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MINISTRY OF HEALTH
UZBEKISTAN
TASHKENT MEDICAL ACADEMY
medical Faculty
Medical-Pedagogical faculty
Medical-Prophylactic faculty
Department of Skin and Venereal Diseases
Lecture 6
Endemic diseases of skin, skin tuberculosis. Lepra. Modern methods of diagnostics and
treatment
The drafters: doc. Musaeva N.Sh, Karimova M.K.
Plan and organizational structure of the lecture:
1. Endemic diseases of skin, skin tuberculosis.
2. Leprosy.
3. Cutaneous leishmaniasis.
4. Modern methods of diagnostics and treatment
Endemic diseases of skin, skin tuberculosis. Leprosy. Cutaneous leishmaniasis.
Modern methods of diagnostics and treatment
Leprosy
- Chronic infectious disease caused by Mycobacterium leprae
(MBL), harakterizutsetsya involvement of skin, mucous membranes, peripheral NA, internal
organs.
Detailed description of neurological and dermatological simtomatikiizvestno from 5-8 century
BC, in Europe two centuries. Most
prevalence in Africa, then Asia, America, Europe. In the 10-12 centuries, the highest incidence
was in Evrope.1874 Daniel Hansen opened MBL.1895 Nilsson - MBL red when stained by
Ziehl-Nilsson.
1919 Mitsuda - leprominovaya trial.
1943 Rage - sulfonic medications that have a bactericidal effect on MBL.
Shelpard 1960 - Methods of assessment activity.
Kirghayner 1971 - an experimental model of leprosy on the battleship.
Classification.
Main forms:
1) tuberculoid;
2) border tuberculoid;
3) border;
4) borderline lepromatous;
5) lepromatous.
Supplemental:
1) lack of differentiation;
2) subpolar lepromatoz.
The men recorded more frequently than women. In the CIS, about 3,000 patients. Once a person
gets sick. The main route of infection-airborne. Possible contamination through broken skin and
mucous membranes. On-site implementation of the inflammatory response does not develop.
In severe natural disease resistance can not develop. When household contacts infection occurs
in 10% of cases, if a natural resistance to leprosy reduced - 70%.
Pathology: form specific granuloma, which consists of a leprous cells, stuff a lot of MBL,
plasma cells, epithelioid cells.
Immunity. Usually, a person has a relatively high natural resistance to the MBL.
Clinic. Prodrome - malaise. The incubation period is 3 months. - 20 years, usually 3-7 years.
Vzbuditel leprosy mycobacterium leprae:-has grampolozhitelnauyu color - acid and alcohol, the
capsule and no disputes may exist in the form of L-forms. For leprosy: typical long incubation
period - a chronic, torpid, prolonged duration - periodic exacerbation (leprosy reactions) - skin
lesions, mucous membranes, the neuroendocrine system, internal organs. Epidemiological
features of leprosy: - spread of the disease is characterized by endemic - there is a link with the
socio-economic factors - for leprosy infection requires prolonged contact with the patient - the
most likely route of infection in the body is etsya infection through the mucosa of the mouth and
nose and Brokers rezhdenny skin. There are 3 types of leprosy: - lepromatous type - the type of
tuberculosis - undifferentiated leprosy (borderline type).
During leprosy distinguish the following stages:
- Progressive;
- Fixed;
- Regressive;
- Residual effects.
For lepromatous leprosy is characterized by the following types of eruptions;: infiltrative
spots, sites (leproma) - diffuse plaques - ulcers. Nutritional observed at lepromotoznom type of
leprosy: hair loss on the hearth, lack of sweating on chagah, formation of venous ulcers - a
violation of pigmentation - spontaneous amputation of limbs - atrophy of sebaceous
zhelez.Vvsledstvie various movement disorders in leprosy: distinguish the following symptoms;
flexion contracture - "kogteobraznaya brush" - "monkey's paw" - as a result of atrophy of the
thenar and hypothenar - lagophthalmos - mask "of St. Anthony." Is depression
functions of sweat, sebaceous glands, baby hair falls out, narushayutsyavse kinds of sensitivity in
the flesh before anesthesia. Narusheniyachuvstvitelnost can leave the centers of 1-1.5 cm
Affects the radial and peroneal nerves - thicken and well palpable.
