Mere Cellulitis by Drs. Mailhot, Perera, and Mandavia

Thomas Mailhot, MDIt was the beginning of my shift and I had just received pass-ons, including a 40-something year old man with leukemia, neutropenic fever, and a leg cellulitis.  Antibiotics were in, and the patient was waiting for a ward bed.  Fine, I thought, I’ll just give him a once over, and he’ll go upstairs as soon as a bed is available.

I introduced myself to the man (a very pleasant fellow – isn’t that always the case with patients who have a horrible diagnosis?) and examined his leg.  The skin from distal thigh to mid calf was red, warm, and tender, with the worst of it centered at his knee.  He ranged his knee pretty well without too much pain, but something didn’t look right about the cellulitis.  I don’t know if it just seemed a bit too ‘juicy’, or ‘angry’, but despite there not being any overt fluctuance, I was still concerned that there was more to it than just a cellulitis.

We are fortunate to have access to bedside ultrasound in my ED, and so I wheeled the machine to the patient to have a look.  Here’s what I saw when I placed the ultrasound transducer directly over the patient’s kneecap:

video clip of prepatellar bursitis

In this clip, you can see a fluid collection about 1-1.5 cm beneath the surface of the skin, indicating a pus pocket.  Towards the bottom of the image, you can see the patella.

We ended up slicing the patient’s skin, confirming (and draining) the prepatellar septic bursitis.  It seems that the bursa was so densely packed with pus that there was no fluctuance, just induration.  Ultrasound was very useful here in confirming that this was more than just a cellulitis, changing the patient’s outcome as well.

Thomas Mailhot, MD

Phil Perera, MD

Diku Mandavia, MD