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8/17/2019 Infection of the Skin, Soft Tissue,
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Titiek Djannatun
Department of Microbiology, Faculty of Medicine
-YARSI ni!er"ity
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Infection of T#e Skin
T#e flora normal of t#e "kin play an
important role in defending t#e "urface from
$foreign in!ader"%
T#e "tructure of t#e "kin #elp" in
under"tanding t#e different "ort of infection
to ic# t#e "kin and it" underlying ti""ue"
are prone
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Three lines of Microbial Attack to The
Skin
Breach of intact skin, allowing infection
from the outside
Skin manifestations of systemic infection,
which may arise as a result of blood-bornespread from infected focus to the skin or by
direct extention
Toxin-mediated skin damage due toproduction of a microbial toxin at another
site in the body (e.g. Scarlet fever, TSS
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Skin manife"tation" of "y"temic infection cau"ed
by bacteria and fungi'
Organism Disease Skin manifestation
Salmonella tiphiSalmonella paratyphi B (S.scholtmuelleri)
)nteric fe!er *Ra"e "pot"+ containing bacteria
Neisseria meningitidis Septicemia, meningiti" etec#ial or maculapapular le"ion" containing bacteria
Pseudomonas aeruginosa Septicemia )ct#yma gangreno"um, "kin le"ion pat#ognomonic ifinfected by t#i" organi"m
Treponema pallidumTreponema pertenue
Syp#ili"Ya&"
Di""eminated infectiou" ra"# "een in "econdary "tage ofdi"ea"e, .-/ mont#" ot#er infection
Rickettsia prowazekii Rickettsia rickettsii Rickettsia coronii
Typ#u"Spotted fe!er Spotted fe!er"
Macular or #emorr#agic ra"#Macular or #emorr#agic ra"#Macular or #emorr#agic ra"#
Streptococcus pyogenes Scarlet fe!er )ryt#ematou" ra"# cau"ed by eryt#rogenic to0in
Staphylococcus aureus To0ic "#ock "yndrome Ra"# and de"cuamation due to to0in
Blastomyces dermatitidis bla"tomyco"i" apule or pu"tule de!elop" into granuloma le""ion"containing organi"m"
Cryptococcus neoformans 1rytococco"i" apule or pu"tule, u""ually on face or neck
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Direct )ntry Into Skin of 2acteria and Fungi
Structure involved Infection Common Cause
3eratini4ed epit#elium Ring&orm Dermatop#yte fungi (Trichophyton,epidermophyton and microsporum5
)pidermi" Impetigo Streptococcus pyogenes and6orStaphylococcus aureus
Dermi" )ry"ipela" Streptococcus pyogenes
7air follicle" Folliculiti"
2oil" (furuncle"5
1arbuncle"
Staphylococcus aureus
Subcutaneu" fat 1elluliti" Streptococcus pyogenes
Fa"cia 8ecroti4ing fa"citi" Anaerobe" and microaerop#ile", u"uallymi0ed infection"
Mu"cle Myonecro"i" gangrene Clostridium perfringens (and ot#er1lo"tridia5
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So what will you beSo what will you be
looking for?looking for? !hysical assessment"!hysical assessment"a inspectiona inspection
b palpationb palpation
c percussionc percussion
d auscultationd auscultation
#bserve#bserve si$e, shape, color of thesi$e, shape, color of thelesions, and %yes%check the odor lesions, and %yes%check the odor
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Bacterial Infections of Skin, Soft Tissue and
Muscle:
T#e cla""ification depend" upon t#e layer of "kin and "oft ti""ue
in!ol!ed'
Ab"ce"" formation 2oil" and carbuncle" re"ult of infection and
inflamation of t#e #air follicle" in t#e "kin (folliculiti"5
Spreading infection" ("ubcutan5
& Impetigo (epidermi"5 bullou", cru"ted or pu"tular eruption of t#e
"kin
& )ry"ipela" ()ryt#ematou" inflamation5 generally on face, leg" or
feet and often accompanied by pain and fe!er
8ecroti4ing infection"
& Fa"ciiti" T#e inflamatory re"pon"e to infection of t#e "oft ti""ue
bello& t#e dermi" cau"ing di"ruption of t#e blood "upply
gangrene or myonecro"i" a""ociated &it# i"c#emia of t#e mu"cle
layer (anaerobic organi"m" ga" gangrene5
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IT!OD"CTIO
Sta#h$loccocci % derived from &reek
'sta#$le( )bunch of gra#es*
&ram #ositive cocci arranged in clusters
+ard$ organisms surviving man$ non
