Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and...
Transcript of Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and...
![Page 1: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/1.jpg)
![Page 2: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/2.jpg)
Learning Objectives Common Bacterial Infections
recognition
treatment
complications
Infectious Dermatologic Emergencies
Necrotizing Fasciitis
Toxic Shock Syndromes
![Page 3: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/3.jpg)
Normal Skin FloraMajor function is to prevent skin infections
Provides ecological competition for pathogens
Hydrolyzes the lipids in sebum into free fatty acids which are toxic to many bacteria- linoleic and linolenic acid are more inhibitory of Staph Aureus
Antimicrobial Peptides from lamellar bodies, Cathelicidins, and Defensins function to control overgrowth of pathogens
![Page 4: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/4.jpg)
Normal Skin FloraAerobic Cocci
Staphylococcus epidermidis Most common coccus on human skin
All body sites, especially intertriginous areas
Staphylococcus aureus More common in Atopic Dermatitis, Diabetes Mellitus, Hemodialysis,
IVDU, Liver Disease, and HIV
resident or contaminant?
anterior nares- 20-35%
perineum- 20%
axillae and toe webs- 5-10%
![Page 5: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/5.jpg)
Normal Skin FloraAerobic Coryneform Bacteria Corynebacterium minutissimum- intertriginous sites
Erythrasma
Anaerobic Coryneform Bacteria Propionibacterium acnes- sebaceous glands, hair follicles
Acne vulgaris
Gram Negative Bacteria Acinetobacter species- axillae, perineum, antecubital fossae
- Requires moisture and maceration which increases pH and CO2
levels
Yeast Pityrosporum ovale/Malassezia furfur- sebaceous sites
Tinea Versicolor
![Page 6: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/6.jpg)
![Page 7: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/7.jpg)
Introduction Strep and Staph cause the majority of skin infections
in immunocompetent patients
Immunodeficiency and underlying systemic disease result in severe infections which tend to be refractory to treatment
![Page 8: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/8.jpg)
Skin Disease related to bacterial pathogens may be: 1. Direct skin infection
2. Toxin mediated cutaneous eruption
3. Secondary skin infection of a primary skin disease
4. Manifestation of primary infection of another organ system
5. Reactive skin condition from antigen/immune mediated process
![Page 9: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/9.jpg)
Impetigo Contagiosa
![Page 10: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/10.jpg)
Impetigo Contagiosa Most common bacterial skin infection in kids
Highly contagious via direct contact
Incidence increased in late Summer and early Fall
Non-bullous and bullous forms
Predisposing factors
warm temps
high humidity
poor hygiene
skin trauma - tinea pedis, varicella, HSV, scabies, insect bites
nasal and/or perineal colonization
![Page 11: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/11.jpg)
Non-bullous Impetigo Staphylococcus aureus primarily (developed countries)
Previously S. pyogenes (continues to be in developing countries)
Bacteria adhere to proteins exposed by trauma or breaks in the skin
70% of all impetigo
![Page 12: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/12.jpg)
![Page 13: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/13.jpg)
![Page 14: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/14.jpg)
![Page 15: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/15.jpg)
![Page 16: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/16.jpg)
![Page 17: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/17.jpg)
![Page 18: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/18.jpg)
![Page 19: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/19.jpg)
Bullous Impetigo(hx pemphigus neonatorum) Staph aureus phage types 55 and 71 or related group 2
phage type
Flaccid blisters mediated by Staph toxins Toxins attack cell adhesion molecule desmoglein 1
“localized Staph Scalded Skin”
Nikolsky sign negative
Lesions appear on intact skin
Neonates primarily Present with weakness, fever, diarrhea
![Page 20: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/20.jpg)
![Page 21: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/21.jpg)
