“He’s started walking with crutches,” said Gunnar. “Well, he tried. Are you sure he doesn’t have gangrene? I don’t want to catch gangrene.”
“What an absurd! He has an infection. It’s called erysipelas.”
“Aaah,” breathed Gunnar.
“Oh,” said Sigurd.
“Don’t bother memorising the name,” said Brynjólf, then looked at the clock above the door. “You came in time. It might have indeed developed into gangrene if you waited too long. And now, if you excuse me…” He looked doubtfully at his unfinished lunch. Just washing his hands might not be enough. The bedding would require changing. Complications from erysipelas were both dangerous and very unpleasant, but there was no need for the two men to know that, not yet.
A long time ago in a galaxy far, far away… Oops, not that fairy tale. Anyway, a long time ago there was a patient suffering from erysipelas. The doctor treated him (or her) with application of mercurial ointment, and the treatment was so effective that the patient’s friends got suspicious. They basically accused the doctor of driving the disease in and, in consequence, another physician was asked to draw it out. As you can see, even over a century ago, devious Big Pharma and its minions tried to scare poor, innocent people by getting them sick first, and then by treating them with their weird magic/medicine skills into submission. All this so that patients will rely on them Big Pharma shills and their dreadful remedies forever.
Kidding. Now we think that doctors were not to blame. At least not in that case.
Erysipelas has been known for centuries. For a very long time it was referred to as St. Anthony’s fire, because sick people asked Saint Anthony the Great (AD 251-356, Egyptian monk and miraculous healer) for healing and help. It was pretty simple: those who prayed – were said to live, those who didn’t – died. Around year 1095 the Order of St. Anthony was established to care for those with the disease. However, at that time probably more than one condition was described under the name. “Erysipelas” likely meant not just erysipelas, but shingles (a viral infection developing due to reactivation of Varicella-Zoster (chickenpox) Virus) and possibly ergotism (long-term food poisoning, caused by ingestion of food contaminated with Claviceps purpurea fungus alkaloids) as well.
What is erysipelas then?
Erysipelas is a bacterial infection. Bacteria affect outer layers of the skin, as well as underlying lymphatic vessels. The disease presents clinically as sensitive and painful, inflamed, brightly red (erythematous) plaques on the skin (hence the name “red skin”, from Greek ἐρυσίπελας), with clearly demarcated margins (in contrast to cellulitis, which sometimes erysipelas may be confused with). Other common symptoms include: malaise, high fever with chills, joint and muscle pains and headache.
Erysipelas is quite common around the world. It appears usually as separated cases, although epidemics have been described, too. There are about 200 thousands cases reported each year in the US; some reports say that the infection may be even more common in Europe.
The prevalence, however, has decreased in the 20th century, most likely due to effective antibiotic treatments and improved sanitation. Erysipelas affects people of all ages, races and genders, but it seems that infants, young children and elderly are more prone to the disease. The necessary and initial point of infection is some kind of skin trauma and bacterial inoculation into the area. Risk factors include: lymphedema (swelling of legs or arms due to blockage in the lymphatic vessels), impaired immune system (the infection develops more readily in immunocompromised patients, e.g. diabetics, alcoholics, people infected with HIV, etc.), mastectomy, improper functioning of the valves in blood vessels (venous insufficiency), nephrotic syndrome (malfunctioning of the kidneys), as well as vagrant lifestyle.
The prognosis for patients with erysipelas is usually very good. With early diagnosis and antibiotic treatment patients recover quickly and without complications. However, in rare cases the causative bacteria may spread deeper into tissues under the skin and cause abscess formation, sepsis, necrotizing fasciitis, pneumonia, meningitis (inflammation of membranes surrounding the brain and spinal cord) and even death (notable casualties of erysipelas were for example: Pope Gregory XVI (died 1846), Queen Anne of Great Britain (died 1714), Queen Christine of Sweden (died 1689), and John Stuart Mill (died 1873)). Up to 20% patients with predisposing factors experience recurrent erysipelas (e.g. Richard Wagner, who suffered multiple outbreaks of the infection throughout his life).
The disease may also resolve spontaneously, without any treatment. As the authors of one ancient paper (1866, Reference No. 6) concluded – after describing some fancy remedies for erysipelas, such as anodyne syrup of gum acacia, painting with iodine, painting with silver nitrate, dosing the patient with the Dover’s powder or Seidlitz powders – no treatment apparently influenced the disease’s natural course.
What’s the etiology?
In 1883 a connection between erysipelas and a bacterium called Streptococcus pyogenes was uncovered by Friedrich Fehleisen, a German surgeon who studied streptococci and streptococcal diseases. Later, authors of another old paper cited here (Reference No. 10), after careful investigation into the etiology of erysipelas, wrote basically what we know now: that erysipelas is an acute inflammation of the skin, and the causative agents are streptococci, most frequently Streptococcus pyogenes.
