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1/20/2017

Case Studies In Infectious Diseases NO DISCLOSURES

Richard A. Jacobs, M.D., PhD.

Case Presentation Should Prophylaxis Be Given?

100% • The dentist of your 45 year old female patient with MVP and moderate mitral 1.Yes regurgitation calls wanting to know if she needs antibiotic prophylaxis for a root 2.No canal and which one.

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1 1/20/2017

Prophylaxis for Endocarditis Prophylaxis for Endocarditis

• Paradigm shift in recommendations – Lack of published data showing benefit • Original AHA Guidelines in 1997 – Transient bacteremia occurs commonly as a result of normal daily activities • Major revision by AHA in 2007 with several • Brushing and flossing—20%‐68% updates, the most recent in 2014 (J Am Coll • Toothpick—20%‐40% Cardiol. 2014;63(22):e57) • Chewing food—7%‐51% – Endocarditis is more likely to occur from frequent bacteremias associated with daily activities than from bacteremias caused by dental, GI or GU procedures

Procedures for Which Endocarditis Prophylaxis for Endocarditis Prophylaxis is Recommended

• Prophylaxis recommended ONLY for: • DENTAL PROCEDURES that involve manipulation of gingival tissue, manipulation of the periapical HIGH RISK PROCEDURES region of the teeth (tooth extraction/root canal In for abscess) or perforation of the oral mucosa — INCLUDING ROUTINE DENTAL CLEANING HIGH RISK INDIVIDUALS • RESPIRATORY PROCEDURES with violation of the mucosa‐‐tonsillectomy/adenoidectomy, bronchoscopy with biopsy, drainage of an infection (empyema)

2 1/20/2017

Procedures for Which Endocarditis Procedures for Which Endocarditis Prophylaxis is Recommended Prophylaxis is NOT Recommended

• SKIN/MUSCULOSKELETAL PROCEDURES— • GI PROCEDURES drainage of abscesses (antibiotics directed at – Risk of bacteremia low even with biopsy (2%‐5%) S. aureus and Group A streptococcus) and organisms involved rarely cause endocarditis • GU PROCEDURES – Risk of bacteremia high with bacteriuria – TREAT BACTERIURIA BEFORE PROCEDURE

Conditions of Highest Risk Recommended Regimens ( Single Dose 30‐60 min Before Procedure)

• Included • Not included Situation Agent Adult Dose – Prosthetic heart valves – Bicuspid aortic valve Oral regimen Amoxicillin 2 g – Prior endocarditis – Acquired aortic or mitral Allergic to Cephalexin or 2 g – Cyanotic heart disease valve disease penicillin or Clindamycin 600 mg • Unrepaired • MVP with regurgitation ampicillin or • Partially repaired • Prior valve repair (minor allergy) Azithromycin/ 500 mg • Repaired within last 6 – Hypertrophic Clarithromycin months cardiomyopathy with Allergic to Clindamycin 600 mg – Heart transplant with latent or resting penicillin or or “valvulopathy” obstruction ampicillin Azithromycin/ 500 mg (anaphylaxis, Clarithromycin angioedema or urticaria

3 1/20/2017

Case Presentation Should Prophylaxis Be Given?

100%

• The dentist of your 65 year old patient who is 9 months s/p total hip 1. Yes arthroplasty calls wanting to know if prophylaxis should be given for a root 2. No canal

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Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints Joints—2013 Guidelines • GOOD NEWS • Area of controversy for years between the ADA, AAOS and IDSA – 2004 AAOS & ADA recommendation prophylaxis if joint placed within past 2 years – 2009 AAOS recommends prophylaxis for all prosthetic joints regardless of when placed – Promise of collaboration with joint guidelines – 2013 AAOS & ADA propose new guidelines

4 1/20/2017

Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints—2013 Guidelines Joints—2013 Guidelines • GOOD NEWS • GOOD NEWS – The practitioner might consider discontinuing the – The practitioner might consider discontinuing the practice of routinely prescribing prophylactic practice of routinely prescribing prophylactic antibiotics for patients with hip and knee antibiotics for patients with hip and knee prosthetic joint implants undergoing dental prosthetic joint implants undergoing dental procedures. procedures. • BAD NEWS

Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints—2013 Guidelines Joints—2013 Guidelines • GOOD NEWS • GOOD NEWS – The practitioner might consider discontinuing the – The practitioner might consider discontinuing the practice of routinely prescribing prophylactic practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic antibiotics for patients with hip and knee joint implants undergoing dental procedures. prosthetic joint implants undergoing dental • BAD NEWS—> Grade of Recommendation is procedures. Limited • BAD NEWS—> Grade of Recommendation is • Practitioners should be cautious in deciding Limited whether to follow a recommendation classified as Limited

5 1/20/2017

What TO DO?? ADA Recommendations

• In 2014 the ADA Council on Scientific Affairs • Disconnect between organisms causing PJIs convened an expert panel to clarify the 2013 and mouth flora ADA/AAOS confusing recommendations – Late infections almost always due to skin flora (S. epi, P. acnes, corynebacterium spp) not streptococci found in the mouth • Bacteremias common as a result of everyday activities • Best study cited in the recommendations: (Clin Infect Dis 2010;50:8-16) • Dental procedures do NOT increase the risk of PJI

ADA Recommendations Take Home Points

• In 2014 the ADA Council on Scientific Affairs convened an expert panel to clarify the 2013 ADA/AAOS confusing recommendations • Prophylaxis NOT indicated for pins, • CLINICAL RECOMMENDATION: plates, fixation devices, THA or TKA – In general, for patients with prosthetic joint regardless of when the implant was implants, prophylactic antibiotics are NOT placed recommended to dental procedures to prevent prosthetic joint infections

JADA 2015:146(1):11‐16

6 1/20/2017

Case Presentation What is Your Therapy?

100% A 22 yr old comes to the office complaining of the acute onset of unilateral of the right side of his face. 1. Prednisolone Your diagnosis is Bell’s Palsy. 2. Acyclovir 3. Prednisolone + acyclovir 4. Nothing

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Etiology of Facial Nerve Palsy Therapy of Bell’s Palsy

• Quite controversial • 50% are idiopathic (Bell’s Palsy) • Herpes Simplex/Varicella Zoster • Because of the association with herpes – Direct invasion v. immunologic/inflammatory the use of acyclovir has been felt to be • Lyme disease (most common cause of bilateral FN beneficial palsy) • Two well done prospective, randomized, • Other infections—CMV, EBV,HIV controlled, blinded studies have been done • Non‐infectious—Diabetes, sarcoid, tumors, trauma

7 1/20/2017

Therapy of Bell’s Palsy

• 839 patients enrolled within 72 hours of Prednisilone Prednisilone onset of symptoms + valacyclovir – Placebo + placebo (206) Placebo – Prednisilone (60mg X 5 days then reduced Valacyclovir by 10 mg/day) + placebo (210) + placebo – Valacyclovir (1000mg TID X 7 Days) + placebo (207) – Valacyclovir X7 Days + prednisolone X10 Days (206)

Lancet Neurol 2008;7:993‐1000

Therapy of Bell’s Palsy Take Home Points

• Case closed on therapy??? NO!! • Early treatment (within 72 hours of • Other less powered studies and subgroup onset) recommended analyses suggest that acyclovir might be • For most cases prednisolone for 10 days beneficial in the most severe cases is adequate – Minimal or no movement of facial muscles and • For severe cases (complete or near inability to close the eye complete paralysis) prednisolone for 10 days + valacyclovir 1000mg TID for 7 days is recommended

8 1/20/2017

Case Presentation Case Presentation (cont)

• 57 yo male with polycystic kidney disease, • Shortly after transplant sustained an “injury” gout, HTN and hyperlipidemia to his (R) ankle resulting in pain and swelling • August 2016 underwent bilateral • October 20 (2 months post‐transplant) at nephrectomies and renal transplant (CMV D routine clinic visit his ankle was warm, red, +/R‐). Required ATG post‐transplant tender and swollen. • Immunosuppression—mycophenolate 360 mg • WBC‐ 12.5 (4.0‐11.0), CRP‐72 (<6.3) and xray BID, tacrolimus 7 mg BID and prednisone 5 mg showed an effusion QD; prophylactic ganciclovir • Admitted for evaluation

Case Presentation (cont) Case Presentation (cont)

