BACTERIAL INFECTIONS PART II

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BACTERIAL INFECTIONSPART II

• Andrews
• P 330 45,821
• (p 330 357)

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Gas gangrene(clostridial myonecrosis)

• Most severe form of infectious gangrene
• Develops in deep lacerated wounds of muscle
  tissue
• Incubation only a few hours
• Sudden onset characterized by a chill, rise in
  temp, marked prostration and severe local pain
• Gas bubbles cause crepitation

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Gas gangrene(clostridial myonecrosis)

• Mousy odor is characteristic
• Caused by a variety of species of the genus
  Clostridium
• Most frequently C. perfringens, C. oedematiens,
  C. septicum, and C. haemolyticum
• A subacute variety occurs peptostreptococcus
• Clinically similar but with a delayed onset

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treatment

• Treatment of all clostridial infections is wide
  surgical debridement and intensive antibiotic
  therapy
• Hyperbaric oxygen therapy may be of value if
  immediately available

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Chronic undermining burrowing ulcers

• Meleneys gangrene
• Described as a postoperative progressive
  bacterial synergetic gangrene
• Usually follows drainage of peritoneal abscess,
  lung abscess, or chronic empyema
• Three skin zones outer bright red middle,
  dusky purple and inner, gangrenous with a
  central area of granulation tissue
• Pain is excruciating

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Chronic undermining burrowing ulcers

• The essential organism is a microaerophilic,
  nonhemolytic streptococcus in the spreading
  periphery of the lesion , associated with S.
  aureus or Enterobacteraceae in the zone of
  gangrene
• Wide excision and grafting are primary therapy
• Antimicrobial agents, pcn, and an aminoglycoside
  should be given as adjunctive therapy

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Fourniers gangrene of the penis or scrotum

• A malignant gangrenous infection of the penis,
  scrotum, or perineum
• May be due to an infection with group A strep or
  a mixed infection with enteric bacilli and
  anaerobes
• Usually considered a form of necrotizing
  fasciitis
• Aerobic and anaerobic culture
• Appropriate antibiotics, sx debridement

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Infections caused by gram-negative organisms
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PSEUDOMONAS INFECTIONSecthyma ganrenosum

• In the gravely ill patient opalescent, tense
  vesicles or pustules surrounded by narrow pink to
  violaceous halos
• Quickly become hemorrhagic and rupture to become
  round ulcers with necrotic black centers
• Usually seen on the buttocks and extremities

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ecthyma ganrenosum

• Occurs in debilitated persons who may be
  suffering from leukemia, in the severely burned
  patient, in pancytopenia or neutropenia,
  functional neutrophilic defect, terminal
  carcinoma, and other severe chronic disease
• Healthy infants in the diaper area, on abx
• Classic vesicle should suggest the diagnosis

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ecthyma ganrenosum

• Contents will show gram-negative bacilli
• Culture grows Pseudomonas aeruginosa
• Treatment with immediate institution of IV
  anti-Pseudomonals
• And aminoglycoside in combination with
  antipseudomonal penicillin

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Green nail syndrome

• Characterized by onycholysis of the distal
  portion of the nail and a striking greenish
  discoloration
• Frequently associated with paronychia in persons
  whose hands are often in water
• 1 acetic acid solution soaks
• Neosporin solution

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Gram-negative toe web infection

• Often begins with dermatophytosis
• Dermatophytosis complex where many types of
  gram-negative organisms may be recovered, and as
  the inflammation and maceration progress, it is
  less often possible to culture dermatophytes
• Prolonged emersion may lead to overgrowth

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treatment

• Topical antifungals
• With progression of disease topical antibiotics
  and acetic acid compresses
• Systemic antibiotics in full blown infection

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Blastomycosis-like pyoderma

• Large verrucous plaques with elevated borders and
  multiple pustules may occur as a chronic
  vegetating infection
• Most patients have underlying systemic or local
  host compromise
• P. aeruginosa, S. aureus, Proteus, E. coli or
  streptococci may be isolated
• Cipro 500 mg bid

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Pseudomonas aeruginosa-folliculitis

• Hot tub folliculitis
• Characterized by pruritic, follicular,
  maculopapular, vesicular, or pustular lesions
• Occurs 1-4 days after swimming in a hot tub,
  whirlpool, or public swimming pool
• Most lesion occur on the side of the trunk,
  axillae, buttocks, and proximal extremities

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• Associated complaints may include earache, sore
  throat, headache, fever, malaise
• Typically involutes within 7-14 days without
  therapy, prolonged episodes have been reported
• Third generation oral cephalosporin or a
  fluoroquinalone
• Prevention measures include water filtration,
  chlorination, maintenance of water, and frequent
  changing

