Clinical Mimics: An Emergency Medicine-Focused Review of Cellulitis Mimics

Tattoo-induced allergic contact dermatitis presents diagnostic challenge as a cellulitis mimic

Allergic contact dermatitis (ACD) is a prevalent condition associated with numerous potential allergen exposures. Tattoo ink is variable and may contain allergens that can be overlooked in patient education and diagnosis. We present a 27-year-old female with ACD following a new tattoo. The patient was repeatedly misdiagnosed with cellulitis by three different clinicians and treated with multiple antibiotics without improvement. The correct diagnosis was eventually made in the emergency department (ED). Although the patient was aware of her allergies to nickel and cobalt from patch testing, she was not aware of the potential for tattoo ink to contain these allergens because prior tattoos had not provoked an allergic reaction. Consequently, the appropriate care was delayed by a month, resulting in significant morbidity. This case demonstrates the potential for ACD to present similarly to cellulitis in an ED setting and the need for clinical vigilance in diagnosis of ACD. It also highlights the importance of detailed patient education on potential allergen sources particularly in the context of tattooing, which is performed with unregulated and variable ink products.

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.

Using Thermal Imaging to Track Cellulitis

Background

Cellulitis is a common soft tissue infection and a major cause of morbidity. The diagnosis is based almost exclusively on clinical history and physical exam. To improve the diagnosis of cellulitis, we used a thermal camera to track how skin temperature of the affected area changed during a hospital stay for patients with cellulitis.

Methods

We recruited 120 patients admitted with a diagnosis of cellulitis. Daily thermal images of the affected limb were taken. Temperature intensity and area were analyzed from the images. Highest daily body temperature and antibiotics administered were also collected.We estimated a longitudinal linear mixed-effects model with a random intercept for the affected body area. All observations on a given day were included, and we used an integer time indicator indexed to the initial day (ie, t = 1 for the first day the patient was observed, etc.). We then analyzed the effect of this time trend on both severity (ie, normalized temperature) and scale (ie, area of skin with elevated temperature).

Results

We analyzed thermal images from the 41 patients with a confirmed case of cellulitis who had at least 3 days of photos. For each day that the patient was observed, the severity decreased by 1.63 (95% CI, -13.45 to 10.32) units on average, and the scale decreased by 0.63 (95% CI, -1.08 to -0.17) points on average. Also, patients' body temperatures decreased by 0.28°F each day (95% CI, -0.40 to -0.17).

Conclusions

Thermal imaging could be used to help diagnose cellulitis and track clinical progress.

Assessing the Ability of Non-dermatology Physicians to Recognize Urgent Skin Diseases

Introduction Many patients present to the emergency department with skin conditions that are not true dermatologic emergencies. Urgent skin conditions are uncommon. Because these conditions are rare, they can be sometimes challenging to diagnose. Few works of literature discussed the accuracy of non-dermatologists' initial judgment on dermatologic conditions concluding that non-dermatologists misdiagnose many common and uncommon skin conditions. Because the study was never done in our region, we aim to conduct an online assessment using a questionnaire assessing the ability of non-dermatologists to recognize urgent skin diseases at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. Methods A cross-sectional study was conducted. Non-dermatologist physicians were contacted through their verified emails, provided by the secretaries of each department and the academic affairs unit. The questionnaire consisted of two main sections, the first section covered demographics, specialty, and academic level. The second part had eight questions, each containing a brief case scenario about an urgent dermatological condition with a picture of the condition attached. Participants were required to answer the questions and assess on a scale from one to 10 how confident they were about their answers. The responses were collected and analyzed. Results Out of all 161 responses, this study included 93 male physicians (57.8%) and 68 female physicians (42.2%). The mean age in the study was approximately 45 ± 3 years. This study showed that the percentage of accuracy by non-dermatologists in diagnosing urgent skin diseases given the typical presentation of the condition was (61.33%); nevertheless, the percentage decreased when it was recalculated in relation to the full level of confidence to (25.3%). Herpes zoster appeared to be the most recognizable urgent skin disease, and Pemphigus vulgaris was the least recognizable one. Conclusion This study shows that it is difficult for physicians to recognize some urgent skin diseases, which affects offering the optimum health care for the patients. Moreover, more dermatology-focused courses are needed to strengthen the knowledge about dermatological diseases.

Cause-Specific Mortality in Patients With Gout in the US Veterans Health Administration: A Matched Cohort Study

OBJECTIVE

To compare all-cause and cause-specific mortality risk between patients with gout and patients without gout in the Veteran's Health Administration (VHA).

