erysipelas-jainishpatel-121123045440-phpapp02.pdf

Erysipelas
Definition
Erysipelas is a superficial bacterial
skin infection that is characteristically
extends into cutaneous lymphatics .
It was referred to as :
Saint Anthony's Fire (= ergotism or
erysipelas or Herpes zoster )
•Bacterial
inoculation into an
area of skin trauma
is the initial event in
developing
erysipelas.
Pathophysiology
The source of the bacteria
in facial erysipelas is often
the host's naso-
pharynx, and a history of
recent streptococcal
pharyngitis has been
reported in up to one third
of cases.
Pathophysiology
Pathophysiology
Lymphoscintigraphy in patients
with a first-time episode of
lower extremity erysipelas has
documented lymphatic
impairment in both affected
and non affected legs.
regional lymph node
swelling and
tenderness
* Streptococci are the primary
cause of erysipelas.
* Most facial infections are
attributed to group A
streptococci,
*lower extremity infections
being caused by non–group A
streptococci.
Causative organism
causes
•Streptococcal toxins are thought to
contribute to the brisk inflammation
that is pathognomonic of this infection.
*No clear proof has emerged that other
bacteria cause typical erysipelas,
although they clearly coexist with
streptococci at sites of inoculation.
causes
Recently, atypical forms reported to be
caused by :
* Streptococcus pneumoniae,
*Klebsiella pneumoniae,
* Haemophilus influenzae,
*Yersinia enterocolitica,
*Moraxella species,
they should be considered in cases refractory
to standard antibiotic therapy.
Race
Erysipelas infections affect persons of all
races.
Sex
•Erysipelas is common in females.
• at an earlier age it is more in males ( more
activities).
• However predisposing factors, rather than
gender, account for any male/female
differences in incidence.
Age
All age groups are susiptable.
The peak incidence at 60-80 years
old, especially in patients :
= At high-risk .
= immuno-compromised .
= those with lymphatic drainage
problems (eg, after mastectomy, pelvic
surgery, bypass grafting).
Clinical
symptoms
Prodromal symptoms :
malaise.
chills.
high fever.
often begin before the onset of the skin
lesions and usually are present within 48
hours of cutaneous involvement..
symptoms
Pruritus .
burning .
tenderness.
are typical complaints
Physical
Erysipelas begins
as a small
erythematous
patch that
progresses to a
fiery-
red, indurated
, tense, and shiny
plaque.
The lesion classically
exhibits raised
sharply demarcated
advancing margins.
Local signs of
inflammation
warmth,
edema,
tenderness
are universal.
Lymphatic
involvement often
is manifested by
overlying skin
streaking and
regional
lymphadenopathy
More severe
infections may
exhibit numerous
vesicles and bullae
along with
petechiae and
even frank
necrosis.
Erysipelas
of
the face
Erysipelas
Of
the leg
Erysipelas
the
buttock
Erysipelas
of
the ear Pena
Differential Diagnoses
Differential Diagnoses
1) Erythema Annulare Centri-
fugum
2) Stasis Dermatitis
3) Cellulitis
4) Erysipeloid
Erythema Annulare Centrifugum
* Eruptions occur at any
age.
* begins as small raised
pink-red spot that slowly
enlarges and forms a ring
shape while the central
area flattens and clears.
There may be an inner
rim of scale.
Erythema Annulare Centrifugum
Lesions most often
appear on the
thighs, legs, face, trunk
and arms.
linked to underlying
diseases , viral
, bacterial or even
tumor.
Stasis
Dermatitis
cellulitis
Erysipeloid
* acute bacterial infection of traumatized skin.
* caused by Erysipelothrix rhusiopathiae
(gram positive rod-shaped bacterium), which
cause animal and human infections.
* Direct contact between infected meat and
traumatized human skin results in Erysipeloid.
•more common among
farmers, butchers, cooks, homemakers.
* Lesions most commonly affect the hands.
Erysipeloid
* Lesions consist of
well-
demarcated, bright
red-to-purple plaques
with a smooth, shiny
surface.
•Lesions are warm
and tender.
Laboratory Studies
Laboratory Studies
* In classic erysipelas, no
laboratory workup is required
for diagnosis or treatment.
* Cultures are best reserved for
immunocopromized patient in
whom an atypical etiologic agent
is suspected.
Imaging Studies
Imaging studies are not usually
indicated and are of low yield.
MRI and bone scintigraphy are
helpful when early osteoarticular
involvement is suspected.
In this setting, standard
radiographic findings typically are
normal.
Histological Findings
The histological hallmarks of erysipelas are
*marked dermal edema,
*vascular dilatation,
*streptococcal invasion of lymphatics & tissues.
This bacterial invasion results in a dermal
inflammatory infiltrate consisting of
neutrophils and mononuclear cells.
