Use of this website is subject to the website terms of use and privacy policy. 2001;176(5):1155-9. You'll need to take the antibiotic for the full course, usually 5 to 10 days, even if you start to feel better. Rahmouni A, Chosidow O, Mathieu D et al. Radiologic Approach to Musculoskeletal Infections. In uncomplicated cellulitis, CT demonstrates skin thickening, septation of the subcutaneous fat, and thickening of the underlying superficial fascia. CT is used to accurately differentiate between superficial cellulitis and deep cellulitis. T2 weighted images with fat saturation demonstrates extensive high signal within the intermuscular septa surrounding the gastrocnemius and soleus muscle bellies suggestive of subfascial fluid (white arrows). Patients with peripheral vascular disease or diabetes mellitusare particularly susceptible to cellulitis since minor injuries to the skin or cracked skin in the feet or toes can serve as a point of entry for infection. Different imaging modalities require different concentrations of contrast for optimal detection of pathology. Stadelmann VA, Potapova I, Camenisch K, Nehrbass D, Richards RG, Moriarty TF. Mitchell C, Dolan N, Drsteler K. Management of Dependent Use of Illicit Opioids. What are the treatment options for myasthenia gravis if first-line agents fail? The American College of Radiology Appropriateness Criteria is a useful online resource. MRI's visualization of the bone marrow allows for the sensitive detection of osteomyelitis, although specificity for the diagnosis of osteomyelitis is aided by other findings, including cortical destruction. Nurse practitioners must be familiar with the contraindications for CT contrast administration. Hayeri MR, Ziai P, Shehata ML, Teytelboym OM, Huang BK. Despite its limitations, radiographs can be more sensitive than physical exam for the detection of soft-tissue gas, with radiographic findings present before clinical crepitus is detected.17 Radiographs can also be helpful in identifying other causes of infection including the presence of a foreign body or underlying fracture.3, 13, The role of ultrasound is limited in the work-up of necrotizing fasciitis given that the lack of resolution of deeper structures.8 The presence of soft-tissue gas can be more apparent on ultrasound compared to radiographs.17, 18 Findings include an echogenic layer of gas above the deep fascia with posterior dirty acoustic shadowing (Figure 4).19 Other nonspecific findings include hyperechogenicity of the overlying fat, with cobblestone appearance indicating subcutaneous edema, but these findings can also be seen in cellulitis or anasarca.8, 19 Color Doppler evaluation may not reveal hypervascularity.8 Specific signs that are helpful to differentiate necrotizing fasciitis from cellulitis include irregularity of the fascia, abnormal fluid collection along fascial planes, and diffuse fascia thickening when compared to the contralateral unaffected side.8. Your email address will not be published. 5. The PPV was 91.3% when more than one deep neck space was involved but only 50.0% in patients with isolated retropharyngeal abscesses. Above this, there is a narrow, relatively hyperechoic epidermal-dermal layer. N Engl J Med. Contrast can cause acute renal failure. Even in osseous infection, CT and MRI can give better anatomic delineation of the extent of infection. In C, the transplanted lung is notable for areas of air trapping in the right upper lobe on expiratory images (blue arrow), which is associated with central airway narrowing. myriad of non-infective erythematous rashes, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Skeletal Radiol. While the plain film and nuclear medicine bone scan are still the traditional imaging modalities used in the evaluation of musculoskeletal infection, the cross-sectional imaging modalities, computed tomography (CT) and magnetic resonance imaging (MRI), have become critical in the delineation of many types of musculoskeletal infection. Turecki M, Taljanovic M, Stubbs A et al. 2020;368:m710. AJR Am J Roentgenol. Yen ZS, Wang HP, Ma HM, Chen SC, Chen WJ. Fugitt JB, Puckett ML, Quigley MM, Kerr SM. One study showed similar increases in serum creatinine levels between inpatient populations who received IV iodinated contrast and those who did not.16, Noncontrast-enhanced CT is used in patients with head trauma and acute stroke. Barium suspensions are not nephrotoxic and