Erysipelas

Erysipelas (/ˌɛrəˈsɪpələs/) is a relatively common bacterial infection of the superficial layer of the skin (upper dermis), extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin. It is a form of cellulitis and is potentially serious.[1][2][3]

This article is about the disease called "erysipelas" in humans. For the disease called "erysipelas" in nonhuman animals, see Erysipelothrix rhusiopathiae.

Erysipelas
Other namesIgnis sacer, holy fire, St. Anthony's fire
Erysipelas of the face due to invasive Streptococcus
Pronunciation
  • /ɛriˈsɪpələs/
SpecialtyDermatology, Infectious disease

Erysipelas is usually caused by the bacteria Streptococcus pyogenes, also known as group A β-hemolytic streptococci, which enters the body through a break in the skin, such as a scratch or an insect bite. It is more superficial than cellulitis, and is typically more raised and demarcated.[4] The term comes from the Greek ἐρυσίπελας (erysípelas), meaning "red skin".[5]

In animals, erysipelas is a disease caused by infection with the bacterium Erysipelothrix rhusiopathiae. The disease caused in animals is called Diamond Skin Disease, which occurs especially in pigs. Heart valves and skin are affected. Erysipelothrix rhusiopathiae can also infect humans, but in that case, the infection is known as erysipeloid, which is an occupational skin disease.[6]

Signs and symptoms

Symptoms often occur suddenly. Affected individuals may develop a fever, shivering, chills, fatigue, headaches, vomiting and be generally unwell within 48 hours of the initial infection.[1][2] The red plaque enlarges rapidly and has a sharply demarcated, raised edge.[4][7] It may appear swollen, feel firm, warm and tender to touch and may have a consistency similar to orange peel.[2] Pain may be extreme.[7]

More severe infections can result in vesicles (pox or insect bite-like marks), blisters, and petechiae (small purple or red spots), with possible skin necrosis (death).[7] Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen.[8]

The infection may occur on any part of the skin, including the face, arms, fingers, legs and toes; it tends to favour the extremities.[1] The umbilical stump and sites of lymphoedema are also common sites affected.[7]

Fat tissue and facial areas, typically around the eyes, ears, and cheeks, are most susceptible to infection.[9] Repeated infection of the extremities can lead to chronic swelling (lymphoedema).[2]

  • Erysipelas (ear)
    Erysipelas (ear)
  • Erysipelas (arm)
    Erysipelas (arm)
  • Erysipelas (leg)
    Erysipelas (leg)
  • Recurrent erysipelas
    Recurrent erysipelas

Cause
Streptococcus pyogenes

Most cases of erysipelas are due to Streptococcus pyogenes, also known as group A β-hemolytic streptococci, less commonly by group C or G streptococci and rarely due to Staphylococcus aureus. Newborns may contract erysipelas due to Streptococcus agalactiae, also known as group B streptococcus or GBS.[7]

The infecting bacteria can enter the skin through minor trauma, human, insect or animal bites, surgical incisions, ulcers, burns and abrasions. There may be underlying eczema or athlete's foot (tinea pedis), and it can originate from streptococci bacteria in the subject's own nasal passages or ear.[7]

The rash is due to an exotoxin, not the Streptococcus bacteria, and is found in areas where no symptoms are present; e.g., the infection may be in the nasopharynx, but the rash is found usually on the epidermis and superficial lymphatics.[10]

Diagnosis

Erysipelas is usually diagnosed by the clinician looking at the characteristic well-demarcated rash following a history of injury or recognition of one of the risk factors.[2]

Tests, if performed, may show a high white cell count, raised CRP or positive blood culture identifying the organism.[2]

Erysipelas must be differentiated from herpes zoster, angioedema, contact dermatitis, erythema chronicum migrans of early Lyme disease, gout, septic arthritis, septic bursitis, vasculitis, allergic reaction to an insect bite, acute drug reaction, deep venous thrombosis and diffuse inflammatory carcinoma of the breast.[11]

