Erysipeloid: Difference between revisions
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==Overview== | ==Overview== | ||
Erysipeloid is an occupational infection of the skin caused by traumatic penetration of Erysipelothrix rhusiopathiae. The disease is characterized clinically by an erythematous oedema, with well-defined and raised borders, usually localized to the back of one hand and/or fingers. Vesicular, bullous and erosive lesions may also be present. The lesion may be asymptomatic or accompanied by mild pruritus, pain and fever. In addition to cutaneous infection, E. rhusiopathiae can cause endocarditis, which may be acute or subacute. Endocarditis is rare and has a male predilection. It usually occurs in previously damaged valves, predominantly the aortic valve. Endocarditis does not occur in patients with valvular prostheses and is not associated with intravenous drug misuse. Diagnosis of localized erysipeloid is based on the patient's history (occupation, previous traumatic contact with infected animals or their meat) and clinical picture (typical skin lesions, lack of severe systemic features, slight laboratory abnormalities and rapid remission after treatment with penicillin or cephalosporin). | Erysipeloid is an occupational infection of the skin caused by traumatic penetration of [[Erysipelothrix rhusiopathiae]] (formerly E. insidiosa). The disease is characterized clinically by an erythematous oedema, with well-defined and raised borders, usually localized to the back of one hand and/or fingers. Vesicular, bullous and erosive lesions may also be present. The lesion may be asymptomatic or accompanied by mild pruritus, pain and fever. In addition to cutaneous infection, E. rhusiopathiae can cause endocarditis, which may be acute or subacute. Endocarditis is rare and has a male predilection. It usually occurs in previously damaged valves, predominantly the aortic valve. Endocarditis does not occur in patients with valvular prostheses and is not associated with intravenous drug misuse. Diagnosis of localized erysipeloid is based on the patient's history (occupation, previous traumatic contact with infected animals or their meat) and clinical picture (typical skin lesions, lack of severe systemic features, slight laboratory abnormalities and rapid remission after treatment with penicillin or cephalosporin). | ||
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==Classification== | ==Classification== | ||
Erysipeloid may be classified according to the extensiveness of the presentation as follows: | |||
===Localized cutaneous erysipeloid=== | |||
This type is usually mild localized infection seen as local swelling and redness of the skin. This is popularly referred to as erysipeloid of Rosenbach) | |||
===Diffuse cutaneous Erysipeloid=== | |||
This type may present with fever. | |||
===Generalized or systemic Erysipeloid=== | |||
This manefests as bacterimia with associated complications like endocarditis. | |||
==Pathophysiology== | ==Pathophysiology== | ||
E rhusiopathiae, which is highly resistant to environmental factors, enters the skin through scratches or pricks. In the skin, the organism is capable of producing certain enzymes that help it dissect its way through the tissues. It has recently been discovered that only pathogenic strains of E rhusiopathiae are capable of producing the neuraminidase enzyme. This enzyme is speculated to help the microorganism invade tissues. Moreover, 2 adhesive surface proteins were discovered and their nucleotide sequence encoded. The proteins are named RspA and RspB and serve in helping the microorganism bind to biotic (collagen types I and IV) and abiotic (polystyrene) surfaces. | |||
Meanwhile, the host's immune system is activated to start fighting against this foreign bacterium. The organism may escape immune surveillance and may spread in the body via the vascular system to the joints, heart, brain, CNS, and lungs. The organ most commonly affected other than the skin is the heart. | |||
==Causes== | ==Causes== | ||
==Differentiating {{PAGENAME}} from Other Diseases== | ==Differentiating {{PAGENAME}} from Other Diseases== | ||
Erysipeloid must be differentiated from other conditions as follows: | |||
*Abscess | |||
*Cellulitis | |||
*Contact dermatitis | |||
*Erysipelas | |||
*Furuncle | |||
*Insect or animal bites | |||
*Ulcer | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Infection with E rhusiopathiae occurs in worldwide distribution in a variety of animals, especially hogs. | |||
Mortality/Morbidity | |||
Erysipeloid usually is an acute, self-limited infection of the skin that resolves without consequences. Individuals with the systemic form of erysipeloid, in which organs other than the skin are involved, may have neurologic, cardiologic, or other impairments. Individuals with systemic infection may even die of sepsis, if the proper diagnosis is not made and treatment is not initiated early on. | |||