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External otitis

• Swelling, maceration and pain may be present
• In up to 70 of cases P. aeruginosa may be
  cultured
• Especially common in swimmers
• Local applications of antipseudomonal Cortisporin
  Otic Solution
• Post op external otitis

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External otitis

• Malignant external otitis
• Occurs in elderly patient with diabetes
• Swelling, erythema and pain are more pronounced,
  with purulence and a foul odor
• Facial nerve palsy develops in 30 of the cases
• Cartilage necrosis may occur
• May be life threatening
• Appropriate systemic antibiotics

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Gram-negative folliculitis

• Usually due to Enterobacteraceae, Klebsiella,
  Escherichia, Proteus, or Serratia
• Occasional cases caused by Pseudomonas

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malacoplakia

• Rare granuloma, originally reported only in the
  genitourinary tract of immunosuppressed renal
  transplant recipients
• May also occur in the skin an the subcutaneous
  tissues of other patients with deficient immune
  responsiveness (HIV)
• Patients are unable to resist infections with S.
  aureus, P. aeruginosa and E. coli

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malacoplakia

• Granulomas may arise as yellowish red papules in
  the natal cleft, as draining sinuses in the
  vicinity of the urethra, as perianal ulcers, ,
  as a painful draining abscess on the thigh, or as
  a lesion on the vulva
• Treatment depends on the isolated organism
• Fluoroquinalones are usually useful

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Haemophilus infuenzae cellulitis

• Haemophilus infuenzae type B a distinctive bluish
  or purplish red cellulitis of the face
  accompanied by fever in children below age 2
• Bacteremia may result meningitis, orbital
  cellulitis, osteomyelitis, or pyarthrosis
• Antibiotic therapy
• Vaccine available, given at 2, 4, and 6 months

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chancroid

• An infectious, contagious, ulcerative, sexually
  transmitted disease
• Haemophilus ducreyi gm- bacillus
• One or more deep or superficial tender ulcers on
  the genitalia and painful adenitis in 50
• Men gt women

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chancroid

• Begins as an inflammatory macule or pustule 1-5
  days after intercourse
• Generally appears on the distal penis or perianal
  area in men
• On the vulva, cervix, or perianal area in women
• Extragenital infections have been reported
• Autoinnoculation forms kissing-lesions

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chancroid

• Pustules rupture and ulcers form
• These bleed easily and are very tender
• the lymphadenitis of chancroid is mostly
  unilateral, tender and may rupture spontaneoulsy
• Culture for definitive diagnosis and sensitivity
  testing

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chancroid

• The selective medium contains vancomycin
• Smears are only diagnostic in 50
• A combined PCR technique allows for the diagnosis
  of syphilis, herpes simplex, and chancroid form a
  single swab
• The diagnosis of chancroid does not rule out
  syphilis
• Repeat serologic testing and HIV is rec.
• Chancroidal genital ulcer disease facilitates the
  transmission of HIV infection

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treatment

• Treatment of choice is azithromycin 1 gm orally
  as a single dose
• Partners with contact less than ten days out
  should also be treated

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Granuloma inguinale(granuloma venereum,
Donovanosis)

• A mildly contagious, chronic, granulomatous,
  locally destructive disease
• Characterized by progressive, indolent,
  serpiginous ulcerations of the groin, pubes,
  genitalia and anus
• Begins as single or multiple subcutaneous,
  nodules, which erode through the skin to produce,
  clean, sharply defined lesions, which are usually
  painless

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Granuloma inguinale(granuloma venereum,
Donovanosis)

• More than 80 of cases demonstrate hypertrophic,
  vegetative granulation tissue, which is soft, has
  a beefy-red appearance, and bleeds readily
• Genitalia are involved in 90 of cases, inguinal
  region 10
• Most commonly occur on the prepuce or glans in
  men, and on the labia in women

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Granuloma inguinale(granuloma venereum,
Donovanosis)

• Incubation period is unknown, 8-80 days, 2-3
  weeks most common
• Persisting sinuses and hypertrophic scars, devoid
  of pigment are characteristic of the disease
• Regional lymph nodes are usually not enlarged
• Lesions are not painful and produce only mild
  subjective symptoms

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Granuloma inguinale(granuloma venereum,
Donovanosis)

• Pseudoelephantiasis may occur with blockage of
  lymph channels
• Dissemination from the inguinal region may be by
  hematogenous or lymphatic routes
• Calymmatobacterium granulomatis
• The exact mode or transmission of infection is
  undetermined

