Case Presentation: A 72-year-old female was admitted for bilateral lower extremity (LE) cellulitis. She reported a week of progressive bilateral LE swelling and pain that acutely worsened and a one-day history of erythema of both legs. She denied fevers or other infectious signs and symptoms but reported abdominal bloating. Cefazolin was started for cellulitis. On admission, the patient’s bilateral LE and lower abdomen were tender, erythematous and warm with pitting edema. Her vital signs were normal. Also notable on exam was a 3/6 systolic murmur. On questioning, she reports the murmur is new as of a clinician mentioning it to her a few weeks ago. She denied intravenous drug use or respiratory complaints. She did have routine dental cleaning a few weeks prior. Her admission labs were unremarkable.Her medical history is notable for metastatic neuroendocrine tumor diagnosed 3 months ago treated with weekly octreotide injections. She also has a history of extensive right LE deep vein thrombosis complicated by chronic clot on warfarin with iliofemoral stenting in 2007 and saphenopopliteal bypass in 2008 followed with serial imaging and intermittent right LE swelling that varied with activity. With bilateral LE involvement and in the absence of fever, the admitting diagnosis of cellulitis was questioned. A broad differential diagnosis was considered and included hepatic vascular obstruction from hepatic metastases, venous obstruction from her vascular disease, endocarditis or other cardiac pathology causing right heart failure. Deep vein ultrasound and CT Venogram showed stable disease without concern for venous obstruction. Abdominal US showed new moderate ascites, stable liver metastases and pulsatile left, right, and main hepatic vein waveform. Given her neuroendocrine tumor diagnosis, new murmur and liver imaging, carcinoid heart became the leading diagnosis. While awaiting echocardiogram, she was given intravenous furosemide with brisk urine output and improvement in symptoms. Echocardiogram (figure) was consistent with carcinoid heart.
Discussion: Up to 28% of patients admitted to the hospital with cellulitis are misdiagnosed.1 Additionally, it is exceptionally rare for cellulitis to present as multifocal so hospitalists must maintain a broad differential and consider alternatives that can mimic cellulitis.2 A good history and exam can lead to further information to guide the diagnostic work-up. This case represents a good example of a thorough history and exam leading to the correct diagnosis. She had signs and symptoms consistent with right heart failure which in the context of her overall medical history lead to the diagnosis even before imaging confirmed carcinoid heart. While carcinoid tumors are rare, up to 50% of patients of patients develop carcinoid heart which most commonly presents with signs and symptoms of right heart failure.3 For this patient, once the diagnosis was confirmed, cardiology and cardiac surgery were consulted. Management started with medical optimization and plans for further evaluation for surgery once her carcinoid disease was under better control.
Conclusions: Clinicians should maintain a healthy skepticism for bilateral cellulitis and consider alternative diagnoses. Acute right heart failure can present with impressive LE edema and erythema that can mimic cellulitis.