Lepromatous. Affects the skin and mucous membranes and internal organs in the early stages.
Peripheral NA later. In scrapings of the nasal mucosa
many MBL. Leprominovaya test negative - low resistance to MBL. The disease begins with the
appearance of pigment or erythematous, symmetrically arranged spots without
clear boundaries. Dark spots first, then yellow, brown, skin is smooth and glossy. Sensitivity is
not affected in the outbreak, the secretion
sebaceous glands increases, hair follicles, the mouth opening of the sebaceous and sweat glands
extensions, skin like lemon peel.
After 3-5 years the hair starts to fall out of eyebrows, eyelashes, in the lesions formed units
occurring in the dermis or hypodermis. Nodes (leproma) emphasize the natural folds of the skin,
eyebrows, nose, lips - "lion's face." Nodes decompose with the formation of ulcers, slow healing,
prone to peripheral growth. After treatment remain
severe scarring. Characterized by: - leproma never located in the armpits, groin,
knee and elbow areas on the scalp - affects mucous membranes: the nasal mucosa becomes a
bluish color, the nose is deformed due to the collapse and scarring of leprosy;
- Often involving the liver (hepatitis lepromatous), kidney - peripheral nerves are affected in the
later stages (polyneuritis, trophic yahvy).
Border tuberkuloidnyts type. Reminds tuberculoid, but plaques less granitsv less clear,
symmetrically arranged,
multiple. Impairment of the function of the sebaceous, sweat glands and impaired
all kinds of sensitivity to a lesser extent. Leprominovaya test
positive or weakly positive.
Edge type. Multiple spots with irregular asymmetric
Thomas blurred, with the central part vypuklotsy
(Reminiscent of the inverted dish) in the center of a lot of small pockets of holes. On the
periphery of lesions - small foci. Violation of the sensitivity in areas of moderate, baby hair
partially
saved. Leprominovaya test negative.
Border lepromatous form. Papules, plaques, diffuse infiltrates. Is different from the presence of
perforating lepromatous type elements with raised edges of fillets. In
some centers reduced chuvstviteltnost, sweat gland function is not suffering, impaired growth of
vellus hair. There is no loss
eyebrows, eyelashes, nose deformations. Leprominovaya test is always negative.
Subpolar lepromatous type. Developed at sharply reduced resistance. Manifests as lepromatous
type, but
elements are more clearly distinguished, asymmetric.
- For tubercular leprosy type: characterized by a more benign course, defeat mostly skin and
peripheral nerves - leprominovye positive sample.
In leprosy concerned hypo-and anesthesia, lack of sensitivity to pain - changing tactile
sensitivity. Undifferentiated type of leprosy otloichaetsya lepormatloznogo type
Leprosy: scanty, unstable symptoms on the skin manifested eritemato-squamous, hypo and
hyperpigmented spots, and the severity of neurological mptomatiki symmetry.
Negative leprominovaya sample observed in lepromatous type; polozhptelnaya the
tubercular type - unstable in undifferentiated tipe.Rezultaty leprominovoy tests: - a negative test
- if after injection lepromin formed edematous papule Diameter less than 3 mm, which
disappears at the end of the second day.; - Weakly positive reaction - during the formation after
injection site-sound infiltration from 3 to 5 mm edematous inflammatory rim - positive reaction appears edematous erythematous papule
from 5 to 10 mm, continuing 2-4 weeks - dramatically positive reaction - characterized later
appearance juicy papules larger than 10 mm in diameter with a pronounced inflammatory
effects.
In order to confirm the diagnosis of leprosy material is taken for laboratory testing:
with the mucous membranes of the nose, from the source to the tissue juice
porazheniya.Osnovnye drugs used for the treatment of leprosy: - sulfone drugs: DDS, avlosulfon,
dapsone - derivatives iomocheviny: ethionamide, protionamid.