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Granuloma inguinale(granuloma venereum,
Donovanosis)

• The role of sexual transmission is controversial
• Giemsa or silver stains for Donovan bodies
• May coexist with syphilis
• Test for HIV
• Trimethoprim-sulfamethoxazole
• Doxycycline
• Therapy continues until all lesions have healed

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Gonococcal dermatitis

• Primary gonococcal dermatitis is a rare infection
  that occurs mostly as erosions that may be 2 - 20
  mm
• Has been reported on the median raphe without
  urethritis, as extragenital gonococcal ecthyma,
  simulating herpetic whitlow, and as scalp
  abscesses in infants secondary to direct fetal
  monitoring
• cipro

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gonococcemia

• Characterized by a hemorrhagic vesiculopustular
  eruption, bouts of fever, and arthralgia or acute
  arthritis of one or several joints
• Lesions begin as tiny erythematous papules
• Evolve into vesiculopustules on a deeply
  erythematous base or a purpuric macule
• The purpuric lesions occur acrally, mostly on the
  palms and soles and over joints

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gonococcemia

• Fever, chills, malaise, migratory polyarthralgia,
  myalgia, and tenosynovitis may accompany lesions
• Lesions are usually tender and sparse, and occur
  principally over the extremities
• Involution in about 4 days
• Many patients seen are women with asymptomatic
  anogenital infections in whom dissemination
  occurs during pregnancy or menstruation

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gonococcemia

• In severe or recurrent cases compliment
  deficiency should be investigated, esp. C5, C6,
  C7 or C8
• Neisseria gonorrhoeae
• Organisms may be seen in early skin lesions,
  blood, GU tract, and joints
• TOC ceftriaxone IV I gm daily for 24 48 hours
  after improvement begins, then switching to PO
  for another week of TX

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meningococcemia

• Presents with fever, chills, hypotension, and
  meningitis
• About ½ - 2/3 of patients develop a petechial
  eruption , most frequently on the trunk and lower
  extremities
• This may progress to ecchymosis, bullous
  hemorrhagic lesions, and ischemic necrosis
• Oral and conjunctival mucous membranes may also
  be affected

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meningococcemia

• Primarily affects young children
• Males more frequently than females
• Inherited or acquired deficiencies of the
  terminal components of compliment or properdin
  are predisposed to infection
• Chronic meningococcemia is a rare variant, seen
  typically in young adults

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• Neisseria meningitides, gm diplococcus
• Human nasopharynx is the only known reservoir
• Carriage rates 5 10
• TX, PCN G
• Chloramphenicol if pcn allergy
• Household members, and day-care and close school
  contacts should receive prophylactic therapy
• Vaccine available for high risk groups

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Vibrio vulnificus infection

• Vibrio vulnificus, gm rod
• Infection produces a rapidly expanding cellulitis
  or septicemia in those exposed
• May be acquired via the GI tract, after eating
  raw oysters or other seafood
• Localized skin infection may occur following
  exposure of an open wound to sea water

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Tabasco kills Vibrio, right?
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Vibrio vulnificus infection

• Skin lesions begin within 24-48 hrs following
  exposure
• Localized tenderness, erythema, edema, and
  indurated plaques are seen in 90 of pts
• Most common on the lower extremities
• If the skin is invaded primarily, septicemia may
  not occur, however with progressive lesions
  amputation may be required
• Mortality with septicemia is gt 50

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TX

• PCN, cephalosporins, tetracyclines,
  cotrimoxazole, chloramphenicol
• Doxycycline with ceftazadime is toc
• Surgical debridement of necrotizing tissue

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Chromobacteriosis andAeromonas infections

• Chromobacteria are gm rod
• Common in water and soil in SE US
• Several types of cutaneous lesions, abscesses,
  cellulitis, anthrax-like carbuncular lesions
• Chromobacterium violaceum, most common
• Aeromonas hydrophilia, gm
• Soil and water, similar lesions

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salmonellosis

• Gm rod
• Exist in humans either in a carrier state or as a
  cause of active enteric or systemic infection
• Most cases are caused by ingestion of
  contaminated food or water
• Poultry and poultry products are believed to be
  involved in half of common-source epidemics

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salmonellosis

• Incubation 1-2 weeks
• Acute onset of fever, chills, HA, constipation
  and bronchitis
• Lesions appear as rose-colored macules or papules
  (rose spots) on the trunk between umbilicus and
  nipples
• These occur in crops, lasting 3-4 days
• Untreated the exanthem may last 2-3 weeks

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salmonellosis

• Rose spots occur in 50 60 of cases
• Diagnosis is confirmed by culturing the organism
  from blood, skin, stool, or bone marrow
• TOC is a fluoroquinalone or ceftriaxone

