Cellulitis - sonographic cobblestone appearance

Case contributed by Hadiel Kaiyasah


History of Crohn disease, presenting with three days of painful right leg swelling

Patient Data

Age: 25 years
Gender: Male

Bedside ultrasound of the right leg cellulitis showing hyperechoic fat lobules separated by hypoechoic fluid-filled areas, typically known as "cobblestone" appearance.

Right leg erythematous swelling over the medial malleolus with surrounding induration.

Case Discussion

Cellulitis is the pathological condition most frequently encountered during soft-tissue bedside ultrasonography. The ultrasound appearance of cellulitis varies depending on the stage and severity. The initial appearance may be generalized swelling and increased echogenicity of the skin and subcutaneous tissues 1,2. As cellulitis progresses and the amount of subcutaneous fluid increases, hyperechoic fat lobules become separated by hypoechoic fluid-filled areas. This later stage of cellulitis is most typical and has been described as having a cobblestone appearance 1,2. The appearance of fluid-filled interlobar septa is not specific for cellulitis but rather of generalized subcutaneous edema, which more commonly results from other conditions such as congestive heart failure 1

The use of bedside ultrasound in the emergency department in patients with signs of cutaneous soft-tissue infection, but no signs of obvious abscess, has helped in planning management correctly 3. By routinely utilizing ultrasound in the evaluation of these patients, physicians are able to avoid unnecessary drainage procedures as well as detect occult abscesses.

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