Cellulitis following pelvic lymph node dissection
- Larry M Baddour, MD, FIDSA, FAHA
Larry M Baddour, MD, FIDSA, FAHA
- Professor of Medicine
- Mayo Clinic College of Medicine
Acute cellulitis can occur in women who have previously undergone surgical procedures with local lymph node dissection for gynecologic cancer. Two reports from the Netherlands in the late 1980s provide the most clinical information characterizing these syndromes [1,2]. Subsequent case reports from the United States have confirmed these initial observations [3-5].
In a series of 270 women who had undergone pelvic lymphadenectomy with radical hysterectomy, acute cellulitis developed in 4 percent of women . Most patients had either cervical or endometrial carcinoma. Collectively, nine women experienced 17 episodes of cellulitis during over 14,000 patient months of follow-up; the average time to the first episode of cellulitis was 29 months (range 4 to 52 months). Surprisingly, cellulitis developed only in patients who had undergone postoperative pelvic irradiation.
In a subsequent study of 126 women who had undergone radical vulvectomy with superficial and deep inguinal lymphadenectomy for vulvar carcinoma, acute cellulitis occurred in 26 percent of cases . Colonization with beta-hemolytic streptococci prior to surgery was the only significant risk factor. The incidence of cellulitis was higher in patients with history of postoperative radiation (33 versus only 16 percent).
Streptococcal sex syndrome — A temporal relationship between vaginal intercourse and the onset of acute cellulitis has been described ("streptococcal sex syndrome") . In one patient who was 22 weeks pregnant and who had undergone a modified radical vulvectomy with inguinal lymphadenectomy for squamous cell carcinoma of the labia majora two months earlier, symptoms of acute infection developed within one hour of coitus. One month later, she again noted the onset of cellulitis promptly after sexual intercourse.
The presentation of acute cellulitis is similar for most patients regardless of the anatomical location of the primary skin lesion. Most patients note the acute onset of fever, chills, and systemic toxicity associated with skin erythema and tenderness. Women who have had surgery and lymph node dissection for the treatment of gynecologic cancer usually develop macular erythema and swelling over the lower abdominal wall, inguinal area, and/or the proximal thigh. Some patients may have raised erythema, which is more characteristic of erysipelas.
- Dankert J, Bouma J. Recurrent acute leg cellulitis after hysterectomy with pelvic lymphadenectomy. Br J Obstet Gynaecol 1987; 94:788.
- Bouma J, Dankert J. Recurrent acute leg cellulitis in patients after radical vulvectomy. Gynecol Oncol 1988; 29:50.
- Binnick AN, Klein RB, Baughman RD. Recurrent erysipelas caused by group B streptococcus organisms. Arch Dermatol 1980; 116:798.
- Chmel H, Hamdy M. Recurrent streptococcal cellulitis complicating radical hysterectomy and radiation therapy. Obstet Gynecol 1984; 63:862.
- Ellison RT 3rd, McGregor JA. Recurrent postcoital lower-extremity streptococcal erythroderma in women. Streptococcal-sex syndrome. JAMA 1987; 257:3260.
- Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis. Association with venous and lymphatic compromise. Am J Med 1985; 79:155.