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shigellosis

• Gm rods
• Cause bacillary dysentery, or acute diarrheal
  illness
• Most cases result from person to person
  transmission, food and water
• Small, blanchable, erythematous macules on the
  extremities, as well as petechial or morbilliform
  eruptions, may occur
• May be sexually transmitted
• fluoroquinolone

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Helicobacter cellulitis

• Fever, bacteremia, cellulitis and arthritis may
  all be caused by Helicobacter cinaedi
• Generally seen in HIV pts
• Cellulitis may have a distinctive red-brown or
  copper color
• ciprofloxacin

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rhinoscleroma

• A chronic, inflammatory, granulomatous disease of
  the upper respiratory tract
• Characterized by sclerosis, deformity, remission
  and eventually debility
• Death may occur
• Infections is limited to the nose, pharynx, and
  adjacent structures
• begins insidiously with nasal catarrh, increased
  nasal secretion and crusting

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rhinoscleroma

• Gradual nodular or diffuse sclerotic enlargement
  of the nose
• Ulceration is common
• Lesions have a distinctive stony hardness, are
  insensitive, and are of a dusky purple or ivory
  color

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rhinoscleroma

• Extensive mutilation of the face and marked
  disfigurement can occur
• Klebsiella pneumoniae, ssp. Rhinoscleromatis
• Gm rod
• Occurs in both sexes
• Most common in the third and fourth decade
• Endemic in Austria and southern Russia
• Occ. Found in US

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rhinoscleroma

• The bacilli are found within foamy macrophages
  known as Mikuliczs cells
• Best visualized with the Warthin-Starry silver
  stain
• Disease has such distinctive features that
  diagnosis should not be difficult
• Dx on bacteriologic, histopathologic and
  serologic tests
• Extremely resistant to therapy
• Fluoroquinalones are the best therapy

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pasteurellosis

• Primary cutaneous infection is caused by
  Pasteurella hemolytica
• A common pathogen in domestic animals
• A case of a woman with cuts on her hands who
  later dressed a deer

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Pasteurella multocida infections

• Pasteurella multocida, gm
• Norma l oral and nasal flora of cats and dogs
• May also be an animal pathogen
• Most common type of human infection follows cat
  and dog bites, and cat scratches
• Erythema, tenderness, and swelling occur within a
  few hours
• May have regional lymphadenopathy
• Septicemia is rare

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Pasteurella multocida infections

• Rec. all cat bites and scratches, and all sutured
  wounds of any animal source receive pcn or tcn
  and tetanus prophylaxix

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ALL YOU CAN EAT??IM THERE!!!!!!!!!!!!!
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Dog and human bite pathogens

• Capnocytophaga canimorsus, DF-2, gm rod
• Normal oral flora of dogs and cats
• Assoc with severe septicemia after dog bites
• A characteristic finding is a necrotizing eschar
  at the site of the bite
• Difficult to identify in the lab, make them aware
• Tx IV abx
• Amoxicillin clavulanate or pen G for human bites

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glanders

• Rare, usually fatal
• Pseudomonas mallei
• Encountered in horse handlers
• The distinctive skin lesion is an inflammatory
  papule or vesicle that arise at the site of
  inoculation
• This rapidly becomes nodular, pustular, and
  ulcerative

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glanders

• Within days or weeks other nodules, farcy buds,
  develop along the lymphatics in the adjacent skin
  or subcutaneous tissues
• Respiratory mucous membranes are esp. susceptible
  to disease
• Dx made by finding of the organism in nasal
  discharge or skin ulcers
• Tx- surgical excision of inoculated lesions
• And streptomycin plus a tetracycline

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melioidosis

• Whitmores disease
• Burkholderia pseudomallei
• The disease has an acute pulmonary and septicemic
  form with multiple miliary abscesses in the
  viscera and ends in early death
• Clinical characteristics are similar to glanders,
  disseminated fungal infections, and tb
• Endemic in Southeast Asia, suspect in military
  personnel

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melioidosis

• Dx made from finding bacillus in skin lesions or
  sputum, and serologic tests
• Therapy is guided by sensitivity
• Majority of infections respond to tcn
• Trimethoprim-sulfamethoxazole
• Third generation cephalosporin

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Infections caused by Bartonella

• Aerobic, fastidious, gm bacilli
• Species that infect humans
• B. henselae
• B. quintana
• B. bacilliformis
• B. clarridgeiae
• Unique to this genus is the ability to cause
  vascular proliferation
• Warthin-Starry silver stain

