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Atypical cellulitis
  1. Debkumar Ray,
  2. Mitesh Khakhar,
  3. Alistair Flowerdew
  1. Department of General Surgery, Dorset County Hospital, Dorchester, Dorset, UK
  1. Mr D Ray, 32 Falconview, Badger Farm, Winchester SO22 4EP, UK (e-mail: debkumarray{at}hotmail.com)

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Answers on p 446.

A 76 year old man was admitted to the surgical ward with a two week history of right iliac fossa pain associated with two days history of high fever (38.6°C) and right inguinoscrotal swelling. There were no associated bowel and/or urological symptoms. He was not diabetic and had a coronary artery bypass graft in 1993. On examination he was slightly confused, dehydrated, and pyrexial. Abdominal examination revealed an ill defined tender lump over right lumbar area along with a tender right inguinoscrotal swelling. There was evidence of cellulitis and spreading lymphangitis over the right groin.

A plain abdominal and chest x film were normal. A full blood count showed a white cell count of 10.6 × 109/l and haemoglobin concentration of 136 g/l. Blood urea concentration was 10.9 mmol/l and serum creatinine 86 mmol/l. Computed tomography was performed next morning.

Two interesting sections of the scan are shown in figs 1 and2.

Figure 1

Computed tomogram of perineum and upper thigh.

Figure 2

Computed tomogram of lumbar area.

Questions

(1)
What are the computed tomography findings in figs 1 and2?
(2)
What is the most likely diagnosis?
(3)
What should be the next step of management?

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