Viruses, , and Fungi of The Chrissy Mitchell, MD University of Florida Human Herpes Viruses • HHV1- HSV 1 • HHV2- HSV 2 • HHV3- Varicella Zoster • HHV4- EBV • HHV5- CMV • HHV6- • HHV7- Roseola • HHV8- Kaposi’s, Castleman’s, primary effusion lymphoma 4 HSV-1 • Primary is usually oral gingivostomatitis • HSV-1 may be triggered by , sunburn, trauma (peel/), or stress • Usually preceded by a of pain or tingling hours before eruption

6 HSV-1 • Usually affects the vermillion border but may also involve other areas of skin

7 • Herpes Gladiatorum is a sports related infection usually affecting wrestlers

• HSV1 primary infection that involves extramucosal sites

• Usually affects the face, neck, upper body

Neonatal herpes

Courtesy of Dermatlas.org Neonatal Herpes • Neonatal Herpes results from infection acquired during vaginal birth • Most mothers have subclinical shedding of virus • Treatment is suppressive therapy for the mother or C-section in women with genital HSV • Associated with increased morbidity and mortality for the newborn • Treatment is IV acyclovir

Herpes associated EM

Courtesy of Dermatlas.org Herpes Associated EM • Presents 7-10 days after HSV infection with typical EM on extremities that may spread centripetally • Self-limited disease • Treat with suppressive antiviral therapy to decrease recurrent disease

Herpes vegetans as a sign of HIV infection

Anisha B Patel MD, Ted Rosen MD Online Journal 14 (4): 6 Verrucous HSV • Chronic ulcerative herpes infections are more common in HIV/immunocompromised patients • May appear verrucous and cancerous • Has been noted on the digits, genitalia, and buttocks • The treatment in acyclovir resistant cases due to mutant viral thymidine kinase of HSV is foscarnet or cidofovir courtesy of dermatlas.org • Eczema herpeticum (Kaposi varicelliform eruption) • Disseminated HSV: upregulated IL-4 downregulates anti-viral response • Seen in patients with skin barrier dysfunction (AD, Darier’s, , Hailey-Hailey, foliaceus) • May be life threatening

Dewdrop on a rose petal

18 19 Varicella • Varicella is the initial infection • Virus lies dormant in dorsal root ganglion • 7-21 day • has a truncal predominance • May result in pneumonitis particularly in cases of immunocompromised patients and adults

20 21 VZV • 75% of cases have a prodrome of pain or paresthesia • Almost always dermatomal • Macules to to vesicles to hemorrhagic crusts • Lesions are infectious until crusted and healing

22 23 VZV • Treatment is oral or IV antivirals • IV acyclovir is warranted if patients have HIV, , widespread disease or visceral involvement • Visceral involvement is more common in immunocompromised patients and may manifest with encephalitis, hepatitis, pneumonitis • Antivirals require renal dosing • Systemic steroids do not alter the development of PHN

24 Hutchinson Sign

Courtesy of Medscape.com • Zoster of the V1 dermatome may cause keratitis and blindness.

• Hutchinson’s sign: Involvement of the nasociliary branch of opthalmic nerve (V1) may cause vesicles at the tip of the nose

Hutchinson’s sign

27 Courtesy of Dermatlas.org 28 Courtesy of Dermatlas.org Ramsay-Hunt Syndrome

Archive of Neuro. 2005;62(11) 1774-1775 Ramsay-Hunt Syndrome • Infection involving the geniculate ganglion

• Zoster involved the ear canal, auricle, and TM

• Vesicles, facial hemiparesis, and ipsilateral hearing loss

Post-herpetic in HIV patient

Fig. 1 Hemorrhagic vesicles along distribution of the 8th cranial nerve on the left hand. Komal F. Chopra , Tanya Evans , Jessica Severson , Stephen K. Tyring

Acute varicella zoster with postherpetic hyperhidrosis as the initial presentation of HIV infection

Journal of the American Academy of Dermatology Volume 41, Issue 1 1999 119 - 121 http://dx.doi.org/10.1016/S0190-9622(99)70419-6 Fig. 2 Moist, glistening areas of hyperhidrosis along the distribution of the 8th cranial nerve on the left hand.

Komal F. Chopra , Tanya Evans , Jessica Severson , Stephen K. Tyring

Acute varicella zoster with postherpetic hyperhidrosis as the initial presentation of HIV infection

Journal of the American Academy of Dermatology Volume 41, Issue 1 1999 119 - 121 http://dx.doi.org/10.1016/S0190-9622(99)70419-6 What is the common thread?

