a rash overview of tropical skin diseases (and other things) boris d. lushniak, md, mph radm usphs,...
TRANSCRIPT
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A Rash Overview of Tropical Skin
Diseases
(and other things)
Boris D. Lushniak, MD, MPH
RADM USPHS, Deputy Surgeon General
Adjunct Professor Dermatology, USUHS
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Insect bites
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Bedbugs
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Gentian Violet
Very messy; stainsTraditional “anti-infective” treatment, rarely
used in USA todayGentian violet can be painted onto bacterial or
fungal infections and left to dry
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Many deep fungal infections can present as leg ulcers
SporotrichosisBlastomycosisCoccidioidomycosisCryptococcosisHistoplasmosisProtothecosisChromoblastomycosis
protothecosis
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ChromoblastomycosisUsually one lower extremity
Male Farmers
Fonsecaea pedrosoi
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ChromoblastomycosisTreatment is difficultSmall lesions: surgical excision or LN2Itraconazole or Terbinafine
Below: fungal elements found in smear taken from ulcer
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Lobomycosis(Lacazia loboi)Acquired from soil,
water, vegetation in forested areas
Recurrence common
Amazonian wetlands
Small lesions- surgical excision
Itraconazole & Clofazimine
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SporotrichosisNodules with
lymphatic spread and ulceration
Sporothrix schenkii• Worldwide• Itraconazole• Potassium Iodide
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Differential for sporotrichoid spread
aka Lymphocutaneous syndromeSporotrichosis Nocardiosis
Leishmaniasis Tularemia
Atypical mycobacteria (esp M. marinum)
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RhinosporidiosisRhinosporidium seeberiIndia, East Asia, Latin AmericaMucosal polypoid lesionsBleed easily
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Rhinosporidiosis Treatment
Destruction of involved area by excision or electrosurgery
Antifungals are of little value
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BasidiobolomycosisEntomophthoromycosisIndonesia, worldwideIndolent courseBasidiobolus ranarumSubcutaneous
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Basidiobolomycosis
Biopsy diagnosis- broad, thin-walled hyphae, aseptate, branched at right angles
Potassium iodide drug of choice, other Antifungals
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Humanitarian mission in Darfur.
Several men have similar appearing painless swollen feet
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Mycetoma (“fungal tumor”) Madura foot, maduramycosis.
Sites of minor trauma and exposure to decaying wood. Foot/leg (75%), upper back. Clinical triad of :
Tumefaction, Draining sinuses, & Extruded grains Etiology and treatment:
True fungal vs bacterial
Madura foot, maduramycosis. Sites of minor trauma and exposure to decaying wood Foot/leg (75%), upper back Clinical triad of : Tumefaction, Draining sinuses, & Extruded grainsEtiology and treatment True fungal vs bacterial
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MycetomaProgressive swelling with sinus tracts and
grainsCulture and BiopsyActinomycetoma: PCN, sulfonamidesEumycetoma: Combo surgery and Antifungal
therapy
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Infestatations and Cutaneous Ectoparasites
LiceScabiesTungiasisCutaneous larva migransMyiasisCercarial Dermatitis
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Head lice
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Pediculosis pubis (crab lice)
– Louse grabs hairs, bites skin, cements nits to hairsCan be on any body hair,
including eyelashes
– Look for other STD’s
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Pediculosis pubisPermethrin cream Coat eyelashes with vaseline bid
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Scabies• Itching often worse at night• Close contacts also itchy• Papules and burrows: webs, wrists,
waist and willie
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Scabies
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Scabies mite burrows in epidermisScrape to see mite, eggs,
or poop
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Crusted scabies
Wear gloves!