Differentiating from cellulitis

Erysipelas can be distinguished from cellulitis by two particular features; its raised advancing edge and its sharp borders. The redness in cellulitis is not raised and its border is relatively indistinct.[7] Bright redness of erysipelas has been described as a third differentiating feature.[12]

Erysipelas does not affect subcutaneous tissue. It does not release pus, only serum or serous fluid. Subcutaneous edema may lead the physician to misdiagnose it as cellulitis.[13]

Treatment

Depending on the severity, treatment involves either oral or intravenous antibiotics, using, among others, penicillins, clindamycin, or erythromycin. While illness symptoms resolve in a day or two, the skin may take weeks to return to normal. Because of the risk of reinfection, prophylactic antibiotics are sometimes used after resolution of the initial condition.[2]

Prognosis

The disease prognosis includes:

  • Spread of infection to other areas of body can occur through the bloodstream (bacteremia), including septic arthritis. Glomerulonephritis can follow an episode of streptococcal erysipelas or other skin infection, but not rheumatic fever.
  • Recurrence of infection: Erysipelas can recur in 18–30% of cases even after antibiotic treatment. A chronic state of recurrent erysipelas infections can occur with several predisposing factors including alcoholism, diabetes, and athlete's foot.[14] Another predisposing factor is chronic cutaneous edema, such as can in turn be caused by venous insufficiency or heart failure.[15]
  • Lymphatic damage
  • Necrotizing fasciitis, commonly known as "flesh-eating" bacterial infection, is a potentially deadly exacerbation of the infection if it spreads to deeper tissue.

Epidemiology

There is currently no validated recent data on the worldwide incidence of erysipelas.[16] From 2004 to 2005, UK hospitals reported 69,576 cases of cellulitis and 516 cases of erysipelas.[16] One book stated that several studies have placed the prevalence rate between one and 250 in every 10,000 people.[17] The development of antibiotics, as well as increased sanitation standards, has contributed to the decreased rate of incidence.[18] Erysipelas caused systemic illness in up to 40% of cases reported by UK hospitals and 29% of people had recurrent episodes within three years.[16] Anyone can be infected, although incidence rates are higher in infants and elderly.[18] Several studies also reported a higher incidence rate in women.[18] Four out of five cases occur on the legs, although historically the face was a more frequent site.[3]

Risk factors for developing the disease include[17][16][18][19]

  • Arteriovenous fistula
  • Chronic skin conditions such as psoriasis, athlete's foot, and eczema
  • Excising the saphenous vein
  • Immune deficiency or compromise, such as
    • Diabetes
    • Alcoholism
    • Obesity
    • Human immunodeficiency virus (HIV)
  • In newborns, exposure of the umbilical cord and vaccination site injury
  • Issues in lymph or blood circulation
  • Leg ulcers
  • Lymphatic edema
  • Lymphatic obstruction
  • Lymphoedema
  • Nasopharyngeal infection
  • Nephrotic syndrome
  • Pregnancy
  • Previous episode(s) of erysipelas
  • Toe web intertrigo
  • Traumatic wounds
  • Venous insufficiency or disease

Preventative measures

Individuals can take preventative steps to increase the chance they do not catch the disease. Properly cleaning and covering wounds is important for people battling an open wound. Effectively treating athlete's foot or eczema if they were the cause for the initial infection will decrease the chance of the infection occurring again. People with diabetes should pay attention to maintaining good foot hygiene.[17] It is also important to follow up with doctors to make sure the disease has not come back or spread. About one-third of people who have had erysipelas will be infected again within three years.[16] Rigorous antibiotics may be needed in the case of recurrent bacterial skin infections.[17]

Notable cases
Fatal, in order of death

Chronic, recurrent

  • Richard Wagner, opera composer, was prone to outbreaks of erysipelas throughout his adult life. He suffered notably from attacks throughout the year 1855 when he was 42.

Acute

  • Jair Bolsonaro, president of Brazil between 2019 and 2022, currently suffers from erysipelas.

