Perianal cellulitis

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Perianal cellulitis
Other namesPerianitis, Perianal streptococcal dermatitis, Perianal dermatitis, [1] Streptococcal anitis, [1] Streptococcal perianitis [1]
Specialty Dermatology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Redness, swelling, itching, pain
DurationTreatment ranges from 14 to 21 days
CausesGroup A Streptococci (Streptococcus pyogenes) (most common)

Staphylococcus aureus

Group B Streptococci (Streptococcus agalactiae)
Diagnostic method Bacterial culture
Differential diagnosis Candidiasis, irritant diaper dermatitis, pinworm infestation, chronic inflammatory bowel disease, seborrheic dermatitis, or even sexual abuse.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. [1] [2] [3] It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. [4] [1] This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues. [5]

Contents

Perianal cellulitis is most commonly caused by group A beta-hemolytic streptococcus bacteria ( Streptococcus pyogenes ), which resides normally ("in small numbers") in the human throat and on the human skin. [6] [7] Other less common causes may include infection with group B beta-hemolytic streptococci (Streptococcus agalactiae), a bacterium found in the human vagina of some, or Staphylococcus aureus, a common component of the bacterial community in the human nose and/or skin. [8] [7]

Perianal cellulitis occurs mainly in male children between six months and 10 years of age, however, there are documented cases of perianal cellulitis in adults as well. [8] Oral antibiotics are the first line treatment for perianal cellulitis and may be used in combination with topical antibiotics. [1] Since the infection occurs within the deeper layers of skin, using a topical treatment by itself may not be effective. [1] In about 20% of cases, recurrence of perianal streptococcal dermatitis infection occurs within 3.5 months. [1] Routine hygiene practices should also be encouraged in children and adults in order to reduce the risk of recurrent infection. [1]

Signs and symptoms

Perianal cellulitis manifests as multiple symptoms that are inconsistent with a systemic disease. The most notable feature is a very distinct redness around the anus, and other signs of inflammation which can include swelling and itching at the site. [4] Other associated symptoms with perianal cellulitis include pain when defecating and bleeding. These symptoms can often be confused with other skin conditions, such as diaper rash, eczema, psoriasis, hemorrhoids, and more. [7] These symptoms can cause extreme discomfort, especially in diaper-wearing infants, and serious complications can arise if left untreated. In about 10% of cases, balanitis or vulvovaginitis can develop concomitantly. In even rarer instances, tonsillopharyngitis can develop concomitantly as well. [9]

Complications most often occur when perianal cellulitis remains undiagnosed and untreated for an extended period of time. In cases where perianal cellulitis is left untreated, it can cause more serious symptoms such as abscess formation and rheumatic fever. [10] Additionally, untreated perianal cellulitis poses a risk of transmission to other people, such as caretakers or family members. Perianal cellulitis can also cause post-streptococcal nephritis, which should be monitored with urinalysis to assess kidney function. [1]

Diagnosis

bacterial culture growth of Streptococcus pyogenes Streptococcus pyogenes agar sangre.jpg
bacterial culture growth of Streptococcus pyogenes

The diagnosis of perianal cellulitis is made either through a rapid strep test or by swabbing the affected areas for a bacterial culture indicating infection by group A β-hemolytic streptococci. [1] [11] In order to confirm diagnosis of perianal streptococcal dermatitis, the anus and genitalia require examination followed by bacterial swabbing of the exudate from the affected area is preferred. [2] [1] The swabs will be sent for microbiological analysis of the culture to confirm the growth of group A β-hemolytic streptococci. [11] "The time to diagnosis of perianal streptococcal dermatitis is ≥3 weeks in 65% of cases." [1] Because perianal cellulitis is commonly misdiagnosed, it is imperative that the proper diagnosing procedures are followed when encountering these symptoms, as delayed detection can result in severe complications. [12]

Within the pediatric population, it is common for the management of rashes to occur under the collaboration of an inter-professional team. [2] Due to the diverse causes of rashes in the pediatric population, it may be necessary to refer pediatric patients to a pediatrician or a dermatologist to prevent misdiagnosis of perianal streptococcal dermatitis. [2] Across the different disciplines of care, nurses have an opportunity to provide education on proper hygiene techniques to reduce the risk of recurrent infection. [2] Pharmacists can provide patient and caretaker counseling on the selected medication therapy and improve medication adherence. [2] By working together as an inter-professional team, all types of clinicians can improve patient health outcomes by raising awareness and reducing both time to diagnosis and the rate of recurrence of perianal streptococcal dermatitis infection. [2]

