BACTERIAL and VIRAL SKIN AND SOFT TISSUE INFECTIONS

BACTERIAL and VIRAL SKIN AND SOFT TISSUE INFECTIONS
ONUR OK HELİN YILMAZ

Skin and soft tissue infections (SSTIs)
SSTIs which include infections of skin, subcutaneous tissue, fascia, and muscle, encompass a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. Diagnosing the exact extent of the disease is critical for successful management of a patient of soft tissue infection.

The Structure of Human Skin
Figure 21.1

Pathogenesis

Necrotizing Fascitis Contact Dermatitis Cellulitis Erysipelas Erythema Multiforme Ecthyma Deep Vein Thrombosis Folliculitis Impetigo

superficial Impetigo Ecthyma Folliculitis Furuncule/Carbuncle/Abscess Erysipelas Cellulitis Necrotizing Fascitis deep Stevens, DL, Bisno, AL, Chambers, HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis

Normal Microbiota of the Skin
Gram-positive, salt-tolerant bacteria Staphylococci Micrococci Diphtheroids Figure 14.1a

Normal Microbiota of the Skin
Grow on oils Aerobes on surface Corynebacterium xerosis Anaerobes in hair follicles Propionibacterium acnes Yeast Malassezia furfur

Skin Lesions Figure 21.2

Staphylococcal Skin Infections
Staphylococcus epidermidis Gram-positive cocci, coagulase-negative Staphylococcus aureus Gram-positive cocci, coagulase-positive Clinical Focus, p. 593

Staphylococcus aureus
Antibiotic resistant Leukocidin Resists opsonization Survives in phagolysosome Lysozyme resistant Exfoliative toxin Superantigen Clinical Focus, p. 593

Staphylococcal Biofilms
Pseudomonas,Enterobacter,Flavobacterim, Alcaligenes, Staphylococcus Figure 21.3

Staphylococcal Skin Infections
Folliculitis: Infections of the hair follicles Sty: Folliculitis of an eyelash Furuncle: Abscess; pus surrounded by inflamed tissue Carbuncle: Inflammation of tissue under the skin Impetigo: crusting (nonbullous) sores, spread by autoinoculation

Nonbullous Lesions of Impetigo
Figure 21.4

Scalded Skin Syndrome Toxic shock syndrome (TSS) Scalded skin syndrome
Toxic shock syndrome toxin 1 Scalded skin syndrome Bullous impetigo Impetigo of the newborn

Lesions of Skin Syndrome
Figure 21.5

Streptococcal Skin Infections
Streptococcus pyogenes Group A beta-hemolytic streptococci Hemolysins Hyaluronidase Streptolysins M proteins

Group A Beta-Hemolytic Streptococci
Figure 21.6

Ecthyma Presentation: Vesicle/pustule which enlarges over several days and becomes thickly crusted. When crust is removed a superficial saucer shaped ulcer remains with elevated edges. Nearly always on shins or dorsal feet. Heals in a few weeks with scarring. Agent: Staph or Strep. Heal with scaring Gangrene in predisposed individuals. Treatment: Clean, topical and systemic ABX.

Ecthyma

Scarlet Fever Presentation: 24 –48 hrs after Strep. Pharyngitis onset.
Cutaneous: Widespread erythema with 1-2 mm papules. Begins on neck and spreads to trunk then extremities. Pastia’s lines – accentuation over skin folds with petechia. Circumoral pallor Desquamation of palms and soles at appox two wks. May be only evidence of disease. Other: strawberry tongue Causes: erythrogenic exotoxin of group A Strep. Culture to recover organism or use streptolysin O titer if testing is late. TX: PCN, E-mycin, Cloxacillin.

Scarlet Fever

Streptococcal Skin Infections
Necrotizing fasciitis Erysipelas Figure 21.7

Necrotizing Fasciitis
Presentation: Following surgery or trauma (24 to 48 hours) - erythema, pain and edema which quickly progress to central patches of dusky blue discoloration. Anesthesia of the involved skin is very characteristic. By day 4-5 the involved area becomes gangrenous. Infection of the fascia. Many causative agents. Aerobic and anaerobic cultures should be taken. Treatment: Early debridement. ABX. 20% mortality in best cases Poor prognostic factors: Age >50, DM, Atherosclerosis, involvement of trunk, delay of surgery >7 days.

