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Case Study

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Title Erysipelas, a Streptococcal Infection of the Skin Case Study SN0011 Author Mindy Gold, RN, MS, CPNP Second Author Pamela J. Burke, RN, PhD, CS-FNP, PNP Contact Hours 1 Target Audience: Pediatric and advanced practice nurses who work in primary care, acute care, and community-based settings Purpose/Goal: The purpose of this case study is to gain knowledge about erysipelas, a superficial cellulitis sometimes seen in children and adolescents, that is most frequently caused by the same bacteria that is responsible for strep pharyngitis, scarlet fever, and impetigo.     Objectives Epidemiology Instructions Clinical Presentation Introduction Differential Diagnosis Medical/Nursing History Course of Care Family/Social History References Physical Exam Findings TEST QUESTIONS Laboratory/Test Data   Sigma Theta Tau International is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

Learner Objectives: Upon completion of this case study, the learner will be able to:

1. Describe the clinical presentation of erysipelas as a dermatological finding.
   
2. Identify other frequently presenting constitutional signs and symptoms associated with erysipelas.
   
3. Designate the causative organism and its epidemiology.
   
4. Consider the differential diagnoses based on clinical manifestations.
   
5. Apply a strategy for treatment of erysipelas.

Meet the Author

Mindy Gold, RN, MS, CPNP Mindy Gold is currently a practicing pediatric nurse practitioner at Harvard Vanguard Medical Associates in Boston, MA. She primarily works in pediatric urgent care where a variety of patients are seen, from newborn to young adult, presenting with acute illnesses and injuries. She works with an experienced staff of PNPs who are responsible for assessment and treatment of HVMA's patients who require assistance in an after-hours setting. Ms. Gold graduated from Boston College School of Nursing in 1995, receiving a master's degree in ambulatory pediatric nursing. During the past seven years she has taught undergraduate students in clinical settings for several colleges in the Boston area. In addition, she has precepted graduate students for both Boston College and Simmons College.

Pamela J. Burke, RN, PhD, CS-FNP, PNP Pam Burke has been a pediatric nurse since 1970, when she graduated from Boston College with a BS in nursing. In 1978, she received an MS from Boston University's Parent Child Health Nursing Program, and in 1990, she earned a PhD in Developmental and Educational Psychology from Boston College's Graduate Program in Arts and Sciences. In 1995, Pam completed a post-masters FNP Certificate Program at Boston College and was certified as both an FNP and PNP. She practices part-time at the Boston Children's Hospital and teaches full-time at Boston College, where she is associate professor and co-director of the Pediatric Nurse Practitioner Program. Her areas of expertise and special interest are adolescent health and parent-infant interaction.

Instructions

• Read the case study. Answer the questions at the end of the case study and click on the submit button to have your answers checked. You will have the opportunity to register for continuing education credit if you score 80% or higher.
• At any time in the case study you may review the references cited. References available online are indicated by an underline. To access simply click on the article.
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Introduction to the case:
Bobby, a 16-year-old male, presented to pediatric urgent care with a 2-day history of fever; malaise; chills; neck stiffness, and most notably a red, swollen, and painful, rapidly-spreading rash covering the left side of his face extending from his entire cheek into his scalp. About seven to ten days prior to presentation, Bobby had a severe sore throat, which subsided in 2 days and was not clinically evaluated. He subsequently did some yard work and might have been exposed to poison ivy. In the 24 hours before evaluation, Bobby had nausea with occasional vomiting but was able to self-hydrate with oral (PO) fluids. He no longer had a sore throat. His maximum oral temperature was 102° Fahrenheit (F). He felt a burning, non-pruritic sensation to the affected area of his face and had a stiff neck but no photophobia.

Medical/Nursing History:
Chief Complaint: Patient states that he feels really ill and has a rash that feels like a burn on his face.

Present Illness: Earliest onset of illness was a sore throat for two days, seven to ten days ago. Bobby felt well without treatment for five days. Two days ago, he developed three bumps on his face that spread into a large erythematous, tender facial rash. Fever to 102° F for two days, and nausea with occasional vomiting in the last 24 hours. Today, he feels drowsy, has a headache, and has a stiff neck. Home treatment has consisted of rest, clear liquids, and ibuprofen as needed (prn).

