[Diagnosis and therapy of erysipelas: A position paper of the Society Initiative Chronische Wunde (ICW) e. V.] / Diagnostik und Therapie des Erysipels: Ein Positionspapier der Initiative Chronische Wunden (ICW) e. V.

Erysipelas is a bacterial soft tissue infection caused by ß-haemolytic streptococci that spreads proximally along the lymphatic system of the skin. The entry sites of the pathogens can be minor injuries or chronic wounds. The diagnosis of erysipelas is made clinically by the spreading eythema and overheating of the skin, the reduced general condition with fever and chills as well as by means of serological inflammation parameters and must be distinguished from numerous differential diagnoses.Systemic therapy is carried out with penicillin usually. In local therapy, the value of measures such as compression therapy or cooling is currently still controversial. Long-term therapy of the lymphoedema and the consistent avoidance and treatment of entry sites are essential, especially for the prevention of recurrence.

Unsuspected Stewart-Treves syndrome clinically mimicked by apparent bullous erysipelas and a systematic review of dermatological presentations of the classical Stewart-Treves syndrome.

BACKGROUND: Stewart Treves-Syndrome (STS) was first characterized as angiosarcoma in the homolateral limb of a patient with breast cancer and lymphedema. Now, other conditions represent STS. It's a rare condition. The diagnosis is easier in the presence of single or multiple purple nodules. Even though other dermatological aspects have been reported, no study has grouped its characteristics. AIM: Evaluate the dermatological characteristics of classical STS (c-STS). METHODS AND RESULTS: We report a patient with chronic lymphedema with a history of recurrent erysipelas that rapidly developed multiple papules in the superior limb. It was initially diagnosed as bullous erysipelas, but unsatisfactory evolution led to biopsy, which demonstrated an unsuspected epithelioid angiosarcoma. We have also performed a review of dermatologic aspects of c-STS using PubMed and Lilacs databases. PICTOS methodology and PRISMA flow chart were considered. The main dermatological aspects associated with c-CTS were summarized. Using a systematic evaluation from 109 articles, 29 were selected and 44 patients were described to whom we added one case. The mean time with lymphedema was 10 years. Of the patients analyzed, 97.2% were female; 95.6% were submitted to radical mastectomy; 81.2% presented with multiple lesions, 67.4% of the lesions were reported as nodules or tumors, 53.4% were purple, 33.4% were associated with an ecchymotic halo, and 33.4% were ulcerated lesions. CONCLUSION: When evaluating patients with chronic lymphedema with new dermatological abnormalities, clinical suspicion, or unfavorable evolution, the knowledge of clinical signs is important for diagnosis, and a biopsy must be considered. Papules associated with erythematous-wine color and bluish hematoma aspect must raise clinical suspicion.

Management of necrotizing and non-necrotic bacterial erysipelas of the face in tropical areas: a series of four cases and a review of the literature.

The necrotizing and not necrotizing acute bacterial dermohypodermitis (DHD) are acute bacterial infections of tissues situated between the skin and the muscles. The localizations of the face are infrequent, and sometimes put diagnostic difficulties with other current facial dermatosis. We report in this article 4 cases of DHD of the face with skin source, hospitalized in the service of the Infectious and Tropical Diseases of the Teaching Hospital Yalgado Ouédraogo of Ouagadougou (Burkina Faso). The objective is to make a current situation of their etiologies and complications, and to look for the difficulties to take care of them in a country with limited resources. The patient's care journey for this disease is long while it constitutes a medical or medical-surgical emergency. Imaging, which is essential for the diagnosis of heart valve disease and the daunting complications of necrotizing fasciitis and mediastinitis, is generally available only in tertiary hospitals. Antibiotic therapy is most often inadequate or insufficient. Anti-inflammatories, widely used, according to several authors contribute to serious forms and excess mortality. Health workers in resource-limited settings need to be better educated and guidelines issued to recognize the signs of this condition in order to enable early referral of patients in specialized settings. In addition, education of the population and hygiene awareness of skin lesions should be a priority to reduce complications.

Cutaneous hemophagocytosis: Clinicopathologic features of 21 cases.

