A comparison of clinical findings of familial Mediterranean fever patients with and without amyloidosis

OBJECTIVE

This study investigates the clinical and demographic characteristics of familial Mediterranean fever (FMF) patients with and without amyloidosis.

PATIENTS AND METHODS

The clinical data of 503 patients with FMF (females:males 250:253) were reviewed. Fifty of these patients had amyloidosis (f:m 23:27).

RESULTS

The ages of attack onset in patients with and without amyloidosis were 7.8+/-6.2 and 11.1+/-8.5, respectively (P<0.05). The time between disease onset and diagnosis was longer in patients with amyloidosis than those without (187.6+/-99.4 months and 132.5+/-110.2 months, respectively, P<0.001). More patients in the amyloidosis group had positive family histories of FMF (68% vs 54%, P<0.05). The frequencies of chest pain (78% vs 51%, P<0.001), arthritis ( 80% vs 60%, P<0.01), and erysipelas-like erythema (44% vs 16%, P<0.001) were higher in the amyloidosis group.

CONCLUSION

In the amyloidosis group, FMF-related manifestations of chest pain, arthritis, and erysipelas-like erythema are more frequent. Our results also support that long periods between disease onset and diagnosis are associated with a high risk of developing amyloidosis.

Resting tachycardia, a warning sign in anorexia nervosa: case report

Background

Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80–90 bpm range, a supervening acute illness should be suspected.

Case presentation

A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight.

Conclusions

Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.

[Relapsing facial erysipelas caused by nickel allergy. Significance of allergy diagnostics in ENT practice]

This case report shows a typical complication of allergic contact dermatitis as it is often seen in hand and foot eczema: relapsing erysipelas. To our knowledge the occurrence of such a complication in the face has never been reported. In the case presented, relapsing facial erysipelas were treated four times in a period of 2 years symptomatically without having identified or eliminated the causing allergen. This clearly indicates how important it is to have a sound knowledge of allergology and its diagnostic procedures, especially in ENT-practice.

[How I prevent erysipelas and its consequences and recurrences]

Erysipelas is a serious infection of the skin. In case of delay in initiating adequate antibiotic treatment, complications, sometimes dismal, can supervene. In addition, erysipelas shows a tendancy to recurrences. The prevention of an episode of erysipelas calls for correct personal hygiene and adequate use of topical antiseptics in case of skin effraction, even when minimal. When erysipelas is established, a rapidly initiated antibiotic treatment for a prolonged period prevents streptococcal gangrene complications. Elastic contention of any leg edema from venous or lymphatic origin and prophylactic antisepsis of discrete wounds help in preventing erysipelas recurrences.

Acute erysipelatous oedema in the scrotum

We present a case of penile and scrotal oedema in a young man. Although oestradiol treatment and compression bandaging provided some relief from the symptoms, neither therapy was ideal. Triangular resection of the foreskin was therefore performed, although the oedema persisted. The aetiology of the condition remains unknown.

Osteoarticular complications of erysipelas

BACKGROUND

Rare osteoarticular complications occurring after erysipelas have been reported. We describe 9 patients in whom various osteoarticular complications developed during erysipelas.

OBJECTIVE

We sought to analyze osteoarticular complications during erysipelas, paying special attention to clinical, bacteriologic, and radiologic data.

METHODS

Data were retrospectively recorded from the files of patients seen in 3 dermatologic centers between 1998 and 2000. They included laboratory tests, bacteriologic cultures, radiologic investigations, and treatment modalities and outcome of both erysipelas and osteoarticular complications.

RESULTS

We observed 9 patients (7 men and 2 women; mean age 49.6 years) who first presented with typical erysipelas of the lower limb and then osteoarticular complications developed during the course of their disease, always localized to a joint contiguous to the erysipelas plaque. These complications included: relatively benign complications, ie, bursitis (n = 5) or algodystrophy (n = 1), occurring after erysipelas with favorable course; and more severe complications, ie, osteitis (n = 1), arthritis (n = 1), and septic tendinitis (n = 1), occurring after erysipelas characterized by local cutaneous complications (abscess, necrosis).