Past History: Bobby has no known illnesses, but he does have a history of intermittent migraine and stress-related headaches. There is no history of previous surgery, and immunizations are up to date. He has not recently traveled. He denies any new contact with commercial products and has no known contact with strep throat, but a possible exposure to poison ivy exists. He has no known food, seasonal, or drug allergies.

Family or Social History:
At this time, there are no family members who share similar signs and symptoms with Bobby. Bobby is accompanied by his mother, who shows appropriate concern about Bobby's current health status and the rapidly-spreading facial rash. The family lives in an apartment in the inner city. The patient attends public high school and is in the ninth grade.

Physical Examination Findings:

Vitals:	B/P 145/61 sitting, pulse 128; temp 99.3° F; Respiration 24; weight 168 pounds (lb) (76.20 kg)
General:	Non-toxic, well nourished, well-developed male who appears ill and drowsy but is able to attend and is conversant
Head:	Normocephalic, atraumatic, frontal skull tenderness on left
Skin:	Erythematous and edematous confluent, non-petechial, maculopapular rash on left side of face with abrupt demarcation from healthy skin; Paranasal Rash, extending beyond hairline into scalp; Possible left (L) periorbital involvement; Marked tenderness on palpation; No exudate or vesicles noted; Trunk and extremities clear
Eyes:	PERRLA, extra ocular movement (EOM) full
ENMT:	Tympanic membranes (TMs) intact with good light reflex; Nares patent, mucosa pink; Mouth and lips intact and without lesions. Pharynx non erythematous, no exudate
Neck:	Lateral nuchal rigidity, range of motion (ROM) decreased on flexion and extension; Negative Kernig; negative Brudzinski; Mild anterior cervical adenopathy present; no posterior nodes palpable; Thyroid is wnl (within normal limits)
Respiratory:	Lungs CTA (clear to auscultation), no wheezes or crackles; No stridor
Cardiovascular:	Normal s1, s2; No rubs, murmurs, or gallops; Tachycardic
Gastrointestinal:	Abdomen soft, non-distended; Positive bowel sounds; No hepatosplenomegaly; No costovertebral angle tenderness (CVA) tenderness
Musculoskeletal:	No deformities noted; No joint effusions or edema; Without erythema or tenderness of extremities
Neurologic:	Mental status alert, oriented, and cooperative; Hearing grossly normal. Motor strength of major flexors and extensors 5/5; Deep tendon reflexes (DTRs) at knees and ankles 2+, toes downgoing; Sensory exam grossly normal; Gait and speech normal; No tremors or dizziness

Laboratory/Test Data:
In the pediatric urgent care unit, Bobby had a rapid strep test that was negative. A throat beta strep culture was sent to the lab that 1 day later revealed a heavy amount of beta strep Group A colonization. Further labs were deferred until Bobby was transferred to the local pediatric emergency department. At the emergency department, Bobby's labs were as follows:

NA Cl K CO2 BUN Cr Glucose WBC ANC Hct Platelets

135 meq/l 98 meq/l 4.0 meq/l 24 meq/l 11 mg/dl 1.0 mg/dl 154 mg/dl 17 thous/mcl (absolute neutrophil count) 16 41% 208 thous/mcl

A lumbar puncture (LP) was done but revealed no evidence of bacterial infection.

Streptococci may be recovered from an aspiration of the wound, particularly at the advancing margin. Other diagnostic studies that might be recommended are blood culture, nasopharyngeal culture, erythrocyte sedimentation rate, anti-streptolysin O, and anti-DNAase B titers. A urinalysis can also be obtained, both at the initial presentation and at follow-up (i.e., 2 weeks), to evaluate for signs of post-streptococcal glomerulonephritis.

Epidemiology:
The history of erysipelas can be traced back to the Middle Ages when it was known as "St. Anthony's Fire," a bright red rash that was associated with a fungus found in contaminated rye. It was believed that only St. Anthony, an Egyptian monk, could cure the condition.