Courtesy of Dermatlas.org EBV (HHV-4)

• Epstein-Barr Virus (HHV-4) • Virus is dormant in B-cells and mucosal epithelial cells • EBV causes mononucleosis, OHL, and is implicated in such as (Hodgkin’s lymphoms, Burkitt’s lymphoma, PTLD, NK T-cell lymphoma) • HHV-4 is a cause of Gianotti-Crosti syndrome and Kikuchi’s disease • Mono treated with ampicillin may result in an impressive morbiliform eruption (not a true drug ) courtesy of dermatlas.org • Oral hairy is seen on the lateral tongue of HIV patients

Atypical Hydroa Vacciniforme-Like Epstein-Barr Virus

Associated T/NK-Cell Lymphoproliferative Disorderr. Lee, Hye; Baek, Jin; Lee, Jong; Park, Sang; Jeon, In; Roh, Joo

American Journal of Dermatopathology. 34(8):e119-e124, December 2012. DOI: 10.1097/DAD.0b013e3181c036de

FIGURE 1 . Clinical features. A, Erythematous ulceronecrotic papules with a puffy face; B, Identical lesions on the trunk; C, Identical lesions on both legs; D, Crusted varioliform atrophic .

© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2 CMV “Blueberry muffin baby” Extramedullary hematopoesis

courtesy of dermatlas.org

• Subclinical infection in healthy people • Severe infection in fetuses and in immunocompromised patients • CMV is the #1 cause of severe birth defects • A cause of the “buleberry muffin baby”

From: Mucocutaneous Presence of Associated With Human Virus Infection: Discussion Regarding Its Pathogenetic Role Arch Dermatol. 2001;137(4):443-448. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-137-4-dst00030

Figure Legend: Perianal condylomata acuminata and chronic ulcers (case 14). A 38-year-old man with condylomata and chronic HSV ulcers of 45 days' duration: CD4 cell count, 6 cells/µL; virus 2 was isolated on culture of the and exudate. Cytomegalovirus was found in the ulcer. Copyright © 2012 American Medical Date of download: 2/10/2013 Association. All rights reserved. CMV • HIV infected patients may have • CMV retinitis • Chronic GI and perianal ulcerations • Treatment of choice is ganciclovir, foscarnet, or cidofovir

Roseola-Berliner’s sign

Palpebral seen during roseola infection Roseola • HHV-6 • The etiologic agent of roseola infantum/sixth disease • Causes a high fever, malaise, irritability (a cause of febrile seizures in infants and toddlers) • Rose pink macules appear after fever breaks • Most children are infected by age 2

45 HHV-8 Kaposi Sarcoma-Associated Herpesvirus • Classic: • AIDS-related • Immunosuppression-associated • African endemic courtesy of dermatlas.org Classic KS • Classic KS- • The most indolent type, slowly growing • Seen in elderly men>>>>>>women from Mediterranean European decent • Predilection for lower extremities, rarely involves GI or oral mucosa courtesy of dermatlas.org AIDS Associated KS • AIDS-Related • Widespread • Seen as macules to plaques on skin and mucosa • Visceral involvement is common • Treatment is HAART Courtesy of Dermatlas.org African Endemic KS • African endemic • Aggressive. • Seen in young African (equatorial) patients • Unrelated to HIV

Human Virus

Type of Frequent HPV Type Common 1,2,4 1 3,10 Butcher’s wart 2,7 Epidermodysplasia verruciformis 2,3,5,8,9,10,12,14,15,17 Focal Epithelial hyperplasia (Heck’s) 13,32 Verrucous 6,11 Condyloma acuminata 6,11 16,18 Subungual SCC 16 EDV associated SCC 5, 8 Cervical/penile/anal SCC 16,18 HPV • HPV is non-enveloped dsDNA virus • More than 100 HPV types • Genome encodes E (early) and L (late) • Viral oncogenes include E6-p53 and E7-pRB • Transmission is from direct skin contact

• was FDA approved for prevention of (and condyloma)

• Quadrivalent composed of L1 capsid protiens with recombinant HPV 6, 11, 16, 18

• Intended for females between ages 9 and 26

• Series of 3 injections at month 0, 2, and 6

55

Courtesy of Dermatlas.org • Subungual SCC- HPV 16

Courtesy of Dermatlas.org • Bowenoid Papulosis • HPV 16>>>18 • Look like genital but are histopathologically consistent with SCCIS

Courtesy of Dermatlas.org “Akerman tumor”

• 3 types: – Oral Florid Papillomatosis: oral cavity carcinoma – Buschke-Lowenstein tumor: anorectal external genital carcinoma – Epithelioma cunniculatum: mass on sole of foot

Courtesy of Dermatlas.org Courtesy of Dermatlas.org • Epidermodysplasia verruciformis • Inherited or acquired susceptibility to HPV • Looks like flat warts • Malignant transformation in 50% of patients

Heck’s Disease •Focal epithelial hyperplasia •HPV -13,-32 •Multiple circumscribed papules on gingival, buccal, lingual or labial mucosa resembling flat warts or condyloma •Common in South American Indians, Greenlander Eskimos or South Africans •Primarily in children Common Disease?

