Twenty Skin Infections that an It itSh ldKInternist Should ... · Twenty Skin Infections that an It...

Twenty Skin Infections that an Twenty Skin Infections that an I t i t Sh ld KI t i t Sh ld KInternist Should Know Internist Should Know

Ana Paula Velez, MD, FACPAna Paula Velez, MD, FACPAssistant ProfessorAssistant Professor

University of South FloridaUniversity of South FloridaUniversity of South FloridaUniversity of South Florida

ObjectivesObjectivesObjectivesObjectives

•• 1.1. Identify the most and challenging skin Identify the most and challenging skin infections commonly encounter in the infections commonly encounter in the outpatient and inpatient practiceoutpatient and inpatient practice

•• 2.2. Recognize some complications Recognize some complications ecog e so e co p cat o secog e so e co p cat o sassociated with skin infectionsassociated with skin infections

•• 33 Formulate medical or surgicalFormulate medical or surgical•• 3.3. Formulate medical or surgical Formulate medical or surgical treatment plan for these infectionstreatment plan for these infections

Case 1

ImpetigoImpetigoImpetigoImpetigo

•• Group A Streptococcus and S. Group A Streptococcus and S. AureusAureus•• Blisters or ulcersBlisters or ulcersBlisters or ulcersBlisters or ulcers•• “Candy like crust” Group A Streptococcus“Candy like crust” Group A Streptococcus•• “Varnish like” bullous S“Varnish like” bullous S aureusaureus•• Varnish like bullous, S. Varnish like bullous, S. aureusaureus•• Culture under the crustCulture under the crust•• Acute GlomerulonephritisAcute Glomerulonephritis•• Not Acute rheumatic Not Acute rheumatic ffeverever

Case 2Case 2Case 2Case 2

ERYSIPELAS

A. group A strept >> group C or G or BB 70-80% lower extremityB. 70-80% lower extremityC. 5-20% on faceD lymphedemaD. lymphedemaE. recurrence rate 30% in 3 yearsF D’ ll d t d l t dF. peau D’orange, well demarcated elevated

border, dermal involvement

ErysipelasErysipelasErysipelasErysipelas

•• Bright red, edematousBright red, edematous•• Advancing, raised, sharply demarcatedAdvancing, raised, sharply demarcatedAdvancing, raised, sharply demarcated Advancing, raised, sharply demarcated

borderborder•• Systemic toxicity: fever leukocytosisSystemic toxicity: fever leukocytosis•• Systemic toxicity: fever, leukocytosisSystemic toxicity: fever, leukocytosis•• Group A streptococci if Group A streptococci if nonpurulentnonpurulent

SS if lif l•• S. S. aureusaureus if purulentif purulent

CELLULITESCELLULITES

1) SQ tissue2) SA, GAS2) SA, GAS3) Indistinct border not elevated

Cellulitis (continued)

4. GAS/Clostridia surgical wound infx 6-48 hr gincubation

5 SA SWI> 48 hr incubation5. SA SWI> 48 hr incubation

6. tinea pedis portal of entry

7. recurrent cellulites grp B or G – esp ? GU malig.

8 h i h i ll li i8. saphaneous vein harvest site – recurrent cellulitis

9. rec. Rx pen augmentin, keflex, clinda, levop g , , ,

BiteBite vsvs FurunculitisFurunculitis ( Case 4)( Case 4)Bite Bite vsvs FurunculitisFurunculitis ( Case 4)( Case 4)

CMRSACMRSACMRSACMRSA

•• Sharing personal itemsSharing personal items•• Skin cuts, abrasions (sports, militarySkin cuts, abrasions (sports, militarySkin cuts, abrasions (sports, military Skin cuts, abrasions (sports, military

recruits)recruits)•• Skin to skin contacts(MSM sportsSkin to skin contacts(MSM sports•• Skin to skin contacts(MSM, sports Skin to skin contacts(MSM, sports

participants, correctional facilities)participants, correctional facilities)•• Crowding(correctional facilities day care)Crowding(correctional facilities day care)•• Crowding(correctional facilities, day care) Crowding(correctional facilities, day care)