Erysipelas is a skin infection typically caused by Group A beta hemolytic strep (streptococcus pyogenes), which is one of the most common human pathogens. The term erysipelas refers to a specific type of cellulitis that involves the dermis, the uppermost layer of subcutaneous tissue, and the cutaneous lymphatics. Less common pathogens associated with the condition can include Group G, C, and B streptococci and rarely staphylococci. Portals of entry for the infection can include local trauma, insect bites, abrasions, eczema, tinea lesions, or surgical incisions. The source of the bacteria often comes from the patient's nasopharynx, and facial erysipelas may follow a streptococcal pharyngitis in about one-third of all cases.

There has been an increasing incidence of erysipelas since the 1980s. It affects people of all ages but is more prevalent among the young, the elderly and the immunocompromised patient. Erysipelas cellulitis can affect all races. Epidemics of this condition are rare despite its increase in incidence. Complications arising from erysipelas do not occur often but, in some cases, it can lead to serious morbidity and mortality. Recurrence is also uncommon but can be a significant complication in immunocompromised patients.

Clinical Presentation:
The clinical presentation of classic erysipelas is very characteristic, and the diagnosis is made clinically. The usual location is the face or the leg. On a histological level, however, the differentiation between erysipelas and other forms of cellulitis may not be readily apparent. Both involve local signs of inflammation, such as redness, tenderness, and warmth and may be accompanied by fever and lymphadenitis. Erysipelas involves the more superficial layers of the skin, and its sharply demarcated advancing borders between involved and normal skin differentiates this from other skin infections.

The rash begins as a small erythematous patch and advances to a bright red, tense, indurated, sometimes shiny, plaque that progresses over 3 to 6 days. Vesicles and bullae may appear over the affected area. Prodromal signs are fever, malaise, chills, headache, poor appetite, gastrointestinal (GI) disturbance, and local skin discomfort.

Differential Diagnosis:
Other forms of cellulitis are contact dermatitis; herpes zoster; necrotizing fasciitis; systemic lupus erythematosus; scarlet fever; urticaria; toxic shock syndrome (TSS); drug eruptions, and erythema migrans.

The following tests/exams are available to rule out the disease conditions listed.

Disease Condition	Test/Exam
Necrotizing Fasciitis	CT Scan or MRI to locate depth of infection (Bisno & Stevens, 1996)
Systemic Lupus Erythematosus (SLE)	ANA, C3, C4 (Behrman, Kleigman, & Jenson, 2000)
Toxic Shock Syndrome (TSS)	Blood cultures and other labs to rule out multi-system involvement (i.e., renal, hepatic, or hematologic) (Pickering, 2000)
Urticaria	IgE, IgG, IgM (Zitelli & Davis, 1997)

Course of Care:
Penicillin has remained a first-line drug for Group A streptococcal infections. Oral or intramuscular (IM) penicillin is often sufficient treatment and should be given for 10-14 days. If the patient has an allergy to penicillin, a macrolide can be prescribed. Cephalosporins also effectively treat streptococcal infections. In cases where co-existent disease is possible, or in severe cases involving children or debilitated adults, hospitalization, close monitoring, and IV antibiotics are recommended.

Local treatment, particularly for an affected limb, involves rest and elevation of the limb in order to reduce swelling and inflammation. Warm, wet saline dressings can be applied to ulcerated lesions. Topical antibiotics or antiseptics do not effectively treat the systemic infection; however, antipyretics and analgesics are most helpful in the treatment of fever and discomfort. Hydration, either intravenously or by oral intake, is a mainstay of care.

Bobby was initially examined in an outpatient pediatric urgent care unit where a pediatric nurse practitioner evaluated him. The covering pediatrician was consulted, and it was decided that because of the patient's constitutional symptoms of spreading rash, stiff neck, fever, and vomiting, this illness required further investigation. Bobby, accompanied by his mother, was directed to the emergency department of a large, local pediatric hospital.

