Friday, December 02, 2005
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
Erysipelas (also called St. Anthony's Fire)is a superficial bacterial skin infection skin generally caused by Strep A bacteria or Strep G 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.
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.
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 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 may include bacteremia or septicemia, abscess, tissue necrosis (gangrene)in the most severe cases, thrombophlebitis, bacterial endorcarditis.
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.
Synonyms and related keywords: group A beta-hemolytic streptococci, hemolytic streptococcus
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.
An erysipelas skin lesion typically has a raised border that is sharply demarcated from normal skin. The underlying skin is painful, intensely red, hardened (indurated), swollen, and warm.
Facial erysipelas classically involve the cheeks and the bridge of the nose.
Blisters may develop over the skin lesion.
Fever and shaking chills are common.
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).
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.
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
If bacteremia is present, infection may spread to other areas such as joints, bones, and heart valves.
Recurrence of infection
Calling your health care provider
Call your health care provider if you have a skin lesion that has features of erysipelas.
PreventionAvoiding cuts and scrapes may reduce the risk for the development of erysipelas.
Update Date: 7/19/2002
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.
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
ErysipelasAlso includes images
Erysipelas Includes images of facial erysipelas