The epidermis is often secondarily involved.
Rarely, bacterial invasion of local blood vessels
may be seen.
Treatment
Hospitalization for close monitoring
and IV. antibiotics is recommended
for :
1) severe cases.
2) infants.
3) elderly patients.
4) patients who are immune-
compromised.
Medical Care
* Elevation and rest of the affected
limb are recommended to reduce
local swelling, inflammation, and pain.
* Saline wet dressings should be
applied to ulcerated and necrotic
lesions and changed every 2-12 hours,
depending on the severity of the
infection.
* penicillin has remained first-line therapy.
administered orally or IM. for 10-20 days.
Dosing : Adult
Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d
Penicillin VK: 250-500 mg PO qid for 10-14 d
Pediatric : Penicillin G procaine: <30 kg: 300,000 U/d
>30 kg: Administer as in adults
Penicillin VK:
<12 years: 25-50 mg/kg/d PO divided tid/qid;
not to exceed 3 g/d
>12 years: Administer as in adults
Medical Care
Medical Care
*A first-generation cephalosporin or
macrolide, such as erythromycin or
azithromycin, may be used if the patient has
an allergy to penicillin.
Dosing
Adult
250-500 mg PO qid for 10 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided
q6-8h; double dose for severe infection.
•Two new drugs:
• roxithromycin & pristinamycin,
have been reported to be extremely
effective in the treatment of erysipelas.
* Several studies have demonstrated greater
efficacy and fewer adverse effects with
these drugs compared with penicillin.
*Currently, FDA has not approved these
drugs in the United States, but they are in
use in Europe.
Recurrent
erysipelas
Patients with recurrent erysipelas
should be educated regarding :
•local antisepstic .
•general wound care.
•Predisposing lower extremity skin
lesions (eg , tineapedis , toe
web intertrigo , stasis ulcers) should
be treated aggressively to prevent
super-infection.
Recurrent erysipelas
•Long-term prophylactic antibiotic therapy
generally is accepted, but no true guidelines are
available.
•Treatment regimens should be tailored to the
patient.
•One reported regimen is benzathine
penicillin G at 2.4 MU IM. every 3 weeks
for up to 2 years . Two-week intervals
have also been used.
Recurrent erysipelas
Surgical Care
Debridement is necessary
only in severe infections
with necrosis or gangrene.
Complications
1) The most common
complications of erysipelas are :
* abscess,
* gangrene,
* Thrombophlebitis .
Complications
Complications
2) Less common complications
(<1%) are :
*acute glomerulonephritis ,
*endocarditis ,
*septicemia,
*streptococcal toxic shock
syndrome.
Prognosis
* The prognosis for patients
with erysipelas is excellent.
* local recurrence has been
reported in up to 20% of
patients with predisposing
conditions
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erysipelas-jainishpatel-121123045440-phpapp02.pdf

  • 2. Definition Erysipelas is a superficial bacterial skin infection that is characteristically extends into cutaneous lymphatics . It was referred to as : Saint Anthony's Fire (= ergotism or erysipelas or Herpes zoster )
  • 3. •Bacterial inoculation into an area of skin trauma is the initial event in developing erysipelas. Pathophysiology
  • 4. The source of the bacteria in facial erysipelas is often the host's naso- pharynx, and a history of recent streptococcal pharyngitis has been reported in up to one third of cases. Pathophysiology
  • 5. Pathophysiology Lymphoscintigraphy in patients with a first-time episode of lower extremity erysipelas has documented lymphatic impairment in both affected and non affected legs.
  • 7. * Streptococci are the primary cause of erysipelas. * Most facial infections are attributed to group A streptococci, *lower extremity infections being caused by non–group A streptococci. Causative organism
  • 8. causes •Streptococcal toxins are thought to contribute to the brisk inflammation that is pathognomonic of this infection. *No clear proof has emerged that other bacteria cause typical erysipelas, although they clearly coexist with streptococci at sites of inoculation.
  • 9. causes Recently, atypical forms reported to be caused by : * Streptococcus pneumoniae, *Klebsiella pneumoniae, * Haemophilus influenzae, *Yersinia enterocolitica, *Moraxella species, they should be considered in cases refractory to standard antibiotic therapy.
  • 10. Race Erysipelas infections affect persons of all races. Sex •Erysipelas is common in females. • at an earlier age it is more in males ( more activities). • However predisposing factors, rather than gender, account for any male/female differences in incidence.
  • 11. Age All age groups are susiptable. The peak incidence at 60-80 years old, especially in patients : = At high-risk . = immuno-compromised . = those with lymphatic drainage problems (eg, after mastectomy, pelvic surgery, bypass grafting).
