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ID for boards pg 1

Staphylococcus
Non-bullous Impetigo
70% of impetigo

Bullous Impetigo
30% of impetigo

Staph Scalded Skin


Synd
SSSS / Ritter's disease
Pemphigus neonatorum

Toxic Shock Synd


TSS

G+ cocci in chains
Classic impetigo
Honey-crust near nose
impetigo = superficial pyoderma

Strep pyogenes

Larger bullae,
Systemic symptoms.
Subgranular blister

S. aureus phage II
type 71 toxin

Nikolskys sign + in
lesional & uninvolved skin;
Path: split @ granular layer.
Mortality: Kids 3%, Adults >50%.

S. aureus phage II

15-35yo w/ sudden onset, very sick,


erythrodermic rash & mucositis
Blood cx: + <15%

Cellulitis (kids > adults)

Subcorneal blister
No Fever, no Pastias lines,
pharyngitis, strawberry tongue
deep dermis & subcutis infection
blood cx: negative (except H.flu)

Folliculitis/Furunculosis

superficial or deep follicle infection

Scarletiniform Eruption
Staph Scarlet Fever

Botryomycosis
Granular bacteriosis
Bacterial pseudomycosis

Felon Staph Whitlow


Acute paronychia (kids)
(chronic paronychia = candida)

Necrotizing Fasciitis
Endocarditis

Clostridial
Anaerobic Cellulitis
Myonecrosis
Gas Gangrene

Grains on light microscopy


blue clouds of bacteria
Fingertip infection (thumb,index)
from trauma (splinter, glucose stick)
From trauma
Adult paronychia more assoc w/ HSV
necrosis of subcutis & fascia
unresponsive to Abx.
Extremities >> Fourniers (perineum)
splinter hemorrhages, Osler's nodes,
Janeway lesions, and petechial lesions

S. aureus >

(3A,3C,55,71)
Exfoliative toxins

ET-A, ET-B

Staph aureus: TSST-1


Enterotoxins B + C
Surgical packing, mesh, abscess,
tampon

Staph aureus: TSST-1


Kids: S.aureus > H.flu
Adults: GAS >> S.aureus
S.aureus
occlusion/maceration/steroids at
face, chest, back, buttocks
> Gram neg (back acne)
> Pseudomonas (ho tub)

S.aureus
> P.aeruginosa, E.coli, Proteus

S.aureus
S.aureus,
Strep pyogenes
90% polymicrobial (type 1)
10% GAS (type 2): M-protein

Clinical: 4mm red papule honey-crusted vesicle; at face/nose or arm/hand.


5% of Strep pyogenes Acute post-strep GN.
Test: anti-DNase B antibodies tests for Staph impetigo only).
Clinical: flaccid large bullae varnish-like erosion w/ weakness, fever, diarrhea.
Tx: bactroban, keflex or augmentin, (-lactam resistant), clarith/azithromycin.
Patho: ET-A (chr), ET-B (plasmid) bind desmoglien 1 at granular layer sterile bullae.
Distant S.aureus infection; often nasal carraige
Clinical: <5yo or renal failure: prodrome, tender skin H&N (perioral) erythema
generalized bullae slough in 1-2d varnish crust w/ sad-man facies.
Tests: Culture S.aureus from conjunctiva or nasopharynx.
Confirm dx: ET-A, ET-B (latex agglutination, double immunodiffusion, and ESLISA)
Clinical: fever, myalgias, N/V/D, HA, pharyngitis, rash, mucositis. May shock
Rash: Scarlatiniform exanthem (trunk centripetally).
Palm/sole: erythema & non-pitting edema desquamation 1-3 weeks after onset.
Mucositis: strawberry tongue, oral erythema, conjunctival hyperemia
TSST-1: 1) directly toxic to mult organs, 2) gut endotoxin clearance, 3) super-Ag
Morbidity: renal fxn, vocal paralysis, CTS, arthralgias, amenorrhea.Mortality: <3%
Tx: Remove mesh, packing, tampon; Tx: Keflex +Clinda/Rifampin (toxin)
Clinical: Generalized scarletiniform rash ONLY w/o other scalet fever s/sx:
Clinical: F/C, malaise tender rash (rubor, dolor, calor, tumor) w/ ill-defined borders
Adults: extremities 2 strep w/ lymphangitis; Kids: H&N
Superficial folliculitis: Brockharts impetigo
small 1-4mm pustules or crusted papules on an erythematous base
Deep folliculitis: Sycosis barbae large, tender, red papules often w/ central pustule
Tx: chlorhexidine or triclosan antibacterial wash; Mupirocin Keflex if diffuse
Clinical: suppurative skin>lungs nodules, verrucous plaques sinuses / fistulae
Risk factors: HIV, diabetes, trauma, alcoholism
Histo: 1-3mm granular clubs = bacteria, cells, and debris
closed-space infections of the fingertip pulp
Clinical: Swollen, red, painful digit following minor nail trauma
Adult paronychia assoc w/ HSV
Clinical: Refractory cellulitis (red blue/gray), hardens, F/C shock
Assoc w/ DM, ETOH, CAD, PVD, s/p blunt trauma or recent surgery
Oslers nodes - tender, red nodules w/ white centers on finger pads & thenar, hypothenar
Janeway lesions - painless, small hemorrhagic macules or papules on the palms and soles

Large, G+ rods; -toxin (destroys cell membranes, hemolysis), -toxin (hemolysis, muscle necrosis, & cardiac toxicity); Tx: PCN G (+ Clinda + Aminoglycoside as 50% polymicrobial
cellulitis with crepitus
C. perfringens
Clinical: dirty wound cellulitis w/ crepitus, + gas, foul-smell
spares deep fascia & muscle
(also Bacteroides,
Gram stain: short, plump, blunt-ended G+ rods, no spores, & variable # PMNs
>3d incubation
Peptostreptococcus, Prevotella)
deep anaerobic cellulitis
Epidermology: elderly w/ DM or PVD trauma >> post-op bowel or GB surgery
to muscle & fascia w/ toxemia
C. perfringens
Clinical: foul painful necrotic nodules; toxic, bronze skin, bullae w/ brown fluid
fast incubation <3d

