Differentiating erysipelas from other diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Luke Rusowicz-Orazem, B.S.

## Overview[edit | edit source]

Erysipelas must be differentiated from other inflammatory dermatological conditions that present with pain, erythema, edema, and blisters of the skin, as well as other systemic conditions such as fever, chills, fatigue, headache, and vomiting.

## Differentiating Erysipelas from other Diseases[edit | edit source]

* Erysipelas must be differentiated from other causes of lower limb edema like chronic venous insufficiency, acute deep venous thrombosis, lipedema, myxedema, lymphatic filariasis and causes of generalized edema.

Diseases  | Symptoms  | Signs  | Gold standard Investigation to diagnose

|
|
|

History  | Onset  | Pain  | Fever  | Laterality  | Scrotal swelling  | Symptoms of primary disease
(Cellulitis-erysipelas-skin abscess)  |

* Acute painful swelling
* Fever

| Acute  | \+  | \+  | Unilateral  | \-  | \-  |

* Tenderness, hotness, and may be fluctuation if abscess formed.
* Lymphangitis in nearby lymph nodes.
* Toxemia and fever in severe cases.
* Cellulitis involves the deeper dermis and erysipelas involves the upper dermis.[1]

* Usually it doesn't need any laboratory tests to diagnose.[2]
* Blood cultures are warranted for patients in the following circumstances:[3]

1. Systemic toxicity
2. Extensive skin or soft tissue involvement
3. Underlying comorbidities
4. persistent cellulitis

* In patients with recurrent cellulitis, serologic testing for beta-hemolytic streptococci is a good diagnostic tool.[4]

Lymphatic filariasis |

* History of living in endemic area or travelling to it

| Chronic  | \+  | \+  | Bilateral  | \+  | \-  |

* Hepatomegaly
* Lymphedema
* Elephantiasis
* Lymphangitis
* Hydrocele
* Scrotal elephantiasis
* Lymphadenopathies
* Rhonchi may be present in patients with Pulmonary tropical eosinophilia syndrome.

Preparing blood smears

* Thick smears

1. Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs).
2. Thick smears allow a more efficient detection of parasites (increased sensitivity).

* Thin smears consist of blood spread in a layer such that the thickness decrease.

By the ultrasound, the following findings can be observed:

* Dilated lymphatic channels
* Living worms tend to be in motion which called "filarial dance" sign.

Chronic venous insufficiency |

* History of untreated varicose veins
* Painful bilateral lower limb swelling that increases with standing and decreases by rest and leg elevation.

| Chronic  | \+  | \-  | Bilateral  | \+

(If congenial)

| \-  |

* Typical varicose veins
* Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg
* Reduction of swelling with limb elevation.

* Duplex ultrasound will demonstrate typical findings of venous valvular insufficiency

Acute deep venous thrombosis |

* History of prolonged recumbency
* Classic symptoms of DVT include acute unilateral swelling, pain, and erythema

| Acute  | \+  | \-  | Unilateral  | \-  | May be associated with primary disease mandates recumbency for long duration  |

* Dilated superficial veins
* Difference in calf diameter is twice as likely to have DVT(most impotant sign )[5]
* Calf pain on passive dorsiflexion of the foot (Homan's sign) isn't realiable sign.

* Compression ultrasonography (CUS) with doppler is the diagnostic test of choice
* D-dimer level is used for unprobable cases

Lipedema |

* Family history especially in women; X-linked dominant or autosomal dominant condition.[6]
* Abnormal deposition of fat and edema and easy bruising.

| Chronic  | \+  | \-  | Bilateral  | \-  | \-  |

* Tender with palpation

* Negative Semmer sign to differentiate from lymphedema.[7]
* Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result.
* In a positive result, it is only possible to grasp a lump of tissue.

* MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema [8]

Myxedema |

* History of untreated hypothyroidism.
* Infiltration of the skin with glycosaminoglycans with associated water retention.

| Chronic  | \+  | \-  | Bilateral  | \-  | \+

(hypothyroidism )

* Pretibial myxedema

* Thyroid function tests.

Other causes of generalized edema |

* History of chronic general condition (cardiac-liver-renal)

| Chronic  | \-  | \-  | Bilateral  | \-  | \+  |  |

* According to the primary cause ( Echo- LFTs\- RFT)

* Erysipelas must be differentiated from other inflammatory dermatological conditions that present with pain, erythema, edema, and blisters of the skin, as well as other systemic conditions such as fever, chills, fatigue, headache, and vomiting.[9]

