Erysipeloid
Erysipeloid is infection caused by the gram-positive bacillus Erysipelothrix
rhusiopathiae. The most common manifestation is an acute but slowly evolving
localized cellulitis. Diagnosis is by culture of a biopsy specimen or occasionally
polymerase chain reaction testing. Treatment is with antibiotics.
Erysipelothrix rhusiopathiae (formerly E. insidiosa) are thin, gram-positive,
capsulated, nonsporulating, nonmotile, microaerophilic bacilli with worldwide
distribution; they are primarily saprophytes.
E. rhusiopathiae may infect a variety of animals, including shellfish, fish, birds,
and mammals (especially swine), and insects. In humans, infection is chiefly
occupational and typically follows a penetrating wound in people who handle
edible or nonedible animal matter (eg, infected carcasses, rendered products
[grease, fertilizer], bones, shells). Most commonly, patients handle fish or shellfish
or work in slaughterhouses. Infection can also result from cat or dog bites.
Nondermal infection is rare, usually occurring as septic arthritis or infective
endocarditis.
Symptoms and Signs of Erysipeloid
Within 1 week of injury, a characteristic raised, purplish red, nonvesiculated,
indurated, slowly evolving localized cellulitic rash appears on the hand,
accompanied by itching and burning. Local swelling, although sharply demarcated,
may inhibit use of the hand, the usual site of infection. The lesion’s border may
slowly extend outward, causing discomfort and disability that may persist for 3
weeks. Localized erysipeloid is usually self-limited.
Regional lymphadenopathy occurs in about one third of cases. Erysipeloid rarely
becomes generalized cutaneous disease, which is characterized by purple skin
lesions that expand as the lesion’s center clears, plus bullous lesions at the primary
or distant sites.
Bacteremia is rare and is more often a primary infection than dissemination from
cutaneous lesions. It may result in septic arthritis or infective endocarditis, even in
people without known valvular heart disease. Endocarditis tends to involve the
aortic valve, and the mortality rate and percentage of patients needing cardiac
valve replacement are unusually high.
Rarely, central nervous system, intra-abdominal, and bone infections occur.
Erysipeloid
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This image shows the characteristic purplish red, indurated rash of erysipeloid
infection.
Image courtesy of Thomas Habif, MD.
Diagnosis of Erysipeloid
Culture
Polymerase chain reaction amplification for rapid diagnosis
Culture of a full-thickness biopsy specimen is superior to needle aspiration of the
advancing edge of a lesion because organisms are located only in deeper parts of
the skin. Culture of exudate obtained by abrading a florid papule may be
diagnostic. Isolation from synovial fluid or blood is necessary for diagnosis of
arthritis or endocarditis due to E. rhusiopathiae infection. E. rhusiopathiae may be
misidentified as lactobacilli.
Polymerase chain reaction amplification may aid rapid diagnosis of erysipeloid.
Rapid diagnosis is particularly important if endocarditis is suspected because
treatment of endocarditis due to E. rhusiopathiae is often different from the usual
empiric treatment of gram-positive bacillary endocarditis (eg, E. rhusiopathiae is
resistant to vancomycin, which is typically used).
Treatment of Erysipeloid
Penicillin, cephalosporins, fluoroquinolones, or clindamycin
For localized cutaneous disease, usual treatment is one of the following, given for
7 days:
Penicillin V or ampicillin (500 mg orally every 6 hours)
Ciprofloxacin (250 mg orally every 12 hours)
Clindamycin (300 mg orally every 8 hours)
Cephalosporins are also effective. Daptomycin and linezolid are active in vitro and
may be considered if patients are very allergic to beta-lactams. Tetracyclines and
macrolides may no longer be dependable.
E. rhusiopathiae are resistant to sulfonamides, aminoglycosides, and vancomycin.
Severe diffuse cutaneous or systemic infection is best treated with one of the
following:
Penicillin G (2 to 3 million units IV every 4 hours)
Ceftriaxone (2 g IV once a day)
A fluoroquinolone (eg, ciprofloxacin 400 mg IV every 12
hours, levofloxacin 500 mg IV once a day)
Endocarditis is treated with penicillin G for 4 to 6 weeks. Cephalosporins and
fluoroquinolones are alternatives. Vancomycin is often used empirically for the
treatment of gram-positive bacillary endocarditis; however, E. rhusiopathiae is
resistant to vancomycin. Thus, rapid differentiation of E. rhusiopathiae from other
gram-positive organisms is critical.
The same antibiotics and doses are appropriate for arthritis (given for at least 1
week after defervescence or cessation of effusion), but repeated needle aspiration
drainage of the infected joint is also necessary.
Key Points
Erysipeloid typically results from a penetrating wound in people who
handle edible or nonedible animal matter (eg, in a slaughterhouse) or
who work with fish or shellfish.
Within 1 week after the injury, a raised, purplish red, nonvesiculated,
indurated, maculopapular rash appears, accompanied by itching and
burning; about one third of patients have regional lymphadenopathy.
Bacteremia is rare but may result in septic arthritis or infective
endocarditis.
Diagnose by culturing a full-thickness biopsy specimen or an exudate
obtained by abrading a florid papule.
If endocarditis due to E. rhusiopathiae is suspected, rapid identification
of the pathogen is critical because treatment is often different from the
usual empiric treatment of gram-positive bacillary endocarditis; E.
rhusiopathiae is resistant to vancomycin, which is typically used to treat
gram-positive bacillary endocarditis.
Treat with antibiotics (eg, penicillin, ciprofloxacin) based on extent and
location of infection.
