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Cellulitis

Cellulitis is a localized or 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 by exogenous bacteria, and often occurs where the skin has
previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical
wounds, intravenous drug injection 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.
Erysipelas is the term used for a more superficial infection of the dermis and upper
subcutaneous layer that presents clinically with a well-defined edge. Erysipelas and
cellulitis often coexist, so it is often difficult to make a distinction between the two.
Cellulitis is unrelated (except etymologically) to cellulite, a cosmetic condition featuring
dimpling of the skin.
Cellulitis (sel-u-LI-tis) is a common, potentially serious bacterial skin infection.
Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may
spread rapidly. Skin on lower legs is most commonly affected, though cellulitis can occur
anywhere on your body or face. Cellulitis may affect only your skin's surface, or cellulitis
may also affect tissues underlying your skin and can spread to your lymph nodes and
bloodstream. Left untreated, the spreading infection may rapidly turn life-threatening.
That's why it's important to seek immediate medical attention if cellulitis symptoms
occur.
The elderly and those with immunodeficiency (a weakened immune system) are
especially vulnerable to contracting cellulitis. Diabetics are more susceptible to cellulitis
than the general population because of impairment of the immune system; they are
especially prone to cellulitis in the feet, because the disease causes impairment of blood
circulation in the legs, leading to diabetic foot/foot ulcers. Poor control of blood glucose
levels allows bacteria to grow more rapidly in the affected tissue, and facilitates rapid
progression if the infection enters the bloodstream. Neural degeneration in diabetes
means these ulcers may not be painful and thus often become infected. Those who have
suffered poliomyelitis are also prone because of circulatory problems, especially in the
legs.
Immunosuppressive drugs, and other illnesses or infections that weaken the
immune system, are also factors that make infection more likely. Chickenpox and shingles
often result in blisters that break open, providing a gap in the skin through which bacteria
can enter. Lymphedema, which causes swelling on the arms and/or legs, can also put an
individual at risk.
Diseases that affect blood circulation in the legs and feet, such as chronic venous
insufficiency and varicose veins, are also risk factors for cellulitis.

Cellulitis is also extremely prevalent among dense populations sharing hygiene


facilities and common living quarters, such as military installations, college dormitories,
nursing homes, oil platforms and homeless shelters. It is advised if a cabin is shared with
a sufferer, urgent medical treatment should be given.

tiology
Cellulitis develops when microorganisms gain entry to the dermal and
subcutaneous tissues via disruptions in the cutaneous barrier. Beta-hemolytic
streptococci and Staphylococcus aureus are most commonly implicated as the causative
agents of cellulitis. However, a number of other microorganisms can uncommonly result
in cellulitis. Usually this occurs in a host with altered immunity or as the result of a
specific exposure. Such organisms include Pseudomonas aeruginosa, Pasteurella
multocida, Capnocytophaga canimorsus, Vibrio vulnificus, and Cryptococcus neoformans.
Causes
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.
Dental infections account for approximately eighty percent of cases of Ludwig's
angina, or cellulitis of the submandibular space. Mixed infections, due to both aerobes
and anaerobes, are commonly associated with the cellulitis of Ludwig's angina. Typically
this includes alpha-hemolytic streptococci, staphylococci and bacteroides groups.[1]
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 intravenous 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.
The appearance of the skin will assist a doctor in determining a diagnosis. A doctor
may also suggest blood tests, a wound culture or other tests to help rule out a blood clot
deep in the veins of the legs. Cellulitis in the lower leg is characterized by signs and
symptoms similar to those of a deep vein thrombosis, such as warmth, pain and swelling
(inflammation).
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 called the fascial
lining. Necrotizing fasciitis, also called by the media "flesh-eating bacteria", is an example
of a deep-layer infection. It is a medical emergency.

Clinical Manifestation

Redness

Swelling

Tenderness

Pain

Warmth

Cellulitis following an abrasion. Note the red streaking up the arm from involvement of
the lymphatic system.
Infected left shin in comparison to shin with no sign of symptoms
Cellulitis of the leg with foot involvement.
Anatomy and Physiology
The following information identifies a few select features of connective tissue.
Nerve supply. Most connective tissues have a nerve supply (as does epithelial
tissue).
Blood supply. There is a wide range of vascularity among connective tissues,
although most are well vascularized (unlike epithelial tissues, which are all
avascular).
Structure. Connective tissue consists of scattered cells immersed in an intercellular
material called the matrix. The matrix consists of fibers and ground substance. The
kinds and amounts of fiber and ground substance determine the character of the
matrix, which in turn defines the kind of connective tissue.
Cell types. Fundamental cell types, characteristic of each kind of connective tissue,
are responsible for producing the matrix. Immature forms of these cells (whose
names end in blast) secrete the fibers and ground substance of the matrix. Cells
that have matured, or differentiated (whose names often end in cyte), function

mostly to maintain the matrix:

Fibroblasts are common in both loose and dense connective tissues.

Adipocytes, cells that contain molecules of fat, occur in loose connective


tissue, as does adipose tissue.

Reticular cells resemble fibroblasts, but have long, cellular processes


(extensions). They occur in loose connective tissue.

