Running head: CELLULITIS R/O ERYSIPELAS

CELLULITIS R/O ERYSIPELAS CHERRY B. MAGLAYA-LEE CHARLES DREW UNIVERSITY N530

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Chief Complaint: Left forearm swelling and pain following self-administration of illicit drug. History of Present Illness (HPI): This is a 49 yr-old male, homeless, with twenty years of polysubstance history, who presents to the clinic for the first time due to left arm tenderness and pain of 2 days duration. Area is tender, warm and reddened, measuring 4 cm by 5 cm on the ventral aspect of the forearm. His condition started 2 days prior to this present consult when he self-administered a liquefied form of methamphetamine (illicit drug) into the vein of his left forearm on the ventral aspect. Apparently, he missed the vein but didnt know he did at the time of administration. Patient stated that this is the first time he took the drug in this form since he didnt get enough high any longer inhaling the vapors of said drug. A day prior to this consult, he started feeling sore in his left arm for which he took Tylenol and some other prescription pain killers. He also applied hot and cold compresses on the area at the recommendation of another friend. Few hours prior to this consult, the affected area became swollen and extended and more painful with intensity of 10/10. He also noticed the nail bed of his left thumb to have turned bluish color. He presented to this clinic miserable, crying and demanding for a strong IV pain medication. Clinic MD recommended ER consultation and possible admission due to likelihood of infection and necrosis and, for better pain control. An ambulance was called and patient was diverted to a nearby hospital. Past medical History (PMH): Type II DM; Hypertension; Hyperlipidemia; Chronic Anemia; Low Back pain due to Compression Fractures, Skin eruptions and subcutaneous nodules due to needle stick use Family History: Father succumbed to complications of Type II DM; Mother is (+) for Type II DM and DM Retinopathy; Hypertension; Breast Tumor.

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Social History: Polysubstance abuse with Cocaine, methamphetamine (crack/poor mans cocaine), marijuana and Vicodin. Twenty pack years (1 pack of cigarettes/day for the past 20 years); Drinks beer and alcoholic beverage everyday. Patient is divorced, lives with a friend, mostly in the streets, estranged from ex-wife and children. Allergies: No known drug or food allergies. Medications: Patient has very poor compliance to following medications: Gabapentin 300 mg 3x a day; Lisinopril 40 mg once daily; Carvedilol 6.125 mg 2x a day; Glipizide 10 mg 2x a day Review of Systems (ROS): General: (+) fever, chills, easy fatigability; (-) weight loss or weight gain, recent travel or outdoor activity Skin: (+) tattoos all over four extremities and over affected area, pallor, diaphoresis, peripheral cyanosis HEENT: (+) frontal headaches, dizziness, yellowish nasal discharge, post nasal drip, sore throat hoarseness; (-) circumoral cyanosis, earache, sinus pains, eye discharge, blurred vision Chest/Lungs (C/L): (-) pain on deep inhalation, shortness of breath, chest pain, exertional dyspnea, orthopnea, palpitations; hemoptysis, wheezing, edema, claudication Abdomen: (+) pain on swallowing, anorexia; (-) nausea, vomiting, change in bowel habits Genitourinary: (-) dysuria, hematuria Musculoskeletal: (+) body malaise, joint stiffness and pains, weakness; (-) joint swelling Neurologic: (+) anxiety; (-) confusion, paresthesia, slurring of speech, syncope, unsteady gait Physical Examination: General: Poorly-nourished, poorly-developed, unkempt, unshaven, anxious, miserable, alert, oriented, weak, diaphoretic, not in respiratory distress Vital Signs: BP=145/95; HR=100; RR=22; T=101.1, oral; O2 Sat=94% RA; Wt=140 lbs; Ht=510

