Bacterial cutaneous infection DERMATOLOGY REVISION NOTES
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LEPROSY CELLULITIS IMPETIGO LEPROSY REVISION NOTES FOR NEET PG AIIMS PREPARATION WITH HIGH YIELD TOPICS BASED ON LECTURE NOTES AND PREVIOUS YEAR QUESTIONS \\
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Bacterial cutaneous infection DERMATOLOGY REVISION NOTES
- 1. Bacterial cutaneous infection TONY SCARIA 2010 KMC
- 2. Erysipelas • a/c inflammation of lymphatics • Grp A beta haemolytic streptococcus pyogenes • Malar area of face & lower extremities • Regional lymphadenopathy + • Recurrent erysipelas 2* to lymphedema • Staphylococcus aureus Skin trauma Inoculation of bacteria Fiery red , indurated tense shiny plaque with raised sharply demarcated advancing margins Erysipiliod caused by eryspilothrix acquired from fish bone
- 4. Milian’s ear sign in erysipelas can involve ear lobule but not in case of cellulitis
- 5. ERYSIPELAS CELLULITIS CAUSATIVE AGENT GROUP A BETA HEMOLYTIC STREPTOCOCCUS STRAPH & STREPT BORDERS SHARP DIFFUSE LYMPHANGITIS MORE COMMON LESS COMMON TOXICITY LESS MORE
- 6. Scarlet fever • Grp A beta haemolytic streptococci • Pyogenic exotoxin A,B,C • Most common in children 2- 10 years usually following streptococcal pharyngitis
- 9. Pastia’s lines in scarlet fever • Accentuation of linear erythema in skin folds
- 11. Impetigo
- 12. Bullous •Staph aureus Non bullous •Impetigo contagiosum •Streptococcus >> staph •Most common
- 13. Impetigo contagiosum(non bullous) • Grp A beta haemolytic streptococci >> staph aureus • Mc infection in Preschool /young children • Face,especially around mouth and nose • Thin walled blisters on erythematous base rupture immediately honey coloured crust • Lesions spread with out central clearing • Lymphadenopathy • Complications • Scarlet fever, erysiplelas, cellulitis,post streptococcal GN Gloden yellow honey coloured crust
- 14. Bullous impetigo • Coagulase positive group II S aureus • Neonates and infants • Face and other parts of body • Thick walled persistent blisters on bland skin rupture slowlyvarnish like crust • Lesions heal in centre to form annular patches • Complications • Ssss ,pemphigus neonatorum,cellulitis,lymphangitis
- 16. • Rx • FUSIDIC ACID • MUPIROCIN • RETAPAMULIN • SYSTEMIC • DICLOXACILLIN • ERYTHROMYCIN • CEPHALOSPORIN
- 17. Complications • PSGN • SSSS • SCARLET FEVER
- 18. Ecthyma • Vesicle or vesicopustule • Deep infection of skin d/t Gp A streptococci • Which involves extra follicular portion (i.e hair follicles spared) • Post streptococcal GN can develop • Involves LL • MC : buttocks , thigh and legs
- 19. • STAPH + STREPTECTHYMA PYOGENICUM • PSEUDOMONAS AERUGINOSAECTHYMA GANGRENOSUM • PARAPOX VIRUS • ZOONOSES FROM SHEEP & GOAT ECTHYMA CONTAGIOSUM
- 20. Ecthyma gangrenosum • Skin manifestation of Ps aeruginosa bacteremia • In critically ill immunocompromised neutropenic patients • Lesions • Haemorrhage necrosis surrounding erythema • In gluteal or perineal region • Early lesion to necrosis in 12 hrs • Rx • Antipseudomonal Ab
- 21. Sycosis barbae • Staph aureus infection of beard deep infection of hair follicles
- 22. Sycosis nuchae • Deep infection of hair follicle caused by staph aureus scarring acne keloid nuchalis
- 23. CORYNEBACTERIUM INFECTION • PITTED KERATOLYSIS • CAUSED BY • CORYNEBACTERIUM DERMATOPHILUS CONGOLENSIS • MICROCOCCUS • MULTIPLE SHALLOW PIT ON PALM & SOLES • IN PATIENTS WITH HYPERHIDROSIS DISHWASHERS
- 24. CORYNEBACTERIUM INFECTION • TRICHOMYCOSIS AXILLARIS • AFFECT AXILLARY HAIR • YELLOWISH NODULES UNDIGESTED KERATIN
- 25. Erythrasma • c/c superficial infection of skin with mild patches in axillae , groins ,toes and ankles • Well demarcated brown red macular patches • Corynebacterium minutussimum • Lipophilic G +ve aerobic di • Produces porphyrin's coral red fluresecence • Doc : erythromycin ,clarithromycin coral red fluresecence
- 26. Leprosy / hansens disease Mycobacterium leprae
- 27. Cardinal signs of leprosy • Hypopigmented or erythematous skin lesions with definite loss of sensation • Involvement of peripheral nerves definite thickening • Skin smear AFB
