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A Rash Overview of Tropical Skin Diseases (and other things)

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1 A Rash Overview of Tropical Skin Diseases (and other things)
Boris D. Lushniak, MD, MPH RADM USPHS, Deputy Surgeon General Adjunct Professor Dermatology, USUHS The events of late 2001 have made bioterrorism a reality on the soil of our nation. As experts in diseases of the skin, dermatologists can better diagnose skin disease, including those caused by biological weapons, than any other physician. Another of our goals is to educate non-dermatologists regarding the skin signs of biological agents used by terrorists. After a short background about biological warfare in general, this talk will focus on anthrax and smallpox with less attention paid to plague, tularemia, and viral hemorrhagic fevers.

2 Insect bites

3 Bedbugs

4 Gentian Violet Very messy; stains
Traditional “anti-infective” treatment, rarely used in USA today Gentian violet can be painted onto bacterial or fungal infections and left to dry

5 Many deep fungal infections can present as leg ulcers
Sporotrichosis Blastomycosis Coccidioidomycosis Cryptococcosis Histoplasmosis Protothecosis Chromoblastomycosis protothecosis

6 Chromoblastomycosis Usually one lower extremity Male Farmers
Fonsecaea pedrosoi Direct inoculation, start as pink scaly papule or warty growth, verrucous/nodular, atrophy/scarring

7 Chromoblastomycosis Treatment is difficult
Small lesions: surgical excision or LN2 Itraconazole or Terbinafine Below: fungal elements found in smear taken from ulcer 10% fail therapy outright, only about 30% cured, >40% have recrudescence, amputation

8 Lobomycosis (Lacazia loboi)
Acquired from soil, water, vegetation in forested areas Recurrence common Amazonian wetlands Small lesions- surgical excision Itraconazole & Clofazimine

9 Sporotrichosis Nodules with lymphatic spread and ulceration
Sporothrix schenkii Worldwide Itraconazole Potassium Iodide

10 Differential for sporotrichoid spread aka Lymphocutaneous syndrome
Sporotrichosis Nocardiosis Leishmaniasis Tularemia Atypical mycobacteria (esp M. marinum)

11 Rhinosporidiosis Rhinosporidium seeberi
India, East Asia, Latin America Mucosal polypoid lesions Bleed easily Organism found in stagnant water, In genitals resemble condylomata, appear as spherules found in larger cystic sporangio- grayish white flecks are transepithelial elimination of sporangia

12 Rhinosporidiosis Treatment
Destruction of involved area by excision or electrosurgery Antifungals are of little value Cultures easiest with microcystis aeruginosa (may represent synergistic infection of fungus and cyanobacterium0 try cipro)

13 Basidiobolomycosis Entomophthoromycosis Indonesia, worldwide
Indolent course Basidiobolus ranarum Subcutaneous 2 types one perinasal dz, 2 caused by B. Ranarum subq nodules ext, buttocks, trunk

14 Basidiobolomycosis Biopsy diagnosis- broad, thin-walled hyphae, aseptate, branched at right angles Potassium iodide drug of choice, other Antifungals

15 Humanitarian mission in Darfur.
Several men have similar appearing painless swollen feet

16 Mycetoma (“fungal tumor”)
Madura foot, maduramycosis. Sites of minor trauma and exposure to decaying wood. Foot/leg (75%), upper back. Clinical triad of : Tumefaction, Draining sinuses, & Extruded grains Etiology and treatment: True fungal vs bacterial Madura foot, maduramycosis. Sites of minor trauma and exposure to decaying wood Foot/leg (75%), upper back Clinical triad of : Tumefaction, Draining sinuses, & Extruded grains Etiology and treatment True fungal vs bacterial Mexico, senegal, sudan, somalia

17 Mycetoma Progressive swelling with sinus tracts and grains
Culture and Biopsy Actinomycetoma: PCN, sulfonamides Eumycetoma: Combo surgery and Antifungal therapy Actinomycetoma (bacteria) and eumycetoma (variety of fungi), produce light, red, or dark grains depending on organism, triad: tumefaction, sinuses, granules