Chondroblasts and chondrocytes occur in cartilage.

Osteoblasts and osteocytes occur in bone.

Hemocytoblasts occur in the bone marrow and produce erythrocytes (red


blood cells), leukocytes (white blood cells), and platelets (formerly called
thrombocytes).

In addition to the fundamental cell types, various leukocytes migrate from


the bone marrow to connective tissues and provide various body defense
activities:

Macrophages engulf foreign and dead cells.

Mast cells secrete histamine, which stimulates immune responses.

Plasma cells produce antibodies.

Fibers. Matrix fibers are proteins that provide support for the connective tissue. There
are three types:

Collagen fibers, made of the protein collagen, are both tough and flexible.

Elastic fibers, made of the protein elastin, are strong and stretchable.

Reticular fibers, made of thin collagen fibers with a glycoprotein coating,


branch frequently to form a netlike (reticulate) pattern.

Ground substance. Ground substance may be fluid, gel, or solid, and, except for blood,
is secreted by the cells of the connective tissue:

Cell adhesion proteins hold the connective tissue together.

Proteoglycans provide the firmness of the ground substance. Hyaluronic


sulfate and chondroitin sulfate are two examples.

Classification. There are five general categories of mature connective tissue:

Loose connective tissue has abundant cells among few or loosely arranged
fibers and a sparse to abundant gelatinous ground substance.

Dense connective tissue has few cells among a dense network of fibers with
little ground substance.

Cartilage has cells distributed among fibers in a firm gellike ground


substance. Cartilage is tough but flexible, avascular, and without nerves.

Bone has cells distributed among abundant fibers in a solid ground


substance

containing

minerals,

mostly

calcium

phosphate.

Bone

is

organized in units, called osteons (formerly known as the Haversian


system). Each osteon consists of a central canal, which contains blood
vessels and nerves, surrounded by concentric rings (lamellae) of hard
matrix and collagen fibers. Branching off the central canal at right angles
are perforating canals. These canals consist of blood vessels that branch off
the central vessels. Between the lamellae are cavities (lacunae) that contain
bone cells (osteocytes). Canals (canaliculi) radiate from the central canal
and allow nutrient and waste exchange with the osteocytes.

Blood is composed of various blood cells and cell fragments (platelets)


distributed in a fluid matrix called blood plasma.

Tissue origin. All mature connective tissues originate from embryonic connective tissue.
There are two kinds of embryonic connective tissues:

Mesenchyme is the origin of all mature connective tissues.

Mucous connective tissue is a temporary tissue formed during embryonic


development.

Pathophysiology
The pathophysiology of cellulitis has not been well studied. The burden of
organisms in cellulitis appears to be low. Some have speculated that the pyrogenic
exotoxins produced by beta-hemolytic streptococci may contribute to the clinical findings
in cellulitis. There is evidence of local production of inflammatory cytokines by
keratinocytes. Interaction between surface proteins ofStreptococcus pyogenes and
adhesions on the surface of keratinocytes and Langerhans cells may be a requirement for
infection to develop. In many instances, tinea pedis may cause a disruption in the
cutaneous barrier and allow entry to offending bacterial organisms.
The pathophysiology of cellulitis begins

when

bacteria

enters

the

skin.

This

bacteria causes an infection, which may cause skin symptoms such as redness and
swelling around the site of the infection. If the bacteria gets into the bloodstream or into
the deeper layers of the skin, complications can occur. Typically, cellulitis is treated with

antibiotics.
Several types of bacteria can set the pathophysiology of cellulitis into motion, the
most common being streptococcus and staphylococcus. Areas where the skin is dry and
flaking, broken, or wounded are the most likely sites for bacteria to enter the body. Insect
bites may also transmit bacteria that can cause a skin infection.
The pathophysiology of cellulitis commonly starts out affecting the lower leg. The
infected skin may be red, swollen, and painful to the touch. The red rash area may get
worse or spread over time. A fever may accompany these symptoms. It is important to
see a doctor early, before the cellulitis infection worsens and affects a larger area.
Any condition that causes chronic skin disruption, such as eczema, can increase
the likelihood of a skin infection. Open wounds can leave a person vulnerable to bacteria
entering the skin, as can intravenous drug use, because it constantly ruptures the skin.
The pathophysiology ofcellulitis can be made more severe by a weakened immune
system caused by conditions such as diabetes or HIV.
When cellulitis is not dealt with, it can become more severe, infecting the inner
layers of the skin. If the bacteria reaches these lower layers, it can enter the lymph nodes
and bloodstream, spreading throughout the body. Chronic or recurrent cellulitis can
damage the lymphatic system and cause chronic swelling of the infected area. In rare
cases, the bacteria can spread to the fascial lining, a deep layer of skin tissue. This is a
very severe complication and a medical emergency.
A doctor will examine the condition of the infected skin and possibly order blood
tests to diagnose cellulitis. Often, tests are necessary to rule out conditions with similar
symptoms, such as blood clots in the legs. A wound culture is another way physicians can
check for infection.
The pathophysiology of cellulitis is typically treated before it reaches a severe and lifethreatening stage. The most common cellulitis treatment is antibiotics, usually taken for
14 days. If oral antibiotics are not effective, a patient may be hospitalized and given
intravenous antibiotics. The symptoms of cellulitis typically disappear after a few days of
antibiotic
Diagnosis
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. Conditions that may resemble cellulitis include deep vein thrombosis,

