Bilateral Cellulitis Is Not The Diagnosis. Trust Me.

My doctor sent me in for intravenous antibiotics.  I also see my wound care doctor twice a week.  Happy:  What does your wound care doctor do for you?  Patient:  He puts lotion on my legs.  This is a common example of a  guy sent in by his doctor for bilateral cellulitis.   Bilateral cellulitis (infection of the skin) is almost always impossible. Infectious cellulitis starts as a foci and spreads out in all directions. A marker can usually be used to identify the advancing lines of infection.  This helps identify the lines of demarcation during daily inpatient hospital or clinic visits.   Rarely does cellulitis start on both legs simultaneously. It does not start at one leg and magically jump through the air to the other leg.  Patients often present as a direct admission from a clinic or small town emergency room saying, "The doctor sent me in for infection in my legs".  My first filtered thoughts are often, "Of course they are.  Bilateral cellulitis with acute exacerbation of you're my problem now". 

Making a diagnosis of bilateral leg cellulitis is a pet peeve of mine. It is  a  tried and true method used to punt the patient to someone else.  I see it far too often, especially when the patient is 400 pounds after gastric bypass and has pitting edema up to their thighs. They do not need to be admitted for IV antibiotics. In the absence of renal, cardio or pulmonary pathology or decompensation, to admit a patient for swollen legs is simply expensive.  Hospitals are not magic buildings.  Bilateral leg swelling can be treated with diuretics and support hose as an outpatient and followed through time.

What are the causes of this misdiagnosis?  Most commonly, chronic stasis dermatitis is the answer.  This is a chronic brownish to reddish discoloration of the skin due to chronic swelling and can mimic (but not really) cellulitis in both legs at the same time.  As a hospitalist, I see this commonly associated with chronic heart failure (right and left side), chronic venous stasis due to insufficient venous valves in the legs, cor pulmonale with elevated right sided heart pressures due to morbid obesity.  I also see chronically swollen legs as a consequence of smoker's lung, better known as COPD and emphysema.  Patients who have been chronically ill and debilitated may have critically low albumin levels.  This allows fluid to diffuse into tissues and patients often complain of bilateral swelling in their legs.  This edema can cause the intense red discoloration on the shins, without sharp lines of demarcation, that is the hallmark of non infectious leg edema.    Eating lots of protein won't help the situation short term.  This issue can take many months to resolve.

In addition, chronic lymphedema can be confused with bilateral cellulitis.  This is most often the case for physicians with poor physical exam skills.  Patients can develop very large extremities with lymphedema.  For those with little medical experience, seeing a case of unilateral or bilateral lymphedema can be shocking.  Patients struggle with their diagnosis.  Crappy doctors tell them they are infected.  Great.  We just gave our depressed patient with obese legs a heart attack thinking about the possibility of losing their legs to infection.    Lastly, deep venous thrombosis (DVT) of the legs can be confused with bilateral "cellulitis".  Many doctors are hard wired not to miss DVT and pulmonary embolism.  I think we order too many Doppler exams looking for clot. However, I feel if the diagnosis is being considered, testing is reasonable given the significant change in management if clot burden is discovered.

As a hospitalist, considering alternatives to a diagnosis of bacterial cellulitis in both legs simultaneously is our duty .   The diagnosis is possible, but not nearly as common as some physicians want it to be.  Most of the time, there is no reason a patient needs to be seeing a wound care surgeon to put aloe vera on their legs twice a week. It's fraud in my book. These  patients are convinced they have infection because everyone they see says  they do to out of ignorance or as a way to pass them on to another medical team.  The problem here is swollen legs full of fluid from being overweight. Treatment is to pee the fluid out and avoid the traps that got them there. They must avoid salt and lose 200 pounds. There is no other way.  This plan does not require hospitalization.  They don't need to be started on IV antibiotics. On principle alone, I would  discharge from the ER. Manage the swollen legs out of the hospital. It is not a hospitalization criteria. Nor does it require a whole team of health care professionals. And it's not cellulitis. Seriously.  Make sure to check out all my original medical humor ecards.

"We are doctors.  We are the few.  We are the proud.  we are the experts in making our problem someone else's problem to deal with."

We are doctors.  We are the few.  We are the proud.  We are the experts in making our problem someone else's problem to deal with ecard humor photo.

"Your legs are fat, not swollen.  And by fat, I don't mean P-H-A-T."

Your legs are fat, not swollen.  And by fat, I don't mean P-H-A-T doctor ecard humor photo.


"Whomever said time heals all wounds has never met the wounds on my patients.  They're nasty."

Whomever said time heals all wounds has never met the wounds on my patients.  They're nasty nursing ecard humor photo.


Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession.  Read at your own risk.

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11 Outbursts:

  1. I unfortunately see this as a wave of the future.
    Patients get bounced around from physician to consultant to consultant to consultant because no one can afford to take the time to address all of the patient's problems or to look at the patient as a whole person.
    Isn't it great how we're getting what we pay for in this system?

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  2. Long time lurker. I love your blog! I don't know if you read The Onion, but I found an article that I think you would find quite entertaining:
    http://www.theonion.com/content/news/man_succumbs_to_7_year_battle_with

    Enjoy!

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  3. I saw a case similar to this couple of weeks ago. A patient had been in a hospital for three days on IV antibiotics for "Cellulitis" after "failing" oral antibiotics. The patient had skin changes due to arterial insufficiency not infection. Three days of hospital stay and two weeks of oral antibiotics for nothing! I discharged him right away on nothing.

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  4. So what was it? Lymphedema? Fat? What?