can be used safely in patients with renal failure. MeSH A CT can help determine the underlying cause of orbital cellulitis. Computed tomography (CT scan or CAT scan) is a noninvasive diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. Axial non-contrast. Other CT findings include increase soft-tissue attenuation, subcutaneous edema and inflammatory fat stranding, which can also be seen in cellulitis.2,2123 In a study by Wysoki et al. Epub 2020 Oct 15. In general, oral contrast is used for most abdominal and pelvic CT scans unless there is no suspicion of bowel pathology (e.g., noncontrast CT to detect kidney stones) or when administration would delay a diagnosis in the trauma setting. Even in osseous infection, CT and MRI can give better anatomic delineation of the extent of infection. Necrotizing fasciitis: early sonographic diagnosis. The parapharyngeal space was the most commonly involved space. Skin findings, pain out of proportion, and signs of systemic shock should alert the clinician to the possibility of necrotizing fasciitis. On MRI, the signal on T2-WI is variable depending on the etiology. Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. These agents for enhancing the image created on CT may be delivered by a number of different routes, the most common of which are oral and intravenous. 1998;170(3):615-20. Dr. Amy Levine answered. 3. The need for enhancement with intravenous (IV) contrast depends on the specific clinical indication (Table 1). The CT and MRI findings in the spectrum of musculoskeletal infections are discussed and contrasted, and pitfalls in their evaluation of musculoskeletal infection are described. As a library, NLM provides access to scientific literature. When I was newer to my role, I had a lot of questions about diagnostic imaging, when it was indicated, and what test to order. Thirteen orbital computed tomographic (CT) scans were obtained in 12 patients with postseptal (orbital) cellulitis. HHS Vulnerability Disclosure, Help If the infection spreads to deeper tissues, soft-tissue abscess, infectious myositis, necrotizing fasciitis, and osteomyelitis can all be detected with CT. MRI is sensitive for distinguishing cellulitis alone from necrotizing fasciitis and infectious myositis and for showing subcutaneous fluid collections and abscesses. Orbital cellulitis. N.p. Skeletal Radiol. 5. Chaudhry AA, Baker KS, Gould ES, Gupta R. Necrotizing fasciitis and its mimics: what radiologists need to know, Musculoskeletal infection: role of CT in the emergency department. Please enable it to take advantage of the complete set of features! Epub 2015 Apr 29. Check for errors and try again. It results in pain, erythema, oedema, and warmth. 2009;16(4):267-76. Large volume of gas seen within the scrotum wall and scrotum sac on the scout image (curved black arrow), consistent with Fourniers gangrene. Miller TT, Randolph DA, Staron RB, Feldman F, Cushin S. Fat-suppressed MRI of musculoskeletal infection: fast T2-weighted techniques versus gadolinium-enhanced T1-weighted images, Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis, Differentiation of necrotizing fasciitis and cellulitis using MR imaging. Clinical presentations include skin erythema without a well-defined border, increased skin temperature, swelling of the affected area, and regional lymphadenopathy and lymphangitis. Copyright 2023 American Academy of Family Physicians. Muscular fascia lies deep to the subcutaneous layer. Postoperative sternal wound infections are not uncommon and range from cellulitis to frank osteomyelitis. Family physicians often must determine the most appropriate diagnostic tests to order for their patients. Lactic acidosis has never been documented in patients with normal renal function who are receiving metformin. 