Erysipelas

Abstract: A retrospective study of 526 adult patients admitted to the Sheba Medical Center for treatment of erysipelas during the period 1972–1982 showed a steady increase in the number of cases admitted as well as a striking change in its classical pattern of distribution, with 86% of the lesions occurring in the lower extremities opposed to 5.9% in the face. Local trauma and superficial abrasions were identified as the major predisposing factors, whereas upper respiratory tract infection was almost negligible among the patients. Peripheral vascular disease, diabetes, and prolonged treatment with corticoids, immunosuppressants, or radiation were less frequently associated with the development of the disease. New trends were also observed for the age groups and seasonal distribution of the population studied.     

Erysipelas

A retrospective study of 526 adult patients admitted to the Sheba Medical Center for treatment of erysipelas during the period 1972-1982 showed a steady increase in the number of cases admitted as well as a striking change in its classical pattern of distribution, with 86% of the lesions occurring in the lower extremities opposed to 5.9% in the face. Local trauma and superficial abrasions were identified as the major predisposing factors, whereas upper respiratory tract infection was almost negligible among the patients. Peripheral vascular disease, diabetes, and prolonged treatment with corticoids, immunosuppressants, or radiation were less frequently associated with the development of the disease. New trends were also observed for the age groups and seasonal distribution of the population studied.     

Erysipelas and necrotizing fasciitis

The clinical course of necrotizing fasciitis in 8 patients is compared with observations on 22 other patients with erysipelas. In necrotizing fasciitis the early erythematous areas turn into a dusky blue colour with later vesiculation and formation of bullae. An important finding is a non-pitting oedema extending outside the erythematous patches. The disease often progresses and involves further skin areas proximal to the initial ones. Gangrene tends to follow in multiple sites after the 1st week of illness. Group A streptococci in conjunction with widespread thrombosis and vascular necrosis of the involved skin are two major factors in the pathogenesis of the gangrene. Early debridement and excision of necrotic tissue in combination with large doses of penicillin and cloxacillin are confirmed as mandatory to remove toxaemia and inhibit further necrosis of the skin. In 3 of the 8 patients with necrotizing fasciitis the syndrome of disseminated intravascular coagulation complicated the course of the disease. A promising therapeutic result was seen in 2 further patients exhibiting alarming signs and symptoms of early necrotizing fasciitis; the combination of heparin, given intravenously in therapeutic doses guided by activated partial thromboplastin time studies, and of systemic antibiotics alleviated the symptoms, which vanished within 10 days of the start of treatment.     

Drug-associated lymphoma and pseudolymphoma: recognition and management

This article discusses ways to recognize and manage lymphomas and pseudolymphomas associated with drug exposure. Over the last 30 years, the classification of pseudolymphomas and lymphomas has undergone significant change, especially following the application of sophisticated immunostaining and gene rearrangement analysis. The term cutaneous pseudolymphomas (CPL) is a nonspecific term for a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes that simulate cutaneous lymphomas clinically or histologically. While pseudolymphomas are relatively rare diseases, their clinical and histological heterogeneity has led to multiple systems of categorization based on immunological factors, causative agents, presentation, and clinical course.     

Erysipelas: a common potentially dangerous infection

Erysipelas is an acute superficial cutaneous cellulitis that commonly occurs not only in elderly and immunocompromised persons, but also in neonates and small children subsequent to bacterial inoculation through a break in the skin barrier. Group A Beta-hemolytic streptococcus (GABHS, Streptoccocus pyogenes) is the usual etiologic agent. Factors that predispose pediatric patients to the development of erysipelas include very young age, diabetes mellitus, an immunocompromised state, and nephrotic syndrome. Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities. Fever with chills and general malaise may be prominent symptoms. Antibiotics are usually effective. Patients handled in a timely manner tend to recover without problems. However, potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema.     

