September
Cellulitis
This is an infection of the subcutaneous tissues.
The infection is generally deeper and has more indistinct margins than erysipelas.
The infective organism is usually Group A strep. S.aureus is less common.
Clinical findings include erythema, warmth, tenderness, lymphangitis and lymphadenitis.
Erysipelas
This is an infection of the superficial soft tissues characterized by a progressively enlarging, well demarcated, red, raised painful plaque.
The most common organism is group A strep (in non-diabetics). In diabetics the common organisms are group A strep, S.aureus, enterobacteriaceae and clostridia.
Diabetic patients with erysipelas may require debridement to rule out underlying necrotizing fasciitis.
Septic patients should have an X-ray to rule out gas in the soft tissues.
Necrotizing fasciitis
Often associated with diabetes. This is an aggressive, potentially lethal condition most commonly caused by Group A strep. May have multiple organisms, including clostridia and anaerobic organisms.
It may follow trauma or surgery or after a streptococcal skin infection.
Can be differentiated from cellulitis or erysipelas by its rapid progression, failure to respond to appropriate antibiotics and marked systemic features.
Treatment is with intravenous antibiotics and extensive surgical debridement.
Mortality of 9-26%.
Gas gangrene
Muscle infection that is associated with grossly contaminated wounds (particularly ones closed primarily).
Due to Clostridia perfringens or Clostridia septicum, which produce exotoxins.
Characterized by pain, swelling, a foul smelling serosanguinous discharge and gas in the soft tissues. May be accompanied by signs of septic shock.
Treatment is with antibiotics (penicillin and clindamycin), radical debridement and hyperbaric oxygen.
Tetanus
Caused by Clostridium tetani, a gram positive anaerobic rod.
Pyomyositis
This is a rare condition that is seen more frequently in the tropics. The mean age in one large review was 28 years old, and males were slightly more commonly affected.
The disease is rare because skeletal muscle is resistant to bacterial infection. For muscle to become infected, it must be damaged in some way, e.g. by trauma or by preceding viral or parasitic infection.
Pyomyositis is seen more frequently in patients with HIV or other causes of immunosuppression. An underlying disease should be sought in any patient over thirty.
The muscle most frequently involved is the quadriceps; other muscles often involved are the glutei and the iliopsoas.
The micro-organism most commonly implicated is S.aureus.
There are three described phases of this infection:
- Initial invasive phase
- Suppurative phase
- Late phase – fluctuance and systemic findings.
The diagnosis is best confirmed with MRI with gadolinium contrast. This allows differentiation between the inflammatory phase and the abscess stage. It also allows differentiation from polymyositis.
Treatment is with surgical debridement and intravenous antibiotics.
One alternative to surgical debridement is CT guided aspiration.
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