CHAPTER V: Pathogenic Microorganisms

Pathogens that Enter the Body through the Skin

Skin Defenses
 Skin is a passive barrier against infections. Keratinocytes in the epidermis are tightly packed to form a tough,
waterproof barrier to prevent passage of pathogens. Periodic shedding of epidermal cells helps remove microbes
from the skin's surface.
 Sebum forms a protective film over the surface of the skin. From the sebaceous gland, sebum flows up through
the follicles and spreads out to the skin surface, keeping the hair and skin soft, moist, and pliable to prevent the
skin from cracking. Additionally, it seals the pore of hair follicles and protects sweat glands. Sweat and
sebaceous gland secretions supply water, amino acids, and lipids, which serve as nutrients for the normal
microbial population. Breakdown of the lipids by the microbiota of skin results in fatty acid by-products that
make the environment on the skin slightly acidic which inhibits the growth of many potential disease-producers.
 Sweat helps flush microbes from surface of skin and contains salts, lysozyme, which breaks down the walls of
certain bacteria, and antimicrobial peptides, which inhibits some bacteria and fungi by disrupting their
membrane integrity and/or ion channels. Ceruminous glands also secrete cerumen that contains lysozyme and
fatty acids.
 The epidermis contains Langerhanns' cells and the dermis has macrophages embedded in it. The skin also
produces cytokines that aid the development and function of cell-mediated immunity.
Routes by which Microorganisms invade the Skin
 Skin injuries (e.g. cuts, punctures, burns, wounds, insect or tick bites) provide a way for pathogens to enter and
infect the skin and underlying tissues.
 Microorganisms can also be carried to the skin by the bloodstream after entering the body from another site.
Many systemic infections involve skin symptoms caused either by the pathogen or by toxins.
 Certain salt-tolerant bacteria can penetrate the skin through hair follicles and sweat gland pores.

Bacterial Skin Diseases

Staphylococcus aureus (gram positive, salt tolerant, coagulase-positive)
1 HAIR FOLLICLE INFECTIONS
 Folliculitis is the inflammation of hair follicles manifested by minute erythematous follicular pustules without
involvement of the surrounding skin. Infected follicle of an eyelash is called a sty. If, however, the infection
extends from the follicle to adjacent tissues, causing localized redness, swelling, severe tenderness and pain,
the lesion (nodule with central pustule) is called a furuncle or boil. A carbuncle, on the other hand, is a large
area of redness, swelling, and pain punctuated by several sites of draining pus (clusters of boils).
 Folliculitis prefers hairy sites and areas exposed to friction, perspiration, and maceration. Infection begins
when virulent staphylococci attach to the cells of a hair follicle, multiply, and spread downward to involve the
follicle and sebaceous glands. This is triggered by recent incidents of folliculitis, friction from clothing or
shaving, poor hygiene, insect bites, or weakened immunity.

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 2 STAPHYLOCOCCAL SCALDED SKIN SYNDROME (SSSS)
 It is also called phemphigus neonatum (blisters appearing mainly in infants and young children) or Ritter’s
disease (after paediatrician Gottfried Ritter von Rittershain). It is a potentially fatal toxin-mediated disease
caused by exfoliatin produced by certain strains of S. aureus. These exfoliative toxins destroy material that
binds together the cellular layers of epidermis. They are absorbed and carried by the bloodstream to large
areas of the skin.
 Symptoms: SSSS begins as a generalized redness of the skin affecting 20% to 100% of the body. Malaise and
fever can also be experienced. Within 48 hours after the redness appears, the skin becomes wrinkled, and large
blisters filled with clear fluid develop. The skin is tender to the touch and looks like sandpaper.
 Loss of body fluid and secondary infections contribute to mortality.

