Erysipelas
Key
Words: Strep A, Lymphedema,
Cellulitis, Bacteremia, Septicemia, Cutaneous lympatics,
immunocompromised, St. Anthony's Fire, Staph aureus, Strep G,
Penicillin,
Probenecid, Dicloxacillin, Erythromycin, Keflex, Augmentin, Necrosis,
Gangrene,
Thrombophebitis, Bacterial endocarditis, Soft tissue infections
Discussion
Erysipelas (also called St. Anthony's Fire)is a
superficial bacterial skin
infection skin generally caused by
Strep A
bacteria or Strep B bacteria. It can spread with alarming rapidity
as
it invades the
cutaneous
lymphatics.
While some classify it as a "form of cellulitis,"
it actually can be
differentiated by the clear lines of demarcation of the infection.
Symptoms include marked lines of infection, fever, pain, an overall
achy feeling
and
swollen lymph
nodes. Most cases involve the legs, and the second largest
number of cases involve the face.
However a delay in treatment can result in deeper cellulitis
or lymphangitis.
Like any type of infection a
lymphedema patient experiences,
antibiotic
treatment needs to start immediately so as to prevent
septicemia or bacteremia.
As with any infection erysipelas present a serious threat due to the immunocompromised
state of the lymphedemous limb and because possible fibrosis
handicaps
effective antibiotic therapy. Also, in lymphedema
patients Staph aureus
(not Strep A) has been implicated as the infective
bacteria.
While very similar and often confused with actual cellulitis it can be differentiated by the raised borders and advancing edges. The most commonly affected body areas are the legs, followed by the face.
Risk Factors
There are a number of factors that might predispose one to erysipelas. The primary cause of course is a break, cut or entry foci in the skin and subsequent infection usually by a Strep A bacterium. Susceptibility factors include edema, lymphedema, venous insufficiency, venous stasis, dermatosis, diabetes, HIV infection, and other immunocompromising medical conditions.
Transmission factors include port of entry through nasal cavity, insect bites, cut, incisions.
Symptoms
The infection may start out as a inconspicuous small red patch and spread rapidly to a painful fiery red plaque. The infection area will be warm or hot and quite tender. Over-all body symptoms might include feeling unusually drained of energy, achiness, chills, fever and malaise. There may also be blisters on the infected area and possible red streaking.
Treatment
Treatment generally will involve the administration of an oral antibiotic. The infection responds well to penicillin based antibiotic. In addition Probenecid may be used as it increase the effectiveness of penicillins. For more resistant infections dicloxacillin may be used. Other antibiotics may include Nafcillin, Erythromycin, Keflex and Augmentin.
Depending upon the severity and spread IV antibiotic therapy may also be used for lymphedema patients. Also, limiting one's activity with limb elevation is standard protcol.
Blood cultures and/or wound cultures may be needed to determine the exact bacteria involved.
Complications
Complications may include bacteremia or septicemia, abscess, tissue necrosis (gangrene)in the most severe cases, thrombophlebitis, bacterial endorcarditis.
Prognosis
Prompt diagnosis and treatment will bring favorable results and in all but a very few patients recovery will be complete and without complications. At risk groups, including those with lymphedema may experience recurrent episodes.
----------------------------------------------------
Erysipelas
Definition
Erysipelas is a type of cellulitis (skin infection) generally caused group A streptococci..
Causes, incidence, and risk factors
Erysipelas may affect both children and adults. The risk factors associated with this infection include local trauma (break in the skin), skin ulceration, and impaired venous or lymphatic drainage.
In the past, the face was most commonly involved yet now accounts for only up to 20% of cases. The lower extremities (legs) are affected in up to 80% of cases.
Symptoms
Signs and tests
The diagnosis of erysipelas is based on the characteristic appearance of the skin lesion. Skin biopsies are usually not needed. Blood cultures are rarely positive (up to 5% of the time).
Treatment
The cornerstone of therapy is treatment with antibiotics such as penicillin, which are active against streptococci. Depending on the severity, intravenous antibiotics may be used. In less severe cases, oral antibiotics may be sufficient. In individuals who have recurrent erysipelas, long-term antibiotics may be required.
Expectations (prognosis)
If appropriate antibiotic therapy is given early, the outcome is favorable. Skin changes may take up to a few weeks to normalize and peeling is common.
In some patients, streptococci may travel to the blood (bacteremia) and additional sites may be involved such as heart valves, joints, and bones
Complications
Calling your health care provider
Call your health care provider if you have a skin lesion that has features of erysipelas.
Prevention
Avoiding cuts and scrapes may reduce the risk for the development of erysipelas.Update Date: 7/19/2002
http://www.nlm.nih.gov/medlineplus/ency/article/000618.htm
----------------------------------------------------
Erysipelas
Diagnosis: ERYSIPELAS
Discussion:
Erysipelas, earlier named St Anthony's fire, is an acute superficial cellulitis characterized by a sharply demarcated advancing border surrounding raised, deeply erythematous, indurated painful skin involving the dermis, lymphatic, and superficial subcutaneous tissue. It is usually associate with a portal of entry. A number of clinical entities can present with similar lesions: the "slapped cheek" of erythema infectiosum (fifth disease), early herpes zoster involving the second division of the fifth cranial nerve before the vesicular eruption, contact dermatitis, insect bites, furunculosis, sialadenitis, impetigo, malar rash of systemic lupus erythematous, photodermatis, rosacia, Melkersson - Rosenthal syndrome, Sweet's syndrome, dermatomyositis and relapsing polychondritis.,
Although all ages are affected, erysipelas primarily is a disease of adults with a peak age of 60 to 80 years. Erysipelas classically involves the face; however, distribution patterns have changed, and lower extremities currently are the predominant location in 70 to 85 per cent of cases. It involves upper extremities in 2% to 10% of cases, face in 6% to 20%, and trunk and external genitalia is less than 2%. As far as the infrequently affected sites are concerned, one may observe erysipelas of the trunk following surgery, erysipelas of the abdomen in the neonate following infection of the umbilical stump, and erysipelas of the external genitalia as the result of an infected circumcision site. Other portals of entry include chronic leg ulcers, tinea pedis, insect bites, eczema, and venectomy for coronary artery bypass surgery.
