ID for boards – 
boards –  pg
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”
Scarletiniform Eruption
“Staph Scarlet Fever”
Cellulitis (kids > adults)
Folliculitis/Furunculosis
Botryomycosis
“Granular bacteriosis”
“Bacterial pseudomycosis”
Felon “Staph Whitlow”
Acute paronychia (kids)
(chronic paronychia = candida)
Necrotizing Fasciitis
Endocarditis
Clostridial
Anaerobic Cellulitis
Myonecrosis
“Gas Gangrene”
G+ cocci in chains
Classic impetigo
Honey-crust near nose
“impetigo” = superficial pyoderma
Larger bullae,
Systemic symptoms.
Subgranular blister
Nikolsky‟s sign + in
lesional & uninvolved skin;
Path: split @ granular layer .
Mortality: Kids
Mortality: Kids 3%, Adults >50%.
15-35yo w/ sudden onset, very sick,
erythrodermic rash & mucositis
Blood cx: + <15%
Subcorneal blister
 No Fever, no Pastia‟s lines,
lines,
 pharyngitis, strawberry tongue
tongue
deep dermis & subcutis infection
 blood cx: negative (except H.flu)
superficial or deep follicle infection
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 >> Fournier‟s (perineum)
splinter hemorrhages, Osler's nodes,
Janeway lesions, and petechial lesions
Large, G+ rods; α-toxin (destroys cell membranes, hemolysis),
cellulitis with crepitus
spares deep fascia & muscle
>3d incubation
deep anaerobic cellulitis
to muscle & fascia w/ toxemia
fast incubation <3d
 pg 1
Clinical: 4mm red papule → honey-crusted
honey-crusted vesicle;
 vesicle; at face/nose or arm/hand.
S. aureus >
5% of Strep pyogenes post-strep GN.
Strep pyogenes → Acute post-strep
Strep pyogenes
antibodies tests for Staph impetigo only).
Test: anti-DNase B antibodies tests
S. aureus phage II Clinical: flaccid large bullae → “varnish-like erosion” w/ weakness, fever, diarrhea.
diarrhea.
type 71 toxin Tx: bactroban, keflex or augmentin, (β-lactam
(β-lactam resistant), clarith/azithromycin.
Patho: ET-A (chr), ET-B (plasmid) bind desmoglien 1 at granular layer → sterile bullae.
Patho: ET-A bullae .
S. aureus phage II Distant S.aureus infection; often nasal carraige
carraige
(3A,3C,55,71) Clinical: <5yo or renal failure: p
failure:  prodrome,
rodrome, tender skin → H&N (perioral) erythema →
Exfoliative toxins generalized bullae slough in 1-2d
1- 2d → varnish crust w/ „sad-
„sad -man‟ facies.
facies.
ET-A, ET-B Tests: Culture S.aureus from conjunctiva or
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
mucositis.. May → shock 
Rash: Scarlatiniform exanthem (trunk → centripetally).
Staph aureus: TSST-1 Palm/sole: erythema & non- pitting edema → desquamation 1-3 1-3 weeks after onset.
Enterotoxins B + C
Mucositis: strawberry tongue, oral erythema, conjunctival hyperemia
Surgical packing, mesh, abscess,
tampon 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)
Staph aureus: TSST-1 Clinical: Generalized scarletiniform rash ONLY w/o other scalet fever s/sx:
Kids:  S.aureus > H.flu Clinical: F/C, malaise → tender rash (rubor, dolor, calor, tumor) w/ ill -defined borders
Adults: GAS >> S.aureus Adults: extremities 2° strep w/ lymphangitis; Kids: H&N
S.aureus Superficial folliculitis: “Brockhart‟s impetigo”
occlusion/maceration/steroids at small 1-4mm pustules or crusted
or  crusted papules on an erythematous base
face, chest, back, buttocks
> Gram neg (back acne)
Deep folliculitis: “Sycosis barbae” large, tender, red papules often w/ central pustule
> Pseudomonas (ho tub) Tx: chlorhexidine or triclosan antibacterial wash; Mupirocin → Keflex if diffuse
Clinical: suppurative skin>lungs nodules,
skin>lungs nodules, verrucous plaques → sinuses
sinuses / fistulae
S.aureus Risk factors: HIV, diabetes, trauma, alcoholism
> P.aeruginosa, E.coli, Proteus
Histo: 1-3mm
 1-3mm granular „clubs‟ = bacteria, cells, and debris
S.aureus closed-space infections of the fingertip pulp
