JAS

N SKIN AND SOFT TISSUE INFECTIONS

RAI
S
FAR
SUBJECT Medicine (June 23, 2008)
TOPIC Skin and Soft Tissue Infections
HUA

LECTURER Dr. Gabriel

JOS
CO
MAR TRANSGROUP Paolo Paraiso Fans Club
ISAY
DY
CAN Skin anatomy tub follicolitis, cellulitis following
NG penetrating injury
KRIStratum corneum g. cellulitis due to gram negative bacillary
- Infection can sets in thru the following:
EISA are common among hospitalized,
E 1. disruption of this layer by burns, abrasion, immunocompromised hosts
ANN
surgery, bites, vascular ulcer
H
2. primary dermatologic disorders- herpes Treatment
KYT
simplex, varicella, etchyma a. Dicloxacillin, nafcillin
b. Ampicillin/clavunate, ampicillin/sulbactam
ON

and erythromycin
AAR
HE Hair follicle
ALP- can serve as portal of c. Quinolones, tetracylines, and
LA 1. components of the normal flora e.g. erythromycin
KAR staphylococcus d. Third generation cephalosphorin-
G 2. extrinsic bacteria pseudomonas in the hot ceftazidime, cefotaxime
PEN
tub folliculitis e. Semisynthetic penicillin- ticarcillin,
KC mezlocillin, piperacillin
Plexus of capillaries
ADI
Folliculitis
N
1. infective vasculitis of the plexus results in
Localized folliculitis
MAA
petechiae, osler’s node, purpura
- are caused by staphyloccus aureus
AM
A 2. metastatic infections of the plexus can
MON results in the cutaneous manifestation of
F disseminated fungal infection, gonoccocal Hot-tub folliculitis
BUF inf, salmonella inf, meningococcemia, - are caused by P. aeroginosa in the waters that
DIE pseudomonas and staphylococcal were insufficiently chlorinated
infections
GOL
Necrotizing Fascitis or fasciitis necroticans
A

Cellulitis -
EZR
KIX commonly known as “flesh-eating bacteria” is
RIZ- an acute inflammatory condition of the skin a rare infection of the deeper layers of skin
EY characterized by localized pain, erythema, and subcutaneous tissue, easily spreading
LAIN swelling and heat across the fascial plane within the
N - Etiologic agent subcutaneous tissue
XTIA
• staph Aureus and staph pyogenes; - Many types of bacteria can cause necrotizing
CES
streptococcus, A, C or G; Haemophilus fasciitis (eg. Group A staphylococcus, Vibrio
vulnificus, Clostridium perfringens,
PS
influenza;
Bacteroides fragilis), of which Group A
HOO
E - CLINICAL FEATURES
VINC a. Cellulitis of the lower extremities- streptococcus (also known as streptococcus
E  Grp A, C, G streptocci in association pyogenes) is the most common causes.
ESS with chronic venous stasis or - “Flesh-eating bacteria” is a misnomer, as the
DEN
saphenous venectomy bacteria do not actually eat the tissue.
LLE
b. cellulitis from patient ith chronic - They cause the destruction of the skin and the
lymphedema, lymph node dissection are muscle by releasing toxins (virulence factors).
CECI

• These include streptococcal pyogenic

JAM
Y KC due to streptococci
PIPO c. cellulitis caused by grp B streptocci occurs exotoxins and the other virulence factors.
H primarily with the elderly patients or S. pyogenes produces an exotoxin known
RIC those with diabetes mellitus or those with as superantigen. This toxin is capable of
HEIN peripheral vascular disease. activating T-cells non-specifically. This
T d. H. influenza typically causes periorbital causes the overproduction of cytokines.
BAR
cellulitis in children a. formerly called streptococcal
e. cellulitis associated with cat’s bite is due Gangrene caused by S. Pyogenes,
RYL

