Erysipelas, Emergency Medicine

Basics

Description

Superficial bacterial infection of the skin with prominent lymphatic involvement
Leukocytosis is common
Positive blood cultures in 3-5%

Etiology

Group A β-hemolytic streptococcus is the causative organism (uncommonly, group C or G streptococci)
Portals of entry:
- Skin ulcers
- Local trauma
- Abrasions
- Psoriatic or eczematous lesions
- Fungal infections

Haemophilus influenzae type b (HIB) causes facial cellulitis in children that may appear similar to erysipelas:
- Should be considered in unimmunized children
- Many will be bacteremic and require admission
- Cefuroxime or other appropriate H. influenzae coverage is important
- H. influenzae is much less common since widespread use of the HIB vaccine
Group B streptococci can cause erysipelas in the newborn
Can develop from infection of umbilical stump

Erythema of the breast in puerperal mastitis is often caused by Staphylococcus organisms, hence methicillin-resistant S. aureus (MRSA) should be covered
- See Mastitis

Diagnosis

Signs and Symptoms

Most common sites of involvement are the face (5-20% of cases), lower legs (70-80% of cases), and ears
Skin has an intense fiery red color, hence the name "Saint Anthonys fire"�
Often bilateral on the face, but unilateral elsewhere
Predilection for infants, children, and the elderly
Systemic symptoms may include malaise, fever, chills, nausea, and vomiting
Traumatic portal of entry on skin is not always apparent
Rarely there may be an associated periorbital cellulitis or cavernous sinus involvement

History

Facial erysipelas may follow a nasopharyngeal infection or trauma
Predilection for areas of lymphatic obstruction:
- Particularly in the upper extremity following radical mastectomy
- Increased frequency after saphenous vein harvesting or stripping
- May be a marker for previously undiagnosed lymphatic obstruction, or patients with congenital lymphedema (such as Milroy disease)
30% recurrence rate within 3 yr, owing to lymphatic obstruction caused by an episode of erysipelas

Physical Exam

Involved skin is:
- Edematous
- Indurated (peau d'orange)
- Painful
- Well-circumscribed plaque with sharp, clearly demarcated edges
Classical butterfly rash on cheeks and across nose when affecting face
Vesicles and bullae may be present in more serious infections

Essential Workup

The diagnosis is clinical:
- Based on the characteristic skin findings and the clinical setting
Needle-aspirate wound cultures are seldom positive and not indicated

Diagnosis Tests & Interpretation

Lab

Swabs of the skin are not indicated for culture, as they will show only skin organisms
CBC with differential, and blood cultures should be performed in diabetics and other high-risk populations, or in patients with hypotension and those who require admission:
- Blood cultures more likely to be positive in patients with lymphedema
Check glucose in diabetics as infection may disrupt control
Urinalysis: To check for proteinuria, hematuria, and red cell casts
- Would suggest diagnosis of post-streptococcal glomerulonephritis (PSGN)
- If it occurs, usually around 2 wk after onset of skin infection
Antistreptolysin O (ASL-O), anti-DNase B and streptolysin antibody serial titer changes are useful in diagnosing post-streptococcal immunologic entities such as rheumatic fever or glomerulonephritis,
- Do not add anything to the diagnosis and management of uncomplicated erysipelas
- Should not be routinely ordered unless there are already manifestations of such complications

Imaging

There is no standard imaging for classical erysipelas
- If deeper infection such as myositis is suspected, plain films of an extremity or CT scan may be performed to assess for the presence of gas
Ultrasound may be useful to evaluate for an abscess if this is suspected, or in the leg to r/o deep vein thrombophlebitis DVT

Differential Diagnosis

Abscess
Acute bacterial sinusitis
Allergic inflammation
Cellulitis
Contact dermatitis
DVT
Diffuse inflammatory carcinoma of the breast
Familial mediterranean fever
Herpes zoster, second division of cranial nerve V
Impetigo
Inflammatory dermatophytosis
Mastitis
Necrotizing fasciitis
Periorbital cellulitis
Systemic lupus erythematosus (SLE) with butterfly rash
Streptococcal or staphylococcal TSS (sunburn-like rash)
Venous stasis dermatitis
Viral exanthem

Treatment

Pre-Hospital

Wearing gloves, followed by hand washing when managing patients, to decrease risk of transmission of streptococcal carriage �

Initial Stabilization/Therapy

Patients may be toxic and in need of intravenous fluid resuscitation or pressure support �

Ed Treatment/Procedures

Appropriate antibiotic therapy; treatment should be for 10 days:
- Patients with extensive involvement should be admitted for parenteral antibiotic treatment
- May switch to oral antibiotics when patient is stable and showing signs of response
Mild cases: Patients can be discharged on oral therapy if nontoxic appearing, good compliance, and close follow-up can be ensured
Penicillin is the drug of choice when symptoms are consistent with erysipelas
If there is difficulty in distinguishing from cellulitis, staphylococcal coverage should be added:
- Use penicillinase-resistant penicillin or 1st-generation cephalosporin
- If in community with high incidence of MRSA, use vancomycin, or other anti-MRSA coverage
- Reports of vancomycin-resistant Staphylococci are occurring
Acetaminophen for fever
Isolation while in hospital
- Contagious

Medication

OUTPATIENT �

Penicillin V: 500 mg PO q6h (peds: 25-50 mg/kg/d div. q6-8h) for 10 days.
Amoxicillin: 500 mg PO q8h (peds: 50 mg/kg/d div. TID) for 10 days.
Clindamycin: 300 mg PO QID (peds: 8-25 mg/kg/d suspension PO div. TID or QID) for 10 days.
Dicloxacillin: 500 mg PO q6h (peds: 30-50 mg/kg/d PO div. q6h) for 10 days
Erythromycin: 250-500 mg PO q6h (peds: 40 mg/kg/d PO in div. doses q6h) for 10 days
Cephalexin: 500 mg PO q6h (peds: 40 mg/kg/d PO div. q8h) for 10 days
Cefuroxime: 250-500 mg PO BID (peds: 30 mg/kg/d PO div. q12h) for 10 days.

INPATIENT �

Penicillin G: 2 million U q4h IV (peds: 25,000 U/kg IV q6h).
Penicillin G, procaine: 600,000 U q12h IM
Clindamycin: 600 mg q8h IV (peds: 20-40 mg/kg/d IV div. q8h)
Vancomycin: 1 g IV q12h given over 1.5-2 hr to decease risk of red man syndrome (peds: 10-15 mg/kg IV q6h)

First Line

Oral or IV: Penicillin or 1st-generation cephalosporin
Clindamycin for penicillin-allergic individuals

Second Line
Oral: Erythromycin �

Follow-Up

Disposition

Admission Criteria

Patients with extensive involvement, fever, toxic appearance, or in whom orbital or periorbital cellulitis is suspected
Patients who live alone or are unable or unreliable to take oral medications will require admission for IV antibiotics
Children more often require admission
- Blood cultures
- Intravenous antibiotics, including coverage for H. influenzae, should be initiated for patients who have not been immunized with HIB vaccine

Discharge Criteria

Minimal facial involvement
Nontoxic appearance
Not immunosuppressed
Able to tolerate and comply with oral therapy
Adequate follow-up and supervision
Diagnosis certain

Issues for Referral

Refer to nephrologist for evaluation and treatment for PSGN if:
- Hematuria, proteinuria, and red cell casts are noted on UA
- Particularly in children between the ages of 5 and 15
Infectious disease consultation for infection in immunocompromised patients who are at risk for unusual organisms

Follow-Up Recommendations

Use of pressure stocking on leg in the presence of lymphedema may reduce incidence of relapses
Following erysipelas of legs, use of topical antifungal cream or ointment to treat underlying tinea pedis when present

Pearls and Pitfalls

Failure to respond, or pain out of proportion to findings, might suggest deeper level of infection and require further workup to rule out necrotizing fasciitis, or mixed aerobic/anaerobic necrotizing cellulitis
Treatment of underlying lymphedema is associated with reduced incidence of relapses
Presence of micropustules would suggest staphylococcal infection/cellulitis rather than erysipelas, and antibiotic coverage would need to be broader
Presence of crepitus in skin should prompt search for alternate diagnosis
Since infection is likely to have entered skin through traumatic skin break, remember to check for tetanus immunization status and update if necessary
Consider prophylaxis for patients with frequent relapses

Additional Reading

Damstra �RJ, van Steensel �MA, Boomsma �JH, et al. 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;158:1210-1215.
Gunderson �CG, Martinello �RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64:148-155.
Kilburn �SA, Featherstone �P, Higgins �B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
Morris �A. Cellulitis and erysipelas. Clin Evid. 2006;(15):2207-2211.

Codes

ICD9

035 Erysipelas �

ICD10

A46 Erysipelas �

SNOMED

44653001 Erysipelas (disorder)
240425002 Facial erysipelas (disorder)
402924002 Recurrent erysipelas (disorder)
44464006 Postpartum AND/OR puerperal erysipelas (disorder)

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