Red-faced?

By Peter Galvin, MD

This case report comes from “The New England Journal of Medicine.” The man in the photo, who was 44 years old, presented to the primary care clinic at Yale School of Medicine. He complained of a two-day history of a facial rash. He was being treated for Crohn’s disease with infliximab (Remicade), an immunosuppressant. In the week before he came to the clinic, his daughter had a sore throat, and his mother had a similar facial rash. He did not have a fever, and physical examination was notable for well-demarcated, warm, erythematous (red), confluent plaques across the cheeks, nose, and glabella (skin above the nose and between the eyes), with a dimpled appearance of the skin (peau d’orange). His pharynx (throat) was normal, and he had no lymphadenopathy (swollen lymph nodes). A diagnosis of erysipelas was made. He was placed on oral antibiotics. While blood cultures are not usually required for erysipelas, they were performed because he was immunosuppressed. When the cultures grew Streptococcus pyogenes, he was called back to the hospital, admitted, and placed on intravenous penicillin G (when blood cultures grow bacteria, this is known as a bacteremia, a medical emergency). His rash resolved after five days.

Erysipelas is a type of skin infection, or cellulitis. It is usually confined to the outer layers of the skin and is usually caused by Beta-hemolytic strep, but Staph can cause it too. The bacteria can enter the skin after the skin barrier is broken, for example after a human, insect, or animal bite, burns, abrasions, and minor trauma. Erysipelas can affect any skin area, but facial infections are common. Symptoms usually appear suddenly and can include fever, chills, fatigue, headache, swollen, red skin, and swollen lymph nodes. The rash is not directly caused by the bacteria, but by an exotoxin it produces. Typically, erysipelas responds to oral antibiotics in non-immunosuppressed people, but if untreated or misdiagnosed, it can lead to more severe disease like necrotizing fasciitis, also called the skin-eating disease, and death.

Historically, before the advent of antibiotics, erysipelas was common and was called St. Anthony’s fire. It was responsible for the death of many historically prominent people, even into the early 20th century, for example Miller Huggins, who died in 1929 from erysipelas-related sepsis and was manager of the Yankees, including the famous “Murderer’s Row” of 1927. Many others survived it and recovered without antibiotics, for example Vladimir Lenin, Ernest Hemingway, and, in fiction, Sherlock Holmes.

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