[Clinical and Laboratory Factors Associated with Prolonged Hospital Stay among Patients with Cellulitis/Erysipelas]. / Fatores Clínico-Laboratoriais Associados ao Internamento Prolongado em Doentes com Celulite/Erisipela.

INTRODUCTION: Cellulitis and erysipelas represent the most frequent cause of hospitalization in the dermatology department of Santa Maria Hospital in Lisbon, Portugal. The aim of this study was to investigate whether patient demographics, comorbidities, previous episodes of cellulitis/erysipelas, the presence of complications, laboratory markers at admission, microbial isolation or previous use of antibiotics, are associated with prolonged stays. MATERIAL AND METHODS: Retrospective analysis, including patients admitted with cellulitis/erysipelas in the inpatient dermatology department of Santa Maria Hospital between July 1st 2012 and June 30th 2017. RESULTS: There were 372 admissions, corresponding to 348 patients. The median length of stay was 11 days. Increased age (p = 0.002, OR 1.03, 95% CI 1.01 - 1.04), previous episode of cellulitis/erysipelas requiring hospitalization (p = 0.005, OR 4.81, 95% CI 1.63 - 14.23), the presence of cellulitis/erysipelas-associated complications (p = 0.001, OR 3.28, 95% CI 1.63 - 6.59), leukocytosis (p = 0.049, OR 1.81, 95% CI 1.00 - 3.30), high levels of C-reactive protein (p = 0.035, OR 1.03, 95% CI 1.00 - 1.06) and a positive culture result (p = 0.002, OR 2.59, 95% CI 1.41 - 4.79) were associated with prolonged hospitalization. DISCUSSION: Prolonged hospitalization for cellulitis/erysipelas is associated with higher costs, additional clinical investigation, invasive treatments, prolonged courses of antibiotic therapy, risk of nosocomial infections, and delayed return to activities of daily living. Thus, the investigation of clinical-laboratory factors associated with prolonged hospitalization for cellulitis / erysipelas is essential and may be useful for the construction of a severity score. CONCLUSION: The knowledge of the characteristics that are associated with prolonged stay among patients with cellulitis/erysipelas may be relevant to improve health care, by reducing the length of hospital stay and associated risks and costs.

Introdução: A celulite e a erisipela constituem a causa mais frequente de internamento no Serviço de Dermatologia do Hospital Santa Maria. Este estudo teve como objetivo investigar se as características demográficas, as comorbilidades, a existência de episódios prévios de celulite/erisipela, a presença de complicações associadas, os parâmetros laboratoriais na admissão, o isolamento de microrganismo em cultura ou o uso prévio de antibióticos estão associados a internamentos prolongados.Material e Métodos: Estudo retrospetivo, incluindo os doentes internados no Serviço de Dermatologia do Hospital Santa Maria com o diagnóstico de celulite/erisipela, entre 1 de julho de 2012 e 30 de junho de 2017.Resultados: Existiram 372 internamentos, correspondendo a 348 doentes. A mediana do tempo de internamento foi de 11 dias. A idade (p = 0,002, OR 1,03, 95% IC 1,01 ­ 1,04), a existência de internamento prévio por celulite/erisipela (p = 0,005, OR 4,81, 95% IC 1,63 ­ 14,23), a presença de complicações associadas à celulite/erisipela (p = 0,001, OR 3,28, 95% IC 1,63 ­ 6,59), a leucocitose (p = 0,049, OR 1,81, 95% IC 1,00 ­ 3,30), valores elevados de proteína C reativa (p = 0,035, OR 1,03, 95% IC 1,00 - 1,06) e o isolamento de microrganismo em cultura (p = 0,002, OR 2,59, 95% IC 1,41 ­ 4,79) estiveram associados a internamentos prolongados.Discussão: A par dos maiores custos associados, o internamento prolongado por celulite/erisipela está frequentemente associado à necessidade de investigação clínica adicional, a tratamentos invasivos, a cursos prolongados de antibioterapia, ao risco de infeções nosocomiais e ao atraso no retorno às atividades da vida diária. Assim, o estudo dos fatores clínico-laboratoriais associados ao internamento prolongado por celulite/erisipela é fundamental e poderá ser útil para a construção de um score de gravidade.Conclusão: O conhecimento de características clínicas e laboratoriais associadas ao internamento prolongado poderá ser relevante para melhorar os cuidados de saúde, através da redução dos tempos de internamento e dos seus riscos e custos associados.

