Erysipelas of the face - the treachery of pathology, its treatment. Acute erysipelas of the leg: symptoms of the disease and its treatment Erysipelas of the foot mkb 10
If it is necessary to indicate septic shock, use an additional code (R57.2).
Excluded:
- during labor (O75.3)
- followed by:
- immunization (T88.0)
- neonatal (P36.0-P36.1)
- postprocedural (T81.4)
- postpartum (O85)
Use an additional code (R57.2) if necessary to indicate septic shock.
Excluded:
- bacteremia NOS (A49.9)
- during labor (O75.3)
- followed by:
- abortion, ectopic or molar pregnancy (O03-O07, O08.0)
- immunization (T88.0)
- infusion, transfusion, or therapeutic injection (T80.2)
- sepsis (caused) (for):
- actinomycotic (A42.7)
- anthrax (A22.7)
- candidal (B37.7)
- Erysipelothrix (A26.7)
- extraintestinal yersiniosis (A28.2)
- gonococcal (A54.8)
- herpes virus (B00.7)
- listeria (A32.7)
- meningococcal (A39.2-A39.4)
- neonatal (P36.-)
- postprocedural (T81.4)
- postpartum (O85)
- streptococcal (A40.-)
- tularemic (A21.7)
- septic (th):
- melioidosis (A24.1)
- plague (A20.7)
- toxic shock syndrome (A48.3)
Erysipelas - description, causes, diagnosis, treatment.
Short description
- A46 Erysipelas
Causes
Risk factors Any inflammatory process of the skin The presence of scars on the skin (operations, trauma) Lymphostasis Trophic ulcers of the lower leg Immunodeficiency states, exhaustion Predisposition to disease Skin sensitization to Streptococcus Ag.
Pathomorphology Edema Vasodilation, expansion of lymphatic vessels Infiltration with neutrophils, lymphocytes and other inflammatory cells Swelling of the endothelium Detection of gram-positive cocci Desquamation of the epidermis With the progression of the process, blisters filled with exudate are formed In severe cases - skin necrosis.
Clinical presentation The incubation period varies from several hours to 5 days. The disease begins acutely with chills, general weakness, headache, fever up to 39-40 ° C, vomiting, and joint pain. On the first day, edema, hyperemia and soreness of the affected area appear, sharply limited by a scalloped border from healthy skin. Later, regional lymphadenitis and lymphangoitis join. The mild form is characterized by a short-term (up to 3 days) relatively low (up to 39 ° C) fever, moderate intoxication, erythematous lesions of the skin of one anatomical region. With moderate erysipelas, fever lasts up to 4-5 days, skin lesions are erythematous - bullous or erythematous - hemorrhagic character Severe lesions are characterized by severe intoxication with mental disorders, erythematous - bullous bullous - hemorrhagic lesions of large areas of skin with frequent purulent - septic complications (abscesses, gangrene, sepsis, infectious - toxic shock). Relapses can occur several days or even years after the initial episode, quite often relapses of erysipelas occur regularly. Chronically recurrent lesions are considered to occur within 2 years after primary disease of the same localization (more often on the lower extremities) Skin manifestations begin with itching and a feeling of skin tension, then after a few hours a small focus of erythema appears, rather quickly increasing in size.In the erythematous form, erythema rises above intact skin, has a uniform bright color, clear boundaries and a tendency towards peripheral spread. The edges of the erythema are irregular, it is clearly delimited from healthy skin. In erythematous - bullous erysipelas, the epidermis exfoliates at the site of erythema (usually 1–3 days after the disease) and bubbles of various sizes filled with serous contents are formed. After opening the blisters, hemorrhagic crusts are formed, which are replaced by healthy skin. In other cases, erosions can form at the site of the blisters with the transition to trophic ulcers.Erythematous - hemorrhagic form of erysipelas proceeds similarly to erythematous, while hemorrhages appear in the affected areas of the skin against the background of erythema. , and hemorrhagic exudate. In the peripheral blood in the acute period of the disease, neutrophilic leukocytosis with a stab shift is detected, the ESR is increased.
Diagnostics
Laboratory investigations Leukocytosis (usually\u003e 15109 / l) with a shift of the leukocyte count to the left, increased ESR Streptococci are inoculated only in the early stages Antistreptolysin O, antistreptohyaluronidase, antistreptokinase Positive blood culture.
Differential diagnosis Erysipeloid (less severe intoxication, itching) Contact dermatitis (no increase in body temperature) Angioedema (no increase in body temperature) Scarlet fever (rashes are more common, not accompanied by edema) SLE (localization - face, less pronounced rise in body temperature, presence ANAT) Polychondritis of cartilage auricle Dermatophytosis Tuberculoid leprosy Phlegmon.
Treatment
Management tactics Antimicrobial therapy Symptomatic treatment pain and febrile syndromes Detoxification therapy.
Drugs of choice Phenoxymethylpenicillin 250–500 mg every 6 hours (children 25–50 mg / kg / day in 4 doses) for at least 10 days. improvement usually occurs in the first 24-48 hours. In severe and complicated course - drugs of the penicillin group parenterally, 1-2 million units every 4-6 hours. In chronic recurrent course, some clinicians recommend prophylactic use of antibiotics in small doses during remission.
Alternative drugs Erythromycin 250 mg 4 r / day (for children 30-40 mg / kg / day in 4 doses) Cephalosporins.
Complications Thrombosis of the underlying vessels Gangrene of the extremity Sepsis Scarlet fever Pneumonia Meningitis.
Course and prognosis Complete recovery with adequate treatment Chronic lymphedema (elephantiasis) or scars in chronic recurrent course.
Age features Children In children of the first year of life, streptococci of group B can be an etiological factor, the involvement of the skin of the anterior abdominal wall Older children are characterized by localization on the face, scalp, legs. Elderly Increase in body temperature may not be so pronounced. High complication rate. Weakened patients with heart disease may develop heart failure.
Prevention Prophylactic courses of antibiotics for chronic recurrent course Patients with erysipelas on the face in the acute period should not shave, because chronic relapses more often occur in men who shaved within 5 days after the first manifestations of erysipelas In chronic cases - identification of possible chronic sources streptococcal infection (palatine tonsils, sinuses, carious teeth).
Synonym. Fire of Saint Anthony
Note. In patients receiving systemic GC, diagnosis can be difficult due to the erased clinical picture.
ICD code A46 | Erysipelas
Erysipelas: A Brief Description
Erysipelas is an infectious and allergic disease of the skin and subcutaneous tissue that affects the superficial lymphatic system skin caused by - group A hemolytic streptococcus.
Code for the international classification of diseases ICD-10:
Erysipelas is an acute streptococcal disease characterized by skin lesions with the formation of a sharply limited inflammatory focus, as well as fever and symptoms of general intoxication, and frequent relapses.
Erysipelas: Causes
Risk factors
Any inflammatory process of the skin The presence of scars on the skin (operations, trauma) Lymphostasis Trophic ulcers of the leg Immunodeficiency states, exhaustion Predisposition to disease Skin sensitization to Streptococcus Ag.
Pathogenesis. As a result of exposure to streptococci and their toxins, serous or serous-hemorrhagic inflammation in the skin develops, complicated by purulent infiltration in severe cases connective tissue and necrosis. Lymphangitis, arteritis, phlebitis develop. The impact of streptococci on the body as a whole is manifested by intoxication, toxic damage to internal organs, the formation of secondary purulent complications.
Pathomorphology
Edema Vasodilation, expansion of lymphatic vessels Infiltration by neutrophils, lymphocytes and other inflammatory cells Endothelial swelling Detection of gram-positive cocci Desquamation of the epidermis With the progression of the process, bubbles filled with exudate are formed In severe cases - skin necrosis.
Calf inflammation classification
The photo shows a severe form of erysipelas
Erysipelas spreads throughout the human body in different ways. Based on the speed of its development and the severity of symptoms, doctors classify the disease into several subsections.
According to the severity of erysipelas, it happens:
- light, with mild signs;
- medium, with pronounced symptoms, but no complications;
- severe, with severe complications and a difficult course of the disease.
Symptoms of erysipelas
Erysipelas on the ankle
Erysipelas: Diagnosis
Laboratory research
Leukocytosis (usually\u003e 15109 / L) with a shift of the leukocyte count to the left, increased ESR Streptococci are inoculated only at early stages Antistreptolysin O, antistreptohyaluronidase, antistreptokinase Positive blood culture.
Differential diagnosis
Erysipeloid (less severe intoxication, itching) Contact dermatitis (no increase in body temperature) Angioedema (no increase in body temperature) Scarlet fever (rashes are more common, not accompanied by edema) SLE (localization - face, less pronounced rise in body temperature, presence of ANAT) Polychondritis of the cartilages of the auricle Dermatophytosis Tuberculoid leprosy Phlegmon.
Erysipelas: Treatment Methods
Erysipelas of the lower leg requires long-term and persistent treatment. As a rule, there are no indications for hospitalization of such patients.
It is enough for the doctor to exercise constant control over the patient. Treatment can be carried out in different ways, and sometimes an integrated approach is used.
The main method of treatment is medication.
In the first 10 days with elevated temperature the doctor prescribes antipyretic drugs (for example, Paracetamol), you need to take a large amount of liquid (warm tea with raspberries, with lemon).
It is necessary to observe bed rest and proper nutrition (increase the consumption of fruits such as apples, pears, oranges; if there is no allergy, then you can eat honey).
In addition, the doctor should prescribe antibiotic treatment to which the patient is not allergic (7-10 days). For this, antibiotics such as Penicillin, Erythromycin are used. The antibiotic can also be applied topically, that is, a powder obtained by crushing the tablets is applied to the affected area. Skin inflammations are eliminated with anti-inflammatory agents.
In addition to local antibiotic treatment, erysipelas of the lower leg can be treated with such agents as ointment, for example, Erythromycin ointment. But in some cases, such drugs are contraindicated.
Your doctor will be able to prescribe the ointment correctly. Additionally, you can prescribe a course of vitamins (groups A, B, C, E) and biostimulants.
Treats erysipelas and physiotherapy (ultraviolet radiation, cryotherapy). Erysipelas are subject to compulsory treatment, otherwise it entails various serious consequences (blood poisoning, necrosis of elephantiasis, thrombophlebitis).
Treatment
Management tactics
Antimicrobial therapy Symptomatic treatment of pain and febrile syndromes
Drugs of choice Phenoxymethylpenicillin 250-500 mg every 6 hours (children 25-50 mg / kg / day in 4 doses) for at least 10 days. improvement usually occurs in the first 24–48 hours. In severe and complicated course - drugs of the penicillin group parenterally 1–2 million units every 4–6 hours. In chronic recurrent course, some clinicians recommend prophylactic use of antibiotics in small doses during remission.
Alternative drugs
Erythromycin 250 mg 4 r / day (children 30-40 mg / kg / day in 4 doses) Cephalosporins.
Local treatment Uncomplicated and erythematous forms - wet - drying dressings with solutions of nitrofural or ethacridine Bullous form - after the initial treatment of bulla, dressings are applied with solution of nitrofural or ethacridine. Subsequently, dressings with ectericide, Shostakovsky's balm are prescribed. Phlegmonous - necrotic form is carried out as usual phlegmons. Local treatment is alternated with physiotherapeutic procedures (UFO, UHF).
Complications
Thrombosis of the underlying vessels Gangrene of the extremity Sepsis Scarlet fever Pneumonia Meningitis.
Course and forecast
Complete recovery with adequate treatment. Chronic lymphedema (elephantiasis) or scarring with chronic recurrent course.
Age features
Children In children of the first year of life, the etiological factor may be group B streptococci, which is characterized by the involvement of the skin of the anterior abdominal wall.Older children are characterized by localization on the face, scalp, legs Elderly Fever may not be so pronounced High complication rate In debilitated patients with heart disease may develop heart failure.
Prevention
Treatment. The most effective antibiotics of the penicillin series.
In case of primary erysipelas and rare relapses, penicillin is prescribed about a dose of ED after 6 hours during a day, at the end of the course, bicillin is additionally administered - 5 (IU / m).
In case of significant residual effects, for the prevention of relapses, Bicillin-5 must be administered within a month (in units after 4 weeks). In case of intolerance to penicillin, erythromycin (0.3 g 5 times a day) or tetracycline (0.3 - 0.4 g 4 times a day) can be prescribed, the duration of the course is one.
For persistent and frequent relapses, antibiotics are combined with corticosteroids (prednisone 30 mg / day).
Preventive measures
Prevention of erysipelas is necessary in order to avoid relapses of the disease. It is possible to prevent the disease.
Prevention includes a number of measures. Direct direct contact of the sick person with family members must be limited.
Meals should be varied and balanced.
Avoid damage to your skin, monitor it carefully and practice personal hygiene. It is better not to wet the site of the lesion with water. The slightest injury or infection can trigger a relapse of the disease. Prevention also consists in treating existing diseases and their consequences: fungus, eczema, tonsillitis, thrombophlebitis. To destroy the causative agent of the infection - staphylococcus, appropriate drugs are needed - antibiotics. Prevention is especially important for people suffering from varicose veins and diabetes. If you find yourself alarming symptoms, immediately contact a specialist so that in the future you do not have to treat equally problematic consequences.
