ERYSIPELAS William Njoroge ML 610

ERYSIPELAS St. Anthony’s fire, Ignis Sacer Erysipelas is an acute beta-hemolytic group A streptococcal infection of the skin involving the superficial dermal lymphatics Streptococcus pyogenes. Others include group C & G Streptococci Recently, atypical forms reportedly have been caused by Streptococcus pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae, Yersinia enterocolitica, and Moraxella species.

Pathophysiology Historically, the face was most affected; today the legs are affected most often. The rash is due to an exotoxin, not the Strep. bacteria itself and is found in areas where no bacteria are present. Bacterial inoculation into an area of skin trauma is the initial event in developing erysipelas. Thus, local factors, such as venous insufficiency, stasis ulcerations, inflammatory dermatoses, dermatophyte infections, insect bites, and surgical incisions, have been implicated as portals of entry.

strep bacteria often originate from the subject's own nasal passages. In erysipelas, the infection rapidly invades and spreads through the lymphatic vessels causing regional lymph node enlargement. Erysipelas does not affect subcutaneous tissue. It does not release pus, only serum or serous fluid.

AGE erysipelas can occur in all age groups, but it does appear that infants, young children, and elderly patients are the most commonly affected groups. The peak incidence has been reported to be in patients aged 60-80 years RISK FACTORS Preexisting lymphedema Immunocompromised persons Skin abrasions, cuts lymphatic drainage problems

Predisposing factors Stasis ulceration Venous insufficiency Diabetes Mellitus Inflammatory dermatoses Lymphatic drainage disorders Surgical wounds Nephrotic syndrome Immunocompromised state

Predisposing factors Stasis ulceration:

Venous insufficiency

inflammatory dermatoses & dermatophytes infections

Diabetes mellitus

lymphatic drainage problems After radical mastectomy

Lymphedema

Surgical incisions

Nephrotic syndrome

Clinical picture Prodromal period Patients typically develop symptoms within 48 hours of the initial infection. high fever Chills Fatigue Headache Vomiting General malaise

The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. The infection may occur on any part of the skin including the face, arms, fingers, legs and toes, but it tends to favor the extremities. Fat tissue is most susceptible to infection, and facial areas typically around the eyes, ears, and cheeks.

Lymphatic involvement often is manifested by overlying skin streaking and regional lymphadenopathy. More severe infections can result in vesicles, bullae, petechiae with possible skin necrosis.

diagnosis This disease is diagnosed mainly by the appearance of well-demarcated rash and inflammation. Blood cultures are unreliable for diagnosis of the disease, but may be used to test for sepsis. Cultures are perhaps best reserved for very immunosuppressed hosts in whom an atypical etiologic agent might be more likely

Differential diagnosis Erythema Annulare Centri-fugum Stasis Dermatitis Cellulitis Erysipeloid

Erythema Annulare Centri-fugum

Stasis dermatitis

cellulitis

treatment Antibiotics such as penicillin are used to eliminate the infection. In severe cases, antibiotics may need to be given through an IV (intravenous line). Those who have repeated episodes of erysipelas may need long-term antibiotics

Medical care Elevation and rest of the affected limb are recommended to reduce local swelling, inflammation, and pain. Saline wet dressings should be applied to ulcerated and necrotic lesions and changed every 2-12 hours, depending on the severity of the infection.

A first-generation cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin. With treatment, the outcome is good. It may take a few weeks for the skin to return to normal. Peeling is common.

complications bacteremia Septicemia Return of infection Septic shock abscess, gangrene, necrotizing fasciitis Thrombophlebitis . acute glomerulonephritis , endocarditis , streptococcal toxic shock syndrome Deep cellulitis