Situational task No. 1 A district therapist was called to see a 53-year-old woman. The disease began acutely, for the first time the body temperature increased to 39.5°C, chills, headache, myalgia and arthralgia appeared. A few hours later, a burning sensation appeared in the area of the right temple, redness of the skin, and then widespread swelling. On examination: condition of moderate severity. On the right side of the face there is an area of erythema covering the upper part of the cheek. The right eye slit is closed due to severe swelling. The skin of the face is hot to the touch, painful to palpation, and tense. Erythema has clear boundaries, the area of hyperemia has uneven edges and is elevated. On the right, painful submandibular lymph nodes are palpated. BP - 115/60 mm Hg. Pulse - 117 per minute. Complete blood count: RBC - 4,2×1012/l, HGB - 130 g/l, WBC - 14,8×109/l, ESR - 31 mm/h. Leukocyte formula: band neutrophils - 7%, segmented neutrophils - 65%, lymphocytes - 21%, monocytes - 7%. General urinalysis: Spec Grav - 1.030, Protein - negative, WBC, /HPF - 3-4, RBC, /HPF - 1-2. Biochemical blood test: TPROT - 72 g/l, UREA - 7,8 mmol/l, CREAT - 97 µmol/l, TBIL - 18,0 µmol/l, DBIL - negative, ALT - 19 U/l, AST - 22 U/l, ALP - 34 U/l, thymol turbidity test (Macglan's test) - 3 units. Questions: 1. Identify the main syndromes of the disease? (OPС-5, PC-6) 2. Evaluate the results of the examination. What specific laboratory tests should be performed to confirm the diagnosis? (OPС-5, PC-5, PC-6) 3. What is your preliminary diagnosis? (PC-6) 4. Name the causative agent, pathogenesis, and transmission routes and mechanisms used in this disease. (OPС-5, PC-5) 5. Conduct a differential diagnosis (OPС-5, PC-5, PC-6) 6. Determine the treatment tactics and further monitoring of the patient (PC-8) 7. Develop a treatment plan: regimen, therapeutic nutrition, medication (etiotropic, pathogenetic, symptomatic) (OPС-6, OPС-7, PC-11) 8. Indicate the complications and possible outcomes of this disease (OPС-7, PC-11) 9. Indicate the anti-epidemic and preventive measures for this disease (PC-8) Answer the questions in short.

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I now have sufficient information from authoritative textbooks to answer all 9 questions comprehensively. Here is the full structured answer:

Situational Task No. 1 — Answers

Preliminary Diagnosis

Erysipelas (рожа) of the right side of the face, erythematous form, acute onset, moderate severity.

1. Main Syndromes

Syndrome	Evidence in this case
Infectious-toxic (general intoxication)	Fever 39.5°C, chills, headache, myalgia, arthralgia, tachycardia (117/min), leukocytosis
Local inflammatory	Erythema with sharp, raised borders; hot, tense, painful skin; non-pitting edema closing the right eye
Lymphadenopathy	Painful right submandibular lymph nodes

2. Evaluation of Results and Specific Tests

CBC: Leukocytosis 14.8×10⁹/l, band neutrophils 7% (left shift), ESR 31 mm/h - confirms acute bacterial inflammation.

Urinalysis: Normal (no organ damage).

Biochemistry: All values within normal limits (no hepatic, renal, or metabolic complication).

Specific laboratory tests to confirm the diagnosis:

Antistreptolysin-O (ASO) titer - elevated in streptococcal infection
Anti-DNase B titer - more sensitive for skin streptococcal infections (ASO may be low with skin-only involvement)
Blood culture - positive in ~5-10% of erysipelas cases; important to exclude bacteremia
Culture from bullae/pustules (if present)
C-reactive protein (CRP) and procalcitonin - to assess severity and monitor response
Latex agglutination / direct immunofluorescence of skin specimens to detect streptococci
Throat swab culture (to identify possible GAS carrier state)

(Goldman-Cecil Medicine; Dermatology 5e)

3. Preliminary Diagnosis

Erysipelas of the right half of the face, erythematous form, first episode, moderate severity.

