SKIN INFECTIONS

TRẦN THỊ THANH VY

Bài giảng lý thuyết dành cho sinh viên Y năm 2
Email: vyttt@pnt.edu.vn
Bộ môn vi sinh y học
Trường đại học Y khoa Phạm Ngọc Thạch
 OBJECTIVES

1. Liệt kê được các tác nhân vi khuẩn gây nhiễm trùng da thường gặp.

2. Liệt kê được các tác nhân virus gây nhiễm trùng da thường gặp.
BACTERIA
 • Staphylococcal and streptococcal skin infections
Gram-positive • Clostridial skin infections
bacteria • Corynebacterial skin infections bạch hầu
• Other Gram-positive skin infections

• Neisseria meningitidis não mô cầu

• Pseudomonas aeruginosa mũ xanh
Gram-negative • Bartonella
bacteria • Other Gram-negative skin infections
• Ehrlichiosis and anaplasmosis

• Borrelia burgdorferi sốt hồi qui

Spirochetes • Non-venereal (endemic) treponematoses giang mai
• Leptospirosis sốt vàng da

Bacteria previously • Actinomycosis

claccified as fungi • Nocardiosis
 GRAM-POSITIVE BACTERIA

• Staphylococcal and streptococcal skin infections

• Clostridial skin infections

• Corynebacterial skin infections

• Other Gram-positive skin infections

 GRAM-
POSITIVE
BACTERIA
Staphylococcal and streptococcal
skin infections
Staphylococcal impetigo. Honey -colored crusts on
the chin of a child with non-bullous impetigo.
Staphylococcal impetigo. Superficial round to oval
erosions with central thin crusting and a peripheral
collarette due to bullous impetigo in the axilla.
Staphylococcal impetigo. Multiple small superficial erosions with
crusting around the nares and on the chin in association with
folliculitis in an adult.
 Bacterial Folliculitis
• Furuncles secondary to
methicillin-resistant Staphylococcus
aureus.
• Fluctuant erythematous nodules
with a central pustule on the ankle
and finger.

Abscesses, Furuncles,
and Carbuncles
Ecthyma. Ulceration with
hemorrhagic crust on the
wrist due to infection with
group A streptococci
 Staphylococcal Scalded
Skin Syndrome
• Staphylococcal scalded skin
syndrome.
• Diffuse erythema with an early
superficial erosion in the antecubital
fossa.
• More extensive involvement on the
neck with a wrinkled appearance of the
erythematous skin in addition to
peeling and multiple erosions. Courtesy,
Julie V Schaffer, MD.
Toxic Shock Syndrome

• Toxic shock syndrome due to Staphylococcus

aureus infection.
• Blotchy erythema is evident on the thigh.
• Hyperemia of the conjunctiva is seen.
Scarlet Fever
• Desquamation of the
foot following scarlet fever
• Caused by streptococcal
pyrogenic exotoxins (SPEs)
types A, B, and C - group A
streptococci
 Erysipelas

Cutaneous streptococcal infections. Sharply demarcated erythema on the upper arm and chest (A) and buttocks (B) in
two patients with erysipelas. Bright red erythema extending from the anal verge in a young boy with streptococcal
perianal disease (C).
Cellulitis

• Bullous and necrotizing cellulitis.

• A Extensive soft tissue infection of the
lower extremity due to group A
streptococcal infection.
• B Edema and confluent bulla.
• C Multiple areas of necrotic crusting and
focal purulence due to streptococcal
cellulitis.
 • Necrotizing fasciitis. Tense,
woody edema of the forearm
with purple–gray areas of
necrosis and bullae with
watery discharge. Intravenous
drug use was a predisposing
factor.

Necrotizing Fasciitis
Bacteremia/Septicemia
Palmar lesions due to staphylococcal endocarditis.
CLOSTRIDIAL SKIN INFECTIONS
CORYNEBACTERIAL SKIN INFECTIONS
Erythrasma.
A Pink to brown scaly patches on the upper
inner thighs.
B Coral-red fluorescence upon illumination with
a Wood’s lamp.
C Hyperpigmented plaques in the inguinal and
periumbilical areas.
D Well-demarcated, scaly, hyperpigmented
plaque of disciform erythrasma.
CORYNEBACTERIAL SKIN INFECTIONS

Pitted keratolysis of the plantar surface of the foot.

