It is the nonsuppurative inflammation of subcutaneous tissues. It is usually caused by hemolytic streptococci or staphylococci which gain entry into the tissues through a scratch, abrasion or surgical wound.
In a child having cellulitis without any skin breach, always think of underlying bone infection.
Clinical Features
There is widespread swelling, redness and pain without definite localization (Fig. 3.5). Soon the skin becomes shiny and boggy especially in areas having loose skin (face, scrotum). To differentiate it from abscess (Box 3.11), the cellulitis is said to have:
No edge No limit No pus No fluctuation
In untreated and neglected cases, cellulitis may progress to abscess formation, skin necrosis and even septicemia.
Treatment
• Bed rest and elevation of the part to reduce edema. • Local application of osmotic paste of glycerin with magnesium sulphate is hygroscopic and reduces edema.
• Injection crystalline penicillin 10 lac units, intra- venous, 6 hourly after sensitivity test for five days is useful in spreading streptococcal infection.
• Amoxycillin with clavulinic acid 1 gm. twice a day for 5 days (oral or injectable) is effective for staphylococcal infection.
• Analgesics and anti-inflammatory drugs for control of pain and inflammation.
CELLULITIS IN SPECIAL SITES
Orbit
Infection spreads from paranasal sinuses and causes orbital cellulitis. There is:
• Proptosis (bulging eyeballs) • Chemosis (conjunctival edema)
• Ophthalmoplegia (impaired ocular movements) • Diminished vision due to pressure on optic nerve.
Uncontrolled infection may have intracranial exten- sion leading to meningitis and cavernous sinus thrombosis.
Early detection of this condition and prompt use of antibiotics can help in prevention of these complications.
Neck
Cellulitis of submental and submandibular region occurring beneath deep cervical fascia is called as Ludwig’s angina (“Angina” means to “throttle”).
The infection is caused by virulent streptococcal infection along with anaerobes. The precipitating factors are 4 ‘C’:
• Caries teeth
• Carcinoma oral cavity
• Chronic sialadenitis (involving submandibular gland) • Chemotherapy
Clinical Features
• There is brawny swelling of submandibular region along with inflammatory edema of mouth (Fig. 3.6).
Fig. 3.5: Cellulitis leg
Box 3.11: Abscess vs cellulitis
Abscess Cellulitis
Well circumscribed Diffuse Limit is defined No limit Contains pus No pus Fluctuant Nonfluctuant
• The patient looks toxic, is febrile and always has putrid halitosis (foul smelling breath).
• Edema of floor of mouth displaces the tongue upwards and backwards causing dysphagia. • In untreated cases, patient may have laryngeal
edema presenting as stridor and choking (Box 3.12).
Box 3.12: Complications of cellulitis in neck
• Laryngeal edema • Stridor
• Mediastinitis • Septicemia Treatment
• Hospitalization and early use of parenteral antibiotics (cefuroxime, amoxycillin with clavulinic acid) and metronidazole for anaerobes.
• If patient does not improve with conservative treatment, surgical drainage should be done. • Under GA or LA, a curved incision is given below
the mandible to incise deep cervical fascia liberally. The mylohyoid muscle may also be incised to decompress the floor of mouth. Wound is irrigated and sutured loosely over subcutaneous drain. • Rarely tracheostomy may be required in cases of
laryngeal obstruction. LYMPHANGITIS
It is the inflammation of lymphatic pathways that presents as painful red streaks in the skin. It is usually
caused by hemolytic streptococcal infection. It is mostly accompanied by inflammatory enlargement of draining lymph nodes, which are painful and tender (lymph- adenitis). In case of infection of hand or fingers red streaks are seen in forearm and axillary lymph nodes are enlarged and tender.
Treatment is antibiotic therapy and rest. ERYSIPELAS
It means “Red Skin” in Greek.
It is acutely spreading inflammation of skin and subcutaneous tissue with associated lymphangitis.
