Erysipelas

(Date of publication 06 May 2004)

Erysipelas has three patron saints - Anthony the Abbott, Benedict and Ida of Nivelles - who date back to the early days of Christianity, indicating that this condition has afflicted mankind since antiquity. It was originally known (as was ergotism) as St Anthony's Fire, the said saint having a reputation for reducing the inflammation and itching of skin diseases. According to Steven Lehrer's book 'Explorers of the Body', the term erysipelas was originally coined by the Ancient Greeks from the redness which developed around an infected wound. It is worth reading the chapter that mentions this, available online, for the chilling account of the lightning-fast surgeon Robert Liston, who, in a moment of regrettable over-exuberance during a leg amputation, accidentally removed one of his patient's testicles and two of his assistant's fingers.

Awareness of erysipelas rose sharply in the mid-19th century, when it was recognised that the disease could be caused by smallpox vaccination. A report at the time used the Registrar-General's figures to demonstrate that from 1859 to 1880 almost 400 people died from erysipelas following vaccination, and that the annual death rate from this cause had increased almost eight-fold over the period.

Erysipelas is a type of cellulitis, or infection of the dermis, that is generally caused by Group A beta haemolytic streptococci (Streptococcus pyogenes). These are Gram-positive, non-motile cocci which are facultative anaerobes and occur in chains or pairs. It is estimated that 5% to 15% of otherwise healthy individuals harbour the bacterium, usually in the respiratory tract, but it is one of the most common pathogens of humans and responsible for a spectrum of diseases. These include puerperal fever, pharyngitis and impetigo, which can now be easily treated, but the organism remains a major concern because of a recent resurgence of severe invasive infections such as necrotising fasciitis and streptococcal toxic shock syndrome. This site has some good electron micrographs of the bacterium, and other relevant photographs can be found here.

The typical skin lesion of erysipelas is a red, painful, warm, swollen and indurated plaque which is sharply demarcated from the surrounding normal tissue. Historically the face was the most common site of infection - see the photograph here which illustrates the characteristic 'orange peel' appearance - but up to 80% of cases now affect the legs. Diagnosis is based upon the appearance of the lesion, skin biopsies not usually being required; the Atlas of Dermatology site has a number of photographs of plaques afflicting different regions of the body. Blisters may form over the affected area and patients frequently exhibit the symptoms of a febrile illness with fever, chills and headaches. The cornerstone of therapy is treatment with antibiotics such as penicillin, which is usually active against streptococci.

From the clinical viewpoint, the initial event in the development of erysipelas is the inoculation of bacteria, frequently from the host's nasopharynx, into an area of skin trauma. Infection then rapidly invades and spreads through the lymphatic vessels, often producing overlying skin 'streaking' as well as regional lymph node swelling and tenderness. Even today, the mortality rate of erysipelas has been reported to be 1 in 500. Predisposed patients tend to develop local recurrence, which can lead to disabling healing reactions such as elephantiasis nostras verrucosa, a chronic warty, oedematous condition caused by lymphatic destruction from repeated infection. As this photograph shows, considerable disfigurement may result.

One of the most serious complications of erysipelas is acute post-streptococcal glomerulonephritis. If you can wade through the abundance of advertisements, there is some patient-orientated information about this relatively uncommon condition at this site. Essentially, immune complexes are trapped in the kidney glomeruli, which become inflamed as a result - see the microscope slide here. The filtering and excretory functions of the kidney are compromised, leading to proteinuria and haematuria, so that the urine becomes rust-coloured and may have visible blood present. Hypertension develops and excess fluid often accumulates in the body; oedema of the feet, face and around the eyes is a common feature. Treatment is largely symptomatic and the condition generally resolves spontaneously after several weeks to months.

More detailed information about the incidence and clinical picture can be found back at the emedicine site. Most cases occur in patients between 5 and 15 years old, individuals over 40 are rarely affected, and the ratio of boys to girls is 2:1. According to this article, the strain of S. pyogenes responsible for post-streptococcal glomerulonephritis following skin infection is serotype 49, and an abrupt onset of symptoms precedes enlargement of the kidneys by up to 50%. However, the long term prognosis is good, with 98% of sufferers asymptomatic after 5 years and less than 3% progressing to chronic renal failure.

Another significant danger of erysipelas is bacteraemia and septic shock, which is characterised by acute circulatory failure, usually with hypotension, and multiple organ failure. An indication of the seriousness of this condition is that the mortality rate ranges from 25% to 90%, and it is the most common cause of death in intensive care units in the USA. Its pathogenesis is not fully understood, but it appears that toxins generated by the infecting bacteria trigger complex immunological reactions, vasodilatation occurs and tissue perfusion is reduced, which particularly affects the kidneys and brain. The presenting sign is often altered mental alertness, but others include reduced blood pressure with paradoxically warm extremities, increased heart rate, rapid breathing and oliguria. The importance of aggressive intervention is strongly emphasised on the Postgraduate Medicine site in its comprehensive account of the different aspects of treatment, some of which are extremely hi-tech. I wonder what St Anthony would make of it all...?

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A Tour around Erysipelas

A Tour around Erysipelas