Twenty Skin Infections that an I t i t Sh ld K Internist Should Know

Twenty Skin Infections that an I t i t Sh ld K Internist Should Know

Twenty Skin Infections that an
I t i t Sh
Internist
Should
ld K
Know
Ana Paula Velez, MD, FACP
Assistant Professor
University of South Florida
Objectives
• 1. Identify the most and challenging skin
infections commonly encounter in the
outpatient and inpatient practice
• 2. Recognize
ecog e so
some
e co
complications
p cat o s
associated with skin infections
• 3.
3 Formulate medical or surgical
treatment plan for these infections
Case 1
Impetigo
• Group A Streptococcus and S. Aureus
• Blisters or ulcers
• “Candy like crust” Group A Streptococcus
• “Varnish
Varnish like
like” bullous,
bullous S.
S aureus
• Culture under the crust
• Acute Glomerulonephritis
• Not Acute rheumatic fever
Case 2
ERYSIPELAS
A.
B
B.
C.
D
D.
E.
F
F.
group A strept >> group C or G or B
70-80% lower extremity
5-20% on face
lymphedema
recurrence rate 30% in 3 years
peau D’orange,
D’
well
ll demarcated
d
t d elevated
l t d
border, dermal involvement
Erysipelas
• Bright red, edematous
• Advancing, raised, sharply demarcated
border
• Systemic toxicity: fever
fever, leukocytosis
• Group A streptococci if nonpurulent
• S.
S aureus if purulent
l
CELLULITES
1) SQ tissue
2) SA, GAS
3) Indistinct border not elevated
Cellulitis (continued)
4. GAS/Clostridia surgical
g
wound infx 6-48 hr
incubation
5 SA SWI> 48 hr incubation
5.
6. tinea pedis portal of entry
7. recurrent cellulites grp B or G – esp ? GU malig.
8 saphaneous
8.
h
vein
i hharvest site
i – recurrent cellulitis
ll li i
9. rec. Rx ppen augmentin,
g
, keflex,, clinda,, levo
Bite vs Furunculitis ( Case 4)
CMRSA
• Sharing personal items
• Skin cuts, abrasions (sports, military
recruits)
• Skin to skin contacts(MSM,
contacts(MSM sports
participants, correctional facilities)
• Crowding(correctional facilities,
facilities day care)
NECROTIZING FASCIITIS
1 Type
1.
T
I
a) anaerobes (Bacteroides, peptostrepto)
b) anaerobic streptococci
c) GNR (E.coli, Enterobacter, Kleb)
NECROTIZING FASCIITIS
2. Type II
a) grp A strept
b) occ Staph a
c) risks – trauma,
trauma diabetes,
diabetes PVD
PVD, cirrhosis
cirrhosis,
steroids
d) toxic shock-like
shock like syndrome – hypothermia,
hypothermia
shock  MS, MSOF, CPK, localized
erethema 30% mortality
y yyoungg healthyy adults
after minor trauma
3. Anesthesia of area involved
Necrotizing Fascitis
• Macule
• Pain
• Red
• Edema
Bullae
Numb
Blue
Blue--grey
Crepitance
Therapy
• Surgical emergency
• Betalactam/beta
Betalactam/beta
/beta--lactamase inhibitor plus
clindamycin with an agent with activity
against
aga
st MRSA
S
• Intravenous Immunoglobulin
Intravenous Immunoglobulin
• Binds toxin presenting TT- cell receptor
activation
• Most experience in streptococcal shock
sy d o e
syndrome
CLOSTRIDIAL CELLULITIS
a))
b)
c))
d)
e)
C. perfringes,
C
fi
C
C. septicum
ti
traumatic wounds
i b i – severall days
incubation
d
crepitus
muscle normal (Clostridial gangrene muscle
involved)
f) pcn/clinda/blactam/BI/carbapenom
/ li d /bl
/ / b
g) (gas also produced by E.coli, Kleb, Aeromonas)
Vib i vulnificus
Vibrio
l ifi





Saltwater exposure within the past 7 days.
In US,, mainlyy states bordering
g Gulf of Mexico.
April through October.
Highest fatality rate in liver disease.
Occupation risk


