Vol 10, No 1 (2024)
Case report
Published online: 2023-11-27

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Difficulties in the diagnosis of erysipelas in immunosuppressed patients

Marta Całus1, Konrad Bagiński1, Małgorzata Duzinkiewicz1, Julia Nowowiejska1, Anna Baran1, Iwona Flisiak1
Forum Dermatologicum 2024;10(1):24-28.

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.

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References

  1. Stevens DL, Bryant AE. Impetigo, erysipelas and cellulitis. In: Ferretti JJ, Stevens DL, Fischetti VA. ed. Streptococcus pyogenes: basic biology to clinical manifestations [Internet]. University of Oklahoma Health Sciences Center, Oklahoma City 2016: Available from: https://www.ncbi.nlm.nih.gov/books/NBK333408/.
  2. Bruun T, Oppegaard O, Kittang BR, et al. Etiology of cellulitis and clinical prediction of Streptococcal disease: a prospective study. Open Forum Infect Dis. 2016; 3(1): ofv181.
  3. Heath A, DiRita VJ, Barg NL, et al. A two-component regulatory system, CsrR-CsrS, represses expression of three Streptococcus pyogenes virulence factors, hyaluronic acid capsule, streptolysin S, and pyrogenic exotoxin B. Infect Immun. 1999; 67(10): 5298–5305.
  4. Michael Y, Shaukat NM. Erysipelas. [Updated 2022 Aug 8]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023: Available from: https://www.ncbi.nlm.nih.gov/books/NBK532247/.
  5. Klotz C, Courjon J, Michelangeli C, et al. Adherence to antibiotic guidelines for erysipelas or cellulitis is associated with a favorable outcome. Eur J Clin Microbiol Infect Dis. 2019; 38(4): 703–709.
  6. Galli L, Venturini E, Bassi A, et al. Common community-acquired bacterial skin and soft-tissue infections in children: an intersociety consensus on impetigo, abscess, and cellulitis treatment. Clin Ther. 2019; 41(3): 532–551. e17.
  7. Bonnetblanc JM, Bédane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003; 4(3): 157–163.
  8. Pizzo PA. Fever in immunocompromised patients. N Engl J Med. 1999; 341(12): 893–900.
  9. Friedman B, Cronstein B. Methotrexate mechanism in treatment of rheumatoid arthritis. Joint Bone Spine. 2019; 86(3): 301–307.
  10. Pålsson-McDermott EM, O'Neill LAJ. Targeting immunometabolism as an anti-inflammatory strategy. Cell Res. 2020; 30(4): 300–314.
  11. Zimmerman MC, Clemens DL, Duryee MJ, et al. Direct antioxidant properties of methotrexate: Inhibition of malondialdehyde-acetaldehyde-protein adduct formation and superoxide scavenging. Redox Biol. 2017; 13: 588–593.
  12. Puckett Y, Gabbar A, Bokhari AA. Prednisone. In: StatPearls. StatPearls Publishing, Treasure Island. (FL): 2022.
  13. Ogoina D. Fever, fever patterns and diseases called 'fever' a review. J Infect Public Health. 2011; 4(3): 108–124.
  14. Macmillan C. What Does It Mean To Be ‘Immunocompromised’? In: Yale Medicine 2021. Updated: 2022. Accessed: October 18, 2023. Available from:. https://www.yalemedicine.org/news/what-does-immunocompromised-mean (16.08.2023).
  15. Janiec W. Leki układu immunologicznego (leki immunotropowe). In: Janiec W, Pytlik M, Cegieła U. ed. Kompendium farmakologii. Wydawnictwo Lekarskie PZWL, Warszawa 2017: 484–493.
  16. Spelman D, Baddour LM. Acute cellulitis and erysipelas in adults: Treatment. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com/contents/acute-cellulitis-and-erysipelas-in-adults-treatment#H2126273051 (17.10.2023).