Differential diagnosis

Due to the non-specific presentation of the symptoms of perianal streptococcal dermatitis, it is frequently misdiagnosed by clinicians. [13] To reach the correct diagnosis of perianal streptococcal dermatitis often ranges from weeks to months and can extend to even longer. [11] During this time, the patient can undergo treatment for a variety of differential diagnoses. [11] Perianal streptococcal dermatitis imitates other common diseases in the anal region and therefore can be mistaken for "candidiasis, irritant diaper dermatitis, pinworm infestation, chronic inflammatory bowel disease, seborrheic dermatitis, or even sexual abuse." [13] The delay in diagnosis of perianal streptococcal dermatitis can result in prolonged discomfort and additional symptoms of constipation, anal discharge or oozing, and anal fissures. [11]

Pathophysiology

Causes

In most cases of perianal streptococcal dermatitis in children, swab cultures indicate that infection is caused by the bacteria Streptococcus pyogenes , more specifically classified as group A beta-hemolytic streptococci (GAS). There have been reported cases, however, that have found perianal streptococcal cellulitis infections to be caused by group B beta-hemolytic streptococci (GBS) and, in rare cases, other groups of beta-hemolytic streptococci or Staphylococcus aureus . [13] [8] It is important to note, however, that in the rare adult cases of perianal streptococcal cellulitis that have been identified, the most common cause is by beta-hemolytic streptococci from group B specified as Streptococcus agalactiae. [8]

Streptococcus pyogenes under 900x magnification, viewed with Pappenheim's stain Streptococcus pyogenes.jpg
Streptococcus pyogenes under 900x magnification, viewed with Pappenheim's stain

Streptococci are gram-positive bacteria that grow in chains, but they have no motility and do not generate spores. Group A streptococci and Group B streptococci are the two most common strains that are associated with pediatric cases. Infections caused by Group A streptococci are generally more mild than infections caused by Group B streptococci. The most common Group A streptococcus infections can range from strep throat to pneumonia to cellulitis. Group B streptococcus is more commonly found in the gastrointestinal and genital tracts, and can also be transmitted vertically from mother to child during vaginal labor. These newborn cases of infection often manifest as sepsis, pneumonia, and meningitis, among other presentations. [14]

Based on cases studied of children with perianal streptococcal dermatitis, there has been a pattern of perianal infection occurring after being diagnosed with previous streptococcal infections (i.e. "strep throat"). It is believed that bacteria from these infections may be introduced to the skin of the perianal region after touching the nose or mouth and then proceeding to use the toilet or touching the area for any other reason. [15]

While perianal streptococcal dermatitis is a treatable condition, there are serious consequences that may arise if left undiagnosed and/or untreated in patients with an infection. Failure to properly diagnose and treat perianal streptococcal dermatitis may lead to more serious infections that could result in injury or death. [16]

Mechanism

Layers of normal human skin. Cellulitis indicates infection in the dermis and/or subcutaneous (fat) layer. 3D medical animation skin layers.jpg
Layers of normal human skin. Cellulitis indicates infection in the dermis and/or subcutaneous (fat) layer.

Upon the initial exposure of Streptococcus pyogenes (group A beta-hemolytic streptocci) bacteria to the skin surrounding the perianal region, the bacteria adheres to the skin's surface with filaments on its cell wall surface called adhesins. An adhesin found in group A beta-hemolytic streptococci of particular importance is called the M protein, which utilizes complex mechanisms to recognize various receptors on human cell types for attachment. [17] After attachment, colonization of Streptococcus pyogenes occurs and the bacteria release many toxins that are responsible for the manifestation of symptoms of perianal cellulitis such as inflammation, fever, and itching. [18] Secretion of hyaluronidase, also known as "spreading factor", encourages the Streptococcus pyogenes bacterium to spread more easily throughout the lower layers of skin tissue (subcutaneous tissue). [19] [6] As the streptococci continue to colonize, the formation of a biofilm may arise and its protective properties may make it more difficult to treat the infection with antibiotics. [20]

In cases of perianal cellulitis infections that are not treated properly, group A beta-hemolytic streptococci may cross into the bloodstream through the epithelium of the perianal area to cause serious infections such as necrotizing fasciitis or toxic shock syndrome. [21] The group A beta-hemolytic streptococci bacteria that enter the bloodstream are able to cause serious infections by overpowering natural immune responses and allowing bacteria to rapidly multiply to cause harm to the body. [21]

