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Twenty Skin Infections That an I T I T Sh Ld K Internist Should Know

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Twenty Skin Infections that an ItIntern itShldKist Should Know Ana Paula Velez, MD, FACP Assistant Professor University of South Florida ObjectivesObjectives •• 1. Identify the most and challenging skin infections commonly encounter in the outpatient and inpatient practice •• 2.2.RRecogniz e som e com pli cati on s associated with skin infections •• 333. Formulate medical or surgical treatment plan for these infections Case 1 Impetigo Impetigo •• Group A Streptococcus and S. Aureus •• Blisters or ulcers •• “Candy like crust” Group A Streptococcus •• “Varnish like ” bullousaureus, S . aureus •• Culture under the crust •• Acute Glomerulonephritis •• Not Acute rheumaticever f fever Case 2Case 2 Case 2 ERYSIPELAS A. group A strept >> group C or G or B B. 70-80% lower extremity C. 5-20% on face D. lymphedema E. recurrence rate 30% in 3 years F. peau D’orange, we ll d emarca te d e leva ted border, dermal involvement Erysipelas Erysipelas •• Bright red, edematous •• Advancing, raised, sharply demarcated border border •• Systemic toxicity: fever, leukocytosis •• Group A streptococci if nonpurulent •• SSS. aureusifif ifpuru llent l CELLULITES 1) SQ tissue 2) SA, GAS 3) Indistinct border not elevated Cellulitis (continued) 4. GAS/Clostridia surgical wound infx 6-48 hr incubation 5. SA SWI> 48 hr incubation 6. tinea pedis portal of entry 7. recurrent cellulites grp B or G – esp ? GU malig. 8.saphihihaneous vein harvest site – recurrent celluli ti s 9. rec. Rx pen augmentin, keflex, clinda, levo BiteBite Bite)vsvs e4Furunculitis s a (C( Case 4) ) e4 s a (C CMRSA CMRSA •• Sharing personal items •• Skin cuts, abrasions (sports, military recruits) recruits) •• Skin to skin contacts(MSM , sports participants, correctional facilities) •• Crowding(correctional facilities , day care) NECROTIZING FASCIITIS 1. TIType 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, diabetes , PVD, cirrhosis, steroids d) toxic shock -like syndrome – hypothermia, shock MS, MSOF, CPK, localized erethema 30% mortalityyy youn g health y adults after minor trauma 3. Anesthesia of area involved NecrotizingNecrotizingFascitis Necrotizing Fascitis •• Macule Bullae •• Pain Numb •• Red BlueBlue--greygrey Edema•• EdemaCrepitance Edema Crepitance Therapy Therapy •• Surgical emergency Betalactam•• /beta Betalactam /beta--lactamase inhibitor plus clindamycin with an agent with activity against MR SA •• Intravenous Immunoglobulin Intravenous Immunoglobulin •• Binds toxin presenting TT--cell receptor activation activation •• Most experience in streptococcal shock sy d osyn edro syme d o e CLOSTRIDIAL CELLULITIS a) CfiCtiC. perfringes, C. septicum b) traumatic wounds c) ibiincubation – severaldl days d) crepitus e) muscle normal (Clostridial gangrene muscle involved) f) pcn/lid//clinda/blactam///BI/carbapenom g) (gas also produced by E.coli, Kleb, Aeromonas) Vibri o vul nifi cus Saltwater exposure within the past 7 days. In US,,y mainly states bordering 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. SEPTICUM a) colon cancer 88% b) diverticulitis c) bowel infarction d) neutropenic enterocolitis AGC <500 e) volvulus f) mortality 67-100% (most in 24 hrs) Neutropppenic Enterocolitis (Typhlitis) (Typhlitis) •• RLQ rebound tenderness •• CT abdomen thicken ileocecum •• Ileus or diarrhea •• Neutropenia day 21 5-- 21 •• Pathogens: Clostridia septicum, GNR’s rarelCly Candid a and mold s •• Rx: Flagyl, Zosyn, Meropenem, Clindamycin Fournier Gangrene Case 8Case 8 Case 8 PdPseudomonas aerug inosa Hot tub folliculitis Appears 1-3 days after exposure Predisposition Length of time in water Increased number of bathers HhlitiHypochlorination Resolves spontaneously Not contagious. FOLLICULITIS A. SA (beard – sycosis barbae) B. PSA whirlpool/hot tub/swimming pool C. Candida D. Malassezia furfur E. Eosinophilic pustular folliculitis Tina Tina What are the toppp 3 dermatophytesdermatophytes?? •• Trichophyton rubrum •• Microsporumcanis canis •• Epidermophyton floculosum ERYTHRASMA 1. CbiiiiiCorynebacterium minitissimum 2. Coral pink flourescence – woods lamp 3. Eythro x 7 days topical clinda 4. Groin R/O tinea cruris NODULAR LYMPHANGITIS 1. Sporo tri ch osi s ( sp hagnum moss)(itraconazol e) 2. Nocardia brasiliensis 3. MbMycobacter ium mar inum, c hlifihelonei, fortuitum 4. Francesella tularensis 5. Leishmania braziliensis Mycobacterium marinum—”Fish TkTank GlGranuloma Acquisition Before 1962--hypochlorinated swimming pools. After 1962--cleaning aquariums. Also crab bites, sea-urchin spines Single ulcerated lesion Sporotrichoid pattern lymphatic spread. Diagnosis delayed Tx for 3-12 months. CCylarithromycin, doxyyycycline,,p