NECROTIZING FASCIITISNECROTIZING FASCIITIS

1 T I1. Type Ia) anaerobes (Bacteroides, peptostrepto)b) anaerobic streptococcic) GNR (E.coli, Enterobacter, Kleb)

NECROTIZING FASCIITIS2. Type II

a) grp A strepta) grp A streptb) occ Staph ac) risks trauma diabetes PVD cirrhosisc) risks – trauma, diabetes, PVD, cirrhosis,

steroidsd) toxic shock like syndrome hypothermiad) toxic shock-like syndrome – hypothermia,

shock MS, MSOF, CPK, localized erethema 30% mortality young healthy adults y y g yafter minor trauma

3. Anesthesia of area involved

NecrotizingNecrotizing FascitisFascitisNecrotizing Necrotizing FascitisFascitis

•• Macule BullaeMacule Bullae•• Pain NumbPain NumbPain NumbPain Numb•• Red BlueRed Blue--greygrey•• EdemaEdema CrepitanceCrepitance•• Edema Edema CrepitanceCrepitance

TherapyTherapyTherapyTherapy

•• Surgical emergencySurgical emergency•• BetalactamBetalactam/beta/beta--lactamase inhibitor pluslactamase inhibitor plusBetalactamBetalactam/beta/beta lactamase inhibitor plus lactamase inhibitor plus

clindamycin with an agent with activity clindamycin with an agent with activity against MRSAagainst MRSAaga st Saga st S

•• Intravenous ImmunoglobulinIntravenous Immunoglobulin

Intravenous ImmunoglobulinIntravenous ImmunoglobulinIntravenous ImmunoglobulinIntravenous Immunoglobulin

•• Binds toxin presenting TBinds toxin presenting T-- cell receptor cell receptor activationactivation

•• Most experience in streptococcal shock Most experience in streptococcal shock syndrome syndrome sy d o esy d o e

CLOSTRIDIAL CELLULITIS) C f i C tia) C. perfringes, C. septicum

b) traumatic wounds) i b i l dc) incubation – several days

d) crepituse) muscle normal (Clostridial gangrene muscle

involved)f) / li d /bl / / bf) pcn/clinda/blactam/BI/carbapenomg) (gas also produced by E.coli, Kleb, Aeromonas)

Vib i l ifiVibrio vulnificus

Saltwater exposure within the past 7 days. In US, mainly states bordering Gulf of Mexico., y g April through October. Highest fatality rate in liver disease.Highest fatality rate in liver disease. Occupation risk

Dock worker, oyster schucker, commercial fisherman Dock worker, oyster schucker, commercial fisherman Tx with cefotaxime, doxycycline or quinolone.

SPONTANEOUS, NONTRAUMATIC GAS GANGRENE C SEPTICUM

a) colon cancer 88%

GAS GANGRENE C. SEPTICUM

)b) diverticulitisc) bowel infarctionc) bowel infarctiond) neutropenic enterocolitis AGC <500 e) volvuluse) volvulusf) mortality 67-100% (most in 24 hrs)

Neutropenic EnterocolitisNeutropenic Enterocolitispp(Typhlitis)(Typhlitis)

•• RLQ rebound tendernessRLQ rebound tenderness•• CT abdomen thicken ileocecumCT abdomen thicken ileocecumCT abdomen thicken ileocecumCT abdomen thicken ileocecum•• Ileus or diarrheaIleus or diarrhea•• Neutropenia day 5Neutropenia day 5 2121•• Neutropenia day 5Neutropenia day 5--2121•• Pathogens: Clostridia septicum, GNR’s Pathogens: Clostridia septicum, GNR’s

l C did d ldl C did d ldrarely Candida and moldsrarely Candida and molds•• Rx: Flagyl, Zosyn, Meropenem, Rx: Flagyl, Zosyn, Meropenem,

ClindamycinClindamycin

Fournier GangreneFournier GangreneFournier GangreneFournier Gangrene

Case 8Case 8Case 8Case 8

P d iPseudomonas aeruginosa

Hot tub folliculitis Appears 1-3 days after

exposure Predisposition

Length of time in water Length of time in water Increased number of

bathersH hl i ti Hypochlorination

Resolves spontaneously Not contagious Not contagious.

