Cellulitis differential diagnosis
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Differentiating Cellulitis from other Diseases
Cellulitis must be differentiated from other causes of lower limb edema like chronic venous insufficiency, acute deep venous thrombosis, lipedema, myxedema, lymphatic filariasis and causes of generalized edema.
|Diseases||Symptoms||Signs||Gold standard Investigation to diagnose|
|History||Onset||Pain||Fever||Laterality||Scrotal swelling||Symptoms of primary disease|
Preparing blood smears
By the ultrasound, the following findings can be observed:
|Chronic venous insufficiency||Chronic||+||-||Bilateral||+
|Acute deep venous thrombosis||Acute||+||-||Unilateral||-||May be associated with primary disease mandates recumbency for long duration|
|Other causes of generalized edema||
Cellulitis can be promptly diagnosed with an appropriate history and physical exam. Administration of an antibiotic therapy will initiate resolution of the condition in 2-3 days. Differentials have to be thought of only when resolution is not seen. Non- resolution of cellulitis can be due to infection by resistant strains of the bacterium involved.
There are many dermatological conditions which manifest in manner similar to cellulitis. Careful evaluation of each case, based on accurate history and physical examinations, is very important. Differentials are as follows:
- Erysipelas is a skin infection similar to cellulitis, but it affects superficial layers of the skin. It has more demarcated edges than cellulitis.
- Erysipeloid is a skin infection which is mostly occupational in nature. It is most commonly seen in people involved in the poultry and meat industry. It is characterized by local lesions, diffuse lesions and systemic forms.
- Deep vein thrombosis is a condition in which a blood clot is formed in the deep veins. It can be differentiated from cellulitis by the presence of tenderness along the clotted vein. Duplex ultrasonography would reveal the clot in the vein.
- Necrotizing fasciitis looks like cellulitis at the onset of the disease but it is much more serious. Large amounts of pain, necrosis, and bullae are noticeable. It often requires surgical exploration.
There are a few conditions which can be misdiagnosed as cellulitis such as thrombophlebitis, contact dermatitis, insect stings, drug reactions, arthritis.
- Contact dermatitis is an inflammation of the skin in response to direct exposure to an allergic or irritating substance. This inflammation is usually present with papular erythematous indistinct margins. The extent of distribution is often limited to the area of exposure.
- Insect bites cause a local reaction leading to the development of erythema, tenderness, pruritus and edema. In severe reactions, it can involve adjacent joints. In very severe cases, insect bites can lead to anaphylaxis.
- Drug rashes are the cutaneous presentation of a drug reaction. The rashes are variable, ranging from a pinkish hue to an exanthem. The rash can be limited or widespread. Itching is the most common symptom. If fever, dehydration and involvement of membranous surfaces is present along with the rash, then other diagnoses have to be considered. Drug rashes present most commonly when taking drugs such as sulfa, anticonvulsant drugs, and insulin from animal sources.
- Arthritis presents as pain in the joints, but at times it can be severe enough to present as erythema. At times, septic arthritis can infect overlying skin and can cause cellulitis.
- Some autoimmune conditions may mimic symptoms of or actually cause cellulitis. Panniculitis, Familial Mediterranean Fever, and Hyper IgD syndrome can present erythema and other systemic symptoms.
- In leukemic patients, some times cancerous cells infiltrate the skin causing erythema, papules, and nodules. The cause of these symptoms has to be differentiated by immunostaining.
|Soft tissue infection
|History of skin warmness, swelling and erythema. Bone probing is the definite way to differentiate them.|
(Avascular necrosis of bone)
|Previous history of trauma, radiation, use of steroids or biphosphonates are suggestive to differentiate osteonecrosis from ostemyelitis.|
MRI is diagnostic.
|Charcot joint||Patients with Charcot joint commonly develop skin ulcerations that can in turn lead to secondary osteomyelitis.|
Contrast-enhanced MRI may be diagnostically useful if it shows a sinus tract, replacement of soft tissue fat, a fluid collection, or extensive marrow abnormalities. Bone biopsy is the definitive diagnostic modality.
|Bone tumors||May present with local pain and radiographic changes consistent with osteomyelitis. |
Tumors most likely to mimic osteomyelitis are osteoid osteomas and chondroblastomas that produce small, round, radiolucent lesions on radiographs.
|Gout||Gout presents with joint pain and swelling. Joint aspiration and crystals in synovial fluid is diagnostic for gout.|
(Synovitis, acne, pustulosis, hyperostosis, and osteitis)
|SAPHO syndrome consists of a wide spectrum of neutrophilic dermatosis associated with aseptic osteoarticular lesions. |
It can mimic osteomyelitis in patients who lack the characteristic findings of pustulosis and synovitis.
The diagnosis is established via clinical manifestations; bone culture is sterile in the setting of osteitis.
|Sarcoidosis||It involves most frequently the pulmonary parenchyma and mediastinal lymph nodes, but any organ system can be affected. |
Bone involvement is often bilateral and bones commonly affected include the middle and distal phalanges (producing “sausage finger”), wrist, skull, vertebral column, and long bones.
|Langerhans' cell histiocytosis||The disease usually manifests in the skeleton and solitary bone lesions are encountered twice as often as multiple bone lesions.|
The tumours can develop in any bone, but most commonly originate in the skull and jaw, followed by vertebral bodies, ribs, pelvis, and long bones.
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