Erysipelas of the Thigh and the Gluteal Region: Retrospective Multicenter Analysis of a Very Rare Entity in 39 Patients.

**Editor's note: Not all infection we lymphers get can correctively be labled as cellulitis.  Often it is another form of infection referred to as erysipelas. This brief article is important specifically due to the closing line where it speaks of the disruption of the lymphatic vessels.  We know of course this can lead to secondary lymphedema**

Glatz M, Degen D, French LE, Aberer W, Müllegger RR.

Source

Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.

Abstract

Background: Erysipelas of the thigh and the gluteal region are rarely described and not well characterized. Therefore we aim to describe the prevalence, clinical characteristics, and risk factors of these erysipelas types. 

Methods: The files of 1,423 patients with erysipelas were analyzed. Data from patients with erysipelas of the thigh or the gluteal region were compared between the two groups and with a control group with erysipelas of the lower leg. 

Results: The thigh was exclusively affected in 2.1%, and the gluteal region in 0.6% of erysipelas patients. Gluteal erysipelas had conspicuous irregular borders and sometimes appeared bilaterally. Major risk factors for erysipelas of both sites were previous surgical interventions. Gluteal erysipelas was common in patients with the metabolic syndrome and required a more intense antibiotic therapy. 

Conclusion: Erysipelas of the thigh and the gluteal region are rare and significantly associated with prior surgical disruption of lymphatic vessels.

Karger

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Lymphedema Erysipelas

Classification and External Resources

ICD-10	A46.0 -  Excludes: postpartum or puerperal erysipelas ( O86.8 )
ICD-9	035 -Erysipelas (gangrenous) (infantile) (newborn) (phlegmonous) (suppurative) 035  035 is a specific code that can be used to specify a diagnosis 035 contains 9 index entries 035 excludes: postpartum or puerperal erysipelas (670)
DiseasesDB	4428
MedlinePlus	000618
eMedicine	derm/129
MeSH	D004886

Incidence of deep vein thrombosis in erysipelas or cellulitis of the lower extremities.

Aug 2012

Mortazavi M, Samiee MM, Spencer FA.

Source

Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.

Abstract

The incidence of deep vein thrombosis (DVT) in patients with erysipelas and cellulitis of the lower extremities is unknown. As such, the indication and efficacy of prophylactic anticoagulation for prevention of DVT in these patients is unclear. The main goal of this review is to provide an estimate of the incidence of DVT in erysipelas and cellulitis based on existing literature. A comprehensive search of the electronic sources: MEDLINE, EMBASE, CINAHL, LILAC and Cochrane without any language limitation was performed from 1950 to April 2011 for articles focused on the occurrence of DVT in cellulitis or erysipelas of the lower extremities. The selected studies were divided into two groups according to presence or absence of systematic investigation for DVT. Those studies in which the patients received prophylactic or therapeutic anticoagulants before a diagnosis of DVT were excluded. The reported incidence rate of DVT in patients with erysipelas or cellulitis of the lower extremities is highly variable, ranging from 0 to 15%. In this review, the overall incidence rates of DVT in studies with and without systematic investigation for thromboembolism were 2.72% (95% CI: 1.71-3.75%) and 0.68% (95% CI: 0.27-1.07%), respectively. Given the low reported overall incidence of DVT, neither routine prophylactic anticoagulation nor systematic paraclinical investigation for DVT is indicated in low risk patients with erysipelas or cellulitis of the lower extremities. DVT should still be considered in patients with high pretest probability or other thromboembolic risk factors.

PubMed

Erysipelas

Erysipelas


Key Words:  Strep A,  Lymphedema,  Cellulitis,  Bacteremia,  Septicemia, Cutaneous lympatics, immunocompromised,  St. Anthony's Fire,  Staph aureus,  Strep G, Penicillin,  Probenecid, Dicloxacillin,  Erythromycin,  Keflex,  Augmentin,  Necrosis,  Gangrene,  Thrombophebitis, Bacterial endocarditis,  Soft tissue infections




Discussion

Erysipelas (also called St. Anthony's Fire)is a superficial bacterial skin infection skin generally caused by (Strep A bacteria or Strep B bacteria. It can spread with alarming rapidity as it invades the cutaneous lymphatics.

While some classify it as a "form of cellulitis," it actually can be differentiated by the clear lines of demarcation of the infection. Symptoms include marked lines of infection, fever, pain, an overall achy feeling and swollen lymph nodes. Most cases involve the legs, and the second largest number of cases involve the face.  However a delay in treatment can result in deeper cellulitis or lymphangitis.

Like any type of infection a lymphedema patient experiences, antibiotic treatment needs to start immediately so as to prevent septicemia or bacteremia.  As with any infection erysipelas present a serious threat due to the immunocompromised state of the lymphedemous limb and because possible fibrosis handicaps effective antibiotic therapy. Also, in lymphedema patients Staph aureus (not Strep A) has been implicated as the infective bacteria.
While very similar and often confused with actual cellulitis it can be differentiated by the raised borders and advancing edges. The most commonly affected body areas are the legs, followed by the face.

Risk Factors

There are a number of factors that might predispose one to erysipelas.  The primary cause of course is a break, cut or entry foci in the skin and subsequent infection usually by a Strep A bacterium.  Susceptibility factors include edema, lymphedema, venous insufficiency, venous stasis, dermatosis, diabetes, HIV infection, and other immunocompromising medical conditions.
Transmission factors include port of entry through nasal cavity, insect bites, cut, incisions.

Symptoms

The infection may start out as a inconspicuous small red patch and spread rapidly to a painful fiery red plaque.  The infection area will be warm or hot and quite tender.  Over-all body symptoms might include feeling unusually drained of energy, achiness, chills, fever and malaise. There may also be blisters on the infected area and possible red streaking. 

Treatment

Treatment generally will involve the administration of an oral antibiotic.  The infection responds well to penicillin based antibiotic. In addition Probenecid may be used as it increase the effectiveness of penicillins. For more resistant infections dicloxacillin may be used.  Other antibiotics may include  Nafcillin, Erythromycin, Keflex and Augmentin.  

Depending upon the severity and spread IV antibiotic therapy may also be used for lymphedema patients.  Also, limiting one's activity with limb elevation is standard protcol.

Blood cultures and/or wound cultures may be needed to determine the exact bacteria involved. 

Complications

Complications may include bacteremia or septicemia, abscess, tissue necrosis (gangrene)in the most severe cases, thrombophlebitis, bacterial endorcarditis.

Prognosis

Prompt diagnosis and treatment will bring favorable results and in all but a very few patients recovery will be complete and without complications.  At risk groups, including those with lymphedema may experience recurrent episodes.

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