ID for boards pg 2

Streptococcus
Strep Toxic Shock Synd
STSS
Toxic Strep Synd

G+ cocci in clusters
20-50 yo w/ any GAS infection,
PAINFUL skin early shock &
organ failure
Blood cx: + >50%; mortality
Super-Antigen Syndrome: M-protein

Ecthyma

Ulcerated non-bullous impetigo


extends into dermis
no systemic symptoms

Scarlet Fever

Prodrome: fever & sore throat


sunburn w/ goosebumps,
Staw/Beefy Tongue, Pastias lines.
peeling skin
2-10yo kids.
No rash in children w/ Antibodies:
80% by 10yo

Scarletina

Erysipelas
St Anthony's fire

Strep perianal disease


Perianal Cellulitis

Purpura Fulminans
Blistering Distal Dactylitis

GAS (S. Pyogenes)


Lacerations, Bites,
Bruises, Varicella
Super-Ag: Strep M proteins

GAS (S. Pyogenes)


staph superinfection

GAS infection after


tonsillitis/pharyngitis.

Erythrogenic toxins
A,B,C

Clinical: 20-50yo w/ severe pain in extremity; flu & CNS sx shock, organ failure
Patho: M-proteins bind MHC II (APCs) & V (TCR): T-cells cytokines shock
Morbidity: renal failure, DIC & ARDS; Mortality: 30-60%
Tests: bx, blood cultures + GAS; bandemia, Bun, Cr, Fibrin split products, LFTs
Tx: Clindamycin (inhibits toxins), IVFs/support, early surgical intervention
Clinical: vesicopustule enlarges/crusts punched-out, necrotic base (not
systemic) Tx: 10d Keflex (staph superinfection)
Prodrome: 1-2d sore throat, tender LNs, HA, N/V & high fevers, palatal petechiae.
Exanthem: blotchy neck/chest erythema sandpaper sunburn w/ goosebumps
Tongue: strawberrybeefy; Pastias lines: linear petechiae at folds
Resolution: fever gone in 1 week or 48h Abx; Peeling skin on day 6 x up to 6 weeks.
Complications: rheumatic fever, otitis/sinusitis, PNA, carditis, meningitis, hepatitis, GN
Tests: Culture NP for GAS, ASO, antihyaluronidase, antifibrinolysin, anti-Dnase B Abs

Tx: PCN prevents rheumatic fever, response in 48h


Well-defined tender erythema on LE or Face x2-5d abrupt F/C, N/V, malaise.
(Vs. cellulitis, which involves subcutis as well)

Dermal GAS infection


w/out lymphatic or subcutis involved

GAS (S. Pyogenes)

Perianal erysipelas, kids <4yo

GAS (S. Pyogenes)

DIC Hemorrhagic infarction


Geographic ecchymoses
on extremities, ears, nose
Distal fingers & toes

GAS

Clinical: pustular petechiae, purulent purpura, subcut abscesses (infection mets)


Risks: Immunocompromised, erythroderma, CTCL, central lines, heart valves, IVDU

GAS

Clinical: tense blisters filled w/ purulent fluid & surrounding erythema

Clinical: <4yo w/ painful defecation, blood-streaked stools, pruritus, fecal hoarding

Other Gram-Positives

Anthrax
woolsorters disease

Animal handler or terrorist w/


malignant pustule:
painful papule hemorrhagic bulla
black eschar
95% cutaneous
also inhalation & GI forms

Bacillus cereus
Diptheria

Neutropenic pt w/
single necrotic bulla
Rare

Bacillus anthracis
G+ rod, spores

Edema toxin (cAMP)


Lethal toxin (TNF, IL-1)
Polyglutamate capsule
(inhibits phagocytosis)

Bacillus cereus
G+ rod, spores

Corynebacterium
diphtheriae
G+ bacillus, no spores

Actinomycoses

Erysipeloid

Lumpy Jaw

Fisherman or butcher
Finger webs

chronic bacterial infection


pt w/ h/o dental problems

Erysipelothrix
rhusiopathiae
G+, no spores

Actinomyces isralii
G+ rod, Non-acid-fast
(normal oral flora)

Nocardia brasilensis
Mycetoma
Nocardiosis

Other Nocardiosis

Chronic granulomatous subcut


infection, draining sinuses, grains;
Usually on foot
Treat with sulfonamides x6-12wks

G+ branching, Acid-fast (soil)


Actinomadura madurae
Actinomadura pelletieri
Streptomyces somaliensis

Micro: large, aerobic, spore-forming, Gram-positive rod


Clinical: small red pustule 48h ring of vesicles around eschar granulates in.
Risks: animal care (sheep, cows, horses, goats); Endemic in West Asia, West Africa
Dx: gram stain/culture of vesicle fluid, histology, PCR, direct fluor. Ab, ELISA serum
Tx: PCN (if bioterrorist suspected, use Doxycycline, Cipro, TCN)
Edema toxin = Edema Factor + Protective factor; Lethal toxin = Lethal factor + PF
Protective Factor: responsible for exotoxin entry via endocytosis.