Treatment

After the diagnosis of perianal streptococcal dermatitis has been confirmed, the most successful treatment regimens utilize a combination of topical and systemic antibiotics. [1] Oral antibiotics are the recommended first-line treatment for perianal streptococcal dermatitis. [1] Perianal streptococcal dermatitis does not resolve on its own. [22] The treatment of choice for oral antibiotics include "penicillin V, azithromycin, clarithromycin, clindamycin, erythromycin, penicillinase-resistant penicillin, or cephalosporins." [1] Oral antibiotics work best in combination with a topical antibiotic such as mupirocin, or an antiseptic such as chlorhexidine. [1] Due to the effect that perianal streptococcal dermatitis has on the deeper layers of the skin, topical antimicrobial therapy alone appears to be poorly effective. [1] Treatment duration ranges from 14 to 21 days and treatment success is determined by clinical examination and post-treatment swabbing of the affected area to confirm that the infection is no longer present. [1]

Prevention & Recurrence

There is little data that currently exists on the prevention of perianal cellulitis. However, "approximately one-third of people with cellulitis suffer recurrent episodes and the only proven strategy for preventing this is long-term, low-dose oral penicillin." [12] Performing post-treatment swabbing and confirming eradication of group A β-hemolytic streptococci infection reduces the chance of perianal streptococcal dermatitis recurrence. [1] In about 20% of cases, recurrence of perianal streptococcal dermatitis infection occurs within 3.5 months. [1] In the case of perianal cellulitis, maintaining the dryness of the site and addressing the infection with topical antifungal ointment is sufficient to prevent recurrent infection for a duration between 3 and 6 weeks. [12] Potential risk factors for perianal streptococcal dermatitis include: poor living conditions, atopic dermatitis, and malnutrition. [22] Routine hygiene practices should also be encouraged in children and adults in order to reduce the risk of recurrent infection. [1] Prescribed antibiotic regimens should also be adhered to until completion, so as to avoid the risk of developing a multi-resistant strain of infection in the future. [12]

Proper screening measures should be followed as perianal cellulitis continues to be severely underdiagnosed. Perianal cellulitis is often misdiagnosed as other skin conditions, such as diaper rash (in infants), eczema, psoriasis, hemorrhoids, and more. [22]

Epidemiology

The incidence of perianal streptococcal dermatitis in the pediatric population has not been determined. [22] It is believed that the lack of data is due to the difficulty clinicians face recognizing perianal streptococcal dermatitis. [22] Perianal streptococcal dermatitis most commonly affects children between 6 months and 10 years old, with males being more commonly affected than females. [1] Results from a systematic literature review further supports this as a majority of childhood cases of perianal streptococcal cellulitis occurred in males younger than 7 years old. [1]

While traditionally thought to be a disease specific to children, there have been case reports of perianal streptococcal dermatitis in adults. [13]

Etymology

The term perianal is made up of two components, peri- (Greek prefix meaning "about" or "around") and anal ("related to, or involving the anus"). Cellulitis describes a bacterial infection affecting the lower layers of the skin. [1]

Historically, perianal cellulitis may be referred to as perianal streptococcal dermatitis. [1] However, perianal cellulitis is best understood to be a cellulitis, an infection of the inner layers of skin, rather than a dermatitis, which implies an irritation of the outermost layers of skin (the epidermis). [1]

See also

Related Research Articles

<i>Streptococcus</i> Genus of bacteria

Streptococcus is a genus of gram-positive coccus or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales, in the phylum Bacillota. Cell division in streptococci occurs along a single axis, so as they grow, they tend to form pairs or chains that may appear bent or twisted. This differs from staphylococci, which divide along multiple axes, thereby generating irregular, grape-like clusters of cells. Most streptococci are oxidase-negative and catalase-negative, and many are facultative anaerobes.

<span class="mw-page-title-main">Erysipelas</span> Human disease from a bacterial infection of the skin

Erysipelas is a relatively common bacterial infection of the superficial layer of the skin, extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin. It is a form of cellulitis and is potentially serious.

<span class="mw-page-title-main">Group A streptococcal infection</span> Medical condition

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 (GABHS) 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). The infection is a type of Group A streptococcal infection. 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">Pharyngitis</span> Inflammation of the back of the throat

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

<span class="mw-page-title-main">Necrotizing fasciitis</span> Infection that results in the death of the bodys soft tissue

Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or purple skin in the affected area, severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

<span class="mw-page-title-main">Tonsillitis</span> Inflammation of the tonsils

Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. Complications include peritonsillar abscess (Quinsy).

