Group A Streptococcal Cellulitis

Aka: Group A Streptococcal Cellulitis, Group A Streptococcus Cellulitis, Erysipelas, Beta-Hemolytic Streptococcal Cellulitis, Group A Strep Cellulitis, Saint Anthony's Fire, Streptococcus Pyogenes Cellulitis, Facial Erysipelas

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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

  1. Acute Skin Infection with Beta-hemolytic Streptococcus
  2. Develops faster than Staphylococcus AureusCellulitis

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

  1. Group A Streptococcus (most common)
  2. See Non-Group A Streptococcus Cellulitis
    1. Group B Streptococcus
    2. Groups C, D, and G Streptococcus

VII. Risk Factors

  1. Immunocompromised patients
  2. Corticosteroid or Chemotherapy use
  3. Acquired Immunodeficiency Syndrome
  4. Nephrotic Syndrome
  5. Diabetes Mellitus
  6. Alcoholism
  7. Venous Insufficiency
  8. Lymphatic Insufficiency

VIII. Symptoms

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

IX. Signs: General

  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: 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
  5. Differential Diagnosis of Facial Erysipelas
    1. Staphylococcus AureusCellulitis
      1. On the face, Staphylococcal Cellulitis may be indistinguishable from streptococcal Erysipelas
    2. Buccal Cellulitis
      1. Haemophilus Influenzae Type B, in the pre-Hib Vaccine era, caused Buccal Cellulitis (much less common now)
    3. Parvovirus B19 (Fifth Disease)
      1. Facial erythema (slapped cheek appearance) spares the chin and periorbital region

XI. Differential Diagnosis

  1. See Cellulitis
  2. See Differential Diagnosis of Facial Erysipelas as above
  3. Contact Dermatitis
  4. Angioneurotic edema
  5. Herpes Zoster
  6. Erysipeloid
  7. Erythema Chronicum Migrans (Lyme Disease)

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
    2. Vancomycin is recommended as first line Antibiotic
      1. Alternatives: Daptomycin, Linezolid
  6. Extremity Erysipelas (Group A Streptococcus)
    1. See Cellulitis for Antibiotic selection
    2. Oral agents: First-Line
      1. Erysipelas is sensitive to Penicillins and Cephalosporins (but often requires higher dose)
      2. Penicillin VK 500 mg orally every 6 hours for 10 days OR
      3. Amoxicillin 500 mg every 8 hours for 10 days
    3. Oral agents: Penicillin Allergic
      1. Cephalexin 500 mg orally four times daily for 10 days OR
      2. Azithromycin 500 mg on day, then 250 mg orally daily for 4 days (days 2-5)
        1. Only indicated for beta-lactam Anaphylaxis (risk of Antibiotic Resistance)
      3. Avoid Doxycycline (due to Streptococcus PyogenesAntibiotic Resistance)
      4. Avoid Trimethoprim Sulfamethoxazole (unless added to other Antibiotic when MRSA is possible cause)
    4. Parenteral agents: First-Line
      1. Penicillin G 1-2 Million Units every 6 hours
    5. Parenteral agents: Penicillin Allergic
      1. Cefazolin 1 gram IV every 8 hours OR
      2. Ceftriaxone 2 grams every 24 hours
    6. Parenteral agents: Beta-Lactam Anaphylaxis
      1. Vancomycin (or Linezolid)

XV. Complications

  1. Abscess (typically due to Staphylococcus Aureus instead)
  2. Gangrene
  3. Superficial Thrombophlebitis
  4. Acute Glomerulonephritis
  5. Sepsis
  6. Endocarditis

XVI. References

  1. (2019) Sanford Guide, accessed on IOS 10/24/2019
  2. Bratton (1995) Am Fam Physician 51(2):401-4 [PubMed]
  3. Carroll (1996) Postgrad Med 100(3):311-22 [PubMed]
  4. Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]

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Related Studies

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, ﾀﾝﾄﾞｸ
Swedish Rosfeber
Czech erysipel, Erysipel
Finnish Ruusu
Russian ROZHA, РОЖА
German Erysipel [Wundrose], Erysipel, Wundrose
Korean 단독
Croatian ERIZIPEL, CRVENI VJETAR
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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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 ﾍﾞ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
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: erysipelas due to group A Streptococcus (C2118543)

Concepts Disease or Syndrome (T047)
English group A Streptococcus erysipelas, erysipelas due to group A Streptococcus (diagnosis), erysipelas due to group A Streptococcus
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Bacterial Infections

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