Courtesy of Dermatlas.org

Erythema Infectiosum or FifthCourtesy of Dermatlas.org disease

• ssDNA virus • Infects RBCs via blood group P • Risk of aplastic crisis in immunocompromised patients or sickle cell dx • Infection in young children manifests as infectiosum- infectious before rash appears • Papular purpuric gloves and socks syndrome is seen in older kids and adults

• Infection during pregnancy can cause fetal demise/hydrops due to viral inhibition of erythropoesis

• Reticulocyte count will be decreased during infection

Parvovirus-Gloves and Socks Syndrome

Courtesy of Dermatlas.org Papular Purpuric (petiechial) Gloves and Socks

• Acute self-limited acral dermatosis that appears after parvoB19 infection • May present with edema and erythema as well as pain or pruritis • Resolves after 7-10 days with

Hepatitis C-Associated

Courtesy of Dermatlas.org Necrolytic Acral Erythema

Courtesy of Dermatlas.org Necrolytic acral erythema

• Highly associated with hepatitis C • Well demarcated acral psoriasiform plaques lacking Auspitz sign • May be a subset of necrolytic migratory erythema related specifically to Hep C • Possibly attributed to zinc dysregulation/hypozincemia • Treatment includes INF and ribavarin for hep C and zinc replacement

Necrolytic acral erythema

Courtesy of Dermatlas.org Bitten by an ewe!

Courtesy of Dermatlas.org - Echthyma Contagiousum

• Parapox virus • Fever, lymphadentitis • 6 clinical stages/6days each: maculopapular, targetoid, acute, regenerative, papillomatous, regressive • Self-limited disease with supportive treatment Hand Foot Mouth Disease • HFMD is caused by an enterovirus (fecal-oral) • The most common causes are coxsackie A and enterovirus 71 • Usually affects young children in summer and fall • Fever, diarrhea, punched out erosions of hard palate, and oval vesicular eruption on palms and soles • Recent reports of onychomadesis following infection Onychomadesis in Children Associated with Coxackie A6 Virus

BMC Infect Dis. 2011; 11:346. “Onychomadesis Developed Only on the Nails Having Cutaneous Lesions of Severe Hand- Foot-Mouth Disease”

(a)A large pustule existed around the of the right index , looking like a herpetic .

(b) At four weeks after the disappearance of cutaneous lesions of HFMD, onychomadesis appeared in the nail of the right index finger.

Case Rep Dermatol Med 2011 Trichodysplasia Spinulosa-Associated Polyoma Virus

PLoS Pathog. 2010. July; 6(7) e1001024

• Clinical appearance and histology of the trichodysplasia spinulosa patient. • Facial appearance at presentation is shown in panel A. Note the thickened skin, particularly on the nose and in the eyebrow region accompanied by central alopecia. Apart from the eyebrows and nose, papules are seen on the cheeks, chin, forehead and ears. Especially on the nose, but occasionally also in cheeks and chin, keratotic spicules protruded from the enlarged follicular orifices. Panel B shows a close-up of the nose at presentation with numerous papules and spicules. In panel C is shown a section of a formalin-fixed, paraffin-embedded biopsy of a hyperkeratotic follicular from the forehead. The reveals enlarged, hyperplastic hair bulbs and hypercornification within a distended follicular infundibulum (HE stain, 10×). Panel D shows a detail of the nose 3 months after topical cidofovir treatment. Papules and spicules have largely resolved and hairs have regained growth

PLoS Pathog. 2010. July; 6(7) e1001024 Bacteria Gram + Infections • Staphylococcal Infections • Streptococcal Infections • Corynebacterial Infections • • • Actinomycosis Staphlococcal Infections • • • Furuncle, , • Serious Staph Infections dermatlas.org Impetigo:

• Highly infectious and common in kids • and non-bullous impetigo • Staph aureus is the most common cause of non- bullous impetigo, Group A beta-hemolytic strep is another culprit • is usually caused by Strep pyogenes (lower extremities) dermatlas.org Bullous impetigo: • characteristic in newborn(can be serious and fatal) but can occur anytime. • In warm climates, common in the axillae, groin, or hands. • Majority are caused by Staph aureus phage Group II types 71 or 55 • Cleavage of granular layer due to exfoliative exotoxin (A/B/D) binding to desmoglien 1

Atopic predisposes patients to impetigo and other staphlococcal infections

dermatlas.org • is a of Group A beta-hemolytic strep skin infections • It occurs in 2-5% of cases of strep impetigo (10-15% with nephritogenic strains) (impetigo not URI) • Type 49,55,57, and 60, and strain M-type 2 are related to AGN more common in children under age 6 and better prognosis than in adults. Early treatment reduces the risk of kidney disease • Treatment: systemic and topical therapy