septra or rifampin +ethambutol Mycob btiaterium f ftitortuitum Atypical, rapidly growing AFB. Associated with pedicures or foot baths. Causes lower extremity furunculosis. Most heal spontaneously but some scar. Could tx with ciprofloxacin, clarithromycin or doxyyycycline. RGM Outbreaks •• Nailll salon wh hllfbhCirlpool footbath in CA •• M fortuitum furunculosis 61 patients•• 61 patients 61 patients •• Mean disease duration 170 days (41(41--336)336) 48•• Rx48median AbxRx 48 Rx Abx 4medianmo 4 median mo(1(1mo-- 4666 mo)) most ••toSensitvity cipro Sensitvitycipro mostand minocyclineto •• Earlier Rx = shorter duration of disease •• 1 pateint had lymphatic dissemination •• CID 2004;38:382004;38:38--4444 RGM Outbreaks •• Nail salon whirlpool footbath in CA fortuitum•• MMM fortuitumfurunculosis •• 110 patients •• # of boils median 37 range) 2 (1 --37 range) 37 range) •• Shaving legs with a razor before pedicure was a rikfisk factor for ifinfect ion •• NEJM 2002;346:1366-2002;346:1366-7171 RGM Outbreaks •• Facelifts (Rhytidectomies(Facelifts Rhytidectomies)) in NJ •• Outpatient surgical center •• 4 patients with M chelonaeinfection •• Contaminated methylene blue used as a tissue marking agent •• MMWR 2004 ;53 :192 --44 RGM Outbreaks •• Lipotourists from U S to DR 2003--44 •• 8 healthy Hispanic females underwent abdominoplasties •• Sx developp(ed median 7 weeks (11--1818 wks)) •• Presented with painful, red, draining SQ abdominal nodulesnodules •• 2of8correctlydiagnosedatpresentation2 of 8 correctly diagnosed at presentation •• 7 I and D’s7 D’s •• 6 Combo Abx macrolide and IV abxcefoxitin, cefoxitin, imipenem,imipenem, amikacinamikacin, and/or linezolid •• All but 1 cured after median 9 mo(2- (2-1212 mo)mo) •• CID 2008;46:11812008;46:1181--88 Atypical HSV Presentations •• Linear Erosive Herpes Simplex Virus Infection in Immunocompromised Patients. It can be seen in the mouth or genitals genitals •• The “Knife-“Knife-CutCut Sign” •• Intertriginousfissures fissures •• Clinical Infectious Diseases 2008;47:1440–2008;47:1440– 14411441 1441 What is the Rx of acyclovir resistant herpes simplex or herpppes zoster? •• Foscarnet IV (NEJM 1991;325:5511991;325:551--5)5) •• Cidofovir IV (JID 1994;170:5701994;170:570--2)2) •• Cidofovir (NEJM 1993;329:9681993;329:968--9,9, JID 1997;176:8921997;176:892--8)8) •• Imiquimod (Am J Med 2006;119:e9-2006;119:e9-11,11, Arch Derm 2001;137:10152001;137:1015--17)17) •• Trifluridine (JAIDSHR 1996;12:147-1996;12:147-152)152) •• Interferon alfa and Trifluridine (Arch Derm 1995;131:241995;131:24--55 Case 16Case 16 Case 16 Hutchinson’ sssign 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 18Case 18 Case 18 Case 19Case 19 Case 19 Case 20Case 20 Case 20 infectiousNon-- Noninfectiousconditionsskin infectiousskin skinconditions conditions Most common bacterial causes of erythema nodosum •Streptococcus infections •TB • Yersinia • Mycoplasma • LGV •Salmonella • ClbCampylobacter What is the most common fungal cause of erythema nodosumnodosum • Coccidiodomycosis • Histoplasmosis • Blastomycosis What is the most common druggg cause of erythema nodosum •• Oral contraceptives Sulfa•• Sulfa •• Halides (gold, iodines)iodines) Do not forget… References References •• Dennis L. Stevens,1,3 Alan L. Bisno,5 Henry F. Practice Guidelines for the Diagnosis and Management of Skin and SoftSoft--TissueTissue Infections. Clinical InfInfecectioustious Diseases ; 2005 ; 41 : 1373 - 1406 1406 Siberry•• GKTekle SiberryGK, GK TekleT, Carroll K , et al . Failure of clindamycin treatment of methicillinresistant--resistant resistant Staphylococcus aureus expressing inducible clindamycin resistance in vitro. ClinInfect Dis. 2003 Nov 1;37(9):12571;37(9):1257--6060 •• Richard L Oehler,Oehler, Ana P Velez, Michelle Mizrachi,Mizrachi, et al. Bite-Bite-relatedrelated and septic syndromes caused by cats and dogs. Lancet Infect Dis 2009; 9: 439–43947 –47 •• Winthrop KL, AlbridgeK, South D, et al. The clinical managementmanagement and outcome of nail salon-salon- acquired Mycobacterium fortuitumskin infection. Clin Infect Dis. 2004 Jan 1;38(1):38-1;38(1):38-44.44. •• Winthrop KL, Abrams M, YakrusM, et al. An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med. 2002 May 2;346(18):13662;346(18):1366--71.71. •• Mycobacterium chelonae Infections Associated with Face Lifts --- New Jersey, 20022003.—— 2003. MMWR 2004;53:192-2004;53:192-44 •• E. Yoko Furuya,1,a Armando Paez,5,a Arjun SrinivasanSrinivasan,, et al. Outbreak of Mycobacterium abscessus Wound Infections among ““LipotouristsLipotourists”” from the United States Who Underwent Abdominoplasty in the Dominican Republic. CID 2008;46:1181--88 •• Jeffrey I. Cohen. Herpes Zoster. N Engl J Med 2013; 369:255369:255--263263 .
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  • Bacterial Skin Infections