INDEXES OF CYTOKINE PROFILE OF BLOOD IN PATIENTS WITH COMPLICATED ERYSIPELAS.

The cytokine blood profile in patients with complicated erysipelas was investigated. It was found that in patients with complications of erysipelas (gangrene, phlegmon, abscess, thrombophlebitis of the subcutaneous veins of the shin) levels of pro-inflammatory cytokines IL-1ß, TNF-α, IL-2, IL-6 in serum significantly increase and level of anti-inflammatory cytokine IL-4 increases slightly, as well as was found a significant increase in coefficients reflecting the ratio of pro-inflammatory and anti-inflammatory cytokines, which indicates the prevalence in the blood of examined patients with complications of erysipelas an anti-inflammatory properties. A more significant increase in pro-inflammatory cytokines serum levels is typical for patients with destructive forms of erysipelas - phlegmonous and gangrenous, a slight increase - for patients without purulent-necrotic component of complication (thrombophlebitis of the subcutaneous veins of the shin). In the future we plan to study pharmacological correction of shifts in cytokine blood profile with drugs with immunomodulating properties in patients with complicated erysipelas.

Analysis of Serum Cytokines and Single-Nucleotide Polymorphisms of SOD1, SOD2, and CAT in Erysipelas Patients.

Increased free radical production had been documented in group A (ß-hemolytic) streptococcus infection cases. Comparing 71 erysipelas patients to 55 age-matched healthy individuals, we sought for CAT, SOD1, and SOD2 single polymorphism mutation (SNPs) interactions with erysipelas' predisposition and serum cytokine levels in the acute and recovery phases of erysipelas infection. Whereas female patients had a higher predisposition to erysipelas, male patients were prone to having a facial localization of the infection. The presence of SOD1 G7958, SOD2 T2734, and CAT C262 alleles was linked to erysipelas' predisposition. T and C alleles of SOD2 T2734C individually were linked to patients with bullous and erythematous erysipelas, respectively. G and A alleles of SOD1 G7958A individually were associated with lower limbs and higher body part localizations of the infection, respectively. Serum levels of IL-1ß, CCL11, IL-2Rα, CXCL9, TRAIL, PDGF-BB, and CCL4 were associated with symptoms accompanying the infection, while IL-6, IL-9, IL-10, IL-13, IL-15, IL-17, G-CSF, and VEGF were associated with predisposition and recurrence of erysipelas. While variations of IL-1ß, IL-7, IL-8, IL-17, CCL5, and HGF were associated with the SOD2 T2734C SNP, variations of PDFG-BB and CCL2 were associated with the CAT C262T SNP.

[INDICATORS OF PHAGOCYTIC ACTIVITY OF MONOCYTES AND CYTOKINE PROFILE IN PATIENTS WITH ERYSIPELAS OF VARYING SEVERITY].

Erysipelas (PB) ­ a serious disease that is accompanied by severe complications and high lethality. The immunological investigations were carry out in 51 patients who were treated at the clinic for erysipelas with an immunomodulator application. Marked changes in the indices of phagocytic activity of monocytes (PHAM) and the cytokine profile in patients with erysipelas were note. Application in complex treatment of immunomodulator give the positive effect on the indices of PHAM.

Use of procalcitonin, C-reactive protein and white blood cell count to distinguish between lower limb erysipelas and deep vein thrombosis in the emergency department: A prospective observational study.

Early differentiation of erysipelas from deep vein thrombosis (DVT) based solely on clinical signs and symptoms is challenging. There is a lack of data regarding the usefulness of the inflammatory biomarkers procalcitonin (PCT), C-reactive protein (CRP) and white blood cell (WBC) count in the diagnosis of localized cutaneous infections. Herein, we investigated the diagnostic value of inflammatory markers in a prospective at-risk patient population. This is an observational quality control study including consecutive patients presenting with a final diagnosis of either erysipelas or DVT. The association of PCT (µg/L) and CRP (mg/L) levels and WBC counts (g/L) with the primary outcome was assessed using logistic regression models with area under the receiver-operator curve. Forty-eight patients (erysipelas, n = 31; DVT, n = 17) were included. Compared with patients with DVT, those with erysipelas had significantly higher PCT concentrations. No significant differences in CRP concentrations and WBC counts were found between the two groups. At a PCT threshold of 0.1 µg/L or more, specificity and positive predictive values (PPV) for erysipelas were 82.4% and 85.7%, respectively, and increased to 100% and 100% at a threshold of more than 0.25 µg/L. Levels of PCT also correlated with the severity of erysipelas, with a stepwise increase according to systemic inflammatory response syndrome criteria. We found a high discriminatory value of PCT for differentiation between erysipelas and DVT, in contrast to other commonly used inflammatory biomarkers. Whether the use of PCT levels for early differentiation of erysipelas from DVT reduces unnecessary antibiotic exposure needs to be assessed in an interventional trial.