WEBMD.com • Impetigo is common on scalp with head lice infestation

Erosive Pustular Dermatosis What the ____! Occurs after XRT, cryo, ED&C, surgery

Colonized with Staph

Treated with potent topical steroids

Courtesy of archivesderm.jamanetwork.org dermatlas.org Furuncles, , and

• Due to S. Aureus • I&D is the treatment • Antibiotics are warranted if: • The lesion affects the mid face • Very large with • Concern for dermatlas.org • Pyogenic : separation of eponychium from nail plate • Organisms: S. aureus, pyogenes, pseudomonas, proteus, anaerobes, and • In children with , subungual black macules followed by edema have been reported as a sign of osteomyelitis

Chronic paronychia in a thumb sucker

dermatlas.org Mild constitutional symptoms

Face and neck become red first

Trunk and other folds are affected later

Blister: subcorneal

dermatlas.org • SSSS: most common in neonates and young children • Association with renal disease and immunosuppression in adults. • Group 2 phage types 71 and 55 which produce exfoliative exotoxins A, B, and D which cleave desmoglein 1. • The skin redness and peeling is from distant effects of the toxins. • Take cultures from mucous membranes to detect Staph aureus • Treatment is IV abx and supportive care (IV fluids) dermatlas.org SSSS • Presents with fever, , and tender erythematous skin particularly in body folds

• The tender diffuse rash may be associated with crusting or fissuring around mouth, nose or eyes

Note the periorificial crusting and fissuring

Overall ill appearance

dermatlas.org Desquamation in intertrigenous regions

+ Nikolsky

dermatlas.org Streptococcal Infections • Cellulitis • • Blistering Distal Dactylitis • • Perianal Strep • Ecthyma • Courtesy of Dermatlas.org • Erysipelas: St Anthonys fire. • Acute beta-hemolytic group A strep infection involving superficial lymphatics. • Characterised by raised border • Prodrome of malaise, chills, high fever, headache, vomiting, arthralgias. • Distinct advancing edge that is so indurated it may feel like a wall • L shift >20K PMNs. • Legs and face are most common. • Systemic therapy is effective Erysipelas from Strep pyogenes

109 Photo courtesy of nih.gov Fig 1 Familial Mediterranean fever. Erysipelas-like

erythema above ankle of patient’s right leg.

Sonja Radakovic , Gregor Holzer , Adrian Tanew Erysipelas-like erythema as a cutaneous sign of familial Mediterranean fever: A case report and review of the histopathologic findings

Journal of the American Academy of Dermatology Volume 68, Issue 2 2013 e61 - e63

http://dx.doi.org/10.1016/j.jaad.2012.09.038 dermatlas.org Blistering distal dactylitis: • Superficial infection of the anterior fat pad on the volar surface • usually children • Group A beta hemolytic strep or S.aureus • Usually one finger • Histology shows overlapping impetigo and cellulitis

dermatlas.org • Perineal dermatitis: usually perianal strep, resembles a dermatitis more than a cellulitis. • Characterized by well demarcated erythema, with or without fissuring. • Pain with defecation. • Get throat and perianal cultures • Systemic and topical treatment are warranted for 2-3 weeks. Monitor for AGN and re-culture post treatment.

Scarlet Fever • : Diffuse sandpapery erythema • From GAS pharyngitis with (SPE-A/B/C) • Pharyngitis, H/A, fever • Mainly in children

SPE: S. pyogenes exotoxins Courtesy of dermatlas.org • Scarlet fever: exanthema occurring during streptococcal pharyngitis1-2 days after . • Strawberry tongue, cutaneous eruption that begins on the neck, spreads to trunk and extremities with accentuation on skin folds. • Linear petechial eruption on armpits and antecubital fossae are Pastia’s lines • Eruption fades and then they desquamate palms and soles 2 weeks later. • Cause: erythrogenic exotoxin

dermatlas.org dermatlas.org dermatlas.org Know your gyrate !!!! Dermatlas.org Dermatlas.org • Erythema marginatum: delayed sequelae of . • Part of the early phase seen with carditis prior to • Jones criteria: erythema marginatum, carditis, polyarthritis, and chorea Corynebacterial Infections Courtesy of Dermatlas.org and NEJM.org :

• sharply demarcated dry brown to red scaly patches in intertrigineous areas. • More common in DM and other debilitating illnesses. • Caused by minutussumum. • Can be seen as a triad with and trichomycosis axillaris, two other diseases caused by corynebacterium. • Woods light is the diagnostic medium: coral red • Tx: Topical or

Courtesy of Dermatlas.org Pitted keratolysis:

• 1-3mm shallow pits of plantar stratum corneum, • stinky • Kytococcus sedentarius has been implicated. • Bacteria produces 2 serine proteases that degrade • Associated with heat, moisture, occlusion

Erysipeloid: Fish Handler’s Disease

Medicalpicturesinfo.com • Erysipeloid: usually seen with sharply marginated polygonal patches of violaceous/bluish erythema. Spares distal . • Tense making movement difficult, migratory in nature. • Caused by erysipelothrix rhusiopathiae • Present on dead animal matter (pigs, turkeys, saltwater fish and shellfish) • Self limited course 3 weeks. • Culture: biopsy advancing edge Tx: PCN Anthrax • anthracis: gm+ spore forming rod • 3 types: cutaneous, pulmonary, GI • Contains 3 virulence factors – Capsule that inhibits phagocytosis – Edema toxin – Lethal toxin • Biological weapon Anthrax:

• rapidly necrotizing, painless eschar with suppurative regional adenitis. • 3 forms of disease: – cutaneous 95% – inhalation(woolsorter’s dx) – GI. • Death in up to 20% of untreated cases.

• Caused by which has 3 virulence factors: – a)a polyglutamate acid capsule that inhibits phagocytosis, – b)an edema toxin composed o edema factor and protective antigen, – c) lethal toxin composed of lethal factor and protective antigen • easily seen with gram stain • treatment with cipro or doxy for 60 days

Courtesy of Dermatlas.org After 2 days of therapy

Courtesy of dermatlas.org Courtesy of Dermatlas.org Cervicofacial Actinomycosis

Courtesy of medicalpicturesinfo.com Actinomycosis • Actinomycosis: usually cervicofacial actinomycosis. • Usually Actinomyces israelii • Nodule or plaque with draining sinuses. • Grains or sulfur granules may be in exudate. • Sulfur granules are peripherally covered with immunoglobulin (Splendore-Hoeppli’s phenomenon)

More Common Dental Sinus

courtesy of dermatlas.org Gram Negative Skin Infections

Pseudomonas aeruginosa and a bunch of others…… 1.5 cm tender pustules that developed on the thighs of a neutropenic patient with leukemia

Courtesy of Dermatlas.org Courtesy of Dermatlas.org Ecthyma gangrenosum:

• In debilitated people who may have leukemia, burns, neutropenia, cancer or other chronic illness. • Begins with tense vesicles or pustules that quickly become hemorrhagic and rupture to become black eschars. • Common on buttocks and grouped. • Treat with IV abx

Subungual Pseudomonas Infection

Courtesy of Dermatlas.org : • distal onycholysis with greenish discoloration of separated portions. • Can be associated with paronychia. • Green foot syndrome is from colonized shoes. • has the ability to produce various pigment: • Pyocyanin (blue), Fluorescein (yellow-green), and pyomelanin (brown-black)

No, that’s not povidone iodine!

Courtesy of Dermatlas.org • Gram Negative toe web infection: may start with tinea pedis or prolonged immersion

Courtesy of Dermatlas.org Hot Tub Folliculitis: • pruritic follicilutis 1-4 days after bathing in a hot tub, whirlpool , or public swimming pool. • May have associated malaise • Self limited resolved within 1-2 weeks Courtesy of Dermatlas.org Gonnococcemia:

• hemorrhagic vesiculopustular eruptions (usually acral), , arthralgias/arthritis • Severe or recurrent cases may be due to defects in C5, C6, C7, or C8 components) • treatment is ceftriaxone

Purpura Fulminans from Neiserria meningitidis

Courtesy of Dermatlas.org Menningococcemia: • Acute meningococcemia characteristic lesion is angulated infarcted lesion with red rim and gun-metal gray interior. • Chronic meningococcemia(rare) manifests with acral hemorrhagic pustules seen in those with gonococcal sepsis. • Tx: high dose IV PCN • 5-10% of humans carry Neisseria meningitides in their nasopharynx

Dermatlas.net 154 Courtesy of aapredbook.aappublications.org Dog and Human Bites: • Pasturella multocida infections most common infection from cat/dog bites and cat scratches. • Treat with oral antibiotics and vaccine. • Small amounts of othr bacteria such as strep, staph, Moraxella, Neisseria, fusobacterium, bacteroides,make augmentin the choice of treatment. Rickettsial Disease • Spotted Fever Group – Rocky Mountain Spotted Fever – Mediterranean Spotted Fever – • Typhus Group – – Endemic Typhus – Rocky Mountain Spotted Fever

• The prototypical rickettsial spotted fever • RMSF is the most deadly of the spotted fevers • The organism is Rickettsia rickettsii • Transmitted by the bite of an infected tick – The American Dog tick (dermacentor variabilis) – The Rocky Mountain Wood tick (dermacentor andersoni)