DIAGNOSIS.
1) history: whether the contact with patients;
2) clinic;
3) The results of a study of the nasal mucosa, biopsy lesions;
4) functional tests:
1% morphine
0.1% of histamine: a drop of the affected and healthy areas in
center of the drop shot. Suction histamine normally appears erythema, then blister, with leprosy
reaction slabovyrazhena or otsutstvuet.proba for perspiration test niacin
- 5-8 ml of 1% of nicotinic acid / in - diffuse erythema, normally 15-20 minutes will begin to
disappear, it stays in the defeat.
Treatment
The WHO recommends multidrug regimens that are safe, effective and
easily administered (Table 75.4). If bacilloscopy is available, patients are
considered to have paucibacillary leprosy if no bacilli are found; they are
treated with rifampin monthly plus a sulfone (usually dapsone) daily for
6 months, and then observed for 2 years. For patients with paucibacillary
disease and a single lesion, single-dose therapy (‘ROM scheme’: single
dose of 600 mg rifampin, 400 mg ofloxacin and 100 mg minocycline),
has yielded good results. If at least one bacillus is detected via bacilloscopy,
the patient should receive rifampin, clofazimine and dapsone
for 1 to 2 years and then be observed for 5 years. A second option is to
combine a sulfone with clofazimine44–46. Pediatric therapeutic schemes
recommended by a WHO are also summarized in Table 75.4.
Multidrug therapy is extremely effective. Importantly, after the first
dose, the patient is no longer infectious to others (i.e. transmission of
leprosy is interrupted). All patients who complete the prescribed
regimen are considered cured, as there are virtually no relapses. Bacilli
may be found but they are non-viable. Drugs that may play a significant
role in the treatment of leprosy in the future include other quinolones
(e.g. moxifloxacin, sparfloxacin), clarithromycin and ansamycins47–49.
Rifapentine (a rifampin derivative) has higher peak serum concentrations,
a longer serum half-life and more bactericidal activity against M.
leprae than does rifampin. In addition, moxifloxacin appears to be more
bactericidal than ofloxacin. As a result, the combination of rifapentine,
moxifloxacin and minocycline (PMM) may be superior to rifampin,
ofloxacin and minocycline (ROM)49.
For the two major inflammatory reactions, additional medications
are often required. Oral prednisone (20–60 mg per day) is used for
type 1 (reversal) reactions, while thalidomide (100–200 mg per day) is
the principal therapy for type 2 reactions (erythema nodosum leprosum).
Systemic corticosteroids are also recommended for the Lucio phenomenon. Although
thalidomide remains the treatment of choice
for type 2 reactions, its teratogenicity can be problematic and it is
unavailable in many countries where leprosy is endemic. Lenalidomide
and pomalidomide are thalidomide analogues with different side-effect
profiles (e.g. less teratogenicity, more myelosuppression) that could
have potential utility in the treatment of type 2 reactions. Additional
drugs with possible benefit in type 2 reactions include clofazimine,
cyclosporine (which has been used for corticosteroid-resistant type 1
reactions), chloroquine, pentoxifylline and phosphodiesterase type-4
inhibitors (e.g. roflumilast)49–51.
Although leprosy is now considered a curable disease with a good
prognosis and excellent survival rate, it can still be incapacitating and
stigmatizing. It is very important to make the diagnosis as early as
possible and to examine contacts, since treatment provided in the early
stages of the disease prevents disability. Recognition of leprosy in its
initial phases (in particular the cutaneous findings) by healthcare professionals
as well as the general population in endemic countries is
essential in order to reduce the impact of this disease8.
Cutaneous leishmaniasis.
Features epidemiology of leishmaniasis: - endemicity - seasonal outbreaks - transmissive
path peredachi.Epidemichnymi for cutaneous leishmaniasis are the following regions: - steppe desert and semi-desert - the country with the hottest varieties klimatom.Klinicheskie
leishmaniasis: - rural (acute necrotizing) type; - city (pozdnoizyavlyayuschiysya) type;
- TB (metaleyshmanioz). Causative respectively clinical form
leishmaniasis:
- Leishmania tropisa major - rural type;
- Leishmania tropisa minor - city type.
