).

What are the causes of an acutely swollen leg?

• Deep vein thrombosis

• Cellulitis

• Arterial occlusion

• Trauma

• Arthritis.

What are the causes of a chronically swollen leg?

• Venous causes: varicose veins, postphlebitic limb

• Lymphoedema: Milroy’s disease, filariasis (in the tropics)

• Congenital.

WF Milroy (1855–1942) described familial lymphoedema of the legs in 1892.

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217 Swollen leg II

Cellulitis

Instruction

Look at this patient’s leg.

Salient features

History

• History of fever and chills

• Diabetes

• Animal (or human!) bites

• Exposure to seawater (Vibrio vulnificus), fresh water (Aeromonas hydrophila) or aquacultured fish (Streptococcus iniae).

Examination

• Red, inflamed leg with a definite demarcation of erythematous area (Fig. 217.1)

• Oedema

• Increased temperature

• Crepitus: crepitant cellulitis is produced by either Clostridia sp. or non-spore-forming anaerobes (Bacteroides spp, peptostreptococci and peptococci).

image

Fig. 217.1 Cellulitis.

(With permission from Habif 2009.)

Proceed as follows:

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