Not What It Seems: Deep Tissue Infection Presenting as Cellulitis

A 34-year-old male with diabetes presented to the emergency department with four days of progressively worsening redness, swelling and pain to his left buttock. The patient denied fevers, chills, rectal pain or purulent drainage from his rectum. His initial vital signs were heart rate of 82; blood pressure of 146/92; and temperature of 98.2°F. The left buttock had a poorly circumscribed area of induration; however, there was no fluctuance or crepitace. Rectal exam was unremarkable. Because the patient’s buttock pain was disproportionate to his exam findings, a point-of-care ultrasound was performed to determine if a more extensive process was present. The ultrasound demonstrated cobblestoning, fascial thickening with edema, and a large 4.5cm fluid collection extending and adjacent to the rectum (Figure 1). A computed tomography (CT) of the pelvis with IV contrast confirmed the presence of a Los Angeles County Medical Center+University of Southern California Medical Center, Department of Emergency Medicine, Los Angeles, California