Rationale:

• Recognize that in some disorders, such as neutropenia or those that require the use of steroids, the clinical signs of severe cellulitis and soft tissue infection may be attenuated and result in underestimation of the severity of the process.

Evidence:

• Infection in neutropenic hosts or those on steroids may lack many of the cardinal signs of inflammation (18).
• Immunocompromised patients with infections often require invasive procedures to obtain adequate specimens for culture to identify the etiologic agents (18; 30; 31).
• Hyperglycemia suppresses neutrophil function, predisposing to a worse outcome. Neuropathy may also reduce acute symptoms such as pain, whereas vascular insufficiency may attenuate other manifestations of the acute inflammatory response, such as swelling, erythema, and heat (13).

Comments:

• The gamut of immunodeficiency runs from quantitative or qualititative deficits in leukocytes, immunoglobulin production, and cell-mediated immunity. Each is associated with its own types of infections including more resistant organisms such as gram-negative bacilli, fungi, and non-tuberculous mycobacteria.