Erythema marginatum

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Erythema marginatum
Leg with erythema marginatum Wellcome L0061869.jpg
Painting of a leg with erythema marginatum
Specialty Dermatology   OOjs UI icon edit-ltr-progressive.svg

Erythema marginatum (also known as chicken wire erythema) [1] is an acquired skin condition which primarily affects the arms, trunk, and legs. [2] It is a type of erythema (redness of the skin or mucous membranes) characterised by bright pink or red circular lesions which have sharply-defined borders and faint central clearing. The lesions typically range from 3 to 10 cm in size, and are distributed symmetrically over the torso and inner surfaces of the limbs and extensor surfaces. [3] The lesions last between one and four weeks but have been known to be present on patients for as long as several months. [4]

Contents

The condition was first reported in 1816 by Jean Cruveilhier and is thought to be linked to other skin conditions such as urticaria and systemic lupus erythematosus.

An association with bradykinin has been proposed in the case of hereditary angioedema. [5]

Presentation

The rings are barely raised and are non-itchy. The face is generally spared.[ citation needed ]

The condition is characterised by circular, non-pruritic, erythematous rashes which form on the trunk and extremities of the body. The rash has a known serpiginous edge, and often appears and disappears spontaneously over time. [6] Histological examination of the rash identifies infiltration of mononuclear cells and neutrophils in the papillary and upper half of the reticular dermis layer. [7]

Associated conditions

It occurs in less than 10% of patients with acute rheumatic fever (ARF), [8] but is considered a major Jones criterion when it does occur. [9] [10] The four other major criteria include carditis, polyarthritis, Sydenham's chorea, and subcutaneous nodules. In this case, it is often associated with Group A streptococcal infection, otherwise known as Streptococcus pyogenes infection, which can be detected with an ASO titer.[ citation needed ]

It is an early feature of acute rheumatic fever though not pathognomonic of it. [11] It some cases it may be associated with mild myocarditis (inflammation of heart muscle).

The condition is also seen as a precursor to or accompany an attack of angioedema, [1] and is seen in conditions like allergic drug reactions, sepsis and glomerulonephritis. [11]

It often occurs as a harbinger of attacks in hereditary angioedema. In this case it may occur several hours or up to a day before an attack.[ citation needed ]

Diagnosis

Types

Some sources distinguish between the following:[ citation needed ]

The diagnosis of erythema marginatum can be made during examination of skin appearance. A skin biopsy may be performed if needed, to confirm the diagnosis. Medical history and family history may also be taken into account.

Treatment

Erythema marginatum can be treated with hydrocortisone and adrenocorticotropc hormone (ACTH). [12]

In cases where the condition is associated with ARF and severe carditis, corticosteroids are indicated [13] alongside the classic treatment protocol for ARF which is a 10-day course of oral Penicillin. Alternatively, one dosage of Penicillin G benzathine may be injected intramuscularly followed with a daily course of oral Amoxicillin for a total of 10 days. In cases of Penicillin allergy, a Cephalosporin or Macrolide may be considered. To avoid recurrences of ARF, secondary prevention is called for. This may include a period of antibiotic prophylaxis determined by the presence of carditis and the amount of remaining heart damage. [14]

Related Research Articles

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Group A streptococcal infections are a number of infections with Streptococcus pyogenes, a group A streptococcus (GAS). S. pyogenes is a species of beta-hemolytic Gram-positive bacteria that is responsible for a wide range of infections that are mostly common and fairly mild. If the bacteria enter the bloodstream an infection can become severe and life-threatening, and is called an invasive GAS (iGAS).

<i>Streptococcus pyogenes</i> Species of bacterium

Streptococcus pyogenes is a species of Gram-positive, aerotolerant bacteria in the genus Streptococcus. These bacteria are extracellular, and made up of non-motile and non-sporing cocci that tend to link in chains. They are clinically important for humans, as they are an infrequent, but usually pathogenic, part of the skin microbiota that can cause Group A streptococcal infection. S. pyogenes is the predominant species harboring the Lancefield group A antigen, and is often called group A Streptococcus (GAS). However, both Streptococcus dysgalactiae and the Streptococcus anginosus group can possess group A antigen as well. Group A streptococci, when grown on blood agar, typically produce small (2–3 mm) zones of beta-hemolysis, a complete destruction of red blood cells. The name group A (beta-hemolytic) Streptococcus is thus also used.

<span class="mw-page-title-main">Scarlet fever</span> Infectious disease caused by Streptococcus pyogenes

Scarlet fever, also known as scarlatina, is an infectious disease caused by Streptococcus pyogenes, a Group A streptococcus (GAS). It most commonly affects children between five and 15 years of age. The signs and symptoms include a sore throat, fever, headache, swollen lymph nodes, and a characteristic rash. The face is flushed and the rash is red and blanching. It typically feels like sandpaper and the tongue may be red and bumpy. The rash occurs as a result of capillary damage by exotoxins produced by S.pyogenes. On darker-pigmented skin the rash may be hard to discern.

<span class="mw-page-title-main">Streptococcal pharyngitis</span> Medical condition

Streptococcal pharyngitis, also known as streptococcal sore throat, is pharyngitis caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.