Disease | Findings

|

Cellulitis | Presents with nearly identical symptoms to erysipelas, and is also usually caused by Streptococcus or Staphylococcus bacteria.[10] Differentiated from erysipelas by its manifestation beneath the epidermis in the dermal layer of the skin; infection can spread to the subcutaneous fat, bones, joints, and muscles of the affected area. The area of inflammation is not as sharply visibly demarcated as those characteristic of erysipelas, due to the deeper manifestation in the skin. Can lead to complications with poor prognosis including osteomyelitis, lymphangitis, endocarditis, and meningitis.
Necrotizing fasciitis | Presents with more severe epidermal signs and symptoms than erysipelas. Necrotizing fasciitis patients usually present with erythema, edema, blisters, pain, suppuration, and clear signs of tissue necrosis (dark violet/blue to black in appearance).[11] Left untreated, necrotizing fasciitis usually leads to subcutaneous nerve destruction; a patient communicating more pain than is visibly apparent or manifested on the epidermis is indicative of nerve damage preceding or disproportionate to visible evidence.[12] In addition to antibiotics, immediate therapeutic surgery is required to prevent morbidity from necrotizing fasciitis.
Shingles | Presents with itching, pain, and tingling on a single side of the body or face, which will develop into a rash with blisters. It can also present with fever, chills, headache, and nausea.[13]. Differentiated from erysipelas by its cause (Varicella zoster virus infection) and is usually self-limited; antiviral therapy and analgesics are indicated to shorten the duration and severity of symptoms, which will usually self-resolve within 7-10 days. Recognition and diagnosis of shingles is important to prevent complications, including postherpetic neuralgia.[14]
Angioedema | An edematous condition that involves swelling occurring below the epidermis, including the dermis and mucous membranes.[15] Angioedema usually presents with edema near the eyes and lips, as well as the hands, feet, and throat.[16] Can present similarly to erysipelas if epidermal welts and blisters form in the regions of edema, as well as cause abdominal pain.[17] Differentiated from erysipelas in that the cause is primarily an allergic reaction to a variety of possible allergens, including pollen, food, or medication. While angioedema is usually self-limited and will resolve itself upon the cessation of exposure to the allergen, treatment with antihistamines, epinephrine, or corticosteroids must be administered to prevent life-threatening complications, including asphyxiation if the edema occurs in the throat.[17]
Contact dermatitis | An inflammatory condition of the epidermis resulting from direct contact with an allergen or irritant. Contact dermatitis is similar to erysipelas due to the usual presentation of erythema, blisters, itching, pain, and discharge. Differentiated from erysipelas by its cause: an allergic response by contact to a specific surface or entity. There is no indication of bacterial infection. Common causes include chemicals from cosmetic and hygienic products, fabrics, metals, and animal hair or skin. Therapy involves avoiding the original cause and application of topical or oral corticosteroids and analgesics.[18]
Inflammatory breast cancer | Presents with edema and erythema of the breast, as well as itching, pain, and tenderness from the inflammation.[19] Differentiated from erysipelas by the fact that inflammation is usually limited to the breast. Additional differential criteria include development of "ridges" on the breast, giving the appearance of an orange peel. It is urgent to differentiate and diagnose inflammatory breast cancer to begin immediate chemotherapy, radiation therapy, and/or surgery when indicated.

## References[edit | edit source]

1. ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
3. ↑ Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). "Cellulitis complicating lymphoedema". Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.CS1 maint: Multiple names: authors list (link)
4. ↑ Leppard BJ, Seal DV, Colman G, Hallas G (1985). "The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas". Br J Dermatol. 112 (5): 559–67. PMID 4005155.CS1 maint: Multiple names: authors list (link)
5. ↑ Goodacre S, Sutton AJ, Sampson FC (2005). "Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis". Ann Intern Med. 143 (2): 129–39. PMID 16027455.CS1 maint: Multiple names: authors list (link)  Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56
6. ↑ Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). "Lipedema: an inherited condition". Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.CS1 maint: Multiple names: authors list (link)
8. ↑ Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). "MRI and ultrasonographic findings in the investigation of lymphedema and lipedema". Int Surg. 82 (4): 411–6. PMID 9412843.CS1 maint: Multiple names: authors list (link)
9. ↑ Inghammar M, Rasmussen M, Linder A (2014). "Recurrent erysipelas--risk factors and clinical presentation". BMC Infect. Dis. 14: 270. doi:10.1186/1471-2334-14-270. PMC 4033615. PMID 24884840.
10. ↑ "Cellulitis: MedlinePlus Medical Encyclopedia".
11. ↑ "Necrotizing soft tissue infection: MedlinePlus Medical Encyclopedia".
12. ↑ Sadasivan J, Maroju NK, Balasubramaniam A (2013). "Necrotizing fasciitis". Indian J Plast Surg. 46 (3): 472–8. doi:10.4103/0970-0358.121978. PMC 3897089. PMID 24459334.
13. ↑ "Shingles | Signs and Symptoms | Herpes Zoster | CDC".
14. ↑ Kawai K, Gebremeskel BG, Acosta CJ (2014). "Systematic review of incidence and complications of herpes zoster: towards a global perspective". BMJ Open. 4 (6): e004833. doi:10.1136/bmjopen-2014-004833. PMC 4067812. PMID 24916088.
15. ↑ Misra L, Khurmi N, Trentman TL (2016). "Angioedema: Classification, management and emerging therapies for the perioperative physician". Indian J Anaesth. 60 (8): 534–41. doi:10.4103/0019-5049.187776. PMC 4989802. PMID 27601734.
16. ↑ "Angioedema: MedlinePlus Medical Encyclopedia".
17. ↑ 17.0 17.1 Bork K (2010). "Recurrent angioedema and the threat of asphyxiation". Dtsch Arztebl Int. 107 (23): 408–14. doi:10.3238/arztebl.2010.0408. PMC 2893523. PMID 20589206.
18. ↑ "Contact dermatitis: MedlinePlus Medical Encyclopedia".
19. ↑ "Inflammatory Breast Cancer - National Cancer Institute".

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