In no case do not self-medicate, as the consequences can be unpredictable. Do not prescribe medications and medications (antibiotics, ointment) yourself. Remember, only a doctor can correctly diagnose and provide adequate treatment.
Coded erysipelas of the lower leg in the ICD
According to the latest data, erysipelas of the lower leg in ICD 10 has a code A46, which does not require clarification. Pathology has only one exception: inflammation after childbirth, which is in another class of the international classification of diseases 10 revision.
Erysipelas is located in the class of infectious pathological processes, in the heading "Other infectious diseases."
Erysipelas is a form of streptococcal disease, which can have an acute or chronic course.
The disease is characterized by involvement of the skin and, less often, mucous membranes in the pathological process. At the site of penetration of bacteria, clearly delimited foci with serous or hemorrhagic contents are formed. The general condition is disturbed slightly.
Favorite localization of the infectious agent: thighs, legs, upper limb and face. To encode erysipelas in ICD 10, the diagnosis should be differentiated from other similar pathologies. Such diseases include:
- eczema;
- eriplezoid;
- contact and atopic dermatitis;
- phlegmon;
- thrombophlebitis (especially if the pathology is localized on the lower leg).
Detection of group A beta-hemolytic streptococcus by laboratory tests is a direct confirmation of the diagnosis. However, the test is rarely performed, more often based on the clinical picture.
Features of treatment and prognosis
This disease is characterized by a recurrent course. Repeated episodes occur at moments of weakened immunity and under the influence of adverse factors.
Therefore, even timely and adequate treatment of the first case of erysipelas does not guarantee complete recovery with no risk of relapse.
However, the overall prognosis for this disease is favorable.
The erysipelas code implies a specific treatment protocol, where the basics of therapeutic measures are prescribed. Since the disease has bacterial origin, then treatment must necessarily include antibacterial drugs. Penicillins, nitrofurans and tetracyclines are used. Corticosteroids are used to relieve signs of inflammation.
Physiotherapy procedures increase the speed of recovery. This pathology does not imply the use of local medicines and procedures, since they irritate the skin and only increase the manifestations of erysipelas.
Erysipelas according to mcb
Erysipelas (erysipelas) is an infectious human disease caused by group A β-hemolytic streptococcus and proceeding in an acute (primary) or chronic (recurrent) form with severe symptoms of intoxication and focal serous or serous-hemorrhagic inflammation of the skin (mucous membranes).
Etiology (causes) of erysipelas
The causative agent is group A β-hemolytic streptococcus (Streptococcus pyogenes). Group A β-hemolytic streptococcus is a facultative anaerobe resistant to environmental factors, but sensitive to heating up to 56 ° C for 30 minutes, to the effects of basic disinfectants and antibiotics.
The features of strains of β-hemolytic streptococcus group A, causing erysipelas, are currently not fully understood. The assumption that they produce toxins identical to scarlet fever was not confirmed: vaccination with erythrogenic toxin does not give a prophylactic effect, and antitoxic anti-scarlet fever serum does not affect the development of erysipelas.
In recent years, it has been suggested that other microorganisms are involved in the development of erysipelas. For example, in bullosa-hemorrhagic forms of inflammation with abundant effusion of fibrin, along with β-hemolytic streptococcus of group A, Staphylococcus aureus, β-hemolytic streptococci of groups B, C, G, gram-negative bacteria (Escherichia, Proteus) are isolated from the wound contents.
Epidemiology of erysipelas
Erysipelas is a widespread sporadic disease with low contagiousness. The low contagiousness of erysipelas is associated with improved sanitary and hygienic conditions and compliance with antiseptic rules in medical institutions. Despite the fact that patients with erysipelas are often hospitalized in general departments (therapy, surgery), among their ward neighbors, repeated cases of erysipelas are rarely recorded in the families of patients. In about 10% of cases, there is a hereditary predisposition to the disease. A wounded face is now extremely rare. There is practically no erysipelas of newborns, which is characterized by high mortality.
The source of the causative agent of the infection is rarely found, which is associated with the wide distribution of streptococci in the environment. Patients with streptococcal infections and healthy bacteria carriers of streptococcus can be the source of the causative agent of infection in the exogenous route of infection. Along with the main, contact mechanism of transmission of infection, an aerosol transmission mechanism (airborne droplet) is possible with primary infection of the nasopharynx and subsequent drift of the pathogen onto the skin by hand, as well as by lymphogenous and hematogenous routes.
In primary erysipelas, group A β-hemolytic streptococcus penetrates the skin or mucous membranes through cracks, diaper rash, various microtraumas (exogenous pathway). With face erysipelas - through cracks in the nostrils or damage to the external auditory canal, with erysipelas of the lower extremities - through cracks in the interdigital spaces, on the heels or damage in the lower third of the leg.
Damage includes minor cracks, scratches, pin pricks and microtrauma.
According to statistics, at present the incidence of erysipelas in the European part of Russia is 150-200 per population. In recent years, there has been an increase in the incidence of erysipelas in the United States and several European countries.
Currently, only a few cases of erysipelas are recorded in patients under the age of 18. From the age of 20, the incidence increases, and in the age range from 20 to 30 years, men get sick more often than women, which is associated with the predominance of primary erysipelas and the occupational factor.
The majority of patients are persons aged 50 years and older (up to 60–70% of all cases). Manual workers prevail among the employed. The highest morbidity is noted among locksmiths, movers, chauffeurs, bricklayers, carpenters, cleaners, kitchen workers and other professions associated with frequent microtraumatization and skin contamination, as well as sudden temperature changes. Housewives and retirees are relatively often sick, and they usually have recurrent forms of the disease. The rise in incidence is noted in the summer-autumn period.
Post-infectious immunity is fragile. Almost a third of patients develop a recurrent disease or a recurrent form of the disease caused by autoinfection, reinfection or superinfection with strains of β-hemolytic streptococcus group A, which contain other M-protein variants.
Specific prevention of erysipelas has not been developed. Non-specific measures are associated with the observance of the rules of asepsis and antiseptics in medical institutions, with the observance of personal hygiene.
Erysipelas pathogenesis
Erysipelas occurs against the background of a predisposition, which is probably congenital in nature and is one of the variants of a genetically determined HRT reaction. People with blood group III (B) are more likely to get erysipelas.
Obviously, a genetic predisposition to erysipelas reveals itself only in old age (more often in women), against the background of repeated sensitization to group A β-hemolytic streptococcus and its cellular and extracellular products (virulence factors) under certain pathological conditions, including those associated with involutional processes.
With primary and repeated erysipelas, the main route of infection is exogenous. With recurrent erysipelas, the pathogen spreads lymphogenically or hematogenously from the foci of streptococcal infection in the body. With frequent relapses of erysipelas, a focus of chronic infection (L-form of β-hemolytic streptococcus group A) occurs in the skin and regional lymph nodes. Under the influence of various provoking factors (hypothermia, overheating, trauma, emotional stress), the L-forms are reversed into the bacterial forms of streptococcus, which cause relapses of the disease. With rare and late relapses of erysipelas, reinfection and superinfection with new strains of β-hemolytic streptococcus group A (M-types) are possible.
The provoking factors that contribute to the development of the disease include violations of the integrity of the skin (abrasions, scratches, scratches, injections, abrasions, cracks, etc.), bruises, a sharp change in temperature (hypothermia, overheating), insolation, emotional stress.
The contributing factors are considered:
Background (concomitant) diseases: mycoses of the feet, diabetes mellitus, obesity, chronic venous insufficiency (varicose veins disease), chronic (acquired or congenital) insufficiency of lymphatic vessels (lymphostasis), eczema, etc.;
Thus, the first stage of the pathological process is the introduction of group A β-hemolytic streptococcus into the skin area when it is damaged (primary erysipelas) or infected from the focus of a dormant infection (recurrent erysipelas) with the development of erysipelas. Endogenous infection can spread directly from the focus of an independent disease of streptococcal etiology.
Reproduction and accumulation of the pathogen in the lymphatic capillaries of the dermis corresponds to the incubation period of the disease.
The next stage is the development of toxinemia, causing intoxication (an acute onset of the disease is characteristic with an increase in temperature and chills).
Subsequently, a local focus of infectious-allergic inflammation of the skin is formed with the participation of immune complexes (the formation of perivascular immune complexes containing the C3-complement fraction), the capillary lymph and blood circulation in the skin is disrupted with the formation of lymphostasis, the formation of hemorrhages and blisters with serous and hemorrhagic contents.
At the final stage of the process, the bacterial forms of β-hemolytic streptococcus are eliminated by phagocytosis, immune complexes are formed, and the patient recovers.
In addition, the formation of foci of chronic streptococcal infection in the skin and regional lymph nodes with the presence of bacterial and L-forms of streptococcus is possible, which becomes the cause of the chronic course of erysipelas in some patients.
The formation of a persistent focus of streptococcal infection in the patient's body (L-form) is considered to be important features of the pathogenesis of often recurrent erysipelas; changes in cellular and humoral immunity; a high level of allergization (type IV hypersensitivity) to group A β-hemolytic streptococcus and its cellular and extracellular products.
It must be emphasized that the disease occurs only in persons who have a congenital or acquired predisposition to it. The infectious-allergic or immunocomplex mechanism of inflammation in erysipelas determines its serous or serous-hemorrhagic nature. The accession of purulent inflammation indicates a complicated course of the disease.
With erysipelas (especially with hemorrhagic forms), the activation of various links of hemostasis (vascular-platelet, procoagulant, fibrinolysis) and the kallikrein-kinin system acquires an important pathogenetic significance. The development of intravascular blood coagulation, along with the damaging effect, has an important protective value: the focus of inflammation is delimited by a fibrin barrier, which prevents the further spread of infection.
With microscopy of a local focus of erysipelas, serous or serous-hemorrhagic inflammation is noted (edema; small-cell infiltration of the dermis, more pronounced around the capillaries). The exudate contains a large number of streptococci, lymphocytes, monocytes and erythrocytes (with hemorrhagic forms). Morphological changes are characterized by a picture of microcapillary arteritis, phlebitis and lymphangitis.
With erythematous-bullous and bullous-hemorrhagic forms of inflammation, the epidermis detaches with the formation of blisters. With hemorrhagic forms of erysipelas, thrombosis of small blood vessels, diapedesis of erythrocytes into the intercellular space, and abundant deposition of fibrin are noted in the local focus. In the period of convalescence with an uncomplicated course of erysipelas, large or small lamellar peeling of the skin is noted in the area of \u200b\u200bthe focus of local inflammation. With a recurrent course of erysipelas, connective tissue gradually grows in the dermis - as a result, lymphatic drainage is disturbed and persistent lymphostasis develops.
The clinical picture (symptoms) of erysipelas
The incubation period for exogenous infection lasts from several hours to 3-5 days. The vast majority of patients have an acute onset of the disease.
Symptoms of intoxication in the initial period appear earlier than local manifestations by several hours - 1-2 days, which is especially characteristic of erysipelas, localized on the lower extremities. Headache, general weakness, chills, myalgia, nausea and vomiting occur (25-30% of patients). Already in the first hours of illness, patients notice an increase in temperature to 38–40 ° C. On areas of the skin, where local lesions will subsequently develop, some patients feel paresthesia, a feeling of bloating or burning, and soreness. Often there is pain on palpation of enlarged regional lymph nodes.
The height of the disease occurs in a few hours - 1-2 days after the first signs appear. At the same time, general toxic manifestations and fever reach their maximum; characteristic local symptoms of erysipelas appear. Most often, the inflammatory process is localized on the lower limbs (60–70%), face (20–30%) and upper limbs (4–7% of patients), rarely - only on the trunk, in the region of the mammary gland, perineum, external genital organs. With timely initiation of treatment and uncomplicated course of the disease, the duration of the fever is no more than 5 days. In 10-15% of patients, its duration exceeds 7 days, which indicates the generalization of the process and the ineffectiveness of etiotropic therapy. The longest febrile period is observed with bullosa-hemorrhagic erysipelas. In 70% of patients with erysipelas, regional lymphadenitis is found (in all forms of the disease).
The temperature returns to normal and the intoxication disappears before the local symptoms regress. Local signs of the disease are observed up to the 5-8th day, with hemorrhagic forms - up to the 12-18th day or more. The residual effects of erysipelas, which persist for several weeks or months, include pastiness and pigmentation of the skin, congestive hyperemia at the site of extinct erythema, dense dry crusts at the site of bullae, edema syndrome.
A poor prognosis and the likelihood of early relapse are indicated by prolonged enlargement and tenderness of the lymph nodes; infiltrative changes in the skin in the area of \u200b\u200ban extinct focus of inflammation; prolonged subfebrile condition; long-term preservation of lymphostasis, which should be considered as an early stage of secondary elephantiasis. Hyperpigmentation of the skin of the lower extremities in patients who have undergone bullous-hemorrhagic erysipelas can persist throughout their lives.
Clinical classification of erysipelas (Cherkasov V.L., 1986)
By the nature of local manifestations:
By severity:
By frequency of flow:
Recurrent (if the disease recurs after two years; other localization of the process);
Recurrent (if there are at least three relapses of erysipelas per year, it is advisable to define "often recurrent erysipelas").