• P&SH • October 22‐taken to the OR for I&D – Lives in Oakland, CA – Chronic appearing inflammation with friable – No travel synovium – No unusual food/animal exposures • WORKING DIAGNOSIS—transient S. aureus • BCs X 2 neg bacteremia from septic (R) ankle with S. • Urine culture‐100,000 CFU of MRSA aureus bacteriuria. • October 21‐aspiration • Started on vancomycin & ceftriaxone pending – Bloody fluid with 102,000 WBCs & 96% PMNs cultures – Negative for crystals

9 1/20/2017

Case Presentation (cont) Case Presentation (cont)

• Cultures/stains from aspiration and OR were • Cultures for: all negative for bacteria, fungus and AFB – Bacteria • October 26‐MRI‐c/w with intraosseous – Fungus abscesses – AFB • October 28—back to the OR • Additional specialized tests – No gross purulence • 1 week later a diagnosis was made – “cystic void” in the calcaneus and talus that were opened

What is your diagnosis?

1. Gout 2. S. aureus 3. Yeast infection (candida) UREAPLASMA UREALYTICUM 4. Mold infection (aspergillus/rhizopus) 5. AFB‐MTb or NTM 6. Other

10 1/20/2017

University of Washington Molecular Culture Negative Septic Arthritis Diagnostic Laboratory Can submit tissue, paraffin blocks or sterile fluid • Prior antibiotics DNA sequencing for: • Sensitivity of the test ( ≈90%) • Lyme disease Bacteria (16S ribosomal RNA) • Fastidious organisms Yeast (26S ribosomal RNA) – Brucella Moulds (28S ribosomal RNA) – Coxiella (Q ) – Legionella – http://depts.washington.edu/molmicdx/mdx/te – Whipple’s disease sts/bctseq.shtml – Mycoplasma (immunoglobulin deficiency)

Culture Negative Septic Arthritis Drug Allergies

• Reactive arthritis • Important to use DOC to maximize outcomes – Following diarrhea • Use of alternative drugs • Salmonella, Shigella, Campylobacter, Yersinia, C. difficile – Worse outcomes – Following urogenital infections – More adverse drug reactions • Chlamydia trachomatis – More readmissions – Often more costly

11 1/20/2017

Clinical Case Scenario Types of Hypersensitivity Reactions • 66M h/o R knee replacement c/b PJI with MSSA • Patient has a self‐reported PCN • TYPE I‐IgE‐mediated immediate‐type allergy and has no documented hypersensitivity history of receiving cephalosporins – Within 1 hour • He describes the rash as being all over his body but can’t recall – Anaphylaxis, angioedema, bronchospasm, urticaria further details—whether he had (hives) hives. • TYPE IV‐cell‐mediated delayed‐type • He states he never had any hypersensitivity difficulty breathing and no swelling – Greater than 72 hours of face or lips or other parts of – Maculopapular rash body. No SOB or wheezing.

History Very Important Cross‐Reactivity among β‐lactams

• Only 5‐10% of individuals who report report an 2-3% allergy to PCN are truly allergic ??? • Timing (early v delayed) and nature of the Penicillin reaction ??? Cephalosporin • Is the reaction an allergy?—nausea, diarrhea, abdominal pain, HA, yeast vaginitis —>No ??? <1% 0% 0% concern • Has the patient received cephalosporins before – If previously tolerated OK to administer 0% Carbapenem Monobactam

Slide courtesy Kathy Yang

12 1/20/2017

What Would You Do At This Point? Skin Testing: Clinical Pearls

1. Prescribe vancomycin • Only useful for detecting IgE mediated hypersensitivity 2. Skin test with reactions to PCN cephalosporins • Skin tests for cephalosporin not standardized • A negative skin test has a high NPV—>OK to give a 3. Skin test with penicillin cephalosporin 4. Give cefazolin • A positive skin test—>2‐3% chance of cross reactivity with cephalosporins some of which are Type I • 80% with IgE‐mediated PCN allergy have lost the sensitivity after 10 Years

1. AAAAI Guidelines 2010 2. Salkind JAMA 2001

cephalosporin administration to patients What Would You Do At This Point? with a history of penicillin allergy

1. Prescribe vancomycin 2. Skin test with PCN Skin testing cephalosporins 3. Skin test with penicillin Negative Positive 4. Give cefazolin

Give Options cephalosporin 1. Give alt drug 2. Give cephalosporin with graded challenge 3. Desensitize to cephalosporin

13 1/20/2017

Take Home Points CASE PRESENTATION

• Of individuals with a H/O PCN allergy very few • A 45 year old man awoke the day prior to are truly allergic presentation with a . Throughout the • A careful history can usually determine day the sore throat worsened, and he had – Allergic from non‐allergic reactions difficulty eating dinner because of pain. The next morning he awoke with an even worse sore – IgE‐mediated reactions from delayed reactions throat and an elevated temperature of 103.5˚ F. • When in doubt, PCN skin testing is very useful In the office he complained of a severe sore with a high NPV —> if negative OK to give throat, his temperature was 98˚ F and his penicillins, cephalosporins, carbapenems. had mild erythema without .