In the emergency department, Bobby's temperature spiked to 105.2° F. His heart rate was 156; resp. rate 28; and B/P 135/74, and his O2 SAT was 95% in room air. He was given 1 liter of Normal Saline via IV for hydration and started on IV oxacillin for a presumptive diagnosis of erysipelas. After further evaluation and pertinent lab work, Bobby was admitted to the hospital in stable condition. He was an inpatient for 2 days while he received IV oxacillin. Bobby had a dermatology consult after developing new patches of rash on his arms and under his chin, which appeared more consistent with a contact dermatitis from an uncertain exposure.

Within 24 hours of admission, Bobby's nausea and vomiting abated, he complained of hunger, and he began to eat a regular diet without difficulty.

There were no complications during hospitalization, and Bobby was discharged on an oral first-generation cephalosporin for continued treatment of his facial rash for seven more days (total of ten days). Bobby's erythematous area was resolving; he was afebrile, and his leukocytosis had resolved, so he was switched from IV to oral antibiotics (Bratton & Nesse, 1995). He was also put on a prednisone taper for ten days in order to treat the possible contact dermatitis. Click here to see a sample of a medication taper schedule sheet.

The patient was given a diagnosis of erysipelas and was treated for his strep pharyngitis.

Discharge instructions included continuing a regular diet and taking medications as instructed. Bobby and his mother were instructed to take the entire prescription of the antibiotics and were cautioned them not to discontinue the pills when he began feeling better. The nurse gave Bobby and his mother a printed sheet with specific instructions about taking Prednisone, explaining that serious side-effects can occur if this medication is not taken as prescribed and/or discontinued suddenly. The nurse completed a medication taper form for Bobby and his mother so they could keep track of the time and the dosage of prednisone.

Bobby and his family were told to follow up immediately for increased headaches, visual changes, fever, neck pain, vomiting, spreading of rash, and difficulty breathing. The family followed up with their primary pediatrician, both by phone and by an appointment in two weeks. Bobby returned to his baseline health status without complications.

References

American Academy of Dermatology (1998). Herpes Zoster. Retrieved April 9, 2002, from http://www.aad.org/pamphlets/herpesZoster.html.

Arndt, K.A. & Bowers, K.E. (2002). Manual of dermatologic therapeutics (6th ed.). Philadelphia: Lippincott Williams & Wilkins.

Behrman, R.E., Kleigman, R.M., & Jenson, H.B. (Eds.). (2000). Nelson textbook of pediatrics. Philadelphia: W.B. Saunders.

Bisno, A.L. & Stevens, D.L. (1996). Streptococcal infections of skin and soft tissues. New England Journal of Medicine, 334(4), 240-245.

Bratton, R.L. & Nesse, R.E. (1995). St. Anthony's Fire: Diagnosis and management of erysipelas. American Family Physician, 51(2), 401-404. Retrieved April 9, 2002, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7840036&dopt=Abstract.

Davis, L. & Benbenisty, K. (2001). Erysipelas. eMedicine Journal, 2(12). Retrieved February 20, 2002, from http://www.emedicine.com/derm/topic129.htm.

EM Rash (n.d.). Retrieved March 25, 2002, from http://ourworld.compuserve.com/homepages/frankd/emrash.htm.

Feigin, R. & Cherry, J. (1987). Textbook of pediatric infectious disease (Vol. 2). Philadelphia: W.B. Saunders.

Hoekelman, R.A. (1997). Primary pediatric care (3rd ed.). St. Louis: Mosby Year Book.

Lupus Foundation of America, Inc. (2002). Facts and Overview. Retrieved March 25, 2002, from http://www.lupus.org/education/overview.html.

McKinley Health Center. Contact Dermatitis. (2002). Retrieved April 9, 2002, from http://www.mckinley.uiuc.edu/health-info/dis-cond/commdis/contderm.html.

Mosby's DRUG Consult (1998). Prednisone. Retrieved March 25, 2002, from http://www.harcourthealth.com/genrxfree/Top_200_1999/Drugs/n2109o.HTM.

