The theme of the lesson:

ERYSIPELAS

The causative agent: ß-hemolytic streptococcus of group А.

The source of the infection: patients with streptococcosis (exogenous

infection); quite often erysipelas occurs as an endogenous infection. Patients
with erysipelas are dangerous to those around them not more than patients with
other streptococcal infections; a direct contagion practically doesn’t happen. An
obligatory condition for beginning of the disease is predisposition to erysipelas
(often – inherited), sensitization of skin by antigens of streptococcus.

Pathogenesis:
Development of local inflammation is promoted by previous sensitization
to hemolytic streptococcus, a decrease in activity of nonspecific immunity
factors (a decrease of complement titer, properdin, lysozyme, bactericidal
properties of blood and bactericidal function of skin), abnormalities in
phagocytosis indices in patients with recurrent erysipelas.
Development of a serous or serohemorrhagic allergic inflammation in
derma and to a lesser degree – in other layers of skin is typical of erysipelas.
It is considered that in case of noncomplicated erysipelas streptococci are
in lymphatic vessels of skin, mainly around the periphery of the inflammatory
nidus, penetrating into blood only during a severe course of the disease, its
complications.
Derangement of vascular permeability is significant for development of
local changes. The permeability changes by phases, i.e. during the high point of
the disease there are serious disorders of microcirculation in the direction “blood
– tissue”. During the recovery period – there is a retarding resorption of the
inflammatory nidus, it can cause formation of a persistent edema. During the
high point of the disease immune state also changes: level of Т-lymphocytes
decreases, an imbalance of subpopulations of Т-cells and a decrease in rate “Т-
helpers: Т-suppressors” are observed, level of immune components (CIC) and
JgM increases, level of JgА decreases.
Thus, disturbances of skin clearance and microcirculation, associated with
an allergic change of the organism and influence of an infectious-toxic factor,
are important components in pathogenesis of erysipelatous inflammation.
Interpretation of pathogenesis of recurrent erysipelas is not single. Many
authors think, that recurrences of erysipelas – are results of an imperfect
microbial sanation of the organism, creating prerequisites for formation of a
latent nidus of the infection. Formation of L-forms of streptococcus and a long-
term persistence of streptococcic antigen in a free state and in immune
complexes are very important for chronicity.
 2

Clinical presentation
The incubation period – is from several hours to 5 days. The onset is acute
– chill, headache and muscle pains, temperature rises to 39-400С. In 12 – 24
hours local occurances appear: skin burning, hyperemia and edema of the
affected area. The most frequent localization – lower extremities, face, more
seldom – upper extremities. Skin hyperemia is intence, with well-defined
scalloped borders (the shape is similar to a geographical map). The affected area
is slightly eminent over a healthy skin.
According to the classification there are the following forms:
- erythematous (there is only hyperemia on the skin);
- erythematous-bullous (against a background of hyperemia as a result of
exfoliation of epidermis bubbles- bullae appear);
- erythematous-hemorrhagic (against a background of hyperemia punctated or
extensive hemorrhages are observed);
- bullous-hemorrhagic (combination of hyperemia, hemorrhages and bullous
elements).
Depending on a time of the appearance erysipelas is considered primary
(for the first time on life), recurrent (at the previous site, at an interval not more
than 2 years), repeated (at another site or the previous one, but in more than 2
years), secondary (occurs around the previous suppurative focus, for example,
around an exit hole of fistula).
In case of primary erysipelas intoxication (temperature rise) foregoes
appearance of local changes. In case of recurrent or repeated erysipelas local
occurances appear concurrently with temperature rise or rather earlier, especially
– reaction of regional lymph nodes.
Lymphatic and venous stasis (edema of extremities, thrombophlebitis),
open wounds, callosities, mycotic lesions of skin and nails, presence of niduses
of streptococcosis, pancreatic diabetes promote appearance and recidivation of
the disease (and a certain localization).

Complications: phlegmons, abscesses, thrombophlebitises, lymphostasis,

secondary pneumonia, sepsis.

