Erysipelas

Classification according to ICD-10
A46	Erysipelas
ICD-10 online (WHO version 2019)

Erysipelas on the lower leg after inflammation

The erysipelas (stress: erysi'pēl, literal meaning about reddened skin : ancient Greek ἐρυσίπελας erysipelas ) is a bacterial infection and inflammation of the upper layers of the skin (less often the mucous membrane) and lymphatic tract and shows itself as a sharply defined extensive reddening. The erysipelas originates from small skin injuries and occurs mostly on the face, arms or legs and less often on the navel . Other names for the erysipelas are Wundrose , Rose and Rotlauf .

root cause

The cause is usually an acute infection of the skin by group A β-hemolytic streptococci ( Streptococcus pyogenes ). Other pathogens can rarely be responsible for the development of an erysipelas. These include streptococci from other groups, Staphylococcus aureus, and gram-negative rods such as Klebsiella pneumoniae . The entry point for the pathogens is often an epithelial defect - a wound , a rhagade or athlete's foot . For example, with athlete's foot, the nail deforms, which usually leads to small injuries to the nail bed and thus to an entry portal for bacteria. Chronic wounds in particular represent a persistent portal of entry for bacteria due to the prolonged course of the wound and can lead to erysipelas. In some cases, a triggering wound may be sought in vain.

Patients with water retention in the tissue ( edema ) are at greater risk of developing erysipelas, especially if they have pre-existing lymphatic damage. The reason for this is that the lymphatic system causes bacteria that have penetrated to be transported away into the lymph nodes, where the bacteria are then killed by immune cells. In the case of lymph vessel damage, this transport only works to a limited extent.

Symptoms

Typical reddening of the skin in the erysipelas

A rapidly spreading, crimson, graduated, flame-shaped, sharply delimited and painful reddening of the skin is typical of the erysipelas. The reddened skin is initially at the level of the surroundings, later swells and is overheated. The symptoms can range from small red spots without any side effects to a high feverish infection ("red runny fever") with chills and severe impairment. In some cases, blisters form that can bleed in (bullous erysipelas / hemorrhagic erysipelas).

course

After an incubation period of a few hours to two days, the erysipelas usually begins suddenly with fever and chills . The typical skin changes only appear hours later.

Diagnosis and differential diagnosis

Recognizing this disease is usually not difficult and can sometimes be done as a "visual diagnosis". The diagnosis is therefore usually made "clinically" - a pathogen detection is usually not possible. Erysipelas cause difficulties on previously damaged skin, e.g. B. in a post-thrombotic syndrome . There is a risk of confusion with so-called stasis dermatitis, especially in the area of the legs or acute dermatitis ( facial rose originating from the nose, eyes or ear ) in the face area. An erysipelas that spreads symmetrically from the bridge of the nose to the adjacent cheeks is known as a "butterfly erysipelago". This is to be distinguished from a butterfly erythema in lupus erythematosus . Also, allergic contact dermatitis or angioedema must be differentiated from erysipelas. In the case of the not uncommon erysipelas of the auricle , perichondritis should be considered in the differential diagnosis , as the choice of antibiotic depends on it. Necrotizing fasciitis is a bacterial disease of the skin and subcutaneous tissue that may look similar at the beginning, but which has a rapid course . The possibility of the initial stage of Lyme borreliosis , triggered by a tick bite, must also be clarified in the differential diagnosis . A circular reddening does not always have to occur here, but so-called erythema migrans, a flat skin reddening that can easily be confused with erysipelas. As a precaution, this should be clarified with the help of a complete blood count including an examination of the Borrelia titer.

treatment

Patients with bullous (blistering) or bullous-hemorrhagic (blistering-bleeding) erysipelas are usually admitted to hospital as an inpatient. As a rule, high-dose intravenous antibiotic therapy is necessary, as the erysipelas show a pronounced tendency to recur (relapses). First and foremost are penicillin or cephalosporins such as cefuroxime . In the case of severe illness (poor general condition, high fever, etc.), the therapy is carried out as a continuous intravenous drip infusion .

Treatment of lighter forms can also be done with antibiotic tablets. If blistering (bullous) occurs during non-inpatient treatment, the doctor must be consulted immediately in order to prevent deterioration into the open (hemorrhagic) state.

