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Ultrasound features of purulent skin and soft tissue infection without abscess

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Abstract

Purpose

Ultrasound (US) aids clinical management of skin and soft tissue infection (SSTI) by differentiating non-purulent cellulitis from abscess. However, purulent SSTI may be present without abscess. Guidelines recommend incision and drainage (I & D) for purulent SSTI, but US descriptions of purulent SSTI without abscess are lacking.

Methods

We retrospectively reviewed pediatric emergency department patients with US of the buttock read as negative for abscess. We identified US features of SSTI with adequate interobserver agreement (kappa > 0.45). Six independent observers then ranked presence or absence of these features on US exams. We studied association between US features and positive wound culture using logistic regression models (significance at p < 0.05).

Results

Of 217 children, 35 patients (16%) had cultures positive for pathogens by 8 h after US and 61 patients (32%) had cultures positive by 48 h after US. We found kappa > 0.45 for focal collection > 1.0 cm (κ = 0.57), hyperemia (κ = 0.57), swirling with compression (κ = 0.52), posterior acoustic enhancement (κ = 0.47), and cobblestoning or branching interstitial fluid (κ = 0.45). Only cobblestoning or interstitial fluid was associated with positive wound cultures in logistic regression models at 8 and 48 h.

Conclusions

Cobblestoning or interstitial fluid on US may indicate presence of culture-positive, purulent SSTI in patients without US appearance of abscess. Although our study has limitations due to its retrospective design, this US appearance should alert imagers that the patient may benefit from early I & D.

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Authors and Affiliations

  1. Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Courtney E. Nelson

  2. Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Aaron E. Chen

  3. Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Aaron E. Chen, Richard D. Bellah, David M. Biko, Victor M. Ho-Fung, Michael L. Francavilla & Summer L. Kaplan

  4. Department of Radiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Richard D. Bellah, David M. Biko, Victor M. Ho-Fung, Michael L. Francavilla & Summer L. Kaplan

  5. Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA

    Rui Xiao

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  1. Courtney E. Nelson
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  2. Aaron E. Chen
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  3. Richard D. Bellah
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  6. Michael L. Francavilla
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  7. Rui Xiao
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  8. Summer L. Kaplan
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Corresponding author

Correspondence to Summer L. Kaplan.

Ethics declarations

Our institutional review board (IRB) approved this retrospective cohort study.

Conflict of interest

The authors declare that they have no conflict of interest.

Appendix

Appendix

Table 3 Bias testing for methods in correlation between US features and positive cultures
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Nelson, C.E., Chen, A.E., Bellah, R.D. et al. Ultrasound features of purulent skin and soft tissue infection without abscess. Emerg Radiol 25, 505–511 (2018). https://doi.org/10.1007/s10140-018-1612-0

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  • DOI: https://doi.org/10.1007/s10140-018-1612-0

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