Laboratory diagnostics: clinical investigations (in common blood test –

there is neutrophilic leukocytosis with stab shift, acceleration of ESR).

Treatment: (doses, regimens) benzylpenicillin, semisynthetic penicillins,

macrolide antibiotics, cephalosporins in therapeutic doses.
Treatment of patients with erysipelas includes two sequential stages:
An arresting of an acute process and elimination of factors, promoting a
repeated disease or chronicity. An acute process is arrested by usage of
 3

etiotropic drugs. Penicillin is prescribed in a daily dose 3-6 million units for up
to 7-10 days. In severe cases the dose can be exceeded.
The preparation is the most effective for treatment of primary, repeated or
late-recurrent forms of the disease.
Often penicillin treatment of recurrent erysipelas is ineffective. In such
cases it is advisable to use broad spectrum antibiotics, reserve antibiotics.
For treatment of patients having primary or repeated erysipelas besides
penicillin it is possible to use oxacillinum, in a daily dose equal to 3 g.
Oxacillinum is also indicated in case of frequent recurrent erysipelas, but the
dose is larger (4-6 g per day during not less than 7 days). During recurrent
erysipelas tetracycline is more effective than penicillin, but if the dose is not less
than 1.2-1.6 g per day during 7 days. In this dose tetracycline also affects
streptococci situated intracellularly. Besides, tetracycline better than other
antibiotics penetrates into lymph, subcutaneous fat in case of elephantiasis, as a
result it is indicated in cases of erysipelas, proceeding in combination with
serious disorders of lymphokinesia.
In case of frequent recurrent erysipelas two-course antibiotic therapy is
pathogenetically reasonable. It is expedient to carry out the first course of the
treatment with reserve antibiotics (ceporin, lincomycin) during 8-10 days. The
second course can be carried out with oletetrinum, semisynthetic tetracyclines
(methacyclinum, rondomycin) or macrolides, the length of the course is 6-7
days. In a number of cases as the second course it is possible to use bicillin-5,
once, intramuscularly, the dose is 1500 000 U – especially, if the first course
was realized with a high-performance antibiotic (ceporin).
On an outpatient basis for treatment of erysipelas it is expedient to use
antibiotic tablets, as well as oletetrinum in a daily dose 1-1.25 g, methacyclinum
(rondomycin) in a daily dose 0.6-0.9 g, doxycycline (vibramycin) in a daily dose
during the first day 0.2 g, 0.1 g during the next days. The course of the treatment
is 7-10 days. It is possible to use local applications of 50 % solution of
dimexidum with penicillin, dimedrolum, novocaine, prednisolone на очагах
воспаления during 5-6 days. They are most efficacious in case of erythematous
form of erysipelas.
Compound drugs, containing sulfanilamides and derivatives of
diaminopyrimidine (biseptol) are used especially in cases of antibiotic
intolerance. Their usage is possible also for out-patient treatment of people with
erysipelas. The duration of treatment with preparations of this group is 7-12
days.
Of nitrofurans it is reasonable to prescribe furazolidonum, which besides
antibacterial action has a property to stimulate phagocytosis. The daily dose is
0.3-0.4 g; the course is 6-8 days. Its effectiveness is not higher than antibiotics
have, therefore it is more expedient to use it in case of a patient’s intolerance to
antibiotics. Chingamin (delagil) can also be referred to chemotherapeutical
drugs for treatment of erysipelas. Its daily dose 0.5 (0.2 g 2 times) during 10
 4

days has a therapeutic effect. Positive results of the treatment are conditioned by
its antimicrobic, immunomodulatory and nonspecific anti-inflammatory actions.
Pathogenetic therapy is aimed at disintoxication, a decrease of vascular
permeability (ascorbic acid), normalization of microcirculation and rheological
properties of blood (trental). Local treatment is required only in case of bullous
form of erysipelas: a moderate tanning action with use of weak solutions of
manganous acid potassium, brilliant green (1-2-times repeated treatment), in
case of a spontaneous rupture of bullae – bandages/ irrigations of the wound
with furacillin or dioxydinum. Hot bandages (with Vishnevsky ointment and
others), physiotherapeutic procedures (including UVI) during augmenting and
high point of clinical manifestations are contraindicated. If bullae suppurate they
are opened and treated as suppurating wounds. If there is only serous fluid in
bullae their drain is necessary seldom, only if there is a great tension of the
surface of a big “blister” (undercutting of the edge, evacuation of exudate,
application of napkin with furacillin).