Antibiotic resistance to penicillin is almost never a problem in the treatment of the disease. For acute treatment, cooling compresses with water or disinfecting substances (e.g. hydroxyquinolone solution) are still used. Bed rest is recommended. In addition, the entry portal of the bacteria must be treated (e.g. athlete's foot , nail fungus ) in order to avoid a relapse.

Consequential damage is only to be feared in extreme, untreated cases in patients with an operated heart valve. Risk patients should therefore consult their family doctor early on. In the case of hemorrhagic erysipelas, after the bladder zone has healed, scarring can occur, which leads to permanent skin discoloration.

Complications

The erysipelas show a spontaneous regression tendency; Without treatment, however, relapses often occur, which can lead to disorders of the lymphatic drainage (secondary lymphedema up to elephantiasis ) of an arm or leg due to the lymphatic system sticking together . A recurrence rate of 30% within three years has been reported, which is why intravenous antibiotic treatment over ten days is often recommended.

Further complications are thrombophlebitis as well as cerebral vein thrombosis and meningitis if the disease occurs on the face due to the pathogen entering the collateral veins in the deep facial region. A necrotizing fasciitis can result from erysipelas on the leg and be confused in the early stages with this.

In the case of recurrent erysipelas, there is a risk of secondary lymphedema with all the possible consequential conditions that may result.

to form

Bullous erysipelas - a form in which flaccid blisters usually develop on the 2nd or 3rd day.
hemorrhagic erysipelas - when bleeding into the lesion
Ekchymatous erysipelas - for small areas of bleeding
gangrenous erysipelas - an erysipelas with skin necrosis
wandering erysipelas - ( Erysipela migrans ) - an erysipelas that spreads into the surrounding area while regressing in the center of the lesion.
phlegmonous or abscessing erysipelas - an erysipelas that progresses into the depths. The phlegmonous erysipelas is rare and often requires surgical intervention.
Smooth or flat erysipelas - ( Erysipelas glabrum or Erysipelas laevigatum ) - an erysipelas in the early stages with a smooth and shiny surface in the rest of the skin level.

Flaming reddening of the skin on the leg caused by erysipelas.
Bullous erysipelas with phlegmon on the foot.
Involvement of the earlobe as opposed to perichondritis .

history

The Erysipelas was already known in ancient times. Until the introduction of asepsis , the “wound rose” was a common problem in hospitals and military hospitals. The streptococci were detected as the pathogen in 1882 by the surgeon Friedrich Fehleisen (1854-1924). Targeted treatment was only possible thanks to modern chemotherapy , which began with the use of Prontosil in erysipelas.

literature

Rudolf Probst, Gerhard Grevers, Heinrich Iro: Ear, nose and throat medicine . Georg Thieme Verlag, Stuttgart 2000, ISBN 3-13-119031-0 , p. 49.

Web links

Commons : Erysipelas - collection of images, videos and audio files

Entry on erysipelas in the online encyclopedia of dermatology, venereology, allergology and environmental medicine edited by Peter Altmeyer

Individual evidence

↑ Joachim Dissemond: Blickdiagnose Chronic Wounds. About the clinical inspection for diagnosis. Viavital Verlag, Cologne 2016, ISBN 978-3-934371-55-2 , page 286
↑ Erysipelas - Dermatology - Altmeyers Encyclopedia. Retrieved October 22, 2017 .
↑ Cf. also Georg Sticker : Hippokrates : Der Volkskrankheiten first and third book (around the year 434–430 BC). Translated, introduced and explained from the Greek. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central Antiquariat of the German Democratic Republic, Leipzig 1968, pp. 123–128 ( Rose, ἐρυσιπέλατα. ).
↑ Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 84-87 ( Erysipelas ), here: p. 84.

[1] Joachim Dissemond: Blickdiagnose Chronic Wounds. About the clinical inspection for diagnosis. Viavital Verlag, Cologne 2016, ISBN 978-3-934371-55-2 , page 286

[2] Erysipelas - Dermatology - Altmeyers Encyclopedia. Retrieved October 22, 2017 .

[3] Cf. also Georg Sticker : Hippokrates : Der Volkskrankheiten first and third book (around the year 434–430 BC). Translated, introduced and explained from the Greek. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central Antiquariat of the German Democratic Republic, Leipzig 1968, pp. 123–128 ( Rose, ἐρυσιπέλατα. ).

[4] Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 84-87 ( Erysipelas ), here: p. 84.