Dock worker, oyster schucker, commercial fisherman
Tx with cefotaxime, doxycycline or quinolone.
SPONTANEOUS, NONTRAUMATIC
GAS GANGRENE C
C. SEPTICUM
a))
b)
c)
d)
e)
f)
colon cancer 88%
diverticulitis
bowel infarction
neutropenic enterocolitis AGC <500
volvulus
mortality 67-100% (most in 24 hrs)
Neutropenic
Enterocolitis
p
(Typhlitis)
• RLQ rebound tenderness
• CT abdomen thicken ileocecum
• Ileus or diarrhea
• Neutropenia day 55--21
• Pathogens: Clostridia septicum, GNR’s
rarely
l Candida
C did and
d molds
ld
• Rx: Flagyl, Zosyn, Meropenem,
Clindamycin
Fournier Gangrene
Case 8
P
Pseudomonas
d
aeruginosa
i



Hot tub folliculitis
Appears 1-3 days after
exposure
Predisposition





Length of time in water
Increased number of
bathers
H
Hypochlorination
hl i ti
Resolves spontaneously
Not contagious
contagious.
FOLLICULITIS
A. SA (beard – sycosis barbae)
B. PSA whirlpool/hot tub/swimming
pool
C. Candida
D. Malassezia furfur
E. Eosinophilic pustular folliculitis
Tina
What are the top
p3
dermatophytes??
dermatophytes
• Trichophyton rubrum
• Microsporum canis
• Epidermophyton floculosum
ERYTHRASMA
11.
2.
3.
4.
Corynebacterium
C
b
i
minitissimum
i ii i
Coral pink flourescence – woods lamp
Eythro x 7 days topical clinda
Groin R/O tinea cruris
NODULAR LYMPHANGITIS
11.
2.
3
3.
4.
5.
Sporotrichosis
S
t i h i (sphagnum
( h
moss)(itraconazole)
)(it
l )
Nocardia brasiliensis
M b
Mycobacterium
i
marinum,
i
chelonei,
h l i ffortuitum
i
Francesella tularensis
Leishmania braziliensis
Mycobacterium marinum—”Fish
T k Granuloma
Tank
G
l

Acquisition




Single ulcerated lesion



Before 1962--hypochlorinated swimming pools.
After 1962--cleaning aquariums.
Also crab bites, sea-urchin spines
Sporotrichoid pattern lymphatic spread.
Diagnosis delayed
Tx for 3-12 months.

C
Clarithromycin,
y , doxycycline,
y y
, septra
p or
rifampin +ethambutol
M
Mycobaterium
b t i
fortuitum
f t it