METHODS

We performed a matched cohort study, identifying patients with gout in the VHA from January 1999 to September 2015 based on the presence of ≥2 International Classification of Diseases, Ninth Revision codes for gout (274.X). Gout patients were matched up to 1:10 on birth year, sex, and year of VHA enrollment with patients without gout and followed until death or end of study (December 2017). Cause of death was obtained from the National Death Index. Associations of gout with all-cause and cause-specific mortality were examined using multivariable Cox regression.

RESULTS

Gout (n = 559,243) and matched non-gout controls (n = 5,428,760) had a mean age of 67 years and were 99% male. There were 246,291 deaths over 4,250,371 patient-years in gout patients and 2,000,000 deaths over 40,441,353 patient-years of follow-up in controls. After matching, gout patients had an increased risk of death (hazard ratio [HR] 1.09 [95% confidence interval (95% CI) 1.08-1.09]), which was no longer present after adjusting for comorbidities (HR 0.98 [95% CI 0.97-0.98]). The strongest association of gout with cause-specific mortality was observed with genitourinary conditions (HR 1.50 [95% CI 1.47-1.54]). Gout patients were at lower risk of death related to neurologic (e.g., Alzheimer's disease and Parkinson's disease) (HR 0.63 [95% CI 0.62-0.65]) and mental health (HR 0.66 [95% CI 0.65-0.68]) conditions.

CONCLUSION

A higher risk of death among gout patients in the VHA was related to comorbidity burden. While deaths attributable to neurologic and mental health conditions were less frequent among gout patients, genitourinary conditions were the most overrepresented causes of death.

Bilateral Lower Limbs Cellulitis: A Narrative Review of an Overlooked Clinical Dilemma

Bilateral lower limbs cellulitis is a rare clinical condition, which has been overlooked for a long time. In daily clinical practice, bilateral cellulitis is a sporadically encountered condition; however, it remains a clinical challenge. There is a broad differential diagnosis for this clinical entity, and there is a lack of accepted international diagnostic criteria. Unnecessary antibiotic prescription is common, which has led to an emerging problem. In this review, we summarize case reports of bilateral lower limbs cellulitis and common pathogens that have been documented.

Comparison of Rates of Lower Extremity Amputation in Patients With and Without Gout in the US Department of Veterans Affairs Health System

Importance

Cardiometabolic and other risk factors could render patients with gout more likely to undergo lower extremity amputation (LEA).

Objective

To examine the rate of and factors associated with LEA in patients with gout.

Design, Setting, and Participants

In this matched cohort study using national administrative data, multivariable Cox proportional hazards regression models were used to examine the associations of gout with LEA. In analyses limited to patients with gout, attributes of serum urate control and treatment with urate-lowering therapy were examined as factors associated with LEA. This study included patients who used US Department of Veterans Affairs services from January 1, 2000, to July 31, 2015. Patients with gout were identified using diagnostic codes and matched with up to 10 controls by age, sex, and year of benefit enrollment. Data analysis was performed from January 26, 2021, to September 3, 2021.

Exposures

Gout classification served as the primary independent variable of interest. In analyses limited to patients with gout, factors associated with serum urate control and urate-lowering therapy were examined.

Main Outcomes and Measures

Overall LEA, as well as toe, transmetatarsal, below-the-knee, and above-the-knee amputation.

Results

This cohort study included 5 924 918 patients, 556 521 with gout (mean [SD] age, 67 [12] years; 550 963 (99.0%) male; 88 853 [16.0%] Black non-Hispanic; 16 981 [4.3%] Hispanic/Latinx; 345 818 [62.1%] White non-Hispanic; 80 929 [14.5%] with race and ethnicity data missing; and 23 940 [4.3%] classified as other) and 5 368 397 without gout (mean [SD] age, 67 [12] years; 5 314 344 [99.0%] male; 558 464 [10.4%] Black non-Hispanic; 204 291 [3.0%] Hispanic/Latinx; 3 188 504 [59.4%] White non-Hispanic; 1 257 739 [23.4%)] with race and ethnicity data missing; and 159 399 [3.0%] classified as other). Compared with patients without gout, patients with gout were more likely to undergo amputation, an increased rate that remained after adjustment (adjusted hazard ratio, 1.20; 95% CI, 1.16-1.24) and was highest for below-the-knee amputation (adjusted hazard ratio, 1.59; 95% CI, 1.39-1.81). In those with gout, poor serum urate control (mean >7 mg/dL during the preceding year) was associated with a 25% to 37% increase in the rate of amputation. In contrast, treatment with urate-lowering therapy was not associated with the LEA rate.

Conclusions and Relevance

In this matched cohort study, patients with gout were more likely to undergo LEA. This increase was independent of other comorbidities that have been associated with amputation, including diabetes and peripheral vascular disease. Serum urate control was independently associated with the LEA rate, suggesting the possibility that lower extremity amputation may be preventable in some patients.

Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Cellulitis and abscess are a common reason for presentation to the emergency department, although there are several nuances to the care of these patients.

