Fast Five Quiz: Cellulitis Key Aspects

Michael Stuart Bronze, MD


January 23, 2020

A directed history is vital to the proper care of a patient with cellulitis. The patient may or may not relate an episode of trauma that preceded symptoms; when cellulitis develops, it is usually several days after the inciting trauma. Rapid progression or significant pain is a concerning sign that may indicate a severe problem, such as necrotizing fasciitis, which should be promptly managed.

The surgical history may include a recent procedure that resulted in wound infection. For example, severe bacterial cellulitis may occur as a postsurgical complication after hip replacement or liposuction. Alternatively, a remote surgical history involving lymph node dissection (eg, after either radical mastectomy or conservative breast surgery) may predispose to cellulitis, even years after the surgery, because of lymphatic occlusion. Impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis, after saphenous vein resection for coronary artery bypass.

The physical examination should first focus on the area of concern. Nonpurulent cellulitis is associated with four cardinal signs of infection: erythema, pain, swelling, and warmth. Several physical examination findings may help the clinician identify the most likely pathogen and assess the severity of the infection, thereby facilitating appropriate treatment. Those findings include the following:

  • The involved site is red, hot, swollen, and tender.

  • Unlike erysipelas, the borders are not elevated or sharply demarcated.

  • The involved site is the leg, which is the most common site.

  • Regional lymphadenopathy is present.

  • Malaise, chills, fever, and toxicity are present.

Lymphangitic spread (red lines streaking away from the area of infection), crepitus, and hemodynamic instability are indications of severe infection, requiring more aggressive treatment. Circumferential cellulitis or pain that is disproportional to examination findings should prompt consideration of severe soft-tissue infection, such as necrotizing fasciitis.

Read more about the presentation of cellulitis.


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