The reservoir of infection in the rural type of disease are: - squirrels, gerbils - jerboas;
- Hedgehogs - dog.
The peculiarities of rural type of leishmaniasis: are - season (disease increases in summer);
epidemichnost (in rural areas), - a short incubation period (from 1-2 to 3-5 weeks.) - For nondurable (3-6 months). - rapid expression of tubercle.
The characteristic features of urban leishmaniasis: are - lack of seasonality - is found in
cities and towns - the tank is a sick man - long incubation period (5-8 months. 1 year) - slow
during the process.
The main diagnostic criteria for leishmaniasis: - a history of the patient stay in endemic
months max - papulose elements (leyshmaniomy) in open areas of the body, beaded thickening
of the lymph vessels (lymphangitis) around the primary tumor;
detection of cells in Borowski scraping the edges of ulcers, mainly by the treatment of
leishmaniasis are skin, surgery, physical therapy - chemotherapy.
Leishmaniasis skin differentiate with:
- Tuberculous lupus;
- Chronic ulcerative pyoderma;
- Papulose syphilis and gum;
- Cancer
Treatment
Factors to consider when planning the treatment of leishmaniasis
include the region of the world in which the infection was acquired,
the species of Leishmania, the site(s) and severity of the infection, and
host factors such as immune status and age. The risks and benefits of
therapy need to be balanced, with goals of maximizing effectiveness
while minimizing drug toxicity. Without treatment, Old World cutaneous
leishmaniasis typically resolves within 2–4 months (L. major) or
6–15 months (L. tropica). New World cutaneous leishmaniasis caused
by L. mexicana resolves within 3 months in >75% of cases. In contrast,
cutaneous disease caused by L. braziliensis and L. panamensis spontaneously
heals in less than 10% and 35% of cases, respectively. Cutaneous
disease is treated to accelerate healing, to decrease scarring
(especially important for lesions in cosmetically sensitive sites), and to
prevent dissemination or relapse. Indications for treatment of cutaneous
leishmaniasis include persistence for >6 months, location over a
joint, and presence of multiple (≥5–10) or large (≥4–5 cm) lesions19,20.
Parenteral pentavalent antimonials are the treatment of choice for
cutaneous and mucocutaneous leishmaniasis, whereas liposomal
amphotericin B is preferred for visceral leishmaniasis19. Table 83.4
summarizes first-line and alternative treatments for cutaneous and
mucocutaneous leishmaniasis20–25. Table 83.5 lists frequent adverse
reactions to the drugs most commonly used for the treatment of leishmaniasis.
Additional interventions that have shown some efficacy for
cutaneous and (in combination with other agents) mucocutaneous
leishmaniasis include heat therapy27, cryotherapy, photodynamic
therapy and oral allopurinol.
Tuberculosis of the skin and mucous
It is an infectious disease characterized by the penetration of the human body MTB with
subsequent lymphatic and hematogenous route in
skin and mucous membranes. In 10,000 patients with one patient tbc tbc kozhi.Osnovnoy way
airborne infection (95%), followed by the gastrointestinal tract, through the skin. Most patients
with type cheolvechesky MTB - 95%, 3% bovine, chicken - 2%. Initially MTB affects the
respiratory system, then lymphatic and hematogenic
amazing - the skin and mucous membranes. Autoinfection - with open forms of sputum
containing a large number of mountain bike, gets on the skin around the
estestvenny holes - tbc ulcerative skin.
Contributing factors:
- Disruption of water and electrolyte metabolism;
- Violation of carbohydrate metabolism;
- Hypovitaminosis;
- Qualitative malnutrition.
CLASSIFICATION.
1) Lupus vulgaris
- Flat
- Tumor
- Ulcer
- Psoriaziformnaya
-Exudative
2) tbc warty skin
3) tbs ulcerative skin
4) indurativnyy erythema Bazin
5) tuberculous chancre - is extremely rare.