Impetigo Circinata
![Page 22: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/22.jpg)
![Page 23: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/23.jpg)
![Page 24: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/24.jpg)
![Page 25: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/25.jpg)
Impetigo: Work-up Gram stain of exudate
neuts with Gram + cocci in chains or clusters
Culture
S. aureus is cultured consistently from fluid
Streptococci are found only occasionally
Usually in combination with Staph
Must rule out resistant organisms (MRSA)
Biopsy is indicated in some cases
![Page 26: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/26.jpg)
![Page 27: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/27.jpg)
Impetigo: Treatment Saline compresses to remove fluid and crust
Mild, localized cases: Remove crust, topical mupirocin to lesions and nares/anus
Extensive and/or bullous cases systemic antibiotics are required 7 days for Staph, 10 days for strep
dicloxacillin or cephalexin
Erythromycin for PCN allergic
If recurrent, culture nares and treat for carriage
![Page 28: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/28.jpg)
Impetigo: Complications Post-streptococcal GN (all age groups)
Meningitis or sepsis (infants)
Ecthyma, erysipelas, cellulitis
Bacteremia
Osteomyelitis, septic arthritis
Pneumonia
![Page 29: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/29.jpg)
Post-Streptococcal Glomerulonephritis Not prevented with antibiotic treatment
2-5% of impetigo cases, 10-15% if nephritogenic strains
Nephritogenic strains include: serotype 49, 55, 57, 60 and M type 2
![Page 30: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/30.jpg)
Impetigo: Prognosis
Early, appropriate therapy results in complete recovery within 7-10 days
Early treatment limits the probability of scarring and complications
Neonates have increased incidence of generalized infection and meningitis
Antibiotic treatment will neither prevent nor halt glomerulonephritis
Culture is mandatory if the lesions have not resolved within 7-10 days
![Page 31: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/31.jpg)
Ecthyma
![Page 32: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/32.jpg)
Ecthyma Initially described in wartime on covered feet
Deeper form of impetigo
Thickly crusted erosions or ulcerations
Streptococcus pyogenes: primary agent
Rapidly superinfected with Staph aureus
Lower extremities, usually < 10 lesions
![Page 33: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/33.jpg)
EcthymaHigh risk populations
poor hygiene
minor trauma
children
neglected elderly
lymphedematous limbs
immunocompromised
Vesicule pustule ‘punched out’ crusted ulcer
Purulent, necrotic base
Heals with a scar
Rare complications bacteremia
cellulitis
osteomyelitis
![Page 35: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/35.jpg)
![Page 36: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/36.jpg)
Ecthyma Diagnosis
deep tissue biopsy for Gram stain and culture
Treatment
dicloxacillin or cephalexin for at least 10 days usually requires several weeks of treatment
![Page 38: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/38.jpg)
Ecthyma Gangrenosum(Pseudomonas Sepsis)
![Page 39: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/39.jpg)
Scarlet Fever
![Page 40: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/40.jpg)
Scarlet Fever Group A β-Hemolytic Streptococcus
Erythrogenic Toxins A, B and C Strains B and C are a more common cause but A is more
virulent
Majority of cases occur in kids aged 1-10 Winter and Springtime Clinical settings:
Following Strep tonsillitis or pharyngitis Following surgery “surgical scarlet fever” Pelvic and puerperal infections Burns
![Page 41: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/41.jpg)
Staph may cause a similar presentation: Scarlatiniform erythroderma
Scarlatiniform rash
No pharyngitis
No strawberry tongue
More tender
![Page 42: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/42.jpg)
Scarlet Fever Eruption is produced by a
toxin- mediated delayed-type hypersensitivity reaction
Antibodies against the toxins are protective
80% of the population has protective Ab by age 10
![Page 43: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/43.jpg)
