Enter multiple addresses on separate lines or separate them with commas. 2001 Mar;39(2):277-303. doi: 10.1016/s0033-8389(05)70278-5. 2004;350(9):904-12. Wall DB, Klein SR, Black S, de Virgilio C. A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection. Above this, there is a narrow, relatively hyperechoic epidermal-dermal layer. 3. What are the treatment options for myasthenia gravis if first-line agents fail? Nonanaphylactoid reactions are dependent on contrast osmolality and on the volume and route of injection (unlike anaphylactoid reactions).10 Typical symptoms include warmth, metallic taste, and nausea or vomiting. Epub 2017 Mar 30. Muscular fascia lies deep to the subcutaneous layer. no financial relationships to ineligible companies to disclose. At our institution, the CT protocol includes concomitant injections in the upper-extremity veins, with imaging timed for venous phase enhancement (pulmonary venogram). Ultrasonographic screening of clinically-suspected necrotizing fasciitis. CT is used to accurately differentiate between superficial cellulitis and deep cellulitis. 4. All rights reserved. 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. Many types of contrast agents can be used in computed tomography: oral, intravenous, rectal, and intrathecal. Special consideration should be given to geriatric patients, in whom cellulitis of the lower extremities is more likely to develop into thrombophlebitis. In B, the native left lung is small, with evidence of bronchiectasis, bronchiolectasis, and areas of honeycombing (black arrow). 2001;176(5):1155-9. There is subcutaneous emphysema (arrows) overlying the right ankle with plate and screw fixation seen (a). National Library of Medicine 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. %PDF-1.7 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. Swartz M. Clinical Practice. Since the epidermis is not involved, cellulitis is not transmitted by person-to-person contact. A history of anaphylactic reactions would preclude IV contrast except in extreme emergencies. Horton L, Jacobson J, Powell A, Fessell D, Hayes C. Sonography and Radiography of Soft-Tissue Foreign Bodies. We are grateful for the editorial assistance of Megan M. Griffiths, scientific writer for the Imaging Institute, Cleveland Clinic. On MRI, the signal on T2-WI is variable depending on the etiology. Cellulitis. Diffuse thickening of the superficial fascia, which can be seen in the early phase of necrotizing fasciitis (c). 2009;16(4):267-76. A 53-year-old male with necrotizing fasciitis of the left knee. 1. There are several contrast agents that may be used in performing CT scans. Since the epidermis is not involved, cellulitis is not transmitted by person-to-person contact. When does chest CT require contrast enhancement? BMJ. Weaver JS, Omar IM, Mar WA, Klauser AS, Winegar BA, Mlady GW, McCurdy WE, Taljanovic MS. Pol J Radiol. Wronski M, Slodkowski M, Cebulski W, Karkocha D, Krasnodebski IW. CT is helpful in guiding surgical debridement and drainage by evaluating the extent of soft tissue and osseous involvement, identifying the potential infectious source and identifying potential complications including vascular rupture or tissue necrosis.1, 2,13,22 MAGNETIC RESONANCE IMAGING Copyright 2013 by the American Academy of Family Physicians. It results in pain, erythema, oedema, and warmth. endobj Yu J & Habib P. MR Imaging of Urgent Inflammatory and Infectious Conditions Affecting the Soft Tissues of the Musculoskeletal System. Clinical findings suggestive of necrotizing fasciitis vs cellulitis.7, There have been association with intravenous drug use as well as chronic conditions including diabetes mellitus, immunosuppression, obesity, and peripheral vascular disease.3, 8 A history of recent surgery (within the past 90 days) at the affected site has been shown to be a strong predictor for necrotizing fasciitis.7, Infection typically begins in the superficial fascial planes, then rapidly progress into the deep fascial layers, which causes necrosis secondary to microvascular occlusion.1 The rate of spread of infection is directly proportional to the thickness of the subcutaneous layers, with fastest spread seen in the lower extremities due to the lack of fibrous boundaries between subcutaneous tissue and fascia.2, 9, Necrotizing fasciitis is a clinical diagnosis since imaging findings can be nonspecific or unremarkable early in the course of the disease.1 The majority of cases are initially misdiagnosed, causing delay in diagnosis.10 