It is usually caused by hemolytic streptococcal infection. The precipitating factors are malnutrition, poor hygiene and extremes of ages. The lesion develops around a skin abrasion and spreads rapidly as a ‘rose pink’ rash. The skin is red, swollen and tender and there is distinct line of demarcation at the advancing margin of infection. It commonly involves the face affecting nose and cheeks in a “butterfly lesion”. The patient has systemic features in form of fever, chills and prostration. A brownish discoloration of skin remains once the rash fades away.
Erysipelas of face is sometimes difficult to distinguish from cellulitis. However, this distinction is of only academic interest since treatment remains the same, i.e. antibiotics. Milian’s ear sign helps in distinguishing the two conditions. As facial erysipelas spreads, it involves the pinna as well due to cutaneous lymph- angitis. But cellulitis stops short of the pinna since it is inflammation of subcutaneous tissue and in the region of pinna; skin is closely adherent to the cartilage. Treatment
Injection crystalline penicillin 10 lac units, intravenous, 6 hourly is given for 7-10 days along with local antiseptic application.
BACTEREMIA
It is defined as bacteria circulating in the blood without toxins or clinical manifestations (Box 3.13). It is usually transient and may last for a few minutes since body defenses destroy these organisms. It may follow dental procedures, debridement of infected wounds, etc. It can be dangerous when patient has prosthetic implant since the implant can get infected. Hence, a surgical procedure should be done under cover of antibiotics.
SEPTICEMIA
It is defined as bacteria as well as their toxins circulating in the blood (Box 3.13). It has systemic manifestation in form of fever, rigors, chills, tachycardia and hypotension.
It is caused by streptococci, staphylococci and gram negative bacilli. The organisms enter the circulation when procedures are performed in infected tissues (e.g. tooth extraction in abscess).
Treatment
• Systemic antibiotics, change antibiotics according to blood culture and sensitivity report.
• Hydrocortisone.
• Plasma expanders, blood transfusion. Prevention
The procedures should be performed under antibiotic cover.
TOXEMIA
Toxins are circulating in the blood without presence of bacteria (producing these toxins) in circulation (Box 3.13). For example, toxins produced by Clostridium welchii causing gas gangrene.
PYEMIA
It is septicemia in which bacteria and their toxins are carried in the blood stream and subsequently they produce multiple focal abscesses in different parts of the body (Box 3.13). The features of these abscesses are: • These are multiple and deep seated.
• Local signs of inflammation (redness, tenderness, pain) are minimal.
It is usually seen in malnourished children and organism responsible is Staph aureus.
Treatment • Antibiotics.
• General measures to improve nutrition. • Multiple incisions to drain the abscesses. CANCRUM ORIS
It is severe ulcerative form of stomatitis affecting malnourished children and spreads rapidly (Box 3.14). Commonest predisposing cause is measles, but it may follow other acute illness as well (typhoid, gastro- enteritis). Causative organism is Borrelia vincentii that starts as Vincent’s stomatitis.
Initially, painful purple papule appears on alveolar margin of the gum. An ulcer then forms exposing underlying bone and extending to cheek or lip which become tender and swollen. In 2-3 days, soft tissue gets sloughed leading to full thickness tissue loss and a hole in cheek or lip. There is foul smelling discharge. The bone and teeth get sequestrated. If uncontrolled, child may develop septicemia and die.
Treatment
• IV Penicillin and Metronidazole. • Regular wound care.
• High protein diet with nasogastric tube feeding. • Small ulcer may heal with scarring
• Full thickness skin loss may require a pedicle flap at a later date to fill the defect.
Box 3.14: Spread of Cancrum oris Box 3.13: Definitions
• Bacteremia – Bacteria in blood.
• Septicemia – Bacteria + Toxins in blood. • Toxemia – Toxins (only) in blood.
• Pyemia – Bacteria + Toxins in blood leading to multiple abscesses in the body.