In the majority of erysipelas cases, group A beta-hemolytic streptococci are the responsible organisms with group G streptococci being the second most frequent causative organism. However, group B and C streptococci, Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and Yersinia enterocolitica have all been reported as etiologic organisms.
Patients may become bacteremic developing metastatic foci of infection. Infants are at particular risk for systemic spread. Complications such as sepsis, deep gangrene, abscess formation, or death due to systemic toxicity are more frequent in the immunocompromized patient. An intense treatment regimen is warranted in patients suffering from diabetes mellitus, cirrhosis, malignancies, and alcohol abuse. Cultures of tissue aspirate from the advancing border of the lesion and cultures of the nose and throat typically are positive for group A streptococci, as are blood cultures in septic patients. The laboratory evaluation usually shows an elevated white blood cell count with polymorphonuclear leukocytes and nonspecific signs of inflammation such as increased erythrocyte, sedimentation rate and elevated fibrinogen. Hematuria and proteinuria should be tested for at the initial presentation and approximately 3 weeks later to monitor development of acute glomerulonephritis.3
The clinical picture of erysipelas is so characteristic that streptococcal infection can be presumed and antimicrobial treatment initiated. The treatment of choice is penicillin. It can be administered intravenously, orally, or intramuscularly depending on severity of symptoms and patient reliability with a duration of treatment of at least 10 days. For the penicillin-allergic patient, erythromycin or cephalexin can be used.
In cases where coexistant disease is possible, broad spectrum antibiotics should be used pending cultures and clinical response. Since bacterial endocarditis must be considered in all IV drug abusers with fever, this patient is treated with naficllin 2 grams IV, gentamycin 120 mg IV and hospitalization.
Admission criteria include patients at the extremes of age, demonstrate systemic toxicity, immune compromise such as HIV disease, parenteral drug abuse, diabetes mellitus, or cancer.
Clinical Pearls:
1) Diagnosis is made on the characteristic clinical picture.
2) Features that help distinguish erysipelas are acute onset, erythema, warmth, edema, pain, fever, and isolated regional involvement with clearly demonstrated margins.6
3) Erysipelas in children, unless quite limited, requires hospitalization.
4) Treatment of choice is penicillin unless coexistant diseases mandate broad spectrum antibiotic coverage.
Author: J. Alan Morgan, DO, LTC, MC - Program Director -Joint Military Medical Centers of San Antonio - Emergency Medicine Residency - Brook Army Medical Center - Wilfor Hall Medical Center, Lacklan AF Base, Texas 78236-5300
*Link no longer available
----------------------------------------------------
Alain Dupuy
a Dermatology Department, Hôpital Henri Mondor, 94010 Créteil, France, b Public Health Department, Hôpital Henri Mondor, c Dermatology Department, Hôpital Robert Debré, 51092 Reims, France, d Dermatology Department, Hôpital Trousseau, 37044 Tours, France, e Dermatology Department, Hôpital Pitié-Salpêtrière, 75013 Paris, France, f Dermatology Department, Centre Hospitalier Universitaire de Brest, 29285 Brest, France, g Dermatology Department, Hôpital Pasteur, 68024 Colmar, France, h Dermatology Department, Hôpital Sainte-Marguerite, 13009 Marseille, France
Correspondence
to: Dr Bastuji-Garinsylvie bastuji-garin@hmn.ap-hop-paris.fr
Objective: To assess risk factors for erysipelas of
the leg
(cellulitis).
Design: Case-control study.
Setting: 7 hospital centres in France.
Subjects: 167 patients admitted to hospital for
erysipelas of
the leg and 294 controls.
Results: In multivariate analysis, a disruption of
the
cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo,
pressure
ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence
interval
10.7 to 52.5), lymphoedema
(71.2, 5.6 to 908), venous insufficiency
(2.9, 1.0 to 8.7), leg oedema
(2.5, 1.2 to 5.1) and
being overweight (2.0, 1.1 to 3.7) were independently
associated with
erysipelas of the leg. No association was observed with diabetes,
alcohol,
or smoking. Population attributable risk for toe-web intertrigo
was
61%.
Conclusion: This first case-control study highlights
the major
role of local risk factors (mainly lymphoedema
and site of entry) in erysipelas of the leg.
From a public health
perspective, detecting and treating toe-web
intertrigo should be
evaluated in the secondary prevention of
erysipelas of the leg.
Introduction
Commonly caused by streptococci, erysipelas is an infectious condition of the skin or subcutaneous tissue, which usually affects the leg (cellulitis).1-3 Although a potentially serious disease, erysipelas of the leg can be controlled with antibiotics. As recurrences of erysipelas are common and patients are usually admitted to hospital, cost is an important issue. The identification of risk factors for erysipelas is therefore critical in prevention of the disease.
