Prevalence of misdiagnosis of cellulitis: A systematic review and meta-analysis.

BACKGROUND: There is no gold standard test to accurately identify patients with cellulitis and therefore misdiagnosis is common. Using the clinical impression of a dermatology or an infectious disease specialist as a reference standard, we sought to determine the prevalence of misdiagnosis of cellulitis among nonspecialist physicians. METHODS: A systemic search was performed using MEDLINE, Cochrane Library, and EMBASE databases for studies reporting diagnostic accuracy of cellulitis. Inclusion criteria required dermatology or infectious disease consultation for all patients diagnosed with cellulitis by generalist physicians. We used random effects modeling to estimate the prevalence of misdiagnosis using consultant diagnosis as a reference standard. RESULTS: Eight studies contributed to the analysis. For the seven studies involving inpatients, the results were sufficiently homogeneous to justify pooling data. Of 858 inpatients initially diagnosed with cellulitis, 335 (39%, 95% confidence interval: 31-47) received an alternative diagnosis from the specialist. Heterogeneity was large (I2 = 74%) and the greatest contributor to between-study variance was the year of publication. Alternative diagnoses were mostly noninfectious (68%, 221/327), with stasis dermatitis (18%, 60/327) being the most common. An abscess was the most common alternative infectious diagnosis (10%, 32/327). DISCUSSION: Cellulitis is commonly misdiagnosed among inpatients, leading to unnecessary hospital admissions and antibiotic overuse. Most alternative diagnoses are noninfectious. Continuing medical education among general practitioners and urgent care providers will likely reduce cellulitis misdiagnoses.

Brachial plexopathy as a complication of COVID-19.

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

Increasing Incidence and Unique Clinical Characteristics of Spinning-Induced Rhabdomyolysis.

OBJECTIVE: To compare outcomes of spinning-induced rhabdomyolysis to those with exertional rhabdomyolysis from other physical activities. DESIGN: Retrospective cohort study. SETTING: Academic medical center, single-center. PATIENTS: A retrospective chart review was conducted on patients evaluated from December 2010 through November 2014. Patients were selected by ICD-9 code for rhabdomyolysis. Patients were included if the reason for admission was rhabdomyolysis caused by exertion. Cases of rhabdomyolysis caused by trauma or drugs were excluded. MAIN OUTCOME MEASURES: Muscle group involvement, admission, and peak creatine kinase levels, time from activity to hospitalization, length of hospital stay, and incidence of complications. RESULTS: Twenty-nine cases were reviewed with 14 admissions secondary to spinning. Median admission creatine kinase (73 000 IU/L vs 29 000 IU/L, P = 0.02) and peak creatine kinase levels were significantly higher in the spinning group (81 000 IU/L vs 31 000 IU/L, P = 0.007). Hospital admissions for spinning-induced rhabdomyolysis increased over time. CONCLUSION: Health care providers should be aware of the potential dangers of spinning-related rhabdomyolysis especially in otherwise healthy young people.