Tx: Vancomycin, Imipenem


Clinical: punched-out ulcer dirty gray margins & overlying eschar.
Tx: 1) diphtheria antitoxin + 2) oral penicillin/erythromycin, + 3) topical antibiotic
Micro: G+, non-motile, smooth or curved bacillus; occasional septicemia /
endocarditis
Tx: PCN (Erythro), use gloves to prepare meat
Clinical: submandib blue swelling breaks down pus w/ sulfur granules, sinus,
fever
Pulmonary Actinomycosis 15% aspiration of lumpy jaw; GI rarely involved
Tx: Chronic PCN G (2-6 weeks IV or 3-12 months PO). ddx: dental sinus
Clinical: painless swollen node after trauma purulent/necrotic to muscle/bone.
Tx: Sulfonamides (Bactrim)
Culture: any media, but have to hold 2 weeks. Acid fast: Ziehl-Neelsen +

Lymphocutaneous abscess + lymphangitis after trauma, unresponsive to ABX

ID for boards pg 3

Corynebacterium

G +, catalase positive
Superficial localized, mild/chronic
infection @ moist areas
Woods: Coral-red fluorescence

Erythrasma
Interdigital Erythrasma
Disciform Erythrasma
Pitted Keratolysis (PK)

Trichomycosis Axillaris

#1 bacterial infection of foot


not intertriginous
Asymptomatic; on feet
assoc w/ hyperhidrosis & foot odor
Asymptomatic, axillary & pubic hair
30% military persons
Red-stained sweat stains clothing

Corynebacterium
minutissimum
Micrococcus sedentarius
or Corynebacterium spp

Corynebacteria tenuis
(NL flora)

Clinical: irregular, red patches w/ fine scales red fades to brown ( mildly pruritic)
Woods Lamp: porphyrins produced by C.minutissiumum bright coral-red
Treatment: AlCl, topical antibiotics, oral erythromycin
Chronic maceration & fissuring between toes
Associated with Diabetes Mellitus
Clinical: 1-7 mm crater punched-out depressions in stratum corneum on feet
Stain: methenamine silver stain;
Clinical: axillary hair shafts develop adherent yellow-brown concretions
Tx: shave affected area, antibacterial soaps, benzoyl peroxide

Gram-Negative Infections:
Meningococcemia

Acute: widespread purpura w/ central


gunmetal gray discoloration
Chronic: maculopapular rash 12h p
fever, relapses q1-4days

Neisseria meningitidis
(nasopharynx reservoir)

Ecthyma Gangrenosum

Septic neutropenic pts only

P. aeruginosa

Ps. Hot-Foot Syndrome

Kids plantar feet, from swimming


Self-limited

P. aeruginosa

Green Nail Syndrome


Pseudomonal Pyoderma

Malta fever

Cutaneous Malacoplakia

Tularemia
Rabbit Fever,
Pahvant Valley Plague

G - motile aerobe

Clinical: diffusely erythematous plantar feet w/ painful, red-to-purple 1-2-cm nodules

P. aeruginosa

pyocyanin (green pigment) produced by P. aeruginosa


Tx: clip back nail, use topical fluoroquinolones / tobramycin x 1-4 months

P. aeruginosa

Clinical: bluish-green purulence, grape-juice or mousy odor, moth-eaten epidermis

P. aeruginosa

Clinical: large verrucous plaques with multiple pustules and elevated borders

Raw goat-milk drinkers or


domesticated animal handlers

Brucella spp.

Clinical: erythema nodosum, vasculitis; farcy buds= nodules along lymph drainage
Other clinical: ocular, pulmonary, GI, cardio, GI, CNS. Tx: doxy / rifampin

Michaelis-Gutmann bodies in
von Hansemann cells

E.coli
G neg rod

Chancre + Bubo on hand of


Rabbit handlers
Vector: Black fly (seminulium), Tsetse

G -, non-motile coccobacillus

non tender paronychia


pt w/ constant water exposure
Common cause of sepsis in burn pts
2 decubitus ulcer infection

Blastomycosis-like Pyoderma
Undulant fever

septicemia

Epidemiology: young children & young adults, males 4:1, winter & spring
Dx: positive culture, tissue gram stain, latex agglutination of Neisseria antigens
Tx: high-dose IV PCN (chloramphenicol); Vaccinate military & co-eds
Clinical: red macule hemorrhagic bulla gangrenous ulcer w/ gray-black eschar
Location: anogenital or extremity. Tx: imipenem (amino

G neg rod

Francisella Tularensis

Cutaneous Malacoplakia (bladder > skin) nodules/plaques


Histo dx: von Hansemann cells (foamy histiocytes CD68+, lysozyme+, 1-antitrypsin+)
Michaelis-Gutmann bodies (intracytoplasmic, laminated phagolysosome concretions, Ca++)

Ulceroglandular (#1 form): ulcer/chancre at rabbit or tick bite (finger/hand), fever,


fluctuant lymphadenopathy. Tx: Streptomycin (Jarisch-Herxheimer rxn possible)

Burkholderia mallei
Glanders
Facial Cellulitis (<2 yo)
Plague
Rhinoscleroma
Rat bite fever
Enteric fever
Vibrio infection

Horse-handlers

(old name: Pseudomonas mallei)


G- bacillus, non-motile, aerobe

Clinical: Ulcerated nodule w/ regional lymphadenopathy

Vaccinations!
Positive blood cultures
Vector: Oriental Rat Flea
(Xenopsylla cheopis)
or wild/domestic rodent contact

Haemophilus influenzae

high fevers, L shift WBC, positive blood cultures (unlike common cellulitis)

Chronic nasal plaques / URI


granulomatous infection
From rodents or contaminated food
F/C/N/V/D
F/C/N/V/D

G- coccobacillus

Yersinia pestis

Gram-negative, rounded, short, bipolar bacillus


Tx: Streptomycin (chloramphenicol if meningitis)

Klebsiella pneumoniae
rhinoscleromatis

Clinical: hypertrophic plaques on external nares


Histo: Mikulicz cells

short, immotile G- bacillus

Streptobacillus
moniliformis
Salmonella
Vibrio vulnificus

Clinical: Arthritis, fevers, acral rash generalized; Mostly in the Orient


Tx: PCN
Rash: 2-8-mm, pink, blanching papules on anterior trunk in groups of 5-15 lesions
raw seafood ingestion or exposure at open wound

ID for boards pg 4
Rickettsial Diseases
Ehrlichiosis
Monocytic Ehrlichia
Granulocytic Ehrlichia
(HGE)

Rocky Mtn Spotted


Fever
Rickettsialpox
Epidemic Typhus
Endemic Typhus
Scrub Typhus
Q Fever

Babesiosis
Tick paralysis
Rickettsia-Like Infections
Cat-Scratch Disease
Bartonellosis = Carrions dz
Oroya Fever