Imaging appearances of necrotizing fasciitis can also overlap with other conditions, including nonnecrotizing fasciitis, dermatomyositis, graft vs host disease, or ischemic myonecrosis.1 The main utility of imaging is to determine the extent of the soft-tissue infection as well as to guide surgical planning.1, 8 If the patient is presenting with shock, imaging should not delay the initiation of treatment.1 Definitive diagnosis is based on surgical exploration and biopsy and aggressive surgical fasciotomy of necrotic tissue is required to prevent the spread of infection.7, Early findings of necrotizing fasciitis on radiography can appear similar to cellulitis including soft-tissue opacity and thickening.1113 The classical findings of dissecting gas along fascial planes in the absence of trauma is a specific sign, but is only seen in 24.855.0% of patients, and may not be seen until late in the disease (Figures 1 and 2).1, 10,12 Necrotizing fasciitis commonly affects the lower extremities, with involvement of the perineum or scrotum, classically known as Fourniers gangrene (Figure 3).3, 14,15 Soft-tissue gas is typically caused by gas-forming anaerobic infections, although this may not be present in diabetic patients.16 As such, the absence of soft-tissue emphysema does not exclude a diagnosis of necrotizing fasciitis.1. When the neoplasm has CT attenuation similar to that of adjacent structures (lymph nodes in the hilum, masses in the mediasti-num or chest wall), IV contrast can improve identification of the lesion and delineation of its margins and the relationship with adjacent structures (eg, vascular structures) (Figure 1). Contrast enhancement of the fascia can be variable depending on the stage of necrosis.1, 13,25 Enhancement of the affected fascia is thought to represent extravasated contrast from increased capillary permeability. 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. x]6}W&VqeYjc=ZZgvmH]"2EV"KL D~x9n_O=~on~{,Je|Sn*nqis7^xgi| RUSpEzs_^c?nRW%74|q)PB#g3F|k9/tp8.r#5zv+t3/z,$f S$Uz`X, Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Skeletal Radiol. In cases of question, Computed tomography (CT) with and without contrast of the orbits and sinuses should be ordered to look for evidence of post-septal involvement. of 20 consecutive patients with necrotizing fasciitis, CT revealed fascial thickening and fat stranding in 80%, soft tissue gas in 55%, and abscesses in 35%.22, CT is helpful in guiding surgical debridement and drainage by evaluating the extent of soft tissue and osseous involvement, identifying the potential infectious source and identifying potential complications including vascular rupture or tissue necrosis.1, 2,13,22, MRI is the gold-standard for soft-tissue infections as it provides excellent soft-tissue contrast resolution with a sensitivity of 93% for the diagnosis for necrotizing fasciitis.1, 24 Essential sequences include T1 weighted imaging to assess anatomy, and T2 fat saturated or short tauinversion-recovery sequences to look for fascial thickening and edema.3, 25 Post gadolinium sequences are helpful to delineate the extent of infection, identify abscesses and areas of necrosis, but may not be feasible in patients with acute renal failure, which is common in this patient population.3, 26, Deep fascial thickening and subfascial fluid accumulation can be seen as high signal on fluid sensitive sequences (Figures 8 and 9).21 The deep intramuscular fascia is usually protected in the setting of cellulitis, but is involved in necrotizing fasciitis.1 Fascial thickening begins in the superficial fascia and extends along the deep intermuscular fascia, not just in areas contiguous to the deep peripheral fascia.1, 18 Hyperintensity and thickness of the fascia greater than or equal to 3 mm on fat saturated T2 weighted or short tauinversion-recovery images with involvement of three or more compartments is a sensitive finding to suggest necrotizing fasciitis.3, 8,13,25,27 The absence of T2 hyperintensity within the deep fascia can essentially exclude a diagnosis necrotizing fasciitis.3, 18,21. E-mail: Received 2018 Jan 20; Revised 2018 Mar 2; Accepted 2018 Mar 8. Saad A, Kho J, Almeer G, Azzopardi C, Botchu R. Br J Radiol. Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot) Oral contrast can be administered through a nasogastric tube to minimize the risk of aspiration. The overall PPV for the prediction of deep neck abscess with contrast-enhanced CT was 79.6%. Different imaging modalities require different concentrations of contrast for optimal detection of pathology. Skeletal Radiol. Specific imaging features exist that help identify the numerous forms of infection in the bones and soft tissues, and CT is invaluable for detecting deep complications of cellulitis and pinpointing the anatomic compartment that is involved by an infection. CT with contrast can help to depict infection of the chest wall or mediastinum and in some instances can also delineate the route of spread.7, Contrast media used in CT contain iodine, which causes increased absorption and scattering of radiation in body tissues and blood. The most common contrast agents used with CT imaging are barium- and iodine-based. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. In the false-positive group, cellulitis was the most . A 64-year-old male with Fourniers gangrene with perforated diverticulitis. Marked preseptal edema and discrete contrast enhancement in the area of the affected left upper eyelid. sharing sensitive information, make sure youre on a federal Bethesda, MD 20894, Web Policies Contrast can cause acute renal failure. In Vivo MicroCT Monitoring of Osteomyelitis in a Rat Model. MR Imaging in Acute Infectious Cellulitis. Created for people with ongoing healthcare needs but benefits everyone. It is injected through an intravenous line during the examination. {"url":"/signup-modal-props.json?lang=gb"}, Radswiki T, Carroll D, Knipe H, et al. Gk MC, Turhan Y, Demirolu M, Kl B, Akku M, zkan K. Radiological assessment in necrotizing fasciitis. It results in pain, erythema, edema, and warmth. Disease processes that involve calcifications may benefit from noncontrast-enhanced images because contrast may mask the appearance of calcifications. 1 0 obj 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. Rahmouni A, Chosidow O, Mathieu D et al. CT Head or brain with and without contrast Note: MRI Brain with/without contrast is preferred. Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. High-resolution CT, which is used to evaluate diffuse lung disease, does not use IV contrast.17 Noncontrast imaging of the abdomen is routinely done to screen for renal stones in patients with flank pain.18 Common clinical scenarios in which noncontrast-enhanced CT is appropriate are summarized in Table 4,19 and common clinical scenarios in which contrast enhancement is recommended are summarized in Table 5.19 Indications for selection of imaging studies for specific clinical scenarios can be searched using the American College of Radiology Appropriateness Criteria at http://www.acr.org/ac.19. 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. Contrast is not used in patients with head, extremity or spine trauma. Check for errors and try again. Alaia E, Chhabra A, Simpfendorfer C et al. Although many radiology departments screen for shellfish allergy, there is no cross-reactivity between shellfish and iodinated contrast. Contrast agents can be further classified as high or low osmolality, based on the iodine concentration. Uncomplicated cellulitis is usually treated conservatively with antibiotics and locally supportive measures. CT is the most sensitive modality for soft-tissue gas detection, and compared with radiography, CT is superior to evaluate the extent of tissue or osseous involvement, show an underlying (and potentially more remote) infectious source, and reveal serious complications such as vascular rupture complicating tissue necrosis [ 10, 13 - 20 ]. Clinical presentations include skin erythema without a well-defined border, increased skin temperature, swelling of the affected area, and regional lymphadenopathy and lymphangitis. 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. doi: 10.5114/pjr.2022.113825. 7. Lactic acidosis has never been documented in patients with normal renal function who are receiving metformin. 2nd ed. Mitchell C, Dolan N, Drsteler K. Management of Dependent Use of Illicit Opioids. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, organs, and blood vessels. MR imaging of pediatric musculoskeletal inflammatory and infectious disorders. Contrast-enhanced CT demonstrates crescentic subfascial fluid (arrow) with fluid also seen superficial to the fascia (arrow head) and between muscle planes (a). Computed tomography (CT) with and without contrast: indications and protocols. Please enable it to take advantage of the complete set of features! A CT can help determine the underlying cause of orbital cellulitis. Radiologic Approach to Musculoskeletal Infections. Potential Harms of Computed Tomography: The Role of Informed Consent. Axial non-contrast. When is contrast needed for abdominal and pelvic CT? endstream Fasciae of the Musculoskeletal System: MRI Findings in Trauma, Infection and Neoplastic Diseases. 