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HEENT: Normocephalic, anicteric sclera, pupils 3 mm equally and bilaterally reactive to light, no ear discharges, nasal mucosa hyperemia, post nasal drip, (+) cervical lymphadenopathy without tenderness, thyroid midline, non tender Lungs: Diminished breath sounds, bilateral lower lobes, decreased tactile fremiti, tympanitic to percussion Cardiovascular: Tachycardia, regular rhythm, PMI at 5th ICS Midaxillary line, (-) jugular vein distention, no murmurs, no carotid bruit Abdomen: soft, non-distended, no organomegaly, no tenderness on palpation GU: no flank pain, no vaginal or urethral discharges Musculoskeletal: (+) 4 cm by 5 cm red, raised, indurated mass on the ventral aspect of the left forearm thats tender and warm to palpation, (+) darkening of the anterior third of the left thumb nail bed, Muscle strength 3/5 on left upper extremity, (-) calf tenderness Neurologic: oriented to person, place and time; Cranial Nerves intact, DTRs (+) 2, steady gait Skin: pale, ashen lips, diaphoretic, subcutaneous nodules following venous distribution on both upper extremities, needle stick marks present Lymphatic: left axillary lymphadenopathy with tenderness Laboratory: Accucheck: 250 mg/dl Course in the Clinic: Patient was brought in by a friend to the clinic. He was frantic, anxious and hyperventilating. Due to the severity of his condition, he was prioritized over the rest of the patients. He was given Acetaminophen 650 mg tablet PO for pain and fever. After 30 minutes of clinic procedure and documentation, an ambulance was called and patient was sent to a nearby hospital with an impression of Cellulitis of the Left forearm, rule out thrombophlebitis; Left thumb cyanosis. Diagnosis: Left forearm mass rule in cellulitis, rule out erysipelas,

thrombophlebitisCellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or

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by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, or sites of intravenous catheter insertion. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. The mainstay of therapy remains treatment with appropriate antibiotics, and recovery periods last from 48 hours to six months. Cellulitis is caused by a type of bacteria entering the skin, usually by way of a cut, abrasion, or break in the skin. This break does not need to be visible. Group A Streptococcus and Staphylococcus are the most common of these bacteria, which are part of the normal flora of the skin, but normally cause no actual infection while on the skin's outer surface. Predisposing conditions for cellulitis include insect or spider bite, blistering, animal bite, tattoos, pruritic (itchy) skin rash, recent surgery, athlete's foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted IV injection "misses" or blows the vein), pregnancy, diabetes and obesity, which can affect circulation, as well as burns and boils, though there is debate as to whether minor foot lesions contribute (HARRISON, 2008, p. 1475). Cellulitis is most often a clinical diagnosis, and local cultures do not always identify the causative organism. Blood cultures usually are positive only if the patient develops generalized sepsis. This patients long history of IV polysubstance abuse and recent IV illicit drug administration support the diagnosis of Celllulitis, an inflammatory skin reaction that is non demarcated and extends well into the deep subcutaneous and muscular tissues. The break in his skin, his being unkempt/homeless, and poorly compliant diabetic all contributed to the development of his condition. This reddened skin or rash may signal a deeper, more serious infection of the inner layers of skin. Once below the skin, the bacteria can spread rapidly, entering the lymph nodes and the bloodstream and spreading throughout the body. This can result in influenza- like symptoms with a high temperature and sweating or feeling very cold with shaking, as the sufferer cannot get warm. In rare cases, the infection can spread to the deep layer of tissue

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called the fascial lining. Necrotizing fasciitis, also called "flesh-eating bacteria", is an example of a deep-layer infection. It is a medical emergency, hence, patient was sent to the hospital for further evaluation, management and admission. Differential Diagnosis (D/Dx): Several diseases and/or conditions can present with clinical features similar to Cellulitis: 1) Erysipelas (also known as "Ignis sacer", "Holy fire", and "St Anthony's fire") is an acute streptococcus bacterial infection of the dermis, resulting in inflammation.("ERYSIPELAS," n.d). This disease is most common among the elderly, infants, and children. People with immune deficiency, diabetes, alcoholism, skin ulceration, fungal infections and impaired lymphatic drainage (e.g., after mastectomy, pelvic surgery, bypass grafting) are also at increased risk. Patients typically develop symptoms including high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen. The infection may occur on any part of the skin including the face, arms, fingers, legs and toes, but it tends to favor the extremities. Fat tissue is most susceptible to infection, and facial areas typically around the eyes, ears, and cheeks. Repeated infection of the extremities can lead to chronic swelling (lymphadenitis). Most cases of erysipelas are due to Streptococcus pyogenes (also known as beta-hemolytic group A streptococci), although non-group A streptococci can also be the causative agent. Historically, the face was most affected; today the legs are affected most often. The rash is due to an exotoxin, not the Strep. bacteria itself and is found in areas where no bacteria are present - e.g. the infection may be in the nasopharynx, but the rash is found usually on the face and arms.

