Case Introduction
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.
Initial Questions
- What would be your plan? And when and how would you present this case to an attending?
- Are labs indicated, which ones, and what are they expected to show? Will that change your plan?
- Any imaging? Your choices range from nothing, to bedside US to look for an abscess, to XR, CT scan or even an MRI, if available.
- Is she a candidate for oral antibiotics and discharge? If so, what sort of follow up does she need?
- Is there any benefit of IV antibiotics if the patient is going to go home?
- What is the worst case scenario here that may not be apparent? Is there any threat to life, limb or both?
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.
Additional Questions
- What if there is no podiatry, and your general or orthopedic surgeon does not handle foot cases? What if there is no surgical coverage at all?
- Would there be a role for a limited ED I&D or needle aspiration in this case?
- Would you transfer this case? How do you justify it, if all the labs and vitals are normal?
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).
Key Points
While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:
- Do not get locked in onto cellulitis as the diagnosis. Abscesses, necrotizing infections and septic joints need to be considered and ruled out at all times.
- Susceptible populations such as diabetics and IV drug users are easy. But the rapidity of symptom development is just as important in any population.
- Beware even chronic appearing calluses as masking places for pus and as barriers to its natural drainage.
- More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
- More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
- To I&D or not to I&D is often the question. Good news is that more often than not I&D is the right answer. There is a reason you have already thought of it. You are in the ED - the last line of defense for many patients. Pus needs to come out. The surgeons are not the only guys with knives. Don’t let yourself or anyone talk you out of it. For the tremulous patients (and providers), there is ketamine.
Further Reading
- 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/
