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Erysipelas and cellulitis are acute spreading infections of the skin, usually involving large confluent areas and accompanied by systemic toxicity. Erysipelas is a superficial skin infection involving the cutaneous lymphatic vessels, caused most commonly by group A streptococci and occasionally by group C or G streptococci. Erysipelas most often involves the face, has a characteristic, well-demarcated appearance with raised margins, and is accompanied by systemic symptoms of fever and chills. Streptococcal cellulitis is an acute, rapidly spreading infection that extends deeper than erysipelas and involves the skin and subcutaneous tissues. Cellulitis is generally associated with diffuse erythema, pain, swelling, lymphangitis, fever, chills, and sometimes bacter-emia. Recurrent cellulitis of the extremities occurs in persons with impaired lymphatic drainage such as in lymphedema after radical mastectomy, or phlebectomy associated with coronary artery bypass surgery (CABG). An association between the presence of tinea pedis and post-CABG cellulitis of a lower extremity has been noted (3).

Although most cases of cellulitis are caused by streptococci or staphylococci, a number of unusual organisms can cause cellulitis (see Table 2). Pasteurella multocida, the major pathogen in dog and cat bites, causes a rapidly progressive cellulitis, often with accompanying lymphangitis occurring several hours after the bite. Cellulitis caused by human bites is polymicrobial similar to bacteriology of oral flora, and usually include streptococci, S. aureus, Fusobacterium, Bacteroides spp. and other anaerobes, and Eikenella corrodens (4). Aeromonas hydrophila is a Gram-negative bacillus causing cellulitis, wound infections, and rarely myonecrosis after exposure to contaminated fresh water. Usually there is a history of preceding trauma (5). A. hydrophila is a normal inhabitant of the foregut of leeches, and Aeromonas soft-tissue infections have occurred after application of leeches (6).

Vibrio vulnificus causes two distinct clinical syndromes involving the skin (7,8). Primary bacteremia occurs after ingestion of contaminated raw oysters or other shellfish. Infection usually occurs in the elderly with chronic underlying disease, especially cirrhosis. Onset of disease is rapid and characterized by high fever, chills, shock in about 30%, and characteristic bullous skin lesions in more than 50% of patients. Primary wound infection occurs after exposure to sea water, and also typically causes a bullous cellulitis that varies from a mild infection to severe necrosis mimicking gas gangrene.

Erysipelothrix rhusiopathiae, a Gram-positive bacilli, is the causative agent of erysipeloid, a localized subacute cellulitis and a rare diffuse cutaneous form of cellulitis. Erysipelothrix is acquired from infected animals or fish, usually via trauma to the skin. Erysipeloid usually occurs on the fingers as a slightly raised, well-demarcated violaceous, very painful cellulitis that may be accompanied by lymphangitis (9).

Nodular lymphangitis is a distinct syndrome characterized by superficial nodules developing along the dermal or subcutaneous lymphatics (10). It is caused most often by Sporothrix schenckii or Mycobacterium marinum (11). S. schenckii is a dimorphic fungus found in the soil, and lymphocutaneous infection characteristically occurs in


Klein and Cunha

Table 2

Unusual Causes of Skin Infection

Risk factor



Dog/cat bites

Pasteurella multocida,

Staphylococcus aureus, streptococci,


Piperacillin-tazobactam or amoxicillin clavulanic acid

Human bite

Anaerobes, Eikenella corrodens, S. aureus, streptococci

Piperacillin-tazobactam or amoxicillin-clavulanic acid

Fresh water exposure Cirrhosis

Aeromonas hydrophila Vibrio vulnificus

Trimethoprim-sulfamethoxazole Doxycycline or

3rd-generation cephalosporin

Salt water exposure Shellfish, meat

Vibrio vulnificus Erysipelothrix

Doxycycline or

3rd-generation cephalosporin Penicillin


Mycobacterium marinum

Doxycycline or trimethoprim-sulfamethoxazole


Sporothrix schenckii



Aspergillus Candida Cryptococcus Pseudomonas aeruginosa

Amphotericin or itraconazole Fluconazole Fluconazole Piperacillin or cefepime or meropenem

gardeners. M. marinum is an atypical mycobacterium found in fresh water and sea water. Most cases of lymphocutaneous infection occur in individuals who have contact with aquariums, swimming pools, or fish.

Immunosuppressed individuals are at risk for developing fungal infections of the skin and soft tissue. Ecthyma gangrenosum, a rapidly developing necrotic ulcer, is most often due to bacteremic P. aeruginosa infection and occurs predominantly in neutropenic patients. Occasionally, Aeromonas, Candida spp, and other Gram-negative bacilli can produce similar lesions.

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