AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Cellulitis is an acute infection of skin and soft tissues characterized by localized pain, swelling, tenderness, erythema, and warmth.

The eMedicine Emergency Medicine article Cellulitis and the Medscape CME course Managing the Complicated Skin and Soft Tissue Infection may be of interest.

Pathophysiology

Cellulitis usually follows a break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Facial cellulitis of odontogenic origin may also occur. Patients with toe web intertrigo and/or tinea pedis and those with lymphatic obstruction, venous insufficiency, pressure ulcers, and obesity are particularly vulnerable to recurrent episodes of cellulitis.^{1, 2, 3} Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis. The vast majority of cases are caused by Streptococcus pyogenes or Staphylococcus aureus. Occasionally, cellulitis may be caused by the emergence of subjacent osteomyelitis. Cellulitis may rarely result from the metastatic seeding of an organism from a distant focus of infection, especially in immunocompromised individuals. This is particularly common in cellulitis due to Streptococcus pneumoniae and marine vibrios.

Frequency

United States

Because cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a relatively common infection. A 2006 study found an incidence rate of 24.6 cases per 1000 person-years.⁴

International

Cellulitis has been found to account for approximately 3% of emergency medical consultations at one United Kingdom district general hospital.

Mortality/Morbidity

Cellulitis generally is a localized infection. Most patients treated appropriately recover completely. Mortality is rare (5%) but may occur in neglected cases or when cellulitis is due to highly virulent organisms (eg, Pseudomonas aeruginosa). Factors associated with an increased risk of death are the presence of concurrent illness (eg, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency) or complications (eg, shock).⁵

Race

No racial predilection has been noted.

Sex

No predilection for either sex is usually reported, although a higher incidence among males has been reported in one study.⁴

Age

No age predilection is usually described; however, recent studies found a higher incidence of cellulitis in general among individuals older than 45 years.^{2, 4} Moreover, cellulitis at certain anatomic sites may show a predilection for persons in certain age groups.

• Facial cellulitis is more common in children younger than 3 years.
• Perianal cellulitis is predominantly a disease of children.⁶

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

The incubation period is somewhat organism dependent. Postoperative cellulitis at the surgical site due to group A beta-hemolytic streptococci may develop rather rapidly. On the other hand, cellulitis due to staphylococci usually is delayed in onset.

• Patients report local pain and swelling at the site of cellulitis.
• The patient may report a history of trauma to the site. Severe bacterial cellulitis may occur as a postsurgical complication, such as following hip replacement⁷ or liposuction, or secondary to lymphatic occlusion following either radical mastectomy^{8, 9} or conservative breast surgery¹⁰; impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass.¹¹ However, cellulitis may follow a trivial injury to the skin (eg, scratch, abrasion, animal bite, intravenous or subcutaneous drug injection, body piercing).^{12, 13, 14}
• Fever is common, and chills may be noted, particularly if suppuration has occurred.
• Malaise may be present.

Physical

The clinical appearance of cellulitis is shown in Media Files 1-3.

• Involved sites are red, hot, swollen, and tender.
• Unlike erysipelas, the borders are not elevated or sharply demarcated.
• Lymphangitis, regional lymphadenopathy, or both may be present.
• Fever is common.
• In severe cases, patients may develop hypotension.
• Local suppuration may follow if therapy is delayed.
• Overlying skin may develop areas of necrosis.
• The most commonly involved site is the leg.^{4, 15}
• Perianal cellulitis due to group A streptococci is usually observed among children with perianal fissures. It is characterized by perianal erythema and pruritus, painful defecation, and bleeding in the stools.⁶
• Pneumococcal facial cellulitis occurs primarily in young children who are at risk for pneumococcal bacteremia.^{16, 17} It may manifest as two distinctive clinical syndromes.
• • Extremity involvement in individuals with diabetes mellitus or substance abuse
  • Head, neck, and upper torso involvement in individuals with systemic lupus erythematosus, nephrotic syndrome, or hematologic disorders