By the prevalence of local manifestations:
Metastatic with the appearance of distant foci of inflammation.
Local (abscess, phlegmon, necrosis, phlebitis, periadenitis, etc.);
General (sepsis, ITSh, pulmonary thromboembolism, etc.).
Persistent lymphostasis (lymphedema, lymphedema);
Secondary elephantiasis (fibredema).
Erythematous erysipelas can be an independent clinical form or initial stage other forms of erysipelas. A small red or pink spot appears on the skin, which after a few hours turns into a characteristic erythema erythema. Erythema is a clearly demarcated area of \u200b\u200bhyperemic skin with uneven borders in the form of teeth, tongues. The skin in the area of \u200b\u200berythema is tense, edematous, hot to the touch, it is infiltrated, moderately painful on palpation (more on the periphery of the erythema). In some cases, you can find a "peripheral roller" - infiltrated and raised edges of erythema. Characterized by enlargement, soreness of the femoral-inguinal lymph nodes and hyperemia of the skin above them ("pink cloud").
Erythematous-bullous erysipelas occurs in a few hours - 2–5 days against the background of erythema erythema. The development of blisters is caused by increased exudation in the focus of inflammation and the detachment of the epidermis from the dermis, accumulated fluid. If the surface of the bubbles is damaged or their spontaneous rupture, exudate flows out of them; erosion appears in place of bubbles; if the bubbles remain intact, they gradually shrink to form yellow or brown crusts.
Erythematous-hemorrhagic erysipelas occurs against the background of erythematous erysipelas 1-3 days after the onset of the disease: hemorrhages of various sizes are noted - from small petechiae to extensive confluent ecchymosis. Bullous-hemorrhagic erysipelas develops from an erythematous-bullous or erythematous-hemorrhagic form as a result of deep damage to the capillaries and blood vessels of the reticular and papillary layers of the dermis. There are extensive skin hemorrhages in the area of \u200b\u200berythema. Bullous elements are filled with hemorrhagic and fibrinous-hemorrhagic exudate. They can be of different sizes; have a dark color with translucent yellow fibrin inclusions. The blisters contain predominantly fibrinous exudate. The emergence of extensive, flattened blisters, dense on palpation, due to significant deposition of fibrin in them. With active repair, brown crusts quickly form in place of the blisters in patients. In other cases, it is possible to observe rupture, rejection of the blister caps together with clots of fibrinous-hemorrhagic contents and exposure of the eroded surface. In most patients, it gradually epithelizes. With significant hemorrhages in the bottom of the bladder and the thickness of the skin, necrosis is possible (sometimes with the addition of a secondary infection, the formation of ulcers).
Recently, hemorrhagic forms of the disease have been more often recorded: erythematous-hemorrhagic and bullous-hemorrhagic.
The criteria for the severity of erysipelas are the severity of intoxication and the prevalence of the local process.
The mild (I) form includes cases with minor intoxication, low-grade fever, localized (more often erythematous) local process.
Moderate (II) form is characterized by severe intoxication. Patients complain about general weakness, headache, chills, muscle pain, sometimes - nausea, vomiting, fever up to 38-40 ° C. Examination reveals tachycardia; in almost half of the patients - hypotension. The local process can be both localized and widespread (it covers two or more anatomical regions).
Severe (III) form includes cases with severe intoxication: with intense headache, repeated vomiting, hyperthermia (over 40 ° C), darkening of consciousness (sometimes), meningeal symptoms, convulsions. Find significant tachycardia, hypotension; in elderly and senile people, with late treatment started, it is possible to develop acute cardiovascular failure. The severe form also includes a widespread bullous hemorrhagic erysipelas with extensive blisters in the absence of pronounced intoxication and hyperthermia.
With different localization of the disease, its course and prognosis have their own characteristics. The lower extremities are the most common localization of erysipelas (60–75%). The disease forms with the development of extensive hemorrhages, large blisters and the subsequent formation of erosions and other skin defects. For this localization, the most typical lesions of the lymphatic system in the form of lymphangitis, periadenitis; chronically relapsing course. Face erysipelas (20-30%) is usually observed in primary and recurrent forms of the disease. With it, a relapsing course is relatively rarely noted.
Timely started treatment facilitates the course of the disease. Quite often the appearance of facial erysipelas is preceded by tonsillitis, acute respiratory infections, exacerbation chronic sinusitis, otitis media, caries.
Erysipelas of the upper extremities (5–7%), as a rule, occurs against the background of postoperative lymphostasis (elephantiasis) in women operated on for a breast tumor.
One of the main features of erysipelas as a streptococcal infection is a tendency towards a chronically recurrent course (25–35% of cases). Distinguish late relapses (a year or more after the previous disease with the same localization of local inflammatory process) and seasonal (annual over many years, most often in the summer-autumn period). Late and seasonal relapses (the result of reinfection) by clinical course are similar to a typical primary erysipelas, but usually develop against the background of persistent lymphostasis and other consequences of previous diseases.
Early and frequent (three or more per year) relapses are considered exacerbations of a chronic disease. In more than 90% of patients, recurrent erysipelas often occurs against the background of various concomitant diseases in combination with disorders of skin trophism, a decrease in its barrier functions, and local immunodeficiency.
Local complications are observed in 5-10% of patients: abscesses, phlegmon, skin necrosis, pustulization of bullae, phlebitis, thrombophlebitis, lymphangitis, periadenitis. Most often, such complications occur in patients with bullous hemorrhagic erysipelas. With thrombophlebitis, the subcutaneous and deep veins of the lower leg are affected.
Treatment of such complications is carried out in the departments of purulent surgery.
Common complications (0.1–0.5% of patients) include sepsis, ISS, acute cardiovascular failure, pulmonary embolism, etc.
Mortality in erysipelas is 0.1–0.5%.
The consequences of erysipelas include persistent lymphostasis (lymphedema) and actually secondary elephantiasis (fibredema). Persistent lymphostasis and elephantiasis in most cases appear against the background of functional insufficiency of the lymph circulation of the skin (congenital, post-traumatic and other). The recurrent erysipelas arising against this background significantly increases the disturbance of lymph circulation (sometimes subclinical), leading to complications.
Successful anti-relapse treatment of erysipelas (including repeated courses of physiotherapy) significantly reduces lymphatic edema. With already formed secondary elephantiasis (fibredema), only surgical treatment is effective.
Diagnosis of erysipelas
The diagnosis of erysipelas is based on a characteristic clinical picture:
· Acute onset with severe symptoms of intoxication;
· Development of typical local manifestations with characteristic erythema, possible local hemorrhagic syndrome;
· Development of regional lymphadenitis;
In 40-60% of patients in the peripheral blood, moderate neutrophilic leukocytosis (up to 10-12 × 109 / l) is noted. In some patients with severe erysipelas, hyperleukocytosis and toxic granularity of neutrophils are observed. Moderate increased ESR (up to 20-25 mm / h) is recorded in 50-60% of patients with primary erysipelas.
Due to the rare isolation of β-hemolytic streptococcus from the blood of patients and the focus of inflammation, it is impractical to conduct conventional bacteriological studies. Definite diagnostic value have an increase in the titers of antistreptolysin O and other anti-streptococcal antibodies, bacterial antigens in the blood, saliva of patients, separated from bullous elements (RLA, RCA, ELISA), which is especially important in predicting relapses in convalescents.
Differential diagnosis
Differential diagnosis for erysipelas is carried out with more than 50 surgical, skin, infectious and internal diseases. First of all, it is necessary to exclude abscess, phlegmon, hematoma suppuration, thrombophlebitis (phlebitis), dermatitis, eczema, herpes zoster, erysipeloid, anthrax, erythema nodosum (Table 17-35).
Table 17-35. Differential diagnosis of erysipelas
Erysipelas according to mcb
RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan
general information
Short description
Classification
Clinical classification of erysipelas (Cherkasov V.L., 1986).
Repeated (if the disease recurs two years or more after the primary disease or at an earlier date, but with a different localization of the process);
· Recurrent (relapses occur in the period from several days to 2 years with the same localization of the process. Often recurrent erysipelas - 3 relapses or more per year with the same localization of the process). Early relapses of erysipelas occur in the first 6 months from the onset of the disease, late - after 6 months.
• scalp;
· Upper limbs (by segments);
Lower limbs (by segments);
Localized (the local process covers one anatomical region (for example, the lower leg or face));
Widespread (migratory) (the local process captures several adjacent anatomical areas);
Metastatic with the emergence of distant foci of inflammation (eg, lower leg, face, etc.).
Local (abscess, phlegmon, necrosis, phlebitis, periadenitis, etc.);
General (sepsis, ITSh, pulmonary embolism, nephritis, etc.).
Persistent lymphostasis (lymphatic edema, lymphedema);
· Secondary elephantiasis (fibredema).
A detailed clinical diagnosis indicates the presence of concomitant diseases.
Primary erysipelas of the right half of the face, erythematous-bullous form, moderate severity.
Recurrent erysipelas of the left leg and foot, bullous hemorrhagic form, severe. Complications: Phlegmon of the left lower leg. Lymphostasis.
Concomitant disease: Epidermophytosis of the feet.
Diagnostics (outpatient clinic)
DIAGNOSTICS AT THE AMBULATORY LEVEL **
· Increase in body temperature up to ° С;
Paresthesia, a feeling of bloating or burning, mild pain, redness in the skin area.
· Acute onset of the disease.
· Violations of the integrity of the skin (abrasions, scratches, scratches, injections, abrasions, cracks, etc.);
· The presence of foci of chronic streptococcal infection: tonsillitis, otitis media, sinusitis, caries, periodontal disease, osteomyelitis, thrombophlebitis, trophic ulcers (more often with the erysipelas of the lower extremities);
· Occupational hazards associated with increased trauma, skin contamination, wearing rubber shoes, etc.;
· Chronic somatic diseases, as a result of which anti-infectious immunity decreases (more often in old age).
· Erythema (a clearly demarcated area of \u200b\u200bhyperemic skin with uneven borders in the form of teeth, tongues of flame, "geographical map");
Infiltration, skin tension, moderate pain on palpation (more on the periphery), local temperature rise in the area of \u200b\u200berythema;
· "Peripheral roller" in the form of infiltrated and raised edges of erythema;
· Edema of the skin, extending beyond the erythema;
Regional lymphadenitis, pain on palpation in the area regional lymph nodes, lymphangitis;
· The predominant localization of the local inflammatory process on the lower extremities and face;
· The absence of severe pain in the focus of inflammation at rest.
Blisters (bullae) against the background of erythema erythema (see above).
Hemorrhages of various sizes (from small petechiae to extensive drainage hemorrhages) into the skin against the background of erythema erythema (see above).
Blisters (bulls) of different sizes against the background of erythema erythema, filled with hemorrhagic or fibro-hemorrhagic exudate;
· Extensive hemorrhages in the skin in the area of \u200b\u200berythema.
An increase in body temperature up to 38 - 40 ° С, the duration of a febrile period is 3-4 days, symptoms of intoxication are moderately expressed (headache, chills, muscle pain, tachycardia, hypotension, sometimes nausea, vomiting),
· Pronounced local process, often widespread, often with the presence of extensive bullae and hemorrhages, even in the absence of pronounced symptoms of intoxication and hyperthermia.
· Complete blood count (CBC): moderate leukocytosis with neutrophilic shift of the formula to the left, moderate increase in erythrocyte sedimentation rate (ESR);
General urine analysis (OAM): in severe cases - oliguria and proteinuria, in the urine sediment - erythrocytes, leukocytes, hyaline and granular casts.
Diagnostics (hospital)
STATIONARY DIAGNOSTICS **
Fever (To C);
Paresthesias, a feeling of bloating or burning, mild pain, redness, the presence of rashes in the skin area.
· Acute onset of the disease.
The presence of provoking factors:
· Violations of the integrity of the skin (abrasions, scratches, wounds, scratches, injections, abrasions, cracks, etc.);
· A sharp change in temperature (hypothermia, overheating);
The presence of predisposing factors:
Background (concomitant) diseases: mycoses of the feet, diabetes mellitus, obesity, chronic venous insufficiency (varicose veins disease), chronic (acquired or congenital) insufficiency of the lymphatic vessels (lymphostasis), eczema, etc.;
· The presence of foci of chronic streptococcal infection: tonsillitis, otitis media, sinusitis, caries, periodontal disease, osteomyelitis, thrombophlebitis, trophic ulcers (more often with the erysipelas of the lower extremities);
· Occupational hazards associated with increased trauma, skin contamination, wearing rubber shoes, etc.;
· Chronic somatic diseases, as a result of which anti-infectious immunity decreases (more often in old age).
Local process (occurs within an hour from the onset of the disease) - pain, hyperemia and edema of the affected area of \u200b\u200bthe skin (in the face, trunk, extremities and in some cases - on the mucous membranes).
· The affected area of \u200b\u200bskin is characterized by erythema, swelling and tenderness. Erythema of uniform bright color with clear boundaries with a tendency to peripheral spread, rises above intact skin. Its edges are irregular in shape (in the form of "tongues of flame", "geographical map"). Subsequently, peeling of the skin may appear at the site of erythema.
