Thursday, April 03, 2008

A Leg to Stand On

Abstract: 85 yo man with cellulitis and lymphedema s/p bypass surgery

HPI: In 2000, this retired professor had CABG surgery with saphenous vein harvesting of the left leg, In 2002, while visiting Vienna, he was hospitalized for cellulitis of the left leg and treated with i.v. antibiotics. In the subsequent years, he has had progressive lymphedema of the left leg with the development of elephiantiasis nostra verrucosa. In the past 6 months he has had four documented episodes of cellulitis which have necessitated antibiotics. Recently, he has developed a generalized dermatitis. His medications include: atenolol, amiodarone, digoxin, diovan, thyrpid, Coumadin, Lovastatin, ASA. He has a possible allergy to penicillin (has not taken it in 40 years). He is otherwise quite healthy and intellectually alert.

O/E: Chronic lymphedema left leg with erythema, scale and some honey-colored crust. The leg in involved from just below the knee to the foot. The left leg is only minimally warmer than the right leg. In addition, he has a wide-spread dermatitis consisting of erythematous scaly patches on legs, arms and abdomen -- sparing the face.

Photos:






Lab: His internist did a skin culture and CBC b efore sending him here (results not back) . He was on Bactrim at the time of the culture.

Diagnosis: Recurrent Cellulitis s/p saphenous veif harvesting wit the development of chronic lymphedema and early elephiantiasis nostras. This was reported in 1982 (see Reference). The wide-spread dermatitis may be an "id" reaction.

Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Follow-up: The patient was treated with compression stockings, cephalexin 250 mg qid for two weeks (based on sensitivities), desoximetasone 0.25% cream and lymphatic massage. There was no evidence of tinea pedis. He has improved markedly.
Photos taken June 10, 2008





Reference:
Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.

12 comments:

  1. Ashok Kumar SharmaApril 04, 2008

    1. From the images posted I do not see any 'lymphedema'. Clinically it may be there as an image is not a substitute for a live case. The mild edema I see may be inflammatory edema accompanying the acute exacerbation of eczema with remote 'ide'spread.
    2. Unilateral eczema (in the left leg in this case) goes against sensitization to superantigens as this would and should lead to a generalized or atleast a bilateral spread/exacerbation of eczema.
    3. There is no doubt eczema is there. Recurrent episodes of cellulitis in the leg may have led to some 'stasis' also in the left leg. Again I do not see prominent 'Elephantiasis nostras verrucosa' from the images (I don't deny its presence in the case).
    Unilateral eczema suggests sensitization to topical medications (contact allergic eczema.
    4. The management should in my view involve:
    - a daily cleansing with simple nonmedicated soap
    - topical corticosteroid, followed immediately by
    - topical emollient application like vaseline
    - A course of oral cloxacillin or a course of amoxicillin/clavulinic acid for 7 days
    - An inj of Triamcinolone acetonide 40 mg IM stat
    - Oral cetirizine tab

    All of this should continue for about 3-weeks before another assessment is made.

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  2. As he is particularly focused on his leg, I would question him very carefully about occult OTC contact sensitizers that he might be using. I would then focus on patch testing and decompressing what appears to be woody phase lymphedema with intermittant positive pressure treatment delivered vai a mechanical pump under the supervision of a physical therapist.

    ReplyDelete
  3. These cases of leg cellulitis generally pose a challenge and I am hoping that the professor gets some measure of relief with a suitable treatment.
    I would have appreciated a picture of the generalized dermatitis to determine whether his 'cellulitis' is isolated or is an extension of a drug hypersensitivity from his oral medications.
    From a dermatological standpoint I would give moisturizers, steroid creams, vitamin e oil ( topical and oral), multiviatmins like aqueous cream, leg elevation,etc.

    I agree with referral to vascular medicine specialist for further testing and treatment of circulatory problems.