- 28. M leprae • Less acid fast than M tuberculae (hence 5 % H2SO4 or 1% HCl is used) • Obligate intracellular bacillus • Can remain viable 1- 7 days • pRopagation is limited to armadillo,mouse foot pad,nude mice • Generation time 12-13 days • First bacillus to be associated with human disease • Modifies fite stain • In tissue sections • Portal of entry skin and respiratory tract • Chief mode of exit nasal mucosa of untreated LL patients • Modes of transmiision • Droplets >>contact>breast milk>transplacental>insect vectors
- 29. • Schwaan cells are first cell to be involved in leprosy
- 30. Leprosy • Grows better in cooler places • Skin • PNS • URT • Eyes • Testis • Spares warmer areas of axilla groin scalp midline back ovaries lung & CNS
- 32. • The Ridley Jopling classification • Indeterminate • Tuberculoid • Borderline: • borderline-tuberculoid, • borderline-borderline, • borderline-lepromatous • Lepromatous
- 33. Indian classification (by indian leprosy association) Most common type in india is tuberculoid (TT)
- 34. WHO Classification treatment Paucibacillary • 1-5 lesion • No nerve or only one nerve • Skin smears –ve at all sites Multibacillary • > 5 lesions • > 1 nerve irrespective of skin lesions • Skin smears + at all sites
- 36. • Pure neuritic (indian classification) • Asymmetric nerve involvement with no skin lesion and usually of tuberculoid origin • Painless trophic ulcers In neuritic type skin biopsy is negative
- 39. Indeterminate leprosy tuberculoid leprosy TT Borderline tuberculoid Borderline lepromatous Lepromatous leprosy Peripheral neuritic Vague solitary assymetrical Usually single raised lesion with well defined & partly ill defined borders & numb when touched Inverted saucer shaped lesion or punched out Small erythematous patches & macules Number Solitary Solitary Satellite lesions Many Innumerable AFB Nil Nil Nil / scanty + + Nerve Local nerve thickened Local nerve thickened Symmetrical nerve thickened Symmetrical Nerve thickening is a late feature Sensory loss Definite sensory loss Definite sensory loss Less definite sensory loss on patches Late glove & stocking anesthesia h/p Epitheliod granuloma in dermis reaching up to ddermis Absent ghrenz zone Many epitheliod granuloma in dermis Ghrenz zone + Diffe Ghrenz zone + Onion peel perineurium Diffuse infiltration with foamy macrophages virchows lepra cells Ghrenz zone +
- 40. Diagnosis • Skin smears • 7 in number • 4 from skin lesion • 2 from ear lobes • 1 from nasal swb • Nerve biopsy is taken from sural nerve
- 41. • Bacilli are absent in lungs , ovaries and CNS • Most common cranial nerve to get involve is VII • Goll & burdech tract proprioception • Not involved in leprosy • Other organs involved in leprosy are • Eyes • Iritis • Corneal beading • Testes • Muscles • Myopathy , wasting
- 42. Mouse foot pad culture • Detect drug resistance • Evaluating potency of antileprosy treatment • Detecting viability of bacilli during Rx
- 43. Histamine test • Very reliable method to detect at an early stage • Peripheral N damage d/t leprosy flare response is lost if peripheral N is damaged
- 44. Morphological index response to Rx/drug resistance/ disease activity/ • Percentage of solid staining bacilli in a stained smear to total no of bacilli Live bacilli solid stained Dead bacilli Fragmented
- 45. Bacteriological index density of bacilli in stained smear
- 46. Downgrading reaction • In untreated patients and in 3rd trimester of pregnancy • Clinically mimic reversal reaction
- 47. Lepromin test to detect CMI / Test for prognosis Early or Fernandez reaction • after 48 hours of injection • Erythema & induration >10 mm is +ve • Delayed hypersensitivity reaction to soluble constituents Late or Mitsuda reaction • After 3 weeks • Nodule > 5 mm is +ve • indicates CMI to bacillary component of Ag of lepra bacilli Mitsuda lepromin / Dharmendra lepromin antigen intradermally
- 48. Lepromatous leprosy • CMI ↓↓ • lepromin test negative • Bacillary load ↑↑ • Temperature and pain lost first >> Hypoaesthesia is a late sign • Ulnar N most common >>low median >posterior tibial> • Radial N is involved last serious • Acral,distal,symmetric anaesthesia common • M.leprae PGL-1(phenolic glycolipid) ab +
- 49. Lepromatous leprosy b/l symmetrical multiple lesions