Rocky Mountain Spotted Fever

The American dog tick (Dermacentor variabilis)

The Rocky Mountain wood tick (Dermacentor andersoni) of RMSF

• RMSF incubation time 5-10 days • Most patients present to M.D in 1st week of illness • Triad of findings: – Fever (100%) – Rash (80%) – History of tick bite (60%) Signs and Symptoms of RMSF

• Initial symptoms – Fever >102 – N/V – Severe headache – Muscle pain – Anorexia • Initial sign (2-5 days) – Macular, very subtle rash on wrist ankles, + blanching Signs and Symptoms of RMSF

• Later signs and symptoms – Petechial or purpuric rash on day 6 – Abdominal pain – Arthritis – Diarrhea – Renal/Respiratory failure – Vascular collapse Treatment of RMSF

Rule #1: Initiate treatment when you suspect RMSF

Rule #2: Doxycycline is first line 100mg PO/IV q12 or 4 mg/kg/day in children

Rule#3: Yes, doxycyline even for pregnant women

Rule#4: Give an adequate course of treatment ( 10 days minimum) Rickettsialpox • The disease is caused by Rickettsia akari

• The house mouse (Mus musculus) is the natural host of the mite

• The mouse mite (allodermanyssus sanguineus) transmits rickettsialpox to humans • Reports in NYC

Rickettsial pox: • develops as a result of Rickettsia akari which comes from the rodent mite allodermanyssus sanguineus which lives on the house mouse. • The initial lesion is a small mite bite which appears as a vesicle. • A week after the bite a febrile illness develops and a rash resembling varicella spreads 3-4 days into the fever fading within one week. • This disease is self limited resolving within 2 weeks.

Rickettsialpox

• 5-10 day incubation • Eschar forms at bite – Similar to anthrax • Regional LAD • Varicella-like rash 2 days after fever • Self-limiting and resolving

Epidemic Typhus

• Organism: R. prowazekii • Vector: human lice • Natural Host: man • Relapsing Brill-Zinnser Disease • Eruption spreads distally Epidemic typhus: • Body lice harboring Rickettsia prowazekii. • Humans and flying squirrels are the reservoir for disease. • The infected lice feces is scratched into the bitten skin. • Pink macular eruption spreads from trunk rapidly to the rest of the body sparing face palms and soles. • Lesions may become hemorrhagic and gangrenous. Endemic Typhus

Organism: – R. typhi – R. felis Vector: rat flea (xenopsylla cheopsis) Host: rats

Endemic typhus: • rickettsia typhus transmitted to humans by the bite of rat flea xenopsylla cheopis. • Less severe disease that epidemic typhus. • 50% of infected humans have the characteristic rash. • Seen in SE states bordering the Gulf of Mexico Tsutsugamushi Disease

• Organism: Orientia tsutsugumushi • Vector: chiggers/mites • Natural host: rodents • Solely in Asia and Australia

Scrub typhus: • Tsutsugamushi fever characterized by fever, chills, headaches skin lesions and pneumonitis. • Primary lesion site of mite bite( trombiculid red mite/chigger) has a red papule that develops into a necrotic ulcer. • Then days later the macular erythematous eruption spreads from trunk over body. Fungal Infections Courtesy of Dermatlas.org : • Common infection on the scalp of children • (spores within hair shaft) • Ectothrix (spores coat outside of hair destroying the cuticle) +/- fluorescence

• #1 Most common cause of tinea capitis is endothrix T. tonsurans • #2 fluorescent ectothrix M canis (very inflammatory) and then M auodouinii

Courtesy of Dermatlas.org Courtesy of Dermatlas.org

Kerion • Variant of tinea capitis with boggy inflammatory alopetic plaques which may result in scarring alopecia • species tend to couse more inflammation and are associated more with (T. violaceum)

Courtesy of Dermatlas.org Courtesy of Dermatlas.org • T. Tonsurans “black-dot tinea” Courtesy of Dermatlas.org • Favus: rare in US concave sulfur-yellow crusts called scutulae are formed around hairs.

• T. schoeleinii, T. violaceum, M. gypseum

Courtesy of Dermatlas.org Tinea Facei

• Erythematous annular or serpigenous plaques • Not uncommon in children • T. rubrum, T. mentagrophytes, M canis

Courtesy of Dermatlas.org : • Can be difficult to diagnose since annular rings are usually lacking and it is photosensitive. • is common. • Can be confused with .

