Red, Swollen Eyelids: What to Consider in the Differential

In Dr Henry Schneiderman's interesting case of swelling and redness of the lids in an elderly woman (CONSULTANT, January 2005, page 89), the photograph clearly illustrates a sharp demarcation of the area of swelling above the cheekbone (Figure). Thus, I was surprised to find that erysipelas was not included in the differential diagnosis. Although the patient did not appear acutely ill, ruling out this disorder may have been warranted.

- Holly Martin, MSN FNP-BC
   Salt Lake City

I appreciate the additional differential diagnosis of erysipelas raised by Ms Martin, and I agree that when there is a sharp cutoff of erythema, this rises in the differential diagnosis of a patch or zone of red skin. Precisely for the reasons stated--namely, that we had another culprit and that the patient was not ill--I considered erysipelas unlikely. Of note, some very knowledgeable colleagues thought that oral antibiotics were called for, but I disagreed.

Nonetheless, it is good to be reminded of the frequency with which these common infections must be entertained, even when they are not ultimately diagnosed. Over the years, many cases of erysipelas, cellulitis, and their mimics have been featured in "What's Your Diagnosis?"^1-5 The protean manifestations of erysipelas, including confusing first manifestations in which fever precedes skin lesions,^6,7 underscore the wisdom of keeping this typically streptococcal process in mind.

- Henry Schneiderman, MD
   Physician-in-Chief Hebrew Health Care, West Hartford, Conn
   Professor of Medicine (Geriatrics)
   Associate Professor of Pathology
   University of Connecticut Health Center
   Farmington

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