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Cat-scratch disease

• Relatively common, 22, 000/yr in US
• 60-90 of cases occur in children and young
  adults
• B. henselae, majority of cases
• Cat to cat by fleas
• Cat to human by bite or scratch
• Primary lesion occurs 3-5 days after inoculation
• Occurs in 50-90 of patients

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Cat-scratch disease

• Resembles an insect bite
• Heals within a few weeks without scarring
• Lymphadenopathy is the hallmark of the disease
• Appears within a week or two of the primary
  lesion
• Typically regional and unilateral
• Most commonly epitrochlear and axillary 50
• Fever, malaise, and anorexia may be present

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Cat-scratch disease

• Without treatment adenopathy resolves over a few
  weeks or months
• Oculoglandular syndrome of Parinaud
• Acute encephalopathy, osteolytic lesions, hepatic
  and splenic abscesses, hypercalcemia, and
  pulmonary manifestations
• Dx clinical features
• Primary skin lesion or lymph node bx

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Cat-scratch disease

• Most cases need no treatment
• Fluctuant lymph nodes should be aspirated
• Erythromycin, tetracycline, or doxycycline, in
  severe disease

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Trench fever

• B. quintana
• Affected more than one million soldiers in WW I
• Spread from person to person by body louse
• Fever initially lasting a week, recurs every 5
  days
• Headache, neck, shin , and back pain
• Ceftriaxone followed by erythromycin

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Bacillary angiomatosis

• A clinical condition characterized by vascular
  skin lesions resembling pyogenic granulomas
• Only 2 organisms have been proven to cause BA
• B. henselae
• B. quintana
• Lesions are identical
• Incubation period is unknown

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Bacillary angiomatosis

• BA occurs primarily in the setting of
  immunosuppression, esp. AIDS
• Rarely in HIV-negative persons
• Local proliferation of bacteria produces
  angiogenic factors leading to the characteristic
  skin lesions
• Immunocompetent host resist bacterial
  proliferation, resulting in granulomatous and
  necrotic lesion

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Bacillary angiomatosis

• Several different cutaneous forms occur
• Lesions are tender and bleed easily
• Lesions may number from one to thousands
• In BA the infection must be considered
  multisystem
• Bacteremia detected in 50 of AIDS pts
• Dissemination to lymphnode, liver and spleen, and
  bone

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Bacillary angiomatosis

• The source of infection and pattern of visceral
  disease can predict the infecting agent
• Radiologic or imaging studies may confirm
  visceral disease
• Bone lesions are typically lytic
• In the liver and spleen peliosis occurs
• BA is distinguished from pg by the presence of
  neutrophils throughout the lesion

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Bacillary angiomatosis

• Natural history of BA is extremely variable
• In most patients, the lesions either remain
  stable , or most commonly, the size and number of
  lesions gradually increases
• Untreated BA can be fatal
• Patients die of visceral disease or respiratory
  compromise from obstructing lesions
• Dx- id infecting organism in affected tissue

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Bacillary angiomatosis

• Tissue and blood cultures may be confirmatory,
  rather than primary diagnostic
• BA is dramatically responsive to tx
• Erythromycin or doxy toc
• Others are affective
• Duration depends on extent of visceral
  involvement
• Chronic suppressive therapy may be required

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Oroya fever and Verruga Peruana

• These represent two stages of the same infection
• Oroya fever is the acute febrile stage
• Verruga peruana is the chronic delayed stage
• Limited to and endemic to Peru and neighboring
  countries
• B. bacilliformis, trans. by sandfly
• Humans are the only known reservoir

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Oroya fever and Verruga Peruana

• 3 week incubation
• Symptomatology is highly variable, fever, ha,
  myalgias may be seen
• Untreated fatality 40 88, with abx 8
• After the acute infection resolves, a latency
  period follows, lasting from weeks to months
• It is then that the eruptive verruga peruana occur

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Oroya fever and Verruga Peruana

• Angiomatous, pyogenic granuloma-like lesions,
  clinically and histologically virtually identical
  to those seen in BA
• Large and few, or small and disseminate
• No visceral disease
• Giemsa stain
• toc chloramphenicol

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plague

• Infection in humans with Yersinia pestis is
  accidental and presents usually as bubonic
  plague, gm- bacillus
• Pneumonic and septicemic plague are other
  clinical forms
• Mild disease malaise, fever, pain and
  tenderness in regional nodes
• Sever disease toxicity, prostration, shock,
  hemorrhagic pneumonia

