Damstra RJ, van Steensel MA, Boomsma JH, Nelemans P, Veraart JC, et al.
The British journal of dermatology. Date of publication 2008 Jun 1;volume 158(6):1210-5.
1. Br J Dermatol. 2008 Jun;158(6):1210-5. doi: 10.1111/j.1365-2133.2008.08503.x.
Epub 2008 Mar 20.
Erysipelas as a sign of subclinical primary lymphoedema: a prospective
quantitative scintigraphic study of 40 patients with unilateral erysipelas of the
leg.
Damstra RJ(1), van Steensel MA, Boomsma JH, Nelemans P, Veraart JC.
Author information:
(1)Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital,
9202 NN Drachen, The Netherlands. r.damstra@nijsmellinghe.nl
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.
DOI: 10.1111/j.1365-2133.2008.08503.x
PMID: 18363756 [Indexed for MEDLINE]
