A 47 year old woman comes to a community ED complaining of pain and redness in her right foot developing quickly over two days. She denies any trauma and otherwise feels well. She is not sure, but may have had a “sore” near her toes that has already healed. Patient has diabetes but is normoglycemic. She has no prior history of cellulitis, joint infections or gout. There is no history of immunocompromise, including steroids, or any IV drug use. All vitals are within normal limits and review of systems is negative for fever, chills, respiratory or gastrointestinal symptoms.
On exam, there is generalized edema, erythema and tenderness, but no tenderness out of proportion, and no open sores or ulcerations. A sub-acute appearing callus is apparent on the plantar surface opposite fifth and fourth distal metatarsals. The ankle joint is tender but less so than the foot, and ranging it does not elicit more pain than at baseline. Distal sensation, pulses and toe motion are intact, though capillary refill is slightly delayed.
Basic labs obtained are unremarkable and patient is receiving IV broad spectrum antibiotics, including MRSA coverage. Plain films are obtained, and there is some concern for small air pockets in the soft tissues.
A phone consultation with podiatry is obtained. A decision is made to take the patient to the OR on the same evening. No further imaging or diagnostic studies are advised.
After the callus is taken off in the OR, large amount of frank pus is obtained that tracks all the way to the third metatarsal. A debridement is performed, and long term antibiotics with close follow up are needed. Overall impression was that while no necrotizing infection was found, any further delay would have risked a trans-metatarsal amputation (at the least).
While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:
- EM Cases – Skin and Soft Tissue Infections – Cellulitis, Skin Abscesses and Necrotizing Fasciitis – https://emergencymedicinecases.com/skin-soft-tissue-infections/
- EM Docs – Cellulitis Antibiotic Selection: Management Updates – http://www.emdocs.net/cellulitis-antibiotic-selection-management-updates/
- LITFL – Cellulitis – https://litfl.com/cellulitis/
- RCEM learning – Cellulitis – https://www.rcemlearning.co.uk/reference/cellulitis/
- #EM3 – Lightning Learning: Orbital Cellulitis – https://em3.org.uk/foamed/7/5/2019/lightning-learning-orbital-cellulitis
- first10EM – Magical thinking in modern medicine: IV antibiotics for cellulitis – https://first10em.com/cellulitis-antibiotics/