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plague

• Transmission occurs through contact with infected
  rodent fleas or rodents
• Rodents carried home by dogs or cats are a
  potential source
• Blood, bubo, or parabubo aspirates, exudates, and
  sputum should be examined
• Streptomycin is toc
• nearly all cases are fatal if not treated
  promptly

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Rat-bite fever

• A febrile, systemic illness usually acquired by
  direct contact with rats or small rodents
• Streptobacillus moniliformis
• Spirillum minor
• Bites of lab rats are an increasing source of
  infection
• Two distinct forms
• sodoku S. minus
• Semticemia S. moniliformis, epidemic arthritic
  erythema or Haverhill fever

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Rat-bite fever
95

• Clinical manifestations are similar
• Both produce a systemic illness characterized by
  fever, rash, and constitutional symptoms
• Clinical differentiation is possible
• Semticemia S. moniliformis, generalized
  morbilliform eruption to include palms and soles,
  may become petechial
• sodoku S. minus, bite site is often inflamed
  and may become ulcerated
• Eruption begins with erythematous macules on the
  abdomen, which enlarge, become purplish red and
  forming extensive indurated plaques

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Rat-bite fever

• Course without tx is typically 1-2 weeks
• Confirm dx by culturing organism from blood or
  joint aspirate
• Prompt cauterization of bites by nitric acid may
  prevent the disease
• Pcn, tcn, second or third generation cephalosporin

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Tularemia(Oharas disease, deer fly fever)

• Francisella tularensis, gm- coccobacillus
• Sudden onset of chills, ha, leukocytosis
• Incubation of 2 7 days
• Clinical course is divided into several general
  types
• Ulceroglandular type, large majority, begins as a
  primary papule or nodule that rapidly ulcerates
  at the site of infection
• Contact with tissues or body fluid of infected
  mammals

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Ulceroglandular type

• Lymphangitis spreads from the primary lesion
• Ulcers extend in a chain from the ulcer to the
  enlarged lymphatic glands
• EM and EN often occur
• The similarity of the primary ulcer to the
  chancre of sporotrichosis, or Pasteurella
  infections is important in the ddx

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Ulceroglandular type
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Tularemia(Oharas disease, deer fly fever)

• Typhoidal type inoculation site is unknown
• Characterized by persistent fever, malaise, gi
  symptoms
• Oculoglandular type primary conjunctivitis is
  accompanied by enlargement or regional lymph
  nodes
• Pneumonic type, most severe
• Oropharyngeal type
• Glandular type

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Oculoglandular type
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Tularemia(Oharas disease, deer fly fever)

• Most frequent sources of human infections are the
  handling of wild rabbits and the bite of deer
  flies or ticks
• Person to person not reported
• Most often occurs in the western and southern US
• Definitive dx by staining the exudates smears
  with specific fluorescent antibody
• Agglutination test is the most reliable
  diagnostic procedure

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Tularemia(Oharas disease, deer fly fever)

• Thorough cooking destroys the infection
• Toc streptomycin
• Gentamycin
• tcn

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Brucellosis(Undulant fever)

• Brucellae are gm- rods that produce an acute
  febrile illness with headache, or at times an
  indolent chronic disease characterized by
  weakness, malaise, and low grade fever
• Acquired primarily by contact with infected
  animals or animal products
• Meat-packers and vets at risk
• 5-10 of pts develop skin lesions

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Brucellosis(Undulant fever)

• Erythematous papules, diffuse erythema,
  abscesses, erysipelas-like lesions, and erythema
  nodosum-like lesions are some possible findings
• Dx by culture and rising serum agglutination
  titer
• Toc doxy and rifampin for 6 weeks

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Rickettsial diseases
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Rickettsial diseases

• Rickettsiae are obligate, intracellular, gm-
  bacteria
• Natural reservoirs are blood sucking arthropods
• Most of the human diseases incurred are
  characterized by skin eruptions, fever, ha,
  malaise, and prostration

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TYPHUS GROUPepidemic typhus

• Rickettsia prowazekii
• Human contraction from infestation of body lice
  harboring organism
• Lice feeds and defacates and feces are scratched
  into the skin
• After 2 weeks, prodrome of fever, chills, aches
  and pains
• Pink macular eruption on trunk and axillary folds
  that spreads rapidly

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epidemic typhus

• 6-30 mortality in epidemics
• Agglutinins for OX-19 are seen
• Toc doxy, alt. Tcn
• Brill-Zinsser disease may occur as a
  recrudescence of previous infection, similar but
  milder course

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Endemic typhus(murine typhus)

• R. typhi
• Natural infection of rats and mice
• Transmitted to humans by the rat flea
• Same skin manifestations as epidemic typhus, but
  less severe
• OX-19 also
• Southeastern US and those states bordering the
  Gulf of Mexico have been the most common sites of
  incidence
• Treatment as for epidemic typhus