Several factors, either local
(for example, disruption of the cutaneous
barrier, lymphoedema,
venous insufficiency) or general (for example,
diabetes mellitus,
overweight, alcohol misuse), have been
suspected as risk factors for
erysipelas of the leg from a few case series.4-8
Owing to the inherent methodological limitations
of such studies,
however, these factors could not be assessed
quantitatively
that
is, compared with a control group. We
conducted a case-control
sudy to assess risk factors for erysipelas of
the leg, particularly
the role of toe-web intertrigo and other
potential sites of entry.
Subjects and methods
Study
design
We conducted our case-control study prospectively from
June
1995 to October 1996 in seven hospital centres in
France. Cases
and controls were matched for age (range 5 years), sex,
and
hospital (admission within the same 2 month period). For a
type
1 error of 0.05%, 130 cases were sufficient to
detect, with a
power of 80%, odds ratios >3.2 for factors with a prevalence
of 5%
in the general population (for example, venous insufficiency)
or odds
ratios >2.5 for factors with a prevalence of 10% in the
general
population (for example, toe-web intertrigo).
Cases
We included patients admitted consecutively to
each of the
participating centres for erysipelas of the leg. We
excluded patients
under 15 years of age and patients with abscess or
necrotising
fasciitis (defined by frank cutaneous necrosis on
physical
examination or fascial oedema and necrosis detected at
surgery).
Erysipelas was defined as the sudden onset (<24 hours)
of a well
demarcated cutaneous inflammation, with fever >38°C or
chills.
Our definition for erysipelasthat
is, an acute bacterial dermohypodermatitiscorresponds
to non-necrotising cellulitis in other
countries or reports. Of the
178 patients recruited, 11 (6%)
did not fulfil the
inclusion criteria (8 had no fever or
chills, and 3 had
cellulitis elsewhere). The 167 cases comprised 87 men
(52%)
and 80 women (48%) (mean age 56.5 (SE 1.8) years).
The
right leg was affected in 85 cases (51%), the left in
78 (47%), and
both in 4 (2%). Overall, 129 patients (77%) were
admitted for
newly diagnosed erysipelas of the leg, 8 (5%) for a first
recurrence,
15 (9%) for a second recurrence, and 15 (9%) for a
third or
more recurrence.
Controls
We included two controls for each case matched for
age, sex, and
hospital, who were admitted for an acute condition not
a priori
related to one of the suspected risk factors nor related
to a chronic
disease. Among 323 potential controls, 21 (7%)
were
excluded because they did not fulfil the above criteria. The
294 controls comprised 154 men (52%) and
140 women (48%) (mean
age 56.6 (1.1) years) who had been admitted for
trauma
(109, 37%), dermatological conditions
(49, 17%), abdominal
surgery (38, 13%), infection
(30, 10%), orthopaedic surgery
(13, 4%), vascular disease (6, 2%),
sciatalgia
(6, 2%), eye disease (2, 1%), and other conditions
(41, 14%).
Data
collection
One dermatologist in each centre conducted direct
interviews with a
structured questionnaire and performed the
clinical examination of
cases and controls. Besides age, sex, and
current or past occupation,
we assessed general and local potential risk
factors. General risk
factors included being overweight (>120%
of the ideal weight as
calculated by Lorentz's formula), diabetes
mellitus, smoking (current
smoker v non-smoker or past smoker),
alcohol misuse (two items
on the CAGE questionnaire9),
and seated
position at work. Local risk factors were a history of
leg surgery, x
ray therapy (inferior limb or pelvis), neurological disorders,
leg
thrombophlebitis, and leg ulcer. Leg oedema, lymphoedema,
leg ulcer, pressure ulcer, leg dermatosis, toe-web
intertrigo, varicose
veins or varicosities, and peripheral pulses were detected by
clinical examination. No laboratory investigations were performed.
Data
analysis
We compared both general and local factors between
cases and controls.
whether
or not erysipelas was present. Toe-web interspaces were
evaluated as:
1, normal; 2, doubtful; 3, abnormal; or
4, fissurated. We
considered intertrigo present with scores of 3 or
4 and absent
with scores of 1 or 2.
In the analysis we included only cases with newly diagnosed erysipelas of the leg (129 patients).10 We retained the controls matched to recurrent cases for the unconditional analysis but discarded them for the conditional analysis. As the results of both analyses were similar, we present only the results of the unconditional analysis.
We conducted a standard case-control analysis.10 For each exposure we calculated odds ratios and 95% confidence intervals separately. We used unconditional logistic regression models and forced the matching variables into all models. For lateralised factors, we took into account only the ipsilateral side.
The factors we chose for inclusion in the multivariate model were selected by using multiple 2 × 2 analyses on those variables that emerged from the univariate analysis, and we assessed interaction and confounding by fitting multiplicative models. We then conducted a final backward step by step regression.
We conducted specific analyses
for lateralised factors. These were defined as
local factors that could be present on a patient's limb
yet absent on
the otherthat
is,
history of phlebitis, leg ulcer, leg surgery,
neurological disorders,
x ray therapy, current lymphoedema,
abolition of a peripheral pulse, and site of entry (leg
ulcer, wound,
pressure ulcer, excoriated leg dermatosis, toe-web
intertrigo). With
the hypothesis that a lateralised factor
may be a site of
entry if situated on the affected leg, we
recorded these factors as
ipsilateral (affected side) or contralateral (healthy
leg) for cases.
