Rosen & Barkin's 5-Minute Emergency Medicine Consult (252 page)

CODES

784.7 Epistaxis

BASICS

• Superficial bacterial infection of the skin with prominent lymphatic involvement
  
• Leukocytosis is common
  
• Positive blood cultures in 3–5%
  

• Group A β-hemolytic streptococcus is the causative organism (uncommonly, group C or G streptococci)
  
• Portals of entry:
  
  • Skin ulcers
    
  • Local trauma
    
  • Abrasions
    
  • Psoriatic or eczematous lesions
    
  • Fungal infections
    

• Haemophilus influenzae
  type b (HIB) causes facial cellulitis in children that may appear similar to erysipelas:
  
  • Should be considered in unimmunized children
    
  • Many will be bacteremic and require admission
    
  • Cefuroxime or other appropriate
    H. influenzae
    coverage is important
    
  • H. influenzae
    is much less common since widespread use of the HIB vaccine
    
• Group B streptococci can cause erysipelas in the newborn
  
• Can develop from infection of umbilical stump
  

• Erythema of the breast in puerperal mastitis is often caused by Staphylococcus organisms, hence methicillin-resistant
  S. aureus
  (MRSA) should be covered
  
  • See Mastitis
    

DIAGNOSIS

• Most common sites of involvement are the face (5–20% of cases), lower legs (70–80% of cases), and ears
  
• Skin has an intense fiery red color, hence the name “Saint Anthony’s fire”
  
• Often bilateral on the face, but unilateral elsewhere
  
• Predilection for infants, children, and the elderly
  
• Systemic symptoms may include malaise, fever, chills, nausea, and vomiting
  
• Traumatic portal of entry on skin is not always apparent
  
• Rarely there may be an associated periorbital cellulitis or cavernous sinus involvement
  

• Facial erysipelas may follow a nasopharyngeal infection or trauma
  
• Predilection for areas of lymphatic obstruction:
  
  • Particularly in the upper extremity following radical mastectomy
    
  • Increased frequency after saphenous vein harvesting or stripping
    
  • May be a marker for previously undiagnosed lymphatic obstruction, or patients with congenital lymphedema (such as Milroy disease)
    
• 30% recurrence rate within 3 yr, owing to lymphatic obstruction caused by an episode of erysipelas
  

• Involved skin is:
  
  • Edematous
    
  • Indurated (peau d’orange)
    
  • Painful
    
  • Well-circumscribed plaque with sharp, clearly demarcated edges
    
• Classical butterfly rash on cheeks and across nose when affecting face
  
• Vesicles and bullae may be present in more serious infections
  

• The diagnosis is clinical:
  
  • Based on the characteristic skin findings and the clinical setting
    
• Needle-aspirate wound cultures are seldom positive and not indicated
  

• Swabs of the skin are not indicated for culture, as they will show only skin organisms
  
• CBC with differential, and blood cultures should be performed in diabetics and other high-risk populations, or in patients with hypotension and those who require admission:
  
  • Blood cultures more likely to be positive in patients with lymphedema
    
• Check glucose in diabetics as infection may disrupt control
  
• Urinalysis: To check for proteinuria, hematuria, and red cell casts
  
  • Would suggest diagnosis of post-streptococcal glomerulonephritis (PSGN)
    
  • If it occurs, usually around 2 wk after onset of skin infection
    
• Antistreptolysin O (ASL-O), anti-DNase B and streptolysin antibody serial titer changes are useful in diagnosing post-streptococcal immunologic entities such as rheumatic fever or glomerulonephritis,
  
  • Do not add anything to the diagnosis and management of uncomplicated erysipelas
    
  • Should not be routinely ordered unless there are already manifestations of such complications
    

• There is no standard imaging for classical erysipelas
  
  • If deeper infection such as myositis is suspected, plain films of an extremity or CT scan may be performed to assess for the presence of gas
    
• Ultrasound may be useful to evaluate for an abscess if this is suspected, or in the leg to r/o deep vein thrombophlebitis DVT
  

• Abscess
  
• Acute bacterial sinusitis
  
• Allergic inflammation
  
• Cellulitis
  
• Contact dermatitis
  
• DVT
  
• Diffuse inflammatory carcinoma of the breast
  
• Familial mediterranean fever
  
• Herpes zoster, second division of cranial nerve V
  
• Impetigo
  
• Inflammatory dermatophytosis
  
• Mastitis
  
• Necrotizing fasciitis
  
• Periorbital cellulitis
  
• Systemic lupus erythematosus (SLE) with butterfly rash
  
• Streptococcal or staphylococcal TSS (sunburn-like rash)
  
• Venous stasis dermatitis
  
• Viral exanthem
  

TREATMENT

Wearing gloves, followed by hand washing when managing patients, to decrease risk of transmission of streptococcal carriage

Patients may be toxic and in need of intravenous fluid resuscitation or pressure support

• Appropriate antibiotic therapy; treatment should be for 10 days:
  
  • Patients with extensive involvement should be admitted for parenteral antibiotic treatment
    
  • May switch to oral antibiotics when patient is stable and showing signs of response
    
• Mild cases: Patients can be discharged on oral therapy if nontoxic appearing, good compliance, and close follow-up can be ensured
  
• Penicillin is the drug of choice when symptoms are consistent with erysipelas
  
• If there is difficulty in distinguishing from cellulitis, staphylococcal coverage should be added:
  
  • Use penicillinase-resistant penicillin or 1st-generation cephalosporin
    
  • If in community with high incidence of MRSA, use vancomycin, or other anti-MRSA coverage
    
  • Reports of vancomycin-resistant Staphylococci are occurring
    
• Acetaminophen for fever
  
• Isolation while in hospital
  
  • Contagious
    

OUTPATIENT

• Penicillin V: 500 mg PO q6h (peds: 25–50 mg/kg/d div. q6–8h) for 10 days.
  
• Amoxicillin: 500 mg PO q8h (peds: 50 mg/kg/d div. TID) for 10 days.
  
• Clindamycin: 300 mg PO QID (peds: 8–25 mg/kg/d suspension PO div. TID or QID) for 10 days.
  
• Dicloxacillin: 500 mg PO q6h (peds: 30–50 mg/kg/d PO div. q6h) for 10 days
  
• Erythromycin: 250–500 mg PO q6h (peds: 40 mg/kg/d PO in div. doses q6h) for 10 days
  
• Cephalexin: 500 mg PO q6h (peds: 40 mg/kg/d PO div. q8h) for 10 days
  
• Cefuroxime: 250–500 mg PO BID (peds: 30 mg/kg/d PO div. q12h) for 10 days.
  

INPATIENT

• Penicillin G: 2 million U q4h IV (peds: 25,000 U/kg IV q6h).
  
• Penicillin G, procaine: 600,000 U q12h IM
  
• Clindamycin: 600 mg q8h IV (peds: 20–40 mg/kg/d IV div. q8h)
  
• Vancomycin: 1 g IV q12h given over 1.5–2 hr to decease risk of red man syndrome (peds: 10–15 mg/kg IV q6h)
  

• Oral or IV: Penicillin or 1st-generation cephalosporin
  
• Clindamycin for penicillin-allergic individuals
  

Oral: Erythromycin

FOLLOW-UP