What Would You Do At This Point?

1. Rapid strep test 2. Antibiotics without testing 3. Observe without antibiotics (send home) 4. Send to ENT 5. Order head/ CT

14 1/20/2017

SORE THROAT DIAGNOSIS NOT TO Uvulitis MISS

• • Uvulitis • Para and • Angioedema/anaphylaxis • Diphtheria • Foreign Body • HIV

SORE THROAT DIAGNOSIS NOT TO Diphtheria MISS

• Epiglottitis • Uvulitis • Para and retropharyngeal abscess • Angioedema/anaphylaxis • Diphtheria • Foreign Body • HIV

15 1/20/2017

SORE THROAT DIAGNOSIS NOT TO When To Suspect Epiglottitis MISS

• Epiglottitis • Uvulitis • “Worst sore throat of my life” • Para and retropharyngeal abscess –With minimal findings on exam • Angioedema/anaphylaxis –Hoarse/muffled voice • Diphtheria –Severe odynophagia • Foreign Body • HIV

Adult Epiglottitis “Thumb Sign”

• Increasing incidence in adults (decreasing in children due to Hib vaccination) • Adults ‐‐more indolent (days vhours) and less toxic appearing • Dx made by direct visualization – fiberoptic laryngoscopy less likely to provoke spasm than mirror exam – Lateral neck films less sensitive than laryngoscopy, but still good in adults – 77% ‐ 88% sensitive (“thumb sign”)

16 1/20/2017

Adult Epiglottitis Case Presentation

• Bacteriology • 20 year old previously healthy male – H. influenzae/parainfluenzae; S. pneumoniae; Gp • Day 1 A strep; S. aureus (MSSA & MRSA) • Onset of sore throat with fever • Therapy • Day 2 rd – Antibiotics –3 generation cephalosporin +/‐ – Evaluated in office—exudative with vancomycin (severe sepsis or require intubation) tender anterior cervical adenopathy, h/o fever and – Airway maintenance—not standard as it is in no (4/4 of Centor Criteria) children – Azithromycin started (within 24 hours of onset of – Steroids—Controversial—generally not given as no symptoms) clear benefit demonstrated

Diagnosis of Gp A Streptococcal Modified Centor Criteria Pharyngitis

• IDSA (Infectious Disease Society of America) – Rapid strep test • ACP (American College of Physicians) and the AAFP (American Academy of Family Practice) – Modified Centor Criteria

Score 3 or 4 —> Rx empirically

17 1/20/2017

Case Presentation Case Presentation

• 20 year old previously healthy male • Day 3 – PC—not better—still with sore throat and fever • Day 1 – Plan—continue azithromycin – Onset of sore throat with fever • Day 5 • Day 2 – Phone Call—not better – Evaluated in office—exudative pharyngitis with tender anterior cervical adenopathy, h/o fever and • Diffuse , difficulty swallowing, pain on no cough (4/4 of Centor Criteria) (R) side of neck – Azithromycin started (within 24 hours of onset of – Plan‐‐to finish Azithromycin; encourage fluids; symptoms) ibuprofen for symptom relief; call if not better

Case Presentation Case Presentation

• ED evaluation – WBC—21,400 with 51% PMNs and 42% bands • Day 6 – Plts—16,000 – PC‐‐SOB and pleuritic chest pain – BUN 80, Cr 4.2 – Instructed to go to ED for evaluation – PTT 50; FDP elevated – pH 7.29 with elevated lactic acid – CXR, chest CT and BCs obtained

18 1/20/2017

Case Presentation‐‐CXR Case Presentation—Chest CT

Lemierre’s Syndrome What Went Wrong?