E svoystvmi characterized Mycobacterium tuberculosis are - Gram-positive; - acid - does
not form spores - not capsules. There are 3 types of Mycobacterium tuberculosis: the human bovine type - tip.Mikobakterii avian tuberculosis can infect the skin: - by exogenous (rare) gemotogennym - lymphatic tuberculosis outbreak of the internal organs;
- By autoinoculation to be organ and tissue infected with tuberculosis.
Etiology of cutaneous tuberculosis confirmed by the following laboratory and instrumental
methods of investigation - tuberculin skin test Pirquet - intradermal Mantoux test;
- Epicutaneous test Moreau - Detection of Mycobacterium tuberculosis lesions ny-by plating
them on nutrient media (method tank. Crops) - detection of tuberculoid structure in biopsies.
Cutaneous lupus are divided into two large groups: alizovanny (focal) - disseminated
tuberculosis.
Localized forms of tuberculosis of the skin:
- Vulgar erythematosus;
- Strumoderma (skrofuloderma);
- Warty tuberculosis;
- Ulcerative lupus.
Group of disseminated tuberculosis of the skin:
- Lichenoid (scrofulous zoster);
- Papulonekrotichesky;
- Indurativnyy (erythema Bazin);
- Miliary.
For ordinary (vulgar lupus) are the critical points of localization - facial skin, nose and upper lip
- at least - on the neck, trunk, limbs and mucous membranes. Symptoms of lupus lupus tubercles:
- symptom Pospelov symptom sagging probe) - a symptom of "apple jelly";
Two outcomes can be observed in the destruction lyupom: - scar atrophy in dry resolution;
- Deep deforming scars with ulceration (more common).
Clinical forms of tuberculosis lupus:
- Flat;
- Ulcerate;
- Hypertrophic (or tumor);
- Mutiliruyuschaya.
The most frequent possible complications of lupus tuberculosis: - erysipelas (the localization
process in the skin of the nose, lips, legs) - lymphangitis - pyogenic process - a malignant
cancerous transformation.
The characteristic localization of the pathological process in kollikvativnom tuberculosis:
- Neck - submandibular and supraclavicular region - parotid shells - in the armpits - about
sustavov.Otlichitelnye ulcer symptoms of tuberculosis of the skin and mucous membranes: combined with active TB of the skin - for more severe than other forms of localized tuberculosis
iron, localized lesions in the mucous membranes of the skin of the orifices (around the mouth,
anogenital) - rapid pitting tubercles.
Characteristic features of lichenoid tuberculosis - occurs in immunocompromised children zlyublennaya localized skin rash, body, mainly the lateral surface - vysypnyh elements shew
dwarf grouped bumps the size of a millet seed - on the site are allowed to tender bumps atrophic
rub counters or small igmentatsiya;
- Subjective feelings are absent. Typical signs papulonekraticheskogo tuberculosis skin: papules to form in the center of caseation - pathognomonic okalizatsii place - on the skin of the
forearm thighs of Lenya, buttocks - stamped scars.
3 groups of specific anti-TB drugs:
- The first group is the most effective drugs (isoniazid, reefpitsin);
second group - the average performance drugs (streptomycin,
ethambutol);
- The third group - the preparations of moderate activity (Pasco, tibon).
Vitamins rekomenduemyepri cutaneous tuberculosis - calcium pantothenate - riboflavin vitamins A, E and C - Vitamin D (ergokaltsiferrol). Requirements for diet in the treatment of
tuberculosis:
- Restriction of salt;
- Increase in protein and vitamin content.
CLINIC.
Ordinary lupus. Children get sick more often. Favourite localization skin of the face (80%), 50-60% of affected mucosa of the nose and the mouth. One in four - tbc
active manifestation of infection in other
organs and tissues. Tuberculin positive. Primary morphological element - bump diameter of 2-3
mm. Primary
morphological element bump diameter of 2-3 mm spherical, soft konsinstentsii. Tubercle color
depends on the time of existence:
Pink - cyanotic - yellow - brown. End result: scar skin atrophy (mosaic scars), accompanied by
hypo-hyperpigmentation.