Verruga peruana
Bacillary Angiomatosis
Disseminated cat-scratch dz

Trench Fever

Spirochetes

Lyme Disease

Relapsing Fever
Louse-Borne

Relapsing Fever

G- bacillus; Tx: Doxycycline

Monocytic: Ehrlichia chaffeensis


HGE: E. equi, E.phagocytophila,
Wristshands/arms
(centrepidally)
NYC: F/C/HA, tender LNs
Human misery / war
Calf: papule eschar
F/C, atypical PNA, truncal
exanthem
Culture negative endocarditis
Post-splenectomy, immune
respiratory support

R. rickettsii
R. akari
R. prowazekii
R. typhi
Orientia tsutsugamushi

Clinical: Fever, malaise, Neutropenia, LFTs, rash (like RMSF but rarely palms/soles);
Vector: (monocytic) Amblyomma americanum = lone star tick; Cytoplasmic PMN
inclusions
Vector: Ixodes scapularis/daminii = black-legged tick; I.pacificus (West US)
Vectors: Dermacentor andersoni (West US); Dermacentor variabilis (East); hard ticks

Vector: Liponyssoides sanguineus (mite of the house mouse)


Vector: Pediculus humanus corporis (human body louse)
Vector: Xenopsylla cheopis (rat flea); orient
Vector: Trombiculid mite larvae (chiggers);

Coxiella burnetii

Vector: none; aerosolization of tick feces or domesticated ungulates: cattle, sheep

Babesia microti
Dermacentor

Vector: I. daminii RBC parasite (northeast US) F/C/sweats/h.anemia


lower motor neuron paralysis 4-7d attachment; Rapid reversal w/ tick removal

Organisms appear adherent to RBCs, may be inside RBCs; Bartonella stain w/ Silver stains only (except Oroya Fever: Giemsa)
Tender lymphadenitis
Clinical: persistent tender regional lymphadenitis
Bartonella henselae
after cat scratch

weeks-mos s/p cat contact

Vector: Lutzomyia Sand fly


Oroya Verruga
Rocha-Lima inclusions

Bartonella bacilliformis
(stains w/ Giemsa)

HIV pt
20% had cat contact
Vector: Human body louse
Pediculus humanus corporis

Bartonella henselae
Bartonella quintana

Progression: Oroya Fever survivors get Verruga peruana


Oroya fever: deadly fever, hemolytic anemia;
Vurruga peruana: benign, disfiguring.
Endothelial intracytoplasmic Rocha-Lima inclusions (Bartonella organisms)
Clinical: subcut vascular prolif, esp in HIV-infected pts; CD4 < 50
20% had cat contact/scratch; Jarisch-Herxheimer reaction w/ treatment (macrolide)

Bartonella quintana

WWII trenches now urban & mostly asymptomatic

false-positive VDRL, RPR;


#1 tick illness in US

Borrelia Burgdorferi

Ixodes scapularis / daminii

Vectors:
I. dammini/scapularis (NE US)
Ixodes pacificus (West US)

summertime, bimodal: 0-14yo / 40-79


Erythema migrans
(Africa, S.Africa)
Tx: single dose Doxy 100mg

Borrelia recurrentis
Vector: Pediculus humanus
(human body louse)

Clinical: Erythema Migrans (1 stage), Acrodermatitis Chronica Atrophicans (3 stage)


outer surface protein C (OspC) traverses tick midgut transfer to human via tick saliva

1 stage (erythema migrans); 2 stage (e.m. resolved), 3 stage (>7 mos s/p e.m.)
Extracutaneous: (tons) F/HA/cough, ophth, CNS, arrhythmias/CHF, arthritis, orchitis
Tx: Doxy 100mg po bid x 21d
Clinical: Paroxysmal fevers (>2), HA, lymphocytoma, myalgias, rash
Rash: Erythematous or petechial macules on trunk & extremities
Tx: Doxycycline

(Western US)
Tx: Doxy 100mg BID x 7d

Borrelia duttonii / hermsii

Yaws

<15yo ulcerated papules form


tracts bone disease

Treponema pallidum
subspecies pertenue

red painless papule ulcerates on LEs of kids < 15 coalesce into tracts bone dz

Pinta

Symmetric vitiligo-like

Treponema carateum

minute papules or macules surrounded by an erythematous halo grow to 10-12cm


plaques 3 (symmetric, depigmented, vitiligo-like lesions)

<15 yo w/ palatal &


nasal septum mutilation

Treponema pallidum
subspecies endemicum

1 (OP papule rarely noticed);


2 (OP patches, angular stomatitis, papular eruptions, lymphadenopathy)
3 gummas mutilation of skin, bone, cartilage (esp palate & nasal septum)

Tick-Borne

N.Africa, Arabia, SE Asia

2.4 million U PCN


Benzathine IM

Endemic Syphilis (Bejel)

Vector: Ornithodoros

ID for boards pg 5

Mycobacterial Infections
LEPROSY
Hansen's disease

Lepromatous

Borderline Lepromatous
Mid-borderline
Borderline Tuberculoid

(Leprosy, Tb, Atypical Mycobacterium)


Mycobacterium leprae

Slowly progressive granuloma &


neurotropism (peripheral nerves)
at cool body sites

Generalized & symmetric


(face, buttocks, LE)
No loss of sensation or sweating

Indeterminate

Solitary lesion
No sensory loss

TUBERCULOSIS

Lupus Vulgaris
Scrofuloderma
Tuberculous Gumma
Tuberculosis Cutis
Orificialis
Miliary Tb of the skin
Tuberculids

Respiratory transmission 1 skin lesion: red or hypopigmented, often anesthetic


Contagiousness: Intimate contact & genetic susceptibility; 25% of convival contacts
IL-4, IL-10, Neg Lepromin test;
Many organisms (multibacillary) in dermis & nasal secretions
Type 2 reaction: Erythema Nodosum Leprosum Vasculitis (bright pink painful nodules erupt
on extremities face during induction phase of treatment 2 excess Ab)