- 50. Lion with out teeth • Leonine facies • Atrophy of anterior nasal spine collapse of nose • Alveolar resorption Loosening of teeth • Loss of eye brow
- 51. Lepromatous leprosy • Clear sub epidermal free grenz zone • Virchow or lepra cells • Foamy macrophages laden with acid fast bacilli • Intracellular bacilli in spheroidal masses (globi) • Epitheliod and giant cells are not seen (absence of CMI)
- 53. Globi in LL/ AFB forming spherical cluster
- 54. Lucio phenomenon • Characterised by arteritis and ulcers on legs is limited to patients with diffuse non nodular lepromatous leprosy • Mexico and carribean only
- 55. Histoid leprosy • Type of LL • Shiny cutaneous and subcutaneous nodules • Caused by drug resistant lepra bacilli • In b/w skin appears normal
- 56. Tuberculoid leprosy (most common type of leprosy in INDIA and Africa • CMI ↑↑ • Lepromin +ve • Bacillary load ↓↓ • Skin lesions anaesthetic early • One or few sharply defined annular asymmetric macules or plaques with a tendency towards central clearing , elevated border
- 57. Tuberculoid leprosy histopathology • Noncaseating granuloma with epitheliod and giant cells
- 58. Grenz zone involved in TL
- 59. Indeterminate leprosy • Bacteriologically negative • One or two vague hypopigmented macules • Definite sensory impairement
- 60. Borderline Tuberculoid • SATellite lesions • Nerve Abscess (mainly ulnar nerve abscess) • Rx with I & D • SANTA BanTa SATellite lesions
- 61. Borderline leprosy (BL) • Inverted saucer shaped ulcers • All kinds of bizzare lesions in single patient distributed asymmetrically • Epitheliod cells +
- 62. Treatment • Chaulmoogra oil • First effective antileprosy Rx • Form Myanmar • MDT is used since 1982 • Not C/I in HIV infected patients and is safe in pregnancy • Rifampicin highly bactericidal and most effective against M leprae • Dapsone is bacteriostatic
- 63. Blister packets for MDT
- 64. Regimen Duration Surveillance Paucibacillary • Rifampicin 600mg once a month (under supervision) • Dapsone 100mg (daily self administered) 6 months 2 years Multibacillary • rifampicin 600mg once a month • Clofazimine 300mg once a monthor Clofazimine 50 mg daily • Dapsone 100mg daily self administered 12 months 5 years
- 65. Treatment of single lesion leprosy • ROM regimen • Rmp • Ofloxacin • Minocycline • ROM -6 (Monthly for 6 months) - Paucibacillary • ROM -12 (Monthly for 12 months) – Multibacillary
- 66. Dapsone • Bacterostatic • Metabolized by acetylation Uses • Dermatitis herpetiformis • Actinomycetoma • Rhinosporidiosis • P. jiroveci s/e • Hemolytic anemia (mc) • Methaemoglobinemia • Hypermelanosis • Hepatitis • Agranulocytosis • IMN like syndrome • Peripheral neuropathy
- 67. Clofazimine • Dye with bacteriostatic action • Interfering with template function • Antiinflammatory action • Used in lepra reaction • s/e • Discolouration of skin & body secretions • Icthyosis of skin
- 68. Lepra reactions Type 1 (reversal) • Borderline type of leprosy (BT,BB,BL) • In 1st month or yr after Rx initiation • Sudden increase in effective CMI in reponse to rapid killing of bacilli • Type IV • a/c tenderness and swelling at the site of skin or nerve lesion • a/c neuritis wrist drop • Rx • Mild NSAIDS • Severe high dose glucocorticoid Type 2 (erythema nodosum leprosum) • In lepromatoum leprosy and also in BL • With in 2 years of RX • d/t activation of t helper cells • Type III HS (arthus reaction) • Tender inflamed subcutaneous nodules • Rx • Glucocorticoids • Thalidomide (DOC) • Cloazimine • Aspirin
- 69. Type 1 reaction (down grade & reversal ) Type 2 reaction(erythema nodosum leprosum) Borderline leprosy (BB BT BL) Lepromatous leprosy Type IV hypersensitivity Type III reaction • Before initiation of antileprotic Rx downgrade • After initiation of antileprotic Rx reversal • Follows institution of antileprotic treatment signs of inflammation in previously involved macule papule or placque Neuritis ulnar nerve is most commonly involved Crops of resh painful erythematous papules or nodules No systemic features Systemic features fever joint pain hepatitis • TNF α PLAYS IMPORTANT ROLE IN TYPE 2 Rx • Glucocorticoid along with continuation of antileprotic drugs • NO ROLE FOR THALIDOMIDE Rx • MILD NSAID • SEVERE GLUCOCORTICOIDS IF IT FAILS THALIDOMIDE 200-300MG