    Bacterial Skin Infections

    MYTHS AND FACTS: BACTERIAL SKIN INFECTIONS A better understanding of these often-serious infections that are rising in incidence and becoming more resistant to antibiotics is the first step to improved treatment. Ronale Tucker Rhodes, MS 38 BIO SUPPLY TRENDS QUARTERLY | Summer 2016 DURING THE PAST several years, disturbing headlines about can result in methicillin-resistant Staphylococcus aureas flesh-eating bacteria have raised fear among the public, but few (MRSA), which can be a life-threatening infection because think they’ll actually be the next victim. That was certainly true certain antibiotics in the penicillin family cannot treat it. 8 of Cindy Martinez, who, in May 2015, somehow contracted one Streptococcal infection also can cause many types of infections, strain of the dangerous bacteria known to cause necrotizing but it more regularly causes impetigo, which results in a rash fasciitis. A former Marine and mother of two small children, several days after infection with small blisters that burst and Cindy survived but only after her feet and right hand were leave crusty, golden patches on the skin — occurring most amputated to halt the bacteria’s effects. 1 Necrotizing fasciitis is commonly on the face. 5 Both Staphylococcus and Streptococcus rare. According to the Centers for Disease Control and also commonly cause cellulitis, which can occur anywhere on Prevention (CDC), which tracks specific infections in the U.S. the body; however, the most common location is the lower leg. 9 through a special system called Active Bacterial Core surveillance Cellulitis is a painful infection of the deeper layers of the skin (ABCs), there are about 650 to 850 cases of necrotizing fasciitis that appears as an area of redness, warmth and swelling that caused, predominantly, by group A Streptococcal bacteria each gradually spreads.
  • Dermatology in the ER

    Dermatology in the ER

    DRUG ERUPTIONS and OTHER DISORDERS Lloyd J. Cleaver D.O. , F.A.O.C.D, F.A.A.D. Professor of Dermatology ATSU-Kirksville College of Osteopathic Medicine INTERNAL MEDICINE BOARD REVIEW COURSE I Disclosures No Relevant Financial Relationships DRUG ERUPTIONS Drug Reactions 3 things you need to know 1. Type of drug reaction 2. Statistics What drugs are most likely to cause that type of reaction? 3. Timing How long after the drug was started did the reaction begin? Clinical Pearls Drug eruptions are extremely common Tend to be generalized/symmetric Maculopapular/morbilliform are most common Best Intervention: Stop the Drug! Do not dose reduce Completely remove the exposure How to spot the culprit? Drug started within days to a week prior to rash Can be difficult and take time Tip: can generally exclude all drugs started after onset of rash Drug eruptions can continue for 1-2 weeks after stopping culprit drug LITT’s drug eruption database Drug Eruptions Skin is one of the most common targets for drug reactions Antibiotics and anticonvulsants are most common 1-5% of patients 2% of all drug eruptions are “serious” TEN, DRESS More common in adult females and boys < 3 y/o Not all drugs cause eruptions at same rate: Aminopenicillins: 1.2-8% of exposures TMP-SMX: 2.8-3.7% NSAIDs: 1 in 200 Lamotrigine: 10% Drug Eruptions Three basic rules 1. Stop any unnecessary medications 2. Ask about non-prescription medications Eye drops, suppositories, implants, injections, patches, vitamin and health supplements, friend’s medications