Streptococcus pyogenes (Gram positive, in chains)

3 IMPETIGO
 Impetigo is the most common type of pyoderma (skin infection characterized by pus formation). Impetigo is
a superficial skin infection, involving patches of epidermis just beneath the dead, scaly outer layer.
Streptococcal impetigo is characterized by isolated pustules or vesicles that become crusted, rupture, and
develop a honey-colored crust. Usually, little fever or pain develop, but lymph nodes near the involved areas
often enlarge, indicating that bacterial products have entered the lymphatic system and an immune response
is occurring.
 It often develops on the face, especially around the nose and mouth, and extremities.
 Infection is probably established by scratches or other minor injuries that introduce the Streptococcus
pyogenes into the deeper layer of epidermis, but the bacteria can also colonize unbroken skin.

Pseudomonas aeruginosa (encapsulated, Gram negative, rod-shaped bacteria)

4 PSEUDOMONAS DERMATITIS (HOT TUB RASH)
 This is a self-limiting rash of about two weeks in duration often associated with swimming pools, pool-type
saunas and hot tubs. When large numbers of people use these facilities, alkalinity rises and the chlorine
becomes less effective, and the concentration of nutrients that support growth of pseudomonads increases.
Hot water facilitates the entry of bacteria into hair follicles by causing the follicles to dilate.
Other bacterial skin diseases
5 ROCKY MOUNTAIN SPOTTED FEVER
 Rocky Mountain spotted fever was first recognized in the Rocky Mountain area of the United States. It is
caused by Rickettsia rickettsii (named after Howard Ricketts), an obligate intracellular bacterium that lives
in the salivary gland of ticks (usually Dermacentor sp.). The organisms are tiny, Gram-negative, nonmotile
coccobacilli. They are released into human capillary once the tick feeds on humans. Organisms multiply at
site of bite; the bloodstream is invaded and endothelial cells of blood vessels are infected; vascular lesions
and endotoxin account for pathologic changes.
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  The disease begins suddenly with a headache, pains in the muscles and joints, and fever. Within a few days,
it rash consisting of faint pink spots appears on the palms, wrists, ankles, and soles. This rash spreads up the
arms and legs to the rest of the body and becomes raised and hemorrhagic, meaning that it is due to blood
leaking from damaged blood vessels. Bleeding may occur at various other sites, such as the mouth and nose.
Involvement of the heart, kidneys, and other body tissues can result in shock and death unless treatment is
given promptly.

6 LYME DISEASE
 It is also a tick-borne illness caused by Borrelia burgdorferi (named after Dr. Willy Burgdorfer) and other
Borrelia spp. that was first recognized in Lyme, Connecticut. Upon transmission, B. burgdorferi reproduce
and spread radially in the skin, causing a target-shaped rash that is quickly expanding (termed as erythema
migrans). The bacteria then enter the bloodstream, cause fever, acute injury to the heart and nervous system.
Further symptoms may include small, oval rashes or reddish lumps (termed as borrelial lymphocytoma)
usually appearing on the earlobes of children and around the nipples of adults. Chronic symptoms develop,
such as arthritis and paralysis due to persisting bacteria and the immune response to them.
 However, not everyone with Lyme disease develops the rash, so if suspected of tick bites, consult the doctor.

7 ACNE (ACNE VULGARIS)

 It is a long term skin disease that occurs when hair follicles are clogged with dead skin cells and oil from the
skin. The sebum accumulation leads to the formation of the familiar whiteheads; if the opening remains open,
the lesions known as blackheads form. The accumulation of sebum often ruptures the lining of the hair
follicle. Bacteria, especially Propionibacterium acnes, a diphtheroid commonly found on the skin, become
involved at this stage. By metabolizing the sebum, P. acnes forms free fatty acids that cause an inflammatory
response by the body. It is this inflammation that leads to the appearance of pustules and subsequent acne
scars.
 Picking or scratching the lesions – or even having tight collars or other clothing in contact with lesions –
increases the incidence of scar formation. Cosmetics frequently aggravate the condition, but diet – including
consumption of chocolate – has been demonstrated to have significant effect on the disease.
 Many treatment options for acne are available, including lifestyle changes, medications (topical applications
containing benzoyl peroxide), and medical procedures.