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Erysipelas infections can enter the skin through minor trauma, eczema, surgical incisions and ulcers, and often originate from strep bacteria in the subject's own nasal passages. Infection sets in after a small scratch or abrasion spreads resulting in toxemia. Unlike cellulitis, Erysipelas does not affect subcutaneous tissue. It does not release pus, only serum or serous fluid. Subcutaneous edema may lead the physician to misdiagnose it as cellulitis, but the style of the rash is much more well-circumscribed and sharply marginated than the rash of cellulitis. This disease is mainly diagnosed by the appearance of well-demarcated rash and inflammation. Blood cultures are unreliable for diagnosis of the disease, but may be used to test for sepsis. Erysipelas must be differentiated from herpes zoster, angioedema, contact dermatitis, and diffuse inflammatory carcinoma of the breast. Erysipelas can be distinguished from cellulitis by its raised advancing edges and sharp borders. Elevation of the antistreptolysin O (ASO) titer occurs after around 10 days of illness. 2) Deep vein thrombosis: is a blood clot (thrombus) in a deep vein, usually in the legs. Clots can form in superficial veins and in deep veins. Blood clots with inflammation in superficial veins (called superficial thrombophlebitis or phlebitis) rarely cause serious problems. But clots in deep veins (deep vein thrombosis) require immediate medical care. These clots are dangerous because they can break loose, travel through the bloodstream to the lungs, and block blood flow in the lungs (pulmonary embolism). A pulmonary embolism is often life-threatening. Symptoms of DVT include swelling of the affected leg. Also, the leg may feel warm and look redder than the other leg. The calf or thigh may ache or feel tender when you touch or squeeze it or when you stand or move. Pain may get worse and last longer or become constant. If a blood clot is small, it may not cause symptoms. In some cases, pulmonary embolism is the first sign that you have DVT. DVT may damage the vein and cause the leg to ache, swell, and change color. It can also lead to leg sores after years of having a DVT. Blood clots most often develop in the calf

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and thigh veins, and less often in the arm veins or pelvic veins. Blood clots can form in veins when you are inactive. For example, clots can form if you are paralyzed or bedridden or must sit while on a long flight or car trip. Surgery or an injury can damage your blood vessels and cause a clot to form. Cancer can also cause deep vein thrombosis. Some people have blood that clots too easily, a problem that may run in families. DVT is mainly diagnosed with a compression leg ultrasound to measure the blood flow through your veins and help find any clots that might be blocking the flow. Other tests, such as a venogram, (X-ray test that takes pictures of the blood flow through the veins) are sometimes used if ultrasound results are unclear. 3) Lyme Disease or Lyme borreliosis is an emerging infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Lyme disease is the most common tick-borne disease in the Northern Hemisphere. Borrelia is transmitted to humans by the bite of infected ticks belonging to a few species of the genus Ixodes ("hard ticks"). Early symptoms may include fever, headache, fatigue, depression, and a characteristic circular skin rash called erythema migrans. Left untreated, later symptoms may involve the joints, heart, and central nervous system. In most cases, the infection and its symptoms are eliminated by antibiotics, especially if the illness is treated early. Delayed or inadequate treatment can lead to the more serious symptoms, which can be disabling and difficult to treat. Lyme disease is a biosafety level 2 disease. Lyme disease can affect multiple body systems and produce a range of symptoms. The incubation period from infection to the onset of symptoms is usually one to two weeks, but can be much shorter (days) or much longer (months to years). Symptoms most often occur from May through September, because the nymphal stage of the tick is responsible for most cases. The classic sign of early local infection with Lyme disease is a circular, outwardly expanding rash called erythema chronicum migrans (also erythema migrans or EM), which occurs at the site of the tick bite three to thirty days after the tick bite. The rash is red, and may be warm, but

