INTRODUCTION — 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].
EPIDEMIOLOGY — In a series of 270 women who had undergone pelvic lymphadenectomy with radical hysterectomy, acute cellulitis developed in 4 percent of women [1]. 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 [2]. 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).
CLINICAL MANIFESTATIONS
General symptoms — 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.
Patients who have suffered recurrent attacks usually recognize the signs and symptoms of cellulitis. Recurrent episodes of cellulitis are similar to previous bouts in terms of symptoms and severity of illness. They usually occur without antecedent precipitating events, although vaginal intercourse appears to initiate the infection in some patients [5].
Streptococcal sex syndrome — A temporal relationship between vaginal intercourse and the onset of acute cellulitis has been described ("streptococcal sex syndrome") in women who have undergone pelvic lymph node dissection [5,6]. In these case reports, Streptococcus agalactiae and Streptococcus mitis/oralis have been recovered from blood and vaginal cultures. The majority of streptococcal sex syndrome cases are likely due to non-group A, beta-hemolytic streptococci [7]. In contrast, S. mitis/oralis and other species of viridans group streptococci are extremely rare causes of cellulitis. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".)
The syndrome may recur after subsequent episodes of vaginal intercourse. 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. In our experience, recurrence of streptococcal sex syndrome can be prevented with precoital prophylaxis (a single dose of penicillin VK). If recurrence occurs despite the use of single-dose penicillin VK, then suppressive therapy should be initiated with this antibiotic to attempt to prevent recurrences. In the extremely rare case of infection due to S. mitis/oralis, failure of either single-dose or suppressive therapy could denote penicillin resistance, which is common among S. mitis/oralis and a non-beta-lactam antibiotic be selected for use [8]. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".).
MICROBIOLOGY — In general, for most patients with cellulitis after surgery for gynecologic cancer, specific pathogens are not recovered from clinical specimens. In the minority of cases in which pathogens have been recovered, most of the isolates were non-group A, beta-hemolytic streptococci [1-5]. These streptococci appear to have a proclivity to produce soft tissue infections in the setting of venous and/or lymphatic compromise [7]. Staphylococcus aureus is also an important pathogen.
TREATMENT — Antibiotic therapy is usually empiric, as pathogens are not typically identified, and should include activity against beta-hemolytic streptococci and S. aureus. For most individuals, antibiotic selection is the same as for cellulitis in general . Patients who have purulent disease or particular risk factors (table 1) may also warrant empiric coverage for methicillin-resistant S. aureus (MRSA) . (See "Acute cellulitis and erysipelas in adults: Treatment".)
For patients who have received recent chemotherapy and are neutropenic, the antibiotic regimen should be broadened to include coverage for aerobic gram-negative bacilli, including Pseudomonas aeruginosa. (See "Overview of neutropenic fever syndromes" and "Treatment and prevention of neutropenic fever syndromes in adult cancer patients at low risk for complications".)
The optimal duration of therapy is uncertain. In general antimicrobial therapy should be continued until the clinical signs of infection have resolved. Response to therapy may be slow; in general patients report improvement in pain before there is a noticeable decrease in erythema and swelling.
PREVENTION — Although there are no clinical trial data addressing the efficacy of suppressive antibiotic therapy in the setting of recurrent cellulitis following lymph node dissection, specifically, the practice is supported by trials that demonstrate benefit in some patients with recurrent, severe bouts of lower extremity cellulitis [1-5,9]. Suppressive therapy should be tailored to individual clinical features, including microbiologic or serologic results. (See "Acute cellulitis and erysipelas in adults: Treatment", section on 'Recurrent infection'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Skin and soft tissue infections".)
SUMMARY
●Acute and often recurrent cellulitis has been described in women who have undergone pelvic lymphadenectomy for gynecologic malignancies. This syndrome is particularly associated with a history of postoperative pelvic irradiation. In some cases, the onset of the cellulitis may be temporally associated with vaginal intercourse. (See 'Introduction' above and 'Epidemiology' above.)
●The clinical manifestations are similar to those of cellulitis in general. In these cases, the lower abdominal wall, inguinal area, and/or proximal thigh are often affected. In the minority of cases in which pathogens have been recovered, most of the isolates were non-group A, beta-hemolytic streptococci. Staphylococcus aureus is also an important pathogen. (See 'Clinical manifestations' above and 'Microbiology' above.)
●Patients should be treated with antibiotics that have activity against beta-hemolytic streptococci and S. aureus. For most individuals, antibiotic selection is the same as for cellulitis in general . Patients who have purulent disease or particular risk factors (table 1) may also warrant empiric coverage for methicillin-resistant S. aureus (MRSA) . The antibiotic regimen should also be active against aerobic gram-negative bacilli, including Pseudomonas aeruginosa, in patients who have received recent chemotherapy and are neutropenic. (See 'Treatment' above and "Acute cellulitis and erysipelas in adults: Treatment".)
●Suppressive antibiotic therapy may be useful for some patients with recurrent, severe bouts of cellulitis. (See 'Prevention' above.)