8 LEPROSY
 Leprosy is a slowly developing, progressive disease that damages the skin and nervous system. It is caused
mainly by infection with Mycobacterium leprae. Signs of leprosy are painless ulcers, skin lesions of
hypopigmented macules (flat, pale areas of skin), and eye damage (dryness, reduced blinking). Inflammatory
nodules (granulomas) and papules can also develop. Later, large ulcerations, loss of digits, skin nodules, and
facial disfigurement may develop. The skin lesions and deformities can be very disfiguring and are the reason
that historically people considered infected individuals outcasts in many cultures.

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  The infection spreads primarily from person to person by nasal secretions or droplets. Three other species
can carry and (rarely) transfer M. leprae to humans: chimpanzees, mangabey monkeys, and nine-banded
armadillos.

Viral Skin Diseases

9 SMALL POX
 It is an infectious disease caused by one of two virus variants, Variola major and Variola minor. The initial
symptoms of the disease included fever and vomiting. This was followed by formation of sores in the mouth
and a skin rash. Variola major was the severe and more common form, with a more extensive rash and higher
fever. Over a number of days the skin rash turned into characteristic fluid filled bumps with a dent in the
center. The bumps then scabbed over and fell off leaving scars.
 The disease used to spread between people or via contaminated objects. The last naturally occurring case was
diagnosed in October 1977 and the World Health Organization (WHO) certified the global eradication of the
disease in 1980. Prevention was by smallpox vaccine.

10 CHICKEN POX
 It is a common, very contagious viral infection caused by the Varicella Zoster Virus. Most cases of
chickenpox are mild, sometimes unnoticed, and recovery is usually uncomplicated. The virus enters the body
through the respiratory system. It begins as small, red spots called macules, little bumps called papules, and
small blisters called vesicles, surrounded by a narrow zone of redness. The lesions can erupt anywhere on
the body, although usually they first appear on the back of the head, then the face, mouth, main body, and
arms and legs, ranging from only a few lesions to many hundreds. The lesions appear at different times, and
within a day or so they go through a characteristic evolution from macule to papule to vesicle to pustule, a
pus-filled blister. After the pustules break, leaking virus-laden fluid, a crust forms, and then healing takes
place. The lesions are pruritic (itchy), and scratching may lead to serious, even fatal, secondary infection by
Streptococcus pyogenes or Staphylococcus aureus.
 Symptoms of varicella tend to be more sever in older children and adults. In about 20% of adults, pneumonia
develops causing rapid breathing, cough, shortness of breath, and a dusky skin color.
 Varicella is also a major threat to newborn babies if the mother develops the disease within 5 days before
delivery to 2 days afterward. Mortality in these babies has been high as 30%. Also, congenital varicella
syndrome develops in a fraction of a percent of babies whose mothers contact varicella earlier in pregnancy.
These babies are born with such defects as underdeveloped head and limbs, and cataracts.

11 SHINGLES
 A characteristic of all herpesvirus is its ability to remain latent within the body. Following a primary infection,
the virus enters the peripheral nerves and moves to a central nerve ganglion where it persists as viral DNA.
Shingles is simply a different expression of the virus that causes chickenpox.
 Vesicles are similar to those of chicken pox but are localized in distinctive areas often as a single stripe of
blisters. They are distributed about the waist, although facial shingles and infections of the upper chest and
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 back also occur. The infection follows the distribution of the affected cutaneous sensory nerves and is usually
limited to one side of the body at a time because these nerves are unilateral. Occasionally, such nerve
infections can result in nerve damage that impairs vision or even causes paralysis. Severe pain is also
frequently reported.
 Exposing children to shingles has led to their contracting chickenpox. Shingles seldom occurs in people under
age 20, and by far the highest incidence is in the elderly population.
 Immunocompromised patients are in serious danger from infection by varicella-zoster virus; multiple organs
become infected, and a mortality rate of 17% is common. In such cases, the antiviral drug acyclovir has
proven helpful. A live, attenuated vaccine is expected to be approved soon.