- 70. Erythema nodosum leprosum • Thalidomide DOC
- 71. Dapsone • Bacteriostatic • 1-2 mg/kg • Half life >24 hours • s/e • Hemolutic anemia • Methaemoglobinemia • c./I • Hb <7 • G6PD deficiency
- 72. clofazimine • Dye with leprostatic and anti inflammatory property • s/e • Reddish brown discolourarion of exposed parts • Hair and body secretions • Dry & itchy skin
- 73. New drugs • Rifapentine • Most effective
- 74. Staphylococcal scalded skin syndrome • Newborns and children • vary from localized blister formation to exfoliation of much of the skin surface • constitutional symptoms, including fever, lethargy, and irritability with poor feeding. • Exfoliative toxin of staph aureus • Nikolsky's sign +ve • The skin is usually fragile and often tender, with thin-walled, fluid-filled bullae. Gentle pressure results in rupture of the lesions, leaving denuded underlying skin • The mucous membranes are usually spared. • Significant amounts of fluid can be lost in more extensive cases.Illness usually follows localized infection at one of a number of possible sites. SSSS is much less common among adults but can follow infections caused by exfoliative toxin–producing strain
- 78. SSSS • Most severe form • Ritters d/s in new born • TEN in older people • Milder and most form of SSSS • Pemphigus neonatorum (neonatorum) • Bullus impetigo(children & adults)
- 80. SSSS • STERILE BULLAE (as it is caused by toxin) • Potato chip peeling
- 81. Tubercular infections of skin
- 82. PAUCI BACILLARY • LUPUS VULGARIS • TUBERCULOUS VERRUCA CUTIS MULTIBACILLARY • SCROFULODERMA • TUBERCULOUS CHANCRE • TUBERCULOUS GUMMA TUBERCULID(ANAPHYLATIC) • LICHEN SCROFULOSUM • BASINS DS • NODULAR TUBERCLE
- 83. Lupus vulgaris • Mc form of skin TB • Females >>males • Seen in previously infected /sensitized patients • a/w underlying active TB in lung or LN • More common in head and neck • Red brown plaques • Apple jelly nodule on diascopy • Scarring & SCC can develop • Lupus vorax • Cartilage of nose and ears is progreesively destroyed
- 84. CENTRAL SCARRING & PERIPHERAL EXTENSION
- 85. Lupus vulgaris mc skin tb in ADULTS • Single erythematous annular plaque slowly increase in size over decades central scarring • Match stick test is positive • For demonstrating apple jelly nodules • Gentle pressure applied it penetrates and on with drawal a drop of blood appears
- 86. Scrofuloderma • Mc in children • Skin TB extension from underlyingtuberculous focus • Infected LN ,muscles or bones
- 87. Buruli ulcer • Mycobacterium ulcerans • Penetrating skin trauma c/c painless heals spontaneously • c/c lymphoedema and disfiguring scarring
- 88. Tuberculids • Symmetric generalised exanthems in skin of tuberculous patients • Hypersensitivity reactions to tubercle bacillus • Strongly +ve mantoux test • Tuberculous involvement of ( usually inactive ) of visera or LN • Absence of M tuberlosis bacilli in tissue by culture or smear • Satisfactory therapeutic response of skin lesions to ATT • 3 entities are accepted as tuberculids /definite/true tuberculid • Papulonecrotic tuberculid • Lichen scrofulosum • Erythema induratum (bazins d/s)
- 89. • Facultative tuberculoids • Erythema nodosum • Erythema induratum • Non tubeculids • Lichenoid tuberculid • Rosacea like tuberculid • Lupus miliaris disseminates faciei
- 90. Swimming pool or fish tank granuloma • M .marinum • After contact with tropical fish tank/swimming pool/salt water fish • At the site of trauma A small violet nodule lymphangitic spread in a sporotrichiod fashion
- 91. Tuberculous chancre • Skin TB in person with no previous infection and immunity • Usually in children follows injury • Firm non healing shallow • Undermined ulcer with a granulomatous base a/w painless regional lymphadenopathy
- 92. Tuberculosis verucca cutis • Anatomist wart/post mortem wart/prosecutors wart • In previously infected individuals with high degree of immunity • Handling of infected sputum/material MC seen on hands and legs • no regional lymphadenopathy
- 93. ERYTHEMA INDURATUM • PAINFUL NODULES OVER BACK OR SIDES OF LEGS OF YOUNG WOMEN