· Onset is the same as erythematous. However, after 1-3 days from the moment of the disease at the site of the erythema, the epidermis detaches and bubbles of various sizes are formed, filled with serous contents. Subsequently, the bubbles burst and a brown crust forms in their place. After their rejection, young tender skin is visible. In some cases, erosions appear in place of the bubbles, which can transform into trophic ulcers.
· Against the background of erythema, hemorrhages appear in the affected areas of the skin.
· It proceeds similarly to the erythematous-bullous form, however, the bubbles formed in the process of the disease at the site of erythema are filled not with serous, but with hemorrhagic exudate.
Regional lymphadenitis (an increase and soreness of the lymph nodes regional in relation to the affected area of \u200b\u200bthe skin).
Lymphangitis (longitudinal changes in the skin, accompanied by hyperemia, induration and soreness).
· Severity of symptoms of intoxication;
· The prevalence and nature of the local process.
Subfebrile body temperature, symptoms of intoxication are mild, the duration of the febrile period is 1-2 days;
Localized (usually erythematous) local process.
An increase in body temperature to 38 - 40 ° C, the duration of a febrile period is 3-4 days, symptoms of intoxication are moderately expressed (headache, chills, muscle pain, tachycardia, hypotension, sometimes nausea, vomiting);
· A localized or widespread process involving two anatomical regions.
Body temperature 40 ° C and above, the duration of the febrile period is more than 4 days, symptoms of intoxication are expressed (weakness, severe headache, repeated vomiting, sometimes delirium, confusion, occasionally meningism, convulsions, significant tachycardia, hypotension);
a pronounced local process, often widespread, often with the presence of extensive bullae and hemorrhages, even in the absence of pronounced symptoms of intoxication and hyperthermia.
KLA: leukocytosis, neutrophilia with stab shift, thrombocytopenia, increased ESR.
OAM: proteinuria, cylindruria, microhematuria (with severe course of the disease as a result of toxic renal damage).
· C-reactive protein: increased content.
· biochemical analysis blood (according to indications): determination of the content of total protein, albumin, electrolytes (potassium, sodium), glucose, creatinine, urea, residual nitrogen).
Coagulogram: in case of violations in the vascular-platelet, procoagulant, fibrinolytic links in patients with severe hemorrhagic forms of erysipelas - determination of blood coagulation time, activated partial thromboplastin time, prothrombin index or ratio, fibrinogen, thrombin time.
· Blood sugar (according to indications);
· Immunogram (according to indications).
· X-ray of the chest organs (according to indications);
Organ ultrasound abdominal cavity, kidneys (according to indications).
Algorithm for diagnostic search in the presence of erythema in the patient
· Biochemical blood test: C-reactive protein, total protein, albumin.
With the development of acute renal failure - potassium, sodium, glucose, creatinine, urea, residual nitrogen;
In case of violations in the vascular-platelet link: coagulogram - blood coagulation time, activated partial thromboplastin time, prothrombin index or ratio, fibrinogen, thrombin time.
· Blood sugar (according to indications);
· Immunogram (according to indications).
· X-ray of the chest organs (according to indications);
· Ultrasound of the abdominal cavity organs, kidneys (according to indications).
Erysipelas with inflammation and erythema of the skin is a common disease that mainly affects older people, much more often in women. The highest frequency of localization of inflammation is on the lower extremities, but there are painful changes on the face and hands. Clinical observations indicate that this pathology mainly affects people with blood group 3.
Erysipelas is an infectious-allergic process that is caused by streptococcal infection. The layers of the skin, subcutaneous tissue, as well as superficial lymphatic ducts are affected.
This process is a kind of reaction to streptococcus, which is transmitted by contact or airborne infection.
ICD-10 code for erysipelas of the lower leg (International Classification of Diseases 10 revision) - A46... The incubation period of the infection from the beginning of the introduction of the pathogen to the first clinical signs is from 2 days to a week.
Inflammation of the outer cover of an erysipelas is caused by beta-hemolytic streptococcus, the effect of which provokes intoxication and local changes in certain areas of the skin. Contact with a microorganism does not provide for an obligatory disease, for this the following factors are necessary:
- decreased immunity;
- allergic readiness of the body;
- violation of the integrity of the skin (scuffs, cuts, scratches);
- a decrease in the intensity of metabolic processes due to age-related changes skin.
Often the disease develops in men with working specialties who spend a lot of time outdoors in unsanitary conditions and are prone to skin microtrauma.
After the transferred pathology, lifelong immunity is not formed, therefore, during life there is the possibility of getting sick several times.
The likelihood of getting sick with erysipelas of the lower leg increases sharply in the warm season, when mosquito and midge bites and skin damage often occur.
Forms of erysipelas of the lower extremities
According to the degree of the pathological process, the following forms are distinguished:
- acute primary;
- recurrent;
- repeated.
According to the depth and mechanism of skin lesions, the following types of ailment are distinguished:
- erythematous;
- erythematous-bullous;
- erythematous-hemorrhagic;
- bullous hemorrhagic.
Depending on the severity of painful manifestations with erysipelas, there are:
The recurrent nature of erysipelas develops in the presence of concomitant diseases:
- fungal infections;
- venous insufficiency of the lower extremities;
- violation of lymph circulation (lymphostasis);
- obesity;
- diabetes mellitus complicated by angiopathy and neuropathy.
The presence in the body of foci of streptococcal infection provokes the development of erysipelas with inflammation of the skin of the lower leg.
The onset of the disease is manifested by general intoxication of the body. The patient presents the following complaints:
- an increase in body temperature up to 38-39 degrees;
- headache;
- nausea, vomiting and lack of appetite;
- muscle soreness;
- weakness.
After deterioration general condition changes appear on the skin. In the erythematous form - sharp hyperemia and swelling of the affected areas, which have clear edges. The inflammation peels off, itching and burning appear.
In the erythematous-bullous form, after a few hours (in rare cases, days) after redness, the epidermis detaches and blisters with fluid appear, which subsequently burst.
With a bullous hemorrhagic manifestation, the blisters are filled with bloody contents.
The erythematous-hemorrhagic variant is accompanied by hemorrhages at the site of inflammation.
The diagnosis is usually straightforward, since the manifestations of the disease are typical. Local symptoms (redness of the skin with sharp boundaries in the form of erythema, edema, burning) is combined with general intoxication (fever, chills, pain in the head and muscles).
In the clinical analysis of blood, moderate leukocytosis appears (during moderate) and an increase in ESR up to 18-20 mm per hour. A severe course is accompanied by toxic granularity of leukocytes.
Serological tests show an increase in antistreptococcal antibody titers. Bacteriological blood culture for streptococcus is impractical to take, since the pathogen in most cases is not sown.
To diagnose concomitant pathological conditions, the following specialists must be consulted:
Often relapses of the lower leg erysipelas develop against the background of chronic alcoholism. Without treatment of the underlying problem, it is difficult to cope with the inflammatory process.
To improve the patient's condition, a set of therapeutic measures will be required to restore the body's defenses and fight infection.
The appearance of the first signs of inflammation requires the appointment of bed rest. The patient should be in a supine position with the affected limb raised. This helps to activate venous circulation and lymph drainage, as well as reduce inflammation.
Dietary recommendations for erysipelas urge to give preference to a high-calorie diet with a balanced ratio of protein, fat and carbohydrates. The food should contain a sufficient amount of vitamins, minerals and amino acids. You should eat often (4-5 times a day) in small portions. Overeating should be avoided. You will also need to observe the drinking regime (up to 2 liters of liquid per day).
Patients with a mild course of the disease can be treated on an outpatient basis. Cases with moderate and severe course of the disease, as well as recurrent forms, require compulsory hospitalization.
The basis of the drug effect is the prescription of antibiotics that suppress the activity of streptococcus:
Antibacterial drugs complement the effect of antibiotics:
To eliminate inflammatory changes on the skin, non-steroidal anti-inflammatory drugs (Ibuprofen, Diclofenac) are needed. In severe cases, the appointment of steroid hormonal drugs (Dexamethasone, Prednisolone).
To reduce the manifestations of general intoxication, the use of detoxification solutions for drip administration will be required:
Paracetamol may be prescribed as an antipyretic agent, if necessary.
To increase the body's defenses, vitamin therapy is needed (drugs of group B, C, E). In order to reduce vascular permeability, the appointment of Ascorutin is justified.
Hospitalization of patients with this form of the disease is required. As antibiotic therapy, a two-phase antibiotic regimen is required.
At the first stage, drugs from the group of cephalosporins are prescribed:
The duration of the course is 10-12 days. After 4-5 days. Lincomycin is prescribed, the period of therapy at the second stage is 6-8 days.
During treatment with antibiotics, it is necessary to take intestinal probiotics (Linex, Bifidum-bacterin) and antifungal drugs (Fucis, Nystatin).
To stimulate venous circulation, venotonic agents are prescribed (Troxevasin, Detralex). Medicines with antioxidant effects on tissues help to improve trophic processes:
- Retinol acetate;
- Tocopherol acetate;
- Succinic acid.
To obtain a noticeable result, the rehabilitation of chronic foci of infection is required.
An addition to antibiotic therapy is physiotherapeutic treatment: it improves trophic processes and blood circulation at the site of the lesion. The following procedures can be assigned:
- magnetotherapy;
- electrophoresis with lidase;
- infrared laser therapy;
- exposure to ultra-high frequency currents.
These procedures improve the patient's condition, help prevent complications associated with impaired lymph circulation.
In the erythematous form, local treatment with bandages, lotions and compresses is not required.
The use of all ointment-based products for erysipelas is categorically contraindicated.
In the bullous form, which is accompanied by the formation of bubbles, they are opened. Bandages with a solution of rivanol or furacilin are applied to the wound surface. The imposition of tight bandages is strictly contraindicated, as they disrupt blood circulation and lymph drainage.
Therapeutic measures prescribed out of time and in insufficient volume, as well as violations of the regime, can lead to the development of complications.
The most dangerous situations are accompanied by destabilization of the general condition against the background of erysipelas:
- sepsis;
- pulmonary embolism;
- pneumonia.
Complications of a local nature with inflammation of other structures aggravate the course of erysipelas:
- phlegmon;
- gangrene;
- soft tissue necrosis of the leg;
- phlebitis and thrombophlebitis;
- violation of lymphatic drainage (elephantiasis).
The development of complications often leads to the need surgical intervention.
Primary forms of inflammation like erysipelas require a sick leave for 10-12 days. Recurrent cases involve disability for 18-20 days.
To prevent the disease, the following recommendations will be required:
- avoid hypothermia and sudden temperature changes;
- treat any damage with disinfectants;
- comply with hygiene requirements;
- timely sanitize chronic infectious foci (carious teeth, inflammation of the tonsils) and fungal changes;
- maintain the protective properties of the body with general strengthening agents.
Timely adequate therapy of chronic venous circulation disorders, diabetes mellitus, alcoholism is of great importance.
Erysipelas with inflammation of the shin skin is a peculiar reaction of the body to the effects of group A streptococcus. Full treatment and adherence to the recommendations of a lifestyle specialist allows in most cases to achieve recovery and avoid unpleasant consequences.
source
Includes: Mycobacterium leprae infection
Excludes: long-term effects of leprosy (B92)
Includes: listeria foodborne infection
Excludes1: neonatal (disseminated) listeriosis (P37.2)
Excludes1: streptococcal angina (J02.0)
If it is necessary to indicate septic shock, use an additional code (R57.2).
Excluded:
- during labor (O75.3)
- followed by:
- immunization (T88.0)
- neonatal (P36.0-P36.1)
- postprocedural (T81.4)
- postpartum (O85)
Use an additional code (R57.2) if necessary to indicate septic shock.
Excluded:
- bacteremia NOS (A49.9)
- during labor (O75.3)
- followed by:
- abortion, ectopic or molar pregnancy (O03-O07, O08.0)
- immunization (T88.0)
- infusion, transfusion, or therapeutic injection (T80.2)
- sepsis (caused) (for):
- actinomycotic (A42.7)
- anthrax (A22.7)
- candidal (B37.7)
- Erysipelothrix (A26.7)
- extraintestinal yersiniosis (A28.2)
- gonococcal (A54.8)
- herpes virus (B00.7)
- listeria (A32.7)
- meningococcal (A39.2-A39.4)
- neonatal (P36.-)
- postprocedural (T81.4)
- postpartum (O85)
- streptococcal (A40.-)
- tularemic (A21.7)
- septic (th):
- melioidosis (A24.1)
- plague (A20.7)
- toxic shock syndrome (A48.3)
source
RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols MH RK - 2016
Erysipelas (English erysipelas) is an infectious human disease caused by group A β-hemolytic streptococcus and proceeding in an acute (primary) or chronic (recurrent) form with severe symptoms of intoxication and focal serous or serous-hemorrhagic inflammation of the skin and mucous membranes.
The ratio of the ICD-10 and ICD-9 codes (if the number of codes is more than 5, highlight in the appendix to the clinical protocol):
| ICD-10 | ICD-9 | ||
| Code | Name | Code | Name |
| A46.0 | Erysipelas | 035 | Erysipelas |
Protocol development date:2016 year.
