Erysipeloid

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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]

Synonyms and Keywords: Erysipelotrichosis, Rose fish-handlers disease, Rosenbach's disease, Rosenbach's Erysipeloid or Erysipeloid of Rosenbach.

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 edema, 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 lesions 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 (typically 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 or fish poisoning. E. rhusiopathiae can cause an indolent cellulitis, most commonly in individuals who handle fish and raw meat. It typically gains entry through abrasions in the hand. Bacteremia and endocarditis are uncommon but serious sequelae. Due to the rarity of reported human cases, E. rhusiopathiae infections are frequently misidentified at presentation.

Historical Perspective

• In 1884, Friedrich Julius Rosenbach (also called Anton Julius Friedrich Rosenbach), a German physician and microbiologist, was the first to accurately describe the association between Erysipelothrix rhusiopathiae and development of erysipeloid.
• Erysipelothrix rhusiopathiae was first isolated from mice in 1880 by Robert Koch.

Classification

Erysipeloid may be classified into the following categories according to the severity of the condition:

Localized cutaneous erysipeloid

• Usually a mild, localized infection
• Patients present with local swelling and redness of the skin
• Popularly referred to as "erysipeloid of Rosenbach"

Diffuse cutaneous erysipeloid

• Patients may present with fever

Generalized or systemic erysipeloid

• Manifests as bacteremia with associated complications (e.g., endocarditis, arthritis)

Pathophysiology

Pathogenesis

Development of erysipeloid is the result of an infection with Erysipelothrix rhusiopathiae after an area of skin containing an abrasion comes into contact with contaminated fish, poultry, or raw meat. Erysipelothrix rhusiopathiae, which is highly resistant to environmental factors, enters the skin through scratches or pricks. Various virulence factors have been implicated in the pathogenicity of erysipeloid. Following infection in the skin, the organism produces certain enzymes that help it dissect its way through the tissues. Significant among them are hyaluronidase and neuraminidase. Neuraminidase has been shown to play a significant role in the attachment of Erysipelothrix rhusiopathiae and subsequent invasion of host cells. The role of hyaluronidase in the disease process is less clear. The presence of a heat labile capsule has been reported as important in virulence. It has been discovered that only pathogenic strains of Erysipelothrix rhusiopathiae are capable of producing the neuraminidase enzyme. In addition, two adhesive surface proteins—RspA and RspB—also help the microorganism bind to collagen (types I and IV) and 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, kidney, central nervous system, and lungs. Besides the skin, the most commonly affected organ is the heart.

Associated conditions

The following conditions are associated with erysipeloid:

• Endocarditis
• Hodgkins lymphoma
• Use of gemcitabine
• Sweet's syndrome
• Renal failure
• Septic arthritis
• Polyarthralgia

Causes

Erysipeloid is caused by an infection with Erysipelothrix rhusiopathiae, a Gram-positive, catalase-negative, rod-shaped, non-spore-forming, non-acid-fast, non-motile bacterium. Infection with Erysipelothrix rhusiopathiae commonly results from contact between skin containing abrasions or lesions and contaminated fish, poultry, or raw meat.

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 worldwide in a variety of animals, including sheep, rabbits, turkeys, birds, cattle, rats, and fish.

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. The following are among those at highest risk for contracting the condition:

• Fishermen
• Farmers
• Slaughterhouse workers
• Butchers
• Meat handlers
• Agricultural workers

Erysipeloid is observed most frequently during the summer and early fall.

Screening

There is no screening modality for erysipeloid.

Natural History, Complications, and Prognosis

The local and cutaneous forms of the disease are usually self-limiting and may resolve spontaneously. In individuals receiving appropriate antibiotic treatment, the prognosis for complete recovery is excellent. In those who are not adequately treated, endocarditis or arthritis may develop, but these conditions are not usually severe and can be effectively treated. Needle aspiration of an infected joint, repeated on multiple occasions if necessary, will, in conjunction with antibiotic therapy, lead to resolution of arthritis.

Antibiotic-resistant strains will complicate therapy. Repeated infection may result in the development of allergies. Reduced immunity may complicate the infection. Individuals with the severe systemic form may suffer irreversible neurological damage. Endocarditis may result in long-term valvular heart disease. Septic arthritis may result in long-term joint disease.

Diagnosis

History and Symptoms

A person with erysipeloid infection usually presents with a history of 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

On physical examination the affected area usually 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. Fever is occasionally present. Individuals with joint involvement may have swelling of some joints. Individuals with endocarditis may have a heart murmur noted on examination.

Laboratory Findings

Laboratory investigations are usually not need to make diagnosis of erysipeloid since the diagnosis is mostly clinical. However, cuture of a specimen from drainage from the infected area may yield the diagnosis. Sometimes, a full-thickness biopsy culture is needed to make the diagnosis. Blood culture is necessary for the diagnosis of erysipeloid endocarditis.

Imaging Findings

CT scan may be helpful in the diagnosis of erysipeloid endocarditis. CT scan may show vegetations, paravalvular abscesses, and pseudoaneurysms.

Treatment

Medical Therapy

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. Erythromycin or doxycycline may be given instead to people who are allergic to penicillin. E. rhusiopathiae is intrinsically resistant to vancomycin.

Surgery

Surgery is usually not necessary. However, in rare cases with massive valvular destruction complicating endocarditis, surgical valvular replacement may be needed.

Prevention

Primary prevention

Effective measures for the primary prevention of erysipeloid include :

• Individuals whose work include meat handling, fishing, and agricultural jobs should wear protective gloves when possible to avoid infection with contaminated food.
• Individuals with erysipeloid should be restricted from handling meat or fish products until the infection is cured.

Secondary Prevention

There are no secondary preventive measures available for erysipeloid.

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

• 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

• Erysipeloid of Rosenbach