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erysipelas

Cellulitis caused by group A Streptococcus. Etiology: - group A Streptococcus (beta-hemolytic Streptococcus) - surgical site infection [7] Pathology: - deeper type of cellulitis - affects dermis & subcutaneous tissue [3] - involves the lymphatics Clinical manifestations: 1) sudden onset of fever/chills, malaise 2) painful, sharply demarcated erythema of the skin (erythematous plaque) with elevated borders 3) local edema, induration, non-pitting 4) vesicles or bullae - skin abscesses, such as furuncles or carbuncles, suggests S aureus. 5) unilateral distribution [3] 6) orange peel appearance [3] 7) site of predilection: a) face b) lower legs more common than face (70-80%) [8] c) areas of pre-existing lymphedema d) umbilical stump 8) violet-red, well-demarcated plaque with edema on the face [4] * images [5,6,8] Laboratory: 1) complete blood count (CBC): leukocytosis 2) gram stain of vesicular fluid 3) culture of vesicular fluid - culturing aspirate from subcutaneous tissue not helpful 4) blood culture not routinely indicated [4] Differential diagnosis: - cellulitis - impetigo - malar rash of systemic lupus erythematosus - female, black predilection - fever/chills absent - skin abscesses, such as furuncles or carbuncles, suggests S aureus Complications: - lymphatic scarring & chronic lymphedema may occur - not life-threatening [8] Management: 1) inpatient antibiotic treatment a) cefazolin (Ancef) 1-2 g IV every 8 hours b) ceftriaxone c) penicillin G or V 2) outpatient antibiotic treatment a) cephalexin (Keflex) 500 mg QID b) penicillin VK 250-500 mg BID c) erythromycin 500 mg QID (for PCN allergy) d) clindamycin

Related

impetigo Streptococcus pyogenes

General

cellulitis

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 882
  2. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 634-43
  3. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  5. Davis L, James WD (images) Medscape: Erysipelas http://emedicine.medscape.com/article/1052445-overview
  6. DermNet NZ. Erysipelas (images) http://www.dermnetnz.org/bacterial/erysipelas.html
  7. NEJM Knowledge+ Question of the Week. Sept 3, 2019 https://knowledgeplus.nejm.org/question-of-week/536/ - Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996 Jan 25; 334:240. PMID: 8532002 https://www.nejm.org/doi/full/10.1056/NEJM199601253340407 - Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014 Jun 21; 59:e10. PMID: 24947530
  8. Elkston CA, Elkston DM Bacterial Skin Infections: More Than Skin Deep. Medscape. July 19, 2021 https://reference.medscape.com/slideshow/infect-skin-6003449