Bacterial infectionsBacterial infectionsZora DubskáZora Dubská

Department of Department of Dermatovenereology of 3rd Faculty of Medicine and Faculty Dermatovenereology of 3rd Faculty of Medicine and Faculty Hospital Kralovske Vinohrady in PragueHospital Kralovske Vinohrady in Prague

Head: Prof. Petr Arenberger, MD, MBAHead: Prof. Petr Arenberger, MD, MBA

Bacterial skin infections

- Pyoderma

- Skin infections caused by corynebacteria

- Mycobacteria

- Borreliosis

- Anthropozoonoses

- Actinomycosis

Pyoderma

- Bacterial infection of skin caused by pyogenic cocci

- Staphylococcus aureus

- Beta hemolytic streptococcus group A

- Pyoderma bound to follicles

- Pyoderma bound to sweat glands

- Superficial pyoderma

- Deep pyoderma

Pyoderma bound to follicles

- Purulent inflammation of hair follicles and hairballs

- Frequent infections (shaving, friction with clothing)

- Most Staphylococcus aureus - coagulase - vertical spread

Ostiofolliculitis - impetigo Bockhardt  - Subcorneal pustules in the ostium of the follicle

Folliculitis - purulent inflammation of the follicle        - 2 forms - Folliculitis simplex disseminata                         - Folliculitis barbae

Folliculitis barbae

Folliculitis - therapy

- ATB solutions (erythromycin, clindamycin)

- Disinfecting solutions containing iodine or   salicylic acid

- Systemic ATB according to the sensitivity

Furunculus

- Follicular skin abscesses that arise from folliculitis

or primarily

- Neck, axilla, buttocks, groins

- Hot and humid environment, obesity, hyperhidrosis,

diabetes mellitus, malnutrition, HIV immunodeficiency

- Follicular pustule followed by erythematosus   painful bump with a central yellowish pin

- Lymphadenopathy, fever

Furunculus

Carbunculus

- Merging several neighboring furunculi

- Extensive hump, which is emptied with several fistulas

- Neck

- Fever

- Leukocytosis

- Bacteremia

Furunculus - therapy

- Saloxyl

- Systemic antibiotics according to sensitivity

- Ev. incision

- The carbuncle surgical incision required!

Pyoderma bound to sweat glands      - Hidradenitis suppurativa axillaris

- Chronic suppurative disease

- Apocrine sweat glands - axilla, perianogenital area

- Inflammatory infiltrates, abscesses, fistulas

- Total excision, systemic retinoids, antibiotics

Pyoderma bound to the nail - paronychia

  - Suppurative disease of lateral nail fold 

  - After injury

  - Disinfecting solution – potassium permanganate,

antibiotic ointment

Impetigo- Superficial pyoderma

- Streptococci ( maculovesiculous form )- Staphylococci (bullous form)

- Maculovesiculous form - red macula with    vesicles, pustules followed by crust formation

- Bullous form - Bull on erythematous base

followed by red scaling leasions

- Face - nasal entrance

Impetigo - http://www.stefajir.cz/q=impetigo

Impetigo - therapy

- Topical treatment with antiseptic solution and antibiotic   ointment (mupirocin, a. fusidicum, bacitracin)

- In case of failure of local treatment – systemic atb according

to sensitivity

- Hygiene

- Streptococcus type A - the risk of glomerulonephritis – Urine                         

Deep pyoderma

- Ecthyma - ulcerative pyoderma in infected                          excoriations of itching dermatoses

- Erysipelas

- Phlegmona - diffuse spreading infection of the skin,

subcutaneous tissue, along fascia, tendons, muscles

- Necrotising fasciitis - inflammation of deep fascia and soft tissue + systemic response

Erysipelas- Frequent acute infection of the skin and

subcutaneous tissue

- Streptococcus pyogenes

- The spread of infection via lymphatic vessels

– entrance - injuries, interdigital mycosis ..

- Fever up to 40 C, chills- Within few hours in the affected area (mostly legs    or face) - sharply bordered erythema

- Skin is warm, painful, edema, lymph nodes swollen

Erysipelas

Erysipelas - therapy

- Applied parenteral penicillin (usually procaine     benzylpenicillin 10 x 1.5 mil.j.i.m. finished by benzathine benzylpenicillin 1.5 mil.j.i.m.)

- Hypersensitivity to PNC - macrolides (erythromycin)                                         - Lincosamides (clindamycin)                                         - Cephalosporins

- The risk of recurrence and lymphedema

- Prevention of relapse - long-term application of benzathinpenicilin every 2-4 weeks

Staphylococcal scalded skin syndrome - Lyell's syndrome

- A life-threatening disease – systemic response

- Staphylococcus aureus produces exotoxins

- Separation of the upper parts of epidermis - large areas

- Infants and children under 5 years of age - the risk of sepsis,

pneumonia

- Fever, generalized erythematous, macular rash,   bullas, leasions, scales, without scarring

- Nikolsky phenomenon of the unafflicted skin- Acantholytic intraepidermal blister of stratum granulosum- Systemic anti- staphylococcal ATB - ad integrum in 2 weeks

Toxic shock syndromes

- Rare shock states with skin symptoms and    multiorgan involvement caused by staphylococci and    beta-hemolytic streptococci group A ( producing toxins )

- Toxins act as superantigens

- Source - soft tissue infections (streptoc. syndrome)

- Alteration of the general condition, generalized macular   rash followed by desquamation of palms and soles after 1-2   weeks, raspberry tongue, erythema, mucosal erosion

- Anti-shock therapy, antibiotics i.v. (antistaphylococcal)   streptococcal etiology - PNC, clindamycin, cephalosporins,   i.v. immunoglobulins, surgery

Scarlatina - scarlet fever- A streptococcal tonsillitis accompanied by rash

- Children between 3 to 10 years of age - Streptococcus pyogenes group A - beta hemolytic       - Pyrogenic exotoxin A

- Entrance – nasopharynx - Within 1-6 days tonsillitis with fever

- Maculopapular rash – goose skin – bending areas of limbs- Face with perioral fading- Petechial enanthema on the palate, raspberry tongue- After 1-2 weeks lamellar scaling of palms, soles

dg.: clinical state, cultivation, leukocytosis in KO

Therapy of scarlatina:

- Isolation

- Parenteral application of Procaine Penicilin G i.m. 3-5 days,    finished by application of Benzatinpenicilin i.m., ev.   erythromycin, cephalosporins, clindamycin

- Complications - Secondary infection                         - Rheumatic fever                         - Glomerulonephritis

Skin infections caused by corynebacteria

- Erythrasma - axilla, groins             - Reddish areas with satellite maculas            

- Wood's lamp - red fluorescence

- Trichomycosis axillaris    - Yellowish deposits on axillary, pubic hair

- Keratoma sulcatum      - Pitting of the soles

Mycobacteriosis - cutaneous tuberculosis

- Specific chronic granulomatous inflammation of the skin

- Mycobacterium tuberculosis (BK)

- Histology – caseificating specific granulomas

- Dying with Ziehl - Neelsen method - cultivation

- Tuberculin (Mantoux) test    - I.d. application of tuberculin - + induration over 6 mm/72h

Clinical forms of skin tuberculosis

- Primary inoculative tuberculosis      - Primary complex - ulcer + regional lymphadenitis

- Tuberculosis verrucosa cutis

- Lupus vulgaris - the most common - vitropression: yellowish brown

colour - Scrophuloderma

- Tuberculosis cutis ulcerosa

- Tuberculosis cutis miliaris

- Tuberculous gumma

Tuberkulidy     - Id - reaction - late allergic response                                 to microbial antigens          - Recurrent disseminated symmetric

non- infectious rashes as response to hematogenous spread of

mycobacterial antigens to the skin

     - Lichen scrophulosorum     - Papulonekrotical tuberculid     - Erythema induratum (Bazin)

Therapy of cutaneous tuberculosis

    - The condition of the patient

    - A combination of drugs is needed

    - Never less than 6 months of therapy

    - Short-term treatment 6-9 months, long 18-24 months

    - Main drugs - isoniazid, rifampicin

    - Ancillary drugs - streptomycin, pyrazinamide, ethambutol

Atypical mycobacteriosis

- Ulcerative and granulomatous processes (ev. lymphadenitis)    caused by other mycobacteria than M. tuberculosis    and M. leprae - Granuloma of swimming pools       - Mycobacterium marinum       - bumps in the area of trauma for 2-3 weeks       - lymphadenitis       - excision       - cryotherapy       - ATB

Leprosy

- Chronic granulomatous intracellular infection caused by bacteria Mycobacterium leprae

- The transfer by air from the nasal secretions of persons with

leprosy lepromatosa to the mucous tissue of breathing vessels of susceptible host

- Long incubation period ( from months till 30 years)

- The most common manifestation of the skin and peripheral nerves

- Early stage - leprosy indeterminata- Border forms - tuberculoid leprosy and leprosy lepromatosa- Transient forms - bordeline (dimorphic) leprosy

Diagnostic criteria of leprosy:- Hypopigmented or erythematous leasions with loss

of sensitivity

- Enlarged peripheral nerves

- Acid - resistant rods in skin swabs or biopsy      (Ziehl-Neelsen dying ) - cultivation is not possible

+ History, stay in endemic areas

- Therapy - a combination of:               - Rifampicin with dapsone or klofazimin                        - 6 months in TT, BT                         - 24 months in LL, BL

Borreliosis

- Infection caused by Borrelia burgdorferi sensu lato

- The most common carrier – tick Ixodes ricinus

- Affects the skin, nervous system, joints, heart

- Acute manifestation occurs in the area of the bite after

     7-10 days and is sometimes accompanied by non-specific

  systemic symptoms

- Erythema chronicum migrans – specific sign

Erythema chronicum migrans

Acrodermatitis chronica atrophicans

- Appears from few years to decades after infection

- Affects skin acral extensor parts of arms and legs

around the joints

- Slight swelling of livid coloured skin

- After regression of edema - skin atrophy

Borreliosis

  - Diagnostics - serology (ELISA, Western blot)

       - IgM antibodies reach peak between 3rd to 6th week after         infection (in ECM often negative)

  - Correlation with the clinical state necessary

  - Therapy - antibiotics - Doxycycline                                     - Amoxicillin                                     - Cefuroxime axetil                                     - Azithromycin                                     - Ceftriaxone i.v.

Anthropozoonoses

    - Diseases caused by microorganisms transferred       from animals to humans

- Anthrax - Bacillus anthracis - cattle

- Tularemia - Francisella tularensis - rodents

- Erysipeloid - Erysipelothrix rhusiopathie

- Maleus - Pseudomonas mallei – toed ungulated animals

Erysipeloid

- Acute inflammation of skin of hand fingers

- After injury in people who are in contact with fish,

poultry

- Non-ulcerative painful red-livid hot bearing

    in the area of injury after 2-7 days

- Penicilin p.o. 7-10 days, ev. erythromycin

Cat scratch disease

- A rare chronic infection with significant regional   lymphadenopathy

- Bartonella henselae

- Papule or vesicle in the area of the scratch after 10 days

- Systemic symptoms

- Regional lymphadenopathy persists 2-6 months

- In most cases benign

Actinomycosis - Chronic granulomatous disease

- Abscesses, fistulas, scars - men

- Fibrous facultative anaerobic bacteria - Actinomyces – G+ - A. Israel - commensals of oropharynx, intestines,

                                                 genital - mucosal injury

- Tough inflammatory infiltrates with elevated edges, fistulas, ulcers

- Cervicofacial, thoracic, abdominal form

- Microscope - yellow granular bacterial conglomerates

- Therapy - Penicillin G i.v. weeks, surgery

Thank you for your attention