For controls, we arbitrarily determined an
ipsilateral and a
contralateral side in each patient thus allowing comparisons
between
cases and controls. We also compared ipsilateral and
contralateral
sides in cases by paired analysis.
In the interests of public health, we calculated population attributable risks as the fraction of the total disease experienced in the population that would not have occurred if the effect associated with the risk factor was absent. This took into account adjusted odds ratios and distribution of exposure among cases.11
We analysed the data with SAS-PC (version 6.12, SAS Institute, Cary, NC) and BMDP software (University of California, Berkeley).
Results
Risk factors for
erysipelas of the leg
In the univariate analysis, seated position at
work, diabetes
mellitus, alcohol misuse, and smoking were not associated
with
erysipelas of the leg (table 1),
and these were not
further analysed. We observed no association with a history of
x
ray therapy. The associations between erysipelas of the leg and
the
presence of either varicosities or a history of neurological
disorders
were close to significance.
|
Table 1. Univariate analysis of risk factors for erysipelas of the leg |
|||
|
|
|||
| Risk factors | No (%) of cases (n=129) | No (%) of controls (n=294) | Odds ratio* (95% CI) |
|
|
|||
| General | |||
| Overweight | 68 (53) | 97 (33) | 2.5 (1.6 to 3.9) |
| Seated position | 13 (11) | 26 (9) | 1.0 (0.5 to 2.0) |
| Diabetes mellitus | 16 (13) | 24 (8) | 1.7 (0.8 to 3.5) |
| Alcohol misuse | 11 (9) | 29 (10) | 0.9 (0.4 to 2.0) |
| Smoking | 26 (20) | 77 (26) | 0.6 (0.3 to 1.2) |
| Local risk factors | |||
| Leg oedema | 48 (38) | 44 (15) | 3.6 (2.2 to 6.0) |
| Varicosities | 55 (43) | 110 (38) | 1.5 (0.9 to 2.5) |
| History of: | |||
| Phlebitis | 9 (13) | 6 (2) | 4.1 (1.4 to 11.6) |
| Leg ulcer | 15 (13) | 5 (2) | 8.3 (3.2 to 21.6) |
| Leg surgery | 36 (30) | 41 (15) | 2.7 (1.6 to 4.6) |
| Neurological disorder | 13 (10) | 12 (4) | 2.1 (0.9 to 5.0) |
| x ray therapy | 5 (4) | 5 (2) | 1.7 (0.5 to 5.8) |
| Lymphoedema | 22 (18) | 1 (0.4) | 57.7 (16.9 to 197) |
| Abolition of a peripheral pulse | 36 (30) | 36 (13) | 2.8 (1.5 to 4.9) |
| Leg ulcer | 17 (14) | 2 (1) | 20.6 (6.7 to 63.0) |
| Wound | 47 (38) | 21 (8) | 6.8 (4.0 to 11.7) |
| Pressure ulcer | 5 (4) | 2 (1) | 6.0 (1.4 to 26.0) |
| Leg excoriated dermatosis | 11 (9) | 7 (3) | 3.6 (1.4 to 9.2) |
| Toe-web intertrigo | 83 (66) | 65 (23) | 6.6 (4.2 to 10.5) |
Table 2 summarises the results of the multivariate analysis. Lymphoedema was the most prominent risk factor; the presence of a site of entry was also a strong risk factor. The risks associated with leg oedema and venous insufficiency were weaker; overweight was the only general risk factor associated with erysipelas of the leg.
|
Table 2. Multivariate analysis of risk factors for erysipelas of the leg |
|
|
|
|
| Risk factor | Odds ratio* (95% CI) |
|
|
|
| Lymphoedema | 71.2 (5.6 to 908) |
| Site of entry | 23.8 (10.7 to 52.5) |
Leg oedema |
2.5 (1.2 to 5.1) |
| Venous insufficiency | 2.9 (1.0 to 8.7) |
| Overweight | 2 (1.1 to 3.7) |
|
|
|
| * Adjusted for age, sex, hospital, and variables in table. | |
|
Excluding oedema related to venous insufficiency. |
|
Lateralised
factors
The analysis comparing both legs among cases showed
that all the
factors were more frequently present on the ipsilateral
leg than on
the contralateral leg, and statistical significance
was reached only
for history of phlebitis and history of x
ray therapy (data
not shown).
Risks associated with
the site of entry
Site of entry was a strong risk factor for erysipelas
of the leg
(24.5; 11.0 to 54.9). We calculated multivariate estimates
of
odds ratios and population attributable risks associated with
each
type of site of entry. Leg ulcer (62.5; 7.0 to 556),
toe-web
intertrigo (13.9; 7.2 to 27.0), and traumatic wound (10.7;
4.8 to
23.8) exhibited strong and highly significant associations with
erysipelas of the leg whereas pressure ulcer and excoriated leg
dermatosis were not significant. The strongest odds ratio was
for leg
ulcer, although the population attributable risks associated
with leg
ulcer (14%) were much smaller than for intertrigo (61%)
or wound
(35%).
Discussion
To our knowledge this is the first controlled study to examine risk factors for erysipelas of the leg. In our study, diabetes and alcohol misuse were not associated with erysipelas of the leg, and being overweight was the only general factor associated with the condition. We showed that lymphoedema and a site of entry were the main risk factors. Among the different potential sites of entry, toe-web intertrigo had the highest population attributable risk.
