Friday, March 31, 2006
Erysipelas after breast cancer treatment (26 cases)
A Masmoudi1, I Maaloul2, H Turki1, Elloumi Y1, 2, S Marrekchi1, S Bouassida1, M Ben Jemaa2, A Zahaf1 Dermatology Online Journal 11 (3): 12 1.
Department of Dermatology, Hedi Chaker Hospital, Sfax, Tunisia.2. Department of Infection Diseases, Hedi Chaker Hospital, Sfax, Tunisia.
Abstract
Erysipelas is a bacterial hypodermal cellulitis usually associated with Streptococcal infection. Erysipelas of the upper limbs in women treated for breast cancer is relatively rare. We undertook a 10-year retrospective study identifying 26 cases of erysipelas of the upper limb following treatment for breast cancer; we describe the clinical, therapeutic, and evolutionary aspects. The age of our patients ranged from 37 to 80 years with a mean age of 53. All patients had a breast surgery and lymphadenectomy. Fifteen patients had chemotherapy and 23 had radiotherapy. The erysipelas appeared with an average of 5.23 years after cancer treatment (3 months to 15 years) and was recurrent in nine cases. Lymphedema occurred in eighteen patients. The first signs were fever and shivering in 25 patients. The clinical aspect was an inflammatory plaque. The physical findings of erysipelas included a raised edge (6 cases), blisters (1 case), purpura (1 case), and cellulitis (1 case). The portal of entry was not found in eleven patients. The upper limb was affected in all cases. Involvement of the axillary folds or the chest was observed in eight cases. Treatment with penicillin was undertaken for all patients; the length of treatment varied from 11 to 26 days. Lympadenectomy and radiotherapy in breast cancer may lead to lymphedema, which can be evident or sometimes discrete. Those patients who developed erysipelas in our series usually fared well with treatment, but many had recurrences attributed to persistent lymphedema. It was also of note that for many patients in this series, the portal of entry was not identified.
Introduction
Erysipelas is a bacterial infection, usually of streptococcal origin, that affects the dermis and dermal lymphatics. Malignancy and local impairment of venous and lymphatic circulation are reported to be predisposing factors. Using a retrospective analysis, we attempted to characterize the clinical and evolutionary characteristics of erysipelas after treatment of breast cancer.
Materials and methods
Our study was a retrospective analysis of 26 patients observed during the period from January 1991 until December 2000 at the department of dermatology and the department of infectious diseases at Hedi Chaker Hospital of Sfax.
The clinical data were collected from the files of the hospitalized patients.
For each patient we recorded the age, past medical history, clinical findings, laboratory finds, treatment, and outcome.
Results
The age of our patients ranged between 37 and 80 years with an average of 53.4 years. All our patients had undergone mastectomy and lymphadenectomy for breast cancer, fifteen had chemotherapy, and 23 had radiotherapy. History of obesity was found in eight patients, diabetes in six, and of HTA in ten. Lymphedema was noted in sixteen patients.
The duration of erysipelas at the time of presentation was 1-3 days with an average of 2 days. For 23 patients the onset of erysipelas was marked by a fever associated with shivering. For eleven cases erysipelas was recurrent; the number of episodes varied from 1 to 3.
The site of involvement was the homolateral superior limb for all the cases with involvement of
forearm: 20 cases (Fig. 1)
arm: 23 cases
hand: 10 cases
axilla: 8 cases
Erysipelas presented as a warm, indurated and painful erythema sharply demarcated by a raised edge in six cases. It was complicated by purpura in one case, blisters in one case (Fig. 2), and cellulitis in one case.
Lymphedema was found in eighteen patients at the time of the examination.
The portal of entry was not known or found in eleven cases. It was present in fifteen cases (post traumatic wound, 16 cases; post radiotherapy burn, 3 cases; interdigital tinea, 2 cases; infected eczema, 1 case; paronychia, 1 case; whitlow, 1 case).
