Cellulitis

An 88-year-old male initially presented to the emergency department with right-hand cellulitis after being bitten by his pet dog. Past medical history included coronary artery disease, TIA, hypertension, hyperlipidemia, osteoporosis, and glaucoma. He previously smoked a few cigarettes per day but quit 60 years ago. He denied any other illicit drug use. One dose of intravenous ampicillin/sulbactam was administered in the emergency department. The wound was thoroughly washed. The patient was then discharged to complete a course of oral amoxicillin/clavulanate. Three days later, he was seen in the orthopaedic clinic for a follow-up. Continued significant erythema, oedema, and warmth of the wound and hand were noted, prompting hospitalization.

Examination

Vitals revealed a fever of 102.7 F, hypotension to 90/62 mmHg, tachycardia at 108 beats per minute, tachypnea to 22 breaths per minute and oxygen saturation of 87% while breathing ambient air. On evaluation, he was breathing and speaking comfortably. Faint crackles were auscultated. A 3/6 systolic murmur loudest at the apex and a flat JVP were noted. His hand exhibited mild erythema and an eschar on the dorsal hand without excessive warmth. There was mild left ankle warmth and oedema. Laboratory studies reflected a leukocytosis to 20.8 k/uL with 74% neutrophils, 20% lymphocytes, and 2.8% eosinophils. Creatinine was slightly elevated at 1.38 mg/dL with normal liver enzymes. A chest radiograph demonstrated small bilateral effusions, and vague bilateral upper lobe lung infiltrates.