Tx: Multibacillary 24 mos (Dapsone, Clofazimine, Rifampin )


Leonine facies, Madarosis (no eyebrows), long earlobes, saddle nose, corneal anesthesia/blind, orchitis
gynecomastia, papal hand (ulnar n.), claw hand (ulnar+median n), foot drop, hammer toes, acquired icthyosis
of LE, neurotrophic plantar ulcers, short digits (bone resorption)

Lesions TNTC & smaller

3 lesions

Tuberculosis Verrucosa
Cutis

TH2 cytokine profile


Ab response
(least cellular immunity)

Many lesions, symmetric


Less anethesia than Tuberculoid
3-10 lesions,
smaller than Tuberculoid

Tuberculoid

Tuberculous Chancre

(intracytoplasmic parasite of
macrophages & Schwann cells)

TH1 cytokine profile


(cellular immunity, CD4+)

IFN-, IL-2, IL-12, Lepromin test +


A few organisms (paucibacillary) well-demarcated plaques rash.
Type 1 reaction: Reversal rxn ( or ) Type IV hypersensitivity rxn neuritis,
inflammation & new lesions; (2 change in immune state of the patient)
Tx: Paucibacillary treat for 6 mos (Dapsone 100mg/d, Rifampin 600mg q mo)

May progress into Lepromatous, Tuberculoid, or Borderline Leprosy


Mycobacterium tuberculosis acid- and alcohol-fast bacillus

1 exogenous inoculation
in non-sensitized host
Exogenous RE-infection
(sensitized host w/ strong immunity)
Hematogenous, lymphatic, or
contiguous spread of Distant Tb
Contiguous spread onto skin from
Underlying Tb focus
(sensitized host w/ low immunity)
Hematogenous spread
( Immunosuppressed host)
Autoinouclation from underlying
advanced visceral Tb
(sensitized host, immunity)
Hematogenous spread from
fulminant Tb of lung/meninges
(immunosuppressed HIV, infant)
cutaneous immune reactions to
M. tuberculosis

Clinical: Painless red-brown papule ulcerates Gohn complex (lung), regional lymphadenopathy 3-8 wk p infection
Pauci- or Multi-bacillary (depends on stage of infection & strength of immune response).
Clinical: Slowly growing verrucous plaques w/ irregular borders on hand
Pauci-bacillary
Clinical: Brownish-red plaque; Apple-jelly diascopy; Head/neck involvement in 90% of cases
Pauci-bacillary
Clinical: Subcut draining nodules sinuses & ulcers w/ granulating bases; mostly over cervical lymph nodes
Pauci- or Multi-bacillary
Clinical: Subcut abscesses fistulas & ulcers; typically on trunk, head or extremities
Multi-bacillary
Clinical: Punched-out ulcers w/ undermined edges; Mucocutaneous junctions of mouth, genitalia.
Multi-bacillary
Clinical: Disseminated erythematous macules, papules, nodules, or purpuric lesions.
Anergic (tuberculin test negative)

#1. papulonecrotic eruption (small dusky red papules w/ necrosis on extremities & buttocks)
#2. erythema induratum of Bazin (women, like nodular vasculitis), #3. lichen scrofulosorum

ATYPICAL MYCOBATERIOSES Most culture in 2-3 weeks; Rapid Growers in 5d (M. fortuitum, M. chelonae, M. abscessus). ACID-FAST
Swimming Pool Granuloma
Buruli ulcer
Bairnsdale ulcer
Searles ulcer
Turtle Tubercle Bacillus
Scrofuloderma-like
AIDS: Mult Purulent LE ulcers

Contaminated water to skin injury;

Mycobacterium Marinum
(skin exposed to water)

firm nodule painless ulcer 1-2cm


Pulmonary dz most common
Post-traumatic subcut nodules on
distal limbs or sporotrichoid pattern
cervical lymphadenitis sinuses
LE ulcers & papulopustules

Mycobacterium ulcerans
Mycobacterium kansasii

Clinical: aquarium, pool, lake small papule nodule granulomatous verrucous plaque
Sporotrichoid spread; Tx: Minocycline
Tx: excision, heat, hyperbaric O2; rifampin, bactrim, minocycline

verrucous plaques, ulcers, nodules, sporotrichoid patterns in immunocompromised pts

fortuitum complex

M. fortuitum = M. chelonei

M. scrofulaceum
M. avium, M. intracellulare

Cervical lymphadenitis sinus formation (indistinguishable from Tb scrofuloderma)


F/C/sweats/wt.loss,pain/HSM, AlkPhos

ID for boards pg 6
Leishmaniasis
New World Cutaneous
New - Mucocutaneous
Old World Cutaneous
oriental sore, Baghdad sore

Old - Mucocutaneous
Visceral Leishmaniasis
kala-azar (India, Kenya)
American Trypanosomiasis
Chagas disease
African Trypanosomiasis
African Sleeping Sickness

Lymphatic Filariasis

Lutzomyia sand fly


Lutzomyia sand fly
Phlebotomous sand fly
Phlebotomous sand fly
Phlebotomous sand fly

Reduvid bug (kissing bug)


Reduviidae spp.

