16H-18H E Caumes Dermatoses Med Voyges DESC MIT 2014

16H-18H E Caumes Dermatoses Med Voyges DESC MIT 2014

Potential links of Interests • In the past 2 years, I (or my department) have received honoraria for lectures on STDs (BMS) or for participation in advisory boards on TBE (Baxter) or KS (Gallen) • I am the Editor in Chief of the Journal of Travel Medicine (IF = 1.7) Dermatoses tropicales • Introduction • Données épidémiologiques • Infections cutanées bactériennes • Larva migrans cutanée ankylostomienne • Leishmaniose cutanée localisée • Dermatoses prurigineuses • Dermatoses marines • Exanthème fébrile • Dépigmentation volontaire Dermatoses tropicales ?? • Dermatoses vues dans les pays tropicaux • Dermatoses vues dans les pays occidentaux .Voyageurs . Immigrés Consultations médicales au retour de voyage 7767 suisses(1) 8 % 2109 italiens(2) 11 % 779 américains(3) 12 % 200 israeliens(4) 19 % (1) Steffen et al ; J Inf Dis 1987;156:84-91 (2) Bruni et al ; J Travel Med 1997;4:61-64 (3) Hill D ; J Travel Med 2000;7:259-266 (4) Winer ; J Travel Med 2002;9:227-232 Part des dermatoses dans les consultations médicales au retour 93 américains (1) 11 % (4eme) 622 français (2) 24 % (2eme) 17343 Monde (3) 17 % (3eme) (1) Hill D. J Travel Med 2000;7:259-266 (2) Freedman DO et al. N Engl J Med 2006; 354: 119-130 (3) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 Part des dermatoses exotiques, tropicales, parmi les dermatoses au retour 224 francais (269) (1) 54 % (1995,Hosp) 114 français (149) (2) 34 % (2007,Hosp) 4594 Monde (4742) (3) 24 % (GeoSent) 10 américains (4) 0 % (ville) (1) Caumes E et al. Clin Inf Dis 1995; 20 : 542-548 (2) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 (3) Freedman DO et al. N Engl J Med 2006; 354: 119-130 (4) Hill D. J Travel Med 2000;7:259-266 What is the most common skin disease diagnosed in returning travellers : 1. Myiasis 2. Syphilis 3. Skin and soft tissue infections 4. Hookworm related Cutaneous larva migrans 5. Arthropod related dermatitis The top nine travel associated dermatoses* in 4594 pts, 1997-2006, WW travellers (GeoS) • Cutaneous larva migrans : 465 (10%) • Insect bites : 388 (8%) • Abcess (pyoderma) : 366 (7%) • Surinfected insect bites : 324 (7%) • Cutaneous allergy : 263 (5%) • Rash of undetermined origin : 262 (5%) • Bite by animals : 203 (4%) • Superficial mycose : 190 (4%) SSTI : 690 • Dengue : 159 (3%) (15%) * 24% tropical; Lederman E et al. Int J Inf Dis 2008, i:10.1016/j.ijd.2007.12.008 The top nine travel associated dermatoses* in 114 pts, 2000s, tourists, migrants, expat • Infectious cellulitis : 21 (14%) • Scabies : 17 (11%) • PUO : 15 (10 %) • Pyoderma : 14 (9%) • Myiasis : 12 (8%) • Tinea : 10 (6%) SSTI : 35 • Filariasis : 9 (6%) • Cutaneous Larva migrans : 8 (5%) (23%) • Urticaria : 8 (5%) * 76 % of 149 dermatoses (34% tropical) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 Dermatoses in 8.227 ill travelers (19%), GeoSentinel, 2007-2011 Rabies PEP required in 12% 18% CLM = 8% of all skin pbs 16% 14% 12% 10% 8% Derm 6% 4% 2% Sentinel 0% SSTI Insect itch Animal Leder K et al. Ann Intern Med 2013; 158: 456-468 www.medecine-voyages.fr Regarding SSTI acquired during travel in tropical countries, the main cause of concern is : 1. Unusual culprit microbial agent 2. Atypical clinical appearance 3. Importance of serologic results 4. Fear of antibiotic resistance 5. Stool examination Inf Cutanées bactériennes (n = 48) • Impétigo : 19 (39%) - S aureus (40%) [12 (63%) avec piqure/ - Streptococcus sp (20%) morsure d’arthropode] - S. aureus + st (20%) - négative (20%) • Erysipèle : 9 (18%) • Ecthyma : 8 (16%) • Abces : 4 (8%) • Furoncle : 4 (8%) • Intertrigo : 2 (4%) • Folliculite : 1 (2%) • DHBA nécrosante : 1 (2%) Caumes et al - Clin Inf Dis 1995;20:542-548 Infections cutanées bactériennes chez 60 voyageurs; 01/2006-08/2007 Formes N (%) % culture + Sa MS SGA Les 2 Impetigo 21 (35%) 76% 31% 38% 31% Abces 14 (23%) 57% 0100% 0 Ecthyma 11 (19%) 91% 10% 60% 30% Cellulite (19%) 011 NA NA NA Folliculite 3 (5%) 33% 0100% 0 Hochedez P et al. Am J Trop Med Hyg 2009; 80: 431-4 Insect bite, impetigo, cellulitis Insect bite, cellulitis, Abcess, fistulisation to the skin Erysipela vs infectious cellulitis Erysipela vs infectious cellulitis –Peripheral surelevated borderline –Clear borderline with surrounding tissues Bisno AL. N Engl J Med 1996; 334:240-245 « In practice, distinguishing between cellulitis and erysipelas clinically may be difficult…. » Stevens DL. Clin Infect Dis 2005; 41: 1373-1406 Criteria of severity when facing an infectious cellulitis • No clinical response to antibiotherapy • Intense and constant pain (+++) • Cutaneous oedema reaching surrounding tissues • Cutaneous necrosis (blue, white then black) • Gaz (crepitation, Xray) • Loss of cutaneous sensitivity (+++) • Having clinical signs of severe infections Stevens DL. Clin Inf Dis 2005; 41: 1373-1406 Regarding S.aureus related SSTI acquired while being in the tropics, the main causes of concern are: • Transmission in the household • Antibiotic resistance • Reccurences • Portage • All of them Femme, 35 ans, Homme, 41 ans, Retour de Apparition Cote d’Ivoire à J6 des retrouvailles Femme, 35 ans; lendemain d’un retour de voyage en Côte d’Ivoire (J 3 lésion) J 1 : piqure d’insecte J 4 : apparition de la lésion cutanée J 6 : retour; J 7 : consultation Homme de 41 ans, compagnon de N°1 Lésion cutanée localisée sur le pied droit apparue 6 jours aprés les “retrouvailles” avec N°1 Lésion cutanée à J5 de l’évolution spontanée …… Male, 33 y, just returning from Fiji Female, 29 y, wife of Mr Fiji and companion of travel Mr Abcess & Mrs impetigo cellulitis MS PVL+ S. aureus Import and spread of PVL+ S.aureus in travelers with SSTI • 38 travelers with S.aureus + SSTI vs 124 control with other trav-dis; genotyping • S.aureus SSTI were associated with travel duration and location (Africa: OR =4.2) • Pts with PVL+ S.aureus SSTI were also colonized in the nares (73% vs 25%) • SSTI due to PVL+ S.aureus were more likely to be complicated, reduced antibiotic susceptibility and 2ry spread (5 clusters) Zanger P et al. Clin Inf Dis 2012; 54: 483-92 Import and spread of PVL+ S.aureus in travelers with SSTI Sa+ nasal PVL+ nasal PVL+ lesion carriage carriage Abscess 0.5 0.1 0.001 Furuncle Recurrent 0.4 0.002 0.001 Disease Surgical 1 0.2 0.015 drainage SSTI contacts 1.8 0.1 0.1 Zanger P et al. Clin Inf Dis 2012; 54: 483-92 Traveling MRSA Imported MRSA in Sweden, 2000-2003 • 1733 cases MRSA reported in Sweden • 444 (25 %) imported cases (acquired abroad) * 292 (65 %) in Swedish travellers * 56 (12 %) in newly arrived immigrants * 40 (9 %) in internat adopted children * 30 (7 %) in foreign residents * 20 (4 %) in Swedish expatriates • Including 246 (55 %) HA and 146 (33 %) CA Stenhem M et al. Emerg Inf Dis 2010;16:189-196 MRSA Imported by