Pamantasan ng Lungsod ng MaynilaCollege of Medicine

Department of Internal Medicine

A Case of a 75 y/o Female withCellulitis T/C Sepsis

Presented to the Faculty of the Department of Medicine

In Partial Fulfillment of the Requirements in Internal Medicine CourseAY 2015-2016

Submitted by:

GONZAGA, Valerie J.Section 3-A Group 5

June 25, 2015

Date and Time of History Taking: June 19, 2015 2:00 PM

Informant: Patient and her son Reliability: 90%

General DataPatient A.D.G is 73 years old woman, born on February 8, 1940. She is married and currently

residing at Pandacan, Manila. She is a Roman Catholic. It is her second time to be admitted at Ospital ng Maynila Medical Center last May 29, 2015 at 12:00nn.

Chief ComplaintPatient complains of a loss of consciousness

History of Present Illness5 days PTA, the patient took a bath in the rain and wade her foot on the flood. The patient has

an existing open wound obtained two years ago due to unrecalled trauma.

4 days PTA, the patient noted redness and warmth on her right foot and leg accompanied by an undocumented fever and decreased appetite. Patient also felt pain on the affected area. The patient has no cough, colds, nor nausea and vomiting. No aggravating and palliative factors. No consult done. Patient was unable to walk as the day progressed.

3 days PTA, the patient’s symptoms manifested. However, swelling began to appear on the right foot and leg. Still, no consult done and no medications administered.

2 days PTA, the patient noticed the swelling of the right foot continue to ascend reaching up to the level of the leg. Blisters and ulcer formed at the right foot ensued reaching the lateral malleolus. The fever still persisted. No consults and palliative measures done.

Few hours PTA, the patient became obtunded, only responsive to speech and tapping of shoulders. Fever is persistent. Serous discharge from the blisters and ulcerations was noted. The patient’s right lower extremity continued to swell. This prompted the patient’s consult at Ospital ng Mayniila Medical Center.

Past Medical HistoryThe childhood diseases of the patients are as follows: varicella, measles, and mumps.

The patient has no history of any allergies from food, medications, and animals. She also had no untoward reactions to vaccines.

She also obtained an open wound two years ago at her right foot which is non healing for two years. Last year, she sought consult to a dermatologist and was prescribed with Silver Sulfadiazine.

She is also a known hypertensive with a usual blood pressure of 160/100mmHg with unrecalled age of onset. Maintenance drugs were unrecalled as well as maintenance drugs revealing poor compliance and uncontrolled hypertension.

The patient also has diabetes mellitus diagnosed last 2000. As maintenance drugs, she takes Metformin.

The past hospital admission occurred last year due to loss of consciousness and was diagnosed with cerebrovascular accident.

The patient has no previous surgeries.

Family HistoryThe patient has no familial history of diabetes mellitus, cancer, hypertension, bleeding disorders,

and epilepsy.

The patient’s spouse died due to Kidney Disease last 2005.

Personal and Social HistoryThe patient is the youngest in the brood of 4. She works as laundry woman. She finished school

up to Grade 2. The patient is unable to read and can only write her name. The patient’s residence is built from wood. They also have metered source of water and garbage was collected everyday.

The patient is a current smoker and can consume 6 sticks per day but cannot recall the onset. She occasionally consumes alcohol and denies using prohibited drugs. She has no significant change in appetite prior to hospitalization. Her diet includes fatty foods and foods rich in high glycemic index.

Review of SystemsConstitutional: No chills, no weight gain and weight loss, no fatigue. Integument: Positive for dry and excoriated skin, positive for itchiness, no rashes, no lumpsHead: No hair loss, lightheadedness or dizziness and headacheEyes: No corrective lenses, blurring of vision, eye pain, redness, lacrimation and photalgiaEars: No ear pain, discharge, tinnitus, vertigo and impaired hearingNose: No epistaxis, congestion and dischargeMouth and Throat: No lesions, gingival bleeding, sore throat, dysphagia and use of dentures. Positive for hoarseness.Neck: No pain, lump and stiffnessBreast: No pain, lumps and dischargeRespiratory: No chest pain, dyspnea, wheezing, cough and hemoptysis. Cardiovascular: No palpitations, easy fatigability and varicose veinsGenital: No pain and dischargesUrinary: No dsyuria, hematuria, urinary urgency, oliguria, nocturia and incontinence. Hematologic: No pallor, easy bruising, hematoma and prolonged bleedingMusculoskeletal: No pain and stiffness of joints, with unilateral edema at left foot, no muscle pain and weaknessNeurologic: No memory loss. No nervousness, seizures, numbness, tingling, speech problems and sensorial changes Endocrine: Positive for polyuria, polydipsia, and polyphagia, no excessive sweating and weight lossPsychiatric: No nervousness, anxiety, depression and hallucinations.