#h$siologic conditions
Include a maor human #athogen and
skin commensals
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Mor#holog$
microsco#is
3oku", po"itif 9ram,ter"u"un "eperti bua# anggur
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&rou#ing for Clinical -ur#oses
1. Coagulase #ositive Sta#h$lococci
Staphylococcus aureus
./ Coagulase negative Sta#h$lococci
Staphylococcus epidermidis
Staphylococcus saprophyticus
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A/ Staphylococcus aureus
Maor human #athogen
+abitat % #art of normal flora in somehumans and animals
Source of organism % can be infectedhuman host, carrier, fomite or
environment
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atural histor$ of disease
Man$ neonates, children, adults%intermittentl$ colonised b$ S. aureus
"sual sites % skin, naso#har$n0,#erineum
Breach in mucosal barriers % can enterunderl$ing tissue
Characteristic abscesses Disease due to to0in #roduction
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DIS1AS1S
Due to direct effect
of organism
2ocal lesions of
skinDee# abscesses
S$stemic
infections
To0in mediated
3ood #oisoning
to0ic shock
s$ndrome
Scalded skin
s$ndrome
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3actors #redis#osing to S. aureus
infections +ost factors
Breach in skin
Chemota0is defects
O#sonisation defectseutro#hil functional
defects
Diabetes mellitus
-resence of foreign
bodies
-athogen 3actors
Catalase )counteracts
host defences*
Coagulase+$aluronidase
2i#ases )Im#/ in
disseminating infection*
B lactasamase)ass/ 4ithantibiotic resistance*
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Virulency factors
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Di"ea"e" of "tap#ylococcu"
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S5I 21SIOS
Boils St$es
3uruncles )infection of hair follicle*
Carbancles )infection of several hair follicles*
4ound infections )#rogressive a##earance of
s6elling and #ain in a surgical 6ound after
about . da$s from the surger$*
Im#etigo )skin lesion 6ith blisters that break
and become covered 6ith crusting e0udate*
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S5I 21SIOS
)tiologi'
)ndogenou" may be ac:uired by *"elf-inoculation+ from a carrier
"ite (eg 8o"e5
)0ogenou" ac:uired by contact &it# anot#er per"on
at#ogen Stap#ylococcu" mo"t met#icylline and6or !ancomycine
re"i"tant
2oil" &it#in .-; day" of inoculation, a" "uperficial infection in
and arround a #air follicle (folliculiti"5 inten"e inflamatory
re"pon"e ab"ce""e", contain abundant yello& creamy pu"
Tretment in!ol!ed drainage and antimicroba (depend on t#e re"ult"
of "en"iti!ity te"t5 may be gi!en en t#e infection i" "e!ere and
t#e patient #e" fe!er
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Folliculiti"
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Impetigo i" a condition
limited to t#e epidermi",
&it# typically yello&,
cru"ted le"ion" It i"commonly cau"ed by
Streptococcus pyogenes
eit#er alone or toget#er &it#
Staphylococcus aureus
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D11- ABSC1SSS1S
Can be single or multi#le
Breast abscess can occur in 7%89 of
nursing mothers in #uer#eriem
Can #roduce mild to severe disease
Other sites % kidne$, brain from se#tic
foci in blood
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S$stemic Infections
'. 4ith obvious focusOsteom$elitis, se#tic arthritis
./ o obvious focus
& heart )infective endocarditis*& Brain )brain abscesses*
8/ Ass/ 4ith #redis#osing factors
multi#le abscesses, se#ticaemia )I drugusers*
Staphylococcal pneumonia )-ost viral*
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B/ TO;I M1DIAT1D DIS1AS1S
1. Sta#h$lococcal food #oisoning
Due to #roduction of entero to0ins
heat stable entero to0in acts on gut#roduces severe vomiting follo6ing a
ver$ short incubation #eriod
!esolves on its o6n 6ithin about .<hours
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./ To0ic shock s$ndrome
+igh fever, diarrhoea, shock and
er$thematous skin rash 6hich des=uamate
Mediated via >to0ic shock s$ndrome to0in?