Atypical, rapidly growing AFB.
Associated with p
pedicures or foot baths.
Causes lower extremity furunculosis.
Most heal spontaneously but some scar.
Could tx with ciprofloxacin, clarithromycin or
doxycycline.
y y
RGM Outbreaks
•
•
•
•
•
•
•
•
•
Naill salon
l whirlpool
h l
l footbath
f b h in CA
C
M fortuitum furunculosis
61 patients
Mean disease duration 170 days (41(41-336)
48 Rx Abx median 4 mo (1
(1--6 mo
mo))
Sensitvity most to cipro and minocycline
Earlier Rx = shorter duration of disease
1 pateint had lymphatic dissemination
CID 2004;38:38
2004;38:38--44
RGM Outbreaks
• Nail salon whirlpool footbath in CA
• M fortuitum furunculosis
• 110 patients
• # of boils median 2 (1(1-37 range)
• Shaving legs with a razor before pedicure
was a risk
i k ffactor ffor iinfection
f i
• NEJM 2002;346:13662002;346:1366-71
RGM Outbreaks
• Facelifts (Rhytidectomies
(Rhytidectomies)) in NJ
• Outpatient surgical center
• 4 patients with M chelonae infection
• Contaminated methylene blue used as a
tissue marking agent
• MMWR 2004;53:1922004;53:192
2004 53 192-4
RGM Outbreaks
•
•
•
•
•
•
•
•
•
Lipotourists from
f
US
S to DR 2003
2003--4
8 healthy Hispanic females underwent abdominoplasties
Sx developed
p median 7 weeks (1(1
( -18 wks)
wks)
Presented with painful, red, draining SQ abdominal
nodules
2 of 8 correctly diagnosed at presentation
7 I and D’s
6 Combo Abx macrolide and IV abx cefoxitin,
cefoxitin, imipenem,
imipenem,
amikacin, and/or linezolid
amikacin,
All but 1 cured after median 9 mo (2(2-12 mo)
mo)
CID 2008;46:1181
2008;46:1181--8
Atypical HSV Presentations
• Linear Erosive Herpes Simplex Virus
Infection in Immunocompromised
Patients. It can be seen in the mouth or
genitals
• The “Knife“Knife-Cut Sign”
• Intertriginous fissures
• Clinical Infectious Diseases 2008;47:1440–
2008;47:1440–
1441
What is the Rx of acyclovir
resistant herpes simplex or
p zoster?
herpes
• Foscarnet IV (NEJM 1991;325:551
1991;325:551--5)
• Cidofovir IV (JID 1994;170:570
1994;170:570--2)
• Cidofovir (NEJM 1993;329:968
1993;329:968--9,
JID
1997;176:892-8)
1997;176:892• Imiquimod (Am J Med 2006;119:e92006;119:e9-11, Arch
Derm 2001;137:1015
2001;137:1015--17)
• Trifluridine (JAIDSHR 1996;12:1471996;12:147-152)
• Interferon alfa and Trifluridine (Arch Derm
1995;131:24--5
1995;131:24
Case 16
Hutchinson’s
Hutchinson s sign
1)Jonathan Hutchinson
(1828-1913)
2) HZ of tip of nose likely to
also involve the eye
3)Nasal branch of the
nasociliary nerve
Case 18
Case 19
Case 20
Non
Non--infectious skin conditions
Most common bacterial causes
of erythema nodosum
•
•
•
•
•
•
•
Streptococcus
p
infections
TB
Yersinia
Mycoplasma
LGV
Salmonella
C
Campylobacter
l b
What is the most common
fungal cause of erythema
nodosum
• Coccidiodomycosis
• Histoplasmosis
• Blastomycosis
What is the most common drug
g
cause of erythema nodosum
• Oral contraceptives
• Sulfa
• Halides (gold, iodines)
iodines)
Do not forget
forget…
References
•
•
•
•
•
•
•
•
Dennis L. Stevens,1,3 Alan L. Bisno,5 Henry F. Practice Guidelines for the Diagnosis and
Management of Skin and SoftSoft-Tissue Infections. Clinical Infectious Diseases ; 2005 ; 41 : 1373 1406
Siberry GK,
GK Tekle T,
T Carroll K,
K et al.
al Failure of clindamycin treatment of methicillinmethicillin-resistant
Staphylococcus aureus expressing inducible clindamycin resistance in vitro. Clin Infect Dis. 2003
Nov 1;37(9):1257
1;37(9):1257--60
Richard L Oehler,
Oehler, Ana P Velez, Michelle Mizrachi,
Mizrachi, et al. BiteBite-related and septic syndromes caused
by cats and dogs. Lancet Infect Dis 2009; 9: 439–
439–47
Winthrop KL, Albridge K, South D, et al. The clinical management and outcome of nail salonsalonacquired Mycobacterium fortuitum skin infection. Clin Infect Dis. 2004 Jan 1;38(1):381;38(1):38-44.
Winthrop KL, Abrams M, Yakrus M, et al. An outbreak of mycobacterial furunculosis associated
with footbaths at a nail salon. N Engl J Med. 2002 May 2;346(18):1366
2;346(18):1366--71.
Mycobacterium chelonae Infections Associated with Face Lifts --- New Jersey, 2002
2002—
—2003.
MMWR 2004;53:1922004;53:192-4
E. Yoko Furuya,1,a Armando Paez,5,a Arjun Srinivasan
Srinivasan,, et al. Outbreak of Mycobacterium
abscessus Wound Infections among ““Lipotourists
Lipotourists”” from the United States Who Underwent
Abdominoplasty in the Dominican Republic
Republic. CID 2008;46:1181
2008;46:1181--8
Jeffrey I. Cohen. Herpes Zoster. N Engl J Med 2013; 369:255
369:255--263