Infections of the skin and soft tissue I&II - Stillwell Flashcards
cellulitis
- inflammation of skin and underlying subcu tissue (deeper than impetigo)
- cause: strep A (GAS) mainly - also group B,C,G,F; also staph aureus, MRSA, MSSA*
- pink –> reddish –> peels like sunburn; no margins
- gets worse before it gets better*
- neutrophils infiltrate subcu
- use antibiotics that treat both staph and strep*
- red area around bullous cellulitis (no red around bullous impetigo - only by staph aureus)
bullous cellulitis vs. bullous impetigo
- bullous cellulitis –> staph or strep; erythema around edge
- bullous impetigo –> only staph aureus; no erythema
erysipelas
- infection of dermis and lymphatics
- more superficial than cellulitis
- cause: group A strep (GAS)
- face or extremities
- lymphatic and venous insufficiency
- bright red, good margins
erythema
- redness of skin/mucous membranes
- cause: increased blood flow
- due to infection (not always), inflammation, skin injury
exanthem
- widespread rash
- cause: infection, toxin, drugs, autoimmune
- ex. measles
enanthem
- rash on mucous membranes of mouth
- viral infection
- ex. herpangina (enterovirus)
pustule (pimple)
- collection of pus in skin (inflammatory cells and fluid)
- small abscess
folliculitis
- inflammation or pustular infection of hair follicle (micro abscesses)
- cause: staph aureus
- hot tub –> pseudomonas aeruginosa
furunculosis
- multiple boils around hair follicles
- larger than folliculitis, smaller than abscesses
skin abscess
- collection of pus in dermis and subcu tissue
- cause: infection or foreign material
- can be sterile or infectious
- larger than furuncle
- staph aureus –> musty odor
- dental abscess –> mixed flora
carbuncle
- cluster of abscesses walled off in separate pockets (loculated) by fibrosis
- many chambers
- I&D to break up pockets
impetigo
- superficial bacterial skin infection (epidermis) –> honey colored rust
- cause: Staph most common (in north); strep most common (in south)*; staph in infants/children
- bullous impetigo –> ONLY staph aureus –> exfoliative toxin (targets desmoglein1) –> cleave off stratum corneum
ecthyma
- same as impetigo, but deeper into dermis
- shallow ulcer that contains pus (punched out lesion)
- brown/black crust; purple, red around edges
- sometimes necrotic
pyoderma
-any skin disease/dermatitis with pus
lymphangitis
- infection of deep lymphatics
- red streaking
lymphadenitis
- infection/inflammation of lymph node –> node enlargement and erythema
- causes: chlamydia and herpes
parnoychia
- infection around nail
- cause: staph aureus (main); can be mix (aerobes and anaerobes)
- recurrent –> herpetic whitlow (HSV1>HSV2) –> vesicles and ulcers
felon
- fingertip abscess (palmar side)
- can be on toe
- can form pus pocket –> I and D
onychomycosis
-fungal infection of nail –> nail thickening
intertrigo
- jock itch - skin inflammation/infection
- many regions; moist areas
- common in diabetics and immunocompromised
- antibiotics –> wipe out normal flora –> fungal overgrowth
- causes: candida –> satellite lesions
miliaria
- heat rash
- inflamed/blocked sweat glands
- backs of patients that are bed ridden
- no antibiotics necessary
- become infectious w/o proper treatment
scarletina
- sandpaper rash
- cause: mainly strep; can be staph
- from toxins released
- scarletina –> scarlet fever –> TSS
Panniculitis
- inflammation of deep, subcu fat (infiltrate of inflammatory cells)
- nodules over extremities and abdomen
- infectious, autoimmune, traumatic, or other diseases
- ex. erythema nodosum (immune response due to infection) and necrotizing panniculitis (necrosis and vasculitis)
- confused with Sweet’s syndrome (superficial nodules in dermis, neutrophil infiltrate, necrosis, non-infectious)**
epidermis
- no blood vessels or nerves
- stratum corneum (dead cells)
- Langerhan cells (macrophages)
- acidic pH of skin
dermis
- macrophages (surveillance)
- fibroblasts
- adipocytes
- contain blood and lymphatic vessels and nerves
subcutaneous tissue (hypodermis)
- fat and connective tissue