[Some features of primary facial erysipelas under the present conditions].

AIM: To establish the features of clinical and laboratory changes in facial erysipelas in relation to its form. SUBJECTS AND METHODS: Twenty-three patients (15 women and 8 men) aged 31 to 78 years who were diagnosed with moderate facial erysipelas, primary facial erysipelas being present in 91% of cases were examined. The investigators studied the biochemical substrates and enzymes and composition of proteins in the serum by an electrophoretic method, the aggregation activity of red blood cells and platelets, plasma hemostasis (a coagulogram, levels of fibrinogen, antithrombin III, and D-dimer), and von Willebrand factor, a marker of vessel wall injury, on hospital admission at disease onset (days 1-3), over time (days 4-6, 7-9), and in convalescence (days 10-12), by obligatorily using control materials. CONCLUSION: Bleeding disorders in facial erysipelas correspond to the vasculite purpuric type of hemorrhagic diathesis (according to the classification developed by Z. S. Barkagan) with the laboratory signs of evolving disseminated intravascular coagulation: impairments in erythrocyte hemostasis and blood vessel endothelium. The changes in the functional properties of red blood cells match with the suppression of metabolic processes. And if the neuraminidase effect of ß-hemolytic streptococcus is shown at the level of the red blood cell membrane, the activity of NADase blocks processes in the entire macroenergetics. In the presence of a high fever reaction, the low levels of transaminases (aspartate aminotransferase, alanine aminotransferase) and membrane enzymes (alkaline phosphatase, creatinine phosphokinase) decrease the detoxification capacities of serum and increase a load on blood albumin and erythrocyte barriers. Rapid normalization of C-reactive protein levels enables one to use this simple and highly sensitive test to monitor the involution of erysipelatous inflammation and the efficiency of treatment. The changes in the hemostatic system and metabolic tests are less pronounced in patients with facial erysipelas than in those with lower-extremity erysipelas.

[The content of substances of low and medium molecular mass in biologic liquids in patients with erysipelas].

The endogenic intoxication is a metabolic response to any aggressive factor. The concentration of substances of low and medium molecular mass biologic liquids of organism w and medium molecular mass is a common indicator of intoxication syndrome. The study analyzed the role of uptake of substances of low and medium molecular mass in biologic liquids of organism in pathogenesis of erysipelas depending on period, form and ration of disease. The sampling included 76 patients with erysipelas aged from 27 to 62 years being in infection hospital for treatment. The concentration of substances of low and medium molecular mass was detected using M. Ya. Malakhova technique (1996). It is established that under erysipelas in organism occurs uptake of toxic substances in blood and gradual increase of concentration of substances of low and medium molecular mass in blood plasma and erythrocytes paralleled by corresponding changes of their concentration in urine. The altitude of increase of concentration level of substances of low and medium molecular mass and their reapportion between biologic mediums of organisms depends on period, form, ratio of course and degree of severity of pathologic process.

Risk of deep vein thrombosis in patients with cellulitis and erysipelas: a systematic review and meta-analysis.

