Download 12_Agents_of_sepsis_2014

Institute for Microbiology, Medical Faculty of Masaryk University
and St. Anna Faculty Hospital in Brno
Miroslav Votava
Agents of sepsis
(plus Infections with the skin symptoms – revision)
The 12th lecture for 3rd-year students
5th December, 2014
Infections with skin symptoms
– revision
1. primary skin infections
2. secondary infections of already
diseased skin
3. skin symptoms of systemic infections
Etiology: bacterial
viral
fungal
parasitic
Primary acute bacterial skin
infections I – revision
acne vulgaris – Propionibacterium acnes
carbunculus nuchae – Staphylococcus aureus
ecthyma gangraenosum – Pseudom. aeruginosa
erysipelas – Streptococcus pyogenes
erysipeloid – Erysipelothrix rhusiopathiae
erythrasma – Corynebacterium minutissimum
folliculitis – Staph. aureus, P. aeruginosa
furunculosis (boil) – Staphylococcus aureus
Primary acute bacterial skin
infections II – revision
hidradenitis suppurativa – Staph. aureus
hordeolum (stye) – Staph. aureus
impetigo – Staph. aureus, Str. pyogenes
lymphangoitis – Streptococcus pyogenes
panaritium – Staphylococcus aureus
paronychium – Staphylococcus aureus
sycosis barbae – Staphylococcus aureus
Primary chronic bacterial skin
infections – revision
actinomycosis – Actinomyces israelii
chronic subcutaneous abscesses – A.
israelii, Nocardia asteroides,
Rhodococcus equi
skin granulomas – Mycobacterium
marinum, M. haemophilum, M. chelonae
leprosy – Mycobacterium leprae
lupus vulgaris – Mycob. tuberculosis
scrophuloderma – M. tuberculosis, M. bovis
Secondary infections of skin lesions
– revision
decubitus (bedsore), trophic ulcer – neighbouring
and endogenous flora (staphylococci,
streptococci, enterococci, enteric bacteria,
pseudomonads and other Gram-negative nonfermenting rods, anaerobes, yeasts)
infected atheroma – S. aureus, Propion. acnes
infected intertrigo (raw) – S. aureus, P. acnes
sec. infected dermatomycoses – S. pyogenes
infected wounds – discussed in previous lecture
(esp. staphylococci, streptococci & clostridia)
Skin symptoms of systemic bacterial
infections – revision
roseola (rash in typhoid fever) – Salmonella Typhi
disseminated gonorrhoea – Neisseria gonorrhoeae
erythema migrans – Borrelia burgdorferi
infective endocarditis – to be dealt with by sepsis
meningococcemia – Neisseria meningitidis
scarlatina (scarlet fever) – Streptococcus pyogenes
SSSS (staphylococcal scalded skin syndrome) –
Staphylococcus aureus
toxic shock syndrome – S. aureus, S. pyogenes
syphilis (branded as a „great imitator“) –
Treponema pallidum
Etiology of skin fungal infections
– revision
Etiology differs in
• superficial mycoses, like pityriasis versicolor
– Malassezia furfur (prev. Pityrosporum ovale)
• mucocutaneous mycoses – Candida albicans
and other species of candidae
• cutaneous mycoses – typical dermatophytes
• subcutaneous mycoses
• opportune skin mycoses in immunodeficites
Etiology of cutaneous mycoses I
– revision
Three genera of dermatophytes:
Trichophyton
e.g. Trichophyton rubrum
2. Microsporum
e.g. Microsporum canis
3. Epidermophyton
only Epidermophyton floccosum
Etiology of cutaneous mycoses II
– revision
tinea pedis – Trichophyton rubrum, Trich.
mentagrophytes var. interdigitale,
Epidermophyton floccosum
onychomycosis – Trich. rubrum, Epid. floccosum
tinea corporis – Trich. rubrum, Microsporum
canis, Micr. gypseum, Trich. mentagrophytes
var. mentagrophytes, Epid. floccosum
tinea capitis, type ectothrix – M. gypseum, Micr.
canis, Micr. audouinii, T. mentagrophytes var.