Multiple small
(A) and larger coalescing (B) craters with decreased stratum
corneum that favor pressure points on the plantar surface.
Trichomycosis Axillaris, Pubis, and Capitis
Trichomycosis axillaris. Cylindrical sheaths and
beading of the axillary hairs. A yellow color is
seen most.
- superficial corynebacterial infection
Cutaneous Diphtheria
Ecthyma diphthericum. Punched - out
ulcer with a black eschar on the upper
lip.
 OTHER GRAM-POSITIVE SKIN INFECTIONS
• Cutaneous Anthrax
• Bacillus cereus Infection
• Erysipeloid: Erysipelothrix
rhusiopathiae - Gram-positive,
non-motile, smooth or curved
bacillus -> Erythema and edema
with vesicle formation on the
hand and fifth.
• Listeriosis - Listeria
monocytogenes
GRAM-NEGATIVE BACTERIA
NEISSERIA MENINGITIDIS
Acute meningococcemia. Purpura
with irregular outline and central
gunmetal gray color
PSEUDOMONAS AERUGINOSA
Green nail syndrome.
Blue–green discoloration of the nail
due to pyocyanin produced by
Pseudomonas aeruginosa. Note the
associated Onycholysis.
PSEUDOMONAS AERUGINOSA
Superficial infection of the skin with Pseudomonas.
Note the maceration, erosions, and motheaten
appearance of the skin.
PSEUDOMONAS AERUGINOSA
Pseudomonas hot-foot syndrome.
Tender erythematous nodules on the
heel.
PSEUDOMONAS AERUGINOSA
Ecthyma gangrenosum. Embolic lesion of
Pseudomonas aeruginosa on the chest.
Note the necrotic center and inflammatory
 BARTONELLA
• Bartonella are small, pleomorphic, facultative intracellular
Gramnegative bacilli closely related to Brucella species.
• Bartonellosis is a potentially life-threatening biphasic infection caused
by Bartonella bacilliformis.
• Two distinct clinical forms may occur independently or sequentially:
(1) Oroya fever, an acute febrile disease with associated hemolytic anemia; and
(2) verruga peruana (Peruvian wart), a chronic disease characterized by
cutaneous vascular lesions
 Bacillary Angiomatosis
• Vascular proliferation is the predominant feature of this condition,
which most often affects HIV-infected individuals.

Bacillary angiomatosis. A Bright red nodule

and papule on the forehead
OTHER GRAM-
NEGATIVE SKIN
INFECTIONS
• Brucellosis: is a chronic
granulomatous disease
caused by Brucella, a genus of
Gram-negative coccobacilli.
Tularemia

• A bacterial infection caused by

Francisella tularensis, a Gram-
negative, non-motile coccobacillus
 Plague

Transmission cycles of Yersinia pestis

Vibrio vulnificus Infection

Hemorrhagic bullae of the leg secondary to

Vibrio vulnificus infection
SPIROCHETES
BORRELIA BURGDORFERI
• Acrodermatitis chronica atrophicans (ACA) is a cutaneous
manifestation of chronic Lyme disease
• Acrodermatitis chronica atrophicans. The acral skin is
atrophic, shiny, and wrinkled, with prominent superficial
NON-VENEREAL (ENDEMIC) TREPONEMATOSES

Cutaneous yaws on the knee of an

adolescent from Indonesia.
BACTERIA PREVIOUSLY CLASSIFIED AS FUNGI
• ACTINOMYCOSIS:
• Actinomycosis is a subacute or chronic bacterial infection characterized by
suppurating abscesses, granulomatous inflammation, and sinus formation.
• Actinomyces israelii, an anaerobic or microaerophilic Gram positive, non-acid-fast
actinomycete, is the most common causative organism.
• NOCARDIOSIS
• Nocardiosis is caused by various species of Nocardia, a filamentous, Gram-positive,
acid-fast organism.
• Nocardia is recognized as an opportunistic pathogen in immunocompromised
individuals, causing disseminated or systemic disease; in contrast, cutaneous
nocardiosis commonly occurs in immunocompetent hosts.
Cervicofacial actinomycosis or “lumpy jaw”. Soft tissue swelling and
draining erythematous nodules are seen. The discharge contained sulfur
granules
 Leprosy