INTRODUCTION: The occurrence of deep vein thrombosis (DVT) is often considered in patients with cellulitis and erysipelas because of the common presentation of unilateral limb swelling, erythema and pain. Different authors however have reached different conclusions about the prevalence of DVT in these patients and for the need for compression ultrasound (CUS). The purpose of this study is to determine the prevalence of DVT in patients with cellulitis and erysipelas, and inform the utility of CUS. METHODS: A systematic literature search was conducted of Medline and Cochrane for studies that reported groups of patients with cellulitis or erysipelas who had CUS to evaluate for DVT. Study quality assessment was based on the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. The incidence rates from the included studies were pooled using a random-effects model to calculate an overall DVT rate. Individual and pooled DVT rates with corresponding upper and lower limits were graphed as a forest plot. Between-study heterogeneity was estimated using the I(2) statistic. RESULTS: Nine studies were included totaling 1054 patients with cellulitis or erysipelas with 18 DVTs. The overall pooled incidence rate was 2.1% (95% confidence interval, 0.5%-9.1%) for proximal DVT and 3.1% (95% confidence interval, 1.9%-4.9%) for any DVT. When analyzed separately, the pooled incidence rate for the three retrospective studies was 1.1% (95% CI, 0.6%-2.2%), while the rate for the six prospective studies was 7.8% (95% CI, 4.2%-14.2%). CONCLUSION: The risk of DVT in cellulitis and erysipelas is low compared to the average risk of patients referred for CUS and comparable to low risk patients as determined by the commonly employed Wells criteria.

[Demographic, clinical and laboratory characteristics of erisypelas in the period 2001-2010]. / Erizipelul--caracteristici demografice, clinice si paraclinice în perioada 2001-2010.

AIM: to describe demographic and clinical characteristics of erysipelas and to compare the sensitivity of two laboratory tests. MATERIAL AND METHODS: we studied patients with erysipelas hospitalized in the Dermatological Clinic between 2001 and 2010. RESULTS: the investigated 140 cases represented 8% of all skin infections hospitalized. Distribution of annual admissions has shown a gradual reduction in the number of admissions in the second half of the decade. A higher frequency was found in the second half of the year. Most patients were from rural areas (55%). The female gender predominated (69.3%). With few exceptions, the patients were adults averaging 59 years. The most common location was the lower leg (91.4%). Most clinical forms were mild and medium. Septic complications were absent. Recurrent erysipelas occurred in 5% of cases. Comorbidity included: chronic venous insufficiency (14.2%), hypertension (10%), obesity (8%), diabetes mellitus (5.7%) or chronic hepatitis (3.5%). CONCLUSIONS: the "benign" appearance of our cases is contrary to the trend rate of severe cases of cutaneous streptococcal infections in some western areas. From comparing laboratory tests results we observed their frequent mismatch. The ESR and the increase in percentage of polymorphonuclear neutrophils were more significant than the total number of leukocytes. Etiological therapy with penicillin G at a dose of 4 million UI/day was effective. The analysis allows the establishment of demographic and clinical features of erysipelas during the period and given territory.

Analysis of epidemiology, clinical features and management of erysipelas.

BACKGROUND: Erysipelas is a superficial form of cellulitis affecting the upper dermis and superficial lymphatics. The widespread use of antibiotics may affect clinical findings and response to therapy of infectious disorders. The purpose of the study was to investigate the epidemiological, clinical, and laboratory features of erysipelas and to compare the results of treatment with penicillin vs. other antibiotic regimens. METHODS: All charts of erysipelas patients treated at the University Hospital of Heraklion, Crete, Greece from 1994 to 2002 were retrospectively studied. RESULTS: Median age of the 99 patients was 54.5 years; 59% were females. The most frequent site involved was the lower extremity (76%), followed by the face (17%) and upper extremity (6%). In 61 patients (62%), a possible entry portal was identified. The most common manifestation of erysipelas was local symptoms and signs (pain, erythema, and swelling) in all patients, together with elevated erythrocyte sedimentation rate (ESR) (60%). Fever was present in 25% of patients. The most commonly used antibiotic was intravenous penicillin G (64%). In the penicillin group, mean duration of fever after treatment initiation was shorter than in the nonpenicillin group (1.7 vs. 4.5 days, P = 0.002). Both treatment failures and recurrences were the same between the two groups. DISCUSSION: The diagnosis of erysipelas can be based on careful examination for local signs and symptoms. The role of ESR in primary diagnosis needs further investigation. Penicillin seems to preserve its fundamental role in the treatment of disease.

[Dermatologic aspects of anticoagulation]. / Antikoagulation in der Dermatologie.