Scarlet Fever:Clinical Features Abrupt onset sore throat, F/C/N/V/HA, malaise Rash begins 24-48 hours later Proximal erythema of neck, chest and axillae
generalizes within 6 hours Spreads from neck down Spares the palms and soles
Red, sandpaper-like rash blanches with pressure Flushed cheeks with circumoral pallor Pastia’s Lines: linear petechiae in flexures White, then red strawberry tongue Desquamation in 7-10 days, lasts 4 weeks
![Page 44: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/44.jpg)
![Page 45: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/45.jpg)
![Page 46: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/46.jpg)
![Page 47: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/47.jpg)
![Page 48: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/48.jpg)
![Page 49: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/49.jpg)
![Page 50: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/50.jpg)
![Page 51: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/51.jpg)
![Page 52: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/52.jpg)
Scarlet Fever
Otitis
Mastoiditis/Sinusitis
Pneumonia
Myocarditis
Meningitis
Arthritis
Hepatitis
Glomerulonephritis
Rheumatic fever
Clinical
Throat culture
Anti-Streptolysin O Ab
Anti-DNase B Ab
Penicillin x 10-14 days
Erythromycin if pen allergy
Treatment prevents rheumatic fever
Complications Diagnosis/Treatment
![Page 53: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/53.jpg)
Staph ScaldedSkin Syndrome
Ritter’s Disease
Dermatitis Exfoliativa Neonaturum
![Page 54: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/54.jpg)
Staph Scalded Skin Syndrome Staphylococcal toxin-mediated infection
Staph Scalded Skin Syndrome
Toxic Shock Syndrome
Bullous Impetigo
Staph aureus phage group II strains
Exfoliative exotoxins ET-A and ET-B
Serine protease which attack cell adhesion molecule-Cadherins (Desmoglein-1)
results in superficial skin cleavage as seen in PemphigusFoliaceous
![Page 55: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/55.jpg)
Staph Scalded Skin SyndromeHigh Risk Populations
Neonates (nursery outbreaks)
Children less than 6 years old
Adults with chronic renal insufficiency
Immunocompromise
Why?
Toxins are renally excreted
Neonates, kids, and CRI pts cannot clear the toxins
![Page 56: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/56.jpg)
Staph Scalded Skin Syndrome
Prodrome
fever, malaise, irritability, skin tenderness
purulent rhinorrhea or conjunctivitis
![Page 57: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/57.jpg)
Staph Scalded Skin Syndrome
Initial:localized tender erythema with periorificial and fexural
accentuation
Hours:erythema generalizes with an orange red color, skin wrinkles,
flaccid bullae
1-2 days:slough results in moist, thin, varnish-like crust
3-5 days:
scaling and desquamation
10-14 days:re-epithelialization without scarring
![Page 58: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/58.jpg)
Differentiating from TEN: Patients should not appear toxic
There should be no mucosal erosions
No palms or sole involvement
Biopsy
![Page 59: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/59.jpg)
![Page 60: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/60.jpg)
![Page 62: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/62.jpg)
![Page 63: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/63.jpg)
![Page 64: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/64.jpg)
![Page 65: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/65.jpg)
![Page 66: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/66.jpg)
Staph Scalded Skin Syndrome:Diagnosis Clinical
Culture:
intact bullae are always negative
conjunctivae, nasopharynx, feces or pyogenic foci on the skin may be positive
blood is negative in kids, may be + in adults
Biopsy: superficial cleavage in granular layer, no organisms
Toxin ID via ELISA, immunodiffusion
![Page 67: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/67.jpg)
Staph Scalded Skin Syndrome:Treatment
Severe Hospitalization for parenteral antibiotics
Local wound care w/ bland emollients
Localized Oral β-lactamase-resistant antibiotic
Dicloxacillin, cephalexin x 7-14d
Local wound care
Isolate affected newborns from other neonates
Identify and treat asymptomatic carriers
![Page 69: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/69.jpg)
Erysipelas(aka St. Anthony’s Fire, Ignis Sacer)