to Pasteurella Multocida while dogbite

SHE
LH Clostridium species mixed aerobic
RAP cellulitis is due to Capnocytophagia and anaerobic resulting to gas
canimorsus
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TINA gangrene
AIN f. P. aeroginosa causes ecthyma
ALL gangrenosum in neutropenic patient hot-
TTE
YVE
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b. If the infection is due to mixed
anaerobic-aerobic may be
associated with gas in deep tissues
Treatment
Early recognition and surgical
interventions and appropriate empiric
antibiotic combination with
Clindamycin or Metronidazole + caused by infection or ischemia, such as from
Ampicillin/ sulbactam or Gentamycin
c. Necrotizing Fasciitis affecting the
gastrointestinal and genitourinary
tract might result from malignancy,
diverticulum, haemorrhoid or anal
fissure as portal of entry
d. Fournier’s gangrene syndrome
resulted from a leakage in the
perianal area affecting the massive
swelling of the scrotum and penis
with extension to the perineum or
the abdominal wall and the leg
Bullae
Staphyloccal scalded-skin syndrome
 Staphyloccal aureus
Blistering distal dactylitis
 S. aureus or strep pyogenes
Necrotizing Fasciitis
 S. pyogenes, Clostridium spp. Mixed
anaerobes-aerobes
Gas gangrene
 clostridium spp
Staphyloccal scalded-skin syndrome
- is seen neonates caused by a toxin (exfollatin)
from phage grp II S. aureus affecting stratum
corneum
Gas Gangrene
• the most offending organism is clostridium
spp but the predominance of Cl. Perfringes
to cause gas gangrene are often seen
• clostridium perfingens possesses at least
17 possible virulence factors including 12
active tissue toxins and enterotoxins
affecting the gastrointestinal colonic flora
or the female genital tract area.
Clinical presentations of Cl. Perfingens may
be in the form of:
a. food poisoning due to cytotoxins
b. necrotizing enterocolitis
c. neutropenic enterocolitis
Medicine (June 23, 2008)
Skin and Soft Tissue Infections
Dr. Gabriel
Paolo Paraiso Fans Club
• Cl. Difficile can cause antibiotic associated
colitis also known as Pseudomembranous
Colitis where the stools are watery,
voluminous with blood and mucus.
Gangrene is a complication of necrosis (i.e., cell
death) characterized by the decay of body
tissues, which become black and malodorous. It is
thrombosis ( blocked blood vessel).
It is usually the result of critically insufficient
blood supply (e.g. peripheral vascular disease).
It is usually the result of critically insufficient
blood supply (e.g. peripheral vascular disease)
and is often associated with diabetes, and long
term smoking.
This condition is the most common in the lower
extremities
Clinical Manifestations
Skin & soft tissue infections- various categories of
traumatic wound infection due to clostridia have
been describe; simple contamination, anaerobic
cellulitis, fasciitis with or without systemic
manifestations and anaerobic myonecrosis that
includes diabetic foot.
Incubation period of gas gangrene
- is usually short almost always less than 3 days
and frequently 24 hrs.
- typically, it begins with the sudden onset of pain
in the region of the wound
- frothiness of the wound exudates may be noted
Diagnosis
• Positive Clostridia in cultures from wound
exudates, scrapings, cervical discharges
showing gram-positive rods
• Wright or Gram’s stain of smear of
peripheral blood may show in severe
sepsis from clostridia
• X-ray exam may show gas in the muscles,
subcutaneous tissues or other organs
affected but not specific only for
clostridium
• ELISA can identify the toxins A of C.
Difficile exhibiting specificity but lower
sensitivity by 70-90%.
• Stool culture however, for C. difficile may
be difficult to obtain but production of the
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toxin is the hallmark of disease.
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Treatment
• Antibiotic combination of clindamycin and
penicillin G for severe sepsis while for
diarrhea cause by Clostridia,
metronidazole is the drug of choice.
Treatment must be 10-14 days to avoid
relapse of the infection.
• The best treatment for gangrene is
revascularization (i.e. restoration of blood
flow) of the affected organ, which can
reverse some of the effects of necrosis
and allow healing. Other treatments
include debridement and local care, or
surgical amputation. The method of
treatment is generally determined
depending on location of affected tissue
and extent of tissue loss. Gangrene may
appear as one effect of foot binding.
Varicella Zoster Virus
Introduction
Varicella or chicken pox, is extremely a
contagious infection, is usually a benign illness of
childhood characterized by an exanthematous
vesicular rash. With reactivation of latent VZV
(which is most common after six decade of life),
herpes zoster presents as dermatomal vesicular
rash. Usually associated with severe pain known
as Post-herpetic neuralgia (PHN)
Pathogenesis
Primary infection
- due to varicella virus affecting children
between 1-4 yrs old or 10-14, very contagious
Recurrent infection
- presumably the virus infects the dorsal root
ganglia during chickenpox where it tremains
latent until unreactived.
Clinical Manifestations
• Incubation period- 14-17 days
• Children are mostly affected age between
5-9 yrs but some countries even beyond
15 yrs are also affected.
• Clinically, chickenpox presents as rash,
low grade fever, and malaise.
• The hallmark of the infection include
maculopapules, vesicles and scabs in
various stages in evolution
Diagnosis
Tzanck smear
Medicine (June 23, 2008)
Skin and Soft Tissue Infections
Dr. Gabriel
Paolo Paraiso Fans Club
- scrapings of the base of the lesion to
demonstrate the giant multi-nucleated cells
Tissue Culture Cell-lines
- to demonstrate the VZV
PCR
- to detect the viral DNA from vesicular fluids
FAMA (fluorescent Antibody to Membrane
Antigen) and ELISA
- serologic tools for assessing host response
PROPHYLAXIS
Varicella-Zoster Immune Globulin (VZIG) &
Varicella Immune Plasma (ZIP) should be given
within 72 hrs of exposure to ensure efficacy
Treatment
Acyclovir 800mg by mouth five times a day
for 5-7 days
Papular and Nodular Lesions
Shistosomiasis
- multiple erythematous papules
Lepromatous Leprosy
- thickened subcutaneous tissue
Secondary Syphils
- flat papulosquamous lesions
Tertiary syphilis
- large nodules or gummae
Human Papillomavirus
- can cause singular warts (VV)
Ulcers with or without eschar
Decubitus ulcers
- this skin infection is due to tissue hypoxia
secondary to pressure-induced vascular
insufficiency and may become secondarily
infected with components of the skin and
gastrointestinal flora, including anaerobes.
Erysipelas
- Infection of the face and extremities due to S.
pyogenes showing a fiery-red swelling
- Its distinct features are well defined indurated
margins along the nasolabial fold, rapid
progression and intense pain
- Flaccid bullae may develop during the 2nd and
Page 3
3rd day of illness, rarely extend to deeper soft
tissues
- Treatment with Penicillin is effective
 SUBJECT Medicine (June 23, 2008)
TOPIC Skin and Soft Tissue Infections
LECTURER Dr. Gabriel
TRANSGROUP Paolo Paraiso Fans Club

- Infants and elderly adult are most commonly

afflicted

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