18 Infestatations and Cutaneous Ectoparasites
Lice Scabies Tungiasis Cutaneous larva migrans Myiasis Cercarial Dermatitis

19 Head lice

20 Pediculosis pubis (crab lice)
Louse grabs hairs, bites skin, cements nits to hairs Can be on any body hair, including eyelashes Look for other STD’s

21 Pediculosis pubis Permethrin cream Coat eyelashes with vaseline bid

22 Scabies Itching often worse at night Close contacts also itchy
Papules and burrows: webs, wrists, waist and willie

23 Scabies

24 Scabies mite burrows in epidermis
Scrape to see mite, eggs, or poop

25 Crusted scabies Wear gloves!

26 Scabies Sarcoptes scabies
Treatments – permethrin, lindane, benzyl benzoate, crotamiton, malathion, topical sulfur, ivermectin

27 21yo soldier returns military exercise in Guyana
Guyana south america, ghana- africa

28 Tungiasis, Sand Flea (Tunga penetrans)
Female burrows into skin (usually foot) Progression of painful red spot to papule to nodule with black dot (anal/genital area of flea) to pearl-like papule (with eggs) to black keratotic crust

29 Gravid female burrows into flesh, leaving uterine pore open
Tungiasis

30 Tungiasis Life cycle of 2-4 mm flea is 5-6 weeks
Infestation self-limited if not reinfected Rare osteomyelitis/ gangrene Sub-Sahara, Caribe, Mexico, S. America Surgical removal of fleas

31 Tungiasis Tunga penetrans, Sand flea, jigger Painful
Curettage or Excision, Topical ivermectin or thiabendazole, Oral thiabendazole for heavily infested Impregnanted fleaburros into skin,eggs develop

32 at Flight Surgeon Course in Pensacola
28yo Navy physician – at Flight Surgeon Course in Pensacola

33 Cutaneous Larva Migrans (Creeping eruption)
Pruritic, serpiginous lesion migrates 2-4 cm /day on feet or buttocks

34 Creeping Eruption (Cutaneous Larva Migrans)
Dog or cat hookworm larvae Beach; sandboxes Unlike human hookworms, dog/cat hookworms cannot penetrate fully and usually die within 2 months Larva migrates ~ 2 cm/day Course: self-limited 1-6 mos Rx: topical thiabendazole or single dose of oral ivermectin 34

35 Myiasis Infestation of human tissue by fly larva

36 Myiasis Painful, boil-like lesion with central punctum (respiratory pore) Exposed skin “obnoxious infestations both medically and esthetically”

37 New World Myiasis Dermatobia hominis Human Botfly Female glues eggs to
When vector bites, larva emerges from egg inot skin, painful furuncle develops Dermatobia hominis Human Botfly Female glues eggs to mosquito, stablefly, or tick

38 . . . and how do you know? Removal- injection of local anesthetic causes larva to bulge outward, also vaseline occlusion of opening of furuncle causes larva to migrate outward

39 African tumbu fly Mango fly Mputsi fly
Old World Myiasis Fly deposits eggs on ground or clothing Young maggots penetrate skin African tumbu fly Mango fly Mputsi fly More likely to develop plaque type myiasis Cordylobia anthrophaga

40 Larval Stage of Tumbu or Bot Fly (Africa, Latin America)

41 Cercarial Dermatitis (Swimmer’s itch)
Transient pruritic papular or urticarial eruption on exposed skin Resolves in 7-10 days after fresh water snail exposures (schistosomal larvae penetrate the skin)

42 Cutaneous Anthrax Clinical Progression
Painless, pruritic papule Juicy papule Bulla (48 hours) Bulla ruptures/early ulcer Eschar with raised border ‘Jet black’ eschar Minimal scarring Lesions of cutaneous anthrax inevitably follow a predictable course after toxin has been released into the skin. After a 7 day latency (range 1-12 days, record = 56 days), a macule or red papule appears at the site of inoculation. This lesions is non-tender which distinguishes it from a number of other skin conditions. The primary lesion soon forms a vesicle that ulcerates. Vesicles are the best place to find bacilli. Within several days, a 1-5 cm depressed, jet-black eschar forms. Vesicles may develop around this lesion, and edema can be significant. Surprisingly, scarring is usually minimal.