S.aureus, Clinical: Swollen, red, painful digit following minor nail trauma
Strep p yogenes Adult paronychia assoc w/ HSV
90% polymicrobial (type 1)
1) Clinical: Refractory cellulitis (red → blue/gray
blue/gray),
), hardens, F/C → shock 
10% GAS (type 2): M-protein Assoc w/ DM, ETOH, CAD, PVD, s/p blunt trauma or recent surgery
Osler‟s 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
hemolysis), θ-toxin (hemolysis, muscle necrosis, & cardiac toxicity); Tx: PCN G (+ Clinda + Aminoglycoside as 50% polymicrobial
C. perfr ingens Clinical: dirty wound →cellulitis w/ crepitus, + gas, foul-smell
(also Bacteroides,
Peptostreptococcus, Prevotella)
Gram stain: short, plump, blunt-ended G+ rods, no spores , & variable # PMNs
Epidermology: elderly w/ DM or PVD → trauma >> post-op post -op bowel or GB surgery
C. perfr ingens
Clinical: foul painful necrotic nodules; toxic, bronze skin, bullae w/ brown fluid

Streptococcus G+ cocci in clusters
20-50 yo w/ any GAS infection,
Strep Toxic Shock Synd PAINFUL skin → early shock &
“STSS” organ failure
“Toxic Strep Synd” Blood cx: + >50%; ↑mortality
Super-Antigen Syndrome: M-protein
Ulcerated non-bullous impetigo
Ecthyma extends into dermis
no systemic symptoms
Prodrome: fever & sore throat →
“sunburn w/ goosebumps”,
Staw/Beefy Tongue, Pastia‟s lines.
Scarlet Fever → peeling skin
“Scarletina” 2-10yo kids.
 No rash in children w/ Antibodies:
80% by 10yo
Erysipelas Dermal GAS infection
w/out lymphatic or subcutis involved
“St Anthony's fire”
Strep perianal disease
Perianal erysipelas, kids <4yo
“Perianal Cellulitis”
Purpura Fulminans DIC → Hemorrhagic infarction
Geographic ecchymoses
on extremities, ears, nose
Blistering Distal Dactylitis Distal fingers & toes
Other Gram -Positives
Animal handler or terrorist w/
“malignant pustule”:
 painful pa pule → hemorrhagic bulla
Anthrax
→ black eschar  Dx: gram stain/culture  of vesicle fluid, histology, PCR, direct fluor. Ab, ELISA serum
“woolsorter‟s disease”
95% cutaneous
also inhalation & GI forms
 Neutropenic pt w/
Bacillus cereus single necrotic bulla
Diptheria Rare
Fisherman or butcher
Erysipeloid Finger webs
  s Lumpy Jaw chronic bacterial infection
  e
  s G+ rod, Non-acid-fast
  o  pt w/ h/o dental problems
  c (normal oral flora)
  y Tx: Chronic PCN G (2-6 weeks IV or 3-12 months PO). ddx: dental sinus
  m
  o Nocardia brasilensis
  n
   i Chronic granulomatous subcut
   t Mycetoma
  c infection, draining sinuses, grains;
   A Nocardiosis Usually on foot
Other Nocardiosis Treat with sulfonamides x6-12wks
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
GAS (S. Pyogenes)
GAS (S. Pyogenes)
GAS
GAS
Bacillus anthracis
G+ rod, spores
Edema toxin (↑cAMP)
Lethal toxin (↑TNFα, IL-1β)
Polyglutamate capsule
(inhibits phagocytosis)
Bacillus cereus
G+ rod, spores
Corynebacterium
diphtheriae
G+ bacillus, no spores
Erysipelothrix
rhusiopathiae
G+, no spores
Actinomyces isralii
G+ branching, Acid-fast (soil)
Actinomadura madurae
Actinomadura pelletieri
Streptomyces somaliensis
Lymphocutaneous –  abscess + lymphangitis after trauma, unresponsive to ABX
ID for boards –  pg 2
Clinical: 20-50yo w/ severe pain in extremity; flu & CNS sx→ shock, organ failure
Patho: M-proteins bind MHC II (APCs) & Vβ (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: strawberry→beefy; Pastia‟s 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 Ab‟s
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)
Clinical: <4yo w/ painful defecation, blood-streaked stools, pruritus, fecal hoarding
Clinical: pustular petechiae, purulent purpura , subcut abscesses (infection mets)
Risks: Immunocompromised, erythroderma, CTCL, central lines, heart valves, IVDU
