1/ We recently had a patient on service with B/l lower extremity edema with inflammation which was considered to be cellulitis and received antibiotics. This definitely made for some great teaching points as well as a rethink of the Dx.
#medtwitter #MedStudentTwitter #FOAMed

2/This was a great opportunity for a deep dive into domain of pseudocellulitides and this approach made the team reconsider the diagnosis especially since this was a bilateral process.

3/Bilateral cellulitis is exceedingly rare and most likely Dx for this patient was gravitational eczema AKA Stasis dermatitis AKA varicose eczema especially with the Hx of decomp. CHF.
The legs did exhibit calor, dolor, rubor, and tumor. Does this help with a Dx of cellulits ?

The tetrad of physical findings Calor, dolor, rubor, and tumor originally recorded by the Roman encyclopedist A. Cornelius Celsus-1st century A.D. that are taught in med school are in actuality non-specific markers of
inflammation
Celsus AC., De medicina. Self published; A.D. 25.

4/Gravitational eczema is a common form of eczema that occurs on the lower extremities in patients with chronic venous insufficiency. It may be a precursor to more problematic conditions, such as venous leg ulceration and lipodermatosclerosis.

5/Interestingly, in this study, early dermatology consultation for presumed cellulitis represents an economical intervention that reduces hospitalization length and antibiotic use for patients with pseudocellulitis. https://jamanetwork.com/journals/jamadermatology/fullarticle/2672583

6/Alarmingly-misdiagnosis rates are estimated to be as high as 28% in some American hospitals and even higher in the outpatient setting

7/Unfortunately, patients with stasis dermatitis who are hospitalized with a Dx of bilateral cellulitis and treated with antibiotics likely improve clinically because of the leg elevation associated with being bedridden rather than the actual antibiotic effect.

8/It is this improvement that helps to to “confirm” the misdiagnosis and thereby propagates the problem.
Remember: Rubor, Dolor, Tumor, and Calor Does Not Always Equal Cellulitis https://www.the-dermatologist.com/content/growing-problem-pseudocellulitis