ICD-10: A46

Reasoning: acute onset with fever/chills/myalgia, followed hours later by fiery-red, sharply demarcated, raised erythema on the face with edema and regional lymphadenopathy, leukocytosis with left shift - this is a classic presentation of erysipelas as described in Andrews' Diseases of the Skin and Goldman-Cecil Medicine.

4. Causative Agent, Pathogenesis, Transmission

Causative agent:

Primary: Streptococcus pyogenes (Group A β-hemolytic streptococcus, GAS)
Occasionally: groups C, G, B streptococci

Pathogenesis:

S. pyogenes enters through a portal of entry (microtrauma, abrasion, fissure, or imperceptible skin defect) on the face.
The organism colonizes the superficial dermis and dermal lymphatics, producing hyaluronidase (spreading factor), streptokinase, M-protein (anti-phagocytic), and erythrogenic toxins.
Lymphangitis develops, causing the characteristic raised, sharply demarcated border (the edge is elevated because infection is confined to the upper dermis/lymphatics, unlike deeper cellulitis).
Cytokines (IL-1, IL-6, TNF-α) released during the inflammatory response cause the systemic toxic syndrome (fever, myalgia, headache).
Histology: diffuse neutrophilic infiltrate, lymphatic dilation, dermal edema - without necrotizing vasculitis.

Transmission routes:

Contact - direct (touching infected person) or indirect (contaminated objects)
Entry via broken skin - the key mechanism; intact skin is resistant
Airborne droplets may transmit the organism (to pharynx first), with subsequent autoinoculation or skin inoculation
Predisposing factors in this patient: age 53, likely facial skin lesion/portal of entry

5. Differential Diagnosis

Condition	Features distinguishing from erysipelas
Cellulitis	Deeper infection (dermis + subcutaneous tissue); borders are ILL-defined, NOT raised; less abrupt onset
Contact dermatitis	No fever, no pain/tenderness; severe pruritus; history of allergen exposure
Angioedema (angioneurotic edema)	No fever, no erythema, no pain; itching prominent; rapid onset/resolution; allergic trigger
Systemic lupus erythematosus (butterfly rash)	Malar rash crosses nasal bridge symmetrically; no fever spike; chronic course; ANA positive
Necrotizing fasciitis	Progresses to purple/blue discoloration, blistering, necrosis, severe systemic toxicity; wooden-hard subcutaneous induration; requires surgical emergency
Orbital/periorbital cellulitis	Proptosis, restricted eye movements, pain on eye movement; usually secondary to sinusitis
Facial abscess/furuncle	Focal fluctuant swelling, purulent collection; less diffuse erythema
Herpes zoster (early)	May begin with unilateral pain/erythema, but vesicles follow dermatomal distribution; not a sharply raised plaque

(Andrews' Diseases of the Skin; Goldman-Cecil Medicine)

6. Treatment Tactics and Monitoring

Hospitalization: Yes - moderate severity, facial involvement with periorbital edema, high fever, tachycardia.

Monitoring:

Vital signs every 4-6 hours (temperature, BP, pulse, respiratory rate)
CBC and CRP on days 3-5 and at discharge to confirm response
Daily wound inspection: measure erythema borders (mark margins with pen) to track spread or regression
Watch for complications: bullae formation, abscess, spreading to orbit/meninges, septicemia
Monitor renal function if IV gentamicin added

Patient education: elevate head of bed, cold compresses for local comfort, rest.