Laboratory abnormalities included increased white blood cell count (with predominance of segmented neutrophils) in sixteen cases, and leukopenia in two cases; the white count was normal in eight cases. The erythrocyte sedimentation rate evaluated in nineteen patients; it was elevated in 17 (43-130 mm/h). Blood cultures were done in fourteen patients and were positive for β-hemolytic Streptococci in one.
Outcome was favorable in 22 patients. All patients were treated with intravenous penicillin (10-20 million units per day). Once the patients became afebrile and otherwise had a marked improvement, the route of penicillin administration was changed to intramuscular or oral. The duration of treatment varied between 11 and 25 days with an average of 16 days. Adequate response was not obtained for two patients and the antibiotic was changed to pristinamycine (Pyostacine®) and those patients did well. One patient, who presented with hard purpuric erysipelas, did not respond to penicillin, clindamycin (Dalacine®) and rifampin; this patient died on the eighth day of hospitalization.
For the eight patients seen in followup, no recurrence was apparent.
Discussion
Erysipelas is a well-known complication following mastectomy and radiotherapy for breast cancer, however, few cases are reported in literature [1, 2, 3]. The lymphatic circulation is affected by the radiotherapy and mastectomy favoring the obstruction and the progressive destruction of lymphatic communications, hence the lymphedema. This lymphatic stasis appeared to play an important role in the occurrence of erysipelas in our patients.
This lymphedema occurs several years after mastectomy or the radiotherapy and is sometimes revealed by the occurrence of erysipelas, such as the case of two patients in our study. The risk of lymphedema correlates with the use of postoperative radiotherapy and the number of lymph nodes removed [4].
Lymphostasis results in edema associated with the retention of high-molecular weight proteins in the interstitial compartment. Tissue involved in lymphostasis appears susceptible to infection, which in turn can worsen the lymphatic dysfunction [5]. Other factors that may play a role in developing infection in areas of lymphedema include venous stasis, diabetes, obesity, treatment with corticosteroids, and immune suppression [6].
Lymphedema following lymph-node dissection for invasive breast cancers is common and its impact on long-term quality of life in survivors of early-stage breast cancer should not be underestimated [7, 8].
Once lymphedema is established, the affected arm is subject to erysipelas developing from minor infections such as paronychia, folliculitis, and interdigital web-space infection; such infections would not be significant in the normal arm. In our study the portal of entry included post-radiotherapy burn (two patients), post-traumatic lesions, eczema, and interdigital tinea. A portal of entry was not identified at the time of the time of examination in 40 percent of cases.
The diagnosis of erysipelas is essentially clinical, a fever of acute onset with a sharply demarcated, warm, indurated and painful erythema. The raised edge was present in 23 percent of our patients.
Penicillin G is the treatment of choice because group A β-hemolytic Streptococcus is sensitive; intravenous injection is advised for the acute phase of the disease. Following the acute phase, penicillin may be given by intramuscular or oral routes. The outcome is generally favorable.
In addition to antibiotics, scrupulous personal hygiene may be beneficial because group-A Streptococci may colonize unbroken skin [9]. Local fungal infection of the skin or nails which may serve as a portal of entry and should be eradicated.
Prevention of lymphedema is often possible; unnecessary irradiation should be avoided. Postoperative early arm motion, isometric exercises, measured compression sleeves; diuretic therapy, and frequent massage have all been found helpful and should be continued throughout the patient's life.
The major late complication of this erysipelas is more lymphedema, which favors recurrence of infection. Each recurrence may do further local damage to lymphatic channels and thus perpetuate a vicious cycle. For patients who have recurrent erysipelas, antibiotic prophylaxis (especially with benzathine-benzylpenicillin or phenoxymethlpenicillin) is recommended [10]. The eradication of every portal of entry is recommended.
Conclusion
The occurrence of erysipelas following treatment of breast cancer correlates with the associated lymphedema. The treatment is an antibiotic during the acute phase of the disease and eventually an antibioprophylaxis to avoid recurrences. Attention should be given to measures that prevent lymphedema and eradicate potential portals of entry.
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