BACKGROUND: Hemophagocytosis is well known in cytotoxic cutaneous T-cell lymphomas (CTCLs), in which it may represent a sign of hemophagocytic lymphohistiocytosis syndrome (HLHS), and is also typical of cutaneous Rosai-Dorfman disease (cRDD) (without prognostic relevance). Only rarely, has cutaneous hemophagocytosis (CH) been described in other skin conditions. OBJECTIVE: To characterize the clinicopathologic features of CH in skin biopsy specimens from patients with conditions other than CTCL or cRDD. METHODS: Case series analyzing clinicopathologic features and follow-up data on patients presenting with histopathologic signs of CH. RESULTS: Biopsy specimens from 21 patients were included. None of the patients had HLHS. The majority (n = 11) presented with leukocytoclastic vasculitis. Other associated diseases were lupus erythematous (n = 2), arthropod bite reaction (n = 2), erysipelas (n = 1), acne conglobata (n = 1), and Sweet syndrome (n = 1). Three patients had a nonspecific rash concomitant with Chlamydia pneumonia, middle ear infection, and pharyngitis, respectively. LIMITATIONS: This was a single-center, retrospective study. CONCLUSION: Isolated CH in conditions other than CTCL and cRDD is a histopathologic finding related mostly to leukocytoclastic vasculitis. Extensive investigations should be performed only if patients have other signs or symptoms of HLHS.

Risk factors associated with local complications of erysipelas: a retrospective study of 152 cases.

Erysipelas is a common skin infection. Hemorrhagic, bullous, abcessing and necrotic lesions are the major local complications. However, their occurrence factors are not clearly known. The aim of this study is to identify the risk factors associated with the occurrence of local complications of Erysipelas. Medical records from all patients hospitalized with local complications of erysipelas admitted to the Military Hospital of Rabat between 2005 and 2015, were retrospectively studied. Using an univariate and multivariate statistical study, the main characteristics were compared with those from patients with erysipelas without local complications. In total, 152 patients were analysed, of whom 72 had local disease complications. Using univariate analysis, the factors significantly associated with disease complications were found to be: age ≤ 50 years, female gender, heart disease, smoking, taking antibiotics or non-steroid anti-inflammatory drug before hospitalization, and accelerated sedimentation rate. However, in multivariate analysis, taking antibiotics before hospitalization (OR 5.15, 95% CI 1.28 to 20.72, P = 0.01) and accelerated sedimentation rate (OR 5, 15, 95% CI 1.00 to 1.06, P = 0.001) were the only independent factors associated with complicated erysipelas. Our study showed that prior antibiotics taking and higher sedimentation rate are independent risk factors for local complications of erysipelas. Patients with these characteristics should be carefully evaluated and monitored.

[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.

Distinction between forensic evidence and dermatological findings.

The external examination after death requires knowledge in forensics/pathology, dermatology, as well as associated diseases and age-related alterations of the skin. This article highlights some findings with forensic evidence versus dermatological findings. The lectures in forensic medicine should be structured interdisciplinarily, especially to dermatology, internal medicine, surgery, pathology, and toxicology in order to train the overlapping skills required for external and internal postmortem examinations.

[The potential of general magnetic therapy for the rehabilitation of the patients presenting with hemorrhagic forms of erysipelas].

The objective of the present study was to evaluate the possibility and effectiveness of the application of general magnetic therapy for the combined treatment and rehabilitation of the patients presenting with hemorrhagic forms of erysipelas. A total of 102 patients were examined and treated; they were divided into two (control and study) groups matched for age and the main clinical manifestations of the disease. All the patients were given basal therapy, those in the study group were additionally treated using general magnetic therapy. It was shown that the inclusion of this procedure in the combined treatment of hemorrhagic forms of erysipelas promoted rapid and well-apparent elimination of the local inflammatory process, reduced oedema of the affected extremity, improved tissue trophicity, and stimulated microcirculation.

HMGB1 in severe soft tissue infections caused by Streptococcus pyogenes.

Extracellular High Mobility Group Box 1 (HMGB1) has been associated with acute and chronic inflammatory conditions. However, little is known about HMGB1 in necrotizing bacterial infections. We hypothesized that the local HMGB1 response is excessive in severe soft tissue infections (STIs), which are characterized by necrosis and hyperinflammation. To explore this, tissue biopsies were collected from patients with varying severity of Streptococcus pyogenes skin and STIs, including erysipelas, cellulitis, and necrotizing fasciitis. Tissue sections were immunostained for HMGB1, S. pyogenes, and inflammatory cell infiltrates and results quantified by acquired computerized image analysis (ACIA). HMGB1 expression increased in parallel to disease severity and was significantly higher in necrotizing fasciitis than in erysipelas (p = 0.0023). Confocal microscopy of sections co-stained for HMGB1 and cell markers revealed both extracellular and cytoplasmic HMGB1, the latter of which was found predominantly in macrophages. To further verify macrophages as main source of activation triggered HMGB1 release, human macrophages were infected with clinical S. pyogenes isolates. The results demonstrated infection triggered release of HMGB1. Dual staining's visualized HMGB1 in areas close to, but not overlapping, with neutrophils, indicating a potential chemotactic role. In vitro transmigration experiments showed a chemotactic effect of HMGB1 on neutrophils. The data furthermore provided in vivo support that HGMB1 may form immunostimulatory complexes with IL-1ß. Taken together, the findings provide the first in vivo evidence that HMGB1 is abundant at the local site of severe bacterial STIs and its levels correlated to severity of infections; hence, indicating its potential value as a biomarker for tissue pathology.