===Race=== | |||
No racial predilection is recognized for erysipeloid. | |||
===Sex=== | |||
Both sexes may be equally affected; however, erysipeloid seems to affect more males than females because of occupational exposure. | |||
===Age=== | |||
Erysipeloid can affect any age group. | |||
==Risk Factors== | ==Risk Factors== | ||
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==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
The local and cutaneous forms of the disease are usually self-limiting and may resolve spontaneously within 2 to 4 weeks. In individuals receiving appropriate antibiotic treatment, the prognosis for complete recovery is excellent. In those who are not treated adequately, endocarditis or arthritis may develop, but these conditions are not usually severe and can be effectively treated. Needle aspiration of an infected joint, possibly repeated on multiple occasions, will, in conjunction with antibiotic therapy, lead to resolution of the arthritis. | |||
Antibiotic-resistant strains will complicate therapy. Repeated infection may result in the development of allergic sensitivities. Reduced immunity may complicate the infection. Individuals with the severe systemic form may have irreversible neurological damage. Endocarditis may result in long-term valvular heart disease. Septic arthritis may result in long-term joint disease. | |||
==Diagnosis== | ==Diagnosis== | ||
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===Physical Examination=== | ===Physical Examination=== | ||
The exam shows bright red-to-purple, nonvesiculated, maculopapular plaques with a smooth, shiny surface, typically found on the webs of the fingers, hands, or forearms; the lesions are clearly defined, raised, and indurated. The rash or lesions may be warm and/or tender. Generalized cutaneous disease is characterized by expanding red-to-purple rash with a clear center, and bullous lesions. Fever is occasionally present. Individuals with joint involvement will have swelling of some joints. Individuals with endocarditis may have a heart murmur noted on examination | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
The bacterium can often be cultured from drainage from the infected area. Sometimes, a full-thickness biopsy culture is needed to make the diagnosis. Isolation of the bacterium in the blood (blood culture) is necessary for the diagnosis of endocarditis. Imaging tests such as computed tomography (CT), magnetic resonance imaging (MRI), radiography, or echocardiography may be recommended if the systemic form of the disease is suspected. | |||
===Imaging Findings=== | ===Imaging Findings=== | ||
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===Prevention=== | ===Prevention=== | ||
Individuals with erysipeloid should be restricted from handling meat or fish products until the infection is cured. They may need to avoid using their infected hand altogether until the infection has resolved and the swelling and pain have disappeared. | |||
Risk: Because erysipeloid infection is an occupational disease, individuals who work in meat handling, fishing, and agricultural jobs should wear protective gloves when possible to avoid recurrence. | |||
===Antimicrobial Regimen=== | ===Antimicrobial Regimen=== | ||
Revision as of 16:49, 17 August 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2] Faizan Sheraz, M.D. [3]
| Erysipeloid | |
 | |
|---|---|
| Cellular and colonial morphology of Erysipelothrix rhusiopathiae | |
| ICD-10 | A26 |
| ICD-9 | 027.1 |
| DiseasesDB | 4432 |
| MedlinePlus | 000632 |
| eMedicine | derm/602 |
| MeSH | D004887 |
Overview
Erysipeloid is an occupational infection of the skin caused by traumatic penetration of Erysipelothrix rhusiopathiae (formerly E. insidiosa). The disease is characterized clinically by an erythematous oedema, with well-defined and raised borders, usually localized to the back of one hand and/or fingers. Vesicular, bullous and erosive lesions may also be present. The lesion may be asymptomatic or accompanied by mild pruritus, pain and fever. In addition to cutaneous infection, E. rhusiopathiae can cause endocarditis, which may be acute or subacute. Endocarditis is rare and has a male predilection. It usually occurs in previously damaged valves, predominantly the aortic valve. Endocarditis does not occur in patients with valvular prostheses and is not associated with intravenous drug misuse. Diagnosis of localized erysipeloid is based on the patient's history (occupation, previous traumatic contact with infected animals or their meat) and clinical picture (typical skin lesions, lack of severe systemic features, slight laboratory abnormalities and rapid remission after treatment with penicillin or cephalosporin).