which can be diagnosed with a compression leg ultrasound, and stasis dermatitis, which
is inflammation of the skin from poor blood flow. Associated musculoskeletal findings are
sometimes reported. When it occurs with acne conglobata, hidradenitissuppurativa, and
pilonidal cysts, the syndrome is referred to as the follicular occlusion triad or tetrad.
Lyme disease can be misdiagnosed as staphylococcal- or streptococcal-induced
cellulitis. Because the characteristic bullseye rash does not always appear in patients
infected with Lyme disease, the similar set of symptoms may be misdiagnosed as
cellulitis. Standard treatments for cellulitis are not sufficient for curing Lyme disease. The
only way to rule out Lyme disease is with a blood test, which is recommended during
warm months in areas where the disease is endemic.
Treatment
Medical Treatment

If the infection is not too severe, you can be treated at home. The doctor will give
you a prescription for antibiotics to take by mouth for about a week to 10 days. Do
not stop treatment early; finish all of the medication you are prescribed unless the
doctor tells you to stop.

The doctor may use intravenous (IV) or intramuscular antibiotic injections in these
situations:

If the infection is severe

If you have other medical problems

If you are very young or very old

If the cellulitis involves extensive areas or areas close to important structures; for
example, infection around the eye socket

If the infection worsens after taking antibiotics for two to three days

Treatment consists of resting the affected area, cutting away dead tissue, and
antibiotics (either oral or intravenous). Flucloxacillin or dicloxacillinmonotherapy (to cover
staphylococcal infection) is often sufficient in mild cellulitis, but in more moderate cases,
or where streptococcal infection is suspected, then this course is usually combined with
oral phenoxymethylpenicillin or intravenous benzylpenicillin, or ampicillin/amoxicillin. Pain
relief is also often prescribed, but excessive pain should always be investigated as it is a
symptom of necrotizing fasciitis. Elevation of the affected area is also important. As in
other maladies characterized by wounds or tissue destruction, hyperbaric oxygen
treatment can be a valuable adjunctive therapy, but is not widely available.

Surgical

Rarely, a soft tissue infection may need surgery.

An abscess, or collection of pus in the tissue, may need to be opened surgically to


allow drainage.

Dead tissue may need to be cut away to allow healing

Diagnostic Exam
MRI is the imaging modality of choice for the diagnosis of pyomyositis. MRI is helpful in differentiating
pyomyositis from osteomyelitis. It is especially useful in differentiating early muscle inflammation from abscess
formation. MRI is also the best imaging modality for evaluation of pelvic infections.[6]
CT scanning may show hypertrophy of involved muscle groups and effacement of the fat planes. Contrast
enhancement may indicate abscess formation. CT is also useful for distinguishing tumors and hematomas from
abscess.
Ultrasound or MRI also may be used to localize involved muscle.
Gallium scan is useful for localization in the early stages of illness.
Procedures
HIV polymyositis: Electromyography (EMG) findings are similar to those of idiopathic polymyositis.
Short-duration motor unit potentials
Low-amplitude polyphasic motor unit potentials
Fibrillations
Pyomyositis
Widespread necrosis of muscle fibers, perimysium, and blood vessels is noted. Pleomorphic inflammatory
response consisting of both neutrophils and lymphocytes is noted.
Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure
commonly to treat the resulting loss ofcirculation to an area of tissue or muscle.[1] Fasciotomy is a limb-saving
procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic
compartment stress syndrome. The procedure has a very high rate of success, with the most common problem
being accidental damage to a nearby nerve.
Contraindications of fasciotomy for treating acute compartment syndrome. After 4 days of ACS, this procedure is
contraindicated because there is already irreversible damage.
Fasciotomy in the limbs is usually performed by a surgeon under general or regional anesthesia. An incision is
made in the skin, and a small area of fascia is removed where it will best relieve pressure.
Plantar fasciotomy is an endoscopic procedure. The physician makes two small incisions on either side of the
heel. An endoscope is inserted in one incision to guide the physician. A tiny knife is inserted in the other. A
portion of the fascia near the heel is removed. The incisions are then closed.
In addition to scar formation, there is a possibility that the surgeon may need to use a skin graft to close the
wound. Sometimes when closing the fascia again in another surgical procedure, the muscle is still too large to
close it completely. A small bulge is visible, but is not harmful.

NCP
1. Acute pain related to irritation of the skin, impaired skin integrity, ischemic tissue.
2. Impaired Skin Integrity related to the presence of gangrene in the extremities.
3. Anxiety related to lack of knowledge about the disease.
4. Imbalanced Nutrition Less Than Body Requirements related to poor food intake.
5. Disturbed Body Image related to changes in the form of one limb.
6. Sleep Pattern Disturbance related to pain in a leg wound.
7. Knowledge Deficit: the prevention of symptoms and treatment of conditions related to
inadequate information.