The coagulation system protects the body from uncontrolled blood loss by means of highly regulated processes. In case of an injury the coagulation system instantly switches from controlled blood flow to acute coagulation and thrombus formation with the goal of stopping the blood loss. Minor changes in this well-maintained equilibrium of coagulation and blood flow tip the balance towards uncontrolled blood loss or even fatal thromboembolic events. Iatrogenic manipulation of this highly regulated system is possible with a variety of therapeutic agents. We review the basics of coagulation physiology and then discuss dermatologically relevant aspects of thrombosis prevention, as well as the use of anticoagulants to treat dermatologic diseases.

[Time course of changes in serum cytokine levels and the erysipelas clinical pattern].

The time course of changes in the values of proinflammatory tumor necrosis factor-alpha (TNF-alpha) and IL-8 and the anti-inflammatory cytokine IL-4 has been studied in 78 patients with erysipelas of different frequencies and pathomorphological forms of the disease. In erysipelas and its erythematous form, there is an increase in the levels of TNF-alpha and IL-8 in early phase of the disease, a decrease in these indices during convalescence, and a rise in the content of the cytokine IL-4, which are typical of an acute cyclic infectious process with a good outcome. In recurrent erysipelas and its most severe bullous-hemorrhagic form, there is imbalance in the production of cytokines that are suggestive of that there might be a disease recurrence. In erysipelas patients with a TNF-alpha value of 2.5 pg/ml or less at the onset of the disease, the relative risk for prolonged signs of systemic and local inflammatory reactions increases as compared with those who have a TNF-alpha level of more than 2.5 pg/ml.

Rheological properties of erythrocytes in patients suffering from erysipelas. Examination with LORCA device.

The rheological properties of erythrocytes: elongation and the aggregation, as well as basic peripheral blood parameters: RBC number, hematocrit, MCV, MCH, MCHC reticulocytes, fibrinogen level, ESR, and glucose level were studied in a group of erysipelas patients. The concentration of malonyl dialdehyde (MDA) in erythrocytes was also measured, as an indicator of oxidative stress exerted. The study involved 18 erysipelas patients and 18 healthy subjects. The rheological properties and the aggregation of erythrocytes were studied with the use of a LORCA instrument (Laser-assisted Optical Rotational Cell Analyser). Differences were found in elongation index (EI) between the blood control (C) and patients (P), with an increase of this value only at 0.58 Pa shear stress and at 1.13 Pa shear stress. Upstroke were used as the indexes of RBC deformability, and the following aggregation parameters: intensity of light scattering in the prior disaggregation (Isc dis) - C - 43.0 au (arbitrary units), P - 44.8 au, time when cells are round and not aggregated (Isc top) - C - 51.6 au, P - 49.3 au, the amplitude of aggregation, the difference between Isc max and Isc min (AMP) - C - 39.9 au, P - 28.7 au, aggregation index (AI) - C - 64.6%, P - 70.0%, time for reach one half of the maximum aggregation (t(1/2)) - C - 2.0 s, P - 1.5 s, threshold shear stress, the lowest force that breaks the aggregation formed (Y(thr)) in P exceed 170% control group were measured. A decrease in the elasticity of erythrocytes in erysipelas patients was associated with the simultaneous increase of MDA - C - 0.08 nM/mgHb, P - 0.11 nM/mgHb content in the membranes of red blood cells. Basic peripheral blood parameters studied in patients with erysipelas did not differ significantly from the control group except for WBC, fibrinogen (C - 3.8 g/l, P - 7.8 g/l), and ESR (C - 6.1 mm/h, P - 45.4 mm/h) which were significantly higher.

[The application wound sorption in complex treatment of destructive forms of erysipelas inflammation]. / Applikatsionnaia ranevaia sorbtsiia v kompleksnom lechenii destruktivnykh form rozhistogo vospaleniia.

The method of application wound sorption with sorbent Vaulen was used in treatment of erysipelatous inflammation in 49 patients. The first signs of healing appeared 1.5-2 times quicker, the rate of lessening the area of the wound surface was 21-35% greater. The period of staying in the hospital was 20-23% shorter.

The CD14+CD16+ monocytes in erysipelas are expanded and show reduced cytokine production.