Causes

• In immunocompetent individuals, cellulitis is usually due to S pyogenes and, occasionally, S aureus.^{5, 18, 19} Isolation of methicillin-resistant S aureus (MRSA) is steadily increasing.²⁰ Bacterial strains may also show multiple resistance to other standard antibiotic treatments, including erythromycin.
• Recurrent staphylococcal cellulitis may occur in patients with nasal carriage of staphylococci and those with Job syndrome. S aureus is also the leading cause of soft tissue infections in persons who abuse injection drugs.²¹
• Recurrent cellulitis due to streptococci may be observed in patients with chronic lymphedema (eg, from lymph node dissection, irradiation, Milroy disease, elephantiasis).^{18, 22} Streptococcal infections are also common in injection drug users.²³
• Non–group A streptococci (ie, groups B, C, and G) are commonly implicated in cellulitis in patients with lymphatic obstruction or venectomy for coronary artery bypass graft.^{11, 24}
• S pneumoniae is an uncommon cause of cellulitis in adults.^{17, 25, 26} Pneumococcal cellulitis may occur via bacteremia. In a review of pneumococcal skin infection in adults, all such patients had an underlying chronic illness or were immunocompromised by drug or alcohol abuse.²⁷ Pneumococcal facial cellulitis occurs primarily in young children at risk for pneumococcal bacteremia.^{16, 28}
• Patients who are immunocompromised with granulocytopenia, such as renal transplant recipients, may develop cellulitis due to infection with other organisms, including gram-negative bacilli (eg, Pseudomonas, Proteus, Serratia, Enterobacter, Citrobacter), anaerobes, other opportunistic pathogens (eg, Helicobacter cinaedi, Fusarium species), mycobacteria, and fungi (eg, Cryptococcus).^{29, 30, 31, 32, 19, 33, 34, 35} Preseptal cellulitis caused by dermatophytes is rarely observed, mostly in the pediatric age group.³⁶ Persistent cellulitis due to Cryptococcus neoformans infection has also been reported in a patient receiving renal dialysis.³⁷
• Escherichia coli may be responsible for cellulitis in patients with nephrotic syndrome.³⁸
• Cellulitis from unusual bacterial species, including Enterococcus faecalis, Enterobacteriaceae, and Bacteroides and Clostridium species, may be observed following subcutaneous injections of illegal drugs.³⁹ If Clostridium species or other anaerobes cause the infection, crepitant cellulitis is often observed clinically.
• Other uncommon causes of cellulitis include Neisseria meningitidis; Pasteurella multocida, following animal bites; Aeromonas hydrophilia, following contact with fresh water; Streptococcus iniae, a fish pathogen causing infections in aquaculture farms; and Vibrio vulnificus, following contact with seawater. Cellulitis from marine vibrios in hepatopathic patients may also follow ingestion of contaminated raw oysters.^{40, 41, 42, 43, 44, 45} Haemophilus influenzae has become a rare cause of buccal cellulitis in children after the introduction of the H influenzae type B vaccine.^{46, 47}

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Other Problems to be Considered

Acute gout
Anaerobic myonecrosis
Cutaneous anthrax
Inflammatory carcinoma of the breast⁴⁸
Cutaneous metastasis from neoplasms (especially adenocarcinoma)
Envenomation by puncture with spines of stone fish (in the South Pacific)
Familial Mediterranean fever
Seal finger secondary to seal bites (in aquarium workers and veterinarians)⁴⁹
Sweet syndrome⁵⁰

Other diseases that may sometimes mimic cellulitis include contact dermatitis, drug or foreign body reactions, urticaria, lymphedema, lupus erythematosus, sarcoidosis, lymphoma, leukemia, Paget disease, dendritic cell sarcoma, rheumatoid arthritis, and panniculitis.⁵¹

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Lab Studies

• A raised white blood cell count is a frequent finding, along with an increased body temperature, in up to 42% of patients.⁵² Erythrocyte sedimentation rate and C-reactive protein are also frequently elevated, especially in patients with severe disease requiring prolonged hospitalization.¹⁵
• Needle aspiration of the advancing edge of cellulitis may be stained with Gram stain and cultured.
• • The organism can be so cultured in approximately 30% of patients with cellulitis.³
  • Needle aspiration is performed only in unusual cases (eg, immunocompromised individuals, those not responding to empiric therapy) because the bacterial etiology of cellulitis in usual cases is highly predictable.^{53, 54}
• Blood cultures are positive in only a few patients.^{54, 55} In one study, blood cultures performed for 553 patients with cellulitis revealed a significant patient-specific microbial strain in only 2%. The low yield from blood cultures has a marginal impact on clinical management, and this testing does not appear to be cost effective for most patients with cellulitis, unless chills and high fever, which strongly suggest bacteriemia, are present.
• The prevalence of bacteriemia is higher in patients with cellulitis complicating lymphedema.⁵⁶ Therefore, blood cultures are advisable in such patients; they are also recommended in patients with cellulitis involving specific anatomic sites, such as the oral and ophthalmic area, and in those with a history of contact with potentially contaminated water.⁴⁴
• If recurrent episodes of cellulitis are suspected to be secondary to tinea pedis, mycologic investigations are advisable.