<span class="mw-page-title-main">Rheumatic fever</span> Post-streptococcal inflammatory disease

Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum. The heart is involved in about half of the cases. Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. The damaged valves may result in heart failure, atrial fibrillation and infection of the valves.

<span class="mw-page-title-main">Chorea</span> Medical condition

Chorea is an abnormal involuntary movement disorder, one of a group of neurological disorders called dyskinesias. The term chorea is derived from the Ancient Greek: χορεία, as the quick movements of the feet or hands are comparable to dancing.

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Rat-bite fever (RBF) is an acute, febrile human illness caused by bacteria transmitted by rodents, in most cases, which is passed from rodent to human by the rodent's urine or mucous secretions. Alternative names for rat-bite fever include streptobacillary fever, streptobacillosis, spirillary fever, bogger, and epidemic arthritic erythema. It is a rare disease spread by infected rodents and caused by two specific types of bacteria:

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Erythema nodosum (EN) is an inflammatory condition characterized by inflammation of subcutaneous fat tissue, resulting in painful red/blue lumps or nodules that are usually seen symmetrically on both shins, on the thighs, arms, and elsewhere. It can be caused by a variety of conditions but 20 to 50% of cases are idiopathic. It typically resolves spontaneously within 30 days. It is common in young people aged 12–20 years.

<span class="mw-page-title-main">Febrile neutrophilic dermatosis</span> Medical condition

Sweet syndrome (SS), or acute febrile neutrophilic dermatosis, is a skin disease characterized by the sudden onset of fever, an elevated white blood cell count, and tender, red, well-demarcated papules and plaques that show dense infiltrates by neutrophil granulocytes on histologic examination.

<span class="mw-page-title-main">Haverhill fever</span> Medical condition

Haverhill fever is a systemic illness caused by the bacterium Streptobacillus moniliformis, an organism common in rats and mice. If untreated, the illness can have a mortality rate of up to 13%. Among the two types of rat-bite fever, Haverhill fever caused by Streptobacillus moniliformis is most common in North America. The other type of infection caused by Spirillum minus is more common in Asia and is also known as Sodoku.

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References

  1. 1 2 Bygum, Anette; Broesby-Olsen, Sigurd (March 2011). "Rapid resolution of erythema marginatum after icatibant in acquired angioedema". Acta dermato-venereologica. 91 (2): 185–186. doi: 10.2340/00015555-1055 . ISSN   1651-2057.
  2. Hinzey, E (June 2023). Arredondo M (ed.). "Erythema Marginatum". Patient Education Reference Center (PERC).
  3. "erythema marginatum" at Dorland's Medical Dictionary
  4. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. p. 281. ISBN   978-1-4160-2999-1.
  5. Starr JC, Brasher GW, Rao A, Posey D (October 2004). "Erythema marginatum and hereditary angioedema". South. Med. J. 97 (10): 948–50. doi:10.1097/01.SMJ.0000140850.22535.FA. PMID   15558919. S2CID   38676096.
  6. Kliegman, R.M.; Stanton, B.F; Gerne, J.W.; Schor, N.F.; Behrman, R.E. (2011). Group A streptococcus. In: Nelson textbook of pediatrics (9 ed.). Elsevier Saunders.
  7. Vijayan, Vini; Sukumaran, Sukesh (July 2023). "Erythema Marginatum". The Journal of Pediatrics. 258: 113330. doi: 10.1016/j.jpeds.2022.12.038 . ISSN   0022-3476.
  8. Sharma, Shreya; Biswal, Niranjan (December 2015). "Erythema Marginatum". Indian Pediatrics. 52 (12): 1100. ISSN   0974-7559.
  9. Tani, L.T.; Veasy, L.G.; Minich, L.L.A.; Shaddy, R.E. (2003). "Rheumatic fever in children younger than 5 years: is the presentation different?". Pediatrics. 112: 1065–8.
  10. Wolfson, Allan B.; Hendey, Gregory W.; Ling, Louis J.; Rosen, Carlo L.; Schaider, Jeffrey J; Sharieff, Ghazala Q. (2012). Harwood-Nuss' Clinical Practice of Emergency Medicine. Wolters Kluwer Health. p. 1302. ISBN   9781451153453.
  11. 1 2 Erythema Marginatum Pictorial CME
  12. Burke, J. B. (1955-08-01). "Erythema Marginatum". Archives of Disease in Childhood. 30 (152): 359–365. doi:10.1136/adc.30.152.359. ISSN   0003-9888. PMC   2011784 . PMID   13249623.
  13. Oski, Frank A.; Barone, Michael A.; Crocetti, Michael, eds. (2004). Oski's Essential Pediatrics. Lippincott Williams & Wilkins. p. 298. ISBN   9780781737708.
  14. Kimberlin, David W.; Barnett, Elizabeth D.; Lynfield, Ruth; Sawyer, Mark H., eds. (2021). Group A Streptococcal Infections. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases (32 ed.). American Academy of Pediatrics. pp. 694–707. ISBN   978-1-61002-521-8.