Clinical: tense blisters filled w/ purulent fluid & surrounding erythema
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
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
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 +

Corynebacterium G +, catalase positive
Erythrasma
Interdigital Erythrasma
Disciform Erythrasma
Pitted Keratolysis (PK)
Trichomycosis Axillaris
Gram-Negative Infections:
Acute: widespread purpura w/ central
Meningococcemia
Ecthyma Gangrenosum
Ps. Hot-Foot Syndrome
Green Nail Syndrome
Common cause of sepsis in burn pts
Pseudomonal Pyoderma
Blastomycosis-like Pyoderma
Undulant fever
„Malta fever‟
Cutaneous Malacoplakia
Tularemia
Rabbit Fever,
Pahvant Valley Plague Vector: Black fly (seminulium), Tsetse
Glanders
Facial Cellulitis (<2 yo)
Plague
Rhinoscleroma
Rat bite fever From rodents or contaminated food
Enteric fever
Vibrio infection
Superficial localized, mild/chronic
infection @ moist areas
Woods: Coral-red fluorescence
#1 bacterial infection of foot
not intertriginous
Asymptomatic; on feet
assoc w/ hyperhidrosis & foot odor  or Corynebacterium spp
Asymptomatic, axillary & pubic hair
30% military persons
Red-stained sweat → stains clothing
gunmetal gray discoloration
Chronic: maculopapular rash 12h p
fever, relapses q1-4days
Septic neutropenic pt‟s only
Kids plantar feet, from swimming
Self-limited
non tender paronychia
 pt w/ constant water exposure
2° decubitus ulcer infection
Raw goat-milk drinkers or
domesticated animal handlers
Michaelis-Gutmann bodies in
von Hansemann cells
Chancre + Bubo on hand of 
Rabbit handlers
Horse-handlers
Vaccinations!
Positive blood cultures
Vector: Oriental Rat Flea
( Xenopsylla cheopis )
or wild/domestic rodent contact
Chronic nasal plaques / URI
granulomatous infection
F/C/N/V/D
F/C/N/V/D
Corynebacterium
minutissimum
 Micrococcus sedentarius
Corynebacteri a tenui s
(NL flora)
Neisseria meningitidis
(nasopharynx reservoir)
P. aeruginosa
septicemia  Location: anogenital or extremity. Tx: imipenem (amino
P. aeruginosa
G - motile aerobe
P. aeruginosa
P. aeruginosa
P. aeruginosa
Brucella spp.
G neg rod
E.coli
G neg rod
Francisella Tularensis
G -, non-motile coccobacillus
Burkholderia mallei
(old name: Pseudomonas mallei)
G- bacillus, non-motile, aerobe
Haemophilus influenzae
G- coccobacillus
Yersinia pestis
Klebsiella pneumoniae
rhinoscleromatis
short, immotile G- bacillus
Streptobacillus
moniliformis
Salmonella
Vibrio vulnificus
ID for boards –  pg 3
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
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
Clinical: diffusely erythematous plantar feet w/ painful, red-to-purple 1-2-cm nodules
pyocyanin (green pigment) produced by  P. aeruginosa
Tx: clip back nail, use topical fluoroquinolones / tobramycin x 1-4 months
Clinical: bluish-green purulence, grape-juice or mousy odor, moth-eaten epidermis
Clinical: large verrucous plaques with multiple pustules and elevated borders
Clinical: erythema nodosum, vasculitis; “farcy buds”= nodules along lymph drainage
Other clinical: ocular, pulmonary, GI, cardio, GI, CNS. Tx: doxy / rifampin
Cutaneous Malacoplakia (bladder > skin) nodules/plaques
Histo dx: von Hansemann cells (foamy histiocytes CD68+, lysozyme+, α1-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)
Clinical: Ulcerated nodule w/ regional lymphadenopathy
high fevers, ↑ L shift WBC, positive blood cultures (unlike common cellulitis)
Gram-negative, rounded, short, bipolar bacillus
Tx: Streptomycin (chloramphenicol if meningitis)
Clinical: hypertrophic plaques on external nares
Histo: Mikulicz cells
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 G- bacillus; Tx: Doxycycline
Clinical: Fever, malaise, Neutropenia, ↑LFTs, rash (like RMSF but rarely palms/soles) ;
