Difficulties in the diagnosis of erysipelas in immunosuppressed patients

Abstract

Introduction: Erysipelas is an acute inflammatory condition of the skin and subcutaneous tissue caused by Streptococci. The lesions usually affect the lower limbs or face unilaterally and are characterized by erythema, oedema and pain. By the definition, the disease is accompanied by high fever. On the laboratory investigations, elevated C-reactive protein and leukocytosis are observed. However, in immunocompromised patients, the diagnosis might be unclear.

Case description: This study presents cases of three patients admitted to the department of dermatology with erysipelas: a 51-year-old woman with rheumatoid arthritis treated with tocilizumab, methotrexate and methylprednisolone, a 51-year-old woman with systemic lupus erythematosus treated with prednisone, and a 75-year-old woman with rheumatoid arthritis treated with methotrexate. Clinical pictures shared common symptoms in all cases: oedema, erythema and pain in one of the limbs. However, none of the patients had a fever on admission. On laboratory tests, in two cases, there was no significant increase in inflammatory markers. The treatment with intravenous antibiotics and low-molecular heparin resulted in good clinical improvement.

Conclusions: Chronic immunosuppressive treatment acting due to inhibition of pro-inflammatory cytokines reduced patients’ immune response, which resulted in the absence of fever and no significant increase in the inflammatory parameters. Presented cases show some peculiarities of erysipelas in the distinct group of immunosuppressed patients and draw attention to unusual manifestations. Nowadays, there are more and more patients treated with biological agents for different diseases, including dermatoses. Hence, the number of atypical erysipelas cases may rise.