Swedish travelers 2000-2003 : countries at risk (ORs) • Nordic 0.1 (0.01-0.6) • Western Europe Reference* • Southern Europe 2.4 (1.0-5.8) • Central and Eastern Europe 2.8 (1.0-8.1) • UK and Ireland 10.3 (4.4-24.0) • North America 10.6 (4.2-26.7) • Northeastern Mediterranean 15.8 (7.0-35.6) • South America 31.2 (10.0-97.6) • East Asia 36.5 (16.2-82.0) • Oceania and Pacific Islands 43.0 (15.5-119.4) • Sub-Saharan Africa 46.3 (17.3-123.6) • North Africa and Middle East 59.0 (25.1-138.9) Stenhem M et al. Emerg Inf Dis 2010;16:189-196 Abscess management • « Ubi pus, Ibi evacuata » Still true since Hippocrate Am J Med 1876; 6: 226 In case of recurrent S.aureus SSTI, the followings can be proposed: • Education • Mupirocin • Antiseptic wash • None of them • All of them Staphylococcal decolonisation in pts with recurrent SSTI: effective? Ref N= S.aureus FU Tt vs P(or E) P = Raz MSSa34 12 m M monthly 0.002 Ellis 134 CA-MRSa 4 m M /5 days 0.76 Gordon 92 27%-MRSa 6-8 m M monthly NS Fritz 300 68%MRSa 6 m E + M (5 d) 0.4 M: mupirocin; E: education; E + M + Chl 0.51 P: Placebo; Chl: Chlorhexidine BB: Bleach baths E + M + BB 0.02 Simar AE. Lancet 2011; 11: 952-962 Decolonization for prevention of recurrent CA-MRSA infections • California, private practice, 31 pts enrolled • Mean age : 40 y; 58% Female; 86% healthy • Mean Nb of episodes < 6 mths = 5 (2-30) • 10 d regimen:nasal mupirocin 2/d, body wash hexachlorophene/d + AB (cycl; tmp/smx) • Mean Infection rate = 0.03 inf/month > 6 mths (FU period) vs 0.84 inf/mth < 6 mths intervention (P < 0.0001) Miller LG et al. Antimicrob Ag Chemoth 2012; 56: 1085-86 Infections cutanées bactériennes • Streptocoques et staphylocoques sont responsables d’infections plus ou moins sévères selon le terrain et la profondeur de l’atteinte cutanée • Streptococcus pyogenes: toujours sensible aux pénicillines (G,A,…), résistance aux macrolides rendant aléatoire le traitement par les antibiotiques du groupe MLSK • Staphylococcus aureus: toujours plus résistant, notamment diffusion mondiale progressive des SARM an ville; pristinamycine (MLSK) efficace Larva migrans cutanée ankylostomienne (larbish) • Même si tout ce qui court sous la peau ne relève pas de la larva migrans cutanée ankylostomienne (HrCLM) • HrCLM reste la cause la + fréquente de dermatite rampante exception faite de quelques pays (Japon….) Boracay, Philippines LMC ankylostomienne c° voyageurs Ref (1) (2) (3) Patients 60 67 64 Nationalité Canada France France > Retour 45 % 51 % 55 % Délai/Retour 5j (0-30) 8j (0-28) 16j (1-120) (1) Davies et al. Arch Dermatol 1993;129:588-591 (2) Caumes et al.

View Full Text

Details

  • File Type
    pdf
  • Upload Time
    -
  • Content Languages
    English
  • Upload User
    Anonymous/Not logged-in
  • File Pages
    199 Page
  • File Size
    -

Download

Channel Download Status
Express Download Enable

Copyright

We respect the copyrights and intellectual property rights of all users. All uploaded documents are either original works of the uploader or authorized works of the rightful owners.

  • Not to be reproduced or distributed without explicit permission.
  • Not used for commercial purposes outside of approved use cases.
  • Not used to infringe on the rights of the original creators.
  • If you believe any content infringes your copyright, please contact us immediately.

Support

For help with questions, suggestions, or problems, please contact us