Bullous Erysipelas: Clinical Presentation, Staphylococcal Involvement and Methicillin Resistance

Abstract

Background: Erysipelas is a bacterial infection of the dermis and hypodermis, mostly of streptococcal origin. Bullous erysipelas represents a severe form of the disease. Objective: To evaluate the clinical and microbiological characteristics and treatment of bullous erysipelas. Methods: Patients with a diagnosis of bullous erysipelas who were treated at the Department of Dermatology, University Hospital of Heraklion, Crete, Greece, between the years 1996 and 2001 were retrospectively studied. Results: Fourteen patients (11 women, 3 men) with bullous erysipelas were evaluated. The lesions were located on the legs and face in 9 and 4 patients, respectively. The median duration of disease before hospital admission was 4 days. Eight patients had fever at presentation. Local trauma and various lesions were common causes for pathogen entry. The initial empirical antibiotic treatment included intravenous β-lactams and was modified according to the sensitivities of the isolated strains. Staphylococcus aureus was isolated from 7 (50%), while S. warneri, Streptococcus pyogenes and Escherichia coli grew from the lesions of 3 other patients. Six out of 7 S. aureus strains were methicillin resistant (MRSA) but susceptible to several other non-β-lactam antibiotics such as quinolones, vancomycin, rifampicin and trimethoprim/sulfamethoxazole. Conclusion: Our findings suggest that S. aureus is frequently involved in and probably contributes in synergy with β-hemolytic streptococci to the complicated course of bullous erysipelas. The frequency of MRSA isolation suggests that β-lactam antibiotics may not be sufficient for the treatment of bullous erysipelas anymore, at least in areas with a high incidence of MRSA strains. The role of other classes of antibiotics providing adequate coverage for MRSA has to be evaluated in prospective clinical trials.

Epidemiology and Comorbidity of Erysipelas in Primary Care

“…Recently also Staphylococcus aureus has been isolated from lesions from bullous erysipelas and the question is whether this bacterium plays an etiological part or whether it is rather a contaminant [17, 18]. Such an increase may be the result of decreased host immunity or increased virulence of the bacteria.…”

Does Erysipelas-Like Rash after Hip Replacement Exist?

“…We cannot exclude the possibility of allergic reactions to prosthetic material that would mimic erysipelas, but most cases of ‘allergic cellulitis’ probably correspond to misdiagnosed erysipelas, as the clinical and histological features of the two entities are highly comparable. Due to the importance of such cases where methicillin-resistant staphylococci are a recognized cause of erysipelas [16, 17], strict control of risk factors for erysipelas (e.g. portal of entry, non-steroidal anti-inflammatory drugs) and thorough antibiotic therapy should be carefully assessed before proposing the diagnosis of ‘allergic cellulitis’ to hip prosthesis.…”

Two Cases of Cellulitis in the Course of African Tick Bite Fever: A Fortuitous Association?

“…ATBF is not known to increase susceptibility to another bacterial infection but, in both cases, one of the inoculation eschars may represent a potential site of entry for cellulitis. Disruption of the cutaneous barrier is one of the most significant risk factors for erysipelas [7,8,9,10,11]; for both patients, the only detectable sites of entry for cellulitis were inoculation eschars with the notable absence of toe web intertrigo. In the first case, other possible sites of entry are skin lesions secondary to insect bites on the patient’s midfoot a few days before the admission.…”