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Erysipelas, Emergency Medicine

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Erysipelas, Emergency Medicine

Basics

Description

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

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

  • 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 ulcersLocal traumaAbrasionsPsoriatic or eczematous lesionsFungal infections
  • 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 childrenMany will be bacteremic and require admissionCefuroxime or other appropriate H. influenzae coverage is importantH. 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
  • 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
  • Erythema of the breast in puerperal mastitis is often caused by Staphylococcus organisms, hence methicillin-resistant S. aureus (MRSA) should be coveredSee Mastitis
  • 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"пїЅ
  • 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
  • Facial erysipelas may follow a nasopharyngeal infection or trauma
  • Predilection for areas of lymphatic obstruction:Particularly in the upper extremity following radical mastectomyIncreased frequency after saphenous vein harvesting or strippingMay 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
  • 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)
  • Involved skin is:EdematousIndurated (peau d'orange)PainfulWell-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
  • Edematous
  • Indurated (peau d'orange)
  • Painful
  • Well-circumscribed plaque with sharp, clearly demarcated edges

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
  • Based on the characteristic skin findings and the clinical setting

Diagnosis Tests & Interpretation

  • 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 castsWould 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 erysipelasShould not be routinely ordered unless there are already manifestations of such complications
  • Blood cultures more likely to be positive in patients with lymphedema
  • Would suggest diagnosis of post-streptococcal glomerulonephritis (PSGN)
  • If it occurs, usually around 2 wk after onset of skin infection
  • 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
  • There is no standard imaging for classical erysipelasIf 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
  • 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

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

Initial Stabilization/Therapy

Ed Treatment/Procedures

  • Appropriate antibiotic therapy; treatment should be for 10 days:Patients with extensive involvement should be admitted for parenteral antibiotic treatmentMay 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 cephalosporinIf in community with high incidence of MRSA, use vancomycin, or other anti-MRSA coverageReports of vancomycin-resistant Staphylococci are occurring
  • Acetaminophen for fever
  • Isolation while in hospitalContagious
  • 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
  • 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
  • Contagious

Medication

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

Follow-Up

Disposition

  • 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 admissionBlood culturesIntravenous antibiotics, including coverage for H. influenzae, should be initiated for patients who have not been immunized with HIB vaccine
  • Blood cultures
  • Intravenous antibiotics, including coverage for H. influenzae, should be initiated for patients who have not been immunized with HIB vaccine
  • Minimal facial involvement
  • Nontoxic appearance
  • Not immunosuppressed
  • Able to tolerate and comply with oral therapy
  • Adequate follow-up and supervision
  • Diagnosis certain
  • Refer to nephrologist for evaluation and treatment for PSGN if:Hematuria, proteinuria, and red cell casts are noted on UAParticularly in children between the ages of 5 and 15
  • Infectious disease consultation for infection in immunocompromised patients who are at risk for unusual organisms
  • Hematuria, proteinuria, and red cell casts are noted on UA
  • Particularly in children between the ages of 5 and 15

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 пїЅRJ, van Steensel пїЅMA, Boomsma пїЅJH, 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 пїЅCG, Martinello пїЅRA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64:148-155.
  • Kilburn пїЅSA, Featherstone пїЅP, Higgins пїЅB, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
  • Morris пїЅA. Cellulitis and erysipelas. Clin Evid. 2006;(15):2207-2211.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abscess
  • Cellulitis
  • MRSA, Community Acquired

Codes

ICD9

ICD10

SNOMED

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