• : zoophillic species (T verrucosum, and T mentagrophytes) Courtesy of Dermatlas.org • Previously treated with topical steroids for dermatitis

Courtesy of Dermatlas.org • Tinea incognito- very little inflammation

Courtesy of Dermatlas.org Fungal folliculitis (majocchi granuloma) • Usually t rubrum or t mentagrophytes • deep pustular type of tinea resembling kerion or a carbuncle. • Most common on shins or wrists. • Seen in areas of occlusion, shaving, or topical steroid use. Courtesy of Dermatlas.org Tinea Imbricata • superficial fungal infection characterized by concentric rings of scales with polycyclic borders • caused by t concentricum. • Infection is limited to SE asia, india, Polynesia, Central America

Onychomycosis: 4 classic types

1. Distal subungual : T rubrum 2. White superficial onychomycosis: toe nail plate on top surface-T mentagrophytes,cephalosporium, , fusarium (T rubrum in HIV) 3. Proximal subungual onychomycosis: Nail plate from proximal nailfold (T rubrum and t megninii possible indication of HIV) 4. Candida onychomycosis: c albicans desdtruction of nai and nailbed hyperkeratosis

Image courtesy of Dr Antonella Tosti • Distal subungual onychomycosis: • Usually T. rubrum infection of hyponychium Image courtesy of Dr Antonella Tosti • White superficial onychomycosis • Usually due to T. mentagrphytes • Sometimes fusarium or aspergillus

• Note: T. rubrum is noted to cause this infection in HIV patients

Image courtesy of Dr Antonella Tosti • Proximal subungual onychomycosis: nail plate is invaded from upper surface of the posterior nail fold. • Rare • Usually T.rubrum • Seen in HIV patients

Chronic from finger sucking

Image courtesy of Dr Antonella Tosti Image courtesy of Dr Antonella Tosti emedicine.medscape.com • Candida onychomycosis • Seen in patients with mucocutaneous candidiasis • Nail is destroyed and crumbly with nail bed hyperkeratosis

Courtesy of Dermatlas.org • Tinea Manum and Pedis is most commonly due to T. rubrum

• T mentagrophytes interditale presents with 3 clinical appearances: – bullous of the arch and sides of feet – second with erythema and desquamation between the toes. – 3rd is white superficial onychomycosis. • Note: In HIV, white superficial onychomycosis is more commonly caused by t rubrum

Courtesy of Dermatlas.org • Oral thrush seen in infants, children and adults after abx therapy • sign of immunosuppression • may involve corners of mouth (perlesche) Courtesy of Dermatlas.org Erosio interdigitalis blastomycetica

Courtesy of Dermatlas.org Courtesy of Dermatlas.org : - • black -like fungus that is found in hot humid environments. (Gulf coast) • One to several brown, gray or black spots on the palms or soles. • Pigment scrapes off easily since it is confined to the stratum corneum. The pigment produced is melanin. • Dermoscopy can also be used to differentiate from nevi. Dark advancing border Courtesy of Dermatlas.org : • Black piedra (piedra hortai) in the tropics – Scalp hair is most common • T. beigelii/ovoides or T inkin in temperate climates – Beard, axillary, and groin hair Courtesy of Dermatlas.org Sciencedirect.com Courtesy of Dermatlas.org • Tinea versicolor furfur/yeast phase is pityrospurum orbiculare. • The organism produces azelaic acid which blocks melanin synthesis • Facial lesions are more common in infants and immunocompromised people. • Penile lesions are seen in immunocompromised states as well.

Pityrosporum Folliculitis:

Monomorphous follicular papules on face, upper trunk

Tx: topical imidazole vs oral fluconazole or

Courtesy of Dermatlas.org Dermatlas.org Mycetomas • Mycetoma occurs primarily in the tropics and the foot is most commonly involved producing the clinical picture of Madura foot. • True fungi (eumycetic mycetomas) • filamentous bacteria of the order Actinmycetales (actinomycetic mycetoma) • and other bacteria (botrymycosis). • A for and culture for fungi and bacteria are necessary to make a specific diagnosis and select appropriate antibacterial or therapy

222 Deep Mycoses

Most deep mycoses are manifestations of systemic infection acquired from inhalation of fungus contaminated dust

Cutaneous lesions are mostly non-specific suppurative granulomas

Large sporangia with numerous

Courtesy of Dermatlas.org

• Coccidioidomycosis: immitis. • Primary pulmonary disease. Respiratory infection mild flulike illness 60% . XRay findings incude hilar adenopathy and infiltrates compatible with bronchopneumonia. • A generalized eruption may be present. • After several weeks, about 30% of women and 15% of men develop e nodosum which is a favorable prognostic indicator as most people recover spontaneously.

Coccidiodiomycosis • A few progress to a disseminated form. • Disseminated disease is more prevalent in Hispanics, native americans, African americans and some Asians. • Pregnancy is a risk factor for dissemination. • Skin lesions occur in 15-20% of disseminated disease. They may appear as verrucous nodules, pink plaques, or SQ abscesses. Mucosal ulcerations occur in 60% of disseminated

Courtesy of Dermatlas.org Histoplasmosis: • Primary pulmonary histoplasmosis- benign self limited infection. 10% of acutely infected patients develop • Progressive disseminated histoplasmosis: most patients are immunocompromised. • Ulcerations and granulomas of the oronasopharynx are most common mucocuaneous lesions. • Seen mostly in central American states along the Mississippi river basin.