L. mexicana
L.braziliensis complex
L. major or L. tropica
L.aethiopica, L.infantum
L.aethiopica
L.donovani
L. chagasi, L.infantum (kids)

T. cruzi
(Central, S. America, Texas)
(Tom Cruise is American)

Tsetse fly
Glossina spp.
Mosquitoe vector

T. brucei gambiense (W Africa)


T.brucei rhodesiense (E Africa)
Wuchereria bancrofti
(Aedes, Anopheles, Culex, Mansonia)
Brugia malayi, B. timori,

Cutaneous Filariasis
Loiasis

Mango fly, deer fly


(Chrysops)

Loa Loa

Onchocerciasis
River Blindness

Black fly (Simulium)

Onchocerca volvulus

Cyclops copepods

Dracunculus medinensis

Dracunculiasis
Larva Currens, Ground Itch
Cutaneous Strongyloides

Disseminated Strongyloides
Cercarial Dermatits
Swimmers itch

Seabathers Eruption
Fishtank Granuloma

(aquatic arthropod)

Strongyloides stercoralis
Strongyloides stercoralis
Schistosomatidae (cercarial flatworms)
Edwardsiella lineata (sea anemone); Linuche unquiculata (thimble jellyfish)
Mycobacterium marinum (deep fungal infection)

Culture medium: Novy-MacNeal-Nicolle (NNN)


Dx: histo or PCR for species ID.
Histo: amastigotes in histiocyte cytoplasm: oval bodies w/ nucleus, kinetoplast
Promastigotes: flagellated extracellular, as in sandfly;
Amastigote transformation w/in host tissue histiocytes.
Tx: Pentavalent Antimony (sodium stibogluconate)
Romaa sign: palpebral/periocular edema when conjunctiva is protal of entry.
Dx: ID trypomastigotes in blood or CSF; amastigotes in tissue.
Tx: Nifurtimox; benzidazole
Clinical: Local erythema, edema, lymphadenopathy ANS, heart & GI tract

Winterbottoms sign posterior cervical adenopathy


Clinical: 'trypanosomal chancre' bite rxn anular eruption + fever
Lymphedema & Elephantiasis; blood sample at midnight microfilariae
Transient Calabar subcutaneous swellings (hands, florist forearms)
Migrating across conjunctivae: Eye worm; daytime microfilariae in blood
Tx: Diethylcabamazine (DEC)
6-12d incubation (grow in thoracic muscles) 2 moults; Tx: Ivermectin
Pruritic papular dermatitis lichenification; Leopard skin depigmented patches
Onchocercal nodules (over bones); Ocular involvement blindness

Transmit: contaminated water; worm emerges from skin (wrap around a stick)
Clinical: Serpiginous urticarial plaques on buttocks, groin, trunk
FAST: 5-15 cm per hour
Periumbilical thumbprint purpura w/ widespread truncal petechiae
Pruritic papules & papulovesicles on uncovered skin;
Northern US & Canada; Tx: prazinquantel
Pruritic erythematous papules/wheals under swimsuit; Saltwater only;
Southern US, Caribbean, Long Island coast.
Ulcerated papule/nodule; Tx: Bactrim, Biaxin, Doxy

ID for boards pg 7
STDs
Disease
1 syphilis
2 syphilis

Micro-organism

Clinical lesion
2-4 weeks incubation (lasts 3-12 weeks)

Darkfield (best for 1), Warthin-Starry stain

Bilateral, rubbery nontender adenopathy (buboes).

Hemagglutination/Treponemal (FTA-Abs) @3 wks


Anticardiolipin/Non-treponemal: (RPR/VDRL)@5wk

Treponema pallidum Painless, Non-purulent, usually single ham-colored indurated ulcer


spirochete

Diagnosis

6 weeks after onset of 1 chancre lasts 4-12 weeks followed by LATENT phase
Early: non-pruritic PR-like rash; Late: copper-colored maculopapular rash, +lymphadenopathy
Palm/soles: symmetric split-papules w/ Biett scale (collarette), moth-eaten alopecia (tel eff)
Condyloma tala (local treponemes); 'corona veneris' @ hairline, prodromal sx;

RPR/VDRL + in 100% (reverts to after tx /latent)

3 syphilis

DTH response: Late benign no cardio or CNS gummas; Cardiovascular or Neurosyphilis. Dx: CSF IgG

False + VDRL: preg, spirochete infxn, viral infection,


autoimmune dz, Lep. leprosy, malaria, drug abuse.
FTA-Abs, remains + (best serology for 1)
MHA-TP (like FTA-Abs, but less sensitive for 1)
ELISA / IgM EIA best for early 1 or congenital)

Congenital

1st 3 mos: marasmic syphilis, snuffles (bullous/erosive 2 syphilis). Hutchinson triad: keratitis, teeth, deafness

FTA-Abs-19-S-IgM (IgM separated, more specific)

Haemophilus ducreyi 3-10d incubation Purulent, painful, 1 ulcers, soft ragged edges.

Culture
School of fish on Giemsa stain

Chancroid
Granuloma
Inguinale
Donovanosis

G bacillus

Unilateral, tender adenopathy (bubo) in 50%.

Calymmatobacterium Indurated chronic red fleshy ulcer


1 lesion: papule, subcut nodule (pseudobubo) or ulcer
granulomatis
G bacillus
4 forms: Ulcerovegatative (most common), Nodular, hypertrophic, cicatricial
Transient painless soft erosion unilateral lymphadenopathy

LGV

Chlamydia trachomatis

serovars L1, L2, L3

Genital herpes HSV (2>1)


Gonococcemia

firm mass & bubo w/ drainage & involusion w/ proctocolitis

groove sign - fluctuant tender groin LN


Serology, culture, PCR

Burning painful vesicles on erythematous base

Antigen detection, culture, PCR

GU: Urethritis/dysuria, purulent urethral discarge PID, perihepatitis

Smears: Male/urethral, Female/Endocervical


(diplococci in PMNs w/ methylene blue or gram)
Culture: (Thayer-Martin)
Gen-Probe: non-amplified DNA hybridization

Neisseria gonorrhea Skin: Sparse hemorrhagic vesiculopustules w/ erythematous


G intracellular diplococci

Donnovan bodies: safety-pin


intracytoplasmic M inclusions

bases on palms/soles, over joints; F/C/arthralgias/malaise


Recurrent Gonorrhea: complement deficiencies (esp C5-8)

Tx
2.4 million U
Benzathine IM

PCN
1, 2 - 1 dose
3 - q week x3
Jarisch-Herxheimer:
treatment fever due
to TNF release.