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Scabies
Sarcoptes scabiesTreatments –
permethrin, lindane, benzyl benzoate, crotamiton, malathion, topical sulfur, ivermectin
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21yo soldier returns military exercise in Guyana
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Tungiasis, Sand Flea (Tunga penetrans)Female burrows into
skin (usually foot)Progression of painful
red spot to papule to nodule with black dot (anal/genital area of flea) to pearl-like papule (with eggs) to black keratotic crust
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Gravid female burrows into flesh, leaving uterine pore open.Gravid female burrows into flesh, leaving uterine pore open
Tungiasis
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TungiasisLife cycle of 2-4 mm flea
is 5-6 weeksInfestation self-limited if
not reinfectedRare osteomyelitis/
gangreneSub-Sahara, Caribe,
Mexico, S. AmericaSurgical removal of fleas
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TungiasisTunga penetrans, Sand flea, jiggerPainfulCurettage or Excision, Topical
ivermectin or thiabendazole, Oral thiabendazole for heavily infested
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28yo Navy physician –at Flight Surgeon Course in Pensacola
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Cutaneous Larva Migrans (Creeping eruption)
Pruritic, serpiginous lesion migrates 2-4 cm /day on feet or buttocks
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Creeping Eruption (Cutaneous Larva Migrans)
Dog or cat hookworm larvae
Beach; sandboxes
Unlike human hookworms, dog/cat hookworms cannot penetrate fully and usually die within 2 months
Larva migrates ~ 2 cm/day
Course: self-limited 1-6 mos
Rx: topical thiabendazole
or single dose of oral ivermectin
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MyiasisInfestation of human tissue by fly larva
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MyiasisPainful, boil-like
lesion with central punctum (respiratory pore)
Exposed skin“obnoxious
infestations both medically and esthetically”
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Dermatobia hominisHuman BotflyFemale glues eggs tomosquito, stablefly, or tick
New World Myiasis
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. . . and how do you know?
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Cordylobia anthrophaga
African tumbu flyMango flyMputsi fly
Old World MyiasisFly deposits eggs on ground
or clothingYoung maggots penetrate skin
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Larval Stage of Tumbu or Bot Fly(Africa, Latin America)
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Cercarial Dermatitis (Swimmer’s itch)
Transient pruritic papular or urticarial eruption on exposed skin
Resolves in 7-10 days after fresh water snail exposures (schistosomal larvae penetrate the skin)
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Cutaneous AnthraxClinical Progression
Painless, pruritic papule Juicy papule
Bulla (48 hours)Bulla ruptures/early ulcer Eschar with raised border
‘Jet black’ escharMinimal scarring
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Orf
Ecthyma contagiosumAcquired from direct contact with lambs,
calves, or goatsSpontaneous resolution
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Rural central and south Africa, central Asia, S America, SW USA
Sudden onset flu-like syndrome
Painful, swollen, tender lymph nodes (Buboes)
IV Streptomycin
Bubonic Plague
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Measles (Rubeola)
Rarely seen among vaccinatedMajor killer in developing worldSpread by respiratory routeIncubation 9-12 daysImmunization highly effective
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Measles Prodrome: high fever, malaise, URIRash begins in hairline of neck/face, then moves downExudative conjunctivitisPhotophobiaSevere bark-like coughKoplik’s spots on buccal mucosa
Cough, coryza, conjunctivitis, rash, & fever
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Leprosy/Hansen’s Disease
Chronic disease caused by M. lepraePeripheral nerve (sensory loss), skin, and
upper airway mucosal involvementAsia, Caribbean, the Americas, S. Europe,
Australia, AfricaIncubation period 3 mos to 40 years Rifampin, Dapsone, Clofazimine
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Sensory Motor Auto-amputation
Claw-hand deformity Lepromatous leprosy
LeprosyMycobacterium leprae
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Lepromatous Leprosy
Nodular infiltrations can destroy underlying structures (saddle nose deformity, leonine facies)
Sensory loss over distal limbs
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Borderline Leprosy
Numerous lesions, annular
Symmetrical nerve involvement appears later
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Tuberculoid leprosy
Hypopigmented saucer shaped single (max 2-3)
Numbness, pain, tingling, muscle weakness
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Mycobacterium tuberculosis
Inoculation from exogenous source (primary inoculation TB, Tuberculosis cutis verrucosa)
Endogenous cutaneous spread (Scrofuloderma, tuberculosis cutis oroficialis)
Hematogenous spread (Miliary TB, Lupus vulgaris)
Tuberculids (erythema induratum)
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Scrofuloderma
Tuberculous involvement of the skin by direct extension from underlying lymphadenitis
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Skin lesions in returned travellers (n=4742)
Cut. larva migrans 9.8% Insect bite 8.2%Skin abscess 7.7% Infected insect bite 6.8%Allergic rash 5.5%Rash, Unknown 5.5%Dog bite 4.3%
Superficial fungal 4.0%Dengue 3.4%Leishmaniasis 3.3%Myiasis 2.7%Spotted fever 1.5%Scabies 1.5%
Int J Infect Dis 2008; 12(6)593-602