Dermatlas.org Histoplasmosis is a small yeast with narrow based unequal budding. The cell wall stains well with methenamine silver (GMS).

Courtesy of Dermatlas.org Parasitized Histiocytes • • • Histoplasmosis • Leishmaniasis

Courtesy of Dermatlas.org Cryptococcus:

• localized to lung in 90% disseminates in 10% to CNS and skin most commonly. • High incidence of dissemination in HIV patients. • Most common cause of fungal . • Skin involvement occurs in 10-15% of those infected. Predilection for head and neck. • Lesions can be of various morphologies but like lesions are most common

Courtesy of Dermatlas.org • Spores with large surrounding capsules are seen in the tissue

Alcian Blue = Blue staining Mucicarmine = Red staining

Courtesy of Dermatlas.org Single broad based budding

Courtesy of dermatlas.org Verrucous plaques with peripheral pustules on face and mucosa May ulcerate Osteomyelitis in 25% of disseminated cases : • Blastomyces dermatitides almost all cutaneous disease comes from dissemination of a primary pulmonary process. • The lesions are characterized by granulomatous verrucous slowly growing lesions with crusts and discharging sinuses along the edge. • Warty growth is most prominent on face, hands and feet Skin is most common site of dissemination. • Present along Ohio and Mississippi river basisn. M>F

Courtesy of Dermatlas.org South American Blastomycosis • Paracoccidioidal granuloma: paracoccidioides braseiliensis. • Begins with small papules and ulcerations in the mouth then as adjacent tissues are involved ultimately destroy the nose, lips, and face. • Mariner’s wheel is characteristic. • 48:1 more common in men as 17Bestradiol inhibits transition from mycelial form to invasive yeast form

Courtesy of Dermatlas.org : • warty growth that spreads with satellite lesions. Usually on one lower leg. Small lesions may resemble warts. • Most commonly seen in farmers. Caused by dematiaceous fungi. • accounts for 90% of cases in S America. • Characterized by pseudoepitheliomatous hyperplasia and intraepidermal abscesses dermal granulomatous reaction and presence of fungal sclerotic bodies (medlar bodies or copper pennies) pigment is melanin.

Courtesy of Dermatlas.org Dermatlas.org • A 14-year-old girl developed 2 firm nodules at the site of a previous BCG vaccination. A skin biopsy revealed fungal structures typical of Loboa loboi, the agent responsible for also known as keloidal blastomycosis. This deep fungal infection is characterized by slow growing -like nodules or ulcerated verrucous plaques on exposed body sites. This infection is found almost exclusively in Central and South America. It affects humans and dolphins, and has been described as a rare complication in chronic lesions. Histopathology demonstrates extensive granulomatous inflammation, and fungal cells are readily identified both inside and outside of macrophages.

Dermatlas.org Courtesy of Dermatlas.org : • - seen as an occupational disease of gardeners, florists, and laborers from injuries by thorns, straw, or sphagnum moss. • 3 forms – Lymphocutaneous (most common) – Fixed cutaneous – Disseminated Sporotrichoid Spread • Mycobacterium marinum • Sporothrix schenckii • Norcardiosis • Leishmaniasis • • • Blastomycosis • Other … Good Luck!

250 References

• Espay AJ, Bull RL. Petrositis in Ramsay Hunt Syndrome With Multiple Cranial Neuropathies. Arch Neurol. 2005;62(11):1774-1775. doi:10.1001/archneur.62.11.1774. • Van der Meijden E. Discovery of a new human polyomavirus associated with trichodysplasia spinulosa in an immunocompromized patient. PloS Pathog. 2010. July; 6(7). • Wei SH et al. An outbreak of A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis. 2011 Dec 14;11:346. • Emi Shikuma et al. Onychomadesis Developed Only on the Nails Having Cutaneous Lesions of Severe Hand-Foot-Mouth Disease. Case Rep Dermatol Med. 2011; 2011: 32419 • Lee, Hye Young MD *; Baek, Jin Ok MD *; Lee, Jong Rok MD *; Park, Sang Hui MD +; Jeon, In Sang MD ++; Roh, Joo Young MD Atypical Hydroa Vacciniforme-Like Epstein-Barr Virus Associated T/NK-Cell Lymphoproliferative DisorderAmerican Journal of Dermatopathology. 34(8):e119-e124, December 2012 • Jain, S. Dermatology: Illustrated Study Guide and Comprehensive Board Review • Barnhill, R. Textbook of Dermatopathology 2nd edition 2004.