Predictors help differentiate cellulitis from its imitators.
These were among the main findings of a retrospective study of all patients admitted to Massachusetts Gencral Hospital, Boston, for suspected cellulitis during a 6month period in 2009, according to Elizabeth E. Bailey.
She reviewed the charts on 390 adults who were admitted with suspected cellulitis after excluding everyone with osteomyclitis, abscess, or bites. Ultimately, 323 of the 390 patients were deemed to have true cellulitis by the physician having primary responsibility for their care.
Among the 17% of patients determined to have a condition other than cellulitis, the most common final diagnosis was stasis dermatitis /Iymphedema, which accounted for 17 cases, said Ms. bailey. a fourth year medical student at Columbia University; New York. The other common mimics of cellulicis included 6 cases of gout or pseudogout, 6 Cases of hematoma, 4 cases of septic arthritis or bursitis, and 4 venous occlusiotis.
In her analysis, one of the significant differences that emerged between patients with true cellulitis, as compared to pseudocellulitis. was that the true cellulitis group had a higher prevalence of coexisting medicai conditions considered by the investigators to be potential risk factors for cellulitis. One or more of these conditions, which included diabetes metlitus, malignancy, intravenous drug use, and histoiy of organ transplantation, was present in 55% of patients with cellulitis and 39% of those with pseudocellulitis.
On physical examination, 53% of ccllulitis patients presented with warmth at the anatomic site, compared with 34% of those with pseudocellulitis. Bilateral disease was present in 13.4% of patients with a condition mimicking cellulitis and 5.9% of those with true cellulitis.
There were no significant between group differences in body temperature; heart rate; reports of pain, itching, or burning: or any other physical exam findings.
In a mulcivariate analysis, the strong. significant predictors of cellulitis included the presence of a predisposing coexisting medical condition, which was associated with a 90% increased likelihood of cellulitis rather than a mimic. Bilateral symptoms rendered a patient 60% less likely to have true cellulitis. Warmth at the anatomic site was associated with a 2.2-fold increased likelihood of true ccllu litis.
Of note, although warmth at the anatomic site was a significant predictor of true cellulitis, the other physical findings classically attributed to cellulitis--erythema, tenderness, and edema--were not.
"The classic tetrad of calor, dolor, rubor, and tumor is truly a cecrad for inflammation, as originally described in the 1st century AD," Ms. Bailey observed.
One of the striking findings in her study was how seldom the dermatology service was consulted in cases of suspected cellulitis. Only five patients with pseudocellulitis saw a dermatologist while in the hospital. and in four of these cases the dermatologic consultation led to a change in diagnosis from ceLlulitis to one of its mimics. A dermatologic consult was obtained in 18 of 323 cases of what was ultimately deemed true cellulitis.
Laboratory findings did not prove useful in making the distinction between true and pseudocellulitis in this study. However, the final word on this score isn't in, because several laboratory values showing some potential weren't measured in a sufficient number of patients to allow for definitive conclusions; among these were C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, and creatine kinase.
This study limitation will be rectified in a planned prospective study to be cartied out at the hospital. In that study, all patients who present to the emergency department with suspected cellulitis will undergo a standardized assessment, including a specified panel of laboratory tests, followed by evaluation by both an infectious disease specialist and a dermatologist, explained Ms. Bailey.
The impetus for this retrospective study, as well as for the planned prospective study, lies in the fact that even though cellulitis accounts for about 10% of all infectious disease-related hospitalizations in the United States, there is no established diagnostic gold standard. It is likely that many other dermatologic or systemic conditions are misdiagnosed as cellulitis, Ms. Bailey said. The goal of the project she is conducting with other investigators at Massachusetts General Hospital is to develop criteria that will increase the specificity of the diagnosis. She reported having no conflicts.
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|Publication:||Internal Medicine News|
|Article Type:||Clinical report|
|Date:||Jun 1, 2011|
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