Recovered

  • Lenin developed an infection in London, and party leadership was exercised by Martov until he recovered.[35][36][37]
  • Ernest Hemingway developed an infection near his left eye after being hit with an oar. He was treated at the Casa di Cura Morgagni in Padua.[38]

Fictional

  • In D. H. Lawrence's novel Sons and Lovers one of the major characters in the novel, William Morel, dies quickly from the complications of erysipelas in conjunction with pneumonia.
  • In Anton Chekhov's 1892 short story "Ward No. 6", erysipelas is among the conditions had by the patients committed to a poorly run mental illness facility in a small town in tsarist Russia.
  • In J. G. Farrell's novel The Siege of Krishnapur the Collector, Mr. Hopkins, is affected during the Siege and recovers.
  • In Mark Twain's Roughing It, mention is made of the disease due to the rarefied atmosphere (Chapter 43).
  • In Dashiell Hammett's The Thin Man, the name is used for a pun on the word "ear" (Chapter 22).
  • In Willa Cather's One of Ours, the main character, Claude, contracts the disease in "the queerest" way, after being dragged into wire by mules, and the next day continuing to work in the dust. The disease plays a key role in the novel, persuading him to marry Enid after she cares for him in recovery. (Book II, Chapter IV, p. 138).
  • In an episode of Downton Abbey, Isobel Crawley misdiagnoses her butler, Molesley, with erysipelas when he develops a rash on his hands. The Dowager Countess of Grantham correctly identifies the rash as an allergy to rue.

History

It was historically known as St. Anthony's fire.[3]