Invasive Group A Streptococcal Infections
Exotoxin A, superantigen Figure 21.8

Erysipelas Presentation: erythematous patch with a distinctive raised, indurated advancing border. Affected skin is very painful and is warm to touch. Freq. associated with fever , HA and leukocytosis >20,000. Face and Legs are most common sites. Involves superficial dermal lymphatics Cause: Group A strep., (Group B in newborns) Differential: Contact derm: more itching little pain. Scarlet fever: widespread punctate erythema Malar rash of Lupus and Acute tuberculoid Leprosy: Absence of fever pain and leukocytosis. Treatment: Systemic PCN for 10 days.

Erysipelas

Streptococcal Toxic Shock Syndrome
M proteins Complex with fibrinogen Binds to neutrophils Activates neutrophils Release of damaging enzymes Shock and organ damage

Infections by Pseudomonads
Pseudomonas aeruginosa Gram-negative, aerobic rod Pyocyanin produces a blue-green pus Pseudomonas dermatitis Otitis externa, or “swimmer’s ear” Post-burn infections Opportunistic Hot-tub folliculitis

Infections by Pseudomonads
Hot Tub Folliculitis Hot tub folliculitis is an infection of the hair follicles caused by the bacteria Pseudomonas aeruginosa. This bacteria is commonly found in contaminated whirlpools, hot tubs, water slides, physiotherapy pools, or even loofah sponges

Folliculitis and Furuncle
Folliculitis Folliculitis is an infection that is localized to the hair follicle. A folliculitis looks like small, yellow pustules that are confined to the hair follicle. Furuncle A furuncle is an infection of the pilosebaceous unit, therefore is more extensive than a folliculitis because the infection also involves the sebaceous gland. Frequently occurs on the neck, face, armpits, and buttocks.

folliculitis staphylococcal pustulosis furuncle carbuncle

Carbuncle A carbuncle can simply be defined as an multiple furuncles grouped together. A carbuncle usually involves the deeper layers of the skin - the subcutaneous fat. It looks like a large, red nodule that is hot and may have visible layers of pus just beneath the surface of the skin

Folliculitis and Furuncle

Cellulitis Cellulitis is a bacterial infection of the deeper layers of the skin, the dermis and the subcutaneous tissue. In adults and children, cellulitis is most often caused by Streptococcus and Staphylococcus aureus bacteria. Sometimes Haemophilus influenzae type B can cause cellulitis in children younger than 3, but this has become less common because of vaccination.

Cellulitis

Necrotizing Fascitis Contact Dermatitis Cellulitis Erysipelas Erythema Multiforme Ecthyma Deep Vein Thrombosis Folliculitis Impetigo

ACNE Acne is an inflammation of the pilosebaceous units of certain body areas (face and trunk, rarely buttocks) that occurs most frequently in adolescence and manifests itself as comedones (comedonal acne), papulopustules (papulopustular acne), or nodules and cysts (nodulocystic acne and acne conglobata).

Mild Acne Topical antibiotics (clindamycin, erythromycin, tetracycline) Benzoyl peroxide gels (2 %, 5 %, 10 %) Topical retinoids (tretinoin, adapalene) Improvement occurs over a period of months (2 to 5) but may take even longer for noninflamed comedones.

Moderate Acne: Oral antibiotics are added to the above regimen.
Minocycline, 50 to 100 mg bid, or, doxycycline, 50 to 100 mg bid. Tetracyclines Erythromycin Azitromycin Bactrim

Severe Acne: Isotretinoin, 0.5 to 1 mg/kg/day, (20 weeks)

FUNGAL SKIN INFECTIONS

CUTANEOUS MYCOSES TINEA CAPITIS Ringworm of the scalp
Occurs chiefly in schoolchildren and less commonly in infants and adults Hair can be infected with Trichophyton and Microsporum fungi. M. canis is the commonest dermatophyte fungus to cause tinea capitis.

Tinea capitis requires
treatment with an oral antifungal agent. Griseofulvin is probably the most effective agent for infection with Microsporum canis, Scalp Trichophyton infections may successfully be eradicated using oral terbinafine, itraconazole or fluconazole for 4 to 6 weeks

TINEA PEDIS The feet are the most common area infected by certain fungi called dermatophytes, causing tinea pedis or athlete’s foot. Athlete’s foot is a very common problem experienced by up to 70% of the population at some time in their life. TREATMENT Mild cases can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine. Topical medications should be applied twice a day until the rash is completely resolved. More serious infections should be treated with oral antifungal medications such as terbinafine or itraconazole for 2 to 6 months.

