58-year-old man with fever and a red swollen leg
A 58-year-old man with obesity and poorly controlled type 2 diabetes comes to urgent care for 2 days of worsening pain, redness, and swelling of the left lower leg after scratching between his toes. He reports fever and chills but no trauma. Temperature is 38.4 C, blood pressure is 128/76 mm Hg, and heart rate is 104/min. The shin is warm, tender, and diffusely erythematous with indistinct borders; there is interdigital scaling and fissuring. No crepitus, bullae, fluctuance, or purulent drainage is present. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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View on AmazonThe Correct Answer
C
Explanation
Clinical Pearl:
Nonpurulent cellulitis is usually caused by beta-hemolytic streptococci and is treated with an oral beta-lactam when the patient is stable and lacks features of abscess or necrotizing infection. Concurrent interdigital tinea pedis should be treated because it often serves as the portal of entry and predisposes to recurrence.
Explanation:
This patient has uncomplicated nonpurulent cellulitis, suggested by diffuse erythema with indistinct margins, warmth, tenderness, fever, and a clear skin barrier break from fissured toe-web tinea, without abscess or necrotizing features. Current skin and soft tissue infection guidance recommends oral therapy targeting streptococci, and cephalexin is an appropriate first-line choice for a stable outpatient. Treating the interdigital fungal infection is also important because it is the likely source and reduces future episodes. Incision and drainage is used for a drainable abscess, which is not present here. Trimethoprim-sulfamethoxazole alone has unreliable streptococcal coverage and is better suited to purulent infection when MRSA is a concern. MRI is unnecessary in routine cellulitis without concern for deep tissue infection, and broad intravenous therapy such as vancomycin plus piperacillin-tazobactam is reserved for severe infection, immunocompromise with systemic instability, or suspected necrotizing process.
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