Figure 136.1 Erysipeloid. (From Gary M. White and Neil H. Cox, Diseases of the Skin, Philadelphia: WB Saunders; 1995.)
Mild pain may occur at the site of inoculation, followed by itching, throbbing pain, burning, and tingling. The characteristic skin lesion slowly progresses from a small red dot at the site of inoculation to a fully developed erysipeloid skin lesion, consisting of a well-developed purplish center with an elevated border. Patients often complain of joint stiffness and pain in the involved fingers, but swelling is minimal or absent. Small hemorrhagic, vesicular lesions may be present at the site of inoculation. Erysipeloid lesions do not resemble true cellulitis, as opposed to erysipelas, which is due to group A streptococcal infection. Thus, Rosenbach introduced the term erysipeloid for the human cutaneous disease caused by Erysipelothrix. Pain may be disproportionate to the degree of apparent involvement. Local lymphangitis and adenitis develop in 30% of patients. However, systemic symptoms such as high fever or chills are uncommon.
A provisional diagnosis is based on a history of contact with potentially contaminated materials or occupational exposure, plus compatible physical findings. Gram-stained smears and cultures of aspirated material from skin lesions are often negative because the organism is deep within the dermis.
Diffuse cutaneous disease
Most erysipeloid skin lesions resolve even without specific treatment. However, erysipeloid occasionally will progress to the diffuse cutaneous form in untreated patients. Eating of contaminated meat has also been reported as a cause of this clinical entity. The characteristic purplish skin lesions expand with gradual clearing of the center. Bullous lesions may appear at the primary site or at distant locations. These patients often have systemic symptoms such as high fever, chills, and arthralgias. Blood cultures are invariably negative.
Systemic infection (bacteremia and/or endocarditis)
Bacteremic infection caused by E. rhusiopathiae is generally a primary infection and not the result of dissemination from localized cutaneous disease. Nevertheless, one-third of patients with bloodstream infection have skin lesions suggestive of erysipeloid. Persistent bacteremia with E. rhusiopathiae has been reported after eating contaminated seafood. Cutaneous serpiginous lesions or multiple bullous lesions over the trunk and extremities may be seen. Many patients have fever for 2 to 3 weeks before presentation. Fever and chills may resolve spontaneously, but relapse is to be expected.
Patients with severe underlying heart disease or liver disease may present with a clinical picture resembling gram-negative sepsis. More than one-third of patients with disseminated infection are alcoholics, and chronic liver disease is a major predisposing factor. Bacteremia has also been reported in immunocompromised individuals, who often are receiving corticosteroid and/or cytotoxic drug treatment for collagen vascular disease or malignancy.
Erysipelothrix rhusiopathiae bacteremia is usually associated with a severe clinical course and is frequently complicated by endocarditis. Erysipelothrix