CONCLUSIONS

Osteoarticular complications of erysipelas can be divided into the 2 groups of nonseptic complications (mainly bursitis), which are characterized by a favorable outcome, and septic complications (osteitis, arthritis, tendinitis), which require specific, often prolonged treatment and, sometimes, operation. Their diagnosis is on the basis of clinical and radiologic findings rather than joint aspirations, which are usually not possible through infected skin tissue.

Wound healing of chronic leg ulcers under the influence of erysipelas

We report four patients with long-lasting therapy-resistant ulcus cruris, on which a new erysipelas was superimposed. In one case there was a total closure of the ulcers under the erysipelas. In three patients a reduction in size occurred. All ulcers became flatter. Other stimuli of wound healing were excluded. Because of the long-lasting existence and well known therapy resistance in each case, these changes suggest a positive effect of the erysipelas on the healing of the ulcers. We assume that serum cytokines could offer a possible explanation for this. The concentrations of the IL-6 and IL-2-receptor were initially raised and then later decreased in three of the four cases. Because of the complex stimulation and regulation mechanisms in the cytokine network which are triggered by inflammation, systemic and local effects of keratinocytes, monocytes/macrophages, fibroblasts and endothelium cells could also be assumed to support wound healing.

Angiosarcoma in a Chronically Lymphedematous Leg: An Unusual Presentation of Stewart-Treves Syndrome

Angiosarcoma arising from chronic lymphedema is referred to as Stewart-Treves syndrome. It typically occurs as a complication of long-lasting lymphedema of the arm after mastectomy and/or radiotherapy for breast cancer. Angiosarcoma associated with idiopathic lymphedema of the lower extremity is extremely rare. We report a case of diffuse angiosarcoma of the leg in a patient with a 25-year history of idiopathic lymphedema. Despite rapid aggressive surgical treatment, the patient died 6 weeks after diagnosis.

Erysipelas: recognition and management

Erysipelas is an acute bacterial infection of the dermis and hypodermis that is associated with clinical inflammation. It is a specific clinical type of cellulitis and, as such, it should be studied as a specific entity. Erysipelas is generally caused by group A streptococci; it is highly probable that streptococcal toxins also play a role, which could, in part, help explain the clinical inflammation. Erysipelas of the leg is the main clinical type encountered. The face, arm, and upper thigh are the other most common sites for the occurrence of erysipelas. After a sudden onset, areas of erythema and edema characteristically enlarge with well-defined margins. Athlete's foot is the most common portal of entry for the disease. Erysipelas is generally associated with high fever, and adenopathy and lymphangitis are sometimes present. At the time of diagnosis, it is important to look for clinical markers of severity (local signs and symptoms, general signs and symptoms, co-morbidity, social context) which would necessitate hospitalization. There are many differential diagnoses, particularly in the case of atypical dermo-hypodermitis. Some bacterial infections may have specific clinical aspects or may lead to a diagnosis of cellulitis. Necrotizing cellulitis or fasciitis are life-threatening diseases and a rapid diagnosis is important. Other noninfectious types of cellulitis have been reported in many diseases, both localized or generalized. The biology of typical erysipelas is of little value in diagnosis and a laboratory workup is usually not required. There are few local complications associated with erysipelas; abscess can occur in some patients and septicemia is rare. Recurrence is the more distressing complication. Treatment of patients with erysipelas has been evaluated in a small number of studies. In most of them, erysipelas has been included in therapeutic studies of 'severe cutaneous infections'. This is not justified as in fact erysipelas is usually sensitive to penicillin G. Amoxicillin and macrolides are also effective. However, comparative, cost-analysis studies need to be performed to determine the best therapeutic option. Bed rest with the leg elevated is also important. Anticoagulants are indicated in patients at risk of venous thromboembolism. The portal of entry will also require treatment. Long-term antibacterial therapy is required for patients with recurrence.