mentagrophytes, Trich. verrucosum
type endothrix – Trich. tonsurans
favus – Trichophyton schoenleinii
Etiology of subcutaneous mycoses
– revision
pheohyphomycosis (lesions with pigmented
hyphae) – genera Alternaria, Aureobasidium,
Cladosporium, Culvularia, Exophiala,
Phaeoannelomyces, Phoma, Wangiella & others
chromoblastomycosis (warty nodules with sclerotic
bodies) – Cladophialophora, Fonsecaea,
Phialophora
mycetoma eumycoticum (swollen lesion with
draining tracts containing small grains) –
Acremonium, Exophiala, Madurella,
Pseudoallescheria (= Scedosporium)
sporotrichosis – Sporothrix schenckii (dimorphic
fungus)
Etiology of opportune skin mycoses
in immunodeficites – revision
Fusarium solani, Fusarium oxysporum,
Fusarium verticillioides
Pseudoallescheria boydii (= teleomorf,
sexual phase of anamorf Scedosporium
apiospermum)
Penicillium marneffei (systemic infection
with skin manifestations – in AIDS)
Scopulariopsis brevicaulis
Skin symptoms in viral diseases I
– revision
Macular (spotted) exanthem:
measles – morbilli virus (Morbillivirus genus)
rubella – rubella virus (Rubivirus genus)
erythema infectiosum (the fifth disease) –
parvovirus B19 (Erythrovirus genus)
exanthema subitum (roseola infantum, the
sixth disease) – human herpesvirus 6
(HHV 6, Roseolovirus genus)
some echovirus infections – ›30 serotypes
(Enterovirus genus)
Skin symptoms in viral diseases II
– revision
Umbiliform papulae:
molluscum contagiosum – molluscum
contagiosum virus (Molluscipoxvirus
genus)
Skin symptoms in viral diseases III
– revision
Vesicles:
herpes simplex (cold sore) – herpes simplex virus
type 1 (HSV 1, Simplexvirus genus)
herpes genitalis – HSV 2 (Simplexvirus genus)
varicella (chicken pox) – primary infection by
varicella-zoster virus (VZV, Varicellovirus genus)
herpes zoster (shingles) – activation of latent
infection by varicella-zoster virus
variola vera (smallpox, now eradicated) – variola
virus (genus Orthopoxvirus)
(continued)
Skin symptoms in viral diseases IV
– revision
Vesicles – cont.:
vaccinia – vaccinia virus (for vaccination against
variola, Orthopoxvirus genus)
cowpox, monkey pox – cowpox and monkey pox
viruses (Orthopoxvirus genus)
tubera mulgentium (milkers´ nodules) – milker´s
nodule virus (Parapoxvirus genus)
aphthae epizooticae (foot and mouth disease) –
foot-and-mouth disease virus (FMDV,
Aphthovirus genus)
hand, foot and mouth disease – coxsackievirus
A16 (Enterovirus genus)
Skin symptoms in viral diseases V
– revision
Petechiae:
hemorrhagic fevers –
Ebola fever, Ebola virus (Ebolavirus genus)
Marburg disease, Marburg virus (genus
Marburgvirus)
Lassa fever, Lassa virus (Arenavirus genus)
generalized congenital cytomegalic disease –
cytomegalovirus (CMV, Cytomegalovirus
genus)
Skin symptoms in parasitoses I
– revision
Domestic (native) parasitoses:
scabies – itch mite (Sarcoptes scabiei)
demodicosis – human follicle mites (members of
Demodex genus)
pediculosis capitis – head louse (Pediculus
capitis)
pediculosis corporis – body louse (Pediculus
humanus, syn. Pediculus corporis)
pediculosis pubis (pthiriasis) – pubic (crab) louse
(Pthirus pubis)
dermatitis cercariosa – cercariae of avian and
mammalian schistosomae non-pathogenic for
man
Skin symptoms in parasitoses II
– revision
Infestation by native ectoparasites:
cimicosis, urticaria cimicosa – bites by bedbug
Cimex lectularius
pulicosis – bites by human flea Pulex irritans,
dog flea Ctenocephalides canis,
cat flea Ctenocephalides felis,
chicken flea Ceratophyllus gallinae
ixodosis – bite by hard tick Ixodes ricinus
culicosis – bites by common mosquitoes, e.g.