<span class="mw-page-title-main">Group B streptococcal infection</span> Medical condition

Group B streptococcal infection, also known as Group B streptococcal disease or just Group B strepinfection,

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

Lymphangitis is an inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel. It may present as long red streaks spreading away from the site of infection. It is a possible medical emergency as involvement of the lymphatic system allows for an infection to spread rapidly. The most common cause of lymphangitis in humans is bacteria, in which case sepsis and death could result within hours if left untreated. The most commonly involved bacteria include Streptococcus pyogenes and hemolytic streptococci. In some cases, it can be caused by viruses such as mononucleosis or cytomegalovirus, as well as specific conditions such as tuberculosis or syphilis, and the fungus Sporothrix schenckii. Lymphangitis is sometimes mistakenly called "blood poisoning". In reality, "blood poisoning" is synonymous with sepsis.

A skin infection is an infection of the skin in humans and other animals, that can also affect the associated soft tissues such as loose connective tissue and mucous membranes. They comprise a category of infections termed skin and skin structure infections (SSSIs), or skin and soft tissue infections (SSTIs), and acute bacterial SSSIs (ABSSSIs). They are distinguished from dermatitis, although skin infections can result in skin inflammation.

<span class="mw-page-title-main">Orbital cellulitis</span> Inflammation of eye tissues

Orbital cellulitis is inflammation of eye tissues behind the orbital septum. It is most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses or through the blood. It may also occur after trauma. When it affects the rear of the eye, it is known as retro-orbital cellulitis.

<i>Arcanobacterium haemolyticum</i> Species of bacterium

Arcanobacterium haemolyticum is a species of bacteria classified as a gram-positive bacillus. It is catalase-negative, facultative anaerobic, beta-hemolytic, and not motile. It has been known to cause head and neck infections, pharyngitis, and sinusitis.

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

Guttate psoriasis is a type of psoriasis that presents as small lesions over the upper trunk and proximal extremities; it is found frequently in young adults.

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

Streptococcus canis is a group G beta-hemolytic species of Streptococcus. It was first isolated in dogs, giving the bacterium its name. These bacteria are characteristically different from Streptococcus dysgalactiae, which is a human-specific group G species that has a different phenotypic chemical composition. S. canis is important to the skin and mucosal health of cats and dogs, but under certain circumstances, these bacteria can cause opportunistic infections. These infections were known to afflict dogs and cats prior to the formal description of the species in Devriese et al., 1986. However, additional studies revealed cases of infection in other mammal species, including cattle and even humans. Instances of mortality from S. canis in humans are very low with only a few reported cases, while actual instances of infection may be underreported due to mischaracterizations of the bacteria as S. dysgalactiae. This species, in general, is highly susceptible to antibiotics, and plans to develop a vaccine to prevent human infections are currently being considered.

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

Streptococcus dysgalactiae is a gram positive, beta-haemolytic, coccal bacterium belonging to the family Streptococcaceae. It is capable of infecting both humans and animals, but is most frequently encountered as a commensal of the alimentary tract, genital tract, or less commonly, as a part of the skin flora. The clinical manifestations in human disease range from superficial skin-infections and tonsillitis, to severe necrotising fasciitis and bacteraemia. The incidence of invasive disease has been reported to be rising. Several different animal species are susceptible to infection by S. dysgalactiae, but bovine mastitis and infectious arthritis in lambs have been most frequently reported.

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

Streptococcal intertrigo is a skin condition that is secondary to a streptococcal bacterial infection. It is often seen in infants and young children and can be characterized by a fiery-red color of the skin, foul odor with an absence of satellite lesions, and skin softening in the neck, armpits or folds of the groin. Newborn children and infants commonly develop intertrigo because of physical features such as deep skin folds, short neck, and flexed posture. Prompt diagnosis by a medical professional and treatment with topical and/or oral antibiotics can effectively relieve symptoms.

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

Streptococcus iniae is a species of Gram-positive, sphere-shaped bacterium belonging to the genus Streptococcus. Since its isolation from an Amazon freshwater dolphin in the 1970s, S. iniae has emerged as a leading fish pathogen in aquaculture operations worldwide, resulting in over US$100M in annual losses. Since its discovery, S. iniae infections have been reported in at least 27 species of cultured or wild fish from around the world. Freshwater and saltwater fish including tilapia, red drum, hybrid striped bass, and rainbow trout are among those susceptible to infection by S. iniae. Infections in fish manifest as meningoencephalitis, skin lesions, and septicemia.

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