    ReplyDelete
  4. Amanda OakleyApril 04, 2008

    I saw a very similar case yesterday, in hospital for confirmed recurrent cellulitis, but also has recently developed a dermatitis. I am in support of prophylactic penicillin after the acute infection has been controlled - I had an interesting discussion with my registrar regarding the role of the ongoing antibiotic. Is it mopping up a few persisting strep? Or preventing invasion by new strep? Or anti-inflammatory (in which case penicillin might not be the best choice)? Does it reduce risk of dermatitis if the dermatitis is driven by bacterial sensitivity rather than by stasis?
    Of course, the dermatitis needs treating vigorously with topical and/or systemic steroids, emollients and reduction of oedema.

    ReplyDelete
  5. M. LacombeApril 05, 2008

    My concern, based on a very narrow point of view, is that his surgery, etc. has set him up for any propensity for edema preferentially in that leg, i.e. any increase in central venous pressure which might cause very little edema in the otherwise normal patient in this man produces a significant degree of edema.

    And the ominous thought is that amiodarone therapy has led to unrecognized pulmonary toxicity, with resultant high right-sided pressures, increased RV, RA, and CV pressures, and this peripheral manifestation.

    Every consideration should be given to r/o amiodarone pulmonary toxicity; in its early stages, it is reversible, but then becomes ‘fixed’ and severely debilitating, if not lethal. "Cardiologist, Augusta, Maine"

    ReplyDelete
  6. DR.KHALIL AL HAMDIApril 06, 2008

    Based on the apparent clinical features i think the pt. is suffering from acute on chronic dermatitis mostly caused by underlying venous vascular abnormalies ,so on should check this possibility &treat accordingly,meamwhile the acute phase dermatitis can can be managed by topical steroid +antibiotics &drying agents.

    ReplyDelete
  7. think the main picture is chronic dermatitis on the top of oedematous leg.This area is highly susceptible for topical sensitizers irritants and infection in form of cellulitis.Also the leg skin could be easily irritated by simple scraching leading to traumatic dermatitis.So to manage this case we should stop all topical remedies apart from local steroid ointment but not cream together with prednisolone 10mg a day,oral antihistamines,elevation of the leg together with systemic anibiotic.The condition will resolve gradually as I hope

    khalifa sharquie

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  8. i think long course of systemic abx with emmollients and supportive measures (raising leg, strapper if can tolerate) is enough. i wouldnt prescribe topical abx which have high rates of contact sensitization in such cases.

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  9. Larry BaddourApril 08, 2008

    Dr. Elpern, thank you for your comments. The "incubation period" and recurrent nature are characteristic of our syndrome. A few comments:

    1. Does the patient have tinea pedis? The multiple recurrences predated the onset of dermatitis - correct? If so, then tinea pedis would be a chronic skin condition that predisposes to recurrent cellulitis in the postvenectomy patient.

    2. Agree that long-term suppressive therapy should be considered. Therefore, need to define the responsible pathogen; likely groups B or G beta-hemolytic streptococci. Obtain ASO and antiDNAse B serology and toe web cultures (if tinea pedis present). Would routinely use penVK but patient is pen-allergic. You need more details on allergy. Macrolide could be used, but some beta-strep are now macrolide resistant.

    3. To hopefully prevent recurrences, agree with lymphedema eval and treatment. Ditto for dermatitis (and tinea pedis if present).

    4. See my chapters in UpToDate for more recs.

    ReplyDelete
  10. I would definitely check for tinea pedis and treat daily with loprox suspension on the feet. Topical steroid in ointment base on leg, like dermatop. Would also switch to only using vanicream, fragrance, preservative etc free and of course a light support knee high.

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  11. I think cellulitis is often overdiagnosed in chronic, recurring edema of the lower extremities. I'd rule out tinea and contact dermatitis to the ingredients in Unna Boots and Circ-Aid pressure garmants, and try to maintain him edema free.

    ReplyDelete

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