Fever and rhomboid target lesion in decompensated cirrhosis

Abstract

A 53-year-old woman with Child-Pugh B, hepatitis C virus-related cirrhosis presented with a 3 day history of high fever (peak 39·5°C) and a non-itchy rash. On admission, physical examination showed mild ascites, and a temperature of 38·5°C, a pulse rate of 88 beats per min, and a respiratory rate of 18 breaths per min were recorded. Many large (about 15 cm diameter) target lesions were present on the patient’s trunk and arms and legs, seen as concentric rings of a dull red, pink, or violet colour surrounding a clear centre (fi gure). No mucosal lesions were noted. Laboratory tests recorded a white-blood-cell count of 12×109 cells per L and a C-reactive protein concentration of 3·4 mg/L. Abdominal ultrasound confi rmed the presence of ascites, and echocardiography did not indicate endocarditis. Treatment with oral levofl oxacin was started; 2 days later, the patient’s fever was reduced, all lesions gradually ameliorated acquiring a rhomboid aspect, and liver decompensation diminished progressively. Meanwhile, two blood cultures yielded Grampositive bacteria identifi ed as Erysipelothrix rhusiopathiae. The patient attended the outpatient’s clinic at the Clinical and Molecular Hepatology Unit of the University Hospital of Messina 1 month after discharge from hospital and every 3 months thereafter. At the last visit (January, 2012) no signs of worsening liver disease were noted and the skin lesions had not reappeared. E rhusiopathiae is a common commensal or pathogen of many vertebrate and invertebrate species. Pigs are a major reservoir. Human disease is mainly an occupationally acquired zoonosis. The portal of entry is typically a puncture wound or abrasion on the hand; however, it can also be acquired from eating contaminated food. The patient does not work with animals and denied any injuries while preparing food. However, the week before she became unwell she ate raw pork meat. Liver dysfunction could be associated with E rhusiopathiae bacteraemia because of the noted impairment of reticuloendothelial function in the patient. Three clinical forms of infection with E rhusiopathiae have been reported in human beings: a localised cutaneous form, or erysipeloid of Rosenbach; a diff use cutaneous form; and a bacteraemic form that occurs with or without endocarditis. The diff use cutaneous form constitutes a rare situation in which violaceous cutaneous lesions can arise at remote areas as widespread urticaria with the rhomboid pattern characteristic of swine erysipelas. In our patient, the pattern was associated with bacteraemia without endocarditis.