Physical ExaminationGeneral Survey

The patient is alert, conscious and not in cardiorespiratory distress. She is not ambulatory and prefers to stay still in left lateral position. She is not well kept.

Vital SignsPatient is afebrile with temperature of 36.7 C, taken on the left axilla. She is hypertensive with

blood pressure of 160/90 mmHg, taken at left arm. Pulse rate is 85 bpm, regular and strong, Respiratory rate is 20 cpm.

SkinThe patient has patches of dry and excoriated skin specifically on her right and left lower

extremities. She has ulceration in her lower back midline in approximately 3x3cm. She also has an ulceration on her right dorsal foot approximately 2x3cm, with dry and scaly margin. She also has a poor skin turger. Fingernails and toenails are cyanotic and not clean.

HEENTHead. Patient’s head is normocephalic with even distribution of black and white hair. No lumps,

leions, and swelling noted.

Eyes. The eyes were symmetrical with even distribution of eyelashes and eyebrows. No periorbital edema noted. Conjunctive is pinkish and sclera is white. Pupils are symmetrical in size (4mm). Pupils are reactive to light and accommodation. No tenderness and enlargement of the lacrimal gland but patient had noticeable excessive watery lacrimal discharge. Patient’s visual acuity tested using counting fingers with ability to identify the numbers of fingers. Extra ocular movement is intact and with positive red orange reflex.

Ears. Auricles are symmetrical with no tenderness and gross abnormalities. Impacted cerumen noted in external canal of both ears. Difficulty assessing the tympanic membrane. Gross hearing is intact with whisper test 10 inches away .

Nose. Septum is midline. Nasolabial folds are symmetrical. Mucosa is pale and absence of discharge. No polyps noted. Frontal and maxillary sinuses are non tender and positive for transillumination.

Throat and Mouth. Lips are pink but dryness and fissures noted. Tongue is midline and no fasciculation noted. Gingiva and mucosa are pink with no bleeding. Dental caries seen with absence of upper first and second molars and lower lateral incisors. Unable to assess palate, uvula and tonsils because patient does not fully open her mouth.

NeckTrachea is midline. Non palpable lymph nodes and thyroid.

Thorax and LungsPatient has symmetric chest expansion with no intercostal retractions and use of accessory

muscles. Anteroposterior diameter and transverse diameter ratio is 1:2. No palpable mass or tenderness. Vesicular sounds heard over the apex and base of the lungs. No adventitious breath sounds noted.

BreastsBoth breasts are symmetrical in size. The areola is round and light brown in color. Nipples are

round and everted. No dimpling, retraction, and obvious mass noted. No prominent and engorged veins present. No palpable lump, tenderness, and discharge from the nipples. No palpable lymph nodes in the axilla.

Chest and HeartAdynamic chest with no heaves and thrills. Unable to assess JVP due to patient’s position. PMI at

the 5th ICS left parasternal border. S1 louder than S2 at the apex. S1 louder than S2 at the base. Heart sounds were distinct but weak. No murmurs heard.

AbdomenAbdomen globular in shape with no presence of striae, dilated veins and visible peristalsis and

pulsations. No bruits heard. Bowel sounds are 15/minute with low pitch sound. Tympanitic on all quadrants. No masses felt on light and deep palpation. Nonpalpable spleen and liver with 8cm liver span.

ExtremitiesLeft and right radial pulses are symmetrical, strong and regular. Fingernails and toenails are pink.

Capillary refill is less than 2.

In the upper extremities, muscle bulk is symmetrical. Weakness is noted both arms and hands. Joints have limited passive range of motion. Tremors are present in left and right hand.

In the lower extremities, pitting edema grade 1 noted at the right foot and leg. Joints have limited passive range of motion. Atrophy noted at the right medial thigh and right anterior leg.

