Rosen & Barkin's 5-Minute Emergency Medicine Consult (253 page)

• Patients with extensive involvement, fever, toxic appearance, or in whom orbital or periorbital cellulitis is suspected
  
• Patients who live alone or are unable or unreliable to take oral medications will require admission for IV antibiotics
  
• Children more often require admission
  
  • Blood cultures
    
  • Intravenous antibiotics, including coverage for
    H. influenzae,
    should be initiated for patients who have not been immunized with HIB vaccine
    

• Minimal facial involvement
  
• Nontoxic appearance
  
• Not immunosuppressed
  
• Able to tolerate and comply with oral therapy
  
• Adequate follow-up and supervision
  
• Diagnosis certain
  

• Refer to nephrologist for evaluation and treatment for PSGN if:
  
  • Hematuria, proteinuria, and red cell casts are noted on UA
    
  • Particularly in children between the ages of 5 and 15
    
• Infectious disease consultation for infection in immunocompromised patients who are at risk for unusual organisms
  

• Use of pressure stocking on leg in the presence of lymphedema may reduce incidence of relapses
  
• Following erysipelas of legs, use of topical antifungal cream or ointment to treat underlying tinea pedis when present
  

• Failure to respond, or pain out of proportion to findings, might suggest deeper level of infection and require further workup to rule out necrotizing fasciitis, or mixed aerobic/anaerobic necrotizing cellulitis
  
• Treatment of underlying lymphedema is associated with reduced incidence of relapses
  
• Presence of micropustules would suggest staphylococcal infection/cellulitis rather than erysipelas, and antibiotic coverage would need to be broader
  
• Presence of crepitus in skin should prompt search for alternate diagnosis
  
• Since infection is likely to have entered skin through traumatic skin break, remember to check for tetanus immunization status and update if necessary
  
• Consider prophylaxis for patients with frequent relapses
  

• Damstra RJ, van Steensel MA, Boomsma JH, et al. Erysipelas as a sign of subclinical primary lymphoedema: A prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg.
  Br J Dermatol
  . 2008;158:1210–1215.
  
• Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas.
  J Infect
  . 2012;64:148–155.
  
• Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas.
  Cochrane Database Syst Rev
  . 2010;(6):CD004299.
  
• Morris A. Cellulitis and erysipelas.
  Clin Evid
  . 2006;(15):2207–2211.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abscess
  
• Cellulitis
  
• MRSA, Community Acquired
  

CODES

035 Erysipelas

BASICS

• Characteristic viral exanthem also known as 5th disease:
  
  • 5th most common childhood rash historically described
    
  • Measles (1st), scarlet fever (2nd), rubella (3rd), Duke disease (4th), roseola (6th)
    
• Common symptoms: Viral prodrome followed by slapped-cheek rash and subsequent diffuse reticular rash +/– arthropathy
  
• Most common in school-aged children <14 yr
  
• Usually self-limited with lasting immunity
  
• Rare complications and chronic cases in patients with congenital anemias or immunosuppression
  
• Potential for severe complications to fetus if infection acquired during pregnancy
  
• Possible link to encephalopathy, epilepsy, meningitis, myocarditis, dilated cardiomyopathy, autoimmune hepatitis, HSP, ITP
  

• Caused by human parvovirus B19, small SS-DNA virus:
  
  • Infects human erythroid progenitor cells, suppressing erythropoiesis
    
• Most common in late winter and spring
  
• Transmitted via respiratory droplets and blood products as well as vertical maternal–fetal transmission
  
• Incubation period 4–21 days
  
• Most contagious during the week PRIOR to rash onset
  
• Majority of adults have serologic evidence of prior infection
  

DIAGNOSIS

• “Slapped-cheek” appearance most common in young children
  
• Fever
  
• Malaise
  
• Delayed symptoms 4–14 days later:
  
  • Diffuse, pruritic, lacy rash (absent in most adults), most pronounced in extremities
    
  • Symmetric polyarthropathy, most common in middle-aged women:
    
    • Small joints involved in adolescents and adults
      
    • Knees most commonly involved in children
      
    • Secondary to immune-complex deposition
      
• However, most patients remain asymptomatic or only develop mild, nonspecific viral symptoms
  

• Mild constitutional symptoms (fever, headache, nasal congestion, nausea, sore throat)
  
• Contagious only until facial rash appears
  

• Stage 1:
  
  • “Slapped-cheek” rash of coalescent, warm, erythematous, edematous papules with circumoral pallor in young children
    
• Stage 2:
  
  • Nonspecific, diffuse, pruritic, maculopapular, reticular eruption
    
  • 4–21 days after facial rash, lasts up to 6 wk
    
  • More prominent on extremities
    
  • Usually spares palms and soles
    
• Stage 3:
  
  • Rash fades but recurs with exposure to sunlight, stress, exercise, and heat
    
• Usually complete resolution without scarring
  

Clinical diagnosis based on characteristic signs and symptoms.

• Usually not necessary
  
• CBC and reticulocyte count if concern for aplastic crisis
  
• Confirm diagnosis if immunocompromised or pregnant:
  
  • Viral DNA PCR now available
    
  • IgM antibody confirms acute infection and persists for 2–3 mo
    
  • IgG presence confers lasting immunity
    
• In pregnancy, ultrasound to detect hydrops fetalis
  

• Allergic reaction
  
• Collagen vascular disease
  
• Coxsackie virus
  
• Drug eruptions
  
• Enterovirus
  
• Erysipelas
  
• Infectious mononucleosis
  
• Measles
  
• Nonspecific viral illness
  
• Rheumatoid arthritis
  
• Roseola
  
• Rubella
  
• Scarlet fever
  
• Sunburn
  

TREATMENT

Erythema infectiosum is usually self-limited and does not require treatment

ABCs for severe cases and septic patients

• ABCs, supplemental oxygen if indicated
  
• IVF with associated severe dehydration
  
• Severe anemia may also cause hypotension and hypoxia, transfuse PRBCs as indicated
  
• Pain control with acetaminophen, NSAIDs, or opiates as needed for severe arthropathy
  

• No specific antiviral treatment or vaccine is available
  
• Send appropriate labs (CBC, reticulocytes, antibody testing) for severe cases
  
• Symptomatic treatment as needed:
  
  • IVF for severe dehydration
    
  • NSAIDs for arthropathy if no underlying renal insufficiency
    
  • Consider diphenhydramine for pruritus, caution parents about possible AMS
    
  • Antipyretics for fever
    
• PRBC transfusion for severe anemia
  
• ID consult: IVIG may have benefit for immunocompromised patients with chronic symptoms and red cell aplasia
  
• Hematology consult for severe cases
  
• Hospitalization and respiratory isolation for aplastic crisis