Ehrlichiosis
Monocytic: Ehrlichia chaffeensis Vector: (monocytic) Amblyomma americanum = lone star tick; Cytoplasmic PMN
Monocytic Ehrlichia
inclusions
Granulocytic Ehrlichia
(HGE)
HGE: E. equi, E.phagocytophila, Vector: Ixodes scapularis/‟daminii‟ = black-legged tick; I.pacificus (West US)
Rocky Mtn Spotted Wrists→hands/arms
(centrepidally)
R. rickettsii Vectors: Dermacentor andersoni (West US); Dermacentor variabilis (East); “hard ticks”
Fever
Rickettsialpox  NYC: F/C/HA, tender LNs R. akari Vector: Liponyssoides sanguineus (mite of the house mouse)
Epidemic Typhus Human misery / war  R. prowazekii Vector: Pediculus humanus corporis (human body louse)
Endemic Typhus R. typhi Vector: Xenopsylla cheopis (rat flea); orient
Scrub Typhus Calf : papule → eschar  Orientia tsutsugamushi Vector: Trombiculid mite larvae (chiggers);
F/C, atypical PNA, truncal
Q Fever exanthem Coxiella burnetii Vector: none; aerosolization of tick feces or domesticated ungulates: cattle, sheep
Culture negative endocarditis
Babesiosis Post-splenectomy, ↓immune Babesia microti Vector: I. daminii RBC parasite (northeast US) –  F/C/sweats/h.anemia
Tick paralysis ± respiratory support Dermacentor lower motor neuron paralysis 4-7d attachment; Rapid reversal w/ tick re moval

Rickettsia-Like Infections
Cat-Scratch Disease
Bartonellosis = Carrion‟s dz
“Oroya Fever”
“Verruga peruana”
Bacillary Angiomatosis
Disseminated cat-scratch dz
Trench Fever
Organisms appear adherent to RBCs, may be inside RBCs; Bartonella stain w/ Silver stains only (except Oroya Fever: Giemsa)
Tender lymphadenitis
after cat scratch
Bartonella henselae Clinical: persistent tender regional lymphadenitis weeks-mos s/p cat contact
Progression: Oroya Fever → survivors get Verruga peruana
Vector: Lutzomyia Sand fly
Bartonella bacilliformis Oroya fever: deadly fever, hemolytic anemia;
Oroya → Verruga
Rocha-Lima inclusions (stains w/ Giemsa) Vurruga peruana: benign, disfiguring.
Endothelial intracytoplasmic Rocha-Lima inclusions (Bartonella organisms)
HIV pt Bartonella henselae Clinical: subcut vascular prolif, esp in HIV- infected pt‟s; CD4 < 50
20% had cat contact Bartonella quintana 20% had cat contact/scratch; ± Jarisch-Herxheimer reaction w/ treatment (macrolide)
Vector: Human body louse
Pediculus humanus corporis
Bartonella quintana WWII trenches → now urban & mostly asymptomatic

Spirochetes false-positive VDRL, RPR;

Clinical: Erythema Migrans (1° stage), Acrodermatitis Chronica Atrophicans (3° stage)
#1 tick illness in US Borrelia Burgdorferi „outer surface protein C‟ (OspC) → traverses tick midgut → transfer to human via tick saliva
Ixodes scapularis / daminii Vectors: 1° stage (erythema migrans); 2° stage (e.m. resolved), 3° stage (>7 mos s/p e.m.)
Lyme Disease
summertime, bimodal: 0-14yo / 40-79 I. dammini/scapularis (NE US)
Erythema migrans Ixodes pacificus (West US) Extracutaneous: (tons) F/HA/cough, ophth, CNS, arrhythmias/CHF, arthritis, orchitis
Tx: Doxy 100mg po bid x 21d
Borrelia recurrentis
Relapsing Fever (Africa, S.Africa)
Clinical: Paroxysmal fevers (>2), HA, lymphocytoma, myalgias, rash
Tx: single dose Doxy 100mg Vector: Pediculus humanus
Louse-Borne
(human body louse) Rash: Erythematous or petechial macules on trunk & extremities
Relapsing Fever (Western US) Borrelia duttonii / hermsii Tx: Doxycycline
Tick-Borne Tx: Doxy 100mg BID x 7d Vector: Ornithodoros
2
.4
<15yo ulcerated papules form Treponema pallidum B
Yaws tracts → bone disease
red painless papule ulcerates on LEs of kids < 15 → coalesce into tracts → bone dz e m
 subspecies pertenue n il
z li
minute papules or macules surrounded by an erythematous halo → grow to 10 -12cm a o
th n
Pinta Symmetric vitiligo-like Treponema carateum in U
