Skin & Soft Tissue Infections: Classic Case Presentations Mark Beilke, M.D. Professor of Medicine Chief of Infectious Diseases Clement J. Zablocki VA Medical Center
Objectives Diagnose and treat water related skin and soft tissue infections Appreciate the role of toxin production in disseminated infections involving the skin Recognize early clues of infectious diseases emergencies
Water-associated Skin & Soft Tissue Infections A 60 y.o. trout fisherman is fly casting in the Milwaukee River, slips and cuts his knee on a sharp rock. Several days later, he develops marked swelling, redness and pain over the area. In the E.D., he is febrile and tachycardic. He is admitted, started on broad spectrum antibiotics, and blood cultures later are growing gram negative rods. Which of the following water-borne organisms is most likely responsible for this infection? A. Mycobacterium marinum B. Erysipelothrix rhusiopathiae C. Vibrio vulnificus D. Aeromonas hydrophila E. Mycobacterium avium-intracellulare
Water-associated pathogens Fish hook Cellulitis Erysipelothrix rhusiopathiae - Gram positive rod - Occupational pathogen (meat processing) - Causes localized cellulitis often erysipelas - Rx: Cephalosporins, Penicillins, Clindamycin Water-borne Mycobacteria These are Gram positive, Acid Fast positive rods Mycobacterium marinum - chronic cellulitis of the hand in aquarium enthusiasts Infections in the Gulf South Waters: Vibrio vulnificus - Gram negative rod - Occupational pathogen (shrimpers, crabbers) - Swimmers (step on a sharp object like a stingray sting) - Necrotizing infections - Bullous skin lesions - Others: Aeromonas hydrophila Mycobacterium marinum Streptococcus pyogenes Others: Rapid growers Mycobacterium fortuitum Mycobacterium chelonae/abscessus Note: M. avium is a slow grower Also: FATAL septicemia in immunocompromised patients and cirrhotics who consume raw seafood (oysters)
Aeromonas hydrophila Both Pseuodomonas aeruginosa and Aeromonas hydrophila are gram negative rods which are ubiquitous in fresh water Pseudomonas aeruginosa necrotic skin lesions in neutropenic patients (ecthyma gangrenosum) cause of hot tub cellulitis Aeromonas hydrophila necrotizing skin/soft tissue infections following contact of broken skin with fresh lake/river water also a cause of gastroenteritis/diarrhea
An Infectious Diseases Emergency: Rash from a systemic infection Jeanette is an 19 y.o. 1 st year college student attending a large university in North Carolina. She wakes up one morning with a severe sore throat, muscle pains and fevers. Within 24 hours she is extremely dizzy and weak. She is found lying on the floor so her roommate calls 911. On presentation to the E.D., her pulse is 120 and thready, temperature is 96.7 and she is found to have several large ecchymotic areas over her extremities and feet. Of the following, which diagnosis could explain her presentation? A. Meningococcemia B. Rocky Mountain Spotted Fever C. Streptococcal Toxic Shock Syndrome D. Purpura fulminans E. DRESS Syndrome F. A, C or D
Neisseria meningitidis Four clinical presentations Bacteremia without sepsis Meningococcal sepsis without meningitis Meningitis with or without meningococcemia Meningoencephalitic presentation
Hemorrhagic rash from Ebola virus similar to Meningococcal septicemia
Purpura Fulminans: Defined as A fulminant, often fatal, syndrome With diffuse Thrombosis In blood Vessels, Purpuric Skin lesions, Bruising, DIC. Reprinted from www.antimicrobe.org Can be caused By sepsis from Many organisms and is also associated with Congenital Protein C Deficiency.
Toxic Shock Syndrome due to Staphyloccus aureus or ß-hemolytic Strep
Late Night Admission from the E.D. You are the hospitalist on duty, and are called at 2 a.m. by the Emergency Room to admit a 69 y.o. male with cellulitis of the calf. You observe that the patient s leg is markedly swollen, tense, red and extremely painful. What would be the MOST beneficial intervention at this point? A. The patient should undergo an MRI of the lower extremity. B. Admit the patient to the floor and order intravenous vancomycin, pipercillin/tazobactam, and clindamycin. C. Contact the trauma surgery physician on call to evaluate the patient prior to admission to the floor. D. Send patient to vascular lab for venous duplex studies to rule our DVT.
Necrotizing Fasciitis Necrotizing fasciitis is a term that describes a disease condition of rapidly spreading infection, usually located in fascial planes of connective tissue that results in tissue necrosis (dead and damaged tissue). Risk factors: poorly controlled diabetes, immunocompromised patients, elderly patients, peripheral vascular disease Etiologic Agents: - Streptococcus pyogenes and Staphylococcus aureus - Often follows trauma or postoperative abdominal surgery - May be polymicrobial as in Fournier s gangrene, Meleney s synergistic gangrene - With creptitation gas forming agents (Clostridial myonecrosis) - Vibrio vulnificus
Necrotizing Fasciitis Medical and Surgical Emergency Urgent need to diagnose, debride necrotic tissues and prevent extension into healthy tissues High index of clinical suspicion needed for early diagnosis and successful management Complications: Fulminant sepsis Massive tissue destruction Multiorgan failure Antimicrobial therapy: Advanced generation betalactams (pip/tazo, carbapenems), metronidazole, vancomycin
Photo acknowledgements Fishhook cellulitis due to Erysipelothrix: www.pathologyoutcomes.com M. marinum infection: http://srxawordonhealth.com/category/hand-washing/ Vibrio vulnificus necrotizing infection: Loyola University New Orleans Center for Environmental Communication: http://www.loyno.edu/lucec/natural-history-writings/flesh-eatingbacteria-coastal-scourge-vibrio-vulnificus-lurking-estuaries Hot tub cellulitis: www.skinsight.com Ecthyma gangrenosum: http://www.huidziekten.nl Aeromonas cellulitis: http://web.mst.edu/~microbio/bio221_2004/a_hydrophila.htm Necrotizing Fasciitis: www.medicinenet.com Ebola Rashes: http://thelibertarianrepublic.com/deadly-ebola-outbreak http://allaboutebolavirus.weebly.com/symptons.html Tox ic Shock Syndrome: www.emedicinehealth.com Meningococcemia: http://gudhealth.com