In adults hospitalized for lower extremity cellulitis, many will eventually receive a different diagnosis of their symptoms

EBM Focus - Volume 11, Issue 48

Read the full EBM Focus and earn CME credit.

Reference - JAMA Dermatol 2016 Nov 2 early online

  • In a cross-sectional analysis of medical records from 259 adults with lower extremity cellulitis diagnosed in the emergency room of a large urban hospital, 79 (30.5%) had a change in diagnosis during the hospital stay or within 30 days of discharge.
  • Of 52 misdiagnosed patients who were admitted to the hospital for treatment of cellulitis, assessment of the final diagnosed condition suggests that 92% had unnecessary antibiotic therapy and 85% had unnecessary hospital admission.

Cellulitis, a common clinically diagnosed infection treated with antibiotics, has symptoms and clinical presentation (localized erythema, swelling, tenderness, and warmth) that may occur with other conditions such as venous stasis dermatitis, deep vein thrombosis, gout, or contact dermatitis (JAMA 2016 Jul 19;316(3):325). Misdiagnosis can lead to inappropriate management including unnecessary antibiotic therapy and hospital admission. To better assess the rate and ramifications of misdiagnosed cellulitis, a recent cross-sectional study used a patient data repository and medical records to retrospectively assess 259 adults with a primary or secondary diagnosis of lower extremity cellulitis in the emergency department of a large urban hospital. Patients were excluded for lesions that were not in the lower extremity or that were associated with significant comorbidities or other factors that might complicate the assessment, including burns, diabetic ulcer, or surgery during the previous 30 days. A misdiagnosis was defined by a subsequent change in diagnosis during hospital course or within 30 days of discharge.

The retrospective medical record review identified misdiagnosis in 79 (30.5%) patients, of whom 52 were admitted to the hospital primarily for treatment of the presumed cellulitis. Of these 52 patients, all had IV antibiotic therapy at the hospital, but antibiotics were later considered unnecessary in 48 (92%) due to an eventual diagnosis of a condition without a bacterial etiology, and 44 (85%) were later considered to have had unnecessary hospital admission for a mean of 4.3 days (also based on the eventual diagnosis). None of these 52 patients developed anaphylaxis or C. difficile or nosocomial infections. Among all 79 patients with misdiagnosed primary or secondary cellulitis, 61% had an eventual diagnosis of a vascular condition (most commonly venous stasis dermatitis or venous stasis ulcer), 19% had an inflammatory condition (most commonly gout/pseudogout or contact dermatitis), 7.6% had an infection (including 2 cases of ecthyma gangrenosum), 2.5% had a musculoskeletal injury, and 10% had another condition.

This retrospective cross-sectional study showed that, among patients hospitalized for cellulitis from the emergency department, a subsequent change in diagnosis, including to a condition without a bacterial etiology, is not uncommon. Misdiagnoses in this paper were determined retrospectively via medical record review, and the events that led to a change in diagnosis, including response to treatment, specialist consultation, or additional assessments, were not reported. It should be emphasized that this study is not a criticism of specific diagnostic practices and that its results do not suggest ways to improve diagnosis or avoid unnecessary antibiotic therapy or hospital admission. Rather, this study reinforces the idea that cellulitis, while common, has many mimics and this is especially important to bear in mind in patients for whom hospitalization is deemed necessary. It may be prudent to carefully consider a broad differential diagnosis and have a low threshold for a second opinion or specialty consultation in these situations.

For more information, see the Cellulitis topic in DynaMed Plus. DynaMed users click here.