ct with or without contrast for cellulitis

CT is used to accurately differentiate between superficial cellulitis and deep cellulitis. sonographic hallmarks of cellulitis include abnormal echogenicity and increased thickness of the dermis with indistinct "haziness" and increased echogenicity of the subcutaneous tissue, it is often helpful to compare the area in question to the (presumably normal)contralateral side, progressive accumulation of edema in the subcutaneous tissue appears as branching, anechoic striations which impart a lobulated ("cobble-stone" appearance), presence of thickened and abnormally echogenic overlying skin will favor cellulitis over edema, linear anechoic bands of fluid deep to the subcutaneous layer favor lymphedema, ultrasound is more sensitive than MRI for the detection of a retained foreign body as the causative agent, especially if small and wooden 4,5. CT Angiography, or CTA, is a type of contrasted CT scan used to evaluate the blood vessels. CT Exams Contrast vs Non-Contrast Guide These suggestions are general guidelines that apply to the use of contrast for CT exams provided at Oregon Imaging Centers. All rights reserved. 2001;176(5):1155-9. The major families of contrast agents are ionic and nonionic. Cellulitis occurs after disruption of the skin and invasion of the subcutaneous tissues by microorganisms that may be skin flora, such as beta-haemolytic streptococci (most often),Staphylococcus aureus(including methycillin-resistant), or other bacteria 9. Contrast materials are generally safe; however, as with any pharmaceutical, there is the potential for adverse reactions. The diagnostic algorithm for lung cancer screening is evolving. Before PDF CT EXAM CPT CODE REFERENCE - Wake Radiology They are used for bowel opacification and are not nephrotoxic. Wysoki MG, Santora TA, Shah RM, Friedman AC. Cellulitis. Weaver JS, Omar IM, Mar WA, Klauser AS, Winegar BA, Mlady GW, McCurdy WE, Taljanovic MS. Pol J Radiol. Data Sources: We used the term radiologic contrast to search the following: PubMed Clinical Queries (systematic reviews); the OVID database (all evidence-based medicine reviews; Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Trial Registry, Cochrane Methodology Register, Health Technology Assessment, and NHS Economic Effectiveness Database); Dynamed; and the U.S. Preventive Services Task Force and Agency for Healthcare Research and Quality clinical guidelines and evidence reports. Cellulitis (rare plural: cellulitides) is an acute infection of the dermis and subcutaneous tissues without deep fascial or muscular involvement. Special consideration should be given to geriatric patients, in whom cellulitis of the lower extremities is more likely to develop into thrombophlebitis. The choice of contrast agent depends on route of administration, desired tissue differentiation, and suspected diagnosis. Turecki M, Taljanovic M, Stubbs A et al. Inflammatory cellulitis is frequently confused with infectious cellulitis. In the false-positive group, cellulitis was the most . Federal government websites often end in .gov or .mil. AJR Am J Roentgenol. Marked preseptal edema and discrete contrast enhancement in the area of the affected left upper eyelid. Epub 2020 Oct 15. While the plain film and nuclear medicine bone scan are still the traditional imaging modalities used in the evaluation of musculoskeletal infection, the cross-sectional imaging modalities, computed tomography (CT) and magnetic resonance imaging (MRI), have become critical in the delineation of many types of musculoskeletal infection. <> Fasciae of the Musculoskeletal System: MRI Findings in Trauma, Infection and Neoplastic Diseases. Extensive streaky soft-tissue gas is seen extending along the fascial planes of the right thigh on radiograph. In cases where the plain film and nuclear medicine bone scan findings are complicated due to previous surgery, trauma, or underlying illness, the anatomic resolution and soft tissue contrast provided by MRI and CT are often necessary to determine if underlying infection exists. A 64-year-old male with Fourniers gangrene with perforated diverticulitis. Yes neuro CTa HeaD Circle of Willis CTA Head with and without contrast Note: MRA Brain without contrast is preferred. Oral contrast agents are barium- or iodine-based and are used for bowel opacification. Radiology. 1998 Aug;6(3):537-59. 