Bacterial infection entered the skin through the burn and started infection of the upper dermis of the skin, before progressing to subcutenuous tissue, becoming cellulitis. Reduced healing due to high glucose levels and diabetes meant that infection progressed quickly, spreading in size on the patient;s skin.

modifiable risk factors:

• obesity

• injury (insect bites, minor trauma, abrasions) (Mr Ranvir scalded his leg with cooking oil)

non-modifiable risk factors:

• weakened immune system (such as DM, leukemia, HIV/AIDS, immunosuppressants - because it increases risk of infection) (Mr Ranvir is showing symptoms of DM such as polydipsia and polyuria, and has family history of DM, lab results shows high glycemic count)

• older age

• skin conditions (such as eczema)

• long term swelling of limbs

• history of cellulitis

• assess the infection severity, whether it has gone into the bloodstream

• figuring out which specific antibiotic is suitable for the infection -> targeted antibiotic therapy

• monitoring -> repeat blood culture can assess the effectiveness of treatment

Development

• Obesity means increased BMI, increase subcutaneous tissue which increase risk of cellulitis

• Obesity stresses the delicate lymphatic vessel, which leads to lymphatic obstruction and is a risk factor contributing to cellulitis

• Obese patients tend to have dry skin and impaired skin barrier repair and their lymphatic flow might be impaired following an inflammatory state

• If cellulitis is left untreated, excess protein-rich fluid will cause the lymphatic channel to increase in size and numbers. This leads to decrease oxygenation in the tissue, creating a culture medium for bacterial growth within the tissue. An increased bacterial load contributes to lymphangitis (inflammation of the lymphatic vessels)

Management

• Bacterial infection treatment

• Weight management

• Wound care management (maintaining skin integrity > prevent future breakdown of skin > preventing recurrent cellulitis)

• Diabetes Management (Obesity is a risk factor for DM, DM > poor blood circulation > slower skin recovery)

• febrile 38.5ºC.

• elevated WBC 13.2

• Neutrophil 90% (75% Norm)

• Slightly elevated Lymphocytes 45% (norm 41%) - it’s a new infection

KIV vancomycin after blood culture is out for target treatment

IV N/S 500ml over 1hr followed by maintenance drip IV N/S 2L/Day

• Maintain blood pressure 99/60mmHg

• prevent dehydration from fever

PO Paracetamol 1g Q6H for fever & Pain,  PO Ibuprofen 400mg TDS for analgesia

• pain score 7 @ Lower left leg upon movement and tender to touch

2H Para

• monitoring for fever and progression of infection

BGM TDS + 10 and SCSI - to monitor and control blood glucose (high blood glucose not beneficial for wound healing)

• Fasting glucose 9mmol/L (7.1 norm)

• HbA1c 10% (below 7 norm)

• Post prandial glucose 16mmol/L (11.1 norm)

• Random glucose (glucometer reading) 13mmol/L (11.1 norm)

Demarcate area of redness & daily review of wound

• for monitoring of spread of redness and infection

1. WBC/neutrophils/lymphocytes

   • due to bacterial infection (cellulitis)

2. Renal - Urea and creatinine

   • potential kidney infection

   • if Kidney is impaired -> giving antibiotics will overwhelm kidneys -> kidney failure

   • infection - less blood supply

3. Blood glucose - Fasting/Postprandial/Random/HbA1C (brother has prolonged elevated glucose - indicating chronic and poorly controlled diabetes)

   • Strong family history of diabetes

   • Currently obesity

   • Sedentary (no exercise)/desk-bound job

   • High risk of diabetes

Pending:

Blood culture to rule out systemic infection

Suggested investigations:

1. Venous Ultrasound/ Doppler Ultrasound - Check for the presence of blood clots,

2. MRI/ CT Scan if there is suspected deep tissue involvement, abscess formation or osteomyelitis

3. Skin test/Tissue biopsy/Gram test - Type of bacteria causing localized infection [in this case, suspected systemic infection hence no point doing a wound culture]

4. Diabetes test for neuropathy