Clinical Case Conference

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Clinical Case Conference

• Vera P. Luther, MD
• January 30, 2006

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DisclosuresSection of Infectious Diseases

• Kevin High, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Astellas Pharma US, Inc.
• Consultant Merck Co., Inc.
• Speakers Bureau Pfizer Pharmaceuticals
• James Peacock, M.D.
• Ownership in Common Stock Pfizer
  Pharmaceuticals
• Sam Pegram, M.D.
• Grant/Research Support Roche, Bristol-Myers
  Squibb, Gilead, Schering-Plough, Tibotec
  Pharmaceuticals
• Consultant Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Gilead,
  Roche
• Speakers Bureau Abbott Laboratories,
  GlaxoSmithKline, Boehringer Ingelheim, Merck,
  Pfizer Pharmaceuticals

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Disclosure (continued)Section of Infectious
Diseases

• Aimee Wilkin, M.D.
• Grant/Research Support Abbott Laboratories,
  GlaxoSmithKline, Tibotec Pharmaceuticals,
  Bristol-Myers Squibb Company, Gilead
• Christopher Ohl, M.D.
• Grant/Research Support Cubist Pharmaceuticals,
  Gene-Ohm Sciences, Merck Pharmaceuticals
• Speakers Bureau/Consultant Ortho-McNeil
  Pharmaceuticals, Cubist Pharmaceuticals,
  Sanofi-Aventis Pharmaceuticals, Pfizer
  Pharmaceuticals, Bayer Pharmaceuticals

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Disclosure (continued)Section of Infectious
Diseases

• Tobi Karchmer, M.D.
• Grant/Research Support Gene-Ohm Sciences
• Speakers Bureau Pfizer Pharmaceuticals, Cubist
  Pharmaceuticals, Cepheid,
• Gene-Ohm Sciences
• Consultant C.R. Bard
• Robin Trotman, D.O.
• Speakers Bureau Pfizer Pharmaceuticals

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Case 1

• 44 y/o female with 3 wk h/o facial swelling
• Swelling started around left eye ? gradually
  spread to involve entire face.
• Pt c/o pruritus and burning pain in and around
  left eye. Also c/o blurred vision and left eye
  drainage ? ophtho eval.
• Otherwise feels well. No fevers or chills.
• Pt treated with ciprofloxacin x 1 wk without
  improvement.

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Case 1

• PMH Asthma
• Allergic Rhinitis
• Atopic Dermatitis
• Chronic Keratoconjunctivitis
• FH Asthma Eczema
• All Aspirin
• Penicillin
• Sulfa
• Meds Clinda 900mg IV q 8 x 2 d
• NaCl eye prep
• Advair
• Albuterol prn

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Case 1

• Exam Tm98.5 vss
• HEENT
• Bilateral facial edema LgtR with prominent left
  periorbital inflammation with weeping
• Bilateral injection of sclera and conjunctivae
  with exudate
• Labs
• wbc 5.8 S 59/L 20/M 10/ E 11 (AEC 600)
• Micro swab of conjunctival discharge gram stain
  and bacterial culture negative

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Case 1

• Further history obtained
• Pt started using new cosmetic products
  (foundation, concealer, eye shadow) 3 weeks ago
  and prior to the onset of her symptoms

Does this change your diagnosis? Management?
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• Falagas et al. Narrative review diseases that
  masquerade as infectious cellulitis. Ann Intern
  Med. 2005 Jan 4142(1)47-55.
• Lack of data on frequency of infectious
  cellulitis versus noninfectious causes
• Searched PubMed and found 126 English-language
  articles that were published between 1950-2004
• Review of diseases that mimic infectious
  cellulitis
• Most cellulitis is infectious, but if no initial
  response to therapy consider
• Inappropriate antibiotic choice
• Antibiotic resistance
• Poor patient adherence
• Underlying deep-seated infection
• Depressed immune status
• Masqueraders

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Vascular Disorders

• Deep vein thrombosis
• Venous stasis
• Thrombophlebitis

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Drug Reactions

• Commonly implicated meds
• Antibiotics trimethoprim-sulfamethoxazole
• Anti-inflammatory drugs

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• Contact dermatitis
• Irritant or Allergic
• Detergents, Solvents, Disinfectants, Metals,
  Dyes, Poison ivy, Poison Oak
• Patch testing can be done when active lesions
  have subsided
• Re corticosteroids
• (topical or systemic)

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Insect stings or bites

• Range from mild local reactions to anaphylaxis
• Extensive local reactions usually peak within 48
  hrs, but can last up to 7 d
• Treatment
• Antihistamines
• /- Acetylsalicylic acid
• /- Systemic steroids
• Often treated with antibiotics instead
• Other
• caterpillar dermatitis
• beetle vesications
• stonefish envenomations
• reactions to corral
• sea urchins

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Eosinophilic dermatitis (Wells syndrome)