Group A β-Hemolytic Strep, occ Group C and G
Group B Strep in Newborns and Postpartum
Involves superficial dermis and lymphatics
At risk populations
Children, elderly
Debilitated, diabetic, alcoholic
Immunocompromised
Lymphedematous extremities
Chronic ulcers
![Page 70: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/70.jpg)
ErysipelasA defect in the skin barrier
allows bacteria to enter
trauma, abrasions, skin ulcers
insect bites, eczema, psoriasis
Other predisposing factors
Lymphatic obstruction or edema
Saphenous vein grafting
Post- radical mastectomy
Arteriovenous insufficiency
Paretic limbs
![Page 71: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/71.jpg)
Erysipelas Lower extremity is most common location
Abrupt onset of fever, chills, nausea, malaise
Well demarcated, indurated elevated border, painful plaque
Regional lymphadenopathy +/- streaking
May develop vesicles, bullae, necrosis
Resolves w/ desquamation &↑pigmentation
Underlying disease may obscure borders
![Page 73: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/73.jpg)
![Page 74: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/74.jpg)
![Page 75: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/75.jpg)
![Page 76: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/76.jpg)
Erysipelas: Diagnosis Clinical
Elevated WBC with a left shift
ASLO and anti-DNase B: reasonable indicators
Cultures Blood: + in 5%
Skin biopsy: rarely +
Portal of entry, pustules or bullae: +/-
Throat and nose: +/-
![Page 77: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/77.jpg)
Erysipelas: Treatment Penicillin x 10 days
Macrolide if penicillin- allergic
Children and debilitated patients
May need admission for IV antibiotics
Recurrent cases may warrant prophylaxis
![Page 78: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/78.jpg)
ErysipelasComplications
Gangrene / amputation
Bacteremia / sepsis
Scarlet fever
Pneumonia
Abscess
Embolism
Meningitis
Death
Prognosis:
Excellent in immunocompetent patients with proper treatment
Chronic edema
Scarring
Elephantiasis in chronic, recurrent cases
![Page 79: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/79.jpg)
![Page 81: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/81.jpg)
Perianal Cellulitis Kids less than 4 years old
Pruritus, painful defecation, bloody stools
No systemic symptoms
May follow/accompany pharyngitis
May initiate guttate psoriasis
Dx: skin culture (anus and throat)
Rx: penicillin or erythromycin x 14-21 days
![Page 82: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/82.jpg)
Cellulitis
![Page 83: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/83.jpg)
Cellulitis
Involves the deep dermis and subcut. tissues
Adults: S. pyogenes and S. aureus
Children: S. aureus and H. flu
Immunocompromised
gram-negative bacilli
Pseudomonas, Proteus, Serratia, Enterobacter
other opportunistic pathogens
Fungi (Cryptococcus)
anaerobes
![Page 84: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/84.jpg)
Cellulitis
Bacterial portal of entry
Immunocompetent External (disrupted skin barrier)
Immunocompromised Hematogenous (S. pneumoniae)
Predisposing factors
Alcoholism, diabetes, malignancy, PVD, IVDA
Tinea pedis
Lymphatic damage node dissection, vein harvest, prior cellulitis
![Page 85: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/85.jpg)
History of preceding event: Surgical Wounds- Staph aureus
Pressure Ulcers- Staph aureus, Pseudomonas aeruginosa, B. fragilis, Enterobacter
Bites- Cat- P. multocida, Dog- P. multocida, Capnocytophaga canimoris Human- Eikenella
![Page 86: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/86.jpg)
![Page 87: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/87.jpg)
Cellulitis Fever, malaise and cutaneous inflammation
Ill defined, non-palpable erythema
May develop vesicles, bullae and necrosis
Ascending lymphangitis and regional LAD
![Page 88: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/88.jpg)
Cellulitis Children- head, neck, perianal
Adults- extremities
IVDA- upper extremities
Complications
Acute GN if caused by a nephritic strain of GAS
Subacute bacterial endocarditis
Lymphatic damage ► stasis ► recurrent cellulitis
![Page 89: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/89.jpg)
![Page 90: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/90.jpg)
![Page 92: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/92.jpg)