Mycobacterial
Cutaneous tuberculosis
Infections
Non-tuberculous
mycobacterioses
 LEPROSY

Lepromatous leprosy. A Numerous erythematous papules and nodules on the forearms and hands. B
Infiltrated nodules coalescing on the forehead with leonine facies and madarosis. Note the ocular
involvement.
 Borderline leprosy. Erythematous plaques with central clearing leading
to annular (A) and arcuate
(B) lesions. Note the ill-defined outer borders and well-demarcated
inner borders.
Tuberculoid leprosy. A Plaque with slightly elevated, erythematous
border and central
hypopigmentation.
B Large annular lesion on the cheek with a red–brown color and rim of
hypopigmentation.
 Leprosy reactions. A Type 1 “upgrading” reaction with lupus erythematosus-like
facial involvement in a “butterfly” distribution with marked inflammation.
B Erythema nodosum leprosum, a type 2 reaction, presenting with erythematous
nodules on the legs. C Type 2 reaction presenting with red facial papulonodules
due to immune complex-mediated small vessel vasculitis in patients with
lepromatous leprosy.
CUTANEOUS TUBERCULOSIS

Tuberculosis verrucosa cutis. A wart-like papule at the

site of exogenous inoculation in a patient with immunity
against M.
Scrofuloderma. Plaques and nodules with central ulceration as well as
resultant scarring with retraction.
Orificial tuberculosis. A non-healing ulcer of the nasal mucosa.
Lupus vulgaris. A Annular granulomatous plaque
with central scarring. B Coalescing pink–brown
papules
C Red–brown plaque on the neck.
Papulonecrotic tuberculid. Erythematous papules and papulopustules
on the heel.
Site of a BCG vaccination. Enlarging granulomatous plaque
Complication of injection of methanol extraction residue (MER) of
BCG. Nodules, some of which have ulcerated, arranged in a linear
“lymphatic” pattern in a patient with a high-risk extremity melanoma
who had received an injection of MER of BCG as adjuvant
immunotherapy
NON-
TUBERCULOUS
MYCOBACTERIOSES
NON-TUBERCULOUS MYCOBACTERIOSES
Mycobacterium marinum
Mycobacterium marinum infections.
A range of presentations, including an erythematous plaque
with scale-crust at the inoculation site on the lateral hand
(A), a sporotrichoid pattern with the inoculation site on the
distal third finger (B), and disseminated necrotic lesions on
the face of an immunocompromised patient
Mycobacterium fortuitum, Mycobacterium
chelonae, and Mycobacterium abscessus
Suppurative lymphadenitis due to
Mycobacterium fortuitum infection. The
inoculation chancre was on the foot.
Mycobacterium chelonae infection.
A This immunosuppressed patient
presented with an area of warmth
and mild erythema on the ankle.

Mycobacterium avium complex cellulitis in an

immunocompromised patient. Note the
sporotrichoid (lymphocutaneous) pattern of the
coalescing nodules with abscess formation.
Rickettsial
Diseases
Rocky Mountain spotted fever. The
cutaneous lesions often appear first
on the wrists and ankles.

Rocky Mountain spotted fever.

Petechiae on the palms and soles
often develop relatively late in the
disease course.
Rickettsialpox.
A Eschar at the site of the mite bite.
B Scattered papules with hemorrhagic crusts
VIRUS
 Human Papillomaviruses

Periungual common warts. Destruction of the nail matrix and bed can lead to
partial (A) or complete (B) absence of the nail plate. Bowen disease may be
considered in the differential diagnosis, especially for a single, recalcitrant digital
wart
 Verrucae vulgares (common warts).
Verrucae plantares (plantar warts). The photo was
taken after shaving of the hyperkeratotic surface; the
black dots represent hemorrhage into the stratum
corneum.
Multiple filiform warts on the lower face.
Verrucae planae (flat warts).
Multiple skin-colored or pink (A) to brown (B) smooth-surfaced, flat-topped papules.
These lesions are typically caused by HPV-3 or -10
 Human Herpesviruses

• Herpes simplex viruses (HSV-1 and HSV-2)

• Varicella–zoster virus (HHV-3)

• Epstein–Barr virus (HHV-4)

• Cytomegalovirus (HHV-5)