Our study has some limitations. Firstly, because our study was hospital based the recruitment of cases could be biased toward more severe disease or more disabled patients. But because no community based study of erysipelas of the leg is available, it was impossible for us to assess whether our cases had more specific risk factors than those patients not referred to hospital. We only assessed patients from dermatology units, and in some hospitals not all cases of erysipelas of the leg are admitted to such units, so referral bias due to concurrent dermatological conditions may have occurred. We do not, however, believe that toe-web intertrigo was a reason for referring patients with erysipelas of the leg to a dermatology unit. Hospital controls were chosen for logistic reasons as we believe that non-inclusion of patients admitted to hospital for a chronic disease or for a disease that could have been a priori related to a suspected risk factor, and recruitment from different surgical or medical units, were sufficient for obtaining an appropriate control group.12
With regard to assessment of exposure and information bias, our investigators were dermatologists who knew whether subjects were controls or cases. The questionnaire, however, was standardised and did not contain open questions. Potential observer bias for assessment of toe-web interspaces was prevented by grouping the four categories in the questionnaire to two for the analysis.
Finally, major confounders were taken into account by matching factors and by adjustment during analysis. For lateralised factors, we controlled for confusion bias for presence or absence of a risk factor on the opposite leg by specific analyses.
Risk
factors for erysipelas of the leg
Local factors seemed to be the most important risk
factors for
erysipelas of the leg. Lymphoedema
showed the greater risk, which was present in
18% of our casesmore
than in most,4
6
8 but not
all,13
prior series. Such a discrepancy may be due to
the retrospective
collection of data in prior studies or to
differences in the
definition of lymphoedema
or lymphatic impairment. For most authors,
lymphatic impairment plays
a major role in the pathophysiology of
erysipelas of the leg.1
13-15
Venous insufficiency was a significant risk factor for erysipelas of the leg although not as significant as the other risk factors. The definition of venous insufficiency is debatable, and as we chose ours on the basis of clinical findings only, this may have led to its underestimation. Interestingly, being overweight was the only general risk factor associated with erysipelas of the leg. In previously published case series, diabetes was present in 4.6% to 15% of cases4-8 and therefore was suspected as a risk factor. Our study had enough power (>80%) to detect an odds ratio >2.5 for prevalence of diabetes among controls. Similarly, we observed no association with alcohol misuse. Thus our findings exclude a strong association between either diabetes or alcohol misuse and erysipelas of the leg. These conclusions, however, do not apply to necrotic cellulitis, which we excluded from our study.
Consequences
in clinical practice
The major concern in long term clinical management of
patients with
erysipelas of the leg is prediction and prevention of
recurrences. As
we restricted the analysis, because of methodological concerns,10
to cases with newly diagnosed erysipelas of the leg,
we did not
specifically study risk factors for recurrences. The
prevalence of
risk factors, however, was shown to be similar in
cases of recurrence
and first episodes, and it can be reasonably assumed
that a patient
with strong risk factors for a first episode also
has a strong risk
for recurrence if these factors remained unchanged.
The prevention of
recurrence is currently based on long term
prophylactic
antibiotherapy.18
19
Toe-web intertrigo is highly prevalent in the
population, and the
high population attributable risk of toe-web
intertrigo in our study
suggests that suppression of this factor would
result in a dramatic
decrease in incidence of erysipelas of the leg.
The importance of
treating toe-web intertrigo has been previously
acknowledged20
21 but
never assessed in a quantitative
way. In contrast to leg ulcers or traumatic
wounds, toe-web
intertrigo is quite easy to avoid by detection
and treatment. We
therefore suggest that screening for, and
treatment of, toe-web
intertrigo should be a priority in subjects at
high risk of
erysipelas of the leg or in whom avoidance of
recurrences is
critical. Whether this strategy is sufficient alone
or requires
antibiotic prophylaxis needs to be iinvestigated.
*Link no longer available
===========================
Selected Clinical Studies and Abstracts
................
Department of Internal Medicine and VA Connecticut Health Care System, Yale School of Medicine, 950 Campbell Avenue, West Haven CT 06516, USA; Veterans Health Administration, Public Health, 950 Campbell Avenue, West Haven CT 06516, USA.
Abstract
Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.
OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.
For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. For cellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.
Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis anderysipelas in terms of the relative proportion of infections due to S. aureus.
................
Rheumatology Unit and Medicine F, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Department of Dermatology, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Medicine F, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Rheumatology Unit, Heller Institute of Medical Research, Sheba Medical Center, Tel-Hashomer, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Background
'Erysipelas-like' erythema (ELE) is a well recognized, although uncommon, manifestation of familial Mediterranean fever (FMF), which is frequently mistaken for infectious erysipelas, especially when forming the initial disease presentation. Aim To clinically and genetically characterize ELE as the first manifestation of FMF. Methods FMF patients with ELE as the first disease presentation (study group), were compared with FMF patients with ELE, appearing during the disease course (control group I), and to those FMF patients who never had ELE (control group II). Results Patients of the study group were comparable to patients without ELE with respect to all demographic, clinical and genetic features studied, and yet differed from patients with ELE appearing later in the disease course in disease severity score (1.7 ± 0.4 vs. 2.4 ± 0.6, P = 0.01), length of diagnosis delay (7.2 ± 6.4 vs. 2.3 ± 3.3 years, P=0.037), age of FMF onset (24.8 ± 19.9 vs. 5.6 ± 5.7 years of age, P=0.014) and rate of homozygosity to the M694V mutation (14.3% vs. 68.7% respectively). ELE traits in the study and control groups were alike. Conclusions FMF with ELE as the first disease manifestation form an uncommon subgroup, clinically and genetically diverging from the rest of the FMF-ELE patients.