FOLLICULITIS

A. SA (beard – sycosis barbae)B. PSA whirlpool/hot tub/swimming

poolC. CandidaD. Malassezia furfurE. Eosinophilic pustular folliculitis

TinaTinaTinaTina

What are the top 3 What are the top 3 ppdermatophytesdermatophytes??•• TrichophytonTrichophyton rubrumrubrum•• MicrosporumMicrosporum caniscanisMicrosporumMicrosporum caniscanis•• EpidermophytonEpidermophyton floculosumfloculosum

ERYTHRASMAERYTHRASMA

1 C b i i i i i1. Corynebacterium minitissimum2. Coral pink flourescence – woods lamp3. Eythro x 7 days topical clinda4. Groin R/O tinea cruris4. Groin R/O tinea cruris

NODULAR LYMPHANGITISNODULAR LYMPHANGITIS

1 S t i h i ( h )(it l )1. Sporotrichosis (sphagnum moss)(itraconazole)2. Nocardia brasiliensis3 M b i i h l i f i3. Mycobacterium marinum, chelonei, fortuitum4. Francesella tularensis5. Leishmania braziliensis

Mycobacterium marinum—”Fish T k G lTank Granuloma

Acquisition Before 1962--hypochlorinated swimming pools. After 1962--cleaning aquariums. Also crab bites, sea-urchin spines

Single ulcerated lesion Single ulcerated lesion Sporotrichoid pattern lymphatic spread.

Diagnosis delayed Diagnosis delayed Tx for 3-12 months.

Clarithromycin, doxycycline, septra or C y , y y , prifampin +ethambutol

M b t i f t itMycobaterium fortuitum

Atypical, rapidly growing AFB. Associated with pedicures or foot baths.p Causes lower extremity furunculosis. Most heal spontaneously but some scar.Most heal spontaneously but some scar. Could tx with ciprofloxacin, clarithromycin or

doxycycline.y y

RGM OutbreaksRGM OutbreaksRGM OutbreaksRGM Outbreaks

l l h l l f b h Cl l h l l f b h C•• Nail salon whirlpool footbath in CANail salon whirlpool footbath in CA•• M M fortuitumfortuitum furunculosisfurunculosis•• 61 patients61 patients•• 61 patients61 patients•• Mean disease duration 170 days (41Mean disease duration 170 days (41--336)336)•• 48 Rx48 Rx AbxAbx median 4median 4 momo (1(1--66 momo))48 Rx 48 Rx AbxAbx median 4 median 4 momo (1(1 6 6 momo))•• SensitvitySensitvity most to most to ciprocipro and minocyclineand minocycline•• Earlier Rx = shorter duration of diseaseEarlier Rx = shorter duration of disease•• 1 1 pateintpateint had lymphatic disseminationhad lymphatic dissemination•• CID 2004;38:38CID 2004;38:38--4444

RGM OutbreaksRGM OutbreaksRGM OutbreaksRGM Outbreaks

•• Nail salon whirlpool footbath in CANail salon whirlpool footbath in CA•• MM fortuitumfortuitum furunculosisfurunculosisM M fortuitumfortuitum furunculosisfurunculosis•• 110 patients110 patients•• # of boils median 2 (1# of boils median 2 (1 37 range)37 range)•• # of boils median 2 (1# of boils median 2 (1--37 range)37 range)•• Shaving legs with a razor before pedicure Shaving legs with a razor before pedicure

i k f f i f ii k f f i f iwas a risk factor for infectionwas a risk factor for infection•• NEJM 2002;346:1366NEJM 2002;346:1366--7171

RGM OutbreaksRGM OutbreaksRGM OutbreaksRGM Outbreaks

•• Facelifts (Facelifts (RhytidectomiesRhytidectomies) in NJ) in NJ•• Outpatient surgical centerOutpatient surgical centerOutpatient surgical centerOutpatient surgical center•• 4 patients with M 4 patients with M chelonaechelonae infectioninfection•• Contaminated methylene blue used as aContaminated methylene blue used as a•• Contaminated methylene blue used as a Contaminated methylene blue used as a

tissue marking agent tissue marking agent MMWR 2004 53 192MMWR 2004 53 192 44•• MMWR 2004;53:192MMWR 2004;53:192--44

