Serial Misdiagnosis of Erythromelalgia in Bilateral Lower Extremities as Cellulitis

Objective

The purpose of this case report is to describe the presentation and initial misdiagnosis of erythromelalgia in a 61-year-old woman in an urgent care and outpatient clinic.

Clinical Features

The patient’s chief complaint was rapid-onset pain and erythema of the right foot following a fall, with initial presentation to a rural urgent care. A plain film radiograph of the right foot was negative for acute fracture or dislocation. A diagnosis of cellulitis of right foot was suggested based on the presentation of frank erythema, pain and pruritus of the right foot. This diagnosis was assumed despite a lack of comorbid diagnosis of diabetes mellitus or history of gout in the patient, denial of penetrating trauma to the extremities, and lack of fever or other systemic symptoms.

Intervention and Outcome

The patient was suspected to have cellulitis of the right lower extremity with an unknown inciting factor. The patient was given oral cephalexin 500 mg three times daily (TID) for seven days; and was advised to return to the clinic if resolution was not achieved. The patient was adherent with outpatient treatment yet returned to the urgent care 1 week later with symptoms of left toe redness, edema and pain. She was suspected to have resistant cellulitis of bilateral feet and was treated with sulfamethoxazole-trimethoprim 800-160 mg twice daily (BID) for fourteen days. The patient did not seek further medical attention until a routine visit with her primary care physician five months later. At this time, she described the episodes which her provider believed were misdiagnosed, and erythromelalgia was considered.

Conclusion

The incident revealed that for this female patient with suspected erythromelalgia of the feet, serial misdiagnosis of her condition as cellulitis, and treatment with antibiotics was insufficient to resolve symptoms. Considerations to improve care are patient education and routine follow-up with a primary care physician. This would establish continuity and identify a lack of response to treatment requiring more extensive investigation. Failure of symptom resolution despite treatment with antibiotics and instead, successful resolution with time, temperature change and elevation suggest an alternative diagnosis of erythromelalgia for the patient.