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Petit Homme, Roodelyne

Right leg cellulitis

This week presents with its own challenge, the clinic is in the process of using another electronic documentation system calls Athena and it has proven to be a bit of a challenge for me to adapt rapidly and be able to provide the patient care and documentation in professional and timely manner. Otherwise, so far this week is announcing itself quite busy. I had the honor of caring for a female, Hispanic patient, aged 53 whose primary language is Spanish. She came in complaining of right leg pain, redness warm and mild inflammation. My preceptor and myself assessed her and we decided after careful examination that she suffers from cellulitis to her right leg. The client is history include diabetes type two, hypertension, hyper cholesterol, she also has had gout in the past and her diabetes is not well managed for various reason.

Cellulitis is a bacterial skin and soft tissue infection which occurs when the physical skin barrier, the immune system and/or the circulatory system are impaired. Diabetes, obesity, and old age are associated with defects in all these areas and as a result are major predisposing factors for cellulitis. All that is red is not cellulitis. The classical symptoms of erythema, edema, warmth, and tenderness are non-specific and vary in severity. (Albakri, 2019) Despite the fact that it is a very visible infection, the underlying etiology is poorly understood. Many patients experience recurrences after the initial infection. Even though we have effective treatment options, studies on the most optimal or effective treatment are scarce. (Cranendonk, 2019) Given the prevalence and associated expense of cellulitis, accurate diagnosis and appropriate treatment are imperative. Typically, suspected cellulitis is first evaluated by primary care, urgent care, or emergency department (ED) physicians and diagnosis is based on clinical features and risk factors. The characteristic finding of cellulitis is expanding, ill-defined redness, warmth, tenderness, and edema. 

Cellulitis is characterized by erythema, warmth, edema, and pain due to the underlying pathophysiology. A nidus of inflammation, such as bacteria penetrating through the skin, triggers immune system response. Histamine, prostaglandins, and bradykinins are released into the soft tissue, causing vasodilation with subsequent erythema and warmth. Histamine also acts on endothelial cells, resulting in leakage of plasma into the interstitial and tissue space, leading to edema. Increased pain at the site of cellulitis is due to sensitization of sensory nerve endings by bradykinin and prostaglandin E2. (Blumberg et al., 2017)

Cellulitis is a form of non purulent skin infection and does not include abscesses, carbuncles, and furuncles. Although it is not considered a purulent skin infection, it is an infection nonetheless and my preceptor chose to approach the treatment plan by ordering the patient Clindamycin for five days and anti-inflammatory agent to help reduce swelling in the leg.  While oral corticosteroids demonstrated disappointing effectiveness, they may still show utility as an adjuvant therapy at low doses or as a bridge to more definitive treatments for more severe or fulminant disease at higher doses. A follow up visit was scheduled for the patient in a week after completion of antibiotic therapy.

References

Albakri, A. (2019). Endocrine cardiomyopathy: A review and pooled analysis of pathophysiology, diagnosis and clinical management. Research and Review Insights, 3(1). https://doi.org/10.15761/rri.1000153

Blumberg, G., Long, B., & Koyfman, A. (2017). Clinical Mimics: An Emergency Medicine-Focused Review of Cellulitis Mimics. The Journal of Emergency Medicine, 53(4), 475–484. https://doi.org/10.1016/j.jemermed.2017.06.002

Cranendonk, D. (2019). On the Pathophysiology and Management of Cellulitis. Amsterdam University Press.

Thomas, J., & Aguh, C. (2019). Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review. Journal of Dermatological Treatment, 32(2), 144–149. https://doi.org/10.1080/09546634.2019.1642441