2Staphylococcal Infections General20% of adults are nasal carriers.HIV infected are more frequent carriers.Lesions are usually pustules, furuncles or erosions with honey colored crust.Bullae, erythema, widespread desquamation possible.Embolic phenomena with endocarditis:Olser nodesJaneway Lesions
3Embolic Phenomena With Endocarditis Osler nodesJaneway lesion
4Superficial Pustular Folliculitis Also known as Impetigo of BockhartPresentation: Superficial folliculitis with thin wall, fragile pustules at follicular orifices.Develops in crops and heal in a few days.Favored locations:Extremities and scalpFace (esp periorally)Etiology: S. Aureus.
5Sycosis Vulgaris (Sycosis Barbae) Perifollicular, Chronic , pustular staph infection of the bearded region.Presentation: Itch/burn followed by small, perifollicular pustules which rupture. New crops of pustules frequently appear esp after shaving.Slow spread.Distinguishing feature is upper lip location and persistence.Tinea is lower.Herpes short livedPseudofolliculitis Barbea ingrown hair and papules.
7Sycosis LupoidesStaph infection that through extension results in central hairless scar surrounded by pustules. Pyogenic folliculitis and perifolliculitis with deep extension into hair follicles often with edema.Thought to resemble lupus vulgaris in appearance.Etiology: S. Aureus
8Treatment of Folliculitis Cleansing with soap and water.Bactroban (Mupirocin)Burrows solution for acute inflammation.Antibiotics: cephalosporin, penicillinase resistant PCN.
9FurunculosisPresentation: Perifollicular, round, tender abscess that ends in central suppuration.Etiology: S. AureusBreaks in skin integrity is important.Various systemic disorders may predispose.Hospital epidemics of abx resistant staph may occurMeticulous hand washing is essential.
12Furunculosis Treatment of acute lesions ABX may arrest early furuncles.Incision and drainage AFTER furuncle is localized with definite fluctuation.No incision of EAC or nasal furuncles. TX with ABX.Upper lip and nose ,‘danger triangle’, requires prompt treatment with ABX to avoid possible venous sinus thrombosis, septicemia, meningitis.
13Treatment of Chronic Furunculosis Avoid auto-inoculation, Eliminate carrier state.Nares, axilla, groin and perianal sites of colonization.Use Anti-staph cleansers – soap, chlorhexidine.Frequent launderingBactroban to nares of pt and family membersBID to nares for one week (q 4th week.).Rifampin 600mg QD for 10 days with cloxacillin 500 mg QID (or Clindamycin 150mg qd for 3 mo)
14Pyogenic ParonychiaPresentation: Tender painful swelling involving the skin surrounding the fingernail.Etiology: Moisture induced separation of eponychium from nail plate by trauma or moisture leading to secondary infection.Often work relatedBacteria cause acute abscess formation, Candida causes chronic swelling.Treatment:Avoid maceration / traumaI&D of abscessPCN, 1st Gen Cephalosporin, augmentin.Chronic infection requires fungicide and a bactericide.
17Other predominately Staph Infections. BotrymycosisPresentation: Chronic, indolent d/o characterized by nodular, crusted, purulent lesions.Sinus tracts discharge sulfur granules. Scaring.Uncommon disorder. Altered immune function.S. Aureus most common. (Pseudo, E-coli, Proteus, Bacteroides, Strep.)PyomyositisS. aureus abcess in deep, large striated muscle.Most frequent location is thighOccurs in tropics and in children as well as AIDS pts.Not associated with previous laceration.
19Impetigo ContagiosaPresentation: 2mm erythematous papule develops into vesicles and bullae. Upon rupture a straw colored seropurulent discharge dries to form yellow, friable crust.Etiology: S. Aureus > S. Pyogenes.Lesions located on exposed parts of body.Group A Strep can cause AGNChildren <6 yrs old.2% to 5%Serotytpes 49, 55, 57, 60 strain M2 most associatedGood prognosis in children.
20Impetigo Contagiosa Treatment PCN, 1st Gen. Cephalosporin.Topical: bacitracin or mupirocin after soaking off crust.Topical ABX prophylaxis of traumatic injury.Reduced infection 47 %Treatment of nares for carriers.
24Bullous ImpetigoPresentation: Large, fragile bullae, suggestive of pemphigus. Rupture leaves a circinate, weepy crusted lesion (impetigo circinata). Collarette of scale present.Affects newborns at the 4-10th days of life. Adults in warm climates
28Staphylococcal Scalded Skin Syndrome. Presentation: Febrile, rapidly evolving generalized desquamation of the skin seen primarily in neonates and children.Begins with skin tenderness and erythema of neck groin, axillae with sparing of palm and solesBlistering occurs just beneath granular layer.Positive Nikolsky’s signEtiology: Exotoxin from S. Aureus infection located at a mucosal surface..Differentiate from TENS by location of blister plane high in epidermis.Treatment as before. Prognosis is good.