12 MEASLES or RUBEOLA
 It is an extremely contagious viral disease that is caused by the Rubeola virus. The development of rubeola
is similar to that of smallpox and chickenpox. Infection begins in the upper respiratory system. After an
incubation period of 10 to 12 days, symptoms develop resembling those of a common cold – sore throat,
headache, and cough. Shortly thereafter, a macular rash appears on the skin, beginning on the face and
spreading to the trunk and extremities. Lesions of the oral cavity include the diagnostically useful Koplik
spots (tiny red patches with central white specks) on the oral mucosa opposite the molars.
 Measles is an extremely dangerous disease, especially among very young and elderly individuals. It is
frequently complicated by middle ear infection or pneumonia caused by the virus itself or by secondary
bacterial infection. Encephalitis strikes approximately 1 in 1000 measles victims; its survivors are often left
with permanent brain damage. As many as 1 in 3000 cases is fatal, mostly in infants. The virulence of the
virus seems to vary with different epidemic outbreaks. Complications such as encephalitis occur, if at all,
about a week after the rash appears.

13 GERMAN MEASLES or RUBELLA

 Rubella, or German measles, is a much milder viral disease (caused by Rubella virus) than measles and often
goes undetected. It goes away within one week, even without treatment. A macular rash of small red spots
that starts on the face and travels downward to the rest of the body, light fever and swollen lymph nodes are
the usual symptoms. The infection can spread from person to person through contact with droplets from an
infected person’s sneeze or cough. German measles is most contagious a week before rashes even appear.
 However, it can be a serious condition in pregnant women, as it may cause congenital rubella syndrome in
the fetus. Congenital rubella syndrome can disrupt the development of the baby and cause serious birth
defects, such as heart abnormalities, deafness, and brain damage.

Fungal Skin Diseases

14 RINGWORM
 Fungi that colonize the hair, nails, and the outer layer (stratum corneum) of the epidermis are called
dermatophytes, and their infections are called dermatomycoses. Dermatophytes grow on the keratin present
in those locations, causing infections called tineas, or ringworms. Tinea capitis, or ringworm of the scalp,

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 is fairly common among elementary school children and can result in bald patches. It is usually transmitted
by contact with fomites. Dogs and cats are also frequently infected with fungi that cause ringworm in
children. Ringworm of the groin, or jock itch, is known as tinea cruris, and ringworm of the feet, or athlete’s
foot, is known as tinea pedis. The moisture in such areas favors fungal infections.
 Three genera of fungi are involved in cutaneous mycoses. Trichophyton can infect hair, skin, or nails;
Microsporum usually involves only the hair or skin; Epidermophyton affects only the skin and nails. The
topical drugs available without prescription for tinea infections are miconazole or clotrimazole. An oral
antibiotic, griseofulvin, is often useful in these infections because it can localize in keratinized tissue. If the
infection is unusually serious, oral ketoconazole may be prescribed.

15 CUTANEOUS CANDIDIASIS
 The bacterial microbiota of the mucous membranes in the genitourinary tract and mouth usually supresses
the growth of such fungi as Candida albicans. Because the fungus is not affected by antibacterial drugs it
sometimes overgrows mucosal tissue when the antibiotics suppress the normal bacterial microbiota. Change
in the normal mucosa pH may have a similar effect. Overgrowths by the yeastlike C. albicans are called
candidiasis. Newborn infants, whose normal microbiota has not become established, often suffer from a
whitish overgrowth of the oral cavity, called thrush. C. albicans is also a very common cause of vaginitis.
Immunosuppressed individuals are unusually prone to candida infections of the skin and mucous membranes.
On people who are obese or diabetic, the areas of the skin with more moisture tend to become infected with
this fungus. The infected areas become bright red, with lesions on the borders. Skin and mucosal infections
by C. albicans are usually treated with topical applications of miconazole, clotrimazole, or nystatin. If
candidiasis becomes systemic, as can happen in immunosuppressed individuals, fulminating disease and
death can result. Oral ketoconazole is the usual treatment for systemic candidiasis.