In human peripheral blood the classical CD14(++)DR(+) monocytes and the pro-inflammatory CD14(+)CD16(+)DR(++) monocytes can be distinguished. In erysipelas we found strongly increased numbers of CD14(+)CD16(+) monocytes on the day of diagnosis (day 1) in 11 patients with an average of 150.5+/-76.0 cells/microl, while 1 patient had low levels (35 cells/microl, control donors 48.8+/-19.8 cells/microl). The classical monocytes were only moderately elevated in the erysipelas patients (factor 1.7 as compared to controls). Patients exhibited increased body temperature, erythrocyte sedimentation rate and increased serum levels for C-reactive protein (CRP), IL-6 and macrophage-colony-stimulating factor. Among these, body temperature and CRP showed a significant correlation to the numbers of CD14(+)CD16(+) monocytes. In 4 of 4 patients with high levels of CD14(+)CD16(+) monocytes, these levels returned to that seen in controls by day 5 of antibiotic therapy. Determination of intracellular TNF was performed by three-color immunofluorescence and flow cytometry after ex vivo stimulation with lipoteichoic acid, a typical constituent of streptococci. Here, patient CD14(+)DR(++) pro-inflammatory monocytes showed a twofold lower level of intracellular TNF. By contrast, expression of TNF was unaltered in the classical CD14(++) monocytes. These data show that in erysipelas the pro-inflammatory CD14(+)CD16(+)DR(++) monocytes are substantially expanded and selectively tolerant to stimulation by streptococcal products.

[Dynamics of erythrocyte electrophoretic mobility in patients with various forms of erysipelas]. / Elektrophoreticheskaia podvizhnost' éritrotsitov u bol'nykh s razlichnymi formami rozhi v dinamike bolezni.

AIM: To study electrophoretic mobility (EM) of erythrocytes in the course of various forms of erysipelas. MATERIAL AND METHODS: 78 patients with various erysipelas clinical forms were examined in the disease acute period and early in convalescence. RESULTS: EM of erythrocytes was significantly higher in hemorrhagic forms of erysipelas vs an erythematous form. CONCLUSION: Manifest changes in functional condition of erythrocytic membranes in patients with erythematous-hemorrhagic and bullous-hemorrhagic forms of erysipelas play an important part in the development of local hemorrhagic syndrome.

[The lipid peroxidation and chemiluminescence indices of patients with erysipelas and concomitant diabetes mellitus]. / Pokazateli peroksidatsii lipidov i khemiliuminestsentsii u bol'nykh rozhei s soputstvuiushchim sakharnym diabetom.

Parameters characterizing chemiluminescence (spontaneous and hydrogen peroxide-induced) and state of lipid peroxidation were studied in 58 patients with erysipelas without diabetes mellitus (group I) and 46 patients with clinically manifest decompensated DM, predominantly type II one (group II), to get more specific information about their role in the pathogenesis of erysipelas presenting with concurrent DM. Group II patients showed more significant increase in measures of lipid peroxidation and degree of chemiluminescence, that did not reverse by the time a patient was discharged from the hospital, which fact is to be considered in instituting therapeutic and rehabilitative measures in those patients with erysipelas concurrent with DM.

[The pathogenetic characteristics and treatment of erysipelas in diabetics]. / Osobennosti patogeneza i lechenie rozhi u bol'nykh sakharnym diabetom.

Pathogenetic role was studied of lipid peroxidation (LPO) in 65 patients with erysipelas with concurrent diabetes mellitus (DM) versus a group of 86 patients without DM. In the former case, significant increase in blood plasma hydroperoxides, such as malonic dialdegide and dienic conjugates, was recordable, which fact suggested activation of LPO processes. Positive correlation was established between blood content of hydroperoxides and levels of circulating immune complexes. A complex of drugs endowed with known antioxidant, anti-inflammatory and immunocorrective activity were found to have a beneficial effect on clinical, immune and biochemical indices.

[Chemiluminescent reaction of leukocytes stimulated with different agents in patients with erysipelas]. / Khemiliuminestsentnyi otvet leikotsitov krovi bol'nykh rozhei pri ispol'zovanii razlichnykh stimuliatorov.

Forty-three patients with erysipelas and 10 donors were examined using chemiluminescent analysis in the presence of latex and staphylococcal reagent containing protein A. Staphylococcal protein A proved to be a more potent activator of oxygen metabolites than latex. Heterogeneity of chemiluminescent response of leukocytes stimulated by different agents makes it possible to assess the functional reserve of neutrophils and differentiate between the hyper-, normo-, and hyporeactive forms of erysipelas.