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RMSF
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SPOTTED FEVER GROUPRocky Mountain Spotted Fever

• Rickettsia rickettsii
• 1-2 weeks after tick bite, fever, chills, and
  weakness
• Eruption begins on ankles, wrists and forehead
• Small red macules which blanch on pressure
• Spread to the trunk in 6-18 hrs, becoming
  petechial an hemorrhagic over 2-4 days
• A vasculitis of the skin is the pathologic process

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Rocky Mountain Spotted Fever

• 10-20 of cases without a rash, there is a risk
  of delayed diagnosis and a fatal outcome is the
  greatest
• Spread by ixodid ticks
• Antibodies to Proteus OX-2 and )x-19 become
  positive
• Tx high dose tcn, or chloramphenicol
• Usual course 5-7 days

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Tick typhus

• A collective name for the varieties of spotted
  fever transmitted by ticks
• Boutonneuse fever, or Mediterranean fever, is an
  acute febrile disease is the prototype
• Affects mostly children
• Characterized by sudden onset of chills, high
  fever, ha, and lassitude
• Tick bite produces a tache noir, small indurated
  papule
• Becomes a necrotic ulcer

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Tick typhus

• R. conorii, transmitted by the dog tick
• Similar manifestations are seen with the other
  diseases in this group
• Tx- tcn or chloramphenicol
• Even without treatment prognosis is good and
  complications are rare

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MITE-BORN DISEASESrickettsialpox

• Acute febrile disease characterized by the
  appearance of an initial lesion at the site of eh
  mite bite about a week before the onset of the
  fever and by the appearance of a rash resembling
  varicella 3 or 4 days after the development of
  the fever
• The lesions are firm round or oval vesicles
• Regional lymphadenitis
• A secondary eruption appears after the fever
  begins and fades within 1 week

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rickettsialpox

• Rickettsia akari
• Transmitted by the rodent mite
• All cases have occurred in neighborhoods infested
  by mice
• Self limited
• Complete involution in 2 weeks in most
• Toc tcn

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Scrub typhus(tsutsugamushi fever)

• Characterized by fever, chills, intense ha, skin
  lesions, and pneumonitis
• Primary lesion is an erythematous papule at the
  site of a mite bite
• Becomes indurated, necrotic ulcer with eschar
  forms, regional lymphadenopathy
• Erythematous macular eruption begins on the
  trunk, extends peripherally, fades in a few days

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Scrub typhus(tsutsugamushi fever)

• Rickettsia tsutsugamushi
• Vector is the chigger
• Antibodies to OX-K proteus antigen
• Tx as for other rickettsias

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Ehrlichiosis

• Illness similar to spotted fever
• Ehrlichia chaffeensis
• Many types of lesions
• A generalized mottled or diffuse erythema, a fine
  petechial eruption or a macular, papular or
  urticarial morphology have all been seen
• tcn

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leptospirosis

• Weils disease, pretibial fever, and Fort Bragg
  fever
• A systemic disease caused by many strains of the
  genus Leptospira
• Starts with abrupt onset of chills, followed by
  high fever, intense jaundice, petechiae, and
  purpura on the skin and mucous membranes, and
  renal disease
• Death in 5-10

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leptospirosis

• Fort Bragg fever, anicteric leptospirosis
• Has an associated acute exanthematous infectious
  erythema, generally most marked on the shins
• High fever, conjunctival suffusion, nausea,
  vomiting, ha
• Eruption occurs as erythematous patches or
  plaques
• Lesions resolve after 4-7 days

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leptospirosis

• May be different clinical manifestations from
  identical strains of leptospira
• Humans acquire these accidentally from urine or
  infected tissues of infected animals
• Also from contaminated soil or form drinking or
  swimming in contaminated water
• Spirochetes in blood by darkfield microscopy
• Tcn and pcn

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Borreliosis

• Spirochetes
• Also cause of relapsing fever
• Nonspecific macular or petechial eruption occurs
  near the end of the 3-5 day febrile illness

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McGinley-Smith DE, Tsao SS, Dermatosis from
ticks. JAAD 200349363-92
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Lyme disease

• Borrelia burgdorferi sensu lato, a tickborne
  spirochete
• The characteristic cutaneous eruption that is the
  early manifestation of systemic illness is
  erythema migrans
• Late sequel if chronic infections is
  acrodermatitis chronica atrophicans (ACA)
• Clinical features begin with EM and a flu-like
  illness