![Page 93: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/93.jpg)
![Page 95: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/95.jpg)
Cellulitis: Diagnosis Clinical
Blood culture- only if bacteremia suspected
Staph and Strep cases positive in < 5%
H. flu may be positive
Needle aspiration
Rarely obtained, ~30% yield
May be helpful in immunocompromised pts as high as 60% positivity
Skin biopsy
Special stains can identify causative organisms
![Page 96: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/96.jpg)
Cellulitis: TreatmentMild cases
Outpatient setting
10 day course of oral agents active against staph and strep dicloxacillin, cephalexin, cefuroxime axetil, clindamycin
Severe cases
Face, immunosuppression, or significant comorbidities
Inpatient setting initially with IV antibiotics, wound care Cefazolin, ceftriaxone, piperacillin/tazobactam
Allergic Patients
Clindamycin, vancomycin, metronidazole + ciprofloxacin
![Page 97: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/97.jpg)
Cellulitis: TreatmentWound Care
Immobilization and elevation
Cool saline compresses to exudative areas
Bland emollients if exfoliative
Avoid NSAIDs mask signs/sx of deeper necrotizing infections
Control underlying disease Tinea pedis, stasis dermatitis, fissures
![Page 98: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/98.jpg)
Necrotizing Fasciitis“Flesh-eating Bacteria”
A rapidly progressing necrosis of subcutaneous fat and fascia
Can be life threatening without prompt recognition, surgical intervention, and immediate
antibiotic therapy
![Page 99: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/99.jpg)
Necrotizing FasciitisType 1: Polymicrobial
Aerobes and anaerobes
Strep, Staph, E. coli, Bacteroides, Clostridium
Organisms enter at sites of trauma or surgery
Slower pace of progression
Type 2: Group A Strep (10%)
M proteins: resist phagocytosis
Pyogenic exotoxins: act as superantigens Mediate fever, shock, and tissue injury
![Page 100: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/100.jpg)
Severe, rapidly progressing cellulitis unresponsive to
standard therapies
Extremities are #1 site
![Page 101: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/101.jpg)
![Page 102: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/102.jpg)
![Page 103: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/103.jpg)
![Page 104: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/104.jpg)
![Page 106: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/106.jpg)
![Page 107: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/107.jpg)
![Page 108: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/108.jpg)
![Page 109: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/109.jpg)
Necrotizing Fasciitis:Clinical Features Involved areas become anesthetic
Tissue may develop woody induration
Patient may become toxic +/- shock
Fournier’s Gangrene- like type 1
Originates from the scrotum
Spreads to perineum and abdominal wall
![Page 110: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/110.jpg)
![Page 111: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/111.jpg)
![Page 112: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/112.jpg)
![Page 113: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/113.jpg)
![Page 114: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/114.jpg)
![Page 115: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/115.jpg)
Necrotizing Fasciitis: Risk Factors
Group A Strep- Type 2 Young, previously healthy patients
Polymicrobial- Type 1 Elderly, diabetics, alcoholics, CAD, PVD
Penetrating or blunt traumatic injury
Ulcers, recent surgery, disrupted skin
Many cases occur in the absence of identifiable risk factors
![Page 116: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/116.jpg)
Necrotizing Fasciitis Mortality ranges from 20-40%
Increased mortality in: Diabetics, elderly, malnourished, obese, PVD
Delayed diagnosis and treatment
Cases caused by Group A Strep
Prognostic factors: Hypotension on admission
WBC on admission >15.4
Serum Na < 135
MRI findings positive
![Page 117: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/117.jpg)
Necrotizing Fasciitis: DiagnosisClinical exam
Severe pain oranesthesia
Rapid progression
Bullae formation
Toxic shock syndrome
Elevated CPK
Relevant history surgery, trauma, NSAIDs,
etc.