  • 13. symptoms Prodromal symptoms : malaise. chills. high fever. often begin before the onset of the skin lesions and usually are present within 48 hours of cutaneous involvement..
  • 16. Erysipelas begins as a small erythematous patch that progresses to a fiery- red, indurated , tense, and shiny plaque.
  • 17. The lesion classically exhibits raised sharply demarcated advancing margins. Local signs of inflammation warmth, edema, tenderness are universal.
  • 18. Lymphatic involvement often is manifested by overlying skin streaking and regional lymphadenopathy
  • 19. More severe infections may exhibit numerous vesicles and bullae along with petechiae and even frank necrosis.
  • 25. Differential Diagnoses 1) Erythema Annulare Centri- fugum 2) Stasis Dermatitis 3) Cellulitis 4) Erysipeloid
  • 26. Erythema Annulare Centrifugum * Eruptions occur at any age. * begins as small raised pink-red spot that slowly enlarges and forms a ring shape while the central area flattens and clears. There may be an inner rim of scale.
  • 27. Erythema Annulare Centrifugum Lesions most often appear on the thighs, legs, face, trunk and arms. linked to underlying diseases , viral , bacterial or even tumor.
  • 30. Erysipeloid * acute bacterial infection of traumatized skin. * caused by Erysipelothrix rhusiopathiae (gram positive rod-shaped bacterium), which cause animal and human infections. * Direct contact between infected meat and traumatized human skin results in Erysipeloid. •more common among farmers, butchers, cooks, homemakers. * Lesions most commonly affect the hands.
  • 31. Erysipeloid * Lesions consist of well- demarcated, bright red-to-purple plaques with a smooth, shiny surface. •Lesions are warm and tender.
  • 33. Laboratory Studies * In classic erysipelas, no laboratory workup is required for diagnosis or treatment. * Cultures are best reserved for immunocopromized patient in whom an atypical etiologic agent is suspected.
  • 34. Imaging Studies Imaging studies are not usually indicated and are of low yield. MRI and bone scintigraphy are helpful when early osteoarticular involvement is suspected. In this setting, standard radiographic findings typically are normal.
  • 35. Histological Findings The histological hallmarks of erysipelas are *marked dermal edema, *vascular dilatation, *streptococcal invasion of lymphatics & tissues. This bacterial invasion results in a dermal inflammatory infiltrate consisting of neutrophils and mononuclear cells. The epidermis is often secondarily involved. Rarely, bacterial invasion of local blood vessels may be seen.
  • 37. Hospitalization for close monitoring and IV. antibiotics is recommended for : 1) severe cases. 2) infants. 3) elderly patients. 4) patients who are immune- compromised.
  • 38. Medical Care * Elevation and rest of the affected limb are recommended to reduce local swelling, inflammation, and pain. * Saline wet dressings should be applied to ulcerated and necrotic lesions and changed every 2-12 hours, depending on the severity of the infection.
  • 39. * penicillin has remained first-line therapy. administered orally or IM. for 10-20 days. Dosing : Adult Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d Penicillin VK: 250-500 mg PO qid for 10-14 d Pediatric : Penicillin G procaine: <30 kg: 300,000 U/d >30 kg: Administer as in adults Penicillin VK: <12 years: 25-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d >12 years: Administer as in adults Medical Care
  • 40. Medical Care *A first-generation cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin. Dosing Adult 250-500 mg PO qid for 10 d Pediatric 30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection.
  • 41. •Two new drugs: • roxithromycin & pristinamycin, have been reported to be extremely effective in the treatment of erysipelas. * Several studies have demonstrated greater efficacy and fewer adverse effects with these drugs compared with penicillin. *Currently, FDA has not approved these drugs in the United States, but they are in use in Europe.
  • 43. Patients with recurrent erysipelas should be educated regarding : •local antisepstic . •general wound care. •Predisposing lower extremity skin lesions (eg , tineapedis , toe web intertrigo , stasis ulcers) should be treated aggressively to prevent super-infection. Recurrent erysipelas
  • 44. •Long-term prophylactic antibiotic therapy generally is accepted, but no true guidelines are available. •Treatment regimens should be tailored to the patient. •One reported regimen is benzathine penicillin G at 2.4 MU IM. every 3 weeks for up to 2 years . Two-week intervals have also been used. Recurrent erysipelas
  • 45. Surgical Care Debridement is necessary only in severe infections with necrosis or gangrene.
  • 47. 1) The most common complications of erysipelas are : * abscess, * gangrene, * Thrombophlebitis . Complications
  • 48. Complications 2) Less common complications (<1%) are : *acute glomerulonephritis , *endocarditis , *septicemia, *streptococcal toxic shock syndrome.
  • 49. Prognosis * The prognosis for patients with erysipelas is excellent. * local recurrence has been reported in up to 20% of patients with predisposing conditions