Streptococcus pyogenes is one of the most important bacterial pathogens that attack humans and causes significant morbidity and mortality worldwide. Its name pretty much sums it up: Greek “streptós” means “easily twisted, pliant”, Modern Latin “coccus” is “grain, seed, berry”, “pyogenes” means suppurative (pus-forming); and together it describes a bacterium with round-shaped cells that stick together and form long chains, and indicates that this bacterium causes infections with a lot of pus produced.
S. pyogenes is a Gram-positive bacterium (Gram staining is one of the most important and basic methods in bacteria classification, it allows to divide these pathogens into two groups: purple-dark blue Gram-positive and pink Gram-negative species). It harbors Rebecca Lancefied A group antigen (carbohydrate C), and this is why – and because it is the predominant species in the group – it is sometimes simply referred to as GAS (group A streptococcus). When grown on blood agar, S. pyogenes causes a complete digestion of red blood cells in the medium around its colonies, which results in a very characteristic beta (clear, complete) hemolysis: normally red medium becomes transparent, like a yellowish halo surrounding bacterial growth.
Streptococcus pyogenes causes about 700 million human infections each year worldwide, resulting in over 500 thousand deaths. Approximately 5 to 15% healthy people are asymptomatic carriers of the bacterium, which colonizes their upper respiratory tract or skin. When a carrier’s immune system is compromised, S. pyogenes may penetrate and spread to other tissues of the body and cause infections. Its very potent virulence factors are definitely helping in this endeavor. These include: a capsule that helps evade the immune system, colonization-allowing adhesins, streptolysin S – a toxin negatively affecting blood cells, and streptococcal pyrogenic exotoxins – mighty superantigens – responsible for a spectrum of streptococcal infection symptoms, toxic shock syndrome and severe tissue destruction included.
In general, Streptococcus pyogenes causes two distinct types of infections: relatively mild and superficial, such as pharyngitis (I’m sure everybody experienced or at least heard of a “strep-throat” – the most common non-viral infection of the throat), erysipelas, cellulitis and impetigo; and much more severe (e.g. scarlet fever, quite rare these days, but one of the main causes of death in children in the early XX century) and often life-threating: bacteremia (blood infection) with sepsis, necrotizing fasciitis, toxic shock syndrome, pneumonia, endocarditis (infection of the inner lining of the heart) and meningitis. Importantly, S. pyogenes infections, especially repeated ones, may lead to dangerous nonsuppurative sequelae, such as acute rheumatic fever and acute glomerulonephritis.
Because of the above, it is very important to treat even mild S. pyogenes infections promptly – to minimize the risk of sequelae development. And the good thing is that we have a very efficient treatment available. Streptococcus pyogenes remains sensitive to beta-lactam antibiotics, including good ol’ penicillin (which is not very common among bacteria these days). In case of erysipelas, the drug of choice is oral penicillin for 10 to 14 days. If the patient is allergic to the drug, erythromycin is prescribed. The prognosis for erysipelas patients receiving proper and timely treatment is excellent.
- Howard JT. Mercurial Ointment in Erysipelas. Correspondence to the Editor. JAMA 1900; XXXIV(3): 185
- Encyclopaedia Britannica. “Erysipelas”. Retrieved from: https://www.britannica.com/science/erysipelas (Dec 27, 2018)
- Celestion R et al. Erysipelas: a common potentially dangerous infection. Acta Dermatoven APA Vol 16, 2007, No 3: 123-127
- Wikipedia contributors. “Erysipelas”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Erysipelas (Dec 27, 2018)
- Centers for Disease Control and Prevention. Content source: National Center for Immunization and Respiratory Diseases, Division of Bacterial Diseases. “Necrotizing Fasciitis: All You Need to Know”. Retrieved from: https://www.cdc.gov/groupastrep/diseases-public/necrotizing-fasciitis.html (Dec 27, 2018)
- Erysipelas; cases illustrating its natural history. The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Vol. LXXIV, No. 19, 1866
- Wikipedia contributors. “Dover’s powder”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Dover%27s_powder (Dec 27, 2018)
- Wikipedia contributors. “Seidlitz powders”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Seidlitz_powders (Dec 27, 2018)
- Wikipedia contributors. “Streptococcus pyogenes”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Streptococcus_pyogenes (Dec 27, 2018)
- Panton PN and Adams JE. An investigation into the etiology of erysipelas and allied infections. The Lancet 1909
- Henningham A. Pathogenesis of Group A Streptococcal infections. Discovery Medicine 2012
- Wikipedia contributors. “Lancefield grouping”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Lancefield_grouping (Dec 27, 2018)
- Wikipedia contributors. “Streptococcus”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Streptococcus(Dec 27, 2018)
- Wikipedia contributors. “Superantigen”. Wikipedia, The Free Encyclopedia. Retrieved from: https://en.wikipedia.org/wiki/Superantigen (Dec 27, 2018)