Hrev_master Emergency Care Journal 2025; volume 21:13175 [Emergency Care Journal 2025; 21:13175] [page 1] A red and warm abdomen. What’s the matter? Erika Poggiali,1 Valeria Giosia,1 Daniele Coen2 1Emergency Medicine Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan; 2Academy of Emergency Medicine and Care, Pavia, Italy. Question Given the patient history and the clinical presentation, what is the most likely diagnosis? 1. Lipodermatosclerosis 2. Cellulitis 3. Papular urticaria 4. Allergic contact dermatitis Answer The right answer is cellulitis. Cellulitis is a common, potential- ly serious bacterial infection that involves the deep dermis and subcutaneous tissue. It represents the most common reason for skin-related hospitalization,1 and it can be a diagnostic and thera- peutic challenge for emergency clinicians.2 Specific criteria do not exist for the diagnosis, that is always clinical with an acute onset of redness, warmth, swelling, tenderness, and pain.3 Patients can complain of fever, chills, and general malaise. Cellulitis usually affects the lower legs, but it can occur on the face, arms, and other body areas. Risk factors include skin injury (any cut, burn, scrape) or skin condition (atopic dermatitis, athlete’s foot), lymphedema, venous insufficiency, overweight, immunodepression, and a previ- ous history of cellulitis.4 Treatment may include antibiotics and pain management, based on paracetamol or ibuprofen for mild to moderate pain, and morphine if severe. The majority of non-puru- lent, uncomplicated cases of cellulitis are caused by β-haemolytic streptococci, followed by methicillin-sensitive Staphylococcus aureus.2 Failure to improve with appropriate first-line antibiotics An 83-year-old woman presented to our emergency department for a fever with nausea and an itching skin rash on her abdomen for two days. She suffered from obesity, Parkinson disease, and depression in treatment with Levodopa/Benserazide and Pramipexole, respectively. She underwent mastectomy for left breast cancer ten years earlier. She denied any allergies or use of antibiotics. Her vital signs were blood pressure 120/65 mmHg, heart rate 72 bpm, peripheral oxygen saturation 94% in room air, respiratory rate 18/min, and body temperature 36.2°C. Examination of her abdomen revealed an extensive red warm rash without blisters or blebs, with a slight skin oedema confirmed by point-of-care ultrasound, that excluded a subcutaneous abscess, pneumoniae, liver and kidney damage, and cholecystitis. Laboratory findings showed WBC 12,400/mm3 (N 59.5%) and CRP 131 mg/L (n.v. < 5). Procalcitonin was 0.3 ng/mL (n.v. < 0.5). SARS-CoV-2 infection was excluded. Correspondence: Erika Poggiali, M.D. Emergency Medicine Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan, Italy. E-mail: poggiali.erika@gmail.com Key words: skin, cellulitis, skin infection, Streptococcus pyogens, Staphilococcus aureus. Contributions: all the authors approved the final version and equally contributed to the work. Conflicts of interest: EP and DC are members of the editorial board of ECJ. The authors declare no conflict of interest. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to Erika Poggiali, erika.poggiali@asst-fbf-sacco.it Ethics approval and consent to participate: as this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: the patient provided consent for the access to medical records at the time of admission. Received: 29 September 2024. Accepted: 23 October 2024. Early view: 21 November 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13175 doi:10.4081/ecj.2025.13175 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly should prompt consideration for resistant organisms - methicillin- resistant Staphylococcus aureus (MRSA)5 - or other conditions that can mimic cellulitis.6,7 If untreated or misdiagnosed, cellulitis can become an emergency for the development of septic shock, endocarditis, osteomyelitis, gangrene, and toxic shock syndrome. In some rare cases, the infection can spread to the fascial lining, causing necrotizing fasciitis.8 Our patient was admitted to the Internal Medicine Unit and treated with Piperacillin/Tazobactam, with complete resolution of the cellulitis in seven days. References 1. Peterson RA, Polgreen LA, Cavanaugh JE, Polgreen PM. Increasing incidence, cost, and seasonality in patients hospital- ized for cellulitis. Open Forum Infect Dis 2017;4:ofx008. 2. Boettler MA, Kaffenberger BH, Chung CG. Cellulitis: a review of current practice guidelines and differentiation from pseudocellulitis. Am J Clin Dermatol 2022;23:153-65. 3. Keller EC, Tomecki KJ, Alraies MC. Distinguishing cellulitis from its mimics. Cleve Clin J Med 2012;79:547-52. 4. Björnsdóttir S, Gottfredsson M, Thórisdóttir AS, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis 2005;41:1416-22. 5. Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016;316:325-37. 6. Nazarko L. Red legs: how to differentiate between cellulitis, venous eczema and lipodermatosclerosis. Br J Community Nurs 2022;27:486-94. 7. Goldenberg M, Wang H, Walker T, Kaffenberger BH. Clinical and immunologic differences in cellulitis vs. pseudocellulitis. Expert Rev Clin Immunol 2021;17:1003-13. 8. Poggiali E, Santilli G, and Vercelli A. A rapidly progressive painful skin lesion. Emerg Care J 2023;19:11046. Images in emergency [page 2] [Emergency Care Journal 2025; 21:13175] Non -co mmerc ial us e o nly