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CASE REPORT
Year : 2012  |  Volume : 39  |  Issue : 1  |  Page : 26-28

Cellulitis and deep venous thrombosis: A rare association


1 Department of Paediatrics, J.N. Medical College and KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, India
2 Department of Paediatric Surgery, J.N. Medical College and KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, India
3 Department of Surgery, J.N. Medical College and KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, India

Date of Web Publication21-May-2012

Correspondence Address:
S M Jali
Department of Paediatric, J.N. Medical College, Belgaum
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.96468

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  Abstract 

A nine-year-old male child presented to us with a history and clinical examination suggestive of bilateral lower limb cellulitis. Investigations revealed leucocytosis, decreased Protein S levels, and growth of methicillin-resistant Staphylococcus aureas in the blood and pus cultures. A Doppler study revealed bilateral lower limb deep vein thrombosis (DVT). The child underwent fasciotomies under the cover of antibiotics and the DVT was treated with heparin followed by oral anticoagulation. In cases of cellulitis, DVT should be ruled out, as the clinical features of cellulitis may mask those of DVT, leading to missed diagnosis and serious complications.

Keywords: Anticoagulants, cellulitis, deep vein thrombosis


How to cite this article:
Jali S M, Kurbet SB, Amarkhed P, Gogate A S. Cellulitis and deep venous thrombosis: A rare association. J Sci Soc 2012;39:26-8

How to cite this URL:
Jali S M, Kurbet SB, Amarkhed P, Gogate A S. Cellulitis and deep venous thrombosis: A rare association. J Sci Soc [serial online] 2012 [cited 2017 Mar 26];39:26-8. Available from: http://www.jscisociety.com/text.asp?2012/39/1/26/96468


  Introduction Top


Deep vein thrombosis is rare in children, and still rarer is its association with cellulitis. The incidence of deep vein thrombosis (DVT) is about one in one lakh children per year. DVT, when associated with cellulitis, is still rarer, as very few case reports exist in literature. Although rare, DVT should be suspected in children presenting with cellulitis, because late or missed diagnosis can cause life-threatening complications. We are presenting this case for its rarity and successful management.


  Case Report Top


A nine-year-old male child presented with a history of fever for three days, followed by pain and swelling in both the lower limbs, secondary to trivial trauma to the left leg. There was also a history of massaging both the lower limbs. On examination, the general condition was poor; with high grade fever, tachycardia, tachypnea, hypotension, and pallor. Local examination revealed redness, swelling, and tenderness, extending from the knees to the feet on both the sides, with painful limb movements [Figure 1]. A clinical diagnosis of septicemia secondary to cellulitis was made, but the disproportionate swelling and tenderness raised the suspicion of DVT, which was further investigated. Investigations revealed hemoglobin of 8.2 gm%, raised WBC (18,800 cells/ cmm) with neutrophilia, thrombocytopenia (19,000 cells / cmm), prothrombin time (PT) (control of 15.8, test of 11.8), international normalized ratio (INR) (0.72), a partial thromboplastin time (PTT) (control of 31.5 seconds, test of 34.5 seconds), fibrinogen 250 mg% (200 - 400%), Protein C of 100%, antithrombin III level, homocysteine level, and lipid profile, which were all in the normal range, but there was mild decrease in protein S level (48%) and increased D-dimer 0.8 ugm / ml (<0.3 ugm / ml). The MRSA had grown in both the pus and blood cultures, and was sensitive to vancomycin, Trimethoprim, and rifampicin. X-rays of both the lower limbs were normal. The USG-doppler showed deep vein thrombosis extending from the posterior tibial to the femoral vein on the right side and from the popliteal vein to the saphenofemoral junction on the left side [Figure 2].
Figure 1: B / L lower limb swelling

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Figure 2: Doppler showing B / L dvt

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The child was treated with IVF, oxygen, inotropes, IV antibiotics (vancomycin, metronidazole, and septran), and oral rifampicin. During fasciotomies pus collection was found in the left lower leg, which was simultaneously drained. DVT was managed with IV heparinization, followed by oral anticoagulation (warfarin), which was continued for six months and gradually tapered and stopped. Repeat Doppler after six months showed complete recanalization and the child was doing well.