Imaging Studies

• Ultrasonography may be helpful in evaluating suppuration at the site and as an aid in guiding needle aspiration.⁵⁷
• CT scanning or MRI may be helpful to rule out any underlying fasciitis or osteomyelitis, if suspected.

Procedures

• Gram stain of soft tissue aspirate is warranted.

Histologic Findings

Areas of cellulitis reveal findings of soft tissue inflammation. Leukocyte infiltration, capillary dilatation, and bacterial invasion of tissue are observed.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical Care

Patients with mild cases of cellulitis may be treated in an outpatient setting. Oral agents with activity against staphylococci and streptococci (eg, dicloxacillin or flucloxacillin, cephalexin, cefuroxime axetil, erythromycin, clindamycin, cotrimoxazole, amoxicillin/clavulanate) are usually effective for treatment of cellulitis in immunocompetent hosts.³

Manage more severe disease initially with intravenous antibiotics in the hospital. This is also recommended in immunosuppressed individuals and in any patients with a clinically significant concurrent condition, including lymphedema and cardiac, hepatic, or renal failure.

Elevating limbs with cellulitis expedites resolution of the swelling. Cool sterile saline dressings may be used to remove purulent discharge from any open lesion.

• Usually, cellulitis is presumed to be due to staphylococci or streptococci infection and is treated with antibiotics (eg, nafcillin, cefazolin). Other options in allergic patients include clindamycin or vancomycin. Ceftriaxone may be useful in the outpatient setting because it can be administered once daily.⁵⁸
• Agents with a broader spectrum of activity are recommended in selected patients, such as diabetic patients.⁴⁴
• More specific antibiotic therapy may be indicated in patients who develop cellulitis in special settings (eg, after a human or animal bite, exposure to potentially contaminated fresh water or seawater).⁴⁴ Treatment of cellulitis caused by uncommon organisms, such as Vibrio species or gram-negative bacteria, should be individualized to those recovered organisms.⁵⁹ In general, these organisms require treatment with drugs other than those discussed above. For instance, cellulitis due to Vibrio infection may be treated with tetracyclines, chloramphenicol, or aminoglycosides.
• Cutaneous cellulitis and soft tissue infections due to community-acquired MRSA represent an emerging problem also among patients who lack traditional risk factors.²⁰
• • In such cases, management with standard gram-positive antibiotics may be ineffective, also because concomitant multiresistance to other antibiotics widely used in common empiric therapy, including erythromycin, may occur. Bacterial strains are usually susceptible to clindamycin, gentamicin, rifampin, trimethoprim/sulfamethoxazole, and vancomycin.
  • Moreover, a randomized, open-label, comparator-controlled, multicenter, multinational study has recently demonstrated the efficacy of linezolid therapy and its superiority to vancomycin in the management of skin and soft tissue infections, including cellulitis, due to MRSA.⁶⁰ However, bacterial culture is still considered essential in order to determine the antibiotic susceptibility of the bacterial isolate and to adjust the systemic antimicrobial therapy according to sensitivity data.
• If mycologic investigations performed to rule out tinea pedis as a possible cause of recurrent episodes of cellulitis detect the presence of fungal infection in toe webs or feet, treatment with topical antifungals is recommended. With severe chronic changes or if onychomycosis is providing a source for repeated infection, oral antifungals such as itraconazole or terbinafine may be considered.

Surgical Care

Incision and drainage are indicated if suppuration has occurred.

Consultations

• Consult an infectious diseases specialist for recommendations on appropriate antibiotic therapy.
• Consult a surgeon for drainage of any abscess and debridement of any devitalized tissue.

