1. Institute for Microbiology, Medical Faculty of Masaryk University and St. Anna Faculty Hospital in Brno Miroslav Votava Agents of skin-manifested infections – II Lecture for 3rd-year students 23 rd November, 2012

2. Common superficial injuries – revision Staphylococcus aureusStaphylococcus aureus Streptococcus pyogenesStreptococcus pyogenes beta-hemolytic streptococci of other groups (above all G, F, C)beta-hemolytic streptococci of other groups (above all G, F, C) ! Attention in case of a foreign body in the wound (splinter, thorn) and in case of deeper stab wounds (fork soiled by horse manure): Clostridium tetani

3. Severe contused wounds – revision Agents of clostridial myonecrosis (mostly Clostridium perfringens, C. septicum, C. novyi, C. histolyticum)Agents of clostridial myonecrosis (mostly Clostridium perfringens, C. septicum, C. novyi, C. histolyticum) clostridial myonecrosis = anaerobic traumatosis = gas gangrene or malignant edema Clostridium tetaniClostridium tetani Staph. aureus, Strept. pyogenes & other pyogenic bacteriaStaph. aureus, Strept. pyogenes & other pyogenic bacteria

4. Wounds sustained in water – revision In fresh water:In fresh water: Pseudomonas aeruginosa Aeromonas hydrophila other pseudomonads and aeromonads In salt water:In salt water: Vibrio parahaemolyticus, V. vulnificus Mycobacterium marinum (also in fresh-water swimming pools, tanks and aquaria)

5. Injuries sustained in the tropics – revision Mainly on feet soil nocardiae (Dermatophilus congolensis, Rhodococcus equi)soil nocardiae (Dermatophilus congolensis, Rhodococcus equi) atypical mycobacteria (Mycobacterium ulcerans, Mycobacterium haemophilum)atypical mycobacteria (Mycobacterium ulcerans, Mycobacterium haemophilum) micromycetes (Sporothrix schenckii, Paracoccidioides brasiliensis)micromycetes (Sporothrix schenckii, Paracoccidioides brasiliensis)

6. Surgical wounds – revision Staphylococcus aureus coagulase-negative staphylococci (mainly Staphylococcus epidermidis) Enterobacteriaceae (Escherichia coli, Proteus mirabilis) Streptococcus pyogenes anaerobes (Peptostreptococcus micros, Peptostreptococcus anaerobius, Bacteroides fragilis)

7. Burns – revision Almost everything, but predominantly: Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pyogenes other streptococci enterococci candidae and aspergilli

8. Man-inflicted bites – revision members of oral microflora - „oral streptococci“ (Streptococcus sanguinis, S. oralis, S. anginosus) - anaerobes (Fusobacterium nucleatum ssp. nucleatum, Porphyromonas gingivalis) Staphylococcus aureus

9. Animal bites – revision Most often: Pasteurella multocida (cats, dogs) Less often: Staphylococcus aureus (any animal) Capnocytophaga canimorsus (dogs) Streptobacillus moniliformis (rats) Spirillum minus (mice, rats, cats, dogs) Francisella tularensis (cats) & many others

10. Other injuries by animals – revision Francisella tularensis (rodents, hares – tularemia) Bartonella henselae (cat scratch disease) Erysipelothrix rhusiopathiae (pigs, carps – erysipeloid) Bacillus anthracis (herbivores – skin anthrax, pustula maligna) Burkholderia mallei (horses, donkeys – glanders, malleus) …

11. Infections with skin symptoms – revision 1.primary skin infections 2.secondary infections of already diseased skin 3.skin symptoms of systemic infections Etiology: bacterial viral viral fungal fungal parasitic parasitic

12. Primary acute bacterial skin infections I – revision acne vulgaris – Propionibacterium acnes carbunculus nuchae – Staph. aureus ecthyma gangraenosum – Ps. aeruginosa erysipelas – Streptococcus pyogenes erysipeloid – Erysipelothrix erythrasma – Corynebact. minutissimum folliculitis – Staph. aureus, P. aeruginosa furunculosis (boil) – Staph. aureus

13. Primary acute bacterial skin infections II – revision hidradenitis suppurativa – Staph. aureus hordeolum (stye) – Staph. aureus impetigo – Staph. aureus, Str. pyogenes lymphangoitis – Streptococcus pyogenes panaritium – Staphylococcus aureus paronychium – Staphylococcus aureus sycosis barbae – Staphylococcus aureus