Neurologic ExaminationThe patient is alert and conscious. She is oriented to place, date, and time. She is cooperative,

tries to answer questions and follow simple commands during assessment. Speech is soft and slurred. Thought process intact. The patient is clean, wearing diapers, with a shirt and blanket covering her body. No gross aphasia, apraxia, and agnosia evident. Able to recall recent memory with few gaps in remote memory.

Mini Mental Status ExamPatient able to state her name and the hospital she is admitted. She repeats names of animals

(pig, dog, and cat). Recites number 1-5 in decreasing order. Able to recall three animals mentioned. Able to name the current mayor of Manila and president of the Philippines. Able to name ballpen and watch. Repeat yes or no. Followed three-step command (hold hand the examiner, grip hand of the examiner, and remove hand of the examiner.)

Cranial Nerves

Motor, Gait and CoordinationPatient unable to sit, stand and walk independently. She prefers to lie in left lateral position. She

needs assistance to be turned to the other side. Able to perform alternating pronation and supination in right hand.

I Ophthalmic Unable to testII Optic Visual acuity is intact but does not react to lightIII Oculomotor IntactIV Trochlear IntactV Trigeminal Facial movement is symmetrical

Temporal and masseter strength intact but weakness notedVI Abducens IntactVII Facial Able to puff cheeksVIII Acoustic Gross hearing intactIX Glossopharyngeal Speech intact but unable to open the mouth widelyX Vagus Trapezius muscle strength

Right: 1/5Left: 1/5Sternocleidomastoid muscle strengthRight: 0/5Left: 0/5

XI Accessory

XII Hypoglossal Tongue can move right and left

Muscle Strength

Deep Tendon ReflexesRight Left

Brachial 0 -Patellar 0 -

Sensory Sensation equal on both upper and lower extremities. Patient can differentiate light and sharp

touch. Vibratory and position sense can be felt. Stereognosis and graphesthesia are present.

Salient Features

SALIENT FEATURES

PERTINENT (+) PERITNENT (-)

Chief Complaint • Decreased level of consciousness

History of Present Illness

• Persistent open wound• Pain, warmth and erythema on right foot to

right lower leg• Fever• Decreased appetite• Swelling of the right leg• Blister and ulcer formation• Obtunded

• No cough and colds• No nausea and vomiting

Past Medical History • Unrecalled trauma• CVA• Hypertension• Uncontrolled diabetes mellitus

Family History • No family history of diabetes mellitus, cancer, hypertension, blood disorders and

Upper extremities Right LeftC5 Shoulder extension 2 -C6 Arm flexion 2 -C7 Arm extension 2 -C8 Wrist extension 2 2T1 Hand grasp 3 3

Lower extremities Right LeftL2 Hip flexion 2 -L3 Knee extension 2 -L4 Knee flexion 1 1L5 Ankle Dorsiflexion 1 -S1 Ankle plantar flexion 1 -

PERTINENT (+) PERITNENT (-)

epilepsy.

Personal and Social History

• Smoker (6sticks per day)• Preference to fatty food and foods with

high glycemic index

Review of Systems • Dry skin• Itchiness• Hoarseness• Unilateral edema• Polyuria• Tremors• Polydypsia• Polyphagia

• No fever• No chills• No weight loss• No fatigue• No rashes• No chest pain• No dyspnea• No increased blood pressure• No nausea• No vomiting

Physical Examination • BP 160/90• Ulceration at the lower back and right

dorsal foot• Abdomen with striae, dilated veins, visible

peristalsis, visible pulsations• Fingernails and toenails are cyanotic• Upper and lower extremities weakness• Upper and lower extremities joints have

limited passive range of motion• Muscle atrophy at the right medial thigh

and anterior leg.• Weak pulse on the right popliteal and

dorsalis pedis• Pitting edema on the left lower leg, grade 2

• Temp= 36.7• HR = 85• RR = 20• Not in cardiopulmonary distress• No atrophy of the tongue• No abdominal bruits• No deformities, swelling or redness of

joints• No muscle atrophy in the lower extremity

Neurologic Examination

• Semi-fowler’s position• Slurred speech• Cannot do tasks using hands due to

tremors

• No problems with sensation

Approach to Diagnosis

The approach to diagnosis can be done by the patient’s clinical history, physical examination, laboratory results, and culture and sensitivity. The patient’s case focuses on inflammation and fever that occurred to the patient. From that pivot point, it is necessary to know the origin of the inflammation, whether it is infectious or noninfectious. Infectious causes may have different etiologies such as due to a foreign body, viral, or bacterial infection. Based on the manifestations presented by the patient, the most likely etiologic cause is bacterial. Bacterial affectation to the different organ system must be identified. On the other hand, noninfectious causes may be due to autoimmune disease or metabolic derangement.