[A case of fulminant acute poststreptococcal glomerulonephritis showing mesangiolysis and crescent formation preceded by erysipelas]

A 66-year-old man with erysipelas was admitted with complaints of oliguria and massive proteinuria/hematuria. He was diagnosed as having acute poststreptococcal glomerulonephritis(APSGN) due to erysipelas infected by group A streptococcus pyogenes. On admission, his white cell count increased to 31,000, and CRP was 27.3 mg/dl. Serum urea nitrogen and creatinine were increased to 90.1 mg/dl and 4.5 mg/dl, respectively. He had diabetes mellitus(HbA1c 7.9%) and liver dysfunction(total bilirubin 3.5 mg/dl, AST 76 IU, ALT 41 IU) caused by alcoholic liver cirrhosis. Hypocomplementemia was found in addition to ASO 216 U/ml and ASK 10,240 x. After antibiotics treatment was initiated, inflammation of the erysipelas began to improve. Disseminated intravascular coagulation syndrome, probably due to sepsis, occurred on the 5th hospital day. He died of gastrointestinal bleeding on the 18th hospital day. Renal autopsy revealed 37% formation of fibrocellular crescents, and marked mesangiolysis was noted by light microscopy. Granular deposition of C3 and IgG was seen along the capillary walls on immunofluorescence study. Intramembranous deposits were scattered on electron microscopy. This case illustrates a fulminant type of APSGN, which was in part attributed to the presence of diabetes and alcoholic liver cirrhosis. Histological findings of crescent formation and marked mesangiolysis may account for the fulminant clinical course.

Fever and cancer in perspective

CONTEXT

A relationship between feverish infection and concurrent remission from cancer has been known about for a very long time. However, a systematic investigation of the phenomenon has not yet been made.

OBJECTIVE

To bring together the isolated observations about the coincidence of spontaneous remissions with feverish infections and William Coley's seminal work, as a basis for devising an immunological hypothesis about the putative anti-cancer effect of fever.

CONCLUSION

Fever induction under medical guidance may be considered as part of a therapy regimen for cancers of mesodermal origin.

[Erysipelas: evolution under treatment, complications]

OBJECTIVE

The authors studied the evolution and the complications of lower limb erysipelas under antibiotherapy.

METHOD

The following parameters were studied in literature over the last 20 years (keyword=erysipelas): percentage of favorable course, delay for cure, local or systemic complications, prognostic factors, and mortality.

RESULTS

Data was only available in series of hospitalized patients. The lower limbs were the exclusive or the most frequently involved areas. Under systemic antibiotherapy, the overall efficacy rates reached 76-84 p. 100, with apyrexia within 24 to 48 h, and regression of local symptoms within 4 to 6 days. The median hospital stay was 10-13 days. A longer hospital stay was observed for: older patients, associated diseases, longer duration of illness prior to admission, and presence of a leg ulcer. Complications were observed: abscess or superficial necrosis (3-12 p. 100), deep thrombophlebitis in 1.4 p. 100 of retrospective studies vs. 2.6-15 p. 100 in prospective series. Mortality was low (0.5 p. 100) due to systemic complications more than to the severity of local symptoms. Relapse was frequent (15-25 p. 100).

DISCUSSION

The unavailability of data concerning outpatients limits the formulation of valid conclusions. Nevertheless the medical course was favorable (80 p. 100) with apyrexia within 2 days, and absence of local symptoms within 4 to 6 days. Mortality or longer duration of hospital stay was linked to age or to associated diseases. The risk of deep thrombophlebitis was rare in absence of predisposing factors. Systematic prevention should be suggested and care given to local predisposing factors responsible for frequent recurrent forms.

[Management of erysipelas]

The objective of this literature review was to evaluate the therapeutic management of erysipelas. We selected 74 publications, some of written a long time ago, and thus open to criticism regarding their methodology. However, no recent or better study was available on the subject. Penicillin G remains the therapeutic reference. The use of macrolides and stretogramins is an alternative after the exclusion of severe forms of erysipelas. The preventive treatment of thrombosis by heparin must be discussed taking into account risk factors. More studies are necessary to suggest a coprescription corticoid/NSAIDs and antibiotherapy. The best antibiotic prophylaxis after the initial treatment isabenzathine-penicillin injection every 15 days.