Bedbugs: an update on recognition and management

The common bedbug (Cimex lectularius) is increasingly prevalent and a source of concern and questions for patients. In addition to a range of cutaneous presentations and potential for serious sequelae, bedbug bites cause significant psychological distress and create an economic burden associated with infestation control. Recognition of characteristic entomology, clinical presentation, diagnostic features and differential diagnosis can support expedient identification of patients exposed to infestations and support their appropriate management.     

Erysipelas carcinomatosum der Abdominalhaut

A 71-year-old patient presented with diffuse and poorly circumscribed erythematous plaques of the abdominal skin, present for 5 months. Histology revealed a diffuse infiltration of the entire dermis with cytokeratin-positive signet-ring-cells. Subsequently, an extensive search for a primary adenocarcinoma uncovered a locally advanced signet-ring-cell gastric carcinoma. There were no metastases to other organs. This case shows the unusual clinical-diagnostic sequence of a patient with a signet-ring-cell-carcinoma of the stomach presenting with an erysipelas-like cutaneous metastasis of the abdominal skin.     

Erysipelas and lymphedema--egg or hen?

The initial lymphatics and peripheral lymph-collectors of both legs of 16 patients were visualized by means of indirect lymphography, after the patients had undergone a rash of erysipelas on their lower extremities. 14 out of 19 legs showed clinical signs of lymphedema after one or several erysipelas. In 16 out of 19 legs after erysipelas, but also in 6 out of 11 healthy contralateral extremities, we found pathological initial lymphatics and changes in size, irregularities of the course, and pathological stops of peripheral lymph-collectors. These findings indicate that in the majority of the patients with erysipelas--contrary to the common opinion--resulting lymphedema should not be termed as secondary. In fact, they are primary lymphedemas deteriorated by erysipelas, with the typical pathological findings in indirect lymphography, as they are seen in simple primary forms.     

Fabry disease: recognition and management of cutaneous manifestations

Fabry disease (angiokeratoma corporis diffusum universale) is a rare, X chromosome-linked lysosomal storage disease. The deficient enzyme, alpha-galactosidase A (alpha-gal A), is responsible for the accumulation of neutral glycosphingolipids within vascular endothelial lysosomes of various organs, including skin, kidneys, heart, and brain. The disease manifests primarily in affected hemizygous men and to some extent in heterozygous women ('carriers'). The diagnosis of Fabry disease is made in hemizygous males after the detection of the presence of angiokeratomas, irregularities in sweating, edema, scant body hair, painful sensations, and of cardiovascular, gastrointestinal, renal, ophthalmologic, phlebologic, and respiratory involvement. A deficiency of alpha-gal A in serum, leukocytes, tears, tissue specimens, or cultured skin fibroblasts further supports the diagnosis in male patients. Since heterozygous women show angiokeratomas in only about 30% of cases and may have alpha-gal A levels within normal range, genetic analysis is recommended. Current treatment of angiokeratomas of Fabry disease is based mainly on the use of laser systems, including variable pulse width 532nm Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser, 578nm copper vapor laser, and flashlamp-pumped dye laser. When cutaneous and mucous glands are affected, restrictions may be required with regard to the time spent in a warm climate and the amount time spent working or on sporting activities, and may necessitate the use of topical and systemic antiperspirant agents, and topical application of artificial lacrimal fluid and saliva, respectively. For the future, new treatment modalities, including enzyme replacement therapy, substrate deprivation strategies, and gene therapy offer extraordinary options for the cutaneous and visceral lesions in patients with Fabry disease.     

