# Life Threatening Complication during Treatment of Erysipelas due to Undiagnosed Ischemia of the Calf

Authors: Tomasz Brzeziński; Tomasz Ostrowski; Maciej Skórski
Journal: Case Reports in Medicine
 (2009)

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## Abstract

Erysipelas is a
superficial skin infection due to streptococci
strains, which usually responds well to
conservative treatment. Coexisting undiagnosed
ischemia of the extremity may lead to severe
complications. 57-year-old man developed large,
circumflex ulceration of his right calf within
two weeks before the admission after three-month treatment of erysipelas. Computer
angiography showed chronic occlusion of the
superficial femoral artery and the above knee
popliteal artery. Rapid debridement of the wound
took control over the infection. Patient
required complex vascular procedure which
allowed to prepare the ulcer for meshed skin
grafts. Patient was discharged home on 64th
hospital day with completely healed
ulcer.


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## Body

## 1. Introduction

Erysipelas is a superficial  skin infection caused by Streptococci diagnosed in dermatologic and surgical outpatient  clinics. It is successfully treated with antibiotics and some relief of symptoms can be observed even after 48 hours [1]. Mortality rate does not exceed 0.5% and is due to organ failure [1]. Small ulcers can appear  when the illness is localized on lower extremities but surgical intervention is seldom necessary.  Ischemia of the calf  predisposes to gangrene and ulcer formation which can develop to giant proportions. Septic shock may  lead to patient death if surgical treatment is not undertaken in time.


## 2. Case History

A 57-year-old  male patient was admitted to our ward  on a duty because of large circumflex  ulcer of his  right  calf.  On admission this patient was tachycardic  with a temperature of 39 degrees  centigrade, chills,  and severe pain  requiring  narcotic pain killer. The circumflex ulceration started  from the upper  mid of the foot  and reached upper one third of the calf. The remaining skin was necrotic and  healthy margins were undermined with pus. The underlaying fascia disclosed  muscles in patches. The smell was characteristic for severe inflammation. The patient also had a history of intermittent claudication  and smoking of 30 cigarettes daily for more than 30 years. On examination there was no pulse in the popliteal fossa.First  report of the patient’s current complaints was made 3 months earlier in dermatology clinic when he presented  with painful, red swelling on his calf.  On that time erysipelas was diagnosed and he received antibiotics. He has been consulted several times by a dermatologist because of adverse course of his illness, small  ulcer and pain. Sudden worsening appeared about two weeks before admission. In our ward the bacteria culture was taken and revealed  strains of Beta Streptococcus and Enterobacter cloacae. Patient was first treated with Ciprofloxacin and then according to the antibiogram. Dedridement of the wound was performed under general anesthesia immediately and wet sponges with Octenisept, Octenidinum dihydrochloricum + Phenoxyethanolum (0,10 g + 2,00 g). Schulke  GmbH, Germany, and 10% saline were continued. The preliminary result was good:  body temperature returned to normal, granulation appeared in the wound, and the exudate was minimal (see Figure 1). Computer angiography revealed occlusion of superficial femoral artery and the above knee  popliteal artery. Two arteries were patent on the calf  (see Figure 2). Patient underwent elective vascular operation  comprising of endarterectomy of the above knee popliteal artery with venous patch-plasty and  femoro-popliteal  bypass  6 mm PTFE, Polytetrafuroethylene, with  above knee  distal anastomosis performed just above the venous patch. Postoperative wounds healed very well. Vascular conduit improved  granulation so much that it covered the whole ulceration; only remaining necrosis required excision. 28 days later the whole wound was covered with intermediate meshed split-thickness skin grafts expanded in a 1.5:1 ratio. The complete ingrowth was observed  within 2 weeks (see Figure 3). Postoperative ankle-brachial index, the comparison of mean arterial pressure  between  foot arteries and brachial artery  in horizontal position, was normal and close to 1.0.  On the 64th  hospital day the patient was discharged home with completely healed  ulcer.Figure 1
The view of the  calf one week after the debridement:  granulation is clearly visible with  shrinking  of the ulceration and remaining necrosis of the skin.Figure 2
Computer angiography presenting  arteries of  the right lower extremity. An arrow shows the bifurcation of femoral artery and occlusion of superficial femoral one.  Deep femoral artery is well developed. Common iliac artery and  external iliac one seem to be normal.Figure 3
The view of the calf at the end of the treatment. Skin grafts nearly completely healed. Postoperative wound  also healed, visible above the knee.


## 3. Discussion

Erysipelas is a superficial  skin infection due to Steptococci which nowadays is localized  on legs in most cases. Apart from  Streptococci group A, a nongroup A Streptococci and other strains  are main isolated pathogens although Enterobacter cloacae in our patient seems to be rather a superinfection. Staphylococcus aureus may play the role in bullous erysipelas with MRSA strains present [2]. Some medical conditions like diabetes, venous insufficiency,  HIV infection, nephrotic syndrome,  and alcohol abuse  may predispose to erysipelas but it is doubtful whether they predispose to complications.Erysipelas itself gives wide undermining of subcutaneous tissue which is very characteristic but even in severe cases like bullous erysipelas big ulcers are rare. Superficial  necrosis and leg ulcer complicate 3%–12% of cases [1]. Ischemic calf  creates completely different situation especially when the condition is not recognized early. As we know it predisposes to each kind of infection so that patients with severe  and critical limb ischemia may present with ulcers of different sizes and localizations. The rapidly  developing necrosis and ulceration within two weeks before admission  could be due to necrotizing fascitis when gangrene tends to follow in multiple sites. Infections with widespread  thrombosis and vascular necrosis of involved skin are two major factors in pathogenesis  of gangrene [3]. Early debridement can prevent the spread of necrosis  what proved to be very effective in our case. The vascular situation of this patient was good  because two patent arteries on the calf provided good run-off. Local  conditions on the ulcerated calf  did not allow to perform the surgical incision below the knee because of  high possibility of wound infection. So this changed the strategy of operation and endarterectomy of popliteal artery with patch plasty had to be done from supragenicular access to create conditions for the above-knee distal anastomosis of  femoro-popliteal bypass. It is known  that both venous and  artificial  femoropopliteal bypasses present with much higher patency rate when distal anastomosis  is done above the knee joint [4].The use of  artificial  vascular conduits is usually avoided at the presence of active inflammation on the operated limb [4]. In our case politetrafuoroethylene bypass seemed justified because of the lack of proper big saphenous vein on both legs [4, 5]. Ankle-brachial index is a useful and simple method  for the assessment of limb ischemia. Normal values range between 0.8 and 1.0. Values of 0.5 and lower are usually due to occlusion of superficial femoral artery.  Healing  of ulcers on ischemic extremity without vascular procedure, classic operation, or endovascular treatment is very difficult or even impossible  and may lead to amputation. In literature the  procedures concerning the ulcer itself, debridement, and skin grafts placing seem to  increase the effectiveness of the whole treatment and allow to achieve a leg ulcer healing in combination  with vascular operation [6, 7].



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