7. Treatment Plan

Regimen

Bed rest; hospitalization
Head slightly elevated

Therapeutic Nutrition

High-calorie, protein-rich diet
Adequate hydration (2-2.5 L/day unless contraindicated)
Vitamin-enriched foods (C, B-group)

Medication

Etiotropic (causal):

Benzylpenicillin (Penicillin G): 1-2 million units IV/IM every 4-6 hours for 10-14 days - drug of choice (Goldman-Cecil; Dermatology 5e)
Ampicillin 500 mg IV every 6 hours is an alternative
If penicillin allergy: Clindamycin 300-600 mg every 8 hours OR Clarithromycin/Erythromycin (macrolide)
If MRSA concern (bullous form): Vancomycin 15-20 mg/kg IV every 12 hours
Course: minimum 10-14 days; continue until erythema resolves

Pathogenetic:

Detoxification: IV crystalloid infusion (0.9% NaCl, Ringer's) 800-1200 ml/day given tachycardia and likely insensible losses
NSAIDs/antipyretics: Ibuprofen 400 mg every 8 h or Paracetamol 500-1000 mg every 6 h (for fever and pain control, also reduce inflammation)
Antihistamines (e.g. Chloropyramine/Suprastin 25 mg twice daily) - to reduce vascular permeability and edema
Desensitization/anti-inflammatory: Prednisolone 30-40 mg/day short course (3-5 days) may be considered in severe edema if no contraindication - controversial; used in some protocols for facial erysipelas with orbital involvement
Rutin (Vitamin P) + Ascorbic acid - to strengthen capillary walls

Symptomatic:

Local treatment: cold compresses or 50% Dimexide solution dressings (analgesic and anti-inflammatory locally)
Ointments and wet-dry dressings generally avoided in the acute phase (maceration risk)
Antipyretics as needed
Analgesia

After resolution: UV local irradiation (physiotherapy) can be applied to speed tissue healing and prevent recurrence.

8. Complications and Possible Outcomes

Local complications:

Bullous/hemorrhagic erysipelas (vesicles, bullae, necrosis) - more severe forms
Abscess formation
Phlegmon (spread to subcutaneous tissue)
Necrotizing fasciitis (rare but life-threatening)
Lymphedema and elephantiasis with recurrent episodes

Regional/systemic complications:

Thrombophlebitis, thrombosis of cavernous sinus (facial erysipelas) - serious
Meningitis (due to proximity of face to meninges)
Orbital cellulitis / septic orbital thrombophlebitis
Septicemia / bacteremia
Endocarditis, pneumonia, septic arthritis (metastatic foci)
Glomerulonephritis (post-streptococcal, immune-mediated) - monitor urinalysis after 2-3 weeks
Rheumatic fever - rare with skin infections (more with pharyngitis)

Outcomes:

With adequate early treatment: full recovery in 10-14 days
Recurrent erysipelas (10-30% of patients) - leads to progressive lymphatic damage and persistent edema
Chronic lymphedema / elephantiasis in recurrent cases

9. Anti-Epidemic and Preventive Measures

Erysipelas is NOT a quarantine infection. No mandatory notification to public health authorities is required (unlike plague, cholera, etc.).

Individual preventive measures:

Treat portals of entry promptly: fissures, abrasions, tinea pedis, interdigital maceration, eczema
Proper wound care and skin hygiene
Treat chronic venous insufficiency, lymphedema, and obesity - risk factors
Treat underlying conditions (diabetes, immunosuppression)

Anti-epidemic measures in healthcare:

Standard contact precautions until wound/lesion secretions are controlled
Gloves, hand hygiene when dressing wounds
Proper sterilization of instruments

Prevention of recurrence (secondary prophylaxis):

Benzathine benzylpenicillin (Bicillin-1) 1.2-2.4 million units IM every 3-4 weeks for 1-2 years (or longer) in patients with recurrent episodes (≥2 per year) - this is the standard approach in Russian/Eastern European protocols
Eliminate predisposing factors (lymphedema management, skin barrier protection)
Regular follow-up with the attending physician

Sources: Andrews' Diseases of the Skin (Clinical Dermatology), p. 308; Dermatology 2-Volume Set 5e, pp. 1524-1526; Goldman-Cecil Medicine, Chapter 408; Cummings Otolaryngology.

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