Twenty Skin 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 ImpetigoImpetigo

•• Group A and S. Aureus •• Blisters or ulcers •• “Candy like crust” Group A Streptococcus •• “Varnish like ” bullous, S . aureusaureus •• Culture under the crust •• Acute Glomerulonephritis •• Not Acute rheumatic fevereverf Case 2Case22

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 emarcat e d e levat ed border, dermal involvement ErysipelasErysipelas

•• Bright red, edematous •• Advancing, raised, sharply demarcated borderborder •• Systemic toxicity: fever, leukocytosis •• Group A streptococci if nonpurulent •• SSS. aureus if puru lifllent

CELLULITES

1) SQ tissue 2) SA, GAS 3) Indistinct border not elevated (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 BiteBiteBite vsvs Furunculitis ((Case4)(Case4) Case 4) CMRSACMRSA

•• 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) 2. Type II a) grp A strept b) occ Staph a c) risks – trauma, , PVD, cirrhosis, steroids d) toxic shock -like syndrome – hypothermia, shock  MS, MSOF, CPK, localized erethema 30% mortalityyy young healthy adults after minor trauma 3. Anesthesia of area involved NecrotizingNecrotizingNecrotizing FascitisFascitis

•• Macule Bullae •• Pain Numb •• Red BlueBlue--greygrey •• EdemaEdemaEdema CrepitanceCrepitance TherapyTherapy

•• Surgical emergency •• BetalactamBetalactam/beta/beta--lactamase inhibitor plus with an agent with activity against MR SA •• Intravenous Immunoglobulin Intravenous Immunoglobulin

•• Binds toxin presenting TT--cell receptor activationactivation •• Most experience in streptococcal shock syn dr ome esyd CLOSTRIDIAL CELLULITIS a) CfiCtiC. perfringes, C. septicum b) traumatic wounds c) ibiincubation – severaldl days d) crepitus e) muscle normal (Clostridial 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 borderin 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 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 5--2121 •• Pathogens: Clostridia septicum, GNR’s rarelCly Candid a and mold s •• Rx: Flagyl, Zosyn, Meropenem, Clindamycin

Fournier Gangrene Case 8Case88 PdPseudomonas aerug inosa

 Hot tub  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

TinaTina What are the toppp 3 dermatophytesdermatophytes?? •• Trichophyton rubrum •• Microsporum caniscanis •• Epidermophyton floculosum

1. CbiiiiiCorynebacterium minitissimum 2. Coral pink flourescence – woods lamp 3. Eythro x 7 days topical clinda 4. Groin R/O

NODULAR

1. Sporot ri ch osi s ( sp hagnum moss)(itraconazol e) 2. 3. MbMycobacter ium mar inum, c hlifihelonei, fortuitum 4. Francesella tularensis 5. Leishmania braziliensis 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 patients61patientspatients •• Mean disease duration 170 days (41(41--336)336) •• 48 Rx Rx48Rx AbxAbx median 4 4median4 momo (1(1--666 momo)) •• Sensitvity most to ciproand minocycline •• 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 •• MMM fortuitumfortuitum furunculosis •• 110 patients •• # of median 2 (1 --37 range) range)37range) •• 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 •• 22of8correctlydiagnosedatpresentation of 8 correctly diagnosed at presentation •• 7 I and D’s7 D’s •• 6 Combo Abx 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 in Immunocompromised Patients. It can be seen in the mouth or genitalsgenitals •• The “Knife-“Knife-CutCut Sign” •• Intertriginous fissuresfissures •• Clinical Infectious Diseases 2008;47:1440–2008;47:1440– 144114411441 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 16Case1616

Hutchinson’ssign 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 18Case1818 Case 19Case1919 Case 20Case2020 NonNon--infectiousinfectiousinfectious skinskinskin conditionsconditionsconditions Most common bacterial causes of erythema nodosum

•Streptococcus infections •TB • Yersinia • • 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 •• SulfaSulfa •• Halides (gold, iodines)iodines) Do not forget… ReferencesReferences

•• 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 •• SiberrySiberry GKGKGK, TekleTekle T, Carroll K , et al . Failure of clindamycin treatment of methicillin--resistantresistantresistant 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: 439–439–4747 •• 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. •• Infections Associated with Face Lifts --- New Jersey, 2002——2003. MMWR 2004;53:192-2004;53:192-44 •• E. Yoko Furuya,1,a Armando Paez,5,a Arjun SrinivasanSrinivasan,, et al. Outbreak of 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