14. Primary chronic bacterial skin infections – revision actinomycosis – Actinomyces israelii chronic subcutaneous abscesses – Actin. israelii, Nocardia asteroides, Rhodococcus equi skin granulomas – Mycobacterium marinum, M. haemophilum, M. chelonae leprosy – Mycobacterium leprae lupus vulgaris – Mycob. tuberculosis scrophuloderma – M. tuberculosis, M. bovis

15. Secondary infections of skin lesions – revision decubitus (bedsore), trophic ulcer – neighbouring and endogenous flora (staphylococci, streptococci, enterococci, enteric bacteria, pseudomonads and other Gram-negative non- fermenting rods, anaerobes, yeasts) infected atheroma – S. aureus, Propion. acnes infected intertrigo (raw) – S. aureus, P. acnes sec. infected dermatomycoses – S. pyogenes infected wounds – discussed in previous lecture

16. Skin symptoms of systemic bacterial infections – revision roseola (rash in typhoid fever) – Salmonella Typhi disseminated gonorrhoea – Neisseria gonorrhoeae erythema migrans – Borrelia burgdorferi infective endocarditis – will be dealt with by sepsis meningococcemia – Neisseria meningitidis scarlatina (scarlet fever) – Streptococcus pyogenes SSSS (staphylococcal scalded skin syndrome) – Staphylococcus aureus toxic shock syndrome – S. aureus, S. pyogenes syphilis – Treponema pallidum …

17. Etiology of skin fungal infections Etiology differs in superficial mycosessuperficial mycoses mucocutaneous mycosesmucocutaneous mycoses cutaneous mycosescutaneous mycoses subcutaneous mycosessubcutaneous mycoses opportune skin mycosesopportune skin mycoses

18. Etiology of superficial skin mycoses Pityriasis versicolor Large hyper- or hypopigmented spots without marks of inflammation Fluorescence in Wood’s UV lamp light: positive Agent: lipophilic yeast Malassezia furfur (formerly Pityrosporum ovale) Cultivation on Sabouraud agar under a olive oil Therapy: local antimycotics (sulphur, azoles)

19. Etiology of mucocutaneous mycoses I Mainly candidoses caused by Candida albicans Examples: intertrigobalanitis erosio interdigitalebalanoposthitis cheilitis angularissoor oesophagitisonychomycosis colpitis mycoticaparonychium vulvovaginitis

20. Etiology of mucocutaneous mycoses II Laboratory diagnostics of candidoses: microscopy cultivation on chromogenic media auxanograms & zymograms Therapy: topical imidazoles (e.g. clotrimazol, econazol, oxiconazol) systemic azoles (e.g. ketoconazol, fluconazol, vorikonazol) systemic azoles (e.g. ketoconazol, fluconazol, vorikonazol) Another candidae: C. parapsilosis, C. tropicalis, C. glabrata, C. krusei Another yeasts: genus Rhodotorula, genus Trichosporon

21. Etiology of cutaneous mycoses I Three genera of dermatophytes: 1.Trichophyton e.g. Trichophyton rubrum 2.Microsporum e.g. Microsporum canis 3.Epidermophyton only Epidermophyton floccosum

22. Etiology of cutaneous mycoses II tinea pedis – Trichophyton rubrum, Trich. mentagrophytes var. interdigitale, Epidermophyton floccosum onychomycosis – T. rubrum, E. floccosum tinea corporis – T. rubrum, Microsporum canis, M. gypseum, T. mentagrophytes var. mentagrophytes, E. floccosum tinea capitis, type ectothrix – M. gypseum, M. canis, M. audouinii, T. mentagrophytes var. mentagrophytes, T. verrucosum type endothrix – T. tonsurans type endothrix – T. tonsurans favus – Trichophyton schoenleinii

23. Etiology of subcutaneous mycoses pheohyphomycosis (lesions with pigmented hyphae) – genera Alternaria, Aureobasidium, Cladosporium, Culvularia, Exophiala, Phaeoannelomyces, Phoma, Wangiella & others chromoblastomycosis (warty nodules with sclerotic bodies) – Cladophialophora emmonsii, Fonsecaea pedrosoi, Phialophora europaea mycetoma eumycoticum (swollen lesion with draining tracts containing small grains) – Acremonium, Exophiala, Madurella, Pseudoallescheria (= Scedosporium) sporotrichosis (dimorphic fungus) – Sporothrix schenckii