Azithromycin,
Ceftriaxone,
Cipro, Erythro

TMP-SMX,
Doxy, Cipro,
Erythro
Doxy
Acyclovir
Single dose:
Ceftriaxone

ID for boards pg 8

Herpesvirus: core of linear ds-DNA, icosahedral capsid, envelope w/ surface glycoprotein spikes;
Orolabial herpes
HSV-1 ALPHA

Eczema herpeticum =
Kaposis varicelliform eruption

replication at mucosal site


Dissemination: atopic dermatitis, burns, pemphigus, MF, icthyosis, Dariers, Sezarys

gG-1 glycoproteins

Herpes gladiatorum
contact sports, ie. Wrestling (arms > H&N)
Erythema multiforme
Western Blot (gold standard)
HSV folliculitis
DIF, Viral culture, Tzank
HSV keratoconjunctivitis
#2 cause of corneal blindness
Herpes encephalitis
1 sporadic fatal encephalitis; temporal lobes; 70% mortality); CSF cx & PCR, EEG, MRI
replication at mucosal site
Genital
herpes
HSV-2 ALPHA
gG-2 glycoproteins
Neonatal herpes
risk of transmission highest (33-50%) w/ 1 eruption near time of delivery; <3% in recurrent herpes
Tx 1 HSV: Valtrex (2g PO BID x10d); HSV Recurrence: Valtrex (500 bid x 3-5d); HSV Supression: 500-1000 qd;
Acyclovir: guanosine analoge inhibits viral DNA polymerase (after thymidine kinase phosphorylation) & 2 viral kinases. (Acyclovir & Famivir require viral TK)
Acyclovir resistance: Foscarnet/Cidofovir (not dependent on viral thymidine kinase)
90% of 10yo; airborne; 11-20d incubation; LNs replication 2 viremia, liver/spleen replicate vesicles
rash: scalp/face rosepetal dewdrops over 12h; enanthem
Varicella
VZV (HHV-3)
Congenital Varicella Synd (1st 20 wks): hypoplastic limbs, ocular & CNS abnormalities
ALPHA
Neonatal Varicella (5d pre-, 2d post-delivery): inadequate transplacental Ab (Tx: VZIG + IV-acyclovir)
20% of healthy adults, 50% of immunocompromised
st
DIF (best), Tzank (1 )
Herpes zoster
disseminated: >20 vesicles outside primary or adjacent dermotomes; more common in immune suppressed
Viral Culture (most specific)
Clinical: Ipsilateral facial paralysis + tinnitus or auditory symptoms
Ramsay Hunt Syndrome
VZV infection of geniculate ganglion (vesicles on external ear or tympanic membrane)
VZV-Ig - w/in 96h passive prophylaxis of immunocompromised, pregnant, neonates; VZV vaccine (Oka) - 95-100% effective in preventing severe disease
Tx VZV: Valtrex w/in 72h of 1st vesicle improves course
1 EBV infxn in 50% of 17-25yo (pharyngitis, fever, lymphadenopathy, spleenomegaly x2-3 weeks)
EBV (HHV-4)
Ampiciliin rash: Mono + Amp = copper macular extensor rash 7-10d later spreads to trunk
Infectious Mononucleosis
GAMMA
desquamates 1 wk later
Epstein Barr Virus
Replicates in B cells
+ monospot or
heterophile Ab >1:40

CMV (HHV-5) BETA


HHV-6 BETA
HHV-7 BETA

HHV-8 GAMMA

Oral Hairy Leukoplakia

HIV / Immunosuppressed: lateral tongue corrugated white plaques

Lymphoproliferative disorders (solid organ transplants or HIV +), Nasopharyngeal Carcinoma, ?Hodgkins lymphoma, African Burkitts lymphoma;
Gianotti-Crosti synd (infantile papular acrodermatitis), EM, EN, urticaria, acrocyanosis, EAC, pityriasis lichenoides, palmar dermatitis
#1 cause of congenital deafness & mental retardation (TORCH synd); #1 congenital virus.
Clinical: SGA, microcephaly, retinitis, colobomas, intracranial calcifications.
Congenital CMV
dermal erythropoiesis purpuric papules ('blueberry muffin lesions)
#1 cause of blindness in AIDS pts.
CMV Retinitis
Roseola Infantum =
Infant toddler febrile illness (6 mos to 3 yrs) high fevers & 48h rash as fever remit.
Rash: rose-red maculopapules 2-5mm, occasionally surrounded by white halo.
Exanthem sibitum = 6th disease
HHV-6B > -6A, -7
CD4+ lymphotropic viruses; Transmitted through saliva
Castlemans syndrome
>60 yo Mediterranean or Ashkenazi Jew; HIV+
Kaposis sarcoma
1. classic KS spongy feel (early) purplish-red plaques on LEs of elderly Mediterranean men (slow progression)
2. HIV/AIDS KS small macules, plaques become exophytic & ulcerative involves oral & perioral, genital, GI tract
3. Immunosuppressed KS similar to AIDS-KS with rapid dissemination
4. African endemic KS -- nodular (benign), lymphadenopathic, florid, infiltrative (aggressive).

Hand-Foot & Mouth Dz

Cocksackie A16 > Enterovirus 71

Herpangina

Coxsackievirus Group A

Measles / Rubeola

Paramyxovirus
Paravaccinia virus
(Parapoxvirus)

Milkers Nodule
Orf

Orf virus
(Parapoxvirus)

Contagious Pustular
Dermatitis
Contagious Ecthyma

6 stages (each last 6 days): 1. Papular (red papule), 2. Target (erythematous w/ white ring); 3. Acute (weeping)
4. Regenerative (crusts w/ black dots); 5. Papillomatous (small papillomas); 6. Regressive (crusts, flat)

Kids: Slapped-cheek appearance


Adults: acute arthropathy w/ fever & adenopathy; lacy reticular macular eruption
Pregnancy: Hydrops fetalis, spont Ab if 1st of preg;
Sicklers: Aplastic crisis; Immunocompromised pts: severe chronic anemia

Fifth Disease
Erythema Infectiosum

Parvovirus B19
(ss-DNA)

Molluscum contagiosum

Molluscum contagiosum virus


(Poxvirus)