• Acute onset
• Pruritic
• Present with one or a few erythematous plaques ?
  evolve over 2-3 d ? resolve completely 2-8 wks
• Recurs

• Peripheral eosinophilia
• Dermal eosinophilic infiltration
• Associated with myeloproliferative disorders,
  immunologic, drugs, and infectious disorders
  (HSV)
• Rx oral corticosteroids

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Sweet syndrome (acute febrile neutrophilic
dermatosis)

• Papules ? tender inflammatory plaques
• Upper extremities, face, neck most commonly
  involved
• Moderate neutrophilia
• Dermal infiltration by PMNs
• Rx corticosteroids

• Associated disorders
• Malignancy in 10
• (AML most common)
• RA
• IBD
• Oshitari et al. Sweet syndrome presenting as
  orbital cellulitisNippon Ganka Gakkai Zasshi.
  2004 Mar108(3)162-5.

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Erythromelalgia

• Episodic burning pain
• Increased skin temperature
• Bilateral redness
• Affects feet most commonly
• Associated with myeloproliferative disorders
• Rx ?aspirin

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• Hepburn et al. Alternative diagnoses that often
  mimic cellulitis. Am Fam Physician. 2003 Jun
  1567(12)2471
• 169 patients with dx of cellulitis
• 23 patients (13.6 ) had alternative dx
• 7 had abscess requiring incision and drainage
• 6 had abscess not requiring incision and drainage
• 2 had herpes zoster
• 2 had septic bursitis
• 1 had herpetic whitlow
• 1 had gangrenous foot
• 1 had septic arthritis
• 1 had tinea pedis
• 1 had gout
• 1 had a foot fracture

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• Sorin et al. Recurrent periorbital cellulitis
  an unusual clinical entity. Otolaryngol Head Neck
  Surg. 2006 Jan134(1)153-6
• Retrospective chart review (1991-2002)
• 6 pts treated for recurrent periorbital
  cellulitis
• (Hx of 3 or more episodes of periorbital
  cellulitis within a 1-year period and
  convalescent periods of at least 1 month)
• 2 pts environmental allergies
• 1 pt underlying recurrent sinusitis (resistant to
  medical management ? resolution with surgery)
• 1 pt with vesicular cellulitis dxd with HSV 1
• 1 pt allergic contact dermatitis from cosmetic
  use
• 1 pt suspected of malingering via repeat SQ
  injections of an irritant

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• Guin. Eyelid dermatitis a report of 215
  patients. Contact Dermatitis. 2004
  Feb50(2)87-90.
• Review of 215 pts seen b/t 2001-2003 for new dx
  of eyelid dermatitis
• 165 had allergic contact dermatitis (ACD)
• personal care products identified as source in 54
  (25)
• 9 had protein contact dermatitis without relevant
  positive patch tests
• 37 had atopic eczema (33 of these pts also had
  contact allergies)
• 35 had seborrheic dermatitis, psoriasis or both
• 5 had rosacea or periorbital dermatitis
• 2 had dermatomyositis
• Other bacterial, fungal viral

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• Cold Urticaria
• (Mimics Cellulitis)
• Burroughs et al. Cold urticaria an
  under-recognized cause of postsurgical
  periorbital swelling. Ophthal Plast Reconstr
  Surg. 2005 Sep21(5)327-30.
• Retrospective case series of 3 pts with primary
  acquired cold urticaria
• Postoperative swelling attributed to primary
  acquired cold urticaria after the routine use of
  cool compresses to their surgical sites

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Contact dermatitis due to antibiotic
ointments(Mimics Cellulitis)

• Zappi et al. Allergic contact dermatitis from
  mupirocin ointment. J Am Acad Dermatol. 1997
  Feb36266.
• Merlob et al. Neonatal orbital irritant contact
  dermatitis caused by gentamicin ointment. Cutis.
  1996 Jun57(6)429-30.
• Wilson et al. High incidence of contact
  dermatitis in leg-ulcer patients--implications
  for management. Clin Exp Dermatol. 1991
  Jul16(4)250-3.
• Leyden et al. Contact dermatitis to neomycin
  sulfate.JAMA. 1979 Sep 21242(12)1276-8.

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Case 1

• Clindamycin was continued
• Oral corticosteroid therapy with prednisone 60mg
  po q day was begun
• Pt had significant improvement in symptoms one
  day after initiation of steroid therapy

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Case 2

• HPI 41 y/o male c/o left neck and shoulder pain
  x 3 wks associated with rapidly growing mass on
  superior aspect of shoulder.
• Pt then noticed pain and swelling on right neck
  1 wk ago.
• Developed fever to 103 two days ago.
• ROS unintentional 15-20lb wt loss over past
  few wks

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Case 2

• PMH
• Ulcerative Colitis
• s/p colectomy
• Meds none
• SH
• Lives in Mocksville.
• No travel. No substance abuse. Works as cook.
  Has 8 mo old kitten at home.