• Human herpesvirus type 6 (HHV-6)

• Human herpesvirus type 7 (HHV-7)

• Human herpesvirus type 8 (HHV-8)

 Herpes simplex viruses (HSV-1 and HSV-2)

Orolabial herpes simplex virus (HSV) infections. A Primary herpes gingivostomatitis

due to HSV-1 in a child. Note the coalescing lesions with scalloped borders. B
Primary versus nonprimary initial HSV-2 infection in a teenager. There are grouped
vesicles on an erythematous base; note the scalloped borders. C Recurrent herpes
labialis (cold sore, fever blister)
Recurrent herpes simplex virus type
1 infection on the cheek.
Occasionally, such lesions are
misdiagnosed as cellulitis or bullous
impetigo.
Eczema herpeticum. A Monomorphic, punched-out erosions with a
scalloped border in this infant with a history of facial atopic dermatitis.
B Monomorphic, small hemorrhagic crusts and erosions coalescing in
the popliteal fossae, an area of pre-existing atopic dermatitis.
VARICELLA–ZOSTER VIRUS (VZV; HHV-3)
Varicella. A–C Lesions in different stages of
evolution, including vesicles, pustules, and
hemorrhagic crusts. Vesicles often develop
central umbilication. D Oral lesions can also
occur (arrow).
Herpes zoster
Distribution of dermatomes.
 Herpes zoster. Erythematous, edematous plaques with early vesicle
formation. Note the perifollicular accentuation
Later stages of evolution with prominent pustule formation and a dusky
purple color associated with older vesicles. Bullous variant on the flexor
arm.
 EPSTEIN–BARR VIRUS (HHV-4)
Ampicillininduced eruption in a
patient with infectious
mononucleosis due to EBV
infection.
Erythematous macules and
papules have become confluent
on the upper

Vulvar ulcers associated with primary EBV

infection. EBVrelated genital ulcers, which
are most common in adolescent girls, are
often misdiagnosed as genital herpes
simplex infection and in some patients
represent a variant of aphthosis
CYTOMEGALOVIRUS • TORCH syndrome due to cytomegalovirus. Multiple purpuric papules of
(HHV-5) dermal hematopoiesis
HUMAN HERPESVIRUS TYPE 6 (HHV-6)
Exanthem subitum (roseola infantum).
Small pink–red macules and papules
developed on the trunk and neck of this
9-month-old boy during defervescence of
a high fever that had lasted for 5 days.
HUMAN HERPESVIRUS TYPE 8 (HHV-8)

Classic Kaposi sarcoma.

Multiple red–violet nodules with hemorrhagic
crusting and plaques on the ankle and foot
Other Viral Diseases
• Enterovirus infections • West Nile virus infection
• Measles • Zika virus infection
• Rubella • Chikungunya fever
• Erythema infectiosum • Barmah Forest and Ross River virus
• Roseola infantum infections

• Unilateral laterothoracic exanthem • Cutaneous Manifestations of

Hepatitis A, B, and C Infection
• Gianotti–Crosti syndrome
• Trichodysplasia spinulosa
• Poxvirus infections
• Kawasaki disease
• Viral hemorrhagic fevers, including
dengue
ENTEROVIRUS INFECTIONS
Hand-foot-and-mouth disease. A Vesicle and erythematous
macules on the sole in classic hand-foot-and-mouth disease. B–G
Coxsackievirus A6 infection presenting as: multiple erythematous
macules and papules with some targetoid lesions resembling
early erythema multiforme on the palm (B); vesicles and
papulovesicles on the dorsal hand (C) and thigh (D); perioral
monomorphic crusted lesions resembling eczema herpeticum
(E); more extensive “eczema coxsackium” in a toddler with atopic
dermatitis (F); and a widespread nonblanching eruption (G)
MEASLES - RUBELLA

Measles.
Pink macules and minimally elevated papules.
ERYTHEMA INFECTIOSUM
Human parvovirus B19
UNILATERAL LATEROTHORACIC EXANTHEM
Unilateral laterothoracic exanthem.
Erythematous macules and papules
involving the left axilla and upper flank
(A) and a slightly more extensive
distribution on the left lateral trunk (B)
GIANOTTI–CROSTI SYNDROME
POXVIRUS INFECTIONS
KAWASAKI DISEASE