Download - The Skin
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The Skin and Beyond:Skin and Soft Tissue Infections
John Sinnott, MD, FACPAssociate Dean, International Affairs
Director, Signature Program in Allergy, Immunology and Infectious DiseaseDirector, Division of Infectious Disease
University of South Florida, College of Medicine
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Pretentious Quote:
… [T]he skin has diseases, one of those diseases is man.
Friedrich Nietzsche
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In General: Skin Lesions
Tumors Rashes
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Melanoma:
• A symmetric
• B order — irregular
• C olor — pigment variable
• D iameter > 0.5 cm
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Skin Infections:
LAYER INFECTION
Epidermis Impetigo
Dermis Erysipelas
SubQ Cellulitis
Fascia Fasciitis-(NSTI)
Muscle Myositis-(NSTI)
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Pathogens:
• Impetigo contagiosum – GAS
• Impetigo bullosum – Staph
• Erysipelas – GAS
• Cellulitis – Staph, GAS
• Fasciitis – GAS, Mixed
• Myositis – Clostridia
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CA-MRSA: NB
• CA – MRSA is increasing and may become more like HA-MRSA
DM, prisoners, contact sports are old risk groups; now everyone is at risk
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Variant Cellulitis: Bites or Water !
Human Bite: GAS
anaerobes
Dog Bite: C. canimorsus
P. multocida
Cat Bite: P. multocida
Saltwater: V. vulnificusM. marinum
Fresh water: E. tarda
A. hydrophila
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Edwardsiella: Treatment
• All Edwardsiella sensitive to: – Tetracyclines, aminoglycosides, most
B-Lactams, cephalosporins, quinolones, antifolates
• All Edwardsiella resistant to:– Macrolides, streptogramins, glycopeptides,
rifampin, PRSP’s
Stock I, Wiedemann B. Natural Antibiotic Susceptibilities of Edwardsiella tarda, E. ictaluri, and E. hoshinae. Antimicrob Agents Chemother, 2001 August; 45 (8): 2245-2255.Harrison's Principles of Internal Medicine, 16th Edition. Kasper D, Braunwald E, Fauci A, et al, Eds. 134: 6. 2006
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Necrotizing Soft Tissue Infections: “NSTI’S”
• Fournier’s gangrene
• Clostridial anaerobic cellulitis
• Clostridial gas gangrene
• Necrotizing fasciitis– Type 1 NF- polymicrobial (Fournier’s)
– Type 2 NF- Grp A Strep (IVIG, HB O2)
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Gas in Soft Tissue:
• Non-bacterial Causes– Trauma / Surgery
– Air Injection
– H2O2 Irrigation
• Bacterial– Glucose Fermenting
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Diagnosis NSTI’s:
• Serial exams!
• Serial exams!
• Soft tissue X- ray, MRI, CT
• Low threshold for surgery–Full thickness frozen-section Bx–Direct visualization–Gram stain
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Management and Therapy:
• Hemodynamic stabilization, nutrition, lytes, fluid resuscitation, oxygenation
• Early, aggressive and repetitive debridement
• Early, aggressive and repetitive debridement
• Hyperbaric tx• A-B’s
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37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A
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37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A
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37 y/o male with alcoholic cirrhosis admitted for RLE cellulitis; DX necrotizing fasciitis, BCX grew Group Strep A
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Miscellaneous Dermatologic Manifestations of Disease:
• Pseudomonas folliculitis• Herpetic Whitlow• Herpes Gladiatorum• Molluscum Contagium• Seborrheic Dermatitis• Secondary Syphilis
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“We know too much and believe too little.”
T. S. Elliot
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END
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