Document Detail


Erysipelas as a sign of subclinical primary lymphoedema: a prospective quantitative scintigraphic study of 40 patients with unilateral erysipelas of the leg.
MedLine Citation:
PMID:  18363756     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Erysipelas is a common skin infection that is usually caused by beta-haemolytic group A streptococci. After having had erysipelas in an extremity, a significant percentage of patients develops persistent swelling or suffers from recurrent erysipelas. We hypothesize that in cases of erysipelas without a clear precipitating agent, subclinical pre-existing congenital or acquired disturbances in the function of the lymphatic system are present. The persistent swelling after erysipelas is then most likely caused by lymphoedema. OBJECTIVES: We designed a study to examine if erysipelas of unknown origin is associated with a pre-existent insufficiency of the lymphatic system. If our hypothesis is correct, patients with erysipelas of unknown cause without previously evident lymphoedema should have evidence of disturbed lymphatic transport in the unaffected extremity. METHODS: A prospective study, in which lymphoscintigraphy of both legs was performed in patients 4 months after presenting with an episode of erysipelas only in one leg. No patient had any known risk factor for erysipelas, such as diabetes mellitus, chronic venous insufficiency or clinical signs of lymphoedema. Lymphoscintigraphy was performed in 40 patients by subcutaneous injection of Tc-99m-labelled human serum albumin in the first web space of both feet. After 30 and 120 min, quantitative and qualitative scans were performed using a computerized gamma camera. During the lymphoscintigraphy, the patients performed a standardized exercise programme. Lymph drainage was quantified as the percentage uptake of Tc-99m-labelled human serum albumin in the groin nodes at 2 h after injection. Groin uptake of < 15% is pathological; uptake between 15-20% is defined as borderline, and uptake of > 20% as normal. RESULTS: The mean +/- SD percentage uptake in the groin nodes in the affected limbs was 9.6 +/- 8.5% vs. 12.1% +/- 8.9% in the nonaffected limbs. The mean paired difference in uptake between the nonaffected vs. affected side was 2.5% (95% confidence interval 1.1-3.9%). This indicates that lymphatic drainage in the nonaffected limb was only slightly better than in the affected limb despite the infectious event in the latter. Of 33 patients with objective impairment of lymph drainage in the affected limb, 26 (79%) also had impaired lymph drainage in the nonaffected limb. Agreement in qualitative measurements between affected and nonaffected leg was less pronounced: 21 patients had abnormal qualitative results in the affected leg of whom nine also had impairment of the nonaffected leg (43%). CONCLUSIONS: Erysipelas is often presumed to be purely infectious in origin, with a high rate of recurrence and a risk of persistent swelling due to secondary lymphoedema. In this study, we show that patients presenting with a first episode of erysipelas often have signs of pre-existing lymphatic impairment in the other, clinically nonaffected, leg. This means that subclinical lymphatic dysfunction of both legs may be an important predisposing factor. Therefore, we recommend that treatment of erysipelas should focus not only on the infection but also on the lymphological aspects, and long-standing treatment for lymphoedema is essential in order to prevent recurrence of erysipelas and aggravation of the pre-existing lymphatic impairment. Our study may change the clinical and therapeutic approach to erysipelas as well as our understanding of its aetiology.
Authors:
R J Damstra; M A M van Steensel; J H B Boomsma; P Nelemans; J C J M Veraart
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't     Date:  2008-03-20
Journal Detail:
Title:  The British journal of dermatology     Volume:  158     ISSN:  1365-2133     ISO Abbreviation:  Br. J. Dermatol.     Publication Date:  2008 Jun 
Date Detail:
Created Date:  2008-05-16     Completed Date:  2008-08-20     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0004041     Medline TA:  Br J Dermatol     Country:  England    
Other Details:
Languages:  eng     Pagination:  1210-5     Citation Subset:  IM    
Affiliation:
Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, 9202 NN Drachen, The Netherlands. r.damstra@nijsmellinghe.nl
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adult
Aged
Child
Erysipelas / etiology*
Female
Humans
Leg / radionuclide imaging*
Lymphatic System / radionuclide imaging*
Lymphedema / complications,  radionuclide imaging*
Male
Middle Aged
Prospective Studies
Radiopharmaceuticals / diagnostic use
Streptococcal Infections / diagnosis
Streptococcus / physiology
Technetium Tc 99m Aggregated Albumin / diagnostic use
Treatment Outcome
Chemical
Reg. No./Substance:
0/Radiopharmaceuticals; 0/Technetium Tc 99m Aggregated Albumin

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