II. History: St. Anthony's Fire

  1. Refers to epidemic gangrene of the 11th century
    1. Patients presented with bright red extremities
  2. Initially attributed to fungus ingestion and Ergotism
    1. Now believed those reactions were Erysipelas
  3. Some thought skin was consumed by holy fire
    1. Only relief was via 300 AD Egyptian Monk St. Anthony

III. Epidemiology

  1. Common Ages
    1. Infants and Young children
    2. Older than age 60 years (face involvement)
  2. More common over summer months
  3. Usually occurs in isolated cases rather than epidemics

IV. Pathophysiology

V. Mechanisms

  1. Most cases do not have inciting wound
  2. Post-operative infection via surgical incision
    1. Occurs 6-48 hours after surgery
  3. Trauma site
  4. Insect Bite
  5. Nasopharyngeal source

VI. Causes: Beta-hemolytic streptococcal infection

VII. Risk Factors

VIII. Symptoms

  1. Abrupt onset with rapid course
  2. Influenza-like prodrome
    1. Fever, Chills, Malaise
    2. Headache
    3. Vomiting
  3. Red rash with feeling of tightness and warmth

IX. Signs

  1. Same signs as for other forms of Cellulitis except
    1. Lesion indurated with elevated margins
    2. Irregular border that is sharply demarcated
  2. Lesions show staged progression
    1. Spreading erythema over 3-6 days
      1. Shiny, bright red erythema
      2. Painful, hot, edematous lesion
    2. Vesicles and bullae may develop and then crust
    3. Central clearing may then develop within 7-10 days
    4. Areas of involved skin may exfoliate
    5. Postinflammatory Hyperpigmentation may occur
  3. Marked lymphangitis
  4. Systemic symptoms often precede local inflammation (erythema, swelling, local warmth)
    1. Hypotension may be first sign before erythema
    2. Fever, chills and malaise may also precede skin changes by more than 24 hours
  5. Common sites of involvement
    1. Legs
      1. Congenital Lymphedema (Milroy's Disease)
      2. CABG saphenous vein harvest
        1. See Non-Group A Streptococcus Cellulitis
    2. Face (less common now than legs, see below)

X. Signs and Symptoms: Facial erysipelas

  1. Pharyngitis may precede rash by several days
  2. Focal area on face of Paresthesia or pain
  3. Rash develops in area of sensory change
    1. Rash develops as described in signs (see above)
    2. May appear similar to SLE butterfly Malar Rash
  4. Edema may develop of eyes and cheeks

XI. Differential Diagnosis

XII. Labs

  1. Complete Blood Count
    1. Leukocytosis with Left Shift
  2. Antistreptolysin O titer increased
  3. Nasopharynx culture
    1. Positive for Beta-hemolytic Streptococcus
  4. Gram Stain and Culture of wound
    1. Compress wound margins for thin serous discharge
    2. Sample obtained from leading edge
    3. Painful and usually not indicated

XIII. Associated Conditions: Other Skin Infections with Group A Streptococcus

  1. Pyoderma (Impetigo)
  2. Perianal Streptococcal Dermatitis
  3. Children with Chronic Perianal Cellulitis
    1. Intense perianal erythema
    2. Painful Defecation
    3. Blood streaked stools from Anal Fissures

XIV. Management

  1. See Cellulitis for antibiotic selection (including Facial erysipelas coverage)
  2. Apply warm, moist compresses to affected area
  3. Intravenous antibiotics may be required initially
  4. Total antibiotic course: 10-14 days
  5. Facial erysipelas appears similar to Staphylococcal Cellulitis of the face
    1. Facial erysipelas requires MRSA coverage
  6. Erysipelas (Group A Streptococcus) is sensitive to Penicillins and Cephalosporins but often requires high dose
    1. See Cellulitis for antibiotic selection
    2. Example for outpatient high dose oral antibiotics
      1. Augmentin 875 mg twice daily AND
      2. Amoxicillin 1000 mg orally three times daily
    3. Example for outpatient high dose parenteral antibiotics
      1. Ceftriaxone 1-2 grams every 12-24 hours

XV. Complications

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Ontology: Erysipelas (C0014733)

Definition (MSH) An acute infection of the skin caused by species of STREPTOCOCCUS. This disease most frequently affects infants, young children, and the elderly. Characteristics include pink-to-red lesions that spread rapidly and are warm to the touch. The commonest site of involvement is the face.
Concepts Disease or Syndrome (T047)
MSH D004886
ICD9 035
ICD10 A46
SnomedCT 266005008, 154305002, 44653001
English ERYSIPELAS, erysipelas, erysipelas (diagnosis), Erysipelas [Disease/Finding], Patch of erysipelas, Erysipelas (disorder), Erysipelas, erysipelas; infection, infection; erysipelas
Japanese 丹毒, タンドク
Swedish Rosfeber
Czech erysipel, Erysipel
Finnish Ruusu
German Erysipel [Wundrose], Erysipel, Wundrose
Korean 단독
Polish Róża-choroba
Hungarian erysipelas
Norwegian Erysipelas, Rosen
Dutch erysipelas; infectie, infectie; erysipelas, erysipelas, Erysipelas
Spanish erisipela (trastorno), erisipela, placa de erisipela, Erisipela
French Erysipèle, Erésipèle, Érysipèle
Italian Erisipela
Portuguese Erisipela

Ontology: Facial erysipelas (C0343488)

Concepts Disease or Syndrome (T047)
SnomedCT 240425002
English erysipelas face, facial erysipelas, Erysipelas of face, Facial erysipelas, Facial erysipelas (disorder)
Spanish erisipelas faciales (trastorno), erisipelas faciales

Ontology: Streptococcus pyogenes cellulitis (C0857865)

Concepts Disease or Syndrome (T047)
Dutch Streptococcus pyogenes-cellulitis
French Cellulite à Streptococcus pyogenes
German Streptococcus pyogenes-Zellulitis
Italian Cellulite da streptococco piogene
Portuguese Celulite por Streptococcus pyogenes
Spanish Celulitis por Streptococcus pyogenes
Japanese 化膿レンサ球菌性蜂巣炎, カノウレンサキュウキンセイホウソウエン
Czech Celulitida vyvolaná Streptococcus pyogenes
English Streptococcus pyogenes cellulitis
Hungarian Streptococcus pyogenes cellulitis

Ontology: Beta haemolytic streptococcal infection (C0948279)

Concepts Disease or Syndrome (T047)
Italian Infezione da Streptococco beta emolitico
French Infection à streptocoques bêta hémolytiques, Infection streptococcique hémolitique bêta
Portuguese Infecção a estreptococo beta-hemolítico, Infecção hemolítica estreptocócica beta
Spanish Infección por estreptococo betahemolítico, Infección por estreptococo beta hemolítico
Japanese ベータヨウケツセイレンサキュウキンカンセン, β溶血性レンサ球菌感染
Czech Infekce beta hemolytickými streptokoky
Hungarian beta-haemolyticus streptococcus fertőzés
English Beta haemolytic streptococcal infection, Beta hemolytic streptococcal infection
Dutch bèta-hemolytische streptokokkeninfectie
German beta-haemolytische Streptokokkeninfektion