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Infectious cellulitis usually is diagnosed clinically without microbiological confirmation, and it has many disease mimics. In a meta-analysis, researchers estimated misdiagnosis of cellulitis in seven studies that involved 858 inpatients who initially received diagnoses of cellulitis; in these studies, all patients in whom cellulitis was diagnosed received second evaluations by a dermatologist or infectious disease specialist. None of the studies was blinded, and studies were excluded if referral for consultation was left to the discretion of the provider making the initial diagnosis. Two of the studies in this meta-analysis were reviewed previously by NEJM Journal Watch (NEJM JW Gen Med Jul 1 2018 and JAMA Dermatol 2018; 154:529, 537).
Among patients in whom cellulitis was diagnosed initially — almost all of whom received specialist evaluations within 24 hours of admission — 39% received alternative diagnoses by specialists, and the two most recent studies (published in 2020) reported that 60% of patients received alternative diagnoses by specialists. In nearly one third of misdiagnoses, patients had some form of dermatitis (e.g., stasis, eczematous, allergic), and one third had some other type of infection (e.g., abscess, septic bursitis, osteomyelitis); 4% had gout or pseudogout.
Cutler TS et al. Prevalence of misdiagnosis of cellulitis: A systematic review and meta-analysis. J Hosp Med 2023 Mar; 18:254. (https://doi.org/10.1002/jhm.12977)
Comment
This analysis provides strong evidence that cellulitis is misdiagnosed quite frequently and reminds us to expand the differential diagnosis for patients who are thought — at first blush — to have infectious cellulitis. A limitation of this report is the inclusion of unblinded studies and unclear duration between initial diagnosis and specialist evaluation (in some studies); nevertheless, the findings confirm my longstanding impression that other conditions often are mistaken for cellulitis.