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Lyme disease

• Untreated, chronic arthritis and neurologic and
  cardiac complications frequently develop
• Skin eruption occurs in 75 of adults, v 25 of
  children
• 20-30 recall a tick bite
• 3-32 days following the tick bite expansion
  occurs
• Burning is seen in half of patients, rarely
  pruritic or painful

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Lyme disease

• 25-50 will develop multiple secondary annular
  lesions, typically smaller
• Lesions fade on an average of 28 days without tx
• 10 develop a chronic arthritis of the knees
• Cardiac involvement most often in young men, AV
  block
• Stiff neck, ha, meningitis, Bells palsy and
  cranial and peripheral neuropathies

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Lyme disease

• Nonspecific findings include
• Elevated ESR
• Elevated IgM
• Mild anemia
• Elevated lfts (20)
• Warthin-Starry silver stain
• B. garinii
• B. afzelii, assoc. ACA in Europe

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Lyme disease

• In US occurs primarily in Northeast, Midwest, and
  West
• Tick transmission, family Ixodidae
• European disease runs a different course
• Transplacental transmission has resulted in fetal
  death
• The clinical finding of EM is the most sensitive
  evidence of early infection
• ELISA 65 when EM is present

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McGinley-Smith DE, Tsao SS, Dermatosis from
ticks. JAAD 200349363-92
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Lyme diseasetreatment

• Toc in adults is doxy, amoxicillin is also
  affective
• Children lt 9, amoxicillin
• IV pcn or IM ceftriaxone in more aggressive
  disease
• Tick inspection is good prevention
• Prophylactic antibiotic therapy after a tick bite
  is not recommended

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BEWARE OF THE FRECKLE THAT MOVES
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Acrodermatitis chronica atrophicans

• aka Primary diffuse atrophy
• Is characterized by the appearance on the
  extremities of diffuse reddish or bluish red,
  paper-thin skin
• Occurs almost exclusively in Europe
• Begins on the backs of he hands and feet and
  gradually spreads
• Subcutaneous fibrous nodules may form

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Acrodermatitis chronica atrophicans

• Diffuse extensive calcification may occur
• Ulcerations and carcinoma may supervene on the
  atrophic patches
• Late sequel of infection with Borrelia afzelii
• Organism may be cultured from skin lesions
• Pen G cures most patients

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Acrodermatitis chronica atrophicans
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mycoplasma

• Lack cell wall
• Mycoplasma pneumoniae (Eaton agent) is an
  important cause of respiratory disease in
  children and young adults
• Skin eruptions occur in 17
• Most frequently is Stevens-Johnson syndrome
• Dx by culture, or by a rise in the specific
  antibody titer
• Tx erythromycin, or tcn

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Chlamydial infections

• Two species recognized
• Chlamydia trachomatis
• Chlamydia psittaci
• Numerous serotypes exist for both
• In humans Chlamydia cause trachoma, inclusion
  conjunctivitis, nongonococcal urethritis,
  cervicitis, epididymitis, proctitis,
  endometritis, salpingitis, pneumonia of the
  newborn, psittacosis and LGV

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Lymphogranuloma venereum(LGV)

• Sexually transmitted disease
• Characterized by suppurative inguinal adenitis
  with matted lymph nodes, inguinal bubo with
  secondary ulceration, and constitutional symptoms
• The primary lesion is a herpetiform vesicle or
  erosion that develops on the glans penis,
  prepuce, coronal sulcus or meatus
• Vulva, vagina or cervix in women

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Lymphogranuloma venereum(LGV)

• Extragenital primary infections of LGV are rare
• Enlargement of regional lymph nodes occurs after
  2 weeks
• Skin overlying nodes becomes violaceous, the
  swelling is tender and the bubo may break down
  forming multiple fistulous openings
• Systemic symptoms include malaise, joint pains,
  conjunctivitis, loss of appetite, weight loss,
  and fever

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Lymphogranuloma venereum(LGV)

• Primary lesions rarely observed in females
• Also lower incidence of inguinal buboes
• Cutaneous eruptions take the form of EN, EM,
  photosensitivity, and scarlatiniform eruptions
• Various extragenital manifestations occur
• The compliment fixation test is the most feasible
  and the simplest serologic test for detecting
  antibodies

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Lymphogranuloma venereum(LGV)

• STD, Chlamydia trachomatis
• Three serotypes, L1, L2, and L3 are known for the
  LGV chlamydia
• Asymptomatic female contacts who shed the
  organism from the cervix are an important
  reservoir for infection
• Recommended treatment is doxy
• Alternative is erythromycin
• Sexual partners should be treated
• Fluctuant nodules are aspirated to prevent rupture

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THE END