7@9 mortalit$ rate
Described in t6o grou#s of #atients
ass/ 4ith $oung 6omen using tam#ones
during menstruationDescribed in $oung children and men
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T
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8/ Scalded skin s$ndrome
Disease of $oung children
Mediated through minorSta#h$lococcal infection b$
>e#idermol$tic to0in? #roducing strains Mild er$thema and blistering of skin
follo6ed b$ shedding of sheets of
e#idermis Children are other6ise health$ and
most eventuall$ recover
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STA7Y?
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Antibiotic sensitivit$ #attern
er$ variable and not #redictable
er$ im#/ In -t/ Management
Mechanisms
7/B lactamase #roduction % #lasmid mediated
&+as made S. aureus resistant to #enicillin grou# ofantibiotics % @9 of S/ aureus ) A*
& B lactamase stable #enicillins )clo0acillin, o0acillin,methicillin* used
./ Alteration of #enicillin binding #roteins
& )Chromosomal mediated*
& +as made S/ aureus resistant to B lactamase stable#enicillins
& 7@%.@9 S/ aureus )B* &+ ColomboT+- resistant toall -enicillins and Ce#halas#orins*
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Te"ted in lab u"ing met#icillin
Referred to a" met#icillin re"i"tant S aureu"(MRSA5
)merging problem in t#e &orld
In Sri ?anka pre!alence !arie" from .C- ;C in#o"pital"
Drug of c#oice - !ancomycin
In Japan emergence of KIRSA(!ancomycin
intermediate re"i"tant S aureu"5
8o effecti!e antibiotic" di"co!ered -Ge mig#t #a!e
to di"co!er
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DIA&OSIS
7/ In all #us forming lesions
&ram stain and culture of #us
./ In all s$stemic infectionsBlood culture
8/ In infections of other tissues
Culture of relevant tissue or e0udate
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./ Sta#h$lococcus e#idermidis
Skin commensal
+as #redilection for #lastic material
Ass/ 4ith infection of I lines, #rosthetic
heart valves, shunts Causes urinar$ tract infection in
cathetarised #atients
+as variable ABS #attern Treatment should be aided 6ith ABST
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8/ Sta#$lococcus sa#ro#h$ticus
Skin commensal
Im#/ Cause of "TI in se0uall$
active $oung 6omen "suall$ sensitive to 6ide range of
antibiotics
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Streptococcal Skin Infection"(Streptococcus pyogenes5
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roperty of 2acterial
?ong c#ain cocci, gram po"iti!e
1oloniforn in 2lood Agar "moot# &it# ß #emoly"i" Sen"iti!e bacitracyn
7yaluronida"e #elp t#e organi"m to "pread in ti""ue,lymp#atic in!ol!ement, re"ulting lymp#adeniti" andlymp#angiti"
?y"ogenic "train" produce pyrogenic e0oto0in"(erytrogenic to0in"5 A" &it# TSST- in S.aureus, are
"uperantigen" &it# a potent influence on t#e immune"y"temyrogenic e0oto0in SpeA act on "kin blood!e""el" to cau"e t#e diffu"e eryt#ematou" ra"# of "carletfe!er, "treptococcal p#aryngiti", to0ic "#ock "yndrome
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roperty of 2acterial
Surface protein" antigen (M and T5 "ubdi!ided (type5
"treptococcu" a""ociated &it# "kin infection (differ from
t#e type" a""ociated &it# "ore t#roat"5
T rotein play no kno&n role in !irulence, and t#eir
function i" unkno&n
M protein !irulence factor" in#ibit op"onini4ation
and confer bacterium re"i"tant to p#agocyto"i"
Additional factor" to t#e !irulence organi"m lipoteic#oat
acid and F protein facilitate binding to epit#el cell"
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Im#etigo
mpetigo is a condition limited to the epidermis, with typically yellow,
crusted lesions. t is commonly caused by Streptococcus pyogenes