31Toxic Shock Syndrome Acute, febrile, multisystem disease. Causes: One diagnostic criteria is widespread maculopapular eruption.Causes:S. Aureus : cervical mucosa historically in early 1980’s. Also: wounds, catheters, nasal packing. Mortality 12 %.Group A Strep : necrotizing fasciitis. Mortality 30%.Diagnosis: CDCTemp >38.9C, erythematous eruption with desquamation of palms and soles 1-2 wks after onset. HypotensionAND involvement of three of more other systemsGI, muscular, renal, CNS.AND Test for RMSF, Leptospirosis and rubeola as well as blood urine and CSF should be negative.
32Toxic Shock Syndrome Treatment: Systemic ABX, Fluid therapy Drainage of S. Aureus infected site.
34EcthymaPresentation: 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 scaringGangrene in predisposed individuals.Treatment: Clean, topical and systemic ABX.
36Scarlet 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 pallorDesquamation of palms and soles at appox two wks.May be only evidence of disease.Other: strawberry tongueCauses: erythrogenic exotoxin of group A Strep.Culture to recover organism or use streptolysin O titer if testing is late.TX: PCN, E-mycin, Cloxacillin.
41ErysipelasPresentation: 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 lymphaticsCause: Group A strep., (Group B in newborns)Differential:Contact derm: more itching little pain.Scarlet fever: widespread punctate erythemaMalar rash of Lupus and Acute tuberculoid Leprosy: Absence of fever pain and leukocytosis.Treatment: Systemic PCN for 10 days.
45CellulitisPresentation: Local erythema and tenderness which intensifies and spreads. Often associated with a discernable wound. Lymphangitis, fever and streaking may accompany the infection.Group A strep and S. Aureus are usually causative.Gangrene and sepsis possible particularly in compromised pt.Treatment: PCNase – resistant PCN, 1st Gen Ceph.
48Necrotizing 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 casesPoor prognostic factors: Age >50, DM, Atherosclerosis, involvement of trunk, delay of surgery >7 days.
49More Staph and Strep Infections Blistering Distal dactylitisSuperficial blisters on volar fat padsTypical pt is 2-16 yrs oldPerianal DermatitisSuperficial, perianal, well demarcated rim of erythema which is often confused with a dermatitis.Typical pt is 1-8 yrs old.Group B infectionConsider in any neonates. Also seen in adults with DM and peripheral vascular disease.Staph Iniae1997 first reportedCellulitis of hands assoc with preparation of tilapia fish.
52Erysipeloid of Rosenbach. Presentation: Purple, often polygonal, sharply marginated patches occurring on the hands. The central portion of the lesion may fade as the border advances. New purplish patches appear at nearby sites ( or possibly distant sites).Causative agent: Erysipelothrix Rhusopathiae. Rod shaped grm (+) that forms long branching filaments. Culture on media fortified with serum at room temp.Organism found on dead animal matter and the affliction is seen most commonly among fishermen, veterinarians, and in the meat packing industry (esp pork)Treatment: PCN 1.0 gm/day 5-10 days.
54AnthraxThree forms:Cutaneous 95% of cases.InhalationGICutaneous presentation: Inflammatory papule rapidly becomes a bulla surrounded by intense erythema which spontaneously ruptures purulent or sanguineous contents. A dark brown eschar surrounded by vesicles then develops with induration. Regional lymph glands then enlarge and frequently suppurate. The lesion is not tender or painful.Mild cases - gangrenous skin sloughs and eschar heals.In severe cases erythema and extensive edema develops. Lesions appear at other sites. Fever, prostration and death (20% of untreated cases.)
55AnthraxHuman infection generally from infected animals. Human to human transmission is possible.Diagnosis: smear with gram stain and cultures of wound.Gamma bacteriophage to identifyMice serum titer.Electrophoretic immunoblots.Treatment: PCN G 2 million units IV q 6 hours for 4-6 days followed by oral PCN for 7-10 days.
61Listeriosis Listeria Monocytogenes Ubiquitous organism which usually causes meningitis of encephalitis.Rare cutaneous affliction causing erythematous, tender papules and pustules with lymphadenopathy, fever and malaise.Risk to immunosuppressedNeonates: Granulomatosis infanta peptica.May be missed on bacteriologic exam. Serologic test useful.Treatment: sensitive to most ABX.