  Discussion Top


Deep vein thrombosis is an occlusion of veins by a blood clot. Cellulitis in children is rare, and its association with DVT still rarer. Hospitalization for skin and soft tissue infections (SSTIs) are common and more than half are due to cellulitis and cutaneous abcesses. [1] The incidence of DVT is about 1 / 100,000 per year. Cellulitis is seen in newborns and teenagers, especially in the extremities. [2] DVT when associated with cellulitis is still rarer, as very few case reports exist in literature. [3] Although rare, DVT should be suspected in children presenting with cellulitis, because missed diagnosis can cause life-threatening complications. [4] Suspected DVT in patients with cellulitis should be evaluated by a Doppler study, as 15 had DVT out of 240 patients with cellulitis, in a study by Maze et al. [5] The risk factors for DVT could be either congenital or acquired. The congenital prothrombotic states encountered in children are protein C, S, and antithrombin III deficiency, activated protein C resistance, an elevated homocystiene level, an abnormal lipid profile, antiphospholipid syndrome, and thrombocythemia. [2] Activated protein C-resistance was found to be the most common pathogenic factor in juvenile deep vein thrombosis, in India. Another study from India in children with venous thrombosis showed four patients had combined protein C and S deficiency. Clinically, patients with protein C and S deficiency are at an increased risk for venous thromboembolic disease, but rarely arterial thrombosis, purpura fulminans, stroke or portal vein thrombosis. Acquired causes of protein C and S deficiencies are seen in illnesses like liver disease, disseminated intravascular coagulation (DIC), therapy with coumarin, and severe bacterial infections, as in our case. The management of these patients is hydration, heparin anticoagulation, protein C concentrate or fresh frozen plasma therapy.

The differential diagnosis of cellulitis includes DVT, lymphedema, compartment syndrome, popliteal cyst rupture, congestive heart failure, venous insufficiency, and arterial occlusive disease. Severe bacterial infection can also cause acquired hypercoagulable states. Although our patient presented with clinical features of cellulitis, a high degree of suspicion of DVT led us to do a Doppler, which confirmed the diagnosis. Patients with cellulitis or infection can present with edema, erythema, pain, and a low-grade fever, similar to that of DVT, but raised blood counts, erythrocyte sedimentation rate (ESR0, and blood cultures help to differentiate the two conditions, as seen in our case. Our patient had cellulitis of the lower limbs with DVT and bronchopneumonia caused by MRSA infection. In a similar study identified with MRSA infections, 14 patients had pulmonary involvement and two had deep venous thrombosis. [6] Studies have shown that symptoms and clinical signs of DVT are inadequate for diagnosis, but when combined with other patient information, can improve the clinical prediction considerably. The thromboembolic complications are becoming more frequent in children, and the use of anticoagulation has increased considerably. [7],[8] The most widely used agents in children are heparin, low-molecular-weight heparin (LMWH), and warfarin. All of them have limitations that are exaggerated in children. This has led to the advent of newer agents with improved pharmacological properties, such as, bivalirudin, argatroban, and fondaparinux. [7]

Concurrent DVT and cellulitis is rare and some studies suggest that investigation with Doppler ultrasonography in the absence of risk factors for DVT has a low yield, but as in our case, a high index of suspicion will lead to diagnosis and appropriate treatment, which results in the reduction of morbidity and mortality. More studies are needed to determine whether clinical prediction indices have a role in improving the diagnosis in patients with suspected DVT.


  Conclusion Top


Cellulitis associated with DVT is of rare occurence, especially in children. Diagnosis of this combination requires a high index of suspicion, as DVT is uncommon in children and the coagulation parameters are age-dependent, and also it is difficult to pick up DVT, even with a color Doppler. D dimer, cell counts, and cultures may help in the diagnosis. Establishment of diagnosis provides for early treatment. This report should increase the awareness of clinicians regarding MRSA infections causing serious complications, and highlights the challenges encountered in the choice of management.

 
  References Top

1.Jenkins TC, Sabel AL, Sarcone EE, Price CS, Mehler PS. Skin and soft-tissue infections requiring hospitalization at an academic medical center: Opportunities for antimicrobial stewardship. Clin Infect Dis 2010;51:895-903.  Back to cited text no. 1
    
2.Turai R, Molnár K, Kiss E, Szokó M, Bauer Z, Simon G. Large deep venous thrombosis in childhood-three cases. Orv Hetil 2010;151:1545-50.  Back to cited text no. 2
    
3.Bersier D, Bounameaux H. Cellulitis and deep vein thrombosis: A controversial association. J Thromb Haemost 2003;1:867-8.  Back to cited text no. 3
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4.Kahn SR. The clinical diagnosis of deep venous thrombosis: Integrating incidence, risk factors, and symptoms and signs. Arch Intern Med 1998;158:2315-23.  Back to cited text no. 4
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5.Maze MJ, Pithie A, Dawes T, Chambers ST. An audit of venous duplex ultrasonography in patients with lower limb cellulitis. N Z Med J 2011;124:53-6.  Back to cited text no. 5
[PUBMED]    
6.Menif K, Bouziri A, Khaldi A, Hamdi A, Belhadj S, Borgi A, et al. Community-associated methicillin-resistant Staphylococcus aureus infections in a pediatric intensive care unit. J Infect Dev Ctries 2011;5:587-91.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Young G. Old and new antithrombotic drugs in neonates and infants. Semin Fetal Neonatal Med 2011;16:349-54.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Molinari AC, Saracco P, Cecinati V, Miano M, Parodi E, Grassi M, et al. Venous thrombosis in children: An emerging issue. Blood Coagul Fibrinolysis 2011;22:351-61.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  


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