Work-Up
MRI delineates depth
CT pinpoints site
Surgical consult
Tissue Bx for culture Advancing edge
Deep fascia
![Page 118: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/118.jpg)
Necrotizing Fasciitis:Treatment Surgical fasciotomy
Antimicrobials based on initial Gram stain
Β-lactam with broad spectrum coverage against GNR, staph, strep, and anaerobes
eg. piperacillin/tazobactam
If septic, add ciprofloxacin
If pen-allergic, consider cipro + metronidazole
![Page 119: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/119.jpg)
Necrotizing Fasciitis:Treatment
Hyperbaric oxygen is controversial- most data in anaerobic bacteria
IVIG in Group A Strep cases- anecdotal
Investigational drug Tefibazumab- humanized monoclonal antibody against microbial surface compounds
Recombinant Activated Protien C in severe sepsis
Intensive supportive care
![Page 120: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/120.jpg)
![Page 121: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/121.jpg)
![Page 123: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/123.jpg)
![Page 124: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/124.jpg)
Toxic Shock Syndromes Toxin-mediated multisystem disease precipitated by
infection with Staph aureus or Strep pyogenes (Group A Strep)
Strep is more common than Staph
Characterized by:
Sudden onset of high fever and hypotension
Petechial or maculopapular rash
Severe N/V/D/HA/ST, myalgia, confusion, coma
High mortality
![Page 125: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/125.jpg)
Toxic Shock Syndromes Consider in anyone presenting with abrupt onset fever,
rash, hypotension, renal or respiratory failure, and mental status changes
Risk factors HIV, diabetes, cancer, other chronic disease
Alcoholism
Recent varicella infection (chicken pox)
Patients using NSAIDs
![Page 126: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/126.jpg)
![Page 127: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/127.jpg)
Strep Toxic Shock Syndrome Healthy adults aged 20-50
A clinically apparent soft tissue infection is usually present in 80%
Abscess; cellulitis; necrotizing fasciitis
![Page 128: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/128.jpg)
Strep Toxic Shock Syndrome
Direct tissue invasion and destruction
Cutaneous barrier disruption = portal of entry
Streptococcal pyrogenic exotoxins, SPEA,SPEB and Strep M protein 1 and 3:
Act as superantigens
Stimulate T-cells
Massive cytokine production-TNFα, IL 1, IL6
Tissue injury and shock
![Page 129: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/129.jpg)
![Page 130: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/130.jpg)
Super Antigens Not MHC restricted
Binds the Variable region of T cell receptor and conserved area of MHC II
Normal antigen binds all five variable sites to activate T cells
While antigen stimulation may case 0.1% T cell activation, superantigen is able to activate 20-30% of T cells
Increases CLA- cutaneous lyphocyte antigen, leading to increased homing of lymphocytes to the skin
Massive release of TNFα, IL1, IL6
![Page 131: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/131.jpg)
Streptococcal TSS:Clinical Features Begins insidiously with flu-like symptoms
Severe pain in an extremity
80% have an apparent soft tissue infection
Not associated with tampon usage
Blood Cultures + in greater than ½ unlike Staph 1/10
Vesicles and bullae indicate a deeper infection and a worse outcome
![Page 132: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/132.jpg)
Streptococcal Toxic Shock SyndromeCutaneous findings:
Soft tissue infection (80%)
Generalized erythematous eruption
Acral desquamation in 20%
Shock and multi-organ failure within 48-72o
![Page 134: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/134.jpg)
![Page 135: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/135.jpg)
![Page 136: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/136.jpg)
![Page 137: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/137.jpg)
Streptococcal TSS Case Definition(JAMA 1993)
Isolation of S. pyogenes from a normally sterile site blood, CSF, pleural fluid definite case
OR
Isolation from a nonsterile site throat, sputum, vagina, superficial skin lesion probable case
![Page 138: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/138.jpg)
Streptococcal TSS Case Definition(JAMA 1993)
PLUS
Hypotension