Division of Plastic Surgery, Department of Trauma Surgery, Plastic and Reconstruction Surgery, University Hospital Goettingen, Germany. mikhail.zvonik@med.uni-goettingen.de
Genital lymphedema represents a severe disability for patients particularly when complicated by erysipelas, the most frequent complication. The objectives of this study were: to investigate the frequency of erysipelas in patients with genitallymphedema and genital lymphatic cysts who underwent evaluation for surgical treatment, to observe the influence of resection operations on the frequency of erysipelas, and to measure changes in the quality of life due to the resection. A total of 93 patients with genital lymphedema were studied. All patients underwent integrated care treatment in the Földi Clinic, Hinterzarten and the Department of Plastic and Hand Surgery of the University Hospital Freiburg during the period between 1997 and 2007. 44 of these patients underwent surgical treatment of genital lymphedema. The results indicate that lymphatic cysts were the most important risk-aggravating factor for recurrent erysipelas with lymphorrhea in the genital region (p < 0.001). Following the resection operation, however, the number of erysipelas incidents significantly decreased (p < 0.001). In addition, the antibiotic dose could be reduced after surgery (p = 0.039) and an improved quality of life was achieved (p < 0.001).
.......................
Erysipelas: a common potentially dangerous infection
Acta Dermatovenerol Alp Panonica Adriat. 2007 Sep
New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103-2714, USA.
Erysipelas is an acute superficial cutaneous cellulitis that commonly occurs not only in elderly and immunocompromised persons, but also in neonates and small children subsequent to bacterial inoculation through a break in the skin barrier. Group A Beta-hemolytic streptococcus (GABHS, Streptoccocus pyogenes) is the usual etiologic agent. Factors that predispose pediatric patients to the development of erysipelas include very young age, diabetes mellitus, an immunocompromised state, and nephrotic syndrome. Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities. Fever with chills and general malaise may be prominent symptoms. Antibiotics are usually effective. Patients handled in a timely manner tend to recover without problems. However, potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema.
........................
Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg.
Br J Dermatol. 2008 Mar 20
Department of Dermatology, Phlebology and Lymphology, Nij Smelinghe Hospital, 9202 NN Drachten, The Netherlands.
Background: Erysipelas is a common skin infection that is usually caused by beta-haemolytic group A streptococci. After having had erysipelas in an extremity, a significant percentage of patients develops persistent swelling or suffers from recurrent erysipelas. We hypothesize that in cases of erysipelas without a clear precipitating agent, subclinical pre-existing congenital or acquired disturbances in the function of the lymphatic system are present. The persistent swelling after erysipelas is then most likely caused by lymphoedema.
Objectives: We designed a study to examine if erysipelas of unknown origin is associated with a pre-existent insufficiency of the lymphatic system. If our hypothesis is correct, patients with erysipelas of unkown cause without previously evident lymphoedema should have evidence of disturbed lymphatic transport in the unaffected extremity.
Methods: A prospective study, in which lymphoscintigraphy of both legs was performed in patients 4 months after presenting with an episode of erysipelas only in one leg. No patient had any known risk factor for erysipelas, such as diabetes mellitus, chronic venous insufficiency or clinical signs of lymphoedema.
Lymphoscintigraphy was performed in 40 patients by subcutaneous injection of Tc-99m-labelled human serum albumin in the first web space of both feet. After 30 and 120 min, quantitative and qualitative scans were performed using a computerized gamma camera. During the lymphoscintigraphy, the patients performed a standardized exercise programme. Lymph drainage was quantified as the percentage uptake of Tc-99m-labelled human serum albumin in the groin nodes at 2 h after injection. Groin uptake of < 15% is pathological; uptake between 15-20% is defined as borderline, and uptake of > 20% as normal.
Results: The mean +/- SD percentage uptake in the groin nodes in the affected limbs was 9.6 +/- 8.5% vs. 12.1% +/- 8.9% in the nonaffected limbs. The mean paired difference in uptake between the nonaffected vs. affected side was 2.5% (95% confidence interval 1.1-3.9%). This indicates that lymphatic drainage in the nonaffected limb was only slightly better than in the affected limb despite the infectious event in the latter. Of 33 patients with objective impairment of lymph drainage in the affected limb, 26 (79%) also had impaired lymph drainage in the nonaffected limb. Agreement in qualitative measurements between affected and nonaffected leg was less pronounced: 21 patients had abnormal qualitative results in the affected leg of whom nine also had impairment of the nonaffected leg (43%).
Conclusions: Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology
........................
Erysipelas today
Med Pregl. 2007 May-Jun
Klinicki centar Srbije, Beograd. elika@eunet.yu
INTRODUCTION: Erysipelas is a form of cellulitis and a bacterial infection affecting the most superficial layers of the skin which is caused by group A--hemolytic Streptococcus. The symptoms of erysipelas usually arise quite suddenly and they are often accompanied by fever, chill and shivering. The affected skin is distinguished from other forms of cellulitis by well-defined, raised edge. The affected skin is red, swollen and may be finely dimpled (like an orange skin).