Activity

Immobilization of the affected part may relieve pain.

MEDICATION

Section 7 of 12  

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• Follow-up
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• Acknowledgments
• Multimedia
• References

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.

Drug Category: Antibiotics

Systemic antimicrobials are the mainstay of therapy for cellulitis. Oral antibiotics may be used for mild or localized forms of cellulitis; intravenous antibiotics are indicated for more severe cases and for patients who are immunocompromised.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• If necrosis ensues, promptly remove diseased tissues by surgical debridement.⁶¹ Plastic reconstruction with skin grafting or cutaneous flap resurfacing may be required to achieve final wound closure.
• In case of partial inefficacy of parenteral antibiotics in patients showing hemorrhage and/or bullous cellulitis, administration of adjuvant systemic corticosteroids (prednisone 0.5 mg/kg/d for 5-8 d) may improve the response to treatment.⁶²

Transfer

• Transfer severely ill patients with cellulitis to an intensive care unit for closer observation and aggressive management.

Deterrence/Prevention

• Support stockings may help in cellulitis of the lower extremities.
• Cuts and fissures should be washed and kept clean while healing.
• Patients with recurrent streptococcal cellulitis may be helped with penicillin G (250 mg bid) or erythromycin (250 mg qd or bid).⁶³
• If recurrent episodes of cellulitis are suspected to be secondary to tinea pedis, treat with topical or systemic antifungals.
• Pneumococcal vaccine should prevent cellulitis due to such organisms in children. A study noted that 96% of the serotypes that cause facial cellulitis are included in the heptavalent-conjugated pneumococcal vaccine recently licensed in the United States.

Complications

• Local suppuration with abscess formation and skin necrosis (gangrenous cellulitis) may occasionally be observed.
• Myonecrosis, fasciitis, acute carpal tunnel syndrome (in upper limb cellulitis), and osteomyelitis may occur.¹⁴
• Thrombophlebitis may develop, particularly in the lower extremities.
• Bacteremia may complicate cellulitis.
• Scarlet fever complicating streptococcal cellulitis has been observed but is rare.⁶⁴
• Bacterial- and toxin-related effects may result in shock and multisystem organ failure.^{5, 61}
• Endocarditis is a dreaded complication in patients with erysipelas.⁶⁵
• Recurrence of cellulitis may cause local persistent lymphedema. The final result is a permanent hypertrophic fibrosis to which the term elephantiasis nostras has been given.

Prognosis

• The prognosis of patients with uncomplicated cellulitis generally is excellent. Appropriate antibiotic therapy generally results in complete resolution of the illness.

Patient Education

• Educate patients regarding proper skin hygiene to prevent cellulitis.
• For excellent patient education resources, visit eMedicine's Diabetes Center. Also, see eMedicine's patient education article Cellulitis.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to diagnose other severe soft tissue infections or deep involvement (eg, gas gangrene, necrotizing fasciitis) is a potential pitfall.
• Failure to hospitalize patients with severe cellulitis for intravenous antibiotic therapy and closer observation may result in disease progression.

Special Concerns

• Cellulitis of the lower extremities is more likely to be complicated by thrombophlebitis in geriatric patients.
• Scar cellulitis is common in areas of previous burns, particularly areas that required treatment with grafts.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Cellulitis involving the hand.
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Media file 2:  Cellulitis involving the lower extremity.
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Media file 3:  Cellulitis involving the abdominal wall.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
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• Follow-up
• Miscellaneous
• Acknowledgments
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• References