Culex pipiens
trombiculosis, trombidiosis – bites by
Neotrombicula autumnalis larvae
Skin symptoms in parasitoses III
– revision
Tropical parasitoses:
ulcus humidum (humid ulcer) – countryside in Near and Middle East,
northern and western Africa; Leishmania major
ulcus siccum (dry ulcer, oriental sore) – cities in Near and Middle East,
seats in northern and eastern Africa; Leishmania tropica
espundia (severe, even fatal disease) – South America; Leishmania
braziliensis
tungosis (sore caused by skin-burrowed female of chigoe or sand flea)
– subtropical and tropical America and Africa; Tunga penetrans
dracunculosis (Guinea worm disease, „the fiery serpent“) – now in
Africa only; Dracunculus medinensis
Loa loa filariosis (loiasis, Calabar swellings) – West Africa (Cameroon);
filariae Loa loa
onchocerciasis (river blindness; various skin signs, e.g. „leopard
skin“) – Africa, Middle and South America; filariae Onchocerca
volvulus and their endosymbiont Wolbachia pipientis
…
Bacteremia versus sepsis – I
Bacteremia = mere presence of bacteria in blood
But: bacteria = starting mechanism of sepsis
Interaction of microbial products with
macrophages releases a lot of cytokines
→ systemic inflammatory response syndrome
(SIRS); symtoms of SIRS =
• elevated temperature
• accelerated pulse and breathing
• leukocytosis
Bacteremia versus sepsis – II
Sepsis = suspect or proved infection +
systemic inflammatory response
syndrome (SIRS)
Severe sepsis = sepsis + organ dysfunction
(hypotension, hypoxemia, oliguria,
metabolic acidosis, thrombocytopenia,
confusion)
Septic shock = severe sepsis + hypotension
despite adequate supply of fluids
Characterization of sepsis
Clinic:
fever or hypothermia
tachycardia
tachypnoe
lowered blood pressure
confusion
↑↓ Temperature
 Pulse
↑ Breathing
↓ BP
Laboratory:
leukocytes
↑↓ Leu
serum bicarbonate
↓ HCO3bacteremia – may not be already demonstrable
Types of bacteremia – I
Intermitent bacteremia – in localized infections:
pneumonia (pneumococci)
meningitis (meningococci)
pyelonephritis (Escherichia coli)
osteomyelitis (Staphylococcus aureus)
septic arthritis (S. aureus, gonococci)
cholecystitis (enteric bacteria, enterococci)
peritonitis (mixed anaerobic and facultatively
anaerobic flora)
wound infections (Staph. aureus, Str. pyogenes)
bedsores (mixed skin and intestinal flora)
Types of bacteremia – II
Continual bacteremia – in general infections:
typhoid fever (Salmonella Typhi)
brucellosis (Brucella melitensis)
plague (Yersinia pestis)
Types of bacteremia – III
Bacteremia in bloodstream infections:
thrombophlebitis (Staph. aureus, Str. pyogenes)
acute endocarditis (S. aureus, S. pyogenes, Str.
pneumoniae, Neisseria gonorrhoeae)
subacute bacterial endocarditis = sepsis lenta
(α-hemolytic streptococci, enterococci,
HACEK group =
Haemophilus aphrophilus,
Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis,
Eikenella corrodens,
Kingella kingae)
„culture-negative“ endocarditis (bartonellae,
coxiellae, legionellae)
Types of bacteremia – IV & V
Bacteremia in some malignities:
colonic carcinoma (Streptococcus bovis)
leukemia (aeromonads, Bacillus cereus, Bacillus
subtilis, Clostridium septicum)
Bacteremia in intravenous drug users:
skin flora (staphylococci, corynebacteria)
mouth flora (neisseriae, eikenellae, even
nasopharyngeal pathogens)
bacteria from the environment (clostridia, bacilli)
Types of bacteremia – VI
Bacteremia in iatrogenic infections:
tooth extraction (α-streptococci, prevotellae)
bronchoscopy (nasopharyngeal flora including
pathogens)
bladder catheterization (Escherichia coli)
infusions (skin flora, G– non-fermenting rods)
vascular catheters (coagulase-negative
staphylococci, yeasts)
invasive devices and implants (coagulase-negative
staphylococci, micrococci, corynebacteria,
nocardiae)
febrile neutropenia (antibiotic-resistant staphs,
enterococci, G– rods, yeasts, moulds)
Clinical types of sepsis
•
•
•
•
•
wound-originated sepsis
urosepsis
abdominal sepsis
fulminant sepsis
nosocomial (hospital-acquired) sepsis
Wound-originated sepsis
Staphylococcus aureus
Streptococcus pyogenes
beta-hemolytic streptococci groups G, F, C
Pseudomonas aeruginosa (burns)
Clostridium septicum
Urosepsis
Escherichia coli
Proteus mirabilis
other enteric bacteria
Abdominal sepsis
Polymicrobial etiology
anaerobes: Bacteroides fragilis
Peptostreptococcus micros
Peptostr. anaerobius
&
facultative anaerobes: Escherichia coli
Proteus mirabilis
Fulminant sepsis
Neisseria meningitidis († in 24 hours!)
Streptococcus pyogenes
Yersinia pestis
Nosocomial sepsis
Staphylococci, coagulase-negative (intravenous
catheter-associated sepsis, infections of plastic devices
in situ, febrile neutropenia)
Staphylococcus aureus (infected surgical wounds)
E. coli & other enterobacteria (catheter-associated
infections of the urinary tract)
Gram-negative non-fermenting rods
(contaminated infusion fluids)
yeasts (catheter-associated sepsis, febrile neutropenia)
many other microbes (see above the agents of
iatrogenic bacteremia)
Treatment of sepsis
•
At intensive care units (ICU) only
Control of infection
–
–
•
antibiotics – initially broad spectrum ones, then
oriented on the isolated microbe
removal of all infected tissues or devices)
Support of breathing and hemodynamics
–
–
–
–
artificial ventilation
oxygen
fluids
vasopressors etc.
…
Homework 11
Jakub Schikaneder (1855-1924):
By the Girl´s Bed (The Death is Coming; 1910)
Homework 11
Successful homework 11 solvers:
No answer has been received
Homework
12
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name of the author
and of the etching
Answer and questions
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