Umbilicated papules; kids>adults


16d incubation. Rash: Erythematous maculopapular FACE to trunk in 24h (disappears as it spreads);
Tender lymphadenopathy (occipital, posterior auricular); + Joint involvement
Forchheimers spots (soft palate petechial macules)
TORCH syndrome w/ Blueberry Muffin Baby (low birth wt, microcephaly, cong heart dz)
TORCH syndrome: HSM, deafness, microcephaly, chorioretinitis, thrombocytopenia
Blueberry Muffin Baby: dermal extramedullary erythropoiesis; Gen. 1-7mm purpuric papules on
H/N/trunk
12d Prodrome 3d F/HA/N/V, back pain; pathognomonic swimming trunk distrib. Petechiae
Generalized centrifugal eruption: eruption of umbilicated papules, deep vesicles, pustules, crusts
Dx: Guarnieris bodies (cytoplasmic eosinophilic bodies) on LM; Fluorescent Ab staining lesion fluid

Rubella (nasopharynx infection)


(Togavirus)
Rubella / German measles
Rubella (congenital infection)
(Togavirus)

Variola (Poxvirus)
Smallpox

Smallpox complications:

ID for boards pg 9
Erythematous papules w/ grayish vesicle & surrounding red areola
Transmission: oral-oral & oral-fecal
Fever, Headache, Cervical Lymphadenopathy
Gray-white papulovesicles on tonsillar fauces, palate ulcerate
3d prodrome of: High Fever + 3 Cs (cough, coryza, conjunctivitis); Kopliks spots
Rash: Erythematous macules & papules begins on forehead, then generalizes (fades on 5th day)
Complications: otitis, PNA, encephalitis, myocarditis, subacute sclerocing panencephalitis (sz, coma)
Transmit: infected cows humans
Single 1cm erythematous targetoid nodule on finger/forearm (may be multiple); Self-limited
Endemic: sheep, goats, musk oxen (nodules on nose/mouth) transmitted to shepherds, farmers, vets
Clinical: Papule/nodule on dorsal index finger;

EM-like eruptions
Bacterial Superinfection
Accidental inoculation
Congenital vaccinia
Generalized vaccinia
Progressive vaccinia

S.aureus, GAS
Eczema vaccinatum p innoculation onto dermatitic skin
Following vaccination of a pregnant woman
Children w/ isolated IgM deficiency are especially prone (ie. Wiscott-Aldrich Synd)
Impaired immunological response to vaccinia (in normal or immunodeficient hosts)

Human Papillomavirus (HPV)


Type of wart
Palmo-plantar
Common, myrmecial
Flat
Butchers
Hecks dz (Oral focal epithelial hyperplasia)
Epidermodysplasia verruciformis (EDV)
Anogenital; Buschke-Lowenstein tumor
High risk anogenital/cervical CA; Bowenoid
Papulosis

HPV type
1
2,4
3,10
7 (2)
13,32
3, 5,8 > 9,12,14,15,17,19-26
6,11
16 >18,31,33-35

DNA Viruses:
H-H-A-P-P-P-y

RNA Viruses:
P-P-R-R-T

herpes, hepadna,
adeno,
papova, ss-parvo, pox
Paramyxovirus (measles, mumps);
Picornavirus (Enterovirus: coxsackie)
Retrovirus (HIV, HTLV);
Rhabdovirus (rabies);
Togavirus (rubella);

ID for boards pg 10

Lice, Mites, Spiders, Bugs


Black widow

Lactodectus mactans

Brown recluse

Loxosceles

Wolf spider
Jumping spider
Sac spider
Hobo spider
Green Lynx spider
Tarantulas
Scorpions
Catepillars
Bee, wasp, hornet, ant
Fire ants
Black flies
Horseflies, Deerflies, Mangoflies
Sand flies
Mosquitoes: Malaria
Mosquitoes: Yellow Fever & Dengue
Bedbugs
Fleas: Typhus & Plague
Centipedes
Millipedes

Lycosidae
Phidippus
Chiracanthium
Tegenaria agrestis
Peucetia viridans
Centuroides sculpturatus/gertschi
Lepidoptera
Hymenoptera
Solenopsis (invicta)
Tabandae
Anopheles
Aedes
Cimicidae
Pulex irritans
Chilopoda
Diploda

White hourglass on abdomen; painful bites, but no necrosis. Antivenin helpful <90 hrs after bite.
Venom: Lactrotoxin neurotoxins F/C/N/V, cramps, paralysis, acute abd.
Tan w/ violin on abdomennecrosis; red-white-blue sign (erythema, ischemia, necrosis).
systemic rxns in kids (f/c/v/hematuria/t-penia/anemia/thrombosis).
Venom: Sphingomyelinase-D (necrosis/hemolysis).
Venom: Histamine (exceedingly painful bites lymphangitis/eschar)
Venom: Hyaluronidase; Aggressive: #1 biting spider in US (esp in South), pain, no systemic sx.
Venom: lipase
Herringbone abdomen; Pacific northwest (#1 necrotic spider bite)
Southern US; Bright green w/ red spots, black leg spines;
Southwest US; urticating hairs penetrate into reticular dermis or cornea (ophthalmia nodosa)
Venom: neurotoxin; pain / numbness /ecchymosis CNS symptoms arrhythmias, HTN
tram track purpura , erythematous papules
Honeybee leaves barbed ovipositor (needs removed QUICKLY) bee dies; tx: ice & lidocaine
Venom: hemolytic factor, solenospin D (causes histamine release); may attack in groups
blood suckers (vectors for onchocerciasis & tularemia)
Blood suckers
transmit Depetalonema perstans
Transmits: Malaria
Transmits: Yellow Fever & Dengue
Flat & broad; Nocturnal feeders; bites in linear purpuric macules
Transmits: typhus, plague; Extremely pruritic red papules on Lower legs
Nocturnal carnivores (painful venom wounds)
Harmless vegetarians (emit toxic substance that may produce blistering & pigmentation, eye irrit)