Protocol users: infectious disease specialists, therapists, general practitioners, emergency doctors, paramedics, surgeons, dermatovenerologists, obstetrician-gynecologists, physiotherapists.
Evidence level scale:
| AND | High-quality meta-analysis, systematic review of RCTs, or large RCTs with very low likelihood (++) of bias whose results can be generalized to the relevant population. |
| IN | High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the relevant population ... |
| WITH | A cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population, or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly extended to the relevant population. |
| D | Description of a case series or uncontrolled study or expert opinion. |
Clinical classification of erysipelas (Cherkasov V.L., 1986).
By frequency of flow:
· Primary;
Repeated (if the disease recurs two years or more after the primary disease or at an earlier date, but with a different localization of the process);
· Recurrent (relapses occur in the period from several days to 2 years with the same localization of the process. Often recurrent erysipelas - 3 relapses or more per year with the same localization of the process). Early relapses of erysipelas occur in the first 6 months from the onset of the disease, late - after 6 months.
By the nature of local manifestations:
Erythematous;
Erythematous-bullous;
· Erythematous-hemorrhagic;
Bullous hemorrhagic.
Localization of the local process:
· Faces;
• scalp;
· Upper limbs (by segments);
Lower limbs (by segments);
· Trunk;
· Genitals.
By severity:
Easy (I);
· Moderate (II);
Severe (III).
By the prevalence of local manifestations:
Localized (the local process covers one anatomical region (for example, the lower leg or face));
Widespread (migratory) (the local process captures several adjacent anatomical areas);
Metastatic with the emergence of distant foci of inflammation (eg, lower leg, face, etc.).
Complications of erysipelas:
Local (abscess, phlegmon, necrosis, phlebitis, periadenitis, etc.);
General (sepsis, ITSh, pulmonary embolism, nephritis, etc.).
Consequences of erysipelas:
Persistent lymphostasis (lymphatic edema, lymphedema);
· Secondary elephantiasis (fibredema).
A detailed clinical diagnosis indicates the presence of concomitant diseases.
Examples of wording a diagnosis:
Primary erysipelas of the right half of the face, erythematous-bullous form, moderate severity.
Recurrent erysipelas of the left leg and foot, bullous hemorrhagic form, severe. Complications: Phlegmon of the left lower leg. Lymphostasis.
Concomitant disease: Epidermophytosis of the feet.
DIAGNOSTICS AT THE AMBULATORY LEVEL **
Diagnostic criteria
Complaints:
· Increase in body temperature up to 38 - 40 ° С;
Chills;
· headache;
• weakness, malaise;
· muscle pain;
· nausea, vomiting;
Paresthesia, a feeling of bloating or burning, mild pain, redness in the skin area.
Anamnesis:
· Acute onset of the disease.
Provoking factors:
· Violations of the integrity of the skin (abrasions, scratches, scratches, injections, abrasions, cracks, etc.);
· Bruises;
· Insolation;
· Emotional stress.
Predisposing factors:
Physical examination:
Erythematous erysipelas:
· Erythema (a clearly demarcated area of \u200b\u200bhyperemic skin with uneven borders in the form of teeth, tongues of flame, "geographical map");
Infiltration, skin tension, moderate pain on palpation (more on the periphery), local temperature rise in the area of \u200b\u200berythema;
· "Peripheral roller" in the form of infiltrated and elevated edges of erythema;
· Edema of the skin, extending beyond the erythema;
Regional lymphadenitis, tenderness on palpation in the region of regional lymph nodes, lymphangitis;
· The predominant localization of the local inflammatory process on the lower extremities and face;
· The absence of severe pain in the focus of inflammation at rest.
Read also: What list does diphenhydramine belong to?
Erythematous-bullous the form faces:
Blisters (bullae) against the background of erythema erythema (see above).
Erythematous-hemorrhagic the form faces:
Hemorrhages of various sizes (from small petechiae to extensive drainage hemorrhages) into the skin against the background of erythema erythema (see above).
Bullous hemorrhagic the form faces:
Blisters (bulls) of different sizes against the background of erythema erythema, filled with hemorrhagic or fibro-hemorrhagic exudate;
· Extensive hemorrhages in the skin in the area of \u200b\u200berythema.
Severity criteria faces:
Light (I) form:
Moderate (II) form:
An increase in body temperature up to 38 - 40 ° С, the duration of a febrile period is 3-4 days, symptoms of intoxication are moderately expressed (headache, chills, muscle pain, tachycardia, hypotension, sometimes nausea, vomiting),
Severe (III) form:
· Pronounced local process, often widespread, often with the presence of extensive bullae and hemorrhages, even in the absence of pronounced symptoms of intoxication and hyperthermia.
Laboratory research:
· Complete blood count (CBC): moderate leukocytosis with neutrophilic shift of the formula to the left, moderate increase in erythrocyte sedimentation rate (ESR);
General urine analysis (OAM): in severe cases - oliguria and proteinuria, in the urine sediment - erythrocytes, leukocytes, hyaline and granular casts.
Instrumental research: are not specific.
Diagnostic algorithm: (diagram)
STATIONARY DIAGNOSTICS **
Diagnostic criteria at the hospital level [1,2]
Complaints:
Fever (T 38-40 o C);
Chills;
Weakness;
Lethargy;
Malaise;
· headache;
· sleep disturbance;
· Decreased appetite;
Body aches;
· nausea and vomiting;
• violation of consciousness;
· Convulsions;
Paresthesias, a feeling of bloating or burning, mild pain, redness, the presence of rashes in the skin area.
Anamnesis:
· Acute onset of the disease.
The presence of provoking factors:
· Violations of the integrity of the skin (abrasions, scratches, wounds, scratches, injections, abrasions, cracks, etc.);
· Bruises;
· A sharp change in temperature (hypothermia, overheating);
· Insolation;
· radiation therapy;
· Emotional stress.
The presence of predisposing factors:
Background (concomitant) diseases: mycoses of the feet, diabetes mellitus, obesity, chronic venous insufficiency (varicose veins disease), chronic (acquired or congenital) insufficiency of the lymphatic vessels (lymphostasis), eczema, etc.;
· The presence of foci of chronic streptococcal infection: tonsillitis, otitis media, sinusitis, caries, periodontal disease, osteomyelitis, thrombophlebitis, trophic ulcers (more often with the erysipelas of the lower extremities);
· Occupational hazards associated with increased trauma, skin contamination, wearing rubber shoes, etc.;
· Chronic somatic diseases, as a result of which anti-infectious immunity decreases (more often in old age).
Physical examination:
Local process (occurs 12-24 hours after the onset of the disease) - pain, hyperemia and edema of the affected area of \u200b\u200bthe skin (in the face, trunk, extremities and, in some cases, on the mucous membranes).
Erythematous form:
· The affected area of \u200b\u200bskin is characterized by erythema, swelling and tenderness. Erythema of uniform bright color with clear boundaries with a tendency to peripheral spread, rises above intact skin. Its edges are irregular in shape (in the form of "tongues of flame", "geographical map"). Subsequently, peeling of the skin may appear at the site of erythema.
Erythematous-bullous form:
· Onset is the same as erythematous. However, after 1-3 days from the moment of the disease at the site of the erythema, the epidermis detaches and bubbles of various sizes are formed, filled with serous contents. Subsequently, the bubbles burst and a brown crust forms in their place. After their rejection, young tender skin is visible. In some cases, erosions appear in place of the bubbles, which can transform into trophic ulcers.
Erythematous-hemorrhagic form:
· Against the background of erythema, hemorrhages appear in the affected areas of the skin.
Bullous hemorrhagic form:
· It proceeds similarly to the erythematous-bullous form, however, the bubbles formed in the process of the disease at the site of erythema are filled not with serous, but with hemorrhagic exudate.
Regional lymphadenitis (an increase and soreness of the lymph nodes regional in relation to the affected area of \u200b\u200bthe skin).
Lymphangitis (longitudinal changes in the skin, accompanied by hyperemia, induration and soreness).
Severity criteria faces:
· Severity of symptoms of intoxication;
· The prevalence and nature of the local process.
Light (I) form:
Subfebrile body temperature, symptoms of intoxication are mild, the duration of the febrile period is 1-2 days;
Localized (usually erythematous) local process.
Moderate (II) form:
An increase in body temperature to 38 - 40 ° C, the duration of a febrile period is 3-4 days, symptoms of intoxication are moderately expressed (headache, chills, muscle pain, tachycardia, hypotension, sometimes nausea, vomiting);
· A localized or widespread process involving two anatomical regions.
Severe (III) form:
Body temperature 40 ° C and above, the duration of the febrile period is more than 4 days, symptoms of intoxication are expressed (weakness, severe headache, repeated vomiting, sometimes delirium, confusion, occasionally meningism, convulsions, significant tachycardia, hypotension);
a pronounced local process, often widespread, often with the presence of extensive bullae and hemorrhages, even in the absence of pronounced symptoms of intoxication and hyperthermia.
Laboratory research
KLA: leukocytosis, neutrophilia with stab shift, thrombocytopenia, increased ESR.
OAM: proteinuria, cylindruria, microhematuria (with severe course of the disease as a result of toxic renal damage).
· C-reactive protein: increased content.
· Biochemical blood test (according to indications): determination of the content of total protein, albumin, electrolytes (potassium, sodium), glucose, creatinine, urea, residual nitrogen).
· Coagulogram: in case of violations in the vascular-platelet, procoagulant, fibrinolytic links in patients with severe hemorrhagic forms of erysipelas - determination of blood coagulation time, activated partial thromboplastin time, prothrombin index or ratio, fibrinogen, thrombin time.
· Blood sugar (according to indications);
· Immunogram (according to indications).
ECG (according to indications);
· X-ray of the chest organs (according to indications);
· Ultrasound of the abdominal cavity organs, kidneys (according to indications).
Diagnostic algorithm
Algorithm for diagnostic search in the presence of erythema in the patient
List of main diagnostic measures:
· UAC;
· OAM.
List of additional diagnostic measures:
· Biochemical blood test: C-reactive protein, total protein, albumin.
With the development of acute renal failure - potassium, sodium, glucose, creatinine, urea, residual nitrogen;
In case of violations in the vascular-platelet link: coagulogram - blood coagulation time, activated partial thromboplastin time, prothrombin index or ratio, fibrinogen, thrombin time.
· Blood sugar (according to indications);
· Immunogram (according to indications).
Instrumental research
ECG (according to indications);
· X-ray of the chest organs (according to indications);
· Ultrasound of the abdominal cavity organs, kidneys (according to indications).
Differential diagnosis and justification for additional research
| Diagnosis | Surveys | Diagnosis exclusion criteria | |
| Phlegmon | Common symptoms: acute onset, severe symptoms of intoxication, fever, erythema with edema, changes in the general blood count (neutrophilic leukocytosis, increased ESR) | Consultation with a surgeon | In the place of localization of the process, there is a strong, sometimes throbbing pain, sharp pain on palpation. Hyperemia of the skin has no clear boundaries, is brighter in the center, develops against the background of an excessively dense infiltrate. Later, the infiltrate softens and fluctuation is detected. Characterized by hyperleukocytosis with a significant neutrophilic shift to the left, significantly increased ESR. |
| Thrombophlebitis of the saphenous veins | consultation with a surgeon / vascular surgeon, |
(pig erysipelas)
Epidemiological data: skin microtrauma during the processing of meat or fish, stay in natural foci of erysipeloid.
a history of chronic tonsillitis
Differential diagnosis for localization of erysipelas on the face
| Diagnosis | Rationale for differential diagnosis | Surveys | Diagnosis exclusion criteria |
| Quincke's edema | Common symptoms: erythema, edema | Allergist consultation | Sudden onset, hyperemia and dense edema, when pressed, which does not form a fossa. Anamnesis: connection with the use of certain food products, medications, etc. |
| Periostitis of the upper jaw. | Erythema, edema, local tenderness | Dentist / Maxillofacial Surgeon Consultation | Formation of a subperiosteal abscess, edema of the peri-maxillary soft tissues, pain in the area of \u200b\u200bthe affected tooth radiating into the ear, temple, eyes. |
| Abscessing furuncle of the nose | Erythema, edema, fever | ENT doctor consultation | After 3-4 days, an abscess may appear at the top of the infiltration, which is a boil core. |
Get advice on medical tourism
TREATMENT AT THE AMBULATORY LEVEL **
Treatment tactics .
On an outpatient basis, mild forms of erysipelas are treated.
Non-drug treatment
Bed rest
Diet: common table (No. 15), plentiful drink. In the presence of concomitant pathology (diabetes, kidney disease, etc.), an appropriate diet is prescribed.
Drug treatment
Etiotropic therapy. When treating patients in a polyclinic, it is advisable to prescribe one of the following antibiotics:
· 1 000 000 IU x 6 times / day, in / m, 7-10 days [UD - A];
or
· Amoxicillin / clavulanate inside at 0.375-0.625 g every 2-3 / once a day for 7-10 days [UD - A];
or macrolides:
· Erythromycin by mouth 250-500 mg 4 times / day for 7-10 days [LE - A];
· Azithromycin inside - on the 1st day, 0.5 g, then within 4 days - 0.25 g once a day (or 0.5 g for 5 days) [UD - A],
or
Spiramycin inside - 3 million IU twice a day (course of treatment 7-10 days) [LEO - A]
or
· Roxithromycin inside - 0.15 g twice a day (course of treatment 7-10 days) [UD - A] or others.
or fluoroquinolones:
· Levofloxacin inside - 0.5 g (0.25 g) 1-2 times a day (course of treatment 7-10 days) [LE - A].