1. Roujeau JC, Sigurgeirsson B, Korting HC, Kerl H, Paul C. Chronic dermatomycoses of the foot as risk factors for acute bacterial cellulitis of the leg: a case-control study. Dermatology. 2004;209(4):301-7. [Medline].
2. Bjornsdottir S, Gottfredsson M, Thorisdottir AS, Gunnarsson GB, Ríkardsdottir H, Kristjansson M, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. Nov 15 2005;41(10):1416-22. [Medline].
3. Roberts S, Chambers S. Diagnosis and management of Staphylococcus aureus infections of the skin and soft tissue. Intern Med J. Dec 2005;35 Suppl 2:S97-105. [Medline].
4. Ellis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, et al. Cellulitis incidence in a defined population. Epidemiol Infect. Apr 2006;134(2):293-9. [Medline].
5. Carratala J, Roson B, Fernandez-Sabe N, Shaw E, del Rio O, Rivera A, et al. Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. Eur J Clin Microbiol Infect Dis. Mar 2003;22(3):151-7. [Medline].
6. Spear RM, Rothbaum RJ, Keating JP, Blaufuss MC, Rosenblum JL. Perianal streptococcal cellulitis. J Pediatr. Oct 1985;107(4):557-9. [Medline].
7. Durupt F, Dalle S, Ronger S, Thomas L. Does erysipelas-like rash after hip replacement exist?. Dermatology. 2006;212(3):216-20. [Medline].
8. Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. Nov 1992;93(5):543-8. [Medline].
9. Masmoudi A, Maaloul I, Turki H, Elloumi Y, Marrekchi S, Bouassida S, et al. Erysipelas after breast cancer treatment (26 cases). Dermatol Online J. Dec 1 2005;11(3):12. [Medline].
10. Zippel D, Siegelmann-Danieli N, Ayalon S, Kaufman B, Pfeffer R, Zvi Papa M. Delayed breast cellulitis following breast conserving operation. Eur J Surg Oncol. May 2003;29(4):327-30. [Medline].
11. Baddour LM, Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass surgery. Ann Intern Med. Oct 1982;97(4):493-6. [Medline].
12. Goldstein EJ. Bite wounds and infection. Clin Infect Dis. Mar 1992;14(3):633-8. [Medline].
13. Dupuy A, Benchikhi H, Roujeau JC, Bernard P, Vaillant L, Chosidow O, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ. Jun 12 1999;318(7198):1591-4. [Medline].
14. Charalambous CP, Zipitis CS, Kumar R, Lipsett PA, Hirst P, Paul A. Soft tissue infections of the extremities in an orthopaedic centre in the UK. J Infect. Feb 2003;46(2):106-10. [Medline].
15. Lazzarini L, Conti E, Tositti G, de Lalla F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. Dec 2005;51(5):383-9. [Medline].
16. Givner LB, Mason EO Jr, Barson WJ, Tan TQ, Wald ER, Schutze GE, et al. Pneumococcal facial cellulitis in children. Pediatrics. Nov 2000;106(5):E61. [Medline].
17. Parada JP, Maslow JN. Clinical syndromes associated with adult pneumococcal cellulitis. Scand J Infect Dis. 2000;32(2):133-6. [Medline].
18. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. Jan 25 1996;334(4):240-5. [Medline].
19. Guay DR. Treatment of bacterial skin and skin structure infections. Expert Opin Pharmacother. Aug 2003;4(8):1259-75. [Medline].
20. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus--an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis. Apr 2003;16(2):103-24. [Medline].
21. Bassetti S, Battegay M. Staphylococcus aureus infections in injection drug users: risk factors and prevention strategies. Infection. Jun 2004;32(3):163-9. [Medline].
22. Chmel H, Hamdy M. Recurrent streptococcal cellulitis complicating radical hysterectomy and radiation therapy. Obstet Gynecol. Jun 1984;63(6):862-4. [Medline].
23. Sierra JM, Sanchez F, Castro P, Salvadó M, de la Red G, Libois A, et al. Group A streptococcal infections in injection drug users in Barcelona, Spain: epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003. Medicine (Baltimore). May 2006;85(3):139-46. [Medline].
24. Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis. Association with venous and lymphatic compromise. Am J Med. Aug 1985;79(2):155-9. [Medline].
