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Fig. Patient distribution. DVT, deep vein thrombosis.  

Fig. Patient distribution. DVT, deep vein thrombosis.  

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Conference Paper
Full-text available
Cellulitis and deep vein thrombosis (DVT) in the lower extremities (LE) often have similar presentations: erythema, swelling, and calf tenderness. The overlap of these symptoms often results in physicians ordering unnecessary LE Doppler ultrasounds in patients with LE cellulitis. This practice leads to subjecting patients to unwarranted procedures...

Citations

... US can exclude a clinical differential of deep vein thrombosis at the same examination in patients with pertinent risk factors. 18 CT shows fat stranding of the inflamed subcutaneous tissues with skin thickening. MRI shows variable patterns of T1-hypointense and T2-hyperintense fluid accumulation within the subcutaneous layer and along the peripheral layer of the deep muscular fascia, which may be diffuse or localised, often with a linear pattern. ...
Article
Full-text available
The clinical diagnosis of musculoskeletal infections can be challenging due to non-specific signs and symptoms on presentation. These infections include infectious myositis, necrotising fasciitis, septic arthritis, septic bursitis, suppurative tenosynovitis, osteomyelitis, spondylodiscitis and periprosthetic infections. Diagnostic imaging is routinely employed as part of the investigative pathway to characterise the underlying infectious disease pattern, allowing expedited and customised patient management plans to optimise outcomes. This article provides an update on the various imaging modalities comprising of radiography, computed tomography, ultrasonography, magnetic resonance imaging and radionuclide procedures, and incorporates representative images of key findings in the different forms of musculoskeletal infections.
Article
Background: Although inflammation and thrombosis are tightly connected, only 45% of patients with lower leg cellulitis receive anticoagulant therapy. Available data about the prevalence of concomitant deep venous thrombosis (DVT) in patients with cellulitis of the lower extremity is scarce and general guidelines regarding diagnosis and prevention of venous thromboembolism are missing. Objective: We sought to determine how frequently DVT occurs as an incidental finding in patients with cellulitis and to provide recommendations for diagnostics and anticoagulant therapy. Methods: Patients' records were analysed and 192 consecutive patients with cellulitis were included in this study. The prevalence of concomitant DVT was examined by duplex ultrasound, as well as comorbidities and risk factors. Results: We detected thrombosis in 12.0% of the patients with lower leg cellulitis, of which 43.5% were located in a proximal vein and 52.2% in the veins of the calf. Conclusions: Our results clearly indicate that cellulitis is not only a differential diagnosis, but should be considered a risk factor for venous thrombosis. Therefore, prophylactic anticoagulation should be considered in patients suffering from cellulitis and a systematic screening for venous thrombosis in patients with cellulitis should be performed.
Article
In Reply We thank Cho et al for their letter to the editor and are grateful for the opportunity to discuss the important points raised therein. Given the word limit of our original article, we were not able to elaborate on this important subject matter and appreciate the opportunity to more clearly elucidate the methodology on where and how the “presumed diagnosis of cellulitis” was determined. We retrospectively analyzed the results of a larger prospective study performed in the emergency department and internal medicine units.¹ The cohort included patients who had been evaluated and suspected of having cellulitis by an emergency department physician prior to admission, rather than patients identified by an International Classification of Diseases code of cellulitis. We agree that a retrospective analysis of patients who had International Classification of Diseases codes for cellulitis following hospitalization would present a biased view of the population and their subsequent imaging. Thus, in this study, the patients who received imaging were already suspected of having cellulitis at the time of imaging.
Article
The " Things We Do for No Reason " series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent " black and white " conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. Because of overlapping clinical manifestations, clinicians often order ultrasound to rule out deep vein thrombosis (DVT) in cases of cellulitis. Ultrasound testing is performed for 16% to 73% of patients diagnosed with cellulitis. Although testing is common, the pooled incidence of DVT is low (3.1%). Few data elucidate which patients with cellulitis are more likely to have concurrent DVT and require further testing. The Wells clinical prediction rule with D-dimer testing overestimates DVT risk in patients with cellulitis and is of little value in this setting. Given the overall low incidence, routine ultrasound testing is unnecessary for most patients with cellulitis. ultrasound should be reserved for patients with a history of venous thromboembolism (VTE), immobility, thrombophilia, congestive heart failure (CHF), cere-brovascular accident (CVA) with hemiparesis, trauma, or recent surgery, and for patients who do not respond to antibiotics. CASE REPORT A 50-year-old man presented to the emergency department with a 3-day-old cut on his anterior right shin. Associated redness, warmth, pain, and swelling had progressed. The patient had no history of prior DVT or pulmonary embolism (PE). His temperature was 38.5°C, and his white blood cell count of 18,000. On review of systems, he denied shortness of breath and chest pain. He was diagnosed with cellulitis and administered intravenous fluids and cefazolin. The clinician wondered whether to perform lower extremity ultrasound to rule out concurrent DVT. WHY YOU MIGHT THINK ULTRASOUND IS HELPFUL IN RULING OUT DVT IN CELLULITIS Lower extremity cellulitis, a common infection of the skin and subcutaneous tissues, is characterized by unilateral erythema, pain, warmth, and swelling. The infection usually follows a skin breach that allows bacteria to enter. DVT may present similarly, and symptoms can include mild leukocytosis and elevated temperature. Because of the clinical similarities, cli-nicians often order compression ultrasound of the extremity to rule out concurrent DVT in cellulitis. Further impetus for testing stems from fear of the potential complications of untreated DVT, including post-thrombotic syndrome, chronic venous insufficiency, and venous ulceration. A subsequent PE can be fatal, or can cause significant morbidity, including chronic VTE with associated pulmonary hypertension. An estimated quarter of all PEs present as sudden death. 1 WHY ULTRASOUND IS NOT HELPFUL IN THIS SETTING Studies have shown that ultrasound is ordered for 16% to 73% of patients with a cellulitis diagnosis. 2,3 Although testing is commonly performed, a meta-analysis of 9 studies of celluli-tis patients who underwent ultrasound testing for concurrent DVT revealed a low pooled incidence of total DVT (3.1%) and proximal DVT (2.1%). 4 Maze et al. 2 retrospectively reviewed 1515 cellulitis cases (identified by International Classification of Diseases, Ninth Revision codes) at a single center in New Zealand over 3 years. Of the 1515 patients, 240 (16%) had ultrasound performed, and only 3 (1.3%) were found to have DVT. Two of the 3 had active malignancy, and the third had injected battery acid into the area. In a 5-year retrospective cohort study at a Veterans Administration hospital in Con-necticut, Gunderson and Chang 3 reviewed the cases of 183 patients with cellulitis and found ultrasound testing commonly performed (73% of cases) to assess for DVT. Only 1 patient (<1%) was diagnosed with new DVT in the ipsilateral leg, and acute DVT was diagnosed in the contralateral leg of 2 other patients. Overall, these studies indicate the incidence of concurrent DVT in cellulitis is low, regardless of the frequency of ultrasound testing. Although the cost of a single ultrasound test is not prohibitive , annual total costs hospital-wide and nationally are large. In the United States, the charge for a unilateral duplex ultrasound of the extremity ranges from 260to260 to 1300, and there is an additional charge for interpretation by a ra-diologist. 5 In a retrospective study spanning 3.5 years and involving 2 community hospitals in Michigan, an estimated $290,000 was spent on ultrasound tests defined as unnecessary for patients with cellulitis. 6 A limitation of the study was defining a test as unnecessary based on its result being negative.