OBJECTIVE

The purpose of this narrative review article was to provide a summary of the background, pathophysiology, diagnosis, and management of cellulitis and abscesses with a focus on emergency clinicians.

DISCUSSION

The most common bacteria causing cellulitis are Staphylococcus aureus, Streptococcus pyogenes, and other β-hemolytic streptococci, and methicillin-resistant S. aureus is most common in abscesses. The history and physical examination are helpful in differentiating cellulitis and abscess in many cases, and point-of-care ultrasound can be a useful tool in unclear cases. Treatment for cellulitis typically involves a penicillin or cephalosporin, and treatment of abscesses is incision and drainage. Loop drainage is preferred over the traditional incision and drainage technique, and adjunctive antibiotics can be considered. Most patients can be managed as outpatient.

CONCLUSIONS

It is essential for emergency physicians to be aware of the current evidence regarding the diagnosis and management of patients with cellulitis and abscess.

Clinical and immunologic differences in cellulitis vs. pseudocellulitis

Introduction: The immunologic mechanisms between cellulitis and pseudocellulitis differ greatly, even though their clinical presentations may overlap.Areas covered: This article discusses cellulitis and common entities within the pseudocellulitis spectrum including acute lymphedema, superficial venous thrombosis, allergic contact dermatitis, lipodermatosclerosis, stasis dermatitis, erythema nodosum, cutaneous gout, and bursitis. The literature search was conducted from PubMed search engine between March and May 2021.Expert commentary: While immunologic differences in cellulitis and the various entities of pseudocellulitis are clear, there is a practice gap in applying these differences to the clinic and hospital setting. Further, existing studies are weakened by the lack of a gold-standard diagnosis in this disease category. Additional work is necessary in developing a gold-standard for the diagnosis and secondly, to project these immunologic differences as biomarkers to differentiate sterile inflammation from a potential life threatening bacterial or fungal infection.

Unsuspected Stewart-Treves syndrome clinically mimicked by apparent bullous erysipelas and a systematic review of dermatological presentations of the classical Stewart-Treves syndrome

BACKGROUND

Stewart Treves-Syndrome (STS) was first characterized as angiosarcoma in the homolateral limb of a patient with breast cancer and lymphedema. Now, other conditions represent STS. It's a rare condition. The diagnosis is easier in the presence of single or multiple purple nodules. Even though other dermatological aspects have been reported, no study has grouped its characteristics.

AIM

Evaluate the dermatological characteristics of classical STS (c-STS).

METHODS AND RESULTS

We report a patient with chronic lymphedema with a history of recurrent erysipelas that rapidly developed multiple papules in the superior limb. It was initially diagnosed as bullous erysipelas, but unsatisfactory evolution led to biopsy, which demonstrated an unsuspected epithelioid angiosarcoma. We have also performed a review of dermatologic aspects of c-STS using PubMed and Lilacs databases. PICTOS methodology and PRISMA flow chart were considered. The main dermatological aspects associated with c-CTS were summarized. Using a systematic evaluation from 109 articles, 29 were selected and 44 patients were described to whom we added one case. The mean time with lymphedema was 10 years. Of the patients analyzed, 97.2% were female; 95.6% were submitted to radical mastectomy; 81.2% presented with multiple lesions, 67.4% of the lesions were reported as nodules or tumors, 53.4% were purple, 33.4% were associated with an ecchymotic halo, and 33.4% were ulcerated lesions.

CONCLUSION

When evaluating patients with chronic lymphedema with new dermatological abnormalities, clinical suspicion, or unfavorable evolution, the knowledge of clinical signs is important for diagnosis, and a biopsy must be considered. Papules associated with erythematous-wine color and bluish hematoma aspect must raise clinical suspicion.

Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department

Septic arthritis is a dangerous medical condition associated with significant morbidity and mortality. However, the differential diagnosis can be broad with conditions that mimic this disease and require different evaluation and treatment. This narrative review presents the emergency medicine evaluation and management, as well as important medical conditions that may mimic this disease. Septic arthritis commonly presents with monoarticular joint pain with erythema, warmth, swelling, and pain on palpation and movement. Fever is present in many patients, though most are low grade. Blood testing and imaging may assist with the diagnosis, but the gold standard is joint aspiration. Management includes intravenous antibiotics and orthopedic surgery consult for operative management vs. serial aspirations. Clinicians should consider mimics, such as abscess, avascular necrosis, cellulitis, crystal-induced arthropathies, Lyme disease, malignancy, osteomyelitis, reactive arthritis, rheumatoid arthritis, and transient synovitis. While monoarticular arthritis can be due to septic arthritis, other medical and surgical conditions present similarly and require different management. It is essential for the emergency clinician to be aware how to diagnose and treat these mimics.