 plaques → 3° (symmetric, depigmented, vitiligo-like lesions) e P
1° (OP papule –  rarely noticed); IM C
Endemic Syphilis (Bejel) <15 yo w/ palatal & Treponema pallidum
2° (OP patches, angular stomatitis, papular eruptions, lymphadenopathy) N
 N.Africa, Arabia, SE Asia nasal septum mutilation  subspecies endemicum 3° gummas → mutilation of skin, bone, cartilage (esp palate & nasa l septum)

Mycobacterial Infections
LEPROSY
“Hansen's disease”
Lepromatous
Borderline Lepromatous
Mid-borderline
Borderline Tuberculoid
Tuberculoid
Indeterminate
TUBERCULOSIS
Tuberculous Chancre
Tuberculosis Verrucosa
Cutis
Lupus Vulgaris
Scrofuloderma
Tuberculous Gumma
Tuberculosis Cutis
Orificialis
Miliary Tb of the skin
Tuberculids
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
Searle‟s ulcer  Pulmonary dz most common
Turtle Tubercle Bacillus
Scrofuloderma-like
AIDS: Mult Purulent LE ulcers
(Leprosy, Tb, Atypical Mycobacterium)
Slowly progressive granuloma & Mycobacterium leprae
neurotropism (peripheral nerves)
at cool body sites
Generalized & symmetric
(face, buttocks, LE)
No loss of sensation or sweating
Lesions TNTC & smaller
Many lesions, symmetric
Less anethesia than Tuberculoid
3-10 lesions,
smaller than Tuberculoid
≤ 3 lesions
Solitary lesion
No sensory loss
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
Contaminated water to skin injury;
firm nodule → painless ulcer 1-2cm
Post-traumatic subcut nodules on
distal limbs or sporotrichoid pattern
cervical lymphadenitis → sinuses
LE ulcers & papulopustules
ID for boards –  pg 5
Respiratory transmission → 1° skin lesion: red or hypopigmented, often anesthetic
(intracytoplasmic parasite of
macrophages & Schwann cells)
Contagiousness: Intimate contact & genetic susceptibility; 25% of convival contacts
IL-4, IL-10, Neg Lepromin test;
Many organisms ( multibacillary) in dermis & nasal secretions
TH2 cytokine profile→
Type 2 reaction: Erythema Nodosum Leprosum Vasculitis (bright pink painful nodules erupt
Ab response on extremities ± face … during induction phase of treatment 2° excess Ab)
(least cellular immunity) Tx: Multibacillary 24 mos (Dapsone, Clofazimine, Rifampin )
Leonine facies, Madarosis (no eyebrows), long earlobes, saddle nose, corneal a nesthesia/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)
IFN-γ, IL-2, IL-12, Lepromin test +
A few organisms ( paucibacillary) well-demarcated plaques ± rash.
TH1 cytokine profile Type 1 reaction: Reversal rxn (↑ or ↓) –  Type IV hypersensitivity rxn → neuritis,
inflammation & new lesions; (2° change in immune state of the patient)
(cellular immunity, CD4+)
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
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
Mycobacterium Marinum Clinical: aquarium, pool, lake → small papule → nodule → granulomatous verrucous plaque
(skin exposed to water) Sporotrichoid spread; Tx: Minocycline
Mycobacterium ulcerans Tx: excision, heat, hyperbaric O2; rifampin, bactrim, minocycline
Mycobacterium kansasii verrucous plaques, ulcers, nodules, sporotrichoid patterns in immunocompromised pts
“fortuitum complex”
M. fortuitum = M. chelonei
M. scrofulaceum Cervical lymphadenitis → sinus formation (indistinguishable from Tb scrofuloderma)
M. avium, M. intracellulare F/C/sweats/wt.loss,pain/HSM, ↑AlkPhos

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
Cutaneous Filariasis
Loiasis
Onchocerciasis
“River Blindness”
Dracunculiasis
Larva Currens, Ground Itch
Cutaneous Strongyloides
Disseminated Strongyloides
Cercarial Dermatits
“Swimmer‟s itch”
Seabather‟s Eruption
Fishtank Granuloma
Lutzomyia sand fly
Lutzomyia sand fly
Phlebotomous sand fly
Phlebotomous sand fly
Phlebotomous sand fly
Reduvid bug (“kissing bug”)
 Reduviidae spp.
Tsetse fly
Glossina spp.