In humans, Erysipelothrix rhusiopathiae infections most commonly present in a mild cutaneous form known as erysipeloid[1] or fish poisoning.[2] E. rhusiopathiae can cause an indolent cellulitis, more commonly in individuals who handle fish and raw meat.[3] It gains entry typically by abrasions in the hand. Bacteremia and endocarditis are uncommon but serious sequelae.[4][5] Due to the rarity of reported human cases, E. rhusiopathiae infections are frequently misidentified at presentation.[1]
Historical Perspective
Classification
Erysipeloid may be classified according to the extensiveness of the presentation as follows:
Localized cutaneous erysipeloid
This type is usually mild localized infection seen as local swelling and redness of the skin. This is popularly referred to as erysipeloid of Rosenbach)
Diffuse cutaneous Erysipeloid
This type may present with fever.
Generalized or systemic Erysipeloid
This manefests as bacterimia with associated complications like endocarditis.
Pathophysiology
E rhusiopathiae, which is highly resistant to environmental factors, enters the skin through scratches or pricks. In the skin, the organism is capable of producing certain enzymes that help it dissect its way through the tissues. It has recently been discovered that only pathogenic strains of E rhusiopathiae are capable of producing the neuraminidase enzyme. This enzyme is speculated to help the microorganism invade tissues. Moreover, 2 adhesive surface proteins were discovered and their nucleotide sequence encoded. The proteins are named RspA and RspB and serve in helping the microorganism bind to biotic (collagen types I and IV) and abiotic (polystyrene) surfaces.
Meanwhile, the host's immune system is activated to start fighting against this foreign bacterium. The organism may escape immune surveillance and may spread in the body via the vascular system to the joints, heart, brain, CNS, and lungs. The organ most commonly affected other than the skin is the heart.
Causes
Differentiating Erysipeloid from Other Diseases
Erysipeloid must be differentiated from other conditions as follows:
- Abscess
- Cellulitis
- Contact dermatitis
- Erysipelas
- Furuncle
- Insect or animal bites
- Ulcer
Epidemiology and Demographics
Infection with E rhusiopathiae occurs in worldwide distribution in a variety of animals, especially hogs. Mortality/Morbidity
Erysipeloid usually is an acute, self-limited infection of the skin that resolves without consequences. Individuals with the systemic form of erysipeloid, in which organs other than the skin are involved, may have neurologic, cardiologic, or other impairments. Individuals with systemic infection may even die of sepsis, if the proper diagnosis is not made and treatment is not initiated early on.
Race
No racial predilection is recognized for erysipeloid.
Sex
Both sexes may be equally affected; however, erysipeloid seems to affect more males than females because of occupational exposure.
Age
Erysipeloid can affect any age group.
Risk Factors
Erysipeloid is most common among individuals who have direct contact with infected animals. Fishermen, farmers, slaughterhouse workers, butchers, meat handlers, and agricultural workers are among those at highest risk for the condition. Erysipeloid is seen most frequently during the summer or early fall. The disease appears to be more common in men, but that may be due to occupational differences
Screening
Natural History, Complications, and Prognosis
The local and cutaneous forms of the disease are usually self-limiting and may resolve spontaneously within 2 to 4 weeks. In individuals receiving appropriate antibiotic treatment, the prognosis for complete recovery is excellent. In those who are not treated adequately, endocarditis or arthritis may develop, but these conditions are not usually severe and can be effectively treated. Needle aspiration of an infected joint, possibly repeated on multiple occasions, will, in conjunction with antibiotic therapy, lead to resolution of the arthritis.
Antibiotic-resistant strains will complicate therapy. Repeated infection may result in the development of allergic sensitivities. Reduced immunity may complicate the infection. Individuals with the severe systemic form may have irreversible neurological damage. Endocarditis may result in long-term valvular heart disease. Septic arthritis may result in long-term joint disease.
Diagnosis
Diagnostic Criteria
History and Symptoms
The individual usually describes an occupation requiring handling of unprocessed meat or fish. Symptoms may include skin irritations either of the localized or the diffuse form. Individuals may report burning, itching, or pain. If systemic infection is present, symptoms may include fever, chills, fatigue, or malaise
Physical Examination
The exam shows bright red-to-purple, nonvesiculated, maculopapular plaques with a smooth, shiny surface, typically found on the webs of the fingers, hands, or forearms; the lesions are clearly defined, raised, and indurated. The rash or lesions may be warm and/or tender. Generalized cutaneous disease is characterized by expanding red-to-purple rash with a clear center, and bullous lesions. Fever is occasionally present. Individuals with joint involvement will have swelling of some joints. Individuals with endocarditis may have a heart murmur noted on examination
Laboratory Findings
The bacterium can often be cultured from drainage from the infected area. Sometimes, a full-thickness biopsy culture is needed to make the diagnosis. Isolation of the bacterium in the blood (blood culture) is necessary for the diagnosis of endocarditis. Imaging tests such as computed tomography (CT), magnetic resonance imaging (MRI), radiography, or echocardiography may be recommended if the systemic form of the disease is suspected.
