UCONN Emergency Medicine Interest Group

EM Images #10

In IMAGES on February 25, 2012 at 11:11 AM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

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A simple question: what is the diagnosis for these patients?

Answer: Erysipelas.

  • Etiologic agent: most often Group A beta-hemolytic strep [GABHS]; rarely, other strep species.
  • Epidemiology: usually affects adults, with slight female preponderance.
  • Why it occurs: although eMedicine cites damage to skin from small abrasions and other portals of entry, in my experience they are not evident and make no difference in diagnosis or treatment since the rash has such a distinguishing appearance. One author (Bernard), in a recent review of common bacterial skin infections, felt that the main risk factors for erysipelas are “toe-web intertrigo and lymphedema.” EMedicine also lists the following prediposing factors, after breaks in the skin from any cause:
    • Lymphatic obstruction or edema
    • Saphenous vein grafting in lower extremities
    • Status postradical mastectomy
    • Immunocompromised patients, including patients who are diabetic or alcoholic
    • Arteriovenous insufficiency
    • Paretic limbs
    • The eMedicine derm site on erysipelas also cites the following as predisposing factors, in addition to immunocompromised hosts:
      • Diabetes
      • Alcohol abuse
      • HIV infection
      • Nephrotic syndrome
      • Vagrant lifestyle
  • Clinical presentation: eruption of bright red, very sharply demarcated (the sine qua non for me), hot and slightly tender; although eMedicine states that it is more common on lower extremities than face, I seem to have seen it more often (or maybe I missed it on LE’s) on face. Systemic symptoms, as with any strep infection, often include fever and myalgias. Rarely can cause devastating systemic consequences, like TSS (see Bomke, below)
    • NB: Scarlet fever is also caused by GABHS but THE ERUPTION IS CAUSED BY A TOXIN elaborated by GABHS; ERYSIPELAS IS AN INFECTION OF THE SKIN. (See references below for scarlet fever, including images [http://www.nlm.nih.gov/medlineplus/ency/imagepages/19082.htm]) Puerperal fever, a disease of women who have recently delivered, was a disease clarified by the great Ignaz Semmelweis, and is also caused by GABHS. As one can easily understand, the roles of strep in these various diseases was not easily intuited by even the sharpest minds of the 19th C. (see Hallett, below)
  • Treatment: Any agent effective against GABHS. One should use least broad spectrum agent possible, e.g., Pen G, Pen V K, et cet. Erythromycin is acceptable alternative for pen allergic folk

References

  • eMedicine: http://www.emedicine.com/emerg/topic172.htm
  • Bernard P. Management of common bacterial infections of the skin. Curr Opin Infect Dis. 2008 Apr;21(2):122-8.
  • Hallett C. The attempt to understand puerperal fever in the eighteenth and early nineteenth centuries: the influence of inflammation theory. Med Hist. 2005 Jan;49(1):1-28.
  • Bomke AK, Vagts DA, Podbielski A. [Toxic-shock-like-syndrome caused by beta-hemolysing group G streptococci in a multimorbid patient with erysipelas] Dtsch Med Wochenschr. 2006 Feb 10;131(6):263-6. German.
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