Home Medicine Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis
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Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis

  • Cynthia E. Burke ORCID logo EMAIL logo , Owen R. Maley , Benjamin Mancini , Sahil Sardesai , Austin B. Montgomery ORCID logo , Tonya S. King and Donald J. Flemming
Published/Copyright: April 11, 2025
Diagnosis
From the journal Diagnosis Volume 12 Issue 3

Abstract

Objectives

Cellulitis shares several clinical features with fulminant deep soft tissue infections, creating a diagnostic dilemma for which clinicians are increasingly using cross-sectional diagnostic imaging to resolve. However, the role of imaging in apparent cellulitis is poorly defined. In particular, the clinical utility of CT in extremity cellulitis is underexplored. The purpose of this study was to determine patient and clinical factors that increase likelihood for finding of deep infection on CT among patients with extremity cellulitis.

Methods

A retrospective observational study was performed of patients with cellulitis of the extremities who were examined with computed tomography from January 1, 2012 to December 31, 2021. Demographics, medical history, and clinical and laboratory characteristics were collected. The presence of positive findings on CT report was recorded. Repeated measures logistic regression was used to evaluate significant predictors of positive CT.

Results

There were 496 eligible patient encounters, and CT was positive for deep infection in 39 cases (7.9 %). Median patient age was 56 years of age, 58.1 % were male, and most patients had a history of diabetes mellitus, history of tobacco use, and/or obesity. Significant predictors for positive CT on multivariable analysis included gas on pre-CT radiographs, febrile leukopenic state, injection drug use, purulence on exam, and white blood cell count extremes. Elevated CRP was also a significant positive predictor on bivariate analysis.

Conclusions

Finding a deep infection on CT in a patient with extremity cellulitis is uncommon and is predominantly associated with a high-risk clinical picture, and/or with high index of suspicion based on pre-CT plain films. In the absence of these patient factors or compelling findings on radiographs, CT does not typically provide clinically actionable information for extremity cellulitis and should not be used as part of standard evaluation.

Keywords: cellulitis; extremity cellulitis; computed tomography; computed tomography utilization; imaging utilization; necrotizing soft tissue infection
Corresponding author: Cynthia E. Burke, Pennsylvania State University College of Medicine, 700 HMC Crescent Rd, 17033 Hershey, PA, USA, E-mail:

  1. Research ethics: The Institutional Review Board deemed this study exempt.

  2. Informed consent: Not applicable.

  3. Author contributions: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: Cynthia E. Burke, BS, Owen Maley, MD, Benjamin Mancini, MD, Sahil Sardesai, BS, Austin B. Montgomery, BS, Tonya S. King, PhD, Donald J. Flemming, MD. Drafting the work or reviewing it critically for important intellectual content: Cynthia E. Burke, BS, Owen Maley, MD, Benjamin Mancini, MD, Sahil Sardesai, BS, Austin B. Montgomery, BS, Tonya S. King, PhD, Donald J. Flemming, MD. Final approval of the version to be published: Cynthia E. Burke, BS, Owen Maley, MD, Benjamin Mancini, MD, Sahil Sardesai, BS, Austin B. Montgomery, BS, Tonya S. King, PhD, Donald J. Flemming, MD. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Cynthia E. Burke, BS, Owen Maley, MD, Benjamin Mancini, MD, Sahil Sardesai, BS, Austin B. Montgomery, BS, Tonya S. King, PhD, Donald J. Flemming, MD. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Use of Large Language Models, AI and Machine Learning Tools: None declared.

  5. Conflict of interest: The authors state no competing interests.

  6. Research funding: None declared.

  7. Data availability: The raw data can be obtained on request from the corresponding author.

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Received: 2024-09-22
Accepted: 2025-03-21
Published Online: 2025-04-11

© 2025 Walter de Gruyter GmbH, Berlin/Boston

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https://doi.org/10.1515/dx-2024-0156
Keywords for this article
cellulitis; extremity cellulitis; computed tomography; computed tomography utilization; imaging utilization; necrotizing soft tissue infection

Articles in the same Issue

  1. Frontmatter
  2. Reviews
  3. Accuracy of pulse wave velocity for screening coronary artery disease: a systematic review and meta-analysis
  4. Prenatal screening for genetic disorders: updated guidelines, proposed counseling, a holistic approach for primary health care providers in developing countries
  5. A scoping review of fever of unknown origin with normal serum C-reactive protein
  6. Mini Review
  7. Overview of dengue diagnostic limitations and potential strategies for improvement
  8. Opinion Papers
  9. Demystifying cognitive bias in the diagnostic process for frontline clinicians and educators; new words for old ideas
  10. Physicians’ prism: illuminating history with structured expertise
  11. Original Articles
  12. Implementation of a curriculum on communicating diagnostic uncertainty for clerkship-level medical students: a pseudorandomized and controlled study
  13. A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list
  14. Equity-Driven Diagnostic Excellence framework: An upstream approach to minimize risk of diagnostic inequity
  15. Two decades of autopsy-detected diagnostic errors in Japan
  16. Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning
  17. Cognitive biases in osteopathic diagnosis: a mixed study among French osteopaths
  18. Racial and ethnic disparities in pediatric emergency department patients with missed opportunities for diagnostic excellence
  19. Diagnostic accuracy of non-mydriatic fundus photography as a triage and telemedicine tool for patients with vision loss
  20. “Innumerable” lesion burden on brain MRI ‒ a diagnostic approach
  21. Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis
  22. Exploring emergency department providers’ uncertainty in neurological clinical reasoning
  23. Analytical performance and user-friendliness of four point-of-care measuring systems for monitoring prothrombin time international normalized ratio in the hands of the intended users
  24. Fetal hematological phenotypes of various hemoglobinopathies and demonstration of embryonic hemoglobins on capillary electrophoresis: a large cohort data from prenatal screening program
  25. Development and assessment of autoverification system for routine coagulation assays in inpatient and outpatient settings of tertiary care hospital: algorithm performance and impact on laboratory efficiency
  26. Validation of new, circulating biomarkers for gliomas
  27. Short Communications
  28. Using language to evaluate curricular impact: a novel approach in assessing clinical reasoning curricula
  29. Comparative evaluation of routine coagulation testing on Stago sthemO 301 and Werfen ACL TOP 750
  30. Letters to the Editor
  31. Reversible systemic vasoconstriction syndrome: a new diagnostic family of generalized vasospasm in multiple organs
  32. The value of designating symptoms as “vague” in diagnosis
  33. Immunoglobulin E in an inverted skin-prick test for rapid detection of cutaneous antigens
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