Lymphoscintigraphic evaluation in patients after erysipelas

Erysipelas (cellulitis/lymphangitis) is a superficial cutaneous infection spread by the lymphatic system which may result in permanent injury to the lymphatic vessels. The study evaluated the lymphatic drainage in the lower limbs of 30 patients with at least two episodes of erysipelas by means of lymphoscintigraphy. Twenty-two (73%) were female and 8 (27%) were male with ages ranging from 26 to 77 years (mean 52 years). Lymphoscintigraphy was performed by intradermal administration of 500 microCi (20 Mbq) of 99mTc antimony sulfur-colloid in two interdigital spaces of the feet. Whole body scintigraphy was performed 45 minutes after the administration of the radiopharmaceutical using a computerized gamma camera. Significant lymphatic abnormalities were found in 23 (77%) of these patients. We conclude that most patients with repeated erysipelas have significant and even permanent abnormalities in regional lymphatic drainage. Recurrent erysipelas suggests underlying primary or secondary lymphedema.

[Heavy and swollen legs]

Painful sensation of heavy or swollen legs are non-specific symptoms frequently associated with chronic venous insufficiency. Clinical evaluation is the first step in defining the cause of the complaint and offering adequate treatment. When a heavy or swollen leg is associated with oedema, venous insufficiency, lymphatic or systemic disease must be considered. If symptoms occur during walking a vascular or nervous disease must be suspected. Associated erythema suggests infection (erysipelas). If clinical data are the cornerstone of diagnosis, difficulty may arise from the high frequency of superficial venous insufficiency and the readiness of linking too quickly any non specific complaint to this particular venous disease.

[Risk factors for local complications in erysipelas]

BACKGROUND AND OBJECTIVE

A complicated course of erysipelas is not uncommon. Bullous, haemorrhagic, necrotic and purulent lesions may be encountered. Today no reliable data exist as to which constitutional factors renders a patient at risk for developing complicated erysipelas though several risk factors, particularly diabetes mellitus, are often suggested. Based on the analysis of patients with erysipelas at the Department of Dermatology in Graz, factors determining the risk for complicated erysipelas should be identified.

PATIENTS/METHODS

In a retrospective case-control study clinical data sheets of 766 in- patients treated at the department were evaluated with respect to the course of the erysipelas and with respect to potential risk factors.

RESULTS

General risk factors for local complications were location at the lower extremities, pre-existing hepatic or renal disease, hyperuricaemia, and diabetes mellitus. Hepatic and renal disease and - to a lesser extent - diabetes particularly predisposed for bullous and haemorrhagic lesions, while vascular occlusive disease enhanced the risk for necrotic lesions.

CONCLUSIONS

Location and hepatic and renal disease are the most important risk factors, while diabetes is probably of less significance than previously suggested.

[Laboratory methods of prognostication in suppurative complications of erysipelas inflammation]

The dynamics of the leukocyte index of intoxication (LII) and the blood-cell index (BCI) was studied in 2756 patients with erysipelas. Both indexes, raised at the height of the disease, are lowering under the therapy influence. At the purulent-inflammatory complications beginning the LII and BCI level remains high or raises 2-3 days before occurrence of clinical signs of complication. The application of above-mentioned indexes for prognostication and diagnosis is possible.

[Eruptive epidermoid cysts secondary to erysipelas]

INTRODUCTION

Eruptive epidermoid cysts often occur following bullous skin diseases and their histopathological origin is from follicular or eccrine structures.

CASE REPORT

A case of a patient who developed eruptive epidermoid follicular cysts following an erysipelas without bullous lesions is reported. The lesions disappeared secondarily to a relapse of the cutaneous infection.

DISCUSSION

This association is rare but can be explained thinking to histogenesis of eruptive epidermoid cysts. The rapid resolution of these lesions occurring during a new inflammatory flare emphasize their tendency toward spontaneous resolution by extruding their contents.