Bullous Erysipelas with Fat Herniation
Bizri LA, Alalwan Y, Alsafadi K, and Scher E. Bullous Erysipelas with Fat Herniation. J Gen Intern Med 2019; 34(2):S498-S499.
J Gen Intern Med
Learning Objective #1: Recognize that fat herniation is a possible complication of erysipelas Learning Objective #2: Distinguish bullous erysipelas from cellulitis or skin abscesses CASE: A 68 year old female presented with acute onset left leg skin erythema and tenderness of two days duration. She attributed her symptoms following a sting to her left leg which woke her up from her sleep. She also reported mild systemic symptoms including fever and chills. Upon presentation she was found to be febrile and tachycardic. Inspection of the left leg showed a raised, well demarcated area of erythema and mild swelling. A presumptive diagnosis of erysipelas was made and the patient was started on a first-generation cephalosporin. Over the next two days her pain and erythema worsened. She began to form very large bullae which were filled with yellow, gelatinous material. She was initially treated with Cefazolin but was escalated to Vancomycin because of her worsening course. A soft tissue ultrasound ruled out any underlying collection of fluid. Dermatology was consulted on day two of admission and made a diagnosis of erysipelas with fat herniation secondary to elevated subcutaneous pressures from the inflammation. She was started on Prednisone to help reduce the inflammation and her antibiotics were switched back from Vancomycin to cefazolin. The Infectious disease service recommended treating for 14 days. During outpatient follow up in dermatology clinic, patient was noted to have resolution of leg pain and improvement of skin lesions after completion of antibiotic treatment. IMPACT/DISCUSSION: Initially, the acute onset of symptoms: fever, pain, erythema and swelling with the appearance of a raised well demarcated skin lesion, made erysipelas the most likely diagnosis. However, the sudden appearance of bullae containing gelatinous-like material while on an appropriate antibiotic regimen forced the primary service to reconsider this diagnosis. Necrosis, abscess formation, deep thrombophlebitisis and hemorrhagic purpura are known complications of erysipelas that have been reported previously in the literature. Therefore, our reported case of fat herniation resembles a unique complication of erysipelas. According to the literature, fat herniation has been described in piezogenic papules which are benign mostly painless skin-colored papules made of fat associated with exercise, repetitive pressure forces, and connective tissue diseases. To our knowledge, cases of soft tissue infections with described fat herniation have not been reported before. The appearance of bullae on the epidermal surface with subcutaneous fat may have dissipated the pressure within the skin and prevented the formation of compartment syndrome within the patient's lower extremity. Conclusion: Erysipelas can present as a severe soft tissue infection creating a challenge for physicians in both diagnosis and management. Fat herniation represents a unique local complication of Bullous erysipelas.