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  5. When legs swell with fluid, they can turn red. The tissues, while technically inflamed, are not infected and do not need antibiotics. They need weight loss and diuretics.

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  6. As an ID Physician who gets conuslts on these patients on a regular basis, all I can say is...hear hear.

    This is an all too frequent after-hours turf from ED to our OPAT service, when the referring ED attending knows full well that bilateral cellulitis doesn't exist, but that we can't say no unless we come in and review the patient personally.

    I've seen patients who have been on IV antibiotics for over a year, referred to me from other physicinas for consideration of "gorillacillin" therapy for their "bilateral cellulitis": I take great pleasure in telling the patient they do not need antibiotics, because they do not have an infection.

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  7. I have an infection in both my feet. It started in the right leg after I twisted the ankle on the sidewalk. This was a Thursday and by Sunday, the leg was just sore to touch. The left foot felt like a cist was coming on the top of the foot and was red. By Wednesday that week I was in Urgent Care at the hospital. Both feet were totally swelled up and red. They gave an antibiotic and inflammation pills. The following Monday, I was in Urgent Care again. They didn't know what to do. I had xrays, blood work and ultra sound to rule out blood clots. By Wednesday the pain was terrible and I was in the clinic. Put on Antibiotic #2 and fluid pill. That Friday I was in so much pain I had to go back. The red is dark, and has moved up my right leg and is covering more of my left foot. The clinic said they've never seen Bi-lateral Cellulitis although that's what they had called it. Antibiotic #3 and pain pills haven't done much. The skin burns to walk. I lay around keeping my legs up missing work. Today the clinic said they don't know what to do, but wrap the feet or use medical socks to help the swelling. That's going to be hard to do as they hurt extremely to touch. I have only a couple pair of shoes I can wear and nothing with a back or sides on them. HELP!

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  8. I have a 5 year old daughter who I sent to school last Monday and she was just fine. By Monday night she was in severe pain (both feet). She kept saying her toes hurt (2 on each foot, but not the same on each foot). Anyway, we went to the dr. the following morning and he precribed antibiotics for cellulitis. By the time we picked up the rx a line began to form up her one foot from the infected toe. We ended up going to the ER several hours later because of the uncontrollable pain in her toes and feet. Another line began to form from the other injured toes. The ER dr. placed her on IV antinbiotics. She had an allergic reaction to the clendomicyn, but since she is allergic to most other antibiotics, they kept her on that w/ benedryl. After another 24 hrs she was discharged. One of the infected toes blistered and opened up several times over the next few days and she had severe itching, sometimes even on the benedryl. A few nights later she developed chest pain, we went back to the ER, but they found nothing wrong. 2 days after that she woke up in severe leg pain. She could barely walk. We took her to the infectious disease specialist who saw her in the ER (he had never seen bilateral cellulitis, practicing medicine since 1982). He did blood work and diagnosed her with mtositis and said it was unrelated to the cellulitis and lymphangitis from a few days prior. My question is can all of this be related and is it possibile that my daughter did have bilateral cellulitis (turned lymphangitis)? I am worried that she has some kind of autoimmune disorder or neoplastic disease. Just FYI, she had no injury, cut, abrasion, rash, bug bite, etc. on either of the infected feet (toes). Also, her bloodwork came back fine (even with the active infection). Her blood work after the myositis showed elevated levels for muscle inflamation, everything else was ok.

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  9. Since my last post, my daughter had another episode of "myositis", which if it was viral, like the dr. had initially suggested then it would not have come back. So we are back to square 1. Her PC saw her today and re checked all of her bloodwork, and included the test for Lyme. Also, he made a referral to Nuerology and Rheumatology. He suggested possible Guillain Barre, but I am not so sure that her symptoms fit...

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  10. The cpk was only mildy elevated. (I just found that out last night when we were back in th ER). The dr. Said her cpk should be 88 and it was 103. We ended up back in the ER because my daughter started having problems with her vision. She told me her vision was "scribbley" (moving side to side). When we got to the ER they ran a bunch of bloodwork. Everything was fine, ct scan on her head was clear. The dr.s are baffled. They ruled out a lot of things...brain tumor, lupus. I called her primary care dr. Today because he had run some bloodwork after her 3rd episode of the "myositis" which occured on the 2nd and 3rd of this month. The Lyme test they did was negative. So I was thinking maybe MS. I just don't know anymore. We saw an opthamologist today who ruled out eye problems...so we are waiting to see the neurologist. We are on the cancellationlist as 'high priority' but as is, they can not see her until March!!! I am so frustrated because she still is having vision problems and probably will not be able to go to school...I am at a loss. Any thoughts?

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  11. FYI - my daughter's conditions has improved some. She still has vision problems at night (with lights), intermittent double vision, and intermittent leg pain. She recently developed another spot of cellulitis on her right arm. We took her to the doctor today and they said they think it is an infected bug bite. My concern was that it is January in the North East and I haven't seen a bug in months...
    We got an appt to see the neurologist for this coming Monday and the Rheumatologist on Wednesday. Hopefully they will be able to come up with something.
    I got all of her bloodwork back. Her CPK has not gone down since December, although not severely elevated (it has remained in the low 100's, should be 88 at the most for a pediatric patient). Also, her Sed Rate was elevated (normal 0-10, her was 15). Her Rheumatoid Factor was negative, so I don't know if that rules out polymyositis or not.
    Also, her Lyme tests, preliminary and Western Blot, came back negative. Also had a brain MRI which was 'normal'.
    I was wondering if it was polymyositis would it just be progressive or could it come and go (at least in the beginning). She did have a period of about 4 days with no symptoms, except the eye stuff).

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