Mosquitoe vector
(Aedes, Anopheles, Culex, Mansonia)
Mango fly, deer fly
(Chrysops )
Black fly (Simulium)  Onchocerca volvulus
Cyclops copepods
(aquatic arthropod)
Schistosomatidae (cercarial flatworms)
Edwardsiella lineata (sea anemone); Linuche unquiculata (thimble jellyfish)
Mycobacterium marinum (deep fungal infection)
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)
T. brucei gambiense (W Africa)
T.brucei rhodesiense (E Africa)
Wuchereria bancrofti
Brugia malayi, B. timori,
Loa Loa
Dracunculus medinensis
Strongyloides stercoralis
Strongyloides stercoralis
ID for boards –  pg 6
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)
Romaña 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
Winterbottom‟s 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/ w idespread 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 Micro-organism Clinical lesion Diagnosis Tx
2-4 weeks incubation → (lasts 3-12 weeks) Darkfield (best for 1°), Warthin-Starry stain
T r e p o n em a p a l l i d u m
1° syphilis Painless, Non-purulent, usually single „ham-colored‟ indurated ulcer  Hemagglutination/Treponemal (FTA-Abs) @ 3 wks 2.4 million U
spirochete  Anticardiolipin/Non-treponemal: (RPR/VDRL)@5wk Benzathine IM
Bilateral, “rubbery” nontender adenopathy (buboes).
PCN
6 weeks after onset of 1° chancre → lasts 4-12 weeks → followed by LATENT  phase RPR/VDRL + in 100% (reverts to – after tx /latent)
2° syphilis
Early: non-pruritic PR-like rash; Late: copper-colored maculopapular rash, +lymphadenopathy False + VDRL: preg, spirochete infxn, viral infection,
Palm/soles: symmetric split-papules w/ Biett scale (collarette), moth-eaten alopecia (tel eff) autoimmune dz, Lep. leprosy, malaria, drug abuse. 1°, 2° - 1 dose
Condyloma tala (local treponemes); 'corona veneris' @ hairline, prodromal sx; FTA-Abs, remains + (best serology for 1°) 3° - q week x3
MHA-TP (like FTA-Abs, but less sensitive for 1°) Jarisch-Herxheimer:
3° syphilis DTH response: Late benign – no cardio or CNS gummas; Cardiovascular or Neurosyphilis. Dx: CSF IgG treatment fever due
ELISA / IgM EIA – best for early 1° or congenital)
to TNFα release.
Congenital 1s  3 mos: marasmic syphilis, „snuffles‟ (bullous/erosive 2° syphilis). Hutchinson triad: keratitis, teeth, deafness FTA-Abs-19-S-IgM (IgM separated, more specific)
 Azithromycin,
H a em o p h i l u s d u c r e y i 3-10d incubation → Purulent, painful, ≥1 ulcers, soft ragged edges. Culture
Chancroid Ceftriaxone,
G – bacillus Unilateral, tender adenopathy (bubo) in 50%. “School of fish” on Giemsa stain Cipro, Erythro

Granuloma C a l y m m a t o b a c t e r i u m Indurated chronic red fleshy ulcer TMP-SMX,

Donnovan bodies: safety-pin
Inguinale granulomatis 1° lesion: papule, subcut nodule ( pseudobubo) or ulcer  Doxy, Cipro,
intracytoplasmic MØ inclusions
“Donovanosis” G – bacillus 4 forms: Ulcerovegatative (most common), Nodular, hypertrophic, cicatricial Erythro
Transient painless soft erosion → unilateral lymphadenopathy
Chlamydia trachomatis  “groove sign” - fluctuant tender groin LN
LGV serovars L1, L2, L3
→ Doxy
Serology, culture, PCR
firm mass & bubo w/ drainage & involusion w/ proctocolitis
Genital herpes HSV (2>1) Burning painful vesicles on erythematous base  Antigen detection, culture, PCR Acyclovir
GU: Urethritis/dysuria, purulent urethral discarge → PID, perihepatitis Smears: Male/urethral, Female/Endocervical
(diplococci in PMNs w/ methylene blue or gram)
Neisseria gono rrhea Skin: Sparse hemorrhagic vesiculopustules w/ erythematous Single dose:
Gonococcemia Culture: (Thayer-Martin)
G – intracellular diplococci bases on palms/soles, over joints; F/C/arthralgias/malaise Gen-Probe: non-amplified DNA hybridization Ceftriaxone
Recurrent Gonorrhea: complement deficiencies (esp C5-8)
 ID for boards –  pg 8
Herpesvirus : core of linear ds-DNA, icosahedral capsid, envelope w/ surface glycoprotein spikes;
Orolabial herpes replication at mucosal site