• Natural History of GpA Streptococcal Pharyngitis • Infection with Fusobacterium necrophorum – w/o therapy, symptoms better in 3‐4 days resulting in septic thrombophlebitis of the internal jugular vein often associated with – With early therapy (24 hours) symptoms bacteremia and septic pulmonary emboli. resolve 24‐48 hours sooner

19 1/20/2017

Fusobacterium necrophorum Fusobacterium necrophorum

• Anaerobic gram‐negative rod • Student Health Service in the US • Common upper respiratory organism in • Students age 15‐30 presenting with a sore ADOLESCENTS AND YOUNG ADULTS (age 15‐30) • Can isolate F. necrophorum from 10% with sore throat throat (equal in frequency to gp A streptococcus) – F. necrophorum detected (by PCR) in 20.5% • Peritonsillar abscesses—F. necrophorum isolated in 23% (most in pure culture) c/w gp A – Gp A strep detected in 10.3% streptococcus—17%

Ann Int Med 2009; 151:812‐ Ann Int Med 2009; 151:812‐815 815 Ann Int Med 2015;162:241‐247 Ann Int Med 2015;162:241‐247

Pharyngitis in Adolescents Take Home Points

• Pharyngitis in the adolescent and young adults • Fusobacterium necrophorum (ages 15‐30) can be more complicated than – Resistant to azalides and macrolides previously thought (azithromycin/clarithromycin) • ALTHOUGH CONTROVERSIAL, SOME HAVE – Sensitive to penicillins, cephalosporins and RECOMMENDED clindamycin – In patients 15‐30 years of age, with a Centor score of >3 and negative diagnostic tests for gp A strep to treat with penicillin, amoxicillin or a cephalosporin

20 1/20/2017

Trivia Question # 1‐‐Which President Take Home Points Died of ?

100% 1. John Quincy • WHAT IS NOT CONTROVERSIAL (Quinsy ?) Adams? – Remember the natural history of pharyngitis 2. Thomas Jefferson – If patients do not improve as expected think about complications 3. George • Peritonsillar abscess Washington • Retropharyngeal abscess 4. Andrew Jackson • Lemierre’s syndrome

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Case Presentation Case Presentation

• 55 y/o woman with a past hx of kidney • The following day, as instructed, she calls stones presents to Urgent Care c/o upper her PCP who orders thoracic and lumbar mid‐back pain and pain in the left shoulder spine films —> degenerative disc disease for 2 days. No history of trauma. On PE • CBC —> WBCs 14.6 (4‐11) with 90% she is afebrile with normal vital signs and PMNs (40‐80) TTP over the left posterior shoulder. • ESR —> 48 (0‐15) • She is treated symptomatically and sent home

21 1/20/2017

Case Presentation Your Next Step?

• Told to go back to Urgent Care b/o elevated 1. Analgesics and WBCs. She c/o pain in the upper back that fluids for renal has been getting progressively worse. Her calculi Temp is 100.6°F and on exam there is 2. Analgesics for tenderness in the thoracic paraspinous area musculoskeletal • WBC—> 14.5 pain • UA—> 10‐20 WBC’s/HPF; 0‐2 RBCs; 1+ 3. Nitrofurantoin for a bacteria UTI • ABD CT—> bilateral renal calculi and no hydronephrosis 4. MRI spine

Case Presentation

• Told to go back to Urgent Care b/o elevated WBCs. She c/o pain in the upper back that has been getting progressively worse. Her Temp is 100.6°F and on exam there is tenderness in the thoracic paraspinous area • WBC—> 14.5 • UA—> 10‐20 WBC’s/HPF; 0‐2 RBCs; 1+ bacteria • ABD CT—> bilateral renal calculi and no hydronephrosis

22 1/20/2017

FEVER AND BACK PAIN Take Home Point

• Pyelonephritis w/wo stone and obstruction • Pancreatitis • Fever and back pain is an epidural • Cholecystitis abscess until proven otherwise*** • PID • Endocarditis • Best diagnostic test is an MRI with • Osteomyelitis/Discitis contrast • Epidural abscess

Role of ESR/CRP in Diagnosis *** • If there is back pain and a predisposing condition for SEA (DM, IVDU, co‐existing infection, recent back surgery, indwelling catheter, immunocompromised) • BUT ONLY ≈ 50% OF PATIENTS WITH AN EPIDURAL ABSCESS HAVE FEVER ON PRESENTATION Obtain an ESR/CRP