43 Orf Ecthyma contagiosum
Acquired from direct contact with lambs, calves, or goats Spontaneous resolution One week incubation, Resolves in about 6 wks, sheepsorter’s disease, less severe than cowpox

44 Bubonic Plague Rural central and south Africa, central Asia, S America, SW USA Sudden onset flu-like syndrome Painful, swollen, tender lymph nodes (Buboes) IV Streptomycin A suppurative, bubo of the femoral lymph nodes (a), the most common site of erythematous, tender, swollen, nodes in a plague victim. Bubo location is primarily a function of the region of the body in which an infected flea inoculates plague bacilli. (Photo courtesy Ken Gage, Ph.D., CDC, Fort Collins, CO) Ecchymoses at the neck base of a girl with plague. Bandage is over the site of a prior bubo aspirate. These lesions probably gave rise to the title line of the children's nursery rhyme 'Ring around the rosy.' (Reprinted from McGovern TW, Friedlander AM. Plague. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of Chemical and Biological Warfare. Chapter 23 In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: US Department of the Army, Office of the Surgeon General, and Borden Institute; 1997: 493.) Most endemic plague presents with tender, erythematous lymphadenopathy, most commonly in the groin and causes bubonic plague (Greek boubon = groin). Buboes may point and drain spontaneously or may require incision and drainage because of pronounced necrosis.] Drained material should be disposed sterilely to prevent the spread of infection. A lesion is seen at the site of a flea bite up to 10% of the time.

45 Measles (Rubeola) Rarely seen among vaccinated
Major killer in developing world Spread by respiratory route Incubation 9-12 days Immunization highly effective

46 Measles Prodrome: high fever, malaise, URI
Rash begins in hairline of neck/face, then moves down Exudative conjunctivitis Photophobia Severe bark-like cough Koplik’s spots on buccal mucosa Cough, coryza, conjunctivitis, rash, & fever

47 Leprosy/Hansen’s Disease
Chronic disease caused by M. leprae Peripheral nerve (sensory loss), skin, and upper airway mucosal involvement Asia, Caribbean, the Americas, S. Europe, Australia, Africa Incubation period 3 mos to 40 years Rifampin, Dapsone, Clofazimine

48

49 Leprosy Sensory Motor Auto-amputation Mycobacterium leprae
Claw-hand deformity Lepromatous leprosy

50 Lepromatous Leprosy Nodular infiltrations can destroy underlying structures (saddle nose deformity, leonine facies) Sensory loss over distal limbs

51 Borderline Leprosy Numerous lesions, annular
Symmetrical nerve involvement appears later

52 Tuberculoid leprosy Hypopigmented saucer shaped single (max 2-3)
Numbness, pain, tingling, muscle weakness

53 Mycobacterium tuberculosis
Inoculation from exogenous source (primary inoculation TB, Tuberculosis cutis verrucosa) Endogenous cutaneous spread (Scrofuloderma, tuberculosis cutis oroficialis) Hematogenous spread (Miliary TB, Lupus vulgaris) Tuberculids (erythema induratum) Tb increasing worldwide, 30-60% adults affected in developing countries, Cutaneous forms,

54 Scrofuloderma Tuberculous involvement of the skin by direct extension from underlying lymphadenitis

55 Skin lesions in returned travellers (n=4742)
Cut. larva migrans 9.8% Insect bite 8.2% Skin abscess 7.7% Infected insect bite 6.8% Allergic rash 5.5% Rash, Unknown 5.5% Dog bite 4.3% Superficial fungal 4.0% Dengue 3.4% Leishmaniasis 3.3% Myiasis 2.7% Spotted fever 1.5% Scabies 1.5% Int J Infect Dis 2008; 12(6)


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