62Cutaneous DiphtheriaCorynebacterium Diphtheriae infection in unimmunized individualPresentation:Ulcer with a hard rolled border with a pale blue tinge. A leathery gray membrane often coves the lesion.Eczematous, impetinginous, vesicular or pustular scratches.Paralysis and cardiac complication from Diphtheria toxin are possible.Common in tropical areas with most U.S. cases from unimmunized migrant workers.Treatment: Diphtheria antitoxin, E-mycin is DOC. Also rifampin and PCN.
63Desert SoreUlcerative disease endemic amongst bushmen and soldiers in Australia.Presentaion: Grouped vesicles on extremities which rupture to form superficial, indolent ulcers that may be 2.0 cm in diameter.Cause: Staph, Strep and Corynebacterium Diphtheria.Treatment: Diphtheria antitoxin if organism present and topical ABX with oral PCN or E-mycin.
64Tropical Ulcer Presentation: Inflammatory papule with vesiculation and ulcer formation frequently with undermined edges.Pseudomembrane may be present or simply crusting.Minimal distress other then mild itching.AutoinnouculationUsually single lesion on one extremity.Most common in native laborers or school children during the ‘rainy season’.Usually occur at sites of cutaneous injury.
65Tropical UlcerEtiology: Many organisms found under description of ‘topical ulcer’:Bacteriodes Fusiformis, spirochetes, anaerobes.Differential:Vascular ulcersArteriosclerotic ulcer – deep to expose fascia and tendons.HTN ischemic ulcer – shallow, painful mid to lower legs.Venous ulcers – shallow, varicosities. Above medial malleolus.Other:Desert ulcer – C diptheriaeGummatous ulcer – punched out, other syphilis signs.Tuberculous ulcer – not usually on leg.Mycotic ulcer – nodular with fungi on inspection.Buruli ulcer – Mycobacterium ulcerans.Leshmania ulcer – contans Leishmania tropicans, not on leg.Ulcer of blood abnormalities.
68ErythrasmaPresentation: sharply delineated, dry, brown, slightly scaling patches located in intertrignous areas esp the axillae, genitocrural crease and webs of 4-5 toes. Rarely, widespread lesions will occur with lamellated plaques.Lesion are generally asymtomatic except for the groin where minor itching may be reported.Extensive involvement is associated with DM and other debilitating disease.Etiology: Corynebacterium Minutissimum.Diagnosis: Woods lamp – coral red.Treatment: e-mycin 250 qid x 7 days. Tolnaftate, miconazole, e-mycin, clindamycin topicals also effective.
71IntertrigoPresentation: Superficial inflammatory dermatitis where two skin surfaces are in apposition.Etiology: Friction and moisture allows infection by bacteria (Staph, Strep, Pseudo.) or fungi or both.
75Pitted KeratolysisPresentation: Thick weight bearing portions of the soles gradually covered by asymtomatic round pits 1-3 mm in diameter. Pits may become confluent forming furrows. Rarely, palms may be affected.Etiology: unknown. Micrococcus sedentarius in synergy with corynebacteria is suspectedMen with sweaty feet are most susceptible.Treatment: Topical E-mycin, clindamycin. Miconazole, benzoyl perioxide gel, AlCl solution.
78Gas GangrenePresentation: Several hours after a patient receives a deep laceration, severe pain and wound site crepitance develop as well as fever, chills and prostration. A mousy odor is characteristic.Etiology: (2 types)Clostridium types: perfringens, oedematiens, septicum and haemolyticum. Acute onset !Peptostreptococcus. Delayed onset up to several days.Treatment:Clostridium: Wide debridement and PCN G, hyperbaricPeptostreptococcus: Surgical debridement limited to glossy necrotic muscle.
80Chronic Undermining Burrowing Ulcers ( Meleney’s Gangrene) Presentation: Pt who recently (1-2 wks) underwent surgical drainage of a peritoneal or lung abscess develops carbunculoid appearance at the sutures or wound site. The lesion then differentiates into three zones: outer zone- bright red, middle zone-dusky purple, inner zone-gangrenous with central areas of granulation tissue. Pain is excruciating.Etiology: Peptostreptococcus in periphery. S. Aureus or Enterobacteriaceae in zone of gangrene.Bacterial synergetic gangreneDifferential: gangrenous ecthyma (pseudomonas), amebic (liver abscess associated), Pyoderma gangrenosa (no bacteria)Treatment: Wide excision with ABX (PCN and aminoglycoside).
81Fournier’s Gangrene of the Penis and Scrotum Presentation: Gangrenous infection of penis, scrotum or perineum which spreads along fascial planes.Etiology: Group A Strep or mixed organism.Ages 20-50Culture for aerobic and anaerobic organisms.Treatment: ABX as indicated.