- larger vessels and nerves
- macrophages and mast cells
- hair follicles and sweat/sebaceous glands
normal skin flora
- help protect from pathogenic organisms
- only worry about in immune compromised or prosthetic devices**
1. staph coagulase neg. species –> staph epidermidis (body odor)
2. propionibacterium (acne)
3. bacillus (foot odor)
4. Cornebacterium
5. micrococcus
6. 30% colonized with MSSA; 1-5% with MRSA –> high chance of infection with surgery, trauma, lesions
ways to get skin and soft tissue infections
- skin barrier disruption (abrasions, wounds, IVDA, gun shot)
- skin inflammation (psoriasis, sunburn, vasculitis)
- penetrate skin (hair follicles, glands)
- secondary infection
- infection spread from blood to skin
- heavy colonization of pathogens
- edema (decreased lymphatic and venous drainage) –> stasis dermatitis in surgeons, truck drivers
- deficient immune system (chemo, diabetes)
- obesity (low blood flow)
pathogens of skin/soft tissue infection
- strep and staph most common –> many virulence factors
- hyaluronidase aka spreading factor (both staph aureus and GAS) –> break polysaccharides and connective tissue*
- coagulase (staph aureus) –> fibrinogen to fibrin forming clots
- M protein in GAS –> prevent opsonization
cellulitis pathogens
- GAS (common) –> also causes erysipelas
2. Staph aureus (rare)
abscess pathogens
- staph aureus (common)
skin infection - unvaccinated children pathogen
- H. influenza
skin infection - water exposure pathogen
- aeromonas hydrophilia (freshwater)
- vibrio vulnificus (saltwater, oysters)
- mycobacterium marinum (fresh/saltwater, fish tanks)
- pseudomonas aeruginosa and edwardsiella (freshwater)
wounds infections - dog and cat bites pathogens
- pasteurella multocida (toxin decreases dendritic cells)
- capnocytophaga canimorsus (splenectomy –> septic)
- bartonella hensalae (cat scratch)
- anaerobes (fusobacterium, prevotella, bactericides)
wound infections - human bites pathogens
- Eikenella corrodens (IV drug abusers)
- staph aureus (common)
- strep viridans (mouth)
wound infections - rat bite pathogens
- streptobacillus moniliformis
- spirillum minus
- both cause rat bite fever –> may lead to sepsis
- septic arthritis or endocarditis
- osler nodes, laneway lesions, petechia
wound infections - snake bite pathogens
- pseudomonas aeruginosa
wound infections - primate bite pathogens
- Herpes B virus (herpes simiae)
2. monkey pox (orthopox virus)
skin lesions - sheep and goats
- orf (paravox virus)
skin lesions - cattle
- cowpox (orthopox virus)
2. bacillus anthracis (anthrax)
surgery site infections pathogens
- staph aureus (common)
- gram negative rodds
- strep
intertrigo pathogens
- fungal infections
1. trichophyton
2. epidermophyton
3. microsporum
4. candida –> satellite lesions is cardinal sign**
puncture wound through shoe pathogens
- pseudomas aeruginosa
cellulitis in butchers, fisherman, farmer pathogens
- erysipelothrix rhusiopathiae (erysipeloid in humans)
- gram positive rod
erythrasma pathogens
- cornebacterium minutissimum (fluoresces, diabetics, obese)
- groin, armpits, under pannus and breasts
ecthyma gangrenosum pathogens
- pseudomonas aeruginosa
- usually elderly people who are septic**
hot tub folliculitis pathogens
- pseudomonas aeruginosa
rocky mountain spotted fever pathogens
- rickettsia rickettsia (rash on palms, soles, ankles, wrists)
- central petechia
- involves endothelial cells
bacterial toxins in skin and systemic tissue infections
- major virulence factors
- exotoxins –> skin changes/damage
- superantigens –> activate immune system –> produce cytokine and lymphokine
exotoxins with local effects
- staph aureus –> hemolysins (form lytic pores causing lysis); ex. PVL (in community acquired MRSA infections)–> tissue necrosis around wound (not spider bite)
- pseudomonas aeruginosa –> protease inhibit fibrin formation; tissue necrosis/apoptosis
- clostridium perferinges –> lecithinase degrades cell membranes and produce liquifactive necrosis
- bacillus anthracis –> 3 exotoxins causing edema, lysis, and decrease in macrophages; form black eschar
