Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg

Abstract

Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology.

New developments in clinical aspects of lymphatic disease

“…It is likely that disturbances in immune cell trafficking compromise tissue immunosurveillance, but the exact mechanism is not known. Cellulitis can develop for the first time as a result of subclinical, and therefore previously unsuspected, lymph drainage abnormalities (27). Lymphedema conveys a 71-fold enhancement of risk for cellulitis, relative to normal conditions (28).…”

Erysipelas of the Thigh and the Gluteal Region: Retrospective Multicenter Analysis of a Very Rare Entity in 39 Patients

“…In previous studies on about 2,000 patients with erysipelas of the lower leg, as well as in our control patients (data not shown), chronic venous insufficiency and lymphedema with 25% each were the most important predisposing conditions [5,9,13,27,33,34]. In the gluteal region, surgical impairment of the lymphatic circulation has been proposed to be a predisposing factor for erysipelas [16,17,22].…”

“…In the gluteal region, surgical impairment of the lymphatic circulation has been proposed to be a predisposing factor for erysipelas [16,17,22]. Lymph stasis after disruption of lymphatic vessels causes retention of high-molecular-weight proteins within the interstitial tissue leading to fibrosis with reduced tissue drainage capacity resulting in a vicious cycle [33,34]. This may also disturb the migration of dendritic cells [35], which could weaken the immunological response to pathogenic agents.…”

Towards an effective management of chronic lymphedema

“…2 Antimicrobial agents should be administered in acute lymph stasis-related inflammations (lymphangitis, erysipelas, cellulitis). 34 Erysipelas/cellulitis recurrence requires prophylactic long-term parenteral or, in case of coagulation disturbance, oral antibiotic treatment. Prophylatic antibiotic medications significantly reduce the frequency of erysipelas; recurrent episodes of bacterial inflammation, however, are still commonly detectable.…”

“…35 Recurrent episodes of erysipelas could be a clue for subclinical primary lymphedema. 34 Fungal infections that make affected areas more prone to bacterial infections should be treated both systemically and topically.…”