Tubercle is formed by the decay of an ulcer with uneven
edges, bottom, covered with ulcerative nekrotcheskim bloom. Heal for a long time, leaving the
deeper skin defects. If there was tubercle
scars on the skin - a strong contraction of the skin, Simtom apple jelly, if pressure on the mound
the slide
and weaken bump - bump gets the color of apple zhele.Simtom bellied probe - when pressure is
applied to the mound, and then remove the pit remains in place pressure because in the first place
lost elastic fibers.
Mucous. Most often the nasal mucosa of the mouth. Hearth congestive hyperemia - plaque ulcer - the destruction of soft tissues of the nose. Unlike ulcerative tbc boleznnenost mild or
absent. At a resolution - a scar.
Complications: connection of a secondary infection - erysipelas, the development of stagnation elephantiasis, in the long course and
irrational treatment - malignancy.
WPPT. DIAGNOSIS.
Papulose syphilis.
- Less localized on the face, usually on the legs, buttocks,
lower back
- Bumps do not merge
- Does not appear in the scar tissue
- Rough scars, clear.
Leishmaniasis.
- The disease is endemic (Sr.Aziya, Caucasus)
- Occurs more sharply
- The presence of nodular lymphangites
- Microscopy - Leishmania.
Necrotic nodular vasculitis.
- Occur more acutely
- Affects the blood vessels of the dermis.
Leprosy (tuberculoid type).
- Begins with the appearance of erythematous or gipopigmentirovanyh
spots were located simetrichnyh
- Appearance on the periphery of nodular elements
- The presence of elements of curb edges
- In the lesions violated all kinds of sensitivity function
sebaceous and sweat glands, loss of baby hair.
TREATMENT.
- Long, mnogokursovoe-diet rich in vitamins, proteins, carbohydrates are limited, salt, water, multivitamin complexes
- Bracing - nonspecific immunotherapy, adaptogens - spa treatment
Specific treatment.
Depending on the degree of efficiency:
1) High: isoniazid 0.3 * 3 times a day
Rifampicin 0.15 * 3-4 times a day
2) Medium: ethambutol 25 mg / kg - one reception after breakfast
protionamid 0.25 * 3 times
streptomycin 500,000 units * 3 times
kanamycin sulfate / m 0.5 * 3 times
kanamycin monosulfates per oss 0.5 * 4-6 times
florimitsina sudfat / m 1.0 times a day
cycloserine 0.25 * 3 times
3) fair Pasco 3-4 g * 3 times
tibon 0.05 * 3 times
The patient should receive at least two drugs for ulcerative tuberculosis - at least three. The most
effective combination of 2 Prospekt 1
Group + 1 Pr 2 groups. The duration of the basic course of at least 6 months. Ulcerative
tuberculosis - at least a year. Then
preventive courses of two months in the spring and fall, changing medications base rate every
time.
Warty tuberculosis - prof. disease in persons handling infected material Office (veterinarians,
pathologists, butchers), the Office
gets into the skin from the outside as a result of damage to the skin. Disease begins with the
appearance of morphological elements - bluish-red
hemispherical, the size of a pea, are prone to growth periferitseskomu nodular elements that are
converted to infiltrate. On the periphery
elements - the area of congestive hyperemia, in the middle zone - horny, warty growths, in the
center - the sunken scar skin atrophy.
As a rule, there is no ulceration elements.
Skrofuloderma (kollikvativny tuberculosis).
Location: under the lower jaw, with the ear, over-, infraclavicular region.
1) MTB gets into the prostate tissue, formed specific granulomas, the small nodule - painless
major center, with the skin
above it is not changed. The molten site involving the skin - in the center of a small vent, through
which flows the pus. Formed
deep ulcer heals deeply involved scar.
2) in the pathological process initially involved lymph nodes after
collapse which produce very deep ulcer healing
mostikoobraznym scar. DD: knotty syphilis, erythema nodosum,
benign tumor of the prostate tissue, lymphogranulomathosis.