A 58 y.o. with metastatic colon ca presents with R leg pain
there is no gas on plain xray and she is admitted as cellulitis?
What could go wrong?
A blister is noted on the dorsum of the foot.
Our patient had necrotizing fasciitis. An ED resident re-evaluating the patient realized this was more than just cellulitis (which she had already been admitted for) and did a CT. Surgery took the patient to the OR where she had an AKA.
Cellulitis, an infection of the dermis, leads to 2.3 million emergency department visits and 650,000 hospitalization per year. It is estimated that at least one third of patients are misdiagnosed. The reason for this is that cellulitis has many mimics.
fortunately most mistakes are made in just a few categories shown below.
Among inpatients, up to 60% receive an alternative diagnosis if seen by a specialist.
1/3 had stasis dermatitis, eczematous dermatitis or allergic dermatitis.
1/3 had another infectious proccess: abscess, bursitis or osteomyelitis
4% had gout or pseudogout.
The most common mimics include:
Stasis dermatitis develops in patients with venous insufficiency the medial ankle is often involved and there is often erythema and scaling skin. It rarely occurs before the fifth decade of life. The complications include non healing venous ulcers and lichenification. Non steroidal calcineurin inhibitors tacrolimus and pimecrolimus have been shown to be effective .
stasis dermatitis.
Contact dermatitis. Is usually pruritic common after chlorhexidine and povidone-iodine. Nickel in splints can cause the same reaction.
reaction to betadiene after a c section
DVT can mimic cellulitis
Insect hypersensitivity can mimic cellulitis because they cause what is known as papular urticaria. They cause intense pruritus and an exuberant allergic reaction. This is most common in children when they are sensitized to bedbug, flea or mosquito bites.
papular urticaria
CLINICAL PEARLS
1 If the patient appears septic look for other sources and consider imaging. It may not be simply cellulitis.
2.Cellulitis should be acute with erythema, warmth and edema.
3. Consider the cellulitis mimics which will change your treatment: necrotizing fasciitis, DVT and compartment syndrome.
Our patient also had metastatic colon cancer and following her amputation she developed hypotension, was placed briefly on pressors and transitioned to comfort care. She expired.
Sundaresan S, Migden M, Silapunt S. Stasis dermatitis :pathophysiology, evaluation and management. Am J Clin Dermatol 2017 Jun. 18(3):383-390.27,2020
Cutler T et al. Prevalence of misdiagnosis of cellulitis: a systematic review and meta-analysis Hosp Med 2023 Mar;18:254
Zuger A, NEJM Journal Watch Gen Med July 1 2018
Li D, Xia F, Khosravi H, et al. Outscomes of early dermatology consultation for inpatients diagnosed with cellulitis JAMA Dermatol 2018;154(5):537-543
Khachatryan A, Stephens D, Johnson K, et al. Skin and skin structure infections in the ED who gets admitted? http//content.stockpr.com/duratatherapeutics/db/Publications/2774/file/5-6e_SAEM_poster.pdf.
Thanks to Dr. Ed Fieg