Differential DiagnosesNecrotizing Fasciitis

Rule In Rule Out Initial lesion trivial Inflammation, edema and discoloration Progression with systemic toxicity high

fever, disoriented, and lethargic Severe constant pain

Wooden-hard induration of the subcutaneous tissues

Broad erythematous tract is sometimes evident along the route of the infection, as it advances proximally in an extremity.

Necrotizing fasciitis is a relatively rare subcutaneous infection that tracks along fascial planes and extends well beyond the superficial signs of infection, such as erythema and other skin changes. Extension from a skin lesion is seen in 80% of cases. The initial lesion, such as a minor abrasion, insect bite, is often is trivial. As it progresses, there is systemic toxicity with high temperatures. The patient may be disoriented and lethargic. A distinguishing clinical feature is the wooden-hard feel of the subcutaneous tissues. In cellulitis, the subcutaneous tissues can be palpated and are yielding. But in fasciitis, the underlying tissues are firm, and the fascial planes and muscle groups cannot be discerned by palpation. It is often possible to observe a broad erythematous tract in the skin along the route of the infection as it advances cephalad in an extremity (Lipsky, 2012).

Erysipelas

Rule In Rule OutIntensely erythematous With delineated borders

Found in the lower extremities 70-80%Common in older adults

Erysipelas is distinguished clinically from other forms of cutaneous infection by the following 2 features: the lesions are raised above the level of the surrounding skin, and there is a clear line of demarcation between involved and uninvolved tissue. In older reports, erysipelas characteristically involved the butterfly area of the face, but at present, the lower extremities are more frequently affected (Lipsky, 2012).

Pyoderma GranulosumRule In Rule Out

Deep ulcerationPainPredominance to females

50% associated with inflammatory bowel diseasepredominant 4 to 5th decade of life

Pyoderma gangrenosum is an uncommon, ulcerative cutaneous condition of uncertain etiology. It is associated with systemic diseases in at least 50% of patients who are affected. Although pyoderma gangrenosum affects both sexes, a slight female predominance may exist. Pain is the predominant historical complaint. Arthralgias and malaise are often present. The disease may affect all ages, but it predominantly occurs in the fourth and fifth decades of life (Jackson, 2014).

Working ImpressionThe working impression for this case is CELLULITIS T/C SEPSIS.

According to Harrisons, cellulitis is an acute inflammatory condition of the skin that is characterized by localized pain, erythema, swelling, and heat. It may be caused by indigenous flora colonizing the skin and appendages (S. aureus and S. pyogenes) or by a wide variety of exogenous bacteria. The patient’s previous nonhealing wound was the portal of entry of the microorganisms. Bacteria can gain access to the epidermis through a skin abrasion or cut. The organism most likely responsible for the infection is Streptococcus agalactiae (group B Streptoccocus), which occurs, primarily in elderly patients with diabetes mellitus.

The patient’s comorbidity of Diabetes Mellitus aggravated the condition. She has a greater risk of having severe infection, specifically skin and soft tissue infcetions. Diabetic patients have abnormalities in cell-mediated immunity and phagocytic function associated with hyperglycemia. This occurrence can be attributed to the patient’s Poor glycemic control.

Diagnostic Work up and Rationalea. Determine and monitor the patient’s blood glucose level. The patient is a known diabetic with

uncontrolled blood glucose levels. In addition, hyperglycemia caused by decreased insulin availability and increased resistance to insulin can affect the cellular response to tissue injury. Immune cells necessary for wound healing, such as PMN leukocytes and fibroblasts, has a delayed response to injury and impaired functioning of immune cells in diabetes mellitus (Rosenberg, 1990)

b. Blood culture. A diabetic patient with cellulitis is recommended to have a base line for empiric and definitive therapy. Culture can identify the organism responsible for the infection. Thus, a targeted therapy can be instituted.

