Milian's ear sign: Erysipelas.

A clinical case is presented here of a patient with fever and ear pain. Physical examination revealed "Milian's ear sign", which supports the diagnosis of erysipelas rather than cellulitis. After intravenous antibacterial treatment, the patient recovered.

An otherwise healthy 48-year-old Japanese woman presented to our emergency department with a 2-day history of fever and right ear pain. Her symptoms developed gradually after ear cleaning. Physical examination revealed that her right ear was red, swollen, and tender, with a well-demarcated facial erythematous lesion (Fig. 1). Laboratory investigations revealed an elevated white cell count of 12,900 cells/mm3. There were no other significant findings, including those on auditory canal and tympanic membrane examination with otoscope. Many disorders, including soft tissue infections and cartilage problems such as relapsing polychondritis [1] must be considered in the differential diagnosis of a patient with a red ear. Milian’s ear sign is an acknowledged sign of otic involvement in infection [2]. Erysipelas occurs in the upper dermis and lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous tissue. There is no deep dermis and subcutaneous tissue in the pinna; thus the pinna involvement supports the diagnosis of erysipelas rather than cellulitis. The most common causative microorganism of erysipelas is group A beta hemolytic streptococcus, Streptococcus pyogenes [3].

Fig. 1

Milian’s ear sign.

Consequently, erysipelas was the most likely diagnosis in this patient. After intravenous antibacterial treatment with ampicillin plus clindamycin, her symptoms resolved without complications.

Conflict of interest

The authors declare no conflicts of interest.

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