Imaging Findings
Other Diagnostic Studies
Treatment
The treatment of choice is a single dose of benzathine benzylpenicillin given by intramuscular injection, or a five-day to one-week course of either oral penicillin or intramuscular procaine benzylpenicillin.[6] Erythromycin or doxycycline may be given instead to people who are allergic to penicillin. E. rhusiopathiae is intrinsically resistant to vancomycin.[6]
Medical Therapy
Surgery
Prevention
Individuals with erysipeloid should be restricted from handling meat or fish products until the infection is cured. They may need to avoid using their infected hand altogether until the infection has resolved and the swelling and pain have disappeared.
Risk: Because erysipeloid infection is an occupational disease, individuals who work in meat handling, fishing, and agricultural jobs should wear protective gloves when possible to avoid recurrence.
Antimicrobial Regimen
- Preferred regimen (1): Penicillin 500 mg qid for 7–10 days
- Preferred regimen (2): Amoxicillin 500 mg tid for 7–10 days
- Erysipelothrix rhusiopathiae [7]
- 1. Erysipeloid of Rosenbach (localized cutaneous infection)
- Preferred regimen (1): Penicillin G benzathine 1.2 MU IV single dose
- Preferred regimen (2): Penicillin VK 250 mg PO qid for 5-7 days
- Preferred regimen (3): Procaine penicillin 0.6-1.2 MU IM qd for 5-7 days
- Alternative regimen (1): Erythromycin 250 mg PO qid for 5-7 days
- Alternative regimen (2): Doxycycline 100 mg PO bid for 5-7 days
- 2. Diffuse cutaneous infection
- Preferred regimen: See localized infection
- 3. Bacteremia or endocarditis
- Preferred regimen: Penicillin G benzathine 2-4 MU IV q4h for 4-6 weeks
- Alternative regimen (1): Ceftriaxone 2 g IV q24h for 4-6 weeks
- Alternative regimen (2): Imipenem 500 mg IV q6h for 4-6 weeks
- Alternative regimen (3): Ciprofloxacin 400 mg IV q12h for 4-6 weeks
- Alternative regimen (4): Daptomycin 6 mg/kg IV q24h for 4-6 weeks
- Note: Recommended duration of therapy for endocarditis is 4 to 6 weeks, although shorter courses consisting of 2 weeks of intravenous therapy followed by 2 to 4 weeks of oral therapy have been successful.
See also
References
- ↑ 1.0 1.1 Brooke C, Riley T (1999). "Erysipelothrix rhusiopathiae: bacteriology, epidemiology and clinical manifestations of an occupational pathogen". J Med Microbiol. 48 (9): 789–99. doi:10.1099/00222615-48-9-789. PMID 10482289.
- ↑ "THE SHIP CAPTAIN'S MEDICAL GUIDE" (PDF). p. 190.
- ↑ Lehane L, Rawlin G (2000). "Topically acquired bacterial zoonoses from fish: a review". Med J Aust. 173 (5): 256–9. PMID 11130351.
- ↑ Brouqui P, Raoult D (2001). "Endocarditis due to rare and fastidious bacteria". Clin Microbiol Rev. 14 (1): 177–207. doi:10.1128/CMR.14.1.177-207.2001. PMC 88969. PMID 11148009.
- ↑ Nassar I, de la Llana R, Garrido P, Martinez-Sanz R (2005). "Mitro-aortic infective endocarditis produced by Erysipelothrix rhusiopathiae: case report and review of the literature". J Heart Valve Dis. 14 (3): 320–4. PMID 15974525.
- ↑ 6.0 6.1 Vinetz J (October 4, 2007). "Erysipelothrix rhusiopathiae". Point-of-Care Information Technology ABX Guide. Johns Hopkins University. Retrieved on October 28, 2008. Freely available with registration.
- ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.