Erysipelas (or non-necrotizing bacterial dermohypodermatitis, DHBNN) is an acute bacterial infection of the dermis and hypodermis responsible for local inflammation associated with general signs [1]. The diagnosis remains clinical, yet misleading atypical forms are also possible, which may delay the initiation of a well-adapted antibiotic treatment and evolve toward a life-threatening situation. In its typical form, DHBNN is manifested by a localized edematous plaque, bright red, hot, with more or less clear edges, of sudden onset and rapid extension on the surface, accompanied by thermal elevation and chills [2]. The two preferred sites of DHBNN are the legs and the face, yet other topographies may be affected as well [3].

A 45-year-old woman with no previous history presented to the emergency department for the management of induration of the right breast and redness of the ipsilateral hemi-trunk evolving for twenty days. A clinical examination revealed an indurated inflammatory plaque affecting the right hemi-trunk with a breast taking on an orange peel appearance surmounted by skin detachment in its outer quadrants (Fig. 1a) evolving in a context of fever at 40°C and a deterioration in general condition. Faced with the suspicion of a paraneoplastic context, breast ultrasound with a cranio-cervico-thoraco-abdomino-pelvic CT scan was performed, returning without abnormalities. A dermatological opinion was sought, and the clinical examination revealed a scratch on the thumb constituting a portal of entry without ipsilateral inflammatory adenopathies, thus the diagnosis of DHBNN was retained. The patient was put on tri-antibiotic therapy (protected amoxicillin + fluoroquinolone + metronidazole) and a treatment of the portal of entry with a good clinical and biological evolution (Fig. 1b).

Figure 1: (a) Indurated and infiltrated erythematous plaque with an orange peel appearance on the right breast topped by a serous, fluid-filled detachment. (b) Regression of the erythematous plaque after treatment.

This is an original observation of an atypical case of erysipelas showing the interest of a meticulous clinical examination before any imaging in search of a portal of entry thus allowing the early initiation of an appropriate treatment.

REFERENCES

1.  Christmann D, Bernard P, Denis F, Dupon M, Kopp M, Meyer P, et al. Conférence de consensus. Érysipèle et fasciite nécrosante:prise en charge. Méd Mal Infect. 2000;30 Suppl 4:252-72.

2.  Bernard P. Management of common bacterial infections of the skin. Curr Opin Infect Dis. 2008;21:122-8.

3.  Lanoux P, Penalba C, Legin C, Kivade M, Reveil JC. L’érysipèle:àpropos de 118 observations. Med Mal Infect. 1993;23:908-1.