Citations
  1. O'Brian, Gail M. (2019). "Section 1. Diseases and Disorders; Erysipelas". In Fred F. Ferri (ed.). Ferri's Clinical Advisor 2019: 5 Books in 1. Philadelphia: Elsevier. p. 523. ISBN 978-0-323-53042-2.
  2. Stanway, Amy; Oakley, Amanda; Gomez, Jannet (2016). "Erysipelas | DermNet NZ". dermnetnz.org. Retrieved 6 June 2020.
  3. Davis, Loretta S. (9 November 2019). "Erysipelas: Background, Pathophysiology and Etiology, Epidemiology". Medscape.
  4. Wanat, Karolyn A.; Norton, Scott A. "Skin & Soft Tissue Infections – Chapter 11 – 2020 Yellow Book | Travelers' Health | CDC". Centres for Disease Control and Prevention. Retrieved 6 June 2020.
  5. Bhat M, Sriram (2019). SRB's Clinical Methods in Surgery. New Delhi: Jaypee Brothers Medical Publishers. p. 141. ISBN 978-93-5270-545-0.
  6. Veraldi, S. "Erysipeloid: a review". Clinical and Experimental Dermatology.
  7. Wolff, Klaus; Johnson, Richard (2009). "Part III; Diseases due to microbial agents". Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology: Sixth Edition. McGraw Hill Professional. p. 609. ISBN 978-0-07-163342-0.
  8. "Cellulitis". The Lecturio Medical Concept Library. Retrieved 7 July 2021.
  9. "Erysipelas". The Lecturio Medical Concept Library. Retrieved 21 July 2021.
  10. "Erysipelas". The Lecturio Medical Concept Library. Retrieved 7 July 2021.
  11. Michael, Y.; Shaukat, N. M. (2022). "Erysipelas". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID 30335280. Retrieved 7 July 2021.
  12. Stevens, Dennis L.; Bryant, Amy E. (2016), Ferretti, Joseph J.; Stevens, Dennis L.; Fischetti, Vincent A. (eds.), "Impetigo, Erysipelas and Cellulitis", Streptococcus pyogenes: Basic Biology to Clinical Manifestations, University of Oklahoma Health Sciences Center, PMID 26866211, retrieved 8 June 2020
  13. Spelman, Denis. "Cellulitis and skin abscess: Clinical manifestations and diagnosis". UpToDate. UpToDate. Retrieved 30 July 2019.
  14. Jorup-Rönström, Christina; Britton, S. (1 March 1987). "Recurrent erysipelas: Predisposing factors and costs of prophylaxis". Infection. 15 (2): 105–106. doi:10.1007/BF01650206. ISSN 0300-8126. PMID 3110071. S2CID 29789051.
  15. Nigar Kirmani; Keith F. Woeltje; Hilary Babcock (2012). The Washington Manual of Infectious Disease Subspecialty Consult. Lippincott Williams & Wilkins. ISBN 9781451113648. Page 194
  16. Morris, Andrew D (2 January 2008). "Cellulitis and erysipelas". BMJ Clinical Evidence. 2008. ISSN 1752-8526. PMC 2907977. PMID 19450336.
  17. Erysipelas and cellulitis: Overview. Institute for Quality and Efficiency in Health Care. 22 February 2018.
  18. Michael, Youstina; Shaukat, Nadia M. (2020), "Erysipelas", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30335280, retrieved 13 November 2020
  19. "Erysipelas | DermNet NZ". dermnetnz.org. Retrieved 30 November 2020.
  20. Descartes, René (1984–1991). The philosophical writings of Descartes. Cambridge [Cambridgeshire]: Cambridge University Press. p. 21. ISBN 0521403235.
  21. "Throckmorton, Margaret [name in religion Magdalen] (1591–1668), prioress of St Monica's, Louvain". Oxford Dictionary of National Biography (online ed.). Oxford University Press. 2004. doi:10.1093/ref:odnb/106107. ISBN 9780198614111. Retrieved 31 January 2021. (Subscription or UK public library membership required.)
  22. "Berkeley, Norborne, baron de Botetourt (1717–1770)".
  23. Dennis Butts, "Hofland, Barbara (bap. 1770, d. 1844)", Oxford Dictionary of National Biography (Oxford, UK: OUP, 2004 Retrieved 20 December 2015, pay-walled.
  24. Green, Elizabeth Alden (1979). Mary Lyon and Mount Holyoke. Hanover, New Hampshire: University Press of New England. p. 310. ISBN 978-0-87451-172-7.
  25. Møller, Jan (1994). Frederik 7. En kongeskæbne. Copenhagen: Aschehoug Dansk Forlag. p. 235. ISBN 978-87-11-22878-4.
  26. Castillo, Dennis (14 April 2017). "Viewpoints: Remembering Buffalo's first Catholic bishop, John Timon, 'a great and good man'". The Buffalo News. Retrieved 17 April 2017.
  27. Capaldi, Nicholas (2004). John Stuart Mill: a biography. Cambridge, UK: Cambridge University Press. pp. 356. ISBN 978-0-521-62024-6.
  28. "Marcus Clarke". Australian Variety Theatre Archive. 31 July 2011.
  29. Ridley, Jane (2013). The Heir Apparent: a life of Edward VII, the Crown Prince. New York, NY: Penguin Random House LLC. p. 287.
  30. America the Beautiful by Lynn Sherr
  31. Macy, Beth. Truevine. Little, Brown & Co, New York, 2016, page 151.
  32. Cox, A. M. "The death of Lord Carnarvon"; The Lancet; 7 June 2003.
  33. Trachtenberg, Leo (1995). The Wonder Team: The True Story of the Incomparable 1927 New York Yankees. Bowling Green State University Popular Press. p. 151. ISBN 0-87972-677-6.
  34. Wollenweber, Brother Leo (2002). "Meet Solanus Casey". St. Anthony Messenger Press, Cincinnati, Ohio, page 107, ISBN 1-56955-281-9,
  35. Rice, Christopher (1990). Lenin: Portrait of a Professional Revolutionary. London: Cassell. ISBN 978-0304318148. pp. 77–78.
  36. Service, Robert (2000). Lenin: A Biography. London: Macmillan. ISBN 9780333726259. p. 150.
  37. Rappaport, Helen (2010). Conspirator: Lenin in Exile. New York: Basic Books. ISBN 978-0-465-01395-1 pp. 85–87.
  38. Hemingway, Mary Welsh (1976). How It Was. London: Weidenfeld & Nicolson. ISBN 0-297-77265-1. p. 236.
  39. Souza Leão, Rodrigo (2013). All Dogs are Blue. High Wycombe: And Other Stories. ISBN 978-1-908-27620-9. p. 49.
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