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is generally painless. Classically, the innermost portion remains dark red and becomes indurated; the outer edge remains red; and the portion in between clears, giving the appearance of a bullseye. However, partial clearing is uncommon, and the bullseye pattern more often involves central redness. Erythema migrans is thought to occur in about 80% of infected patients. Patients can also experience flu-like symptoms such as headache, muscle soreness, fever, and malaise. Management and Treatment of Cellulitis- Cellulitis is a common infection frequently necessitating hospital admission, usually for the administration of intravenous (IV) antibiotic therapy or the exclusion of other conditions such as deep-venous thrombosis. This case warranted hospitalization due to a progressively swollen arm indicative of spread into the deeper subcutaneous and muscle layers and, excruciating pain and tenderness. The intent of cellulitis treatment is to decrease the severity of the infection, speed up recovery, relieve pain and other symptoms, heal the skin, and prevent the infection from coming back. Antibiotics are usually used to treat cellulitis. If the infection is limited to a small area, has not spread to the bloodstream or lymph system, and you don't have any other medical problems, antibiotics you take by mouth (oral) are effective. If the infection is more widespread, or if you're having a slow recovery on oral antibiotics, antibiotics may be used intravenously (IV) or by injection. For cellulitis of the leg or arm, treatment also includes elevating the limb to reduce swelling. In a hospital setting, concurrent MRSA infection must be determined as a rule of thumb for the correct administration and choice of antibiotics. Antibiotics must be given intravenously, but it is also considered if you have signs of complications such as a high fever or if it will be difficult for you to have follow-up care with a doctor.

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Oral, topical (applied to the skin), or intravenous antibiotics may be used to treat cellulitis. The extent of the infection and its location help determine what type of antibiotic is used.

Oral antibiotics include penicillin or a similar medicine such as dicloxacillin. For people who are allergic to penicillin, a cephalosporin, erythromycin, or vancomycin can be used.

In some cases, antibiotics that you spread on the skin (topical antibiotics) may be used to treat mild cellulitis.

Intravenous antibiotics may include nafcillin, levofloxacin, or cephalosporin.

Family Nurse Practitioner Role in Prevention and Education

1) Immunization- age appropriate vaccines such as Influenza and Pneumococcal increase and boost bodys natural defenses. 2) Lifestyle Modification- It is based on the premise that if the factors which increase and decrease stress in the client's life may be identified; it may be possible to alter some aspect of the client's lifestyle to decrease their overall stress level. a) Quitting smoking can decrease your risk of becoming ill. Smoking can damage the airways of the lungs. It can also reduce the ability of the cilia to function effectively. Cilia are small, hair-like cells that move germs and foreign particles out of the lungs. If the cilia are not working right, these particles may stay in your lungs and increase the likelihood of infection. b) Develop a habit of washing your hands frequently, especially during the winter months. Frequent hand washing is a good way to decrease your risk of falling ill with many different illnesses. Hand washing is especially important when someone in your home is ill. There is no guarantee that a family member or a caregiver won't catch pneumonia while caring for an ill person. However, the risk can be lowered with frequent hand washing before eating, before touching the eyes or nose, and

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after going outside. Also wash your hands after caring for the sick person, or handling their laundry, discarded tissues or handkerchiefs, or eating utensils. c) Your body will be better able to defend itself if you lead a healthy lifestyle. Be sure to get enough rest every day. Regular exercise has many benefits, including making your heart and lungs healthier.

3) Dietary Counseling- referral to a Registered Dietitian is important in building up strength and immunity. Eat a balanced diet, drink enough fluids, and get plenty of rest. Eat foods that are rich in the antioxidant vitamins C and E. Ensure that your diet also has foods rich in beta-carotene, such as dark green leafy vegetables (broccoli, spinach) and orange or yellow fruits and vegetables (carrots, oranges, mangos, apricots). Drink plenty of fluids throughout the day (preferably water). This helps to keep your mucus membranes hydrated (moist), which can help your body stop bacteria and viruses from entering. 4) Referral to Community resources for appropriate behavioral and drug therapy Intervention- Teaching on the deleterious effects of intravenous drug administration may be of paramount importance however; this can be viewed by patients as infringement on their individual lifestyles and privacy. It is therefore prudent that whatever the treatment setting may be, it is more politically correct to refer to community resources. 5) Teaching on: a) Skin Integrity- Cellulitis makes skin susceptible to other damage, including bed sores. Even if there are no open sores from the infection, the swelling can weaken the skin and lead to problems. This can be expressed as "risk for impaired skin integrity related to edema." If sores are present, "impaired skin integrity related to edema as manifested by open wounds" is a likely diagnosis. Interventions include

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avoiding friction against the infected area, turning the patient regularly and keeping the area dry.