TINEA CRURIS The rash starts in the groin fold usually on both sides.
Tinea cruris caused by T. rubrum does not involve the scrotum or penis. If those areas are involved, the most likely agent is Candida albicans, the same type of yeast that causes vaginal yeast infections. TREATMENT Mild cases can be treated with topical antifungal creams or sprays such as clotrimazole, ciclopirox, terbinafine, naftifine. Topical medications should be applied twice a day until the rash is completely resolved (2-4 weeks). Extensive disease should be treated with oral antifungal medications such as terbinafine (1-2 week) or itraconazole (1 week).

ONYCHOMYCOSIS Fungal infection of the nails
Onychomycosis can be due to: Dermatophytes such as Trichophyton rubrum (T rubrum), T. interdigitale. The infection is also known as tinea unguium. Yeasts such as Candida albicans. Moulds especially Scopulariopsis brevicaulis and Fusarium species. TREATMENT Mild infections affecting less than 80% of one or two nails may respond to topical antifungal medications but cure usually requires an oral antifungal medication for several months. Combined topical and oral treatment is probably the most effective regime.

SUBCUTANOUS MYCOSES The “subcutaneous” mycoses are due to a large and diverse group of organisms that cause disease when implanted or otherwise introduced into the dermis or subcutis. Chromoblastomycosis, mycetoma, sporotrichosis and lobomycosis The most common portal of entry is the skin, typically after arthropod bites or minor trauma. Clinically, the disease manifests as a solitary, painless, indurated subcutaneous nodule or swelling of the thigh or buttock. TREATMENT The classic treatment is saturated solution of potassium iodide.

CANDIDIASIS Candidiasis (moniliasis) is skin infection with Candida sp, most commonly Candida albicans. Infections can occur anywhere and are most common in skinfolds and web spaces, on the genitals, cuticles, and oral mucosa. Most candidal infections are of the skin and mucous membranes, but invasive candidiasis is common in immunosuppressed patients and can be life threatening. Etiology Candida is a group of about 150 yeast species. C. albicans is responsible for about 70 to 80% of all candidal infections.

Diagnosis Clinical appearance Potassium hydroxide wet mounts Positive culture is usually meaningless because Candida is omnipresent. Treatment General hygiene is vital to the treatment of cutaneous candidiasis. Keeping the skin dry and exposed to air is helpful Topical (applied directly to the skin) antifungal medications may be used to treat infection of the skin, mouth, or vagina. miconazole or nystatin Oral antifungal medications may be necessary for folliculitis, nail infection, or severe candida infections involving the mouth, throat, or vagina. Flucanazole.

PARASITIC SKIN INFESTATIONS
PEDICULOSIS Lice infestation (pediculosis) is a skin infestation by tiny wingless insects. Lice spread most frequently through person-to-person contact. People with lice usually have severe itching. Three species of lice inhabit different parts of the body. Pediculosis capitis,corporis,pubis. Treatment usually involves shampoos, creams, or lotions.

TREATMENT Nonprescription shampoos and creams containing pyrethrins plus piperonyl butoxide are applied for 10 minutes and are then rinsed out. permethrin malathion

SCABIES Scabies is caused by the itch mite Sarcoptes scabiei.
The female itch mite tunnels in the topmost layer of the skin and deposits her eggs in burrows.Young mites (larvae) then hatch in a few days. The infestation causes intense itching which is usually worse at night, probably from an allergic reaction to the mites. The infestation spreads easily from person to person on physical contact, often spreading through an entire household.

TREATMENT can be cured by applying a cream containing 5% permethrin which is left on the skin overnight and then washed off. The itching can be treated with mild corticosteroid cream and antihistamines taken by mouth

BACTERIAL DISEASE OF THE EYE
CONJUNCTIVITIS Conjunctivitis, also known as pinkeye, is an inflammation of the conjunctiva. H.Influenza is the most common cause. Pink eye may affect one or both eyes. Its signs and symptoms include: Redness Itchiness A gritty feeling A discharge that forms a crust during the night that may prevent your eye or eyes from opening in the morning Tearing

Ophthalmia neonatorum
Ophthalmia neonatorum refers to any conjunctivitis occurring in the first 28 days of life. It is most commonly infective in origin: bacterial causes include Chlamydia trachomatis, Neisseria gonorrhoeae, Staphylococcus aureus, Streptococcus pneumoniae and various other organisms.

Affected babies present with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life. They typically show injected conjunctiva and lid swelling.