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? PMC Dr. Amy Levine answered. 4 0 obj Imaging of Musculoskeletal Soft Tissue Infections. Oral contrast is generally used for visualization of the abdomen and/or pelvis when there is suspicion of bowel pathology. My answer is based on the current radiologic practices and terminology employed in the U.S. 1. That said, it is seldom required for diagnosing cellulitis and is therefore usually ordered for suspected complications or to rule out alternative diagnoses in cases of an atypical presentation. Shortness of breath Abdomen andPelvis Without IV contrast 1. In certain situations, however, a contrast medium is essential. 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). CT without contrast in a patient with a history of interstitial lung disease and right lung trans-plant shows the patent but partially narrowed anastomotic site of the right bronchus (A) (red arrow). Next imaging study. 2021 Feb 1;94(1118):20200648. doi: 10.1259/bjr.20200648. In patients with elevated creatinine, withholding IV dye may be necessary. Normally the subcutaneous tissue is hypoechoic with few hyperechoic strands (representing connective tissue). Scout film (a) and contrast-enhanced CT (b) shows intramuscular pockets of gas (arrows) in the left lateral thigh. Contrast: A plain ct looks for stones. : Elsevier Health Sciences, 2013;633-644. 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. Inflammatory cellulitis is frequently confused with infectious cellulitis. 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. Fortunately, orbital fat provides intrinsic background contrast, and most orbital pathologies can be easily visualised without infusion of a contrast medium. It results in pain, erythema, edema, and warmth. In the emergency setting, CT of the neck is often performed to investigate symptoms of acute infection or inflammation or symptoms of aerodigestive tract compromise referable to the neck. Soft-tissue infections and their imaging mimics: from cellulitis to necrotizing fasciitis, Necrotizing soft-tissue infection: diagnosis and management, Red flags for necrotizing fasciitis: a case control study, Sonographic detection of necrotizing fasciitis, Necrotizing soft tissue infections: a primary care review. You'll need to take the antibiotic for the full course, usually 5 to 10 days, even if you start to feel better. Fasciae of the Musculoskeletal System: MRI Findings in Trauma, Infection and Neoplastic Diseases. Special consideration should be given to geriatric patients, in whom cellulitis of the lower extremities is more likely to develop into thrombophlebitis. , Acuterecurrent rhinosinusitis The U.S. Food and Drug Administration advises that metformin should be withheld at the time of IV contrast administration and for 48 hours afterward, and resumed only after reevaluation of renal status (i.e., return to baseline serum creatinine level).13. and transmitted securely. Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-15554. Contrast enhancement of the pulmonary arteries is key, as embolic disease is identified as abnormal filling defects within the pulmonary arteries (Figure 2). T2 weighted image with fat saturation of the left thigh demonstrates a large area of myonecrosis within the proximal rectus femoris muscle, with extensive muscular, fascial, and subcutaneous enhancement and edema, with crescentic fascial fluid collections, predominantly around the rectus femoris and sartorius, suggestive of necrotizing fasciitis. Contrast may also be avoided when the suspected pathology is likely to be visible on noncontrast-enhanced CT. A history should be obtained to determine if the reaction was mild (which typically requires observation but not treatment), moderate (which requires prompt treatment), or severe (which requires rapid intervention and, often, hospitalization). Possible contraindications for using intravenous contrast agents during computed tomography include a history of reactions to contrast agents, pregnancy, radioactive iodine treatment for thyroid disease, metformin use, and chronic or acutely worsening renal disease. Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine. Unenhanced CT is also used in patients with spine and extremity trauma.
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