Eczema herpeticum =
Dissemination: atopic dermatitis, burns, pemphigus, MF, icthyosis, Dar ier‟s, Sezary‟s
HSV-1 – ALPHA Kaposi‟s varicelliform eruption
gG-1 glycoproteins Herpes gladiatorum contact sports, ie. Wrestling (arms > H&N)
Erythema multiforme
Western Blot (gold standard)
DIF, Viral culture, Tzank  HSV folliculitis
HSV keratoconjunctivitis #2 cause of corneal blindness
Herpes encephalitis 1 sporadic fatal encephalitis; temporal lobes; 70% mor tality); → CSF cx & PCR, EEG, MRI
HSV-2 – ALPHA Genital herpes replication at mucosal site
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 replica te → vesicles
rash: scalp/face → rosepetal → de wdrops over 12h; ± enanthem
VZV (HHV-3) –  Varicella st
Congenital Varicella Synd (1  20 wks): hypoplastic limbs, ocular & CNS abnormalities
ALPHA Neonatal Varicella (5d pre-, 2d post-delivery): inadequate transplacental Ab (Tx: VZIG + IV-ac yclovir)
st
20% of healthy adults, 50% of immunocompromised
DIF (best), Tzank (1 ) Herpes zoster
Viral Culture (most specific) disseminated : >20 vesicles outside primary or adjacent dermotomes; more common in immune suppressed
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 pr ophylaxis of immunocompromised, pregnant, neonates; VZV vaccine (Oka) - 95-100% effective in preventing severe disease
Tx VZV: Valtrex w/in 72h of 1 st vesicle improves course
EBV (HHV-4) –  1° EBV infxn in 50% of 17-25yo (pharyngitis, fever, lymphadenopathy, ± spleenomegaly x2-3 weeks)
GAMMA Infectious Mononucleosis Ampiciliin rash: Mono + Amp = copper macular extensor rash 7 -10d later → spreads to trunk →
Epstein Barr Virus desquamates 1 wk later
Replicates in B cells Oral Hairy Leukoplakia HIV / Immunosuppressed: lateral tongue corrugated white plaques
+ monospot or Lymphoproliferative disorders (solid organ transplants or HIV +), Nasopharyngeal Carcinoma, ?Hodgkin‟s lymphoma, African Burkitt‟s lymphoma;
heterophile Ab >1:40 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.
Congenital CMV Clinical: SGA, microcephaly, retinitis, colobomas, intracranial calcifications.
CMV (HHV-5) – BETA dermal erythropoiesis → purpuric papules ('blueberry muffin lesions‟)
CMV Retinitis  –  #1 cause of blindness in AIDS pts.
HHV-6 –  BETA Roseola Infantum = Infant toddler febrile illness (6 mos to 3 yrs) → high fevers & 48h rash as fever remit.
Exanthem sibitum = 6 th disease Rash: „rose-red‟ maculopapules 2-5mm, occasionally surrounded by white halo.
HHV-7  –  BETA
HHV-6B > -6A, -7 CD4+ lymphotropic viruses; Transmitted through saliva
Castleman‟s syndrome
Kaposi‟s sarcoma >60 yo Mediterranean or Ashkenazi Jew; HIV+
HHV-8  –  G A M M A 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 → i nvolves 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
Herpangina
Measles / Rubeola
Milker‟s Nodule
Orf
Contagious Pustular
Dermatitis
Contagious Ecthyma
Fifth Disease
Erythema Infectiosum
Molluscum contagiosum
Rubella / German measles
Smallpox
Smallpox complications:
Human Papillomavirus (HPV)
Heck‟s dz (Oral focal epithelial hyperplasia)
Epidermodysplasia verruciformis (EDV)
Anogenital; Buschke-Lowenstein tumor
High risk anogenital/cervical CA; Bowenoid
ID for boards –  pg 9
Erythematous papules w/ grayish vesicle & surrounding red areola
Cocksackie A16 > Enterovirus 71
Transmission: oral-oral & oral-fecal
Fever, Headache, Cervical Lymphadenopathy
Coxsackievirus Group A
Gray-white papulovesicles on tonsillar fauces, palate → ulcerate
3d prodrome of: High Fever + 3 C‟s (cough, coryza, conjunctivitis); → Koplik‟s spots
th
Paramyxovirus Rash: Erythematous macules & papules begins on forehead, then generalizes (fades on 5  day)
Complications: otitis, PNA, encephalitis, myocarditis, subacute sclerocing panencephalitis (sz, coma)
Paravaccinia virus Transmit: infected cows → humans
(Parapoxvirus)  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
Orf virus Clinical: Papule/nodule on dorsal index finger;
