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Title: Erysipelothrix rhusiopathiae septicemia in systemic lupus erythematosus
Authors: Kitti Totemchokchyakarn
Suchela Janwityanujit
Boonme Sathapatayavongs
Siripen Puavilai
Mahidol University
Faculty of Medicine, Ramathibodi Hospital, Mahidol University
Keywords: Medicine
Issue Date: 1-Jan-1996
Citation: International Journal of Dermatology. Vol.35, No.11 (1996), 818-820
Abstract: A 43-year-old Thai women was admitted to Ramathibodi Hospital because of an erythematous eruption on her hands and arms for 7 days. She had been diagnosed as having systemic lupus erythematosus (SLE) for 2 years. The criteria for diagnosis were: a malar rash, photosensitivity, autoimmune hemolytic anemia, and renal involvement. She had positive fluorescence antinuclear antibody (FANA) test of a speckled pattern. Her kidney biopsy showed lupus nephritis, class II, with local tubulointerstitial inflammation and sclerotic glomeruli. She was treated with prednisolone, 45 mg per day. Seven days before admission, she had an erythematous eruption on her fingers and hands, that later turned out to be purpuric. The lesions spread to her arms, legs, and trunk. Because of this eruption, she went to a hospital. Physical examination on admission showed no fever and normal vital signs. She was pale and had a cushingoid appearance. No cardiac murmur was described. She had multiple discrete erythematous and purpuric patches, 1 to 3 cm in diameter, with large tens bullae or vesicles on top. The lesions were distributed over the chest, abdomen, back, buttock, and the upper and lower extremities. Laboratory examination: hematocrit 20%; white cell count 5,900 per mL3, with 85% neutrophils, and 14% lymphocytes. The platelet count was 28,000 per mL3. The urine was negative for protein and blood. The blood creatinine was 1.6 mg per 100 mL. A coagulation study was normal. She was treated as a case of active lupus with pulse methylprednisolone, 1000 mg for 3 days, followed by prednisolone 60 mg per day. Although the fluid drawn from the bullae revealed a few gram-positive bacilli, this was considered contamination. Two days later, her platelet count had decreased to 18,000 per mL3with worsening of skin lesions and she was referred to our hospital. The physical examination revealed a middle-aged cushingoid woman who was slightly pale but not icteric. The temperature was 36.8°C, respiratory rate 20 per min, and the pulse rate 60 per min. Her blood pressure was 130/80 mm Hg. The cardiovascular examination and those of the lungs, fundi, abdomen, and the nervous system were normal. Examination of the skin revealed multiple, discrete sharp 'diamond shaped' erythematous and purpuric patches. Some of these patches had clear centers, others had large tense hemorrhagic bullae or vesicles on top. These lesions were distributed over the extremities, chest, abdomen, back, and buttock. The hemocrit had decreased to 21%; white cell count to 1,400 per mL3which was too low for a differential cell count. Platelet count was 28,000 per mL3, erythrocyte sedimentation rate 115 mm per hour and a direct Coomb's test was 3+ positive. A urinalysis was normal, urea nitrogen was 47 mg and creatinine 1.0 mg per 100 mL. Results of electrolyte determination, liver function, and coagulation study were normal. The FANA test was positive with a finely speckled pattern and a titer of 1:64. Anti-Sm and anti-nRNP were positive, but anti-DNA was negative. The total hemolytic complement (CH50) was 18% and beta-1-C (B1C) was < 200 ng per mL. A skin biopsy specimen showed dense diffuse neutrophil infiltrate with extravasated erythrocytes and marked edema of the papillary dermis, giving a microscopic diagnosis of 'diffuse neutrophilic dermatitis'. The immunofluorescence study was negative. The patient's initial diagnosis was active SLE with anemia, leukopenia, thrombocytopenia, and bullous LE. She was given prednisolone 60 mg per day, and broad-spectrum antibiotics while waiting for the report of the cultures. Two days later, cultures of blood and skin biopsies revealed the growth of Erysipelothrix rhusiopathiae; this organism was susceptible to ampicillin, cephalotin, chloramphenicol, erythromycin, lincomycin, methicillin, and tetracycline. To exclude septic endocarditis, an echocardiogram showed the size of the left ventricle to be at the upper normal limits with good contraction; no endocardial vegetation was seen. The definitive diagnosis was Erysipelothrix septicemia with active SLE. The patient was given cefazolin 4 gm per day for 2 weeks and continued with amoxicillin 2 gm per day for another 2 weeks. The prednisolone dosage was gradually reduced to 20 mg per day.
ISSN: 00119059
Appears in Collections:Scopus 1991-2000

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