exotoxins with distal effects
- streptococcus –> pyrogenic exotoxins –> scarletina, scarlet fever, TSS
- scarletina (sandpaper rash, pastia lines, spares palms/soles)**
- scarlet fever (more sever, GAS, fever, pharyngitis, strawberry tongue)
- TSS (hypotension, organ failure, scarletinaform rash) –> progress to necrotizing fasciitis and pneumonia - staph aureus –> TSST-1 and enterotoxin/exfoliative toxins –> staph scarletina, staph scalded skin syndrome (SSSS), staph TSS
- staph scarletina (less common than strep)
- SSSS (scarletinaform rash, Nikolsky sign*, bullous impetigo)
- staph TSS (scarletinaform rash that desquamates, hypotension, organ failure) –> can get from menstrual or nonmenstrual
necrotizing fasciitis aka gas gangrene or flesh eating
- polymicrobial (aerobes and anaerobes)
- causes: clostridium perferinges (main), clostridium septicum, fusobacterium, peptostreptococcus, bacteroides, prevotella
- also staph aureus and strep, which make exotoxins
- need antibiotics and debridement
Fournier’s gangrene**
- type of necrotizing fasciitis
- perineum, groin, thighs (entire scrotum lost)
- poorly controlled diabetics and alcoholics
- bad mortality
hidradenitis suppurativa (acne inversa)
- occur after puberty
- dysfunctional apocrine sweat glands and hair follicles
- inflammatory nodules –> abscesses –> scars
- excise glands following with skin graft
- genetic and environmental
acne
- clogged hair follicles and oil glands
- genetic and increase in testosterone
- cause: propionibacterium acne –> pustular infection
- secondary infection of lesions with staph. aureus
Vibrio vulnificus**
- marine environments, fresh/saltwater
- oyster shucking/eating
- worry about immune compromised (cirrhosis due to alcoholics, hemochromatosis from bad Fe metabolism)
- develop shock, bullous lesions (dark, purple/black), necrotizing infections
localized lymphadenitis
- inflammation of lymphatic vessels
- usually pyogenic secondary to staph or strep
- causes: Tularemia and cat scratch disease/bartonella (common), some STIs like chancroid and chlamydia, mycobacterium TB and atypical mycobacterium, plague (yersinia), and fungal infections (blastomycosis/histoplasmosis)
mycobacterium marinum*
- fish tank granuloma**
- AFB stains and cultures –> tissue fite
tuberculous leprosy (Hansen’s disease)
- atypical mycobacterium (mycobacterium leprae) –> noncaseating granulomas
- inflammation in nerves
- biopsy with AFB stain to prove
- does not grow on culture
- hypopigmented plaques
- malaysian people
periorbital (preseptal) cellulitis
- inflammation/infection around orbit –> eyelid shut
- spread from sinuses or dental infections
- antibiotic therapy alone
- risk of retrograde seeding –> venous plexus and cavernous sinus –> septic phebitis and cavernous sinus thrombosis
- can damage cranial nerves (3,4,5)
- orbital cellulitis (more severe) –> restrict extra ocular muscles, cause proptosis
dacrocystitis
infection of lacrimal sac due to obstruction of nasal lacrimal duct
-need surgical drainage
pyoderma gangrenosum (PG)
- not infected, use steroids or immunosuppressives instead
- immune mediated –> “sea of neutrophils” –> vasculitis and fibrin clot
- ulcerative lesion with localized necrosis
- arms, legs, face –> occur at trauma sites or pinpricked
- not treated with antibiotics
methods to diagnose skin/soft tissue infections - lab
- blood cultures (always done prior to antibiotics; both aerobic and anaerobic)
- injection of saline and re-aspiration
- swabs or tissue biopsy from open wounds for culture
- aspiration of fluid from abscess
- swabs and fluid sent for gram stain, aerobic and anaerobic cultures
- tissue sent for histology/H&E stain
histology/H&E stains
- warthin-starry cat scratch stain –> bartonella
- GMS stain –> fungal/yeast (ex. aspergillus)
- mucicarmine stain –> cryptococcus
methods to diagnose skin/soft tissue infections - radiology
- X ray (tissue swelling, gas)
- sonography (fluid, aspiration guidance)
- CT (inflammation, fluid/gas, aspiration guidance)
- MRI (best; soft tissue)