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. Barium suspension from fluoroscopy or CT will not produce an artifact on abdominal magnetic resonance imaging. If the infection spreads to deeper tissues, soft-tissue abscess, infectious myositis, necrotising fasciitis, and osteomyelitis can all be detected with CT. MRI is sensitive for distinguishing cellulitis alone from necrotising fasciitis and infectious myositis and for showing subcutaneous fluid collections and abscesses. CT without contrast in a patient with a history of interstitial lung disease and right lung transplant shows the patent but partially narrowed anastomotic site of the right bronchus (A) (red arrow). Unenhanced CT is also used in patients with spine and extremity trauma. Oral contrast is generally used for visualization of the abdomen and/or pelvis when there is suspicion of bowel pathology. 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 ]. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. During the injection you may feel flushed and get a metallic taste in your mouth. Wronski M, Slodkowski M, Cebulski W, Karkocha D, Krasnodebski IW. IV contrast may be used to visualize vasculature as well as the internal organs of the abdomen and pelvis. Horton L, Jacobson J, Powell A, Fessell D, Hayes C. Sonography and Radiography of Soft-Tissue Foreign Bodies. 2009;16(4):267-76. Diagnosing Pediatric Orbital Cellulitis: CT or rMRI? Axial non-contrast. The location and extent of the inflammatory process was accurately demonstrated with axial CT scans in all cases. Speak with a Radiologist: 541-284-4016 Many practices have their own protocols for IV dye administration in patients using metformin so nurse practitioners must familiarize themselves with these policies. 2019;10(1):47. Contrast-enhanced CT demonstrates crescentic subfascial fluid (arrow) with fluid also seen superficial to the fascia (arrow head) and between muscle planes (a). Ct urogram with and without contrast | HealthTap Online Doctor In uncomplicated cellulitis, CT demonstrates skin thickening, septation of the subcutaneous fat, and thickening of the underlying superficial fascia. If youre ever stuck when it comes to the correct diagnostic imaging method for your patient, pick up the phone and call the radiologist or imaging facility with whom you work. Clear communication between the physician and radiologist is essential for obtaining the most appropriate study at the lowest cost and risk to the patient. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The American College of Radiology recommends using IV iodinated contrast in pregnant women when the information needed affects the care of the patient and fetus and cannot be obtained without contrast, and when the referring physician thinks that imaging should not wait until after the pregnancy.7, Iodinated contrast media can saturate the thyroid gland and significantly reduce uptake of iodine 131, rendering the treatment ineffective. A neck mass or adenopathy also may be investigated, particularly when it results in airway or vascular compromise. No mutagenic or teratogenic effects have been shown with nonionic, low-osmolality contrast in animal studies. Ultrasound is helpful to rule out deep venous thrombosis, assess for possible foreign bodies, and guide potential diagnostic fluid aspiration.8, 13 Sensitivity of ultrasound for the diagnosis of necrotizing fasciitis is 88.2%, with a specificity of 93.3%.20, CT is the primary imaging modality in the work-up of necrotizing fasciitis given its wide availability and high spatial resolution compared to radiography or ultrasound.3 Soft-tissue gas is a pertinent CT finding, but absence of it should not exclude the diagnosis of necrotizing fasciitis if clinically suspected.1, 2,11,17 Gas within fluid collections along subfascial planes is the hallmark of necrotizing fasciitis (Figures 5 and 6).11, 21 The lack of soft-tissue gas on CT may be due to early disease, aerobic infections, or if the patient is diabetic.1, 16 The sensitivity of CT in diagnosing necrotizing fasciitis is 80%, but it lacks specificity as findings can also be seen in nonnecrotizing fasciitis.21, 22 Thickening and nonenhancement of the fascia on contrast-enhanced CT may be helpful to distinguish from nonnecrotizing fasciitis.2 Subfascial and intermuscular fluid accumulation can also be seen on CT, and may represent early findings of necrotizing fasciitis (Figure 7).21. The https:// ensures that you are connecting to the Necrotizing Fasciitis and Its Mimics: What Radiologists Need to Know 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. N Engl J Med. At our institution, to assess dynamic airway narrowing, we use a dedicated airway protocol, including inspiratory and expiratory phases and multi-planar reformatted images. A 45-year-old male with necrotizing fasciitis of the right thigh. N/A No CT WRIST LEFT WO CONTRAST (IMG3906) CT WRIST RIGHT WO CONTRAST(IMG3909) CT HAND LEFT WO CONTRAST (IMG3794) CT HAND RIGHT WO CONTRAST (IMG3797) 73200 Water-soluble, iodine-based contrast agents can also be given orally. Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine. In general, oral contrast is used for most abdominal and pelvic CT scans unless there is no suspicion of bowel pathology (e.g., noncontrast CT to detect kidney stones) or when administration would delay a diagnosis in the trauma setting. Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-15554. Case 1: orbital and periorbital cellulitis, see full revision history and disclosures. Orbital cellulitis. Alaia E, Chhabra A, Simpfendorfer C et al. The concentration of barium determines whether it enhances the diagnosis or causes an artifact and obscures pathology. 2. Sinus radiographs, which were also obtained, were not helpful in diagnosis or management. Necrotizing fasciitis: CT characteristics. There are several contrast agents that may be used in performing CT scans. 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. Schmid M, Kossmann T, Duewell S. Differentiation of Necrotizing Fasciitis and Cellulitis Using MR Imaging. This is commonly ordered for diagnosis of: 1. It is injected through an intravenous line during the examination. 2022 Mar 5;87:e141-e162. Imaging of Musculoskeletal Soft Tissue Infections. Clinical presentations include skin erythema without a well-defined border, increased skin temperature, swelling of the affected area, and regional lymphadenopathy and lymphangitis. Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Signs of cellulitis are easy to appreciate on CT and MRI and include thickening of the fat, best appreciated on the preseptal space, fat infiltration, and contrast enhancement. Although classically a clinical diagnosis, imaging is a powerful adjunct to facilitate early diagnosis in equivocal cases. Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue - ACR Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Preseptal cellulitis | Radiology Case | Radiopaedia.org Soft-tissue gas is a specific finding on all modalities, but is not present in all patients with necrotizing fasciitis. Contrast-enhanced CT demonstrates a horse-shoe shaped perirectal air collection (arrows), extending into the subcutaneous tissues of the ischiorectal fossa and medial gluteal region (b). <>/Metadata 2 0 R/ViewerPreferences 6 0 R>> MR Imaging in Acute Infectious Cellulitis. MR Imaging in Acute Infectious Cellulitis. 2009;16(4):267-76. 4. A 53-year-old male with necrotizing fasciitis of the left knee. Mediastinitis may likewise be iatrogenic or may spread from the oropharynx. FOIA An official website of the United States government. Abstract. The US Preventive Services Task Force currently recommends low-dose CT without contrast, along with appropriate patient counseling, for patients with a history of smoking and an age range as detailed in the Task Force statement.3. Most centers use nonionic contrast agents (which are generally low osmolality) for IV contrast studies.5 The rate of major reactions (e.g., anaphylaxis, death) is the same for ionic and nonionic IV contrast agentsan estimated one in 170,000 administrationsbut nonionic contrast has a lower rate of minor reactions.6 Approximately 5% to 12% of patients who receive high-osmolality contrast have adverse reactions, most of which are mild or moderate.7 Use of low-osmolality contrast has been associated with a reduction in adverse effects. A CT can help determine the underlying cause of orbital cellulitis. The PPV was 91.3% when more than one deep neck space was involved but only 50.0% in patients with isolated retropharyngeal abscesses. References. 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. The concentration of barium used for fluoroscopy is more than 20 times that of the typical oral contrast suspension for CT. For example, the barium concentration from an upper gastrointestinal series or an enema will produce an artifact on abdominal CT because it is significantly more concentrated than bowel contrast agents used for CT. Barium enemas are also given after abdominal CT to allow time for the less-dense barium to leave the colon. Reinert CP, Pfannenberg C, Dittmann H, Gckel B, la Fougre C, Nikolaou K, Hoefert S. J Clin Med. Before It is usually due to underlying bacterial sinusitis. Inclusion in an NLM database does not imply endorsement of, or agreement with, Since the epidermis is not involved, cellulitis is not transmitted by person-to-person contact. Stadelmann VA, Potapova I, Camenisch K, Nehrbass D, Richards RG, Moriarty TF. Turecki M, Taljanovic M, Stubbs A et al. 2020;368:m710. 