Erysipelas

Patient is 42-year-old female who recently had a severe reaction causing swelling and a red spot on her left cheek and around her left eye. She did end up going to the urgent care for this and was given a Keflex treatment for erysipelas. It then progressed, so she ended up going to the ER where they increased her dose of Keflex to four times a day and added Bactrim twice a day and also gave her IV antibiotics. They do think in fact that this is an erysipelas infection. She noticed this around June 27, 2016. At the urgent care, they were concerned about any herpes or shingles infection, so they started Valtrex and she was also given prednisone pack on June 28, 2016 to help with inflammation. She did finish this on Sunday. Everything was going quite well after her antibiotic treatments from the ER and she is continuing with her antibiotics at home and Valtrex she just finished on Sunday. However, on Monday, she started feeling some irritation again. Tuesday, it got worse and now she is feeling that her infection or whatever is going on is progressing. They did pursue CT scan in the ER and did notice an infection, but it had not penetrated through to the brain or caused any infection in periorbital fossa. She is not having any eye pain or tenderness on movement of her eyes. She states it is not painful. It is not itchy. However, the swelling seems to be a little bit tender. She said it started out of what she thought might have been a spider bite or a type of abscess and has progressed to this and does feel that this may be an infection. I did talk briefly with Dr. on the phone and she wanted to make sure that this is not any type of hereditary angioedema and more or less it is being forgotten.

Stacy denies any history of angioedema in the family or any other Mastisol disorders. However, she does have a lot of allergic skin conditions in the past including perioral dermatitis that she has had twice requiring a desonide treatment. Also, she has had an allergic contact dermatitis. She also has a chronic cough and that has been treated as asthma. She did undergo a methacholine challenge test in 2006 and it was negative. However, her cough does seem to flare with exercise and with infection and responds to steroid use. She currently is taking amitriptyline for this chronic cough and it is helping. She also has a history of fibromyalgia.

She does have some mild allergy symptoms and that seem to occur spontaneous throughout the year, but nothing that would have brought her here. She has had some sneezing, clear nasal discharge, and nasal stuffiness occasionally. She denies problems with sinus infections or nasal polyps. She does have TMJ and frequent headaches. She denies aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis.

She denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.

She denies any eye itching, redness, tearing, dryness, burning, light hurting her eyes, and yellow discharge from eyes. She does have eyelid swelling and eyelid irritation. She is not having any pain with movement of her eyes.

She denies any wheezing or lung problems but does have a chronic cough particularly during exercise. She has not been on any inhalers in the past but currently is taking amitriptyline for a cough with success. She has not had a chest x-ray in the last five years.

She did have an allergy evaluation done many years ago shown positive to various trees, weeds, and molds.

ASSESSMENT:
1. Erysipelas.
2. Concern for angioedema.
3. History of periorbital dermatitis with allergic contact dermatitis.
4. Chronic cough.

PLAN:
1. At this time, I do feel that the emergency room has diagnosed her currently with erysipelas. I am unsure why she is having hard time getting this resolved. She does have a slight rash on her torso and some swelling around her face and the lesion on her face. I do think her immune system is reacting significantly to this and getting off the prednisone caused a flare of this reaction. I do think she may need to do a little longer course of prednisone until this reaction completely clears. We will do a taper of 40 mg for three days, 30 mg for three days, 20 mg for three days, and 10 mg for three days. She will also continue taking the antibiotics. I also extended her Bactrim for ten more days so, that this resolves completely and she has about five more days of her cephalexin four times a day. If it continues to get worse tonight or in the morning I did encourage her to go back to the ER to see if we get more IV antibiotics and treatment for this as I do not want this to progress to get more severe.
2. I have referred her to Dr. to establish care since she is new in the area and help monitor resolution of this.
3. We will go ahead and do some lab work per her internal medicine doctor in Utah and request doing an angioedema panel. We will also check CBC, CMP, ESR, CRP, and serum tryptase and a lipid panel per patient’s request to rule out any hereditary or acquired angioedema or other Mastisol disorder. We will follow up with Stacy over phone to let her know what her lab work is and I want her to get into an internal medicine provider. If she has any concerns with this reaction, she will contact me and/or come to see me anytime.

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