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b) Pain- Severe cellulitis can be very painful, especially if it has spread throughout the system. A possible diagnosis is "acute pain related to skin infection as manifested by patient reporting extreme discomfort." Ask the patient to describe the type and intensity of the pain and monitor the effect of pain medication. If the medication isn't helping, contact the patient's doctor to determine if a higher dose needs to be given. Regularly assess vital signs, as pain can increase heart rate and blood pressure. c) Activity- The patient's tolerance for activity can be affected by cellulitis. The related factor may include pain, fatigue due to medication or general weakness as expressed by the patient. For example, "activity intolerance related to side effects of medication as manifested by patient saying she feels weak." Encourage the patient to engage in as much physical activity as she feels possible, help her perform range of motion exercises and allow for adequate periods of rest and relaxation. d) Fever is a common symptom of cellulitis and could be expressed as "hyperthermia related to bacterial infection." The evidence may include elevated heart rate, flushing, warm skin or excessive sweating. Since fever can lead to dehydration, it is important to make sure your patient gets plenty of fluids. Fever can also be the cause of a diagnosis, such as "risk for deficient fluid volume." In this case, your interventions would involve keeping the patient free of fever by administering doctorprescribed fever reducers and monitoring vital signs. e) Knowledge Deficit- Cellulitis may be prevented by taking simple precautions, especially with wounds. A nursing diagnosis of "knowledge deficit related to wound care" should be followed up with interventions that teach the patient how to properly care for a wound. These include cleaning the wound, applying antibiotic cream, keeping it covered and watching for signs of infection.

CELLULITIS R/O ERYSIPELAS References HARRISON (2008). Harrisons Principles of Internal Medicine (16TH ed.). Retrieved from http://en.wikipedia.org/wiki/Cellulitis). (n.d). In ERYSIPELAS. Retrieved 3/28/11, from http://en.wikipedia.org/wiki/Cellulitis http://www.bing.com/health/article/mayo-126149/Cellulitis?q=cellulitis http://www.ehow.com/about_5474782_nursing-diagnosis-cellulitis.html#ixzz1I6tpTJxb Cellulitis at Dorland's Medical Dictionary Scheinfeld N. Dissecting Cellulitis: A Review. "Dermatol Online J." 2003; 9(1):8. [PMID: 12639466]. Nowakowski, John, et al. "Failure of Treatment with Cephalexin for Lyme Disease means you can die." Archives of Family Medicine, Vol. 9, June 2000. Vinh DC, Embil JM (September 2007). "Severe skin and soft tissue infections and associated critical illness". Curr Infect Dis Rep 9 (5): 41521. doi:10.1007/s11908-007-0064-6. PMID 17880853. Douso ML (2009). "Hyperbaric oxygen therapy as adjunctive treatment for postoperative cellulitis involving intrapelvic mesh". J Minim Invasive Gynecol 16 (2): 2223. doi:10.1016/j.jmig.2008.12.007. PMID 19249714.

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Escobar SJ, Slade JB, Hunt TK, Cianci P (2005). "Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotizing fasciitis reduces mortality and amputation rate". Undersea Hyperb Med 32 (6): 43743. PMID 16509286. http://archive.rubicon-foundation.org/4061. Retrieved 2009-03-07. Adam EN, Southwood LL (August 2006). "Surgical and traumatic wound infections, cellulitis, and myositis in horses". Vet. Clin. North Am. Equine Pract. 22 (2): 33561, viii.

CELLULITIS R/O ERYSIPELAS doi:10.1016/j.cveq.2006.04.003. PMID 16882479. http://journals.elsevierhealth.com/retrieve/pii/S0749-0739(06)00031-9. Retrieved 2009-03-07. Fjordbakk CT, Arroyo LG, Hewson J (February 2008). "Retrospective study of the clinical features of limb cellulitis in 63 horses". Vet. Rec. 162 (8): 2336. doi:10.1136/vr.162.8.233. PMID 18296664.

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