(Parapoxvirus) 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
Parvovirus B19 Adults: acute arthropathy w/ fever & adenopathy; ± lacy reticular mac ular eruption
(ss-DNA) Pregnancy: Hydrops fetalis, spont Ab if 1 st ½ of preg;
Sicklers: Aplastic crisis; Immunocompromised pts: severe chronic anemia
Molluscum contagiosum virus
Umbilicated papules; kids>adults
(Poxvirus)
16d incubation. Rash: Erythematous maculopapular FACE to trunk in 24h (disappears as it spreads);
Rubella (nasopharynx infection)
Tender lymphadenopathy (occipital, posterior auricular); + Joint involvement
(Togavirus)
Forchheimer‟s spots (soft palate petechial macules)
TORCH syndrome w/ Blueberry Muffin Baby (low birth wt, microcephaly, cong heart dz)
Rubella (congenital infection) TORCH syndrome: HSM, deafness, microcephaly, chorioretinitis, thrombocytopenia
(Togavirus) 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
Variola (Poxvirus) Generalized centrifugal eruption: eruption of umbilicated papules, deep vesicles, pustules, crusts
Dx: Guarnieri‟s bodies (cytoplasmic eosinophilic bodies) on LM; Fluorescent Ab staining lesion fluid
EM-like eruptions
Bacterial Superinfection S.aureus, GAS
Accidental inoculation Eczema vaccinatum p innoculation onto dermatitic skin
Congenital vaccinia Following vaccination of a pregnant woman
Generalized vaccinia Children w/ isolated IgM deficiency are especially prone (ie. Wiscott-Aldrich Synd)
Progressive vaccinia Impaired immunological response to vaccinia (in normal or immunodeficient hosts)
Type of wart HPV type DNA Viruses: herpes, hepadna,
Palmo-plantar 1 H-H-A-P-P-P-y adeno,
Common, myrmecial 2,4
 papova, ss-parvo, pox
Flat 3,10
Butcher‟s 7 (2)
RNA Viruses: Paramyxovirus (measles, mumps);
13,32
P-P-R-R-T Picornavirus (Enterovirus: coxsackie)
3, 5,8 > 9,12,14,15,17,19-26
Retrovirus (HIV, HTLV);
6,11
Rhabdovirus (rabies);
16 >18,31,33-35 Togavirus (rubella);
Papulosis
 ID for boards –  pg 10
Lice, Mites, Spiders, Bugs
White hourglass on abdomen; painful bites, but no necrosis. Antivenin helpful <90 hrs after bite.
Black widow L actodectus mactans
Venom: α Lactrotoxin neurotoxins → F/C/N/V, cramps, paralysis, acute abd.
Tan w/ violin on abdomen→necrosis; “red-white-blue” sign (erythema, ischemia, necrosis).
Brown recluse L oxosceles systemic rxns in kids (f/c/v/hematuria/t-penia/anemia/thrombosis).
Venom: Sphingomyelinase-D (necrosis/hemolysis).
Wolf spider L ycosidae Venom: Histamine (exceedingly painful bites → lymphangitis/eschar)
Jumping spider Phidippus Venom: Hyaluronidase; Aggressive: #1 biting spider in US (esp in South), pain, no systemic sx.
Sac spider Chiracanthium Venom: lipase
Hobo spider Tegenaria agrestis Herringbone abdomen; Pacific northwest (#1 necrotic spider bite)
Green Lynx spider Peucetia viri dans Southern US; Bright green w/ red spots, black leg spines;
Tarantulas Southwest US; “urticating hairs” penetrate into reticular dermis or cornea (ophthalmia nodosa)
Scorpions Centuroides sculpturatus/gertschi Venom: neurotoxin; pain / numbness /ecchymosis → CNS symptoms →arrhythmias, HTN
Catepillars Lepidoptera “tram track” purpura , erythematous papules
Bee, wasp, hornet, ant Hymenoptera Honeybee – leaves barbed ovipositor (needs removed QUICKLY) → bee dies; tx: ice & lidocaine
Fire ants Solenopsis (invicta) Venom: hemolytic factor, solenospin D (causes histamine release); may attack in groups
Black flies blood suckers (vectors for onchocerciasis & tularemia)
Horseflies, Deerflies, Mangoflies Tabandae Blood suckers
Sand flies transmit Depetalonema perstans
Mosquitoes: Malaria Anopheles Transmits: Malaria
Mosquitoes: Yellow Fever & Dengue Aedes Transmits: Yellow Fever & Dengue
Bedbugs Cimicidae Flat & broad; Nocturnal feeders; bites in linear purpuric macules
Fleas: Typhus & Plague Pulex irr itans  Transmits: typhus, plague; Extremely pruritic red papules on Lower legs
Centipedes Chilopoda  