Management & TreatmentThe patient warrants admission due to her severe infection with complicating features of

Systemic Inflammatory Response Syndrome (SIRS), uncontrolled glycemic control and hypertension, altered mental status, and old age.

1. CELLULITIS Non Pharmacologic ManagementAppropriate wound care should be provided such as:

a. Debridement, involves removing necrotic or nonviable tissue, slough, or foreign material from the wound, as well as trimming any surrounding hyperkeratosis (callus). This process also removes colonizing bacteria, aids granulation tissue formation and reepithelialization, reduces pressure at callused sites, facilitates the collection of appropriate specimens for culture, and permits examination for the presence of deep tissue (especially bone) involvement. Sharp methods are generally best, but mechanical, autolytic, or larval debridement techniques may be appropriate for some wounds.

b. Selection of dressings that allow for moist wound healing because the patient has a dry nonpurulent wound. The goal is to create a moist wound environment to promote granulation (new tissue containing all the cellular components for epithelialization), autolytic processes (wherein host generated enzymes help break down de- vitalized tissues), angiogenesis (new blood vessel formation), and more rapid migration of epidermal cells across the wound base. The following dressings are applicable:

Continuously moistened saline gauze: for dry or necrotic wounds Hydrogels: for dry and or necrotic wounds and to facilitate autolysis Films: occlusive or semiocclusive, for moistening dry wounds

Pharmacologic ManagementMost severe infection starts with severe broad-spectrum empiric antibiotic therapy, pending

culture results and antibiotic susceptibility data. Definitive therapy will be based on the results of an appropriately obtained culture and sensitivity testing of a wound specimen as well as the patient’s clinical response to the empiric regimen. Severe infection necessitates parental therapy switching to oral agents when the patient is systemically well and culture results are available.

For cellulitis with systemic signs of infection systemic antibiotics are indicated. A coverage against methicillin-susceptible S. aureus (MSSA) is recommend. In severely compromised patients), broad-spectrum antimicrobial coverage may be considered. Vancomycin plus either piperacillin- tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections. The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period. Hospitalized patients may be treated for as long as 2-3 weeks.

Prior to discharge, the patient should be clinically stable, have achieved acceptable glycemic control; and have a well-defined plan that includes an appropriate antibiotic regimen to which she will adhere, specific would care instructions, and appropriate outpatient follow-up.

2. DIABETES MELLITUSNon Pharmacologic Therapy Diet, avoid food rich in high glycemic index Regular exercise

Pharmacologic TherapyConsidering the patient’s suspicion for infection, the best oral hypoglycemic drug would be alpha

glucosidase inhibitor. Metformin is contraindicated for patients with sever infection. Insulin can be an option as long as administration will be on strict aseptic technique for better patient compliance.

3. HYPERTENSIONNon Pharmacologic Therapy Moderate sodium restriction Weight reduction Moderately intense physical activity, such as 30–45 min of brisk walking most days of the week

Pharmacologic TherapyInitial therapy for diabetic hypertensive patients includes Angiotensin-converting enzyme (ACE)

inhibitors, Angiotensin receptor blockers (ARBs), Diuretics, and β-blockers. Many patients required three or more drugs to achieve the specified target levels of blood pressure control. Patients over age 55 years, with another cardiovascular risk factor (patient is a smoker), an ACE inhibitor (if not contraindicated) should be considered to reduce the risk of cardiovascular events.

ReferencesRosenberg CS (1990) Wound healing in the patient with diabetes mellitus. Nurs Clin North Am. 1990

Mar;25(1):247-61. Review. PubMed PMID: 2179891.

Benjamin A. Lipsky, et. al (2012) 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

Dennis L. Stevens, et.al (2014) Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

Jackson, M. (2014, March 3). Cellulitis. Retrieved June 35, 2015, from Mescape: http://emedicine.medscape.com/article/1123821-clinical

American Diabetes Association. (2002, January). Treatment of Hypertension in Adults With Diabetes. Retrieved June 25, 2015, from Diabetes Journals: http:// care.diabetesjournals.org /content/25/suppl_1/s71.full#ref-list-1