Pathogenetic therapy:
Non-steroidal anti-inflammatory drugs (contraindicated in hemorrhagic forms of erysipelas):
· Indomethacin 0.025 g 2-3 times a day, by mouth, for 10-15 days [UD - B]
or
· Diclofenac 0.025 g 2-3 times a day, by mouth, for 5-7 days [UD - B]
or
· Nimesulide 0.1 g 2-3 times a day, by mouth, for 7-10 days [UD - B]
or
· Ibuprofen 0.2 g, 2-3 times a day, by mouth for 5-7 days [UD - B].
Symptomatic therapy with fever
or
paracetamol 500 mg, by mouth [DD - B].
Desensitizing therapy:
· Mebhydrolin inside 0.1-0.2 g 1-2 times a day [UD - C];
or
· Hifenadine inside at 0.025 g - 0.05 g 3-4 times a day [LE - D];
or
or
or
· Loratadine 0.01 g orally 1 time per day [UD-B].
Antibacterial therapy:
· Benzylpenicillin sodium salt, powder for preparation of a solution for intramuscular administration in a vial of 1,000,000 units [UD - A];
or
· Amoxicillin / clavulanate 375 mg, 625 mg, by mouth [UD - A];
or
· Azithromycin 250 mg, by mouth [UD - A];
or
· Erythromycin 250mg, 500 mg, by mouth [DD - A];
or
· Spiramycin 3 million IU, inside [UD - A];
or
· Roxithromycin 150mg, inside [UD - A];
or
· Levofloxacin 250 mg, 500 mg, by mouth [DD - A].
or
or
· Nimesulide 100 mg orally [DD - B];
or
· Ibuprofen 200 mg, 400 mg, by mouth [LOA - A];
or
· Paracetamol 500 mg, by mouth [DD - A];
or
or
or
or
or
· Cetirizine 5-10 mg, by mouth [UD - B].
Drug comparison table
| Class | INN | Benefits | disadvantages | UD |
| Antibiotic, biosynthetic penicillins | "-" m / o. | AND | ||
| Antibiotic, combined penicillin | amoxicillin / clavulanate | Possesses a wide spectrum of antibacterial action. | Side effects (very rare and weakly expressed): dysfunction of the gastrointestinal tract (nausea, diarrhea, vomiting), allergic reactions (erythema, urticaria) | AND |
| Macrolides | erythromycin | Active against gram “+”, gram “-” m / o. | Low activity against Escherichia coli, Pseudomonas aeruginosa, Shigella spp., Salmonella spp., Bacteroides fragilis, Enterobacter spp. and etc. | AND |
| azithromycin | Active against gram "+". It is quickly absorbed from the gastrointestinal tract, which is due to its stability in an acidic environment and lipophilicity. | Low activity against anaerobic pathogens | AND | |
| spiramycin | Active against Streptococcusspp. (Incl. Streptococcus pneumoniae) | AND | ||
| roxithromycin | Active against gram “+”, gram “-” m / o. | low activity against anaerobic pathogens | AND | |
| Fluoroquinolones | levofloxacin | Active against gram “+”, gram “-” m / o. | low activity against anaerobic pathogens. | AND |
| Antihistamines | mebhydroline | absolute contraindication - stomach ulcer, duodenum, hyperacid gastritis, ulcerative colitis. | WITH | |
| hifenadine | Antihistamine and anti-allergic action. | | D | |
| chloropyramine | C | |||
| loratadine | B | |||
| cetirizine | IN | |||
| NSAIDs | indomethacin | Strong anti-inflammatory activity | Frequent development of undesirable reactions can lead to the development of aspirin bronchial asthma. | IN |
| diclofenac | Strong anti-inflammatory activity | Increased risk of developing cardiovascular complications. | IN | |
| nimesulide | IN | |||
| Ibuprofen | Increased risk of toxic amblyopia. | IN | ||
| Paracetamol | Hepatotoxic and nephrotoxic effects (with prolonged use in large doses) | IN |
· Consultation of an endocrinologist: in case of concomitant diseases - diabetes mellitus, obesity;
· Consultation with a rheumatologist: for differential diagnosis with erythema nodosum;
· Consultation of an obstetrician-gynecologist: with erysipelas in pregnant women;
· Consultation of a clinical pharmacologist for correction and justification of treatment;
At PHC: primary prevention:
· Informing the patient on the prevention of microtraumas, diaper rash, hypothermia, careful adherence to personal hygiene, fungal and pustular skin diseases.
Secondary prevention (relapses and complications):
Timely and full-fledged etiotropic and pathogenetic therapy of primary disease and relapses;
Treatment of severe residual effects - erosion, persistent edema in the area of \u200b\u200bthe local focus, the consequences of erysipelas (persistent lymphostasis, elephantiasis);
Long-term and persistent treatment chronic diseases skin, leading to a violation of its trophism and the appearance of an entrance gate for infection;
· Treatment of foci of chronic streptococcal infection (chronic tonsillitis, sinusitis, otitis media, etc.);
· Treatment of disorders of lymph and blood circulation in the skin as a result of primary and secondary lymphostasis and elephantiasis; chronic peripheral vascular disease; treatment of obesity, diabetes mellitus (frequent decompensation of which is observed with erysipelas);
· Bicillin prophylaxis.
Prophylactic administration of bicillin-5 is carried out at a dose of 1,500,000 U once every 3-4 weeks for convalescents after full therapy of erysipelas in the acute period of the disease. An injection of desensitizing drugs is recommended 15-20 minutes before its introduction in order to prevent allergic complications.
There are the following methods of bicillin prophylaxis:
Year-round (with frequent relapses) for 2-3 years with an interval of 3 weeks of drug administration (in the first months, the interval can be reduced to 2 weeks);
· Seasonal (three seasons within 4 months). The drug begins to be administered one month before the onset of the season of incidence;
· One-course to prevent early relapses within 4-6 months after the disease.
Patient monitoring: is carried out by KIZ doctors / general practitioners with the involvement of doctors of other specialties through medical examination.
Medical examination is subject to:
· 1 group - persons who have frequent, at least 3 in the last year, relapses of erysipelas;
Group 2 - persons with a pronounced seasonal nature of relapses;
Group 3 - persons with prognostically unfavorable residual events at discharge from the hospital.
For the 1st group:
· Regular, at least 1 time in 3 months, medical examination of patients, which allows timely detection of the deterioration of their condition, an increase in lymphostasis, exacerbation of chronic concomitant skin diseases and foci of chronic streptococcal infection, contributing to the development of relapses of erysipelas.
· Systematic laboratory examination of patients, including a clinical blood test, determination of the level of C-reactive protein. Prophylactic year-round (continuous) for 2-3 years administration of Bicillin-5 1.5 million units 1 time in 3-4 weeks, intramuscularly (1 hour before the administration of Bicillin-5, antihistamines must be prescribed).
· Repeated physiotherapy treatment in the presence of persistent lymphostasis.
· Sanitation of foci of chronic ENT infection.
· Treatment of diaper rash, mycoses and other concomitant skin diseases.
· Treatment in specialized medical institutions of chronic vascular diseases, endocrine diseases.
· Employment of patients under unfavorable working conditions. Dispensary observation of patients in this group is advisable for 2-3 years (in the absence of relapses). Patients with especially aggravated concomitant diseases (trophic ulcers, other skin defects, lymphorrhea, deep skin cracks with hyperkeratosis, papillomatosis, who have undergone surgery for elephantiasis) need the maximum observation period (3 years).
For the 2nd group:
· Regular medical examination at least once every 6 months.
· Annual laboratory examination before the relapse season (CBC, C-reactive protein level).
Prophylactic seasonal administration of bicillin-5 (1.5 million units once a day, intramuscularly (1 hour before the administration of bicillin-5, antihistamines must be prescribed) 1 month before the start of the morbidity season in a patient with a 3-week interval for 3-4 months annually 3 seasons.
In the presence of appropriate indications - sanitation of foci of chronic ENT infection, treatment of concomitant chronic skin diseases, etc.
For the 3rd group:
· Medical examination in 1-4 months if necessary and 6 months after the illness.
· Laboratory examination at the beginning and at the end of dispensary observation (clinical blood test, determination of the level of C-reactive protein).
· Physiotherapy treatment of prognostically unfavorable residual effects of erysipelas.
· Course prophylactic administration of Bicillin-5 at intervals of 3 weeks for 4-6 months.
Criteria for the effectiveness of dispensary observation and treatment of persons who have undergone erysipelas:
· Prevention of relapses of the disease, reducing their number;
· Relief of edematous syndrome, persistent lymphostasis, and other residual effects and consequences of the disease.
DIAGNOSTICS AND TREATMENT AT THE STAGE OF EMERGENCY EMERGENCY
If outpatient treatment is possible - transfer the asset to the clinic at the patient's place of residence.
Hospitalization according to indications.
To transport the patient by ambulance in the supine position, taking into account the pain syndrome and signs of intoxication.
To reduce body temperature and relieve pain, the administration of 2.0 ml of a 50% solution of analgin (can be combined with a 1% solution of diphenhydramine 2.0).
STATIONARY TREATMENT **
Treatment tactics
Non-drug treatment
Bed rest - until the temperature is normalized, in case of damage to the lower extremities - during the entire period of the disease.
Diet №15 - complete, easily digestible food, plenty of drink. In the presence of concomitant pathology (diabetes mellitus, kidney disease, etc.), an appropriate diet is prescribed.
Drug treatment
Etiotropic therapy
treatment regimen for severe forms and complications
№2
1,000,000 units x 6 times / day i / m, 10 days
Reserve drug:
Ceftriaxone 1.0 - 2.0 g x 2 times / day, i.m., i.v., 7-10 days
or cefazolin
2-4 g / day, i.m., 7-10 days
or cefuroxime 2.25-4.5 g / day in 3 doses i / m, i / v, 7-10 days or cefotaxime 2-8 g / day in 2-4 doses i / v or i / m, 7- 10 days.
1,000,000 units x 6-8 times / day. i / m, i / v, 10 days
+
Ciprofloxacin 200 mg x 2 times / day. i.v. cap., 10 days (single dose may be increased to 400 mg);
or cefazolin 1.0 g 3-4 times a day, 10 days;
orceftriaxone 2.0 - 4.0 g / day, IM, IV, 10 days or cefuroxime 0.75-1.5 g 3 times a day IM, IV, 10 days or cefotaxime 1-2 g 2-4 times a day i / v or i / m, 10 days
+
Clindamycin 300 mg x 4 times a day. i / m, i / v
10 days
1,000,000 units x 6-8 times / day. i.m., 10 days
+
Gentamicin sulfate
80 mg x 3 times a day / m,
10 days.
1,000,000 U x6-8 times / day i / m, 10 days
+
Clindamycin 300 mg x 4 times a day. i / m, i / v
(a single dose may be increased to 600 mg),
10 days
In case of intolerance to antibiotics of the penicillin and cephalosporin classes, one of the antibiotics of other classes is used (macrolides, tetracyclines, sulfonamides and co-trimoxazole, rifimycins).
Reserve drugs for the treatment of severe forms of erysipelas - carbapenems (imipenem, meropenem), glycopeptides (vancomycin, teicoplanin).
Treatment of recurrent erysipelas carried out in a hospital setting. Mandatory prescription of reserve antibiotics that have not been used in the treatment of previous relapses - cephalosporins:
Cefazolin 1.0 g 3-4 times a day, 10 days;
or
Ceftriaxone 1.0 - 2.0 g x 2 times / day, i.m., i.v., 10 days;
or
Cefuroxime 0.75-1.5 g 3 times a day i / m, i / v, 10 days;
or
· Cefotaxime 1-2 g 2-4 times a day, i / v, i / m, 10 days.
With frequently recurrent erysipelas, 2 courses of treatment:
1 course: cephalosporins (10 days), break 3-5 days,
2 course: antibiotics of bacteriostatic action (drug of choice - antibiotics of a number of lincosamides: lincomycin 0.6-1.2 g 1 - 2 times a day intramuscularly or 0.5 g orally three times a day or others), 7 days.
Pathogenetic therapy:
Detox therapy (the amount of fluid is strictly controlled according to the indicators of daily urine output, the volume of injected fluid, taking into account the severity) :
With an average severity of the infectious process, patients should drink plenty of fluids at the rate of 20-40 ml / kg.
With a severe degree of the infectious process - parenteral administration of isotonic (0.9% sodium chloride solution, 400; 0.5% dextrose solution, 400.0, etc.) and colloidal (sodium meglumine succinate, 400.0) solutions in the ratio of 3- 4: 1 in a total volume of 1200-1500 ml for 3-5 days.