TREATMENT OF ERYSIPELAS: Uncomplicated erysipelas can be treated on an outpatient basis. Indications for hospitalization include a severe clinical picture and socioeconomics factors. Most patients suffering from erysipelas in Belgrade are treated at the Institute of Infectious and Tropical Diseases, and the aim of this study was to analyze patients treated during 2002 and 2003, in order to determine characteristics of erysipelas at the beginning of the XXI century.
MATERIAL AND METHODS: During the studied period, we treated 60 patients (26.7%) of all registrated erysipelas cases in Belgrade. The male/female ratio was 1:1.6.
DISCUSSION AND CONCLUSION: Prevalence was higher during the summer months. In most cases, the severity and the need for hospitalization were recognized at the beginning; therefore, 74% of patients were hospitalized during the first five days from the onset of nonspecific signs of illness. Laboratory tests showed mild leukocytosis (med 12.05 x 10/9/l), with predominant neutrophils (74.8%) and increased fibrinogen (med 5.4 g/l). Predisposing factors were present in 83.3% of cases; of them, in 35% of cases this was not the first episode of this illness. In 85% of cases erysipelas of the leg was established, and it was the most frequent localization of all.
........................
T-cell responsiveness to specific group A streptococcus antigens in patients with primary erysipelas
Klin Lab Diagn. 2007 Nov
Peripheral blood leukocytic migratory activity (LMA) was studied in 63 patients with primary erysipelas. To reveal LMA, a screening cell migration test (SCMT) was used as an indicator of the cooperation of T- and B-lymphocytes and macrophages in the stimulation with polysaccharide A, surface proteins, L-antigen, hyaluronidase, streptolysin O, a complete S. pyogenes antigen complex after Grasse. The prognostic value of MAL parameters was established at week 1 after the onset of erysipelas. A rapid transition of LMA from the phase of acceleration to that of inhibition was shown to characterize the formation of an adequate response, to correspond to the good course of the disease, and to be followed by the low likelihood of recurrences. The probability of a subsequent recurrence is much higher than that when LMA tends to transit from suppression to acceleration and when LMA parameters are constant in the phase of suppression or acceleration. No transition of LMA to the phase of suppression in early convalescence suggests that the formation of an immune response to streptococcus is delayed.
........................
Erysipelas--course of disease, recurrence, complications; a 10 years retrospective study
Przegl Epidemiol. 2007
Katedra i Klinika Dermatologii Collegium Medicum Uniwersytetu Jagiellońskiego w Krakowie. wojaspelca@su.krakow.pl
OBJECT: we studied erysipelas by conducting a retrospective analysis of 319 patients with erysipelas treated in Dermatology Department Jagiellonian University in Krakow between 1994 and 2004.
METHODS: we performed a retrospective analysis of 319 patients hospitalized for erysipelas in our institution during a 10 year period. The statistical significance was examined by chi square and Kruskal-Wallis test (significant value p< or =0.05).
RESULTS: there were 35% males and 65% females patients. Median age was 63 years. Most of the female patients were pensioners (32.7%), most of the male patients were physical workers (40.5%). Summer time was the most frequent season for hospitalization (32.3%), and winter time was the rarest (17%). Most of the erysipelas has involved the lower limb (59.2%). There was significant dependence between the regional risk factors and occupation. The recurrent cases occurred in 67.3% cases with lower limb localisation in 69.44% cases. The most rare recurrent cases found on upper limb (6%). The systemic risk factors were associated with recurrent erysipelas in 69.44%. Complications, such as abscess formation, lymphangitis, venous insufficiency, osteitis, arthritis, septic tendonitis and elephantiasis were found in 25%.
CONCLUSIONS: after review of the literature and our experiences it is clear that there is a strong need for interdisciplinary treatment to avoid various potential complications of erysipelas.
====External Links===================
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-4632.2010.04464.x/abstract
======================================
Severe Leg Erysipelas
-------------------------------
Diagnostic Images
http://images.google.com/images?q=erysipelas&hl=en
http://images.search.yahoo.com/search/images?p=erysipelas&fr=FP-tab-img-t&toggle=1&ei=UTF-8
-------------------------------
External Links:
Erysipelas: a common potentially dangerous infection
http://www.mf.uni-lj.si/acta-apa/acta-apa-07-3/6.pdf
-------------------------------
Erysipelas after breast cancer treatment (26 cases).
http://dermatology.cdlib.org/113/case_reports/erysipelas/masmoudi.html
-------------------------------
Recurrent Erysipelas: 47 Cases
http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=000096913
-------------------------------
Recurrent erysipelas despite antibiotic prophylaxis: an analysis from case studies.
http://www.njmonline.nl/getpdf.php?id=10000156
-------------------------------
Erysipelas
http://www.emedicine.com/derm/topic129.htm
-------------------------------
Erysipelas
Synonyms and related keywords: group A beta-hemolytic streptococci, hemolytic streptococcus
http://www.emedicine.com/emerg/topic172.htm
-------------------------------
Erysipelas
http://www.nlm.nih.gov/medlineplus/ency/article/000618.htm
br /
-------------------------------
Erysipelas
http://www.merck.com/
-------------------------------
Erysipelas
Also includes images
http://health.allrefer.com/health/erysipelas-info.html
-------------------------------
Diagnostic Images
http://images.google.com/images?q=erysipelas&hl=en
http://images.search.yahoo.com/search/images?p=erysipelas&fr=FP-tab-img-t&toggle=1&ei=UTF-8
-------------------------------
Classification and External Resources
| ICD-10 | A46.0 -
|
|||||||
|---|---|---|---|---|---|---|---|---|
| ICD-9 | 035 -Erysipelas (gangrenous)
(infantile) (newborn) (phlegmonous) (suppurative) 035
035 excludes:
|
|||||||
| DiseasesDB | 4428 | |||||||
| MedlinePlus | 000618 | |||||||
| eMedicine | derm/129 | |||||||
| MeSH | D004886 | |||||||
-------------------------------
Related Lymphedema People Medical Blogs:
Antibiotic Therapy, Types of Antibiotics
http://www.lymphedemapeople.com/thesite/lymphedema_antibiotics.htm
http://bacteriainfections.blogspot.com
http://antibioticinformation.blogspot.com/
http://cellulitisinfections.blogspot.com/
http://mrsainformation.blogspot.com/
http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=34
===========================
Join us as we work for lymphedema patients everywehere:
Advocates for Lymphedema
Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.