24. Etiology of opportune skin mycoses in immunodeficites Fusarium solani, Fusarium oxysporum, Fusarium verticillioides Pseudoallescheria boydii (= teleomorph, sexual phase of anamorph Scedosporium apiospermum) Penicillium marneffei (systemic infection with skin manifestations) Scopulariopsis brevicaulis

25. Skin symptoms in viral diseases – I Macular (spotted) exanthem: morbilli – morbilli virus (Morbillivirus genus) rubella – rubella virus (Rubivirus genus) erythema infectiosum (the fifth disease) – parvovirus B19 (Erythrovirus genus) exanthema subitum (roseola infantum, the sixth disease) – HHV 6 (Roseolovirus genus) Umbiliform papulae: molluscum contagiosum – molluscum contagiosum virus (Molluscipoxvirus genus)

26. Skin symptoms in viral diseases – II Vesicles: herpes simplex (cold sore) – HSV 1 (Simplexvirus genus) herpes genitalis – HSV 2 (Simplexvirus genus) varicella (chicken pox) – varicella-zoster virus (VZV, Varicellovirus genus) herpes zoster (shingles) – varicella-zoster virus (VZV, Varicellovirus genus) variola vera (smallpox) – variola virus (Orthopoxvirus genus) (continued)

27. Skin symptoms in viral diseases – III Vesicles – cont.: vaccinia – vaccinia virus (Orthopoxvirus genus) cowpox and monkey pox – cowpox virus and monkey pox virus (Orthopoxvirus genus) tubera mulgentium (milkers´ nodules) – milker´s nodule virus (Parapoxvirus genus) aphthae epizooticae (foot and mouth disease) – foot-and-mouth disease virus (FMDV, Aphthovirus genus) hand, foot and mouth disease – coxsackievirus A16 (Enterovirus genus)

28. Skin symptoms in viral diseases – IV Petechiae: Hemorrhagic fevers – Ebola fever, Ebola virus (Ebolavirus genus) Ebola fever, Ebola virus (Ebolavirus genus) Marburg disease, Marburg virus (Marburgvirus genus) Marburg disease, Marburg virus (Marburgvirus genus) Lassa fever, Lassa virus (Arenavirus genus) Lassa fever, Lassa virus (Arenavirus genus) Generalized congenital cytomegalic disease – cytomegalovirus (CMV, Cytomegalovirus genus) cytomegalovirus (CMV, Cytomegalovirus genus)

29. Skin symptoms in parasitoses – I Domestic (native) parasitoses: scabies – itch mite (Sarcoptes scabiei) demodicosis – human follicle mites (members of Demodex genus) pediculosis capitis – head louse (Pediculus capitis) pediculosis corporis – body louse (Pediculus humanus, syn. Pediculus corporis) pediculosis pubis (phthiriasis) – pubic (crab) louse (Phthirus pubis)

30. Skin symptoms in parasitoses – II Infestation by native ectoparasites: cimicosis, urticaria cimicosa – bites by bedbug Cimex lectularius pulicosis – bites by human flea Pulex irritans, dog flea Ctenocephalides canis, cat flea Ctenocephalides felis, chicken flea Ceratophyllus gallinae ixodosis – bite by hard tick Ixodes ricinus culicosis – bites by common mosquito Culex pipiens trombiculosis, trombidiosis – bites by Neotrombicula autumnalis larvae

31. Skin symptoms in parasitoses – III Tropical parasitoses: ulcus humidum (humid ulcer) – Leishmania major ulcus siccum (dry ulcer) – Leishmania tropica espundia – Leishmania braziliensis tungosis – chigoe flea Tunga penetrans dermatitis cercariosa – cercariae of Schistosoma, Bilharziella andTrichobilharzia genera dracunculosis – Dracunculus medinensis filariosis – filariae Loa loa and Onchocerca volvulus …

32. Homework 9 Jan Havickzoon Steen (1626-1679): The Sick Woman (c. 1665)

33. Homework 9 Another two pictures by Jan Havickzoon Steen (1626-1679) on the similar topic: The Lovesick Woman (1960) The Doctor´s Visit (1960-63)

34. Homework 9 Successful homework 9 solver: Filippos-Paschalis Rorris Congratulations!

35. Homework 10 Please give the name of the author and of the painting

36. Answer and questions The solution of the homework and possible questions please mail to the address mvotava@med.muni.cz Thank you for your attention