Non-steroidal anti-inflammatory drugs (simultaneously with antibiotic therapy, taking into account contraindications, the course is 7-10 days):
· Indomethacin 0.025 g 2-3 times a day, inside [UD - B];
or
· Diclofenac 0.025 g 2-3 times a day, by mouth, for 5-7 days [UD - B];
or
· Nimesulide 0.1 g 2-3 times a day, by mouth, for 7-10 days [UD - B];
or
· Ibuprofen 0.2 g, 2-3 times a day, by mouth for 5-7 days [UD - B].
Desensitizing therapy:
· Mebhydrolin inside 0.1-0.2 g 1-2 times a day [UD - C];
or
· Hifenadine inside 0.025 g - 0.05 g 3-4 times a day [LE - D];
or
· Chloropyramine inside 0.025 g 3-4 times a day [UD - C];
or
· Cetirizine inside at 0.005-0.01 g once a day, 5-7 days [UD-B];
or
· Loratadine 0.01 g orally 1 time per day [UD-B].
Glucocorticosteroids are prescribed for persistent recurrent erysipelas, with the development of lymphostasis: prednisolone orally, 30 mg per day with a gradual decrease in the daily dose (course dose 350-400 mg) [UD - B].
To improve microcirculation and rheological properties of blood, with an antiplatelet purpose (taking into account the indicators of the coagulogram):
· Pentoxifylline 2% solution 100 mg / 5 ml, 100 mg in 20-50 ml of 0.9% sodium chloride, IV course from 10 days to 1 month [UD - B];
or
· Heparin subcutaneously (every 6 hours) 50-100 U / kg / day for 5-7 days [LE - A];
or
Warfarin 2.5-5 mg / day, by mouth;
or
Enoxaparin sodium 20-40 mg 1 time / day n / a.
Symptomatic therapy
For fever:
one of the following drugs:
· Ibuprofen 200 mg, 400 mg, 3-4 times a day [LOA - B];
or
· Diclofenac 75 mg / 2 ml, i / m [UD - B];
or
· Paracetamol 500 mg, by mouth, with an interval of at least 4 hours [DD - B];
or
· Paracetamol (1 g / 6.7 ml) 1.5 g-3 g per day i / v [UD - B].
List of essential medicines
Benzylpenicillin sodium salt, for intramuscular injection of 1,000,000 units;
· Or ceftriaxone, for injection for intramuscular and intravenous administration 1 g.
Or ciprofloxacin, for infusion 0.2%, 200 mg / 100 ml; 1% solution of 10 ml (concentrate to be diluted);
Or gentamicin sulfate, 4% for injection 40 mg / 1 ml in 2 ml ampoules;
Clindamycin, for intramuscular and intravenous administration, 150 mg / ml, in 2 ml.
Or cefazolin, for intramuscular and intravenous administration, 0.5 g, 1.0 g, 2.0 g.
Or lincomycin, for intramuscular and intravenous administration, 300 mg, 600 mg.
Or cefuroxime, i / v and i / m administration, 750 mg, 1.5 g.
Or cefotaxime, i / v and i / m administration, 1.0 g
List of complementary medicines
Sodium chloride 0.9% - 100, 200, 400 ml
Dextrose 5% - 400 ml;
Megglumine succinate for infusion 400.0
· Indomethacin 25 mg, by mouth [DD - B];
or
· Diclofenac 25 mg, 100 mg, by mouth [DD - B];
or
· Nimesulide 100 mg orally [DD - B];
or
· Ibuprofen 200 mg, 400 mg, by mouth [DD - B];
or
· Paracetamol 500 mg, by mouth [DD - B];
· Mebhydrolin, 100 mg, by mouth [UD-S];
or
· Hifenadine, 25 mg, by mouth [UD-D];
or
· Chloropyramine 25 mg, orally [UD - C];
or
· Loratadine 10 mg, by mouth [DD - B];
or
· Cetirizine 5-10 mg, by mouth [DD - B];
· Prednisolone 5 mg, by mouth [DD - A];
Pentoxifylline 2% solution 100 mg / 5 ml, 100 mg in 20-50 ml 0.9% sodium chloride, ampoules.
Heparin, 1 ml / 5000 U, ampoules 1.0 ml, 5.0 ml, 5.0 ml each.
or
Warfarin 2.5 mg, by mouth;
or
Enoxaparin sodium 20-40 mg, s / c syringes.
Drug comparison table:
| Class | INN | Benefits | disadvantages | UD |
| Antibiotic, biosynthetic penicillins | benzylpenicillin sodium salt | Active against gram "+" cocci (streptococci) | It is not resistant to beta-lactamases. Low activity against most grams "-" m / o. | AND |
| Antibiotic, III generation cephalosporin | ceftriaxone | Active against gram “+”, gram “-” m / o. Resistant to beta-lactamase enzymes. Penetrates well into tissues and liquids. The half-life is 8-24 hours. | Low activity against anaerobic pathogens. | AND |
| Antibiotic, 1st generation cephalosporin | cefazolin | Active against gram "+", and some gram "-" m / o., Spirochaetaceae and Leptospiraceae. | Ineffective in relation to P. aeruginosa, indole-positive strains Proteusspp., M. tuberculosis, anaerobic microorganisms | AND |
| Antibiotic, cephalosporin II generation | cefuroxime | Has a bactericidal effect. It is highly active against gram "+", and some gram "-" m / o. | Inactive against Clostridium difficile, Pseudomonas spp., Campylobacter spp., Acinetobacter calcoaceticus, Listeria monocytogenes, methicillin-resistant strains of Staphylococcus aureus, Staphylococcus epidermidis, Entero goris spp., Streptococcus morphogenes (Entero fauna) Citrobacter spp., Serratia spp., Bacteroides fragilis. | AND |
| Antibiotic, cephalosporin III generation | cefotaxime | Broad-spectrum antibiotic. Has a bactericidal effect., Highly active against gram "+", gram "-" m / o. | Resistant to most beta-lactamases of gram-positive and gram-negative microorganisms. | |
| Fluoroquinolones | ciprofloxacin | It is active against some gram "+", gram "-" m / o. antipseudomonal drug | Moderate activity towards Str.pn. If you suspect or have an infection caused by Pseudomonas aeruginosa | A |
| Antibiotic, aminoglycoside | gentamicin sulfate | Potentiates the action of b-lactam antibiotics | Low activity against anaerobic pathogens. Oto-nephrotoxic action | AND |
| Antibiotic, lincosamide | clindamycin | Bacteriostatic, active against gram "+", gram "-" m / o (Strept., Staph.) | Low activity for Clostridium sporogenes and Clostridiumtertium | AND |
| Antibiotic, lincosamide | lincomycin | Bacteriostatic, active against gram "+", gram "-" o / o (Strept., Staph.), Corynebacterium diphtheriae, anaerobic bacteria Clostridium spp., Bacteroidesspp., Mycoplasmaspp. | Low activity against most gram-negative bacteria, fungi, viruses, protozoa. | AND |
| Antihistamines | mebhydroline | Antihistamine and antiallergic action | Side effects: increased fatigue, dizziness, paresthesia; when using high doses - slowing down the reaction rate, drowsiness, blurred visual perception; rarely - dry mouth, nausea, heartburn, irritation of the gastric mucosa, pain in the epigastric region, vomiting, constipation, urinary disorders. granulocytopenia, agranulocytosis. | WITH |
| hifenadine | Antihistamine and anti-allergic action. | Has a moderate antiserotonin effect. | D | |
| chloropyramine | It does not accumulate in the blood serum, therefore, even with long-term use does not cause overdose. Due to its high antihistamine activity, a quick healing effect is observed. | {!LANG-7d3a26412a7f6163ba7920303b21d7c8!} | C | |
| loratadine | {!LANG-7f2efa0949c33b4fa4e9bc0d13a2f451!} | {!LANG-3aa6272944ae10e73e11d3c49cd11804!} {!LANG-4c0e32669208b17e03215d0de3f4d305!}{!LANG-6c3fb241e3e223a80c2b2c064ed6ec15!} | B | |
| cetirizine | {!LANG-3da0738b0231214e0de6069b225ee601!} | {!LANG-04caeba7cc590a1a960b4d110f302c46!} | IN | |
| NSAIDs | indomethacin | {!LANG-f65bd2a39b5b70d43a1729ebd663697e!} | IN | |
| diclofenac | {!LANG-8fdbc09207527bb1d424d1aa13f7bb80!} | {!LANG-14d452688a99a1de136819ee1f0e9730!} | IN | |
| nimesulide | {!LANG-4028d70cf33b6b8eb2af6f22b585c879!} | {!LANG-1d82380ea16e8359cb493f5216eae306!} | IN | |
| {!LANG-ff25ddbcfaecc8c60e71fa663381598c!} | {!LANG-3517d221783d60f8d26e0bb4236d2a9c!} | {!LANG-fc50ac50d6b04b37135f51443ae2a07c!} | IN | |
| {!LANG-d94bdb861212bacbe4935be70b3023f0!} | {!LANG-68a09380946b063ba6892b6afd5a6b08!} | {!LANG-24594bbd375e1dd9f9485307fdacb3ce!} | IN |
{!LANG-6513315070f0a54347bc589dd490c679!}
{!LANG-8adfafc1784b00c69b99b562355a7448!}
{!LANG-3d5268fc2c87b733b94750bcdc7d4004!}
{!LANG-61f2392847ae528bc5c63d61465b0119!}
{!LANG-545e0f7d45e69178c237d4174ce43fa1!}
{!LANG-95f10233cb99e6f4a7448807f9f42727!}
{!LANG-39cbd8f62f0c1bfcb29e1dd7a66fd356!}
{!LANG-2199167696df2606d3164125a756ee05!}
{!LANG-126068dcd12cb50d06ac86d5db60ef94!}
{!LANG-0d37f6728c1e8d62290ffdcebac04f21!}
{!LANG-9c1c7becfdcd1a6488bb72e8b0d27a59!}
{!LANG-ec4abab4a13abf7c89d6c17f02c30165!}
{!LANG-11f3300aff78a8b989c2212a69aa1d02!}
{!LANG-ace48a6bbc1d994c1079b725deec2637!}
{!LANG-3b7c6a0200851cba5b3acec5bb15961e!}
{!LANG-97f9df138557e79e824c05f16bfc7ad0!}
{!LANG-1a4a6c643e77700d025404ad1de0fd1b!}
{!LANG-626dee276625c8b0052eeab9fbc767a5!}
{!LANG-b9c8259fd947a40a3e4bf5d09a9f1a42!}
{!LANG-899aaa25d58be497202f3e5d4d8680eb!}
{!LANG-964f801392a033df3a0004570ef2aa4c!}
{!LANG-f23ac78e4bc6bbf756ecec7f566eedb8!}
{!LANG-db02b0d6b08248c564ae26b7cea62d75!}
{!LANG-1e3f5898555d671d346d9fdb5e61f677!}
{!LANG-49d447e8985714c062f0b784a73fafe1!}
{!LANG-4e27059045f68b30eab4cd46d295c6b1!}
{!LANG-bfe473c7af936e83275c9f9b9b16d20d!}
{!LANG-fee68c3466afa450fc83608c179e1e29!}
{!LANG-de49fff4b2c1f85786d6223d9185625d!}
{!LANG-2dc9edf012942fdce542d3bef4a87a0c!}