• Exam T101.8 vss
• Gen appears uncomfortable
• Skin Large bilateral erythematous, fluctuant
  masses at base of neck.
• Labs
• wbc 19.5 (S 85/L9/B2/M4)

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• Impression?
• Management?

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Evaluation

• Lymph node distribution
• Region
• Regional vs Generalized
• Onset
• Acute vs Chronic
• Presence of suppuration

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Infectious causes of suppurative lymphadenitis

• Staphylococcus aureus
• Streptococcus spp.
• Anaerobic bacteria
• Bartonella henselae
• Pasturella multocida
• Gram-negative bacilli
• Pasternack et al. Lymphadenitis and
  Lymphangitis. In Mandell GL , et al. (eds).
  Principles and Practice of Infectious Diseases
  (Sixth Edition). Philadelphia, Pennsylvania
  Elsevier, 2005 1204-1214.

• Scrofula
• M. tuberculosis
• M. scrofulaceum
• M. avium-intracellulare
• Yersinia pestis
• Francisella tularensis
• Burkholderia pseudomallei
• Burkholderia mallei

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Noninfectious causes of cervical lymphadenitis

• Lymphoma
• Kikuchis disease
• Castlemans disease
• Systemic lupus erythematosus
• Drugs
• Phenytoin
• Carbamazepine
• Pasternack et al. Lymphadenitis and
  Lymphangitis. In Mandell GL , et al. (eds).
  Principles and Practice of Infectious Diseases
  (Sixth Edition). Philadelphia, Pennsylvania
  Elsevier, 2005 1204-1214.

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• Sundaresh et al. Etiology of cervical
  lymphadenitis in children. Am Fam Physician. 1981
  Jul24(1)147-51.
• Review of 30 children with cervical
  lymphadenopathy
• 10 pts Group A beta-hemolytic streptococci
• 4 pts Staphylococcus aureus
• 4 pts infectious mononucleosis
• 2 pts had infectious mononucleosis and Group A
  beta-hemolytic streptococci
• 1 pt Acinetobacter
• 1 pt with Mycobacterium
• 8 pts no etiologic agent found

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• Simo et al. Microbiology and antibiotic
  treatment of head and neck abscesses in children.
  Clin Otolaryngol Allied Sci. 1998
  Apr23(2)164-8.
• Retrospective review of 65 children who had
  undergone I D of suppurative lymphadenitis
• 78 had positive culture
• Of the positive cultures
• 45 were Staphylococcus aureus
• 9 were Streptococcus pyogenes
• 8 were atypical mycobacterium
• 3 grew anaerobes

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• Brook et al. Microbiology of cervical
  lymphadenitis in adults. Acta Otolaryngol. 1998
  Jun118(3)443-6.
• Needle aspirates from 40 adult patients with
  inflamed cervical lymph glands were studied for
  aerobic and anaerobic bacteria, fungi and
  mycobacteria.
• 11 (27.5) revealed aerobic bacteria alone
• 5 (12.5) revealed anaerobes alone
• 7 (17.5) revealed mixed aerobic and anaerobic
  bacteria
• 11 (27.5) revealed Mycobacterium spp.
• 6 (15) revealed fungi

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• Brook et al. Microbiology of cervical
  lymphadenitis in adults.Acta Otolaryngol. 1998
  Jun118(3)443-6.
• 12 Aerobic bacteria were recovered
• 8 were Staphylococcus aureus
• 4 were group A streptococci
• 24 anaerobic bacteria were recovered
• 6 were Prevotella
• 5 were Peptostreptococcus spp.
• 4 were Propionibacterium acnes
• 3 were Fusobacterium spp.
• 6 were others

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• Johnigan et al. Community-acquired
  methicillin-resistant Staphylococcus aureus in
  children and adolescents changing trends. Arch
  Otolaryngol Head Neck Surg. 2003
  Oct129(10)1049-52
• Retrospective review of seven pts who were seen
  with CA MRSA in a 4-month period
• 3 pts had suppurative lymphadenitis
• 3 pts had superficial abscesses
• 1 pt had mastoiditis
• All infections resolved with antibiotics

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• FNA Results 4 Staphylococcus aureus
• SENSITIVITY MIC
• CLINDAMYCIN lt0.25 SUSCEPTIBLE
• ERYTHROMYCIN gt4 RESISTANT
• GENTAMICIN lt1 SUSCEPTIBLE
• OXACILLIN gt2 RESISTANT
• TMP/SMX lt2/38 SUSCEPTIBLE
• VANCOMYCIN lt2 SUSCEPTIBLE
• RIFAMPIN lt1 SUSCEPTIBLE
• TETRACYCLINE lt4 SUSCEPTIBLE

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• Pt underwent two I Ds of left cervical lesion,
  left supraclavicular lesion and right
  supraclavicular lesion with drain placement
• Also treated with 2 weeks of vancomycin ? TMP/SMX

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