In a paper recently published in Journal of the American Academy of Dermatology, researchers proposed there is a three-part pathogenesis of acute inflammatory edema, a form of pseudocellulitis commonly seen in critically ill patients.
Elizabeth M. Marchionne, MD, from the department of dermatology at the University of California, San Francisco, and colleagues described “a ‘three hit’ pathogenesis of acute inflammatory edema” that includes “acute onset volume overload ... in patients with impaired lymphatic return ... [that] leads to dermal edema, microtears in connective tissue, and an influx of inflammation.”
Acute inflammatory edema, a form of pseudocellulitis, commonly presents on the thighs and abdomen in critically ill patients as bilateral, erythematous and edematous plaques, according to the researchers. The distribution of the edema is localized to where fluid accumulates in a supine patient, such as the thighs, lower abdomen and flanks, according to the study. The presentation may be spared on areas of pressure on the skin, including folds and appositional skin and where external objects are in contact with the skin.
The retrospective study included the charts of 15 patients, nine women and six men, who were diagnosed with acute inflammatory edema. The patients were aged 52 to 73 years, with an average age of 63 years.
Consultation was requested for evaluation of suspected cellulitis in five patients, nine consultations were for a new rash of unknown etiology, and one was for an inflamed cyst.
In all 15 patients, the thighs were affected; nine patients had abdomen involvement, and five had lower leg involvement.
An abnormal white blood cell count was present in 11 patients, with an average of 17.4 × 10e9/L (reference range: 3.4 × 10e9/L to 10 × 10e9/L). Thirteen patients had a BMI of 25 kg/m2 or greater; 14 patients had findings of fluid overload.
Interventions in cases of acute inflammatory edema include decreasing the fluid overload on the tissue, compression, repositioning and increased mobility. If antibiotics are used for a cellulitis indication, they should be discontinued.
Acute inflammatory edema, unlike cellulitis, is bilateral and spares areas of pressure. Patients with fluid overload and a high BMI are more often affected.
Patients with suspected acute inflammatory edema should undergo a complete skin examination that focuses on areas of increased pressure to detect sparing. This includes skin folds, appositional skin, and areas in contact with devices such as lines, tubes, catheters and compression devices, as well as the sacrum and medial back where fluid is pushed away to areas of lower resistance.
“Recognizing and naming this entity allows for a bedside diagnosis and avoidance of a broad, costly workup and treatment,” the researchers wrote. – by Abigail Sutton
Disclosures: The authors report no relevant financial disclosures.