SBP < 90 mmHg or < 5th percentile (kids)
AND
Multi-organ involvement (2 or more systems)
renal, hepatic, pulmonary, hematologic, cutaneous
![Page 139: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/139.jpg)
Strep TSS Treatment Intensive supportive therapy
Intravenous antibiotics
Surgical intervention
![Page 140: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/140.jpg)
Strep TSS Treatment Clindamycin (900 mg IV q8h)
1st line
Inhibits bacterial toxin production
β-lactam antibiotics alone are not 1st line
aggressive S. pyogenes infections do not respond well to penicillin and are associated with high morbidity/mortality
![Page 141: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/141.jpg)
Strep TSS Treatment Clindamycin 900 mg IV q8h
Clindamycin 900 mg IV q8h
+
Penicillin G 4 million U IV q4h
Mortality: high (30-70%)
![Page 142: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/142.jpg)
![Page 143: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/143.jpg)
Staph Toxic Shock Syndrome Toxin production by Staphylococcus aureus
Described in 1978
Associated with tampons in 1980
Currently, non-menstrual cases predominate
![Page 144: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/144.jpg)
Staph Toxic Shock SyndromeToxic Shock Syndrome Toxin-1- menstruation
Exotoxin has 3 main mechanisms acts as a superantigen
direct toxic effects on organ systems
impairs clearance of endogenous endotoxins derived from gut flora
Able to cross mucous membranes
Staph Enterotoxin B and C for nonmentruating
![Page 145: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/145.jpg)
Staph Toxic Shock Syndrome:Clinical Settings/Risk Factors
Surgical wounds
Postpartum infections
Focal pyodermas
Deep abscesses
Nasal packing
Tampons
Insulin pump infusion sites
Peritonsillar abscesses
Sinusitis
Osteomyelitis
![Page 146: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/146.jpg)
Staph Toxic Shock Syndrome:
Clinical Features Abrupt onset
F/N/V/D/HA, pharyngitis, myalgias
Rapid progression to shock
Spectrum: mild to rapidly fatal
Skin findings are extensive and predictable
![Page 147: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/147.jpg)
Staph TSS: Clinical Features Diffuse scarlatiniform exanthem
Erythema and edema of the palms and soles
Mucous membrane erythema
Strawberry tongue
Conjunctival hyperemia
Generalized non-pitting edema
Acral desquamation 1-3 weeks after onset
![Page 148: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/148.jpg)
![Page 149: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/149.jpg)
![Page 150: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/150.jpg)
![Page 151: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/151.jpg)
![Page 152: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/152.jpg)
![Page 153: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/153.jpg)
![Page 154: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/154.jpg)
![Page 155: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/155.jpg)
![Page 156: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/156.jpg)
Dx: Staph Toxic Shock SyndromeCenters for Disease Control and Prevention, 1990
Fever: > 39.6 C / 102 F
Rash: diffuse macular erythroderma
Desquamation of palms/soles in 1-2 weeks
Hypotension: SBP < 90 mmHg or < 5th %
Involvement in 3 or more organ systems
Absence of other causes
![Page 157: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/157.jpg)
Rx: Staph Toxic Shock Syndrome
Intensive supportive care
Removal of nidus of infection
Combination antibiotic therapy
eradicate Staph and suppress toxin production
Surgical debridement
IVIG (anecdotal; small series)- Demers, 1993; Stevens, 1998; Kaul, 1999
![Page 158: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/158.jpg)
Rx: Staph Toxic Shock Syndrome
IV β-lactamase resistant antimicrobial
nafcillin or oxacillin (2 g q4h)
1st generation cephalosporins
vancomycin if penicillin allergic
Add clindamycin to reduce toxin synthesis
Continue antibiotics for 10-14 days
Mortality: low (<3%)
Recurrance in 20% -avoid triggers
![Page 159: Learning Objectives - DermpathMD.comdermpathmd.com/Clinical Dermatology/Bacterial Infections and Infectious... · Pelvic and puerperal infections Burns Staph may cause a similar presentation:](https://reader035.fdocuments.in/reader035/viewer/2022063017/5fda0691ff42cd490e54f7e6/html5/thumbnails/159.jpg)