December07, 2022

Abstract Volume: 1 Issue: 1 ISSN:

Atypical Erysipelas – a Diagnostic Challenge

 Jochanan E*, Naschitz .MD1

Bait Balev Nesher and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.              

*Corresponding Author: Jochanan E, Bait Balev Nesher and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel. 

Received Date:  July 07, 2020                                            

Publication Date: July 15, 2020

Atypical Erysipelas – a Diagnostic Challenge

Case Report

Erysipelas is a superficial skin infection with lymphatic involvement. Predisposed are persons with a disrupted skin barrier caused by trauma, eczema, tinea, impetigo, or an unbroken epidermis but affected by edema, venous stasis, lymph stasis, a pelvic limb, diabetes mellitus, nephrotic syndrome, or alcohol abuse (1). In most cases, group A streptococci are responsible organisms. The second most frequent causative organisms are group G streptococci, also during the recent MRSA epidemic (2).

After prodromal symptoms lasting 4 to 48 hours of malaise, chills, fever, and occasionally anorexia and vomiting, one or more red, tender, firm spots appear at the site of infection. These spots rapidly increase in size, forming a tense, hot, red, shining, uniformly elevated, large patch with an irregular outline and a sharply defined, raised border. Lymphangitic streaking may be prominent. In older reports, erysipelas was described as characteristically involving the face. At present, the lower extremities are more frequently involved. Typically, erysipelas is unilateral. The diagnosis of erysipelas is based on the lesion’s appearance on physical examination. Bacteriologic cultures are useless in patients with typical features because positive results are rare. The differential diagnosis entails contact dermatitis, stasis dermatitis, lymphoma cutis, as well as cellulitis the acutely spreading infection of the skin which extends more deeply than erysipelas and involves the subcutaneous tissues. Sometimes it is difficult to distinguish between erysipelas and cellulitis. Typical sites involved by erysipelas are the calf and less often the face. In unusual locations, the diagnosis may be challenging as illustrated in the following.                                 

 Erysipelas of the face 

A 78-year-old woman was in comprehensive geriatric care after surgery for neuroglioma. She was in a vegetative state and was breathing through tracheostomy when fever 39.50C emerged, followed by erythema and swelling of the right side of the face also spreading to the neck, the pinna of the ear, and to both sides of the chin (Figure 1). Facial erythema spreading to the pinna is known as a specific finding that differentiates erysipelas from cellulitis (3). It is also held that erysipelas spares the nasolabial fold (4); the latter rule was not met in this patient. In diagnosing erysipelas and the patient being allergic to penicillin treatment with clindamycin and ciprofloxacin was started. Within twenty-four hours the temperature returned to normal, within three days the erythema and swelling remitted, and by day seven had completely resolved. 

Erysipelas of the thigh

A 42-year-old woman had suffered a traumatic brain injury and remained in a vegetative state. Erysipelas confined to the thigh was an unusual event during her long stay in our ward (Figure 2). No portal of entry of the infection could be found. The favorable response to cefazolin treatment was fast, as expected. Erysipelas of the thigh is rare and significantly associated with prior surgical disruption of lymphatic vessels (5). This was not the clinical context in this patient.

Though abdominal wall cellulitis is occasionally seen in the morbidly obese, the literature contains few data concerning erysipelas of the abdominal wall (6). Abdominal wall cellulitis is a distinctive infectious complication in patients with morbid obesity. At a difference, the well-defined margins of the erythema in this patient are consistent with erysipelas.   


The diagnosis of erysipelas is straightforward in the typical case but maybe challenging when involving unusual sites, as illustrated above. There may be confusion with the diagnosis when a skin eruption, infectious or not, resembles erysipelas (7-9). The acute onset of the illness with high fever, the strictly delimitated margins of the erythema, associated leukocytosis, and a quick response to antibiotic treatment make an important difference. The diagnosis may be elusive in the immune-deficient host when atypical fever patterns may be noted or facial swelling preceding the fever (10). Recognition of erysipelas, whether typical or atypical, is important to ensure quick and appropriate management.


1. Maxwell-Scott H, Kandil H. “Diagnosis and management of cellulitis and erysipelas”. Br J Hosp Med (Lond). 2015.                                                                                                                     

2. Jeng A, Behesti M, Li J, Nathan R. “The Role of [beta]-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation”. Medicine (Baltimore) 2010.                                                                                                                                                             

3. Madke B , Nayak C . “Eponymous signs in dermatology”. Indian Dermatol Online J 2012.                                                                                                                                           

4. Pakran J . “Sparing phenomena in dermatology”. Indian J Dermatol Venereol Leprol 2013.                                                                                                                                  

5. Glatz M, Degen D, French LE, Aberer W, Müllegger RR. “Erysipelas of the thigh and the gluteal region: retrospective multicenter analysis of a very rare entity in 39 patients.  Dermatology” 2012.                                                                                                                  

6. Thorsteinsdottir B, Tleyjeh IM, Baddour LM. “Abdominal wall cellulitis in the morbidly obese” Scand J Infect Dis. 2005.                                                                                                                                                   

7. Weyers W, Diaz-Cascajo C, Preinfalk P, Löffler “H. Mycosis fungoides mimicking erysipelas”. J Dtsch Dermatol Ges. 2008.                                                                                                        

8. Dompmartin  A, Troussard X, Lorier E, Jacobs F, Reman O, et al. “Sweet syndrome associated with acute myelogenous leukemia. Atypical form simulating facial erysipelas”. Int J Dermatol. 1991.                                                                                                                                    

9. Kavukcu S, Türkmen M, Soylu A, Kasap B, Güne? BT. “Skin and muscle involvement as presenting symptoms in four children with Familial Mediterranean fever”. Clin Rheumatol. 2009.                                                                                                                                              

10. Cupps TR, Cotton DJ, Schooley RT, Fauci AS.“Facial erysipelas in the immunocompromised host. Report of two cases”. Arch Dermatol. 1981.


Volume 1 Issue 1 July 2020

©All rights reserved by Dr. Jochanan E.

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