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Case Note

Case Note: Erythema and Swelling

History

A 40-year-old woman with rapid onset of erythema and swelling of the left ear. She is febrile, feels unwell, and has no history of trauma to the ear. No topical medications or cosmetics have been applied to the ear.

Initial evaluation

  • Systemically ill-appearing, febrile
  • Bright erythema and marked edema of the left ear, extending from the pinna onto the helical rim

         
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Enter your diagnosis

Diagnosis

  • A diagnosis of erysipelas cellulitis is rendered
  • Blood work reveals a leukocytosis, elevated erythrocyte sedimentation rate

Initial Treatment

  • Admitted to hospital for intravenous antibiotics (penicillin G)

The general treatment strategy for erysipelas cellulitis is provided below.


First-line treatment:

In all cases, the therapeutic strategy is to eliminate the pathogenic microorganism using an effective antimicrobial agent. Penicillin antibiotics remain first-line for erysipelas. There is sparse evidence supporting the use of particular antibiotic classes for cellulitis; limited data suggests that macrolide antibiotics may be more effective than penicillin antibiotics for cellulitis. There is similarly limited data to support the use of intravenous antibiotics over the use of oral antibiotics; in fact, there are small studies demonstrating that oral therapies may be in some cases more effective than intravenous treatment. Early data may also support the use of prophylactic antimicrobial therapy following an episode of leg cellulitis in patients who are high risk of recurrence.

Patients with systemic symptoms, significant neutrophilia, diabetes mellitus, immunosuppression, neutropenia, erysipelas of the face, associated with decubitus ulcers, or cellulitis on dependent extremities should be hospitalized and parenteral therapy is recommended.

Follow-up evaluation strategy

  • The following day, patient feeling better
  • Significant reduction in erythema and edema of the left ear
  • Fever resolved
  • Discharge with 10-day course of oral amoxicillin
  • Follow up in 10 days in outpatient clinic (resolved)

General discussion

Erysipelas and cellulitis are infections of the dermis and subcutaneous layers of the skin that are rapidly progressive and are often accompanied by systemic signs, such as fever, leukocytosis, and elevated markers of systemic inflammation.


The clinical presentation of erysipelas and cellulitis are similar, presenting with unilateral erythema, edema, warmth, and tenderness.

  • Erysipelas affects the lower extremities (76% of cases) but commonly has facial involvement (17%), is sharply demarcated, typically involves more superficial lymphatics within the dermis to give a waxy or intensely superficial edematous appearance.
  • Cellulitis commonly affects the lower extremities, typically affects one limb, and may result from an underlying abscess or trauma.

There is an important non-infectious differential diagnosis of cellulitis, including contact dermatitis, venous stasis dermatitis, deep vein thrombosis, and vasculitis. Venous stasis dermatitis is commonly bilateral, and is not accompanied by signs of systemic inflammation. Most cases of cellulitis are caused by streptococci. Staphylococcus aureus is an important consideration in cases of cellulitis associated with trauma or an underlying abscess.


Both erysipelas and cellulitis require systemic antibiotic therapy. Although initial therapy is dictated by the likelihood that the causative organisms are streptococci or, less likely, S. aureus, in immunocompromised individuals, many other organisms may be responsible. More serious soft tissue infections, such as early necrotizing fasciitis, may resemble cellulitis.

Further reading

Bailey E and Kroshinsky D. Cellulitis: diagnosis and management. Derm Therapy 2011;24:229-39.

Kilburn SA, et al. Interventions for cellulitis and erysipelas. Cochrane Database of Systematic Reviews 2010;6(10):CD004299.

Krasagakis K, et al. Analysis of epidemiology, clinical features and management of erysipelas. Int J Derm 2010;49:1012-7.

UK Dermatology Clinical Trials Network's PATCH Trial Team. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the U.K. Dermatology Clinical Trials Network's PATCH II trial. BJD 2011. September 2011, e-pub ahead of print.

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