either alone or together with Staphylococcus aureus
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ImpetigoImpetigo
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ImpetigoImpetigo
Superficial skin infectionSuperficial skin infection
Bacterial%staphylococcusBacterial%staphylococcus
or streptococcusor streptococcus
Spread w) direct contactSpread w) direct contact
w) lesionsw) lesions
Thick, yellow crustThick, yellow crust
(commonly on the face(commonly on the face
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ImpetigoImpetigo
S)SS)S
- one or more pimple-like- one or more pimple-like
lesions surrounded bylesions surrounded by
reddened skinreddened skin- lesions fill w) pus and- lesions fill w) pus and
later form a thick crustlater form a thick crust
- itching- itching
TxTx
- Topical or oral *B+- Topical or oral *B+
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Erysipelas : infeksi oleh Streptococcus pyogenus melibatkan dermal lymphatic. Batas jelas dari
erythema dan indurasi. Bila infeksi pd mukamaka bentuk radang seperti kupu!kupu " butter-fy wing) R#eumatic fe!er "ebagai
kelanjutan dari infek"i
Streptococcus pyogenus
pd kulit jarang terjadi
R#eumatic fe!er
kebanyakan terjadi
"bg kelanjutan infek"i
Streptococcus
pyogenus pada
tenggorokan
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Acute 9lomerulonep#riti"
1auced by M type" (M;E5 Streptococcus pyogenes
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Acute 9lomerulonep#riti"
enicillin i" drug of c#oi"e, alt#oug#
eryt#romycin or an oral cep#alo"porin may be
u"ed for penicllin-allergic patient"
Se!ere infection may re:uire #o"pitali4ation Since A98 rarely recur" on "ub"e:uent
"treptococcal infection, longLterm pfofila0i"
&it# penicillin i" not indicated (in contra"t
follo&ing r#eumatic fe!er5
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1elluliti" and 9angrene
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Introduction
1elluliti" i" an acute "preading infection of t#e "kin t#at in!ol!e"
"ubcutaneu" ti""ue" )0tend deeper t#an ery"ipela"
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G#en t#e focu" of infection i" in "ubdermal fat, celluliti"-a "e!ere and
rapidly progre""i!e infection-i" t#e typical pre"entation ?arge bli"ter"
and "cab" may al"o be pre"ent on t#e "kin "urface
#$%$&I'S(() %I'&*BI*+*,I
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#$%$&I'S(() %I'&*BI*+*,I-$+++I/IS
2a#an pemerik"an'
a"pirat pada daera# pinggiran le"i pada bagian trauma (bila ada5
biop"i kulit
dara#
enyebaran penyakit "angat progre""if
keber#a"ilan i"ola"i patogen dari penderita .-/
penyebab utama adala# Streptococcus pyogenus dan
Staphylococcus aureus karena #al-#al ter"ebut diata" maka
diagno"e infek"i #anya dari gambaran klinik "akit
antimikroba pili#an, adala# antimikroba yang dapat
menanggulangi etiologi utama (S.pyogenus & S.aureus)
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Anaerobic 1elluliti"
Terjadi pad adaera# yang mengalami trauma, pada lukaopera"i
1endrung terjadi pada penderita diabete"
)tiologinya erat #ubungannya dengan loka"i infek"i'
ada bagian ba&a# tubu# kuman dari tinja danurin (pd &anita5
ada luka gigitan kuman bera"al dari mulut
2ila terjadi "ynergi"me antar etiologi (kuman aerob
Stapylococcu" dll dengan kuman anaerob Infek"i yg"angat de"truktif
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Anaerobic 1elluliti"
ciri-ciri k#a"nya' di"c#arge bau, pembengkakan di"ertai adanya ga" pada
bagian ba&a# jaringan
i b i l " hi i
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0iabetic ulcers "this one is0iabetic ulcers "this one is
necrotic tissue1necrotic tissue1
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0iabetic lcers0iabetic lcers
