Internal Medicine

0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

292 Celiac Sprue and Malabsorption Cellulitis

■Refractory celiac sprue: intestinal ulcerations; risk of intestinal lym-

phoma or carcinoma increased but not common; physician must be

alert for these developments

■Long-term prognosis is usually excellent if gluten-free diet is main-

tained.

Cellulitis...........................................

RICHARD A. JACOBS, MD, PhD

history & physical

History

■Predisposing factors include trauma, IV drug use, underlying skin

disease (psoriasis, eczema), peripheral edema (CHF, venectomy for

CABG, lymph node dissection), diabetes, peripheral vascular disease

and bites (human, dogs, cats)

■Epidemiology determines bacteriology:

➣Community-acquired – 90% group A streptococcus (S. pyogenes),

10% Staphylococcus aureus. Increasing reports of community-

acquired methicillin-resistant S. aureus skin and soft tissue infec-

tions, especially in athletes, gay men, drug users, prisoners.

➣Nosocomial (surgical wounds, IV sites, decubitus ulcers) – S.

aureus, enterococcus, enteric Gram-negative rods, group A strep-

tococcus

➣IV drug use – S. aureus, streptococci, Eikenella corrodens, other

mouth flora

➣Diabetes/peripheral vascular disease – localized cellulitis sur-

rounding ulcer in patient without systemic symptoms due to

group A strep and/or S. aureus; extensive cellulitis with systemic

symptoms polymicrobial including S. aureus, group A strep,

anaerobes, enteric Gram-negative rods

➣Dog and cat bites – S. aureus, streptococci, anaerobes, Pas-

teurella multocida and other Pasteurella species, Capnocytopha-

gia species

➣Human bites – viridans streptococci, mouth anaerobes, Eikenella

corrodens, S. aureus

Signs & Symptoms

■Pain, tenderness and erythema (pain absent in diabetics with

neuropathy); may spread rapidly with systemic symptoms, local

adenopathy and bullous formation in severe cases