INCLUSION CONJUNCTIVITIS
Inclusion conjunctivitis is an inflammation of the by Chlamydia trachomatis. Inclusion conjunctivitis, known as neonatal inclusion conjunctivitis in the newborn and adult inclusion conjunctivitis in the adult, is also called inclusion blennorrhea, chlamydial conjunctivitis, or swimming pool conjunctivitis. Inclusion conjunctivitis in the newborn results from passage through an infected birth canal and develops 5-14 days after birth. Both eyelids and conjunctivae are swollen. There may be a discharge of pus from the eyes.

Untreated inclusion conjunctivitis in the newborn persists for 3-12 months and usually heals; however, there may be scarring or neovascularization. TREATMENT Treatment in the newborn consists of administration of tetracycline ointment to the conjunctiva and erythromycin orally or through intravenous therapy for fourteen days.

TUS 2012 Aşağıdakilerden hangisinde dissemine kandidiazis görülme olasılığı diğerlerine göre en düşüktür? A) Kanser kemoterapisi alan hastalar B) Nötropenik hastalar C) Uzun süreli sistemik steroid tedavisi alan hastalar D) Total parenteral beslenen hastalar E) Kronik mukokütanöz kandidiazisli hastalar

TUS 2012 “Hot-tub follikülit” etkeni aşağıdakilerden hangisidir?
A) Klebsiella pneumoniae B) Streptococcus pyogenes C) Pseudomonas aeruginosa D) Staphylococcus aureus E) Candida albicans

TUS 2012 Aşağıdakilerden hangisi, uyuz tedavisinde topikal olarak kullanılmamaktadır? A) Permetrin B) Sülfür C) Benzil benzoat D) Krotamiton E) İvermektin

TUS 2012 Otuz beş günlük bir kız bebek öksürük ve solunum zorluğu yakınmalarıyla getiriliyor. Öyküsünden vajinal yolla zamanında doğduğu ve izleminde bilateral pürülan konjunktivit saptandığı öğreniliyor. Bu bebekte etken olarak öncelikle aşağıdakilerden hangisi düşünülmelidir? A) Streptococcus pyogenes B) Chlamydia trachomatis C) Mycoplasma pneumoniae D) Listeria monocytogenes E) Staphylococcus aureus

TUS 2012 Üç yaşında bir kız çocuk 3 gündür devam eden 39-40°C ye varan ateş, boğaz ağrısı ve boyunda bezeler nedeniyle getiriliyor. Fizik muayenede eksüdatif tonsillit ve splenomegali saptanıyor. Laboratuar incelemelerinde AST ve ALT düzeylerinde normalin üst değerinin iki katı yükselme gözleniyor. Bu çocuk için en olası tanı aşağıdakilerden hangisidir? A) Grup A streptokok enfeksiyonu B) 6. hastalık C) Kawasaki hastalığı D) Enfeksiyöz mononükleoz E) Difteri

TUS 2012 Aşağıdaki etkenlerden hangisi en ciddi ophthalmia neonatorum formuna neden olur? A) Chlamydia trachomatis B) Herpes simpleks virusu C) Sitomegalovirus D) Staphylococcus aureus E) Neisseria gonorrhoeae

TUS 2013 Aşağıdaki bulaşıcı hastalık - kontrol programı eşleştirmelerinden hangisi yanlıştır? A) Kızamık - Eliminasyon B) Neonatal tetanoz - Eradikasyon C) Kızamıkçık - Eliminasyon D) Polio - Eliminasyon E) Tüberküloz - Hastalık kontrolü

TUS 2013 Aşağıdaki mikroorganizmalardan hangisi, sağlam kornea epitelini geçemez? A) Neisseria gonorrhoeae B) Neisseria meningitidis C) Corynebacterium diphtheriae D) Haemophilus influenzae E) Streptococcus pyogenes

TUS 2013 Stafilokokkal toksik şok sendromunda, aşağıdaki klinik örneklerden hangisinde Staphylococcus aureus üreyebilir? A) Dışkı B) Kemik iliği C) Beyin omurilik sıvısı D) Vajen E) Nazofarenks

TUS 2013 Wright veya Giemsa ile boyandığında ortaya çıkan Donovani cisimciği aşağıdaki mikroorganizmalardan hangisinin varlığında görülür? A) Neisseria gonorrhoeae B) Chlamydia trachomatis C) Treponema pallidum D) Klebsiella granulomatis E) Candida glabrata

TUS 2015

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