Prevalence of Met-203 type spaA variant in Erysipelothrix rhusiopathiae isolates and the efficacy of swine erysipelas vaccines in Japan.

Since 2009, erysipelas infection among pigs in Japan has been increasing. This study investigated the prevalence, and characteristics of Erysipelothrix rhusiopathiae isolates in Japan from 2008 to 2010 and assessed the efficacy of current commercial erysipelas vaccines. Based on polymorphisms in a 432-bp hypervariable region in the surface protective antigen A (spaA) gene, 34 isolates were classified into three groups: (i) Group 1 with methionine at position 203 (Met-203) and isoleucine at position 257 (Ile-257) (18 isolates of serotype 1a and one untypable isolate). (ii) Group 2 with Ile-257 (12 isolates of serotypes 1a, 1b, 2, 10 and 11), and (iii) Group 3 with alanine at position 195 (Ala-195) and Ile-257 (three isolates of serotype 1a). Isolates with Met-203 were highly pathogenic in mice and pigs, causing death in the pig and LD50 values of 0.45-1.45 CFU per mouse. One live and three inactivated commercial E. rhusiopathiae vaccines were evaluated for efficacy against a Met-203 isolate. Almost all mice and pigs that received vaccine survived, while non-vaccinated controls all died within 5 days of the challenge. This indicates that swine erysipelas vaccines might be still effective in protecting animals against the recently prevalent Met-203 isolates in Japan.

Febrile ulceronecrotic Mucha-Habermann disease.

The Mucha-Habermann disease is an inflammatory disease of the skin and is a variant of pityriasis lichenoides et varioliformis acuta. We describe the case of a 64-years-old woman who was admitted for erysipelas of the face. Despite treatment, evolution was marked by the appearance of a necrotising ulcerative area in the centre of the erysipelas associated with local oedema and headache. A skin biopsy revealed a pityriasis lichenoides et varioliformis acuta. Corticosteroids led to a rapid stabilisation of lesions, and after 6 months the patient shows only a small area of frontal hypopigmentation. The aetiology remains uncertain. There is no established standard treatment. We would like to draw attention of the medical and surgical specialists to this rare disease. The diagnosis should be considered in a necrotic lesion associated with rapid expansion of systemic and peripheral cutaneous signs. Diagnosis must be considered to avoid unnecessary debridement and extensive scars.

Erysipelas-like erythema of familial Mediterranean fever syndrome: a case report with emphasis on histopathologic diagnostic clues.

We report histopathological findings in a case of familial Mediterranean fever (FMF) syndrome with an erysipelas-like erythema (ELE). ELE is the only pathognomic cutaneous manifestation of FMF. ELE is characterized by well-demarcated, tender, erythematous and infiltrated plaques recurring on the same site and resolving spontaneously within 48-72 h. FMF is a monogenic autoinflammatory syndrome highlighted by recurrent fever associated with polyserositis involving mainly the peritoneum, synovium and pleura. FMF results from a mutation of the MEFV gene, which encodes for pyrin, leading to Il-1ß activation and promoting neutrophil migration into the dermis. Histopathological findings in our case showed a sparse superficial perivascular and interstitial lymphocytic infiltrate admixed with some neutrophils, no eosinophils and mild papillary dermal edema. Venules and lymphatics were dilated, though no vasculitis was identified. Neutrophils are the most common cutaneous marker of autoinflammation, and cutaneous manifestations of monogenic autoinflammatory syndromes are represented by the spectrum of aseptic neutrophilic dermatoses. Neutrophils in the presence of recurrent fever and in the correct clinical context of recurrent erysipelas in the same site are a diagnostic clue for FMF.

Erysipelas of the thigh and the gluteal region: retrospective multicenter analysis of a very rare entity in 39 patients.

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.

Three family members with familial Mediterranean fever carrying the M694V mutation showed different clinical presentations.

Familial Mediterranean fever (FMF) is an inherited disease characterized by recurrent episodes of fever and serositis. FMF is caused by mutations in the MEFV gene that encodes pyrin/marenostrin. The 5 most frequent mutations are M694V, M694I, V726A, M680I and E148Q. Here, we reported 3 FMF patients, a sister and two brothers, who have the same M694V mutation with different clinical presentations. While the sister presented with abdominal pain, one of the brothers presented with erysipelas-like erythema and the other brother with bilateral sacroiliitis. Here, we report the different clinical courses of FMF in a family carrying the same M694V mutation.