25. Parada JP, Maslow JN. Adult pneumococcal cellulitis: case report and review. Clin Infect Dis. Apr 1999;28(4):918. [Medline].
26. Bachmeyer C, Martres P, Blum L. Pneumococcal cellulitis in an immunocompetent adult. J Eur Acad Dermatol Venereol. Feb 2006;20(2):199-201. [Medline].
27. Capdevila O, Grau I, Vadillo M, Cisnal M, Pallares R. Bacteremic pneumococcal cellulitis compared with bacteremic cellulitis caused by Staphylococcus aureus and Streptococcus pyogenes. Eur J Clin Microbiol Infect Dis. Jun 2003;22(6):337-41. [Medline].
28. Patel M, Ahrens JC, Moyer DV, DiNubile MJ. Pneumococcal soft-tissue infections: a problem deserving more recognition. Clin Infect Dis. Jul 1994;19(1):149-51. [Medline].
29. Anderson DJ, Schmidt C, Goodman J, Pomeroy C. Cryptococcal disease presenting as cellulitis. Clin Infect Dis. Mar 1992;14(3):666-72. [Medline].
30. Kiehlbauch JA, Tauxe RV, Baker CN, Wachsmuth IK. Helicobacter cinaedi-associated bacteremia and cellulitis in immunocompromised patients. Ann Intern Med. Jul 15 1994;121(2):90-3. [Medline].
31. Horrevorts AM, Huysmans FT, Koopman RJ, Meis JF. Cellulitis as first clinical presentation of disseminated cryptococcosis in renal transplant recipients. Scand J Infect Dis. 1994;26(5):623-6. [Medline].
32. Nucci M, Anaissie E. Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: implications for diagnosis and management. Clin Infect Dis. Oct 15 2002;35(8):909-20. [Medline].
33. Yoo SS, Tran M, Anhalt G, Barrett T, Vonderheid EC. Disseminated cellulitic cryptococcosis in the setting of prednisone monotherapy for pemphigus vulgaris. J Dermatol. May 2003;30(5):405-10. [Medline].
34. Gupta R, Rauf SJ, Singh S, Smith J, Agraharkar ML. Sepsis in a renal transplant recipient due to Citrobacter braakii. South Med J. Aug 2003;96(8):796-8. [Medline].
35. Seyahi N, Apaydin S, Kahveci A, Mert A, Sariyar M, Erek E. Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient. Transpl Infect Dis. Jun 2005;7(2):80-5. [Medline].
36. Rajalekshmi PS, Evans SL, Morton CE, Williams RE, Ng CS. Ringworm causing childhood preseptal cellulitis. Ophthal Plast Reconstr Surg. May 2003;19(3):244-6. [Medline].
37. Suranyi E, Maroon M, Tyler WB. Persistent cellulitis in a patient receiving renal dialysis. Cutis. Oct 2003;72(4):320-2. [Medline].
38. Asmar BI, Bashour BN, Fleischmann LE. Escherichia coli cellulitis in children with idiopathic nephrotic syndrome. Clin Pediatr (Phila). Nov 1987;26(11):592-4. [Medline].
39. Dancer SJ, McNair D, Finn P, Kolsto AB. Bacillus cereus cellulitis from contaminated heroin. J Med Microbiol. Mar 2002;51(3):278-81. [Medline].
40. Porras MC, Martínez VC, Ruiz IM, Encinas PM, Fernandez MT, García J, et al. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand J Infect Dis. 2001;33(1):56-9. [Medline].
41. Cartolano GL, Barbier C, Arnoult L, Simon D, Ricome JL, Hayon J. Fatal acute cellulitis due to Neisseria meningitidis. J Clin Microbiol. Aug 2003;41(8):3996-7. [Medline].
42. Winner JS, Gentry CA, Machado LJ, Cornea P. Aztreonam treatment of Pasteurella multocida cellulitis and bacteremia. Ann Pharmacother. Mar 2003;37(3):392-4. [Medline].
43. Lau SK, Woo PC, Tse H, Leung KW, Wong SS, Yuen KY. Invasive Streptococcus iniae infections outside North America. J Clin Microbiol. Mar 2003;41(3):1004-9. [Medline].
44. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. Feb 26 2004;350(9):904-12. [Medline].
45. Falcon LM, Pham L. Images in clinical medicine. Hemorrhagic cellulitis after consumption of raw oysters. N Engl J Med. Oct 13 2005;353(15):1604. [Medline].
46. Branca G, Dym H. Haemophilus influenza cellulitis. A review and case report. N Y State Dent J. Mar 2003;69(3):34-6. [Medline].
47. Lin WJ, Lai YS, Lo WT, Hung CH, Cheng SN, Wang CC. Cellulitis resulting from infection by Haemophilus influenzae type b: report of two cases. Acta Paediatr Taiwan. Mar-Apr 2004;45(2):100-3. [Medline].
48. Kaplansky DB, Kademian ME, VanCourt RB. Metastatic squam