If elevated —> obtain MRI (sensitivity 98% Specificity 70%) (J Neurosurg Spine 14:765‐770, 2011)

23 1/20/2017

Case Presentation Case Presentation

• A 62 y/o man with HTN, hyperlipidemia and CAD • presents with new onset of . He notes He presents 2 weeks later to the ED with a that over the last 2‐3 weeks he has not been visual field defect. An CT is done and he is feeling well with intermittent low‐grade found to have a (R) posterior and decreased appetite. On PE he is afebrile communicating artery infarct. He notes with a BP of 118/65 and a P of 98. He has a 2/6 that initially he felt better on the SEM at RUS boarder (old) but an otherwise antibiotics, but when stopped he normal exam. developed low grade fevers again. • A diagnosis of is made —> Augmentin • CBC —> 14.3 with a normal diff; Hct = 32 for 7 days • ESR —> 77

At This Point You Would??

1. MRI of the Brain 2. CT of the sinuses 3. Do a temporal artery BX 4. Obtain BCs

Blood Cultures– Gram negative rods

24 1/20/2017

Case Presentation Trivia Question # 2

• HACEK organisms • – named after the American bacteriologist Elizabeth O. King • aphrophilus • Can you name the two other organisms with • actinomycetemcomitans same genus and species name to honor their (Aggregatibacter actinomycetemcomitans) discoverer? • Cardiobacterium hominus • NOTE—LOA LOA does not qualify • Eikenella corrodons – Mongin, a French surgeon was the first to remove • Kingella kingae the worm from a patient’s eye

Take Home Points Trivia Question

• A prolonged fever is NOT a viral syndrome or a self‐limited bacterial infection • Can you name the two other organisms with – Anyone with a prolonged fever should have blood same genus and species name to honor their cultures drawn discoverer? • “A central nervous system event, especially in a young, otherwise healthy individual, is endocarditis until proven otherwise”

25 1/20/2017

Trivia Answer Case Presentation

• A 36 y/o F underwent a reduction mammoplasty • Per protocol she was on Keflex® 500 mg TID for 7 days • Morganella morganii—named after the British • Post‐op day #5 she developed wound breakdown bacteriologist H. de R. Morgan with serous drainage • —named after the • Antibiotics were changed to Avelox® American pathologist Howard Taylor Ricketts • Despite this her wound worsened and she was admitted to the hospital for IV antibiotics and debridement

Case Presentation Case Presentation

• A 36 y/o F underwent a reduction mammoplasty and abdominoplasty • Per protocol she was on Keflex® 500 mg TID for 7 days • Post‐op day #5 she developed wound breakdown with serous drainage • Antibiotics were changed to Avelox® • Despite several days of Avelox® her wound worsened and she was admitted to the hospital for IV antibiotics and debridement

26 1/20/2017

Case Presentation Case Presentation

• She was taken to surgery where she had an I&D BEFORE systemic antibiotics (vanco & Zosyn®) were started • Her cellulitis progressed despite broadening coverage (vanco/meropenem/caspofungin) and she was taken to surgery 3 more times over the next week • All intra‐operative cultures were negative and she was eventually transferred to UCSF

Case Presentation Case Presentation

• An Infectious Disease Consult was called and a diagnosis was made

27 1/20/2017

What Is The Diagnosis? Case Presentation

1. Fungal infection 2. NTM (M. abscessus/chelonae) 3. Hydradenitis suppurativa • Review of the pathology slides revealed soft 4. Sweet’s syndrome tissue necrosis with abscess formation c/w 5. Pyoderma gangrenosum PYODERMA GANGRENOSUM

Pyoderma Gangrenosum Take Home Point

• Neutrophilic dermatosis • Occurrence – IBD • If it looks like a typical case of cellulitis but – After trauma does does not respond to what should be – Cosmetic surgery appropriate therapy – • Pathergy Get a Dermatology Consult for biopsy to R/O mimickers of cellulitis • Clue to diagnosis – Worsening disease with negative cultures

28 1/20/2017

Masqueraders of Cellulitis (Fallagas ME et al. Ann Intern Med 2005;142:47)

• Superficial and deep venous thrombosis • Contact dermatitis • Insect stings/tick bites • Fixed drug eruptions • Hydradenitis suppurativa • Erythema nodosum • Panniculitis • Sweet’s syndrome • Pyoderma gangrenosum

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