Hospitalization – is performed by clinical indications. Sanation of niduses

of streptococcosis and mycotic infection is carried out.

Prophylaxis of recurrences of erysipelas is realized with a monthly use of

bicillin-5 by 1.5 million Units or retarpen by 2.4 million Units during 3-6
months. If seasonality of the recurrences is evident it is recommended to start
usage of these preparations a months before the season and continue it 1-2
months after termination of the period of a probable recurrence. In case of
frequent relapses of erysipelas bicillinoprophylaxis is performed uninterruptedly
during 1-3 years.

CONDUCTION OF THE LESSON

The purpose – is to study how to diagnose erysipelas according to clinical

data, anamnesis (presence of predisposing diseases), as well as to plan
therapeutic and prophylactic measures.

Control questions at the beginning of the lesson:

1. Name causative agents of erysipelas.
2. Enumerate factors, predisposing to falling ill with erysipelas.
3. Which changes happen in derma in case of erysipelas?
4. Enumerate basic symptoms of erysipelas.
5. Name clinical forms of erysipelas.
6. Enumerate basic antibacterial preparations for treatment of erysipelas.
7. Peculiarities of therapy of recurrent erysipelas.
8. Enumerate preparations for local treatment of erysipelas.
 5

9. Enumerate therapeutic measures aimed at treatment of lymphostasis in

case of erysipelas.
10. Enumerate anti-recurrent measures in case of erysipelas.

To discuss the topic of the lesson a student manages a patient, makes a

brief report about the patient's history. It is necessary to find out the following
data about the patient:
Surname, name, patronymic name; age, place of work and residence (city,
village), date of the falling ill;
Complaints at present time;
The first symptoms of the disease: temperature rise (to which level, for
how many days), intoxication, onset of burning, skin hyperemia, hemorrhages,
vesicles. It is necessary to pay attention to the presence of predisposing diseases,
sensitization factors, an immediate cause of the disease or relapse of change in
skin color, an appearance of eruption.
Which derangements of health bothered the patient? Did the patient notice
a decrease in volume of excreted urine?
When and how (hypothetically) did the contamination of the patient
happen? It is necessary to find out the epidemiological anamnesis: sanitary
living and feeding conditions, presence of rodents at home, trips to the
countryside. What is the duration of the incubation period?
Objective data of the patient’s examination: state, color of skin, presence
of dryness or edema of skin and mucous membranes, appearance of skin rash.
Condition of the cardio-vascular (tachycardia, arrhythmia; pulse rate, arterial
pressure rate when it was measured by a doctor last time) and respiratory
systems. Condition of the gastrointestinal tract (presence of erosions,
hemorrhages, enteroparesis – during examination, palpation, on the basis of
indirect signs). A special attention should be paid to condition of the urinary
system: diuresis, color of urine, tenderness during tapping in the lumbar region –
it is necessary to test this symptom very carefully!
Case histories of the patients with erysipelas are discussed in groups. The
students together plan the examination of the patients. The teacher introduces
the students to the results of the laboratory examinations. On the basis of all
available data the students make out a diagnosis indicating severity of the
disease. The treatment is discussed. The students together plan the treatment of
the patients, discus them with the teacher. Making out this plan it is necessary to
take into consideration severity of the disease, condition of renal and hepatic
functions, urinary output during a day – depending on it, to determine the
volume of the introduced fluid.
At the end of the lesson the students do clinical tasks and answer the
questions to them. Accomplishing the tasks the students write in their copy-
books:
 6

clinical diagnosis (taking into consideration the form and severity of the
disease);
plan of patient’s examination;
they write out in Latin preparations having antibacterial and pathogenetic
actions.

