{"id":2425,"date":"2025-06-06T19:00:00","date_gmt":"2025-06-06T19:00:00","guid":{"rendered":"https:\/\/emultrasound.sdsc.edu\/?p=2425"},"modified":"2025-06-06T17:16:50","modified_gmt":"2025-06-06T17:16:50","slug":"case-46-skin-and-soft-tissue-infection","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2025\/06\/06\/case-46-skin-and-soft-tissue-infection\/","title":{"rendered":"Case 46: Skin and Soft Tissue Infection"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Alma Fregoso Leyva<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">73 year old male with a past medical history of coronary artery disease, congestive heart failure, COPD, pulmonary fibrosis on 5L NC, and left lower extremity prosthetic joint infection s\/p total femur replacement presented via EMS with 3 days of worsening left lower leg pain and swelling.\u00a0He reported pain around the left lower leg down to the foot. His symptoms were associated with chills and fatigue. He reported compliance with Eliquis.\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vitals: BP 92\/80, Pulse 100, Temp 98.1 F, RR 11, SpO2 93% on 5L NC&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Physical Exam:<br>- General: A&amp;O x4<br>- Cardiac: RRR<br>- Lungs: CTAB w\/o increased work of breathing while on 5L NC<br>- Extremities: 1+ non -pitting edema of right lower extremity, 2+ at left lower extremity. Intact sensation to light touch at left lower extremity, able to wiggle all toes, diffuse swelling below the left knee and down to the foot L>R, with diffuse tenderness. No crepitus or pain out of proportion. Erythema over anterior shin, scattered skin excoriations of bilateral lower legs.\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Bedside ultrasound was performed and the following images were obtained:&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"388\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2025\/06\/image-2.png?resize=525%2C388&#038;ssl=1\" alt=\"\" class=\"wp-image-2428\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-2.png?w=815&amp;ssl=1 815w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-2.png?resize=300%2C222&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-2.png?resize=768%2C567&amp;ssl=1 768w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure 1: Left popliteal vein.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"388\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2025\/06\/image-3.png?resize=525%2C388&#038;ssl=1\" alt=\"\" class=\"wp-image-2429\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-3.png?w=811&amp;ssl=1 811w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-3.png?resize=300%2C222&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-3.png?resize=768%2C568&amp;ssl=1 768w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure 2: Collapsed left popliteal vein.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"413\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2025\/06\/image-4.png?resize=525%2C413&#038;ssl=1\" alt=\"\" class=\"wp-image-2430\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-4.png?w=784&amp;ssl=1 784w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-4.png?resize=300%2C236&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/06\/image-4.png?resize=768%2C603&amp;ssl=1 768w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Figure 3: Cobblestone appearance of the left lower leg.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">DISCUSSION<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Concern for deep vein thrombosis (DVT) was present given asymmetric edema and pain, Point-of-care ultrasound (POCUS) was performed and DVT was ruled out. Ultrasound of the lower leg also demonstrated \u201ccobblestoning\u201d. Left lower extremity and peri-prosthetic fluid collection found on CT. The patient was started on antibiotics for the SSTI.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">POCUS has become a valuable tool in the Emergency Department given its availability, portability, lack or radiation and tolerability by patients. Skin and soft tissue infections (SSTIs) are primarily diagnosed clinically based on history and physical exam, but imaging is used to assess beyond superficial tissue. Clinically SSTIs are characterized by symptoms such as erythema, swelling, warmth, pain, fever, chills and leukocytosis, especially in patients with predisposing factors. The primary sonographic finding in cellulitis is referred to \u201ccobblestone\u201d appearance, this appears as fluid collects in the subcutaneous tissue. However, this pattern is not unique to cellulitis and may be seen in other medical conditions. POCUS is valuable for diagnosis abscesses, guiding drainage and plays a crucial role in evaluating severe soft-tissue infections such as necrotizing fasciitis. When POCUS is performed prior to incision and drainage, it can help prevent invasive procedures over vascular or neoplastic lesions that can resemble abscesses on physical exam. Studies have shown that the use of POCUS is more accurate for diagnosing abscesses than clinical examination alone.\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">REFERENCES<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">1. Hazra, Darpanarayan; Elshehry, Ashraf. Cobblestone Appearance in Point-of-Care Ultrasonography (POCUS). Current Medical Issues 22(1):p 54-55, Jan\u2013Mar 2024. | DOI: 10.4103\/cmi.cmi_128_23\u00a0<br>2. Koppa BM, Kelly CT. Point-of-care ultrasound in skin and soft tissue infections. J Hosp Med. 2024 Oct;19(10):938-944. doi: 10.1002\/jhm.13467. Epub 2024 Jul 31. PMID: 39082276.\u00a0<br>3. Subramaniam, Sathyaseelan, et al. \"Point\u2010of\u2010care ultrasound for diagnosis of abscess in skin and soft tissue infections.\" <em>Academic Emergency Medicine <\/em>23.11 (2016): 1298-1306.\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"Alma Fregoso Leyva 73 year old male with a past medical history of coronary artery disease, congestive heart failure, COPD, pulmonary fibrosis on 5L NC, and left lower extremity prosthetic joint infection s\/p total femur replacement presented via EMS with 3 days of worsening left lower leg pain and swelling.\u00a0He reported pain around the left &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2025\/06\/06\/case-46-skin-and-soft-tissue-infection\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Case 46: Skin and Soft Tissue Infection\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[4],"tags":[17],"class_list":["post-2425","post","type-post","status-publish","format-standard","hentry","category-clinical-cases","tag-soft-tissue"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - 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