Perineal streptococcal dermatitis/disease: recognition and management

Perianal streptococcal dermatitis (PSD) is a pediatric dermatologic infectious disease predominantly affecting children, particularly younger children, which is most commonly caused by group A beta-hemolytic streptococci (GABHS). Although the clinical picture of a sharply demarcated erythema is very characteristic, PSD is often misdiagnosed for long periods of time and patients are subjected to treatments for a variety of differential diagnoses. Vulvar and penile involvement with similar signs and symptoms have been documented in several patients with PSD. The diagnosis is made by either a swab of the affected region submitted for microbiological analysis with the specific question for GABHS, or a rapid strep test. Systemic antibiotics such as penicillin, erythromycin, newer macrolides, or others, probably augmented by topical antiseptic or antibiotic ointments are the treatment of choice. Treatment duration should be at least 14 days or, even better, 21 days, and be dictated by clinical and microbiological cure. Therefore treatment success should be investigated not only by clinical examination but also by post-treatment perineal swabs as well as a urine analysis to monitor for post-streptococcal glomerulonephritis. The author of this review supports the recent suggestion to summarize GABHS-induced vulvovaginal and penile infections together with PSD under the inclusive term 'perineal streptococcal disease' because these conditions coincide, share important clinical characteristics and, therefore, represent manifestations of the same disease.     

Xerosis and pruritus in the elderly: recognition and management

Xerosis (dry skin) is characterized by pruritic, dry, cracked and fissured skin. Dry skin may be diagnosed as xerosis, eczema craquelé, dyshidrotic eczema, or asteatotic eczema. Two of the most common dermatologic problems found in nursing home residents are xerosis and pruitus. This article focuses on the recognition and treatment of these conditions, and stresses the importance of comprehensive treatment for these conditions as a preventative against stasis dermatitis and ulcer formation.     

乳腺癌术后丹毒12例分析

目的 分析12例乳腺癌术后丹毒住院患者的临床特点、细菌学特点及治疗方法。 方法 回顾性分析宁波市三家三级甲等医院确诊的12例乳腺癌术后丹毒患者的临床资料。 结果 8例患者行乳腺癌改良根治术 + 腋窝淋巴结清扫术,3例患者行乳腺癌根治术 + 腋窝淋巴结清扫术,1例患者行乳腺切除术,12例患者均有术后患侧的淋巴水肿。丹毒发生于乳腺癌手术治疗后1 ~ 18年（平均8.0年）,4例患者存在复发。8例患者感染部位为手术同侧上肢,1例患者为手术侧胸壁,另1例患者为手术侧下肢,多部位感染者有2例。5例患者行血培养,2例阳性,1例为似马链球菌,另1例为肺炎克雷伯菌。6例患者使用青霉素类抗生素,其中2例初始治疗失败,更换抗生素后,12例患者均好转出院。 结论 乳腺癌术后淋巴水肿的上肢及胸壁容易发生丹毒,病原学上需警惕革兰阴性菌,在抗生素治疗的同时需注重淋巴水肿的治疗。     

Serumeiweiß-Untersuchungen beim Erysipelas recidivans

Zusammenfassung Verfasser haben im Serum von 50 Patienten mit rezidivierendem Erysipel AST-, Serumeiweiß- und immunelektrophoretische Untersuchungen durchgeführt. Als charakteristisch wurde die Erhöhung der AST-(45 Fälle) und der Beta₁-Globulinfraktion (32 Fälle) befunden. Den Anstieg der Alpha₁-, Alpha₂- und Beta-Globulinfraktionen sowie deren immunelektrophoretischer Repräsentanten (Alpha₁-Antitrypsin, Alpha_2M-Globulin, Transferrin) lassen die Autoren als eine bei chronisch-entzündlichen Krankheitsprozessen zu beobachtende Erhöhung des Serum-Glykoproteidgehalt auf, halten diese aber für das recidivierende Erysipel als charakteristisch.

---

Serum protein studies in erysipelas recidivans

Summary Antistreptolysin titer (AST), serum protein analysis and immunelectrophoretic studies of the serum have been carried out in 50 patients suffering from erysipelas recidivans. An increase of AST (in 45 cases) and of beta_1c globulin (in 32 cases) was found to be caracteristic. The increase of the alpha₁, alpha₂ and beta globulin fractions, as well as of their immunelectrophoretic representatives (alpha₁ antitrypsin, alpha_2M globulin, transferrin), is in agreement with literature data and can be explained by the increase of the serum glycoproteid level present in chronic inflammatory processes. They are regarded as characteristic for this disease.