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 NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. 3 Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity. Rectal contrast can be used in patients with a suspected penetrating colonic injury.2 Rectal contrast does not always reach the cecum, so the small bowel and appendix can remain unopacified. Assessment of interstitial lung disease does not require use of IV contrast; rather, a tailored protocol with thinner slices and non-contiguous expiratory images can be used to evaluate for air-trapping and dynamic airway compromise (Figure 4). Detailed protocols for premedication and management of contrast adverse reactions are beyond the scope of this review and the reader is advised to refer to dedicated manuals.10. CT pulmonary angiography with intravenous contrast in a patient being evaluated for arteriovenous malformation. 2007 Nov-Dec;27(6):1723-36. doi: 10.1148/rg.276075033. Thirteen orbital computed tomographic (CT) scans were obtained in 12 patients with postseptal (orbital) cellulitis. 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? Scout film (a) and contrast-enhanced CT (b) shows intramuscular pockets of gas (arrows) in the left lateral thigh. Below is an overview of the following CTA studies and their indications: Abdominal Aorta (CTA Abdomen) - Aneurysm, dissection, post stent grafting, renal artery stenosis, metastatic stenosis Signs of cellulitis are easy to appreciate on CT and MRI and include thickening of the fat, best appreciated on the preseptal space, fat infiltration, and contrast enhancement. Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC. It is essential to know the types of contrast agents, their risks, contraindications, and common clinical scenarios in which contrast-enhanced computed tomography is appropriate. 3. Federal government websites often end in .gov or .mil. endstream CT and MR imaging of orbital inflammation | SpringerLink This site needs JavaScript to work properly. Muscular fascia lies deep to the subcutaneous layer. Risk factors include chronic kidney disease, diabetes mellitus, heart failure, older age, anemia, left ventricular systolic dysfunction, and contrast volume. E-mail: Received 2018 Jan 20; Revised 2018 Mar 2; Accepted 2018 Mar 8. Careers, Unable to load your collection due to an error. Moran CORE | Preseptal vs Orbital Cellulitis - University of Utah At the time the article was last revised David Carroll had Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-15554. Subcutaneous and subfacial emphysema, which are classical finding of necrotizing fasciitis (a). 1994;192(2):493-6. A 35-year-old male with necrotizing fasciitis of the right calf. The site is secure. Finally, imaging of the abdomen and pelvis to assess for renal stones also does not require CT contrast. Cellulitis can affect any region of the body, and commonly affects a lower limb. official website and that any information you provide is encrypted Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. N.p. ADVERTISEMENT: Supporters see fewer/no ads. The need for enhancement with intravenous (IV) contrast depends on the specific clinical indication (Table 1). 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. Although it is a clinical diagnosis, imaging is a powerful adjunct to facilitate early diagnosis in equivocal cases. Radiologic Approach to Musculoskeletal Infections. At the time the article was last revised David Carroll had In certain situations, however, a contrast medium is essential. Pitfalls of CT for deep neck abscess imaging assessment: a These experts are usually happy to help select the correct test for your patient. CT is used to accurately differentiate between superficial cellulitis and deep cellulitis. Fugitt JB, Puckett ML, Quigley MM, Kerr SM. Search dates: November 2009 and April 27, 2010. 5. Cross-sectional imaging findings include asymmetric thickening of fascia, soft tissue air, blurring of fascial planes, inflammatory fat stranding, reactive lymphadenopathy, and nonenhancement of muscular fascia. Kidney/ureteral stones With IV contrast 1. Case 1: orbital and periorbital cellulitis, see full revision history and disclosures. 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.
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