TASK №1.
A male patient S., aged 35, was admitted to a clinic, having complaints
about chill, headache, twice repeated vomiting, reddening of the left crus. He fell
ill acutely – 2 days ago, when temperature rose to 380, the patient had headache,
loss of appetite, pain in muscles, burning on the anterior surface of the left crus.
The condition became worse: temperature was 39.50, headache intensified,
weakness, edema, hyperemia in the middle one-third of the left crus with clear
borders appeared; the patient took aspirin, analgin tablets. On the 3d day of the
disease the area of the hyperemia on the left crus increased, vesicles with serous
contents appeared, temperature was – 39-400, there was a twice repeated
vomiting at the peak of headache. The patient was taken by an ambulance car
into infectious diseases department.
Objective data: the patient's condition is mild, he is flaccid, adynamic, the
temperature – is 39.70, the pulse is 120 beats/min, ABP – is 100/60 mm of
mercury column, on the left crus there is hyperemia with clear borders on the
anterolateral and posterior surfaces; vesicles, inguinal lymph nodes at the left are
palpated. There are no peculiarities in the lungs.
QUESTIONS:
1. Formulate a diagnosis.
2. With which disease it should be differentiated?
3.Make up plan of the examination and treatment.

TASK №2.
A female patient N., aged 58, was brought to a clinic on the 5th day of the
disease. She had complaints about fever, headache, chest pains.
Case report: she fell ill 5 days ago acutely. When the temperature rose,
burning and redness on skin of the left part of the chest appeared, the patient call
called the district doctor. Out-patient treatment was prescribed: oxacillinum,
dimedrol, calcium gluconate, abundant drinking. There still was fever,
cutaneous edema and hyperemia increased; isolated hemorrhages in the area of
the hyperemia appeared.
Epidemiological anamnesis: 8 months ago the patient was operated for
cancer of the left mammary gland, chemotherapy was received. General
condition is mild, skin is of a normal color, the pulse is 110 beats/min, rhythmic,
ABP – is 150/100 mm of mercury column, on skin of the trunk in the area of the
left half of the chest there is a postoperative scar, there are edemas of the
 7

hyperemia with clear borders, hemorrhages; the left shoulder and forearm are
edematic.

QUESTIONS:
1. Formulate a clinical diagnosis.
2. Plan the examination and treatment.

TASK № 3.
A female patient N., aged 45, a worker, was admitted to a hospital on 10
August during the second day of the disease. She had complaints about
weakness, headache, pain and burning in the area of the cheeks.
The case report: on 9 August in the middle of the day the patient ailed, in
the evening the patient felt worse, chill appeared, temperature rose to 380, she
slept badly. In the morning on 10 August there was weakness, malaise,
headache, chill, the temperature was 38.50. Pain, burning and redness in the area
of the right cheek appeared. She asked for medical help of the district
therapeutist.
Epidemiological anamnesis: 5 years ago the patient had face erysipelas. 3
days ago on the tip of the nose there was a small pustule; she extruded it,
anointed the skin with tincture of iodine.
Objective data: general condition is mild, the temperature – is 38.50, skin
is of a normal color; the tongue is furred with a white coating, wet. The pulse –
is 105 beats/min, rhythmic, of a satisfactory tension. ABP – is 120/70. the
abdomen is soft, painless, the liver and spleen are not palpated.
On the both cheeks and in the area of the nasal bridge there is hyperemia
and cutaneous edema with clear uneven contours. Palpation of the affected area
is painful. The edema involves the inferior eyelids; the right palpebral fissure is
narrowed.

QUESTIONS:
1. Formulate a clinical diagnosis.
2. Therapeutic approach.
3. Plan of the treatment and examination.