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Patient Case: Erysipelas

Patient Case: Erysipelas

Discussion

A 55-year-old woman presents to the emergency department with a two-day history of painful, red, and swollen skin on her right lower leg. She reports that the redness started suddenly, has been rapidly spreading, and is accompanied by fever, chills, and fatigue. She denies any trauma but recalls a small scratch on her shin a few days ago while gardening.

Her past medical history includes type 2 diabetes and chronic venous insufficiency. On examination, the right lower leg is intensely red, swollen, warm, and tender, with a well-defined, raised border separating the affected area from the normal skin. No pus or abscess formation is noted. The patient has a fever of 38.5°C (101.3°F) and mild tachycardia.

A clinical diagnosis of erysipelas is made, likely caused by Streptococcus pyogenes. The patient is started on intravenous antibiotics (penicillin or cefazolin) due to the extent of the infection and her risk factors. She is advised to elevate the leg, keep the skin moisturized, and monitor for worsening symptoms. Given her diabetes and venous insufficiency, she is educated on proper foot and leg care to prevent recurrent infections.

Questions
1. What is the most likely diagnosis in this patient?

a) Erysipelas
b) Cellulitis
c) Contact dermatitis
d) Deep vein thrombosis (DVT)

2. What is the most common causative organism of erysipelas?

a) Streptococcus pyogenes
b) Staphylococcus aureus
c) Pseudomonas aeruginosa
d) Candida albicans

3. Which clinical feature best distinguishes erysipelas from cellulitis?

a) Presence of abscess formation
b) Well-defined, raised borders
c) Purulent drainage from the affected area
d) Chronic skin discoloration

4. What is the most appropriate treatment for this patient?

a) Intravenous or oral antibiotics (penicillin or cefazolin)
b) Topical steroids and antihistamines
c) Antifungal therapy
d) Surgical excision of the affected skin

Reveal answers

Answers

  1. (a) Erysipelas
    • The patient presents with sudden-onset, well-demarcated, red, swollen, warm, and painful skin, which is characteristic of erysipelas. Cellulitis (b) is a deeper infection but lacks the well-defined, raised border. Contact dermatitis (c) is typically pruritic and not associated with fever. DVT (d) can cause swelling and warmth but does not cause redness with a sharp demarcation.
  2. (a) Streptococcus pyogenes
    • Streptococcus pyogenes (Group A Streptococcus) is the most common cause of erysipelas. Staphylococcus aureus (b) is more commonly associated with cellulitis and abscesses. Pseudomonas aeruginosa (c) is seen in moist environments and immunocompromised patients. Candida albicans (d) is a fungal pathogen, not a typical cause of bacterial skin infections.
  3. (b) Well-defined, raised borders
    • A sharp, raised margin distinguishes erysipelas from cellulitis, which has more diffuse, ill-defined borders. Abscess formation (a) and purulent drainage (c) suggest Staphylococcus aureus infections, not erysipelas. Chronic skin discoloration (d) is seen in venous insufficiency, not acute bacterial infections.
  4. (a) Intravenous or oral antibiotics (penicillin or cefazolin)
    • Penicillin or first-generation cephalosporins are the first-line treatment for erysipelas. Topical steroids and antihistamines (b) are used for allergic reactions, not bacterial infections. Antifungal therapy (c) is not indicated since this is a bacterial infection. Surgical excision (d) is unnecessary unless there is tissue necrosis or complications.

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