National Institute of Allergy and Infectious Diseases (1999, March). Group A streptococcal infections. Retrieved February 20, 2002, from http://www.niaid.nih.gov/factsheets/strep.htm.

Nochimson, G. (2001). Erysipelas. eMedicine Journal, 2(6). Retrieved February 20, 2002, from http://www.emedicine.com/emerg/topic172.htm.

O'Dell, M.L. (1998). Skin and wound infections: An overview. American Family Physician, 57(10), 2424-2432. Retrieved April 9, 2002, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9614412&dopt=Abstract.

Pickering, L.K. (Ed.) (2000). 2000 red book: Report of the committee on infectious diseases (25th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Piette, W. ( n.d.). Erysipelas. An introduction to basic dermatology. Retrieved March 25, 2002, from http://www.vh.org/Providers/Lectures/PietteDermatology/BlackTray/05Erysipelas.html.

RxInsider.com. (n.d.). Prednisone taper sheet. Retrieved March 25, 2002, from http://www.rxinsider.com/prednisone_taper_sheet.htm.

Southgate,T. (1999). The death of St. Anthony. Journal of the American Medical Association 282(21), 1990. Retrieved February 20, 2002, from http://jama.ama-assn.org/issues/v282n21/ffull/jcs90042-1.html.

Stevens, D.L. (1995). Streptococcal toxic-shock syndrome: Spectrum of disease, pathogenesis, and new concepts in treatment. Emerging Infectious Diseases 1(3). Retrieved March 25, 2002, from http://www.cdc.gov/ncidod/EID/vol1no3/stevens.htm.

Walsh, S. (1999). Boy with a facial rash. Journal of Pediatric Health Care, 13(1), 40, 48.

Yarmase, H. (n.d.). Postinfectious glomerulonephritis. Retrieved March 25, 2002, from http://155.37.5.42/eAtlas/GU/1539.htm.

Zitelli, B.J. & Davis, H.W. (Eds.). (1997). Atlas of pediatric physical diagnosis (3rd ed.). St. Louis: Mosby-Wolfe.

Test Questions

Please select the correct answer for each of the following questions. If you answer 80% or more correctly, you will be given the opportunity to register for continuing eduation credit. After receipt of the registration information and fee, a continuing education certificate will be mailed to you.

Question 1

Choose the statement that accurately describes erysipelas.

Erysipelas extends deeply into the subcutaneous tissues.
Erysipelas presents acutely as marked redness, pain, and swelling in the affected area.
Erysipelas has poorly demarcated borders.
Erysipelas is most common among adult males.

Question 2

Which of the following statements about erysipelas is true? Bobby’s mother wants to know more about erysipelas. The nurse can tell her:

Patients with erysipelas report the appearance of a rash followed by fever.
The causative organisms usually are found in the upper respiratory tracts of afflicted patients.
The patient should be able to identify an entry site such as a laceration, insect bite, eczema, or dental problem.
The most common infecting organism is staph aureus.

Question 3

Which of the following statements about erysipelas is true?

There were no documented cases of erysipelas until the 20th century.
Immunocompromised patients may be at higher risk.
Erysipelas may be caused by a virus.
The most common sites for erysipelas are the face and trunk.

Question 4

There were a number of conditions to rule out in Bobby’s case. Which of the following conditions should be ruled out?

Necrotizing fasciitis
Systemic lupus erythematosus (SLE)
Toxic shock syndrome
All of the above

Question 5

Bobby's throat culture was positive for group A Streptococci (GAS), and his facial rash fit the profile for erysipelas. Which of the following would be an appropriate action for Bobby's treatment and follow-up?

Four weeks after discharge from the hospital, a urinalysis could be done to observe for post-streptococcal glomerulonephritis.
An important criterion for switching from IV to oral antibiotics is the proposed date of discharge from the hospital.
Treating Bobby with IV oxacillin would cover him for staph aureus, most strains of which produce penicillinase and are resistant to penicillin and ampicillin.
If Bobby were allergic to penicillin, a good alternative for an oral antibiotic would be tetracycline or a sulfonamide.