Sores on feet, especially onSores on feet, especially on
diabetic patientsdiabetic patients
hyhy
herehere- areas subected to weight- areas subected to weight
bearingbearing
- heel- heel
- tips of most prominent toes- tips of most prominent toes
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0iabetic lcers0iabetic lcers
S)SS)S
- painful, red sore on foot- painful, red sore on foot
- pus when infected- pus when infected
- foul-smelling discharge- foul-smelling discharge
TxTx
- sterile cleaning, dressings- sterile cleaning, dressings
- refer to diabetic- refer to diabeticspecialist)surgeon forspecialist)surgeon fordebridement or amputationdebridement or amputation
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8ecroti4ing Faciiti"
Merupakan infek"i yg akut dan fatal, etiologinya campurandari kuman anaerob dan kuman fakultatif anaerob
infek"i yg "angat tok"ik, menyebabkan nekro"i" berat yang
menyebar ke jaringan "ekitar dan ba&a#nya
)tiologi utamanya Streptococcus pyogenus (fle"# eating bacteria5 kematian tinggi
)k"i"i radical diperlukan untuk mengangkat jaringan
nekrotik
pembrian antibiotik lokal dan "i"temikFa"ciiti" pada dinding perut berakibat fatal
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8ecroti4ing Faciiti"
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Tok"in yang tela#
berikatan dengan
"yaraf tidak dapatdinetralkan ole#
antitok"in
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Traumatic or Surgical Gound" Infected
infek"i "ynergi"tik antara 7i"toto0ic 1lo"tridia dan kuman
fakultatif anaerob (flora normal tubu# lingkungan5
infek"i ber"ifat aggre""if dan de"trukti!e
tindakan amputa"i terpak"a dilakukan guna mencega# penyebaran
tok"in ke bagian tubu# lainnya
Yang tergolong dalam 7i"toto0ic 1lo"tridia' C.perfringens (yang
utama5, C.histolyticum' C.no%yi' C.solderli dll 5
Memproduk"i aneka ragam tok"in dan en4ym, memiliki
kemampuan memeca# karbo#idrat,gunanya untuk mempermuda#
in!a"i kuman dan pembentukan ga" pada antar aringan
aringanmati membengkak memberi bau khas
sbg isolat dpt ditemukan satu atau lebih kuman /lostridia, dan kuman
fakultatif anaerob lainnya
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er#atikan jaringan necro"i" dan akumula"i dari ga" pada jaringan
8ecro"e di"ebabkan ole# N tok"in memuda#kan infek"i kejaringan "e#at lainnya
(jarpengikat antar "el ru"ak5
3umula"i ga" "ebagai akibat fermenta"i (di"ertai pembentukan ga"5 pemeca#an
protein ole# Clostridium perfringens dan kuman aerob ikutan lainnya
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A 2
erbeni#an agar telur
A L H anti-tok"in
2 L tanpa anti-tok"in
ji netrali"a"i tok"in 8A9?)R untuk penentuan typeClostridium perfringens
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#ropionibacterium acnes and (cne
*cne teradi karena kera sama antara Propinibacteriun acnes denganperubahan horman pada masa puber
merupakan infeksi campuran, sebagai isolat selalu ditemukan" kuman
anaerob P.acnes (sebagai etiologi dan kuman aerob
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Mycobacterial Di"ea"e" of T#e Skin
0isebut uga sbg 1orbus 2ansen (2ansen3s disease atau 4epra
5tiologi Mycobacterium leprae
Bentuk batang (6 7ram" tahan asam
Belum dapat dibiak pd perbenihan sintetis
1asa inkubasinya lama (belum ada kesepakatan !enyebaran penyakit erat hubungannya dengan sosial ekonomi,
kepadatan penduduk, hygin dll
7ambaran klinik penyakit erat hubungannya dengan 8 /ell 1ediated
mmune (/19 response terhadap M.leprae”
Bentuk tuberculoid leprosy (TT lesi merah, mati rasa, padamuka, badan kaki dan tangan, dapat sembuh dengan sendirinya
Bentuk lepromateus leprosy (44, prognosisnya lebih buruk dari
pada (TT
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Mycobacterial Di"ea"e" of T#e Skin