An 84 y.o. male noted redness and weeping of the R leg for several months.
Multiple courses of antibiotics did not improve the condition. What should be done?
Our patient underwent a biopsy showing eosinophilic spongiosis consistent with contact dermatitis. Based on his history Neosporin was assumed to be the culprit. He had been treated for months as cellulitis.
There are 14.5 million cases of cellulitis which cost $3.7 billion yearly in annual health costs. Cellulitis involves the epidermis, dermis and subcutaneous layers of skin. It is most commonly caused by S aureus or beta-hemolytic strep. Blood cultures and skin cultures are rarely diagnostic. The challenge of diagnosing cellulitis is that it has many mimics.
CELLULITIS MIMICS
CONTACT DERMATITIS- can occur from touching poison ivy and usually happens within hours of exposure. This can also come from soaps or topical antibiotics like neomycin.
ARTHROPOD BITES- A hornet sting causes severe pain x 1-2 hours followed by increased swelling for 48 hours . Redness lsts about 3 day and swelling lasts 7 days. A million people a year visit an ED for severe pain. Pain that worsens more than 2 days after a sting an in indication that infection is present.
FUNGAL INFECTIONS- fungal infections can mimic bacterial cellulitis. Sporotrichosis (also known as “rose gardener’s disease” is an infection caused by a fungus called sporothrix. Usually it is transmitter from soil and on plant matter like sphagnum mass, rose bushes and hay. It can however be transmitted through animal bites. Sporothrix brasiliensis is being spread in Brazil and South America by cat bites.
STASIS CHANGES- Stasis dermatitis results from chronic edema, mostly on the shins. Erythema, scaling and lichenification and weeping may occur. Pooling of blood and increased pressure in the veins over months to years can cause the skin to become brown or reddish. -
scaling, redness and weeping lesions can occur with stasis
GOUT- Gout can cause high WBC counts and erythema mimicking cellulitis. It is not always in joints and should be considered in any patient on diuretics or drinking two beers daily(beer contains high levels of purines which trigger gout) . Gout is usually sudden in onset and can occur in areas of trauma. Recent vaccination has also been shown to trigger a gout flare.
this patient had bumped her shin and had a gouty tophus develop
ERYTHEMA NODOSUM—is a localized inflammatory lesion forming nodules in fatty tissue. Nodules are usually palpable on the shins. Infections like strep, drug exposures like birth control pills, and systemic inflammatory diseases like Behcets ‘s or Crohn’s can cause e nodosum..
E nodosum is an inflammation of fat similar to paniculitis.
NECROTIZING FASCIITIS- This is the mimic that cannot be missed. This is a rare bacterial infection that spread quickly and can cause death. Group A strep is the most common cause. There is usually severe pain out of proportion to the area of skin that is red.
necrotizing fasciitis can present with severe pain, rapid spreading and a dark center or blister
Our patient was discharged with a prednisone taper over two weeks and follow up with dermatology. Because of the low likelihood of infection he was given a 10 day course of Bactrim for cellulitis.
Chakrabarti A, Bonifaz A, Gutierrez-Galhardo M et al. Global epidemiology of sporotrichosis. Med Mycol. 2015 Jan;53(1):3-14.
Simman R, Kirkland B, Jackson S. Posttraumatic tophaceous gout; A case report and literature review J Am Col Certif Wound Spec. 2009 Dec;1(4):114-116.
Hua C, Bosc R, Sbidian E, et al.Interventions for necrotizing soft tissue infections in adults. The Cochrane Database of systematic Reviews. 2018(5) CD011680 doi 10.1002/14651858. CD011680.pub2