http://health.groups.yahoo.com/group/AdvocatesforLymphedema/
| Subscribe: | AdvocatesforLymphedema-subscribe@yahoogroups.com |
Pat O'Connor
Lymphedema People / Advocates for Lymphedema
===========================
For information about Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\
For Information about Lymphedema Complications
http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema
For Lymphedema Personal Stories
http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3
For information about How to Treat a Lymphedema Wound
http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound
For information about Lymphedema Treatment
http://www.lymphedemapeople.com/wiki/doku.php?id=treatment
For information about Exercises for Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema
For information on Infections Associated with Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema
For information on Lymphedema in Children
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children
Lymphedema Glossary
http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing
===========================
Lymphedema People - Support Groups
-----------------------------------------------
Children
with Lymphedema
The time has come for families, parents, caregivers to have a support
group of
their own. Support group for parents, families and caregivers of
chilren with
lymphedema. Sharing information on coping, diagnosis, treatment and
prognosis.
Sponsored by Lymphedema People.
http://health.groups.yahoo.com/group/childrenwithlymphedema/
Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com
......................
Lipedema
Lipodema Lipoedema
No matter how you spell it, this is another very little understood and
totally
frustrating conditions out there. This will be a support group for
those
suffering with lipedema/lipodema. A place for information, sharing
experiences,
exploring treatment options and coping.
Come join, be a part of the family!
http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515
Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com
......................
MEN WITH LYMPHEDEMA
If
you are a man with lymphedema; a man with a loved
one with lymphedema who you are trying to help and understand come join
us and
discover what it is to be the master instead of the sufferer of
lymphedema.
http://health.groups.yahoo.com/group/menwithlymphedema/
Subscribe: menwithlymphedema-subscribe@yahoogroups.com
......................
All
About Lymphangiectasia
Support group for parents, patients, children who suffer from all forms
of
lymphangiectasia. This condition is caused by dilation of the
lymphatics. It can
affect the intestinal tract, lungs and other critical body areas.
http://health.groups.yahoo.com/group/allaboutlymphangiectasia/
Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com
......................
Lymphatic
Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema... there is
nothing out
there for other lymphatic disorders. Because we have one of the most
comprehensive information sites on all lymphatic disorders, I thought
perhaps,
it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the
lymph
system. Includes lymphangiomas, lymphatic malformations,
telangiectasia,
hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of
information
available through sister site Lymphedema People.
http://health.groups.yahoo.com/group/lymphaticdisorders/
Subscribe: lymphaticdisorders-subscribe@yahoogroups.com
Lymphedema People New Wiki Pages
Have
you seen our new “Wiki” pages yet?
Listed below are just a sample of the more than 140 pages
now listed in our Wiki section. We are also working on hundred more. Come and take a
stroll!
Lymphedema Glossary
http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing
Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema
Arm
Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema
Leg
Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema
Acute
Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema
The
Lymphedema Diet
http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet
Exercises
for Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema
Diuretics
are not for Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=diuretics_are_not_for_lymphedema
Lymphedema
People Online Support Groups
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_people_online_support_groups
Lipedema
http://www.lymphedemapeople.com/wiki/doku.php?id=lipedema
Treatment
http://www.lymphedemapeople.com/wiki/doku.php?id=treatment
Lymphedema
and Pain Management
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pain_management
Manual Lymphatic Drainage (MLD) and
Complex Decongestive Therapy (CDT)
Infections
Associated with Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema
How
to Treat a Lymphedema Wound
http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound
Fungal
Infections Associated with Lymphedema
http://www.lymphedemapeople.com/wiki/doku.php?id=fungal_infections_associated_with_lymphedema
Lymphedema
in Children
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children
Lymphoscintigraphy
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphoscintigraphy
Magnetic
Resonance Imaging
http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging
Extraperitoneal para-aortic lymph node
dissection (EPLND)
Axillary node biopsy
http://www.lymphedemapeople.com/wiki/doku.php?id=axillary_node_biopsy
Sentinel
Node Biopsy
http://www.lymphedemapeople.com/wiki/doku.php?id=sentinel_node_biopsy
Small Needle Biopsy -
Fine Needle Aspiration
http://www.lymphedemapeople.com/wiki/doku.php?id=small_needle_biopsy
Magnetic Resonance Imaging
http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging
Lymphedema Gene FOXC2
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_foxc2
Lymphedema Gene VEGFC
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_vegfc
Lymphedema Gene SOX18
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18
Lymphedema
and Pregnancy
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pregnancy
Home page: Lymphedema People
http://www.lymphedemapeople.com
Page Updated: Feb. 1, 2012