{!LANG-0c56fbbb0eeddd10ff6ecb3db6788caf!}
{!LANG-9d8d6d9986e7922b40e96fca52ef2fd7!}
{!LANG-c19fcc477d526f4eb21ed54d6d5f0dd7!}
{!LANG-ceb0ce5fc9e1338ff37624d44c0a715f!}
{!LANG-4c05c21cb8ab652c461536f401db0b93!}
{!LANG-e43ed70cc22a323a4503bbc767f0f6ad!}
{!LANG-17d32bf78d56bd68067ed7cb7ce57d8a!}:
{!LANG-6c18002f8f84df5bcca8431df6b735db!}
{!LANG-90915d147ddfc8076a0f21a4602e885f!}
{!LANG-04890b7dcf7fb2f5f8ebf50851bbf513!}{!LANG-23d3c30ee8e0fda26b3716e3c4833cfe!}
{!LANG-43a0d3adc2f5846e478f622bb8bae2a3!}
{!LANG-ee7212ad687836b433c51eecbee8ee61!}
{!LANG-40523ea75a9858b2bca827f7f92aa194!}
{!LANG-cb2413b49951ef5cc471f8958da727b9!}
{!LANG-a94a5e142dd2fb4ca711e69905f91182!}
{!LANG-aef7a302a207bcd3ad95c0f9af1a02ac!}
- {!LANG-1369430be76aa5d32560097bd8ccfb2f!} {!LANG-5ad9b7b1b3719c8c3acd9c97e92a5100!}{!LANG-2f14591aa0c316e085b7c5ffc1b2c966!}
- {!LANG-ff82482a25b90b9dd8a68e57d766695a!} {!LANG-204bb45e1fb927aa70dbdd45e8ee5b07!}{!LANG-4648622ace5ad5d3c44daeef7a465319!} {!LANG-2dd0d2cf1cbd6bb129a6ec6e3a7687aa!}{!LANG-cabe69032648fcbb1df5880dddb7f664!} {!LANG-e241742a761dec8ac4deecdcaaa8a9d6!}{!LANG-a05a6e74e25e1869241940c650e2c21b!} {!LANG-d9dc70cf397ab4fd6883ba63f85090e2!}{!LANG-4128aca9c72161beff2728139af995da!}
{!LANG-a533f36337dad6c007a96e0d775fd5d1!}
{!LANG-e776c0ce02b459c8f2dffffe73a047b1!}
{!LANG-4b676625b40423da7a881d556b4d6f1b!}
{!LANG-4120ca08500c1bd8f46aaf6e1d98dc96!}
{!LANG-377773bc6627a5e2a225e63e84e6626d!}
{!LANG-edf7afd1b09d37dfde6f8d9b1d8c105b!}
{!LANG-345fa1de7c0919543fc3a4acee1161a6!}
{!LANG-4f6c60cbfc70121ec61b75b532a715b1!}{!LANG-59ca11ae8c81a6900b8913780795c1b0!}
{!LANG-4604ad57f8959090d96e97f7a2c5bf00!}{!LANG-0f0f8ff984ec72dc6b4e10dceba53f3d!}
{!LANG-9de1467e1cc0be6e48aad2ca90c7ec82!}{!LANG-372004f8b423515243159df3e6b248a1!}
{!LANG-2c9945d76d27e00df83270dc061669e7!}
{!LANG-1a2c42857c8ce52bfaaacfcc3187d55e!} {!LANG-4977a6ddcae7f580a474a7c16dd346dd!}{!LANG-89753197624de30cae8006de53c51f76!} {!LANG-e3df34668754a7e32c0a4709075396a4!}{!LANG-fc84f56ebe723ce402099b0a6d0dc0c1!}
{!LANG-5741011e33bf20d6539f071e853380c7!}{!LANG-b6004f4b72ee1bfd33fb0b977d240e5c!}
{!LANG-ada200e5433d60c89f08a300fa5cf50b!}
{!LANG-b078e16c7b8ccd7cb7f60970954845ba!}
{!LANG-29996b5bbffe7d42b977f7f10257175f!}
{!LANG-69e640f58d7e26262145202a814d1969!}
{!LANG-28b8c62416ab22339d2c47919657ee63!} {!LANG-9d22c799ea0e3f77ce7674b25ec1ed6d!}{!LANG-72f52f40f98a67e5bfb0345b9c71e3a0!}
{!LANG-0068d7fe5e2888845811b9822c705c8f!}
{!LANG-c2a6a253adceb80d3f8f908977762acb!}
{!LANG-7ac9a93252e831253a60fef4729fcfc6!}
{!LANG-69e640f58d7e26262145202a814d1969!}
{!LANG-bf6a165605c009d9e286d6457aaf72ab!}
{!LANG-42501313a1618c129d6c311779798caf!}
{!LANG-0068d7fe5e2888845811b9822c705c8f!}
{!LANG-c2a6a253adceb80d3f8f908977762acb!}
{!LANG-e56633ea9c426f1d813a9543a5566f0a!}
{!LANG-500eae788768fde0485a6ca1fa22e710!}
{!LANG-8188d268d00e47e923d36e256e4d7528!}
- {!LANG-dd1b3295964b8770af10af4b999fa537!}
- {!LANG-e3c2a7b161a310db5e0af4389f0cdb27!}
- {!LANG-4dfd82beb44a04536f56298496399d5e!}
Treatment
- {!LANG-78f29b356ae2cc13aed6c1d216067ef0!}
- {!LANG-54d861fdbabba9794e54950be5d0e437!}
- {!LANG-fdc5185fbfb80f91b4eaf698d86e2702!}
- {!LANG-fac11f9bf560a8a4fd157178cad959ee!}
- {!LANG-f79281981b6e7fb4682d2db7ba0c1863!}{!LANG-19f9c8beb40d5b1d9ac8a3d392897846!}
- {!LANG-0fc2e6949835fea851183796c926b973!}
- {!LANG-165a196f014783e103484b9955a4cb0e!}
- {!LANG-5e8ac145591742c7f44ebfad71fb2fc8!}
- {!LANG-cc3f22a048a2222c4c183d021ab2c51d!}
- {!LANG-0927ef262ec254e7f731acb2dfd7e7ec!}
- Etiotropic therapy
- {!LANG-f22c22c9d3d8de7a1949763079ead3ac!}
- {!LANG-347ae5291e516502015b1413efb46ac0!}
- {!LANG-4b0cb2f09c365e57776684da6f4ab312!}
- {!LANG-8bec1b772f85bb7301c56987a4871f95!}
- {!LANG-d5eca1bdd087aece52949e5cd9e18d6c!}
- {!LANG-5519f064012e71a1715df982398b25e5!}
- {!LANG-3ba243f4222e65ad3afedbb4040818e4!}
- {!LANG-9427e69209294b3fb6cec2e262448a95!}
- {!LANG-4229c7770cfd4633c7892153534de14f!}
- {!LANG-12954b69b3e8ce49dc2f7b231b5a779b!}
- {!LANG-13f085de6e851df28c5244dd057a7f4d!}
- {!LANG-2ce7fb89289d73a3ecbd6ef16f275482!}
- {!LANG-c7082c822d824e1f77000d91a8c3101c!}
- {!LANG-7b03e7b8aa8b8b3d898f215d49932c59!}
- {!LANG-8fe5b3ba5a57216999a7817dccff804e!}
- {!LANG-dbea61c56728b38c3afa2af11c139fbd!}
- {!LANG-5739e33082f67236bcb063473ccf9179!}
- {!LANG-b2dd875fd6dbb574ae4dcbb969c79210!}
- {!LANG-f7db92e4e1101c92189df5eb59c5d345!}
- {!LANG-b2ea8814dc52b5e7c3158677f111f2f1!}
- {!LANG-6bd2a2529da3666bdff4e3294b99f6eb!}
- {!LANG-4162f00efac2864cac4df8b37d2ebaca!}
- {!LANG-33879a2203884890104214cf2dbf772d!}
- {!LANG-36550eb3992bdd2249467183c7abb61a!}
- {!LANG-7ac4ca26f12c183faf8454a6c941a02f!}
- {!LANG-ab07abd32852c6950c3b2ea123d9bca4!}
- {!LANG-9d5c8ceae0d51e3367fc106d3ef5de9f!}
- {!LANG-53c21fe041e711b77716d273a95ef259!}
- {!LANG-5bf2ee887185f495836d6991a175d56a!}
- {!LANG-f22c22c9d3d8de7a1949763079ead3ac!}
- {!LANG-2bf3adedf6ea2309b99350ae1c9ec6d4!}
- {!LANG-a70aab5bf23efced740fc49245e34046!}
- {!LANG-f9b1a31136cab374e00fca134b2a38c1!}
- {!LANG-fadb92de577671faf3aafb26e0b1506f!}
- {!LANG-83b5c2697103e328b1ea29ab23e384f7!}
- {!LANG-f8b88b13de02213694e5c64236a3469d!}
- {!LANG-cd32060b53beeea721c5f7f7c6510746!}
- {!LANG-2ab11f3f7ffab91b28bbdd7a6f58ecc1!}
- {!LANG-d04b091cad6e370fd54863884f97de03!}
- {!LANG-ab9abeb985176f62139c455b3570809b!}
- {!LANG-0a3d98b2a44293fa96124623ae0082f2!}
- {!LANG-f0cd462757dfda76e715e0cb2c675a7e!}
- {!LANG-9c39b44fbf89e214b1c6e657a8a13995!}
- {!LANG-210a0693105392ba014ae05d20730ce1!}
- {!LANG-19cf9251e092143641cea0d4671a0e54!}
- {!LANG-45e2b719f3647c475f3b31ec1335930d!}
- {!LANG-863b5aef02f7e34b1081780cff000b50!}
- {!LANG-188fa9ecf10643c3c4fe364067f0a305!}
- {!LANG-3a3d05ba35455ed0c7ccae926c30ea3b!}
- {!LANG-6a06401d5bde45dddec425d47861b581!}
- {!LANG-25754e8ab96a5b4ab25401fdd6d4aa23!}
- {!LANG-ff8567343d38c43be7fdd4335121da47!}
- {!LANG-3d602151dbef33c3720406ad0a1e7751!}
- {!LANG-9e107e1ac5e839df02541eb304fb579a!}
- {!LANG-5940c61f5f0c3726aff96975ad95fc0e!}
- {!LANG-3a3d05ba35455ed0c7ccae926c30ea3b!}
- {!LANG-86774559b940c829b9d05a1f11b949bb!}
- {!LANG-60d0262dc65aefa24f5c77d1e184543c!} {!LANG-5dd0efe2f4bf7ab08b94d69dfe8e227e!}{!LANG-106daac6dd91c073e3d1fdfb3887cb82!} {!LANG-59d8d0e9317e4616d2b2323bab3ce544!}{!LANG-7b80d0694c6cb102b89d6a12b232eb7a!}
- {!LANG-6a06401d5bde45dddec425d47861b581!}
- {!LANG-3a690b58de4ce711d16d54e482bdd486!}
- {!LANG-b65fb518782496fdae3dbf3739e60f4b!}
- {!LANG-8466f09ee5215f879a79be6083d8c16e!}
- {!LANG-9d1aa8769f9e7a9e8ee4add4b83921d9!}
- {!LANG-3a3d05ba35455ed0c7ccae926c30ea3b!}
- {!LANG-86774559b940c829b9d05a1f11b949bb!}
- {!LANG-4a828d72c583e439783b53051ffd7a66!}
- {!LANG-0e9dd82339fc2bde078cd9e41054d6a7!}
- {!LANG-5b40182c7e86a7e02c8f638c6ead4f85!}
- {!LANG-af31f3c712d3ee16f6bbd8a70a288301!}
- {!LANG-24407a0beec15bdd6b632f125fc504cd!}
- {!LANG-7dfb194d3c01230bd23e69021dd82334!}
- {!LANG-9d1aa8769f9e7a9e8ee4add4b83921d9!}
- {!LANG-3a3d05ba35455ed0c7ccae926c30ea3b!}
- {!LANG-86774559b940c829b9d05a1f11b949bb!}
- {!LANG-dc2fee7215bb28fee69989b5c2c667da!}
- {!LANG-4a828d72c583e439783b53051ffd7a66!}
- {!LANG-0e9dd82339fc2bde078cd9e41054d6a7!}
- {!LANG-5b40182c7e86a7e02c8f638c6ead4f85!}
- {!LANG-219ffc97f0420107b65ddad0b02a54c4!}
- {!LANG-7fabc58b975fa6bda5dd1c140114a92a!}
{!LANG-2ab6930a61bae02b33869d4181a7fdc0!}
{!LANG-9bdfc4ecf73148095986e49ca09124f5!}
{!LANG-6761ea95bd1e3ff59ad95a00c9ed2c76!}
{!LANG-d17e2e169b7403c96a8f5ca9c7e51a61!}
{!LANG-08d693a3638acd29d3a74c0e77d87500!}
- {!LANG-ff8567343d38c43be7fdd4335121da47!}
- {!LANG-44c550d7cf58d2290b172a726054890d!}
- {!LANG-d95f46143320933dcf2259aaf0403664!}
- {!LANG-37ceae46784b44c488f0ce739e07d432!}
- {!LANG-3a3d05ba35455ed0c7ccae926c30ea3b!}
- {!LANG-ba70d76bd225bc5d0615a21086ea2b40!}
- {!LANG-bb3a8ce22ed857a99a4dffefb8e10d94!}
- {!LANG-4a828d72c583e439783b53051ffd7a66!}
- {!LANG-0e9dd82339fc2bde078cd9e41054d6a7!}
- {!LANG-5b40182c7e86a7e02c8f638c6ead4f85!}
- {!LANG-35df4dfb6fb01cbe879475f44279b21c!}
- {!LANG-f4402dd7aec295e790909b89dc6d22aa!}
- {!LANG-652995ff165ba1c98f50cd92adf668ee!}
- {!LANG-d1f5663e104dab512a52d1d08739eeb8!}
- {!LANG-4e5c841f5bc546e8d2395d5558f533bd!}
- {!LANG-30e3b6e3145ead7c79d4fe350168ae3c!}
- {!LANG-f30cf4f55cc77549e1a2b8ed0ca1e0ca!}
- {!LANG-7481a68fa22301258d4a8ae0a532e351!}
- {!LANG-1bcde078d610700d5966097b37c54fe5!}
- {!LANG-a77471c69fa0de461624670d707c7cd7!}
- {!LANG-7005a273fa3d67a94557e94980653488!}
- {!LANG-18e0b0a8d9ae6ca757f4468cd44370ea!}
- {!LANG-fc49d7e11224fe8af496e0b7d66eee42!}
- {!LANG-82e43f07ca239fbbf245b3b17e1efcac!}{!LANG-a09d3a1a4e371cd985cda331e8746ec1!} {!LANG-e7110ad0c75469a85dc7c9565cbfed8c!}{!LANG-aee5aa24a0ade4f806a2f32e9e3a55d4!}
- {!LANG-45e2b719f3647c475f3b31ec1335930d!}
- {!LANG-a70aab5bf23efced740fc49245e34046!}