2004;350(9):904-12. Magnetic resonance imaging of musculoskeletal infections. They are used for bowel opacification and are not nephrotoxic. CT Exams Contrast vs Non-Contrast Guide These suggestions are general guidelines that apply to the use of contrast for CT exams provided at Oregon Imaging Centers. A history of anaphylactic reactions would preclude IV contrast except in extreme emergencies. Radiology. Cellulitis. Become a Gold Supporter and see no third-party ads. thickening of skin and superficial fascia, diffuse subcutaneous linear/reticular or ill-defined hyperintensity tending to collect at the hypodermis, contrast enhancement differentiates cellulitis from stasis edema, areas of necrotizing cellulitis do not enhance, degree of enhancement depends on the post contrast delay. IV dye may cause a temporary alteration in kidney function. The concentration of barium used for fluoroscopy is more than 20 times that of the typical oral contrast suspension for CT. For example, the barium concentration from an upper gastrointestinal series or an enema will produce an artifact on abdominal CT because it is significantly more concentrated than bowel contrast agents used for CT. Barium enemas are also given after abdominal CT to allow time for the less-dense barium to leave the colon. Emergency Medicine: Clinical Essentials. Given that metformin is excreted through the kidneys, IV contrast may impair metformin clearance from the body putting the patient at risk for metabolic acidosis. Disclaimer. 2021;50(12):2319-47. Check for errors and try again. The decision to order contrast-enhanced CT is based on the clinical question being asked. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Created for people with ongoing healthcare needs but benefits everyone. BMJ. Before Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-15554. Cross-sectional schematic diagram through the right thigh demonstrating the various findings of necrotizing fasciitis. Federal government websites often end in .gov or .mil. Contrast-enhanced CT demonstrates air (arrows) and edema in the scrotum, surrounding the right testicle (a). Kirchgesner T, Tamigneaux C, Acid S et al. CT may also be ordered for cross-sectional images of the spine with contrast in the thecal sac. MRI Nomenclature for Musculoskeletal Infection. <>/Metadata 2 0 R/ViewerPreferences 6 0 R>> Since the epidermis is not involved, cellulitis is not transmitted by person-to-person contact. At the time the article was last revised David Carroll had However, if contrast must be administered within two months of iodine 131 treatment, consultation with an endocrinologist should be considered.7 Administration of iodinated contrast may provoke thyrotoxicosis, although this is rare.12, Approximately 90% of absorbed metformin is excreted by the kidneys within 24 hours. Wall DB, Klein SR, Black S, de Virgilio C. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. No circumscribed collection, or signs of bulbar or intraconal involvement (note the preservation of the normal intraorbital fat density). This can be filled at Baystate Pharmacies at 759 Chestnut Street and 3300 Main Street as well as at many local pharmacies. A 35-year-old male with necrotizing fasciitis of the right calf. It is essential to know the types of contrast agents, their risks, contraindications, and common clinical scenarios in which contrast-enhanced computed tomography is appropriate. 3 0 obj Epidemiology Risk factors trauma foreign bodies A paranasal sinus pathology is . Clipboard, Search History, and several other advanced features are temporarily unavailable. Most healthcare facilities have protocols dictating the cutoff at which IV dye may be administered in patients with impaired renal function. Peri-orbital cellulitis is of concern in children because it may be secondary to occult underlying bacterial sinusitis or, rarely, due . 30 0 obj All rights reserved. National Library of Medicine sharing sensitive information, make sure youre on a federal Skeletal Radiol. , Acuterecurrent rhinosinusitis A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Scout film (a) and contrast-enhanced CT (b) shows intramuscular pockets of gas (arrows) in the left lateral thigh. BMJ. Paz Maya S, Dualde Beltrn D, Lemercier P, Leiva-Salinas C. Necrotizing fasciitis: an urgent diagnosis. My answer is based on the current radiologic practices and terminology employed in the U.S. 1. Sagittal CT reformation demonstrates linear fluid collection (arrow) deep to the rectus femoris muscle (b). The concentration of barium determines whether it enhances the diagnosis or causes an artifact and obscures pathology. 1994;192(2):493-6. endobj Contrast enhancement is also used to evaluate superior vena cava syndrome. JAMES V. RAWSON, MD, AND ALLEN L. PELLETIER, MD. The US Preventive Services Task Force currently recommends low-dose CT without contrast, along with appropriate patient counseling, for patients with a history of smoking and an age range as detailed in the Task Force statement. One of these questions that came up frequently related to CT scans was Do I need contrast?. It is important to tell the technician and your doctor if you have had a previous allergic reaction to iodinated contrast. Laryngeal edema (severe or rapidly progressing), Methylprednisolone (Medrol), 32 mg orally 12 and 2 hours before contrast administration; plus diphenhydramine (Benadryl), 50 mg intravenously, intramuscularly, or orally 1 hour before contrast administration, Prednisone, 50 mg orally 13, 7, and 1 hour before contrast administration; plus diphenhydramine, 50 mg intravenously, intramuscularly, or orally 1 hour before contrast administration, Normal renal function and no comorbid disorder, Metformin (Glucophage) can be continued when contrast is administered; serum creatinine does not need to be measured, Normal renal function and at least one comorbid disorder, Metformin should be discontinued when contrast is administered; if the patient remains clinically stable and has no new intercurrent risk factors for renal impairment, metformin may be resumed in 48 hours without repeating serum creatinine measurement, Metformin should be discontinued when contrast is administered; resume only after careful reevaluation and monitoring of renal status, Noncontrast-enhanced CT of the head is the preferred initial study if performed within three hours of acute symptom onset; contrast-enhanced CT should be obtained for patients with symptoms lasting longer than three hours; contrast-enhanced CT combined with CT angiography of the neck may be needed for follow-up, Thin section high-resolution CT without contrast, Extremity soft tissue swelling, infection, or trauma, Contrast is necessary if vascular involvement or injury is suspected, Scan suspected area of trauma in cervical, thoracic, or lumbar spine, Abdominal and pelvic CT; oral or rectal contrast agent based on institutional preference, Protocols vary depending on cancer type and stage, Diverticulitis; suspected complications of inflammatory bowel disease, Intravenous contrast agent for diverticulitis; oral and/or rectal contrast agent can be administered to visualize bowel, Noncontrast-enhanced CT is sensitive for calcifications (chronic pancreatitis); contrast-enhanced CT is best for evolving pancreatitis or pancreatic pseudocyst, Many centers now include venous phase CT of the pelvis and lower extremities in combination with CT angiography of the lung. 2022 Jul 10;11(14):3998. doi: 10.3390/jcm11143998. 2 0 obj During the injection you may feel flushed and get a metallic taste in your mouth. Follow-up of a solitary pulmonary nodule also typically does not require contrast enhancement, though some investigators have reported high sensitivity with dynamic contrast enhancement of pulmonary nodules.4 This rep resents a rare clinical application of chest CT with and without contrast. Unenhanced CT is also used in patients with spine and extremity trauma. Cellulitis(rare plural: cellulitides) is an acute infection of the dermis and subcutaneous tissues without deep fascial or muscular involvement. Cellulitis. Next imaging study. However, patients with a documented anaphylactic reaction to any medication are at higher risk of a reaction to iodinated contrast.9,10, Many centers screen outpatients with suspected renal insufficiency by measuring serum creatinine one month before administration of contrast agents. Recent studies suggest that a combination of hydration, sodium bicarbonate, N-acetylcysteine, and decreased contrast volume may reduce this risk in high-risk populations.14,15, The question of whether this risk has been overstated has been raised in the medical literature. FOIA Jamal K, Mandel L, Jamal L, Gilani S. 'Out of hours' adult CT head interpretation by senior emergency department staff following an intensive teaching session: a prospective blinded pilot study of 405 patients. Sign In to Email Alerts with your Email Address. The site is secure. [18F]Fluoride Positron-Emission Tomography (PET) and [18F]FDG PET for Assessment of Osteomyelitis of the Jaw in Comparison to Computed Tomography (CT) and Magnetic Resonance Imaging (MRI): A Prospective PET/CT and PET/MRI Pilot Study. [ 16, 17, 18] On CT scans, a preseptal cellulitis may appear as. These agents are not used for imaging of the abdomen and/or pelvis if bowel pathology is not suspected, or if doing so will delay scanning as in the case of acute trauma. N Engl J Med. Case 1: orbital and periorbital cellulitis, see full revision history and disclosures. Oral contrast can be administered through a nasogastric tube to minimize the risk of aspiration. Possible reactions are listed in Table 1.7 If a patient has had a previous minor reaction to an IV iodinated contrast agent, precontrast administration of oral or IV corticosteroids and diphenhydramine (Benadryl) may decrease their risk (Table 27 ). 7 0 obj Kim KT, Kim YJ, Won Lee J, Kim YJ, Park SW, Lim MK, et al.. Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? Subfacial fluid along the superficial fascial layers, which can be seen in early necrotizing fasciitis (b). Turecki M, Taljanovic M, Stubbs A et al. Inclusion in an NLM database does not imply endorsement of, or agreement with, We do not capture any email address. Patients with a mild allergy may be pre-medicated with an antihistamine or steroids before imaging. Contrast agents can be further classified as high or low osmolality, based on the iodine concentration. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The American College of Radiology recommends using IV iodinated contrast in pregnant women when the information needed affects the care of the patient and fetus and cannot be obtained without contrast, and when the referring physician thinks that imaging should not wait until after the pregnancy.7, Iodinated contrast media can saturate the thyroid gland and significantly reduce uptake of iodine 131, rendering the treatment ineffective. Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine. Contrast materials are generally safe; however, as with any pharmaceutical, there is the potential for adverse reactions. In particular, the evaluation of soft tissue infections, including cellulitus, myositis, fasciitis, abscess, and septic arthritis are often best evaluated by MRI or CT due to their excellent anatomic resolution and soft tissue contrast. Almost always, CTs should be ordered with or without contrast, not both. 07/16 RH /MF Contrast-related nephrotoxicity has been reported,11 although this has been challenged more recently.12 Suspected risk factors for this complication include advanced age, cardiovascular disease, treatment with chemotherapy, elevated serum creatinine level, dehydration, diabetes, use of nonsteroidal anti-inflammatory medications, myeloma,13 renal disease, and kidney transplant. If the infection spreads to deeper tissues, complications can occur, such as soft-tissue abscess,necrotizing fasciitis,infectious myositis, and/or osteomyelitis. National Library of Medicine Radiology. {"url":"/signup-modal-props.json?lang=gb"}, Radswiki T, Carroll D, Knipe H, et al. Since the epidermis is not involved, cellulitis is not transmitted by person-to-person contact. 2001 Oct;42(4-5):259-305. www.acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Thoracic.pdf, www.acr.org/~/media/37D84428BF1D4E1B9A3A2918DA9E27A3.pdf, EVALUATION OF PULMONARY PARENCHYMAL DISEASE, EVALUATION OF STERNAL AND MEDIASTINAL INFECTIONS, Cleveland Clinic Center for Continuing Education. CT is used to accurately differentiate between superficial cellulitis and deep cellulitis. 7. no financial relationships to ineligible companies to disclose. Cellulitis treatment usually includes a prescription oral antibiotic. Related editorial: Potential Harms of Computed Tomography: The Role of Informed Consent. Imaging of Musculoskeletal Soft Tissue Infections. References. . Necrotizing fasciitis is a rapidly spreading soft tissue infection involving the deep fascial layers, which can cause secondary necrosis leading to significant morbidity and mortality.13 It most commonly affects the lower extremities accounting for approximately 50% of cases, and can affect different body parts including the perineum (as in Fourniers gangrene), and submandibular region (as in Ludwig angina). Infect Dis Clin North Am. endobj In later stages, nonenhancement of the fascia may be seen due to necrosis, which can be helpful to differentiate from nonnecrotizing fasciitis.3, 28,29, Although more apparent on CT, gas in the soft tissues is represented by punctate or curvilinear T1 and T2 low signal with corresponding blooming artifact on gradient echo sequences.1, 18,25,30 Although a highly specific finding, the absence of soft-tissue gas does not exclude the diagnosis of necrotizing fasciitis.3, 11.
Exotic Travelers Membership Levels,
What Happened To Reed Flake Rodeo Video,
Articles C