RGM OutbreaksRGM OutbreaksRGM OutbreaksRGM Outbreaks

f S 2003f S 2003•• LipotouristsLipotourists from US to DR 2003from US to DR 2003--44•• 8 healthy Hispanic females underwent 8 healthy Hispanic females underwent abdominoplastiesabdominoplasties•• SxSx developed median 7 weeks (1developed median 7 weeks (1--18 18 wkswks))p (p ( ))•• Presented with painful, red, draining SQ abdominal Presented with painful, red, draining SQ abdominal

nodulesnodules•• 2 of 8 correctly diagnosed at presentation2 of 8 correctly diagnosed at presentation2 of 8 correctly diagnosed at presentation2 of 8 correctly diagnosed at presentation•• 7 I and D’s7 I and D’s•• 6 Combo 6 Combo AbxAbx macrolide and IV macrolide and IV abxabx cefoxitincefoxitin, , imipenemimipenem, ,

amikacinamikacin and/or linezolidand/or linezolidamikacinamikacin, and/or linezolid, and/or linezolid•• All but 1 cured after median 9 All but 1 cured after median 9 momo (2(2--12 12 momo))•• CID 2008;46:1181CID 2008;46:1181--88

Atypical HSV PresentationsAtypical HSV PresentationsAtypical HSV PresentationsAtypical HSV Presentations

•• Linear Erosive Herpes Simplex Virus Linear Erosive Herpes Simplex Virus Infection in Infection in ImmunocompromisedImmunocompromisedPatients. It can be seen in the mouth or Patients. It can be seen in the mouth or genitalsgenitals

•• The “KnifeThe “Knife--Cut Sign” Cut Sign” •• IntertriginousIntertriginous fissuresfissures•• IntertriginousIntertriginous fissuresfissures•• Clinical Infectious Diseases 2008;47:1440Clinical Infectious Diseases 2008;47:1440––

144114411441 1441

What is the Rx of acyclovir What is the Rx of acyclovir resistant herpes simplex orresistant herpes simplex orresistant herpes simplex or resistant herpes simplex or herpes zoster? herpes zoster? pp•• FoscarnetFoscarnet IV (NEJM 1991;325:551IV (NEJM 1991;325:551--5)5)•• CidofovirCidofovir IV (JID 1994;170:570IV (JID 1994;170:570--2)2)•• CidofovirCidofovir (NEJM 1993;329:968(NEJM 1993;329:968--9, JID 9, JID

1997;176:8921997;176:892--8)8)•• ImiquimodImiquimod (Am J Med 2006;119:e9(Am J Med 2006;119:e9--11, Arch 11, Arch

DermDerm 2001;137:10152001;137:1015--17)17)•• TrifluridineTrifluridine (JAIDSHR 1996;12:147(JAIDSHR 1996;12:147--152)152)•• Interferon Interferon alfaalfa and and TrifluridineTrifluridine (Arch (Arch DermDerm

1995;131:241995;131:24--55

Case 16Case 16Case 16Case 16

Hutchinson’s signHutchinson’s signHutchinson s sign Hutchinson s sign

1)Jonathan Hutchinson (1828-1913)2) HZ of tip of nose likely to also involve the eye3)Nasal branch of the3)Nasal branch of the nasociliary nerve

Case 18Case 18Case 18Case 18

Case 19Case 19Case 19Case 19

Case 20Case 20Case 20Case 20

NonNon infectiousinfectious skinskin conditionsconditionsNonNon--infectious infectious skin skin conditions conditions

Most common bacterial causes Most common bacterial causes of erythema of erythema nodosumnodosum

• Streptococcus infectionsp• TB• Yersinia• Yersinia• Mycoplasma• LGV• LGV• Salmonella

C l b• Campylobacter

What is the most common What is the most common fungal cause of erythemafungal cause of erythemafungal cause of erythema fungal cause of erythema nodosumnodosum

Coccidiodomycosis• Coccidiodomycosis• Histoplasmosis• Blastomycosis

What is the most common drug What is the most common drug ggcause of erythema cause of erythema nodosumnodosum•• Oral contraceptivesOral contraceptives•• SulfaSulfaSulfaSulfa•• Halides (gold, Halides (gold, iodinesiodines))

Do not forgetDo not forgetDo not forget…Do not forget…

ReferencesReferencesReferencesReferences

•• Dennis L. Stevens,1,3 Alan L. Bisno,5 Henry F. Practice Guidelines for the Diagnosis and Dennis L. Stevens,1,3 Alan L. Bisno,5 Henry F. Practice Guidelines for the Diagnosis and Management of Skin and SoftManagement of Skin and Soft--Tissue Infections. Clinical Infectious Diseases ; 2005 ; 41 : 1373 Tissue Infections. Clinical Infectious Diseases ; 2005 ; 41 : 1373 --1406 1406

•• SiberrySiberry GKGK TekleTekle T Carroll K et al Failure of clindamycin treatment of methicillinT Carroll K et al Failure of clindamycin treatment of methicillin--resistantresistantSiberrySiberry GK, GK, TekleTekle T, Carroll K, et al. Failure of clindamycin treatment of methicillinT, Carroll K, et al. Failure of clindamycin treatment of methicillin resistant resistant Staphylococcus Staphylococcus aureusaureus expressing inducible clindamycin resistance in vitro. expressing inducible clindamycin resistance in vitro. ClinClin Infect Dis. 2003 Infect Dis. 2003 Nov 1;37(9):1257Nov 1;37(9):1257--6060

•• Richard L Richard L OehlerOehler, Ana P Velez, Michelle , Ana P Velez, Michelle MizrachiMizrachi, et al. Bite, et al. Bite--related and septic syndromes caused related and septic syndromes caused by cats and dogs. by cats and dogs. Lancet Infect Dis 2009; 9: 439Lancet Infect Dis 2009; 9: 439––4747

•• Winthrop KL, Winthrop KL, AlbridgeAlbridge K, South D, et al. The clinical management and outcome of nail salonK, South D, et al. The clinical management and outcome of nail salon--acquired Mycobacterium acquired Mycobacterium fortuitumfortuitum skin infection. skin infection. ClinClin Infect Dis. 2004 Jan 1;38(1):38Infect Dis. 2004 Jan 1;38(1):38--44.44.

•• Winthrop KL, Abrams M, Winthrop KL, Abrams M, YakrusYakrus M, et al. An outbreak of mycobacterial M, et al. An outbreak of mycobacterial furunculosisfurunculosis associated associated with footbaths at a nail salon. N with footbaths at a nail salon. N EnglEngl J Med. 2002 May 2;346(18):1366J Med. 2002 May 2;346(18):1366--71.71.

•• Mycobacterium Mycobacterium chelonaechelonae Infections Associated with Face Lifts Infections Associated with Face Lifts ------ New Jersey, 2002New Jersey, 2002——2003. 2003. MMWR 2004;53:192MMWR 2004;53:192--44

•• E. Yoko Furuya,1,a Armando Paez,5,a E. Yoko Furuya,1,a Armando Paez,5,a ArjunArjun SrinivasanSrinivasan, et al. Outbreak of Mycobacterium , et al. Outbreak of Mycobacterium abscessusabscessus Wound Infections among “Wound Infections among “LipotouristsLipotourists” from the United States Who Underwent ” from the United States Who Underwent AbdominoplastyAbdominoplasty in the Dominican Republic CID 2008;46:1181in the Dominican Republic CID 2008;46:1181 88AbdominoplastyAbdominoplasty in the Dominican Republic. CID 2008;46:1181in the Dominican Republic. CID 2008;46:1181--88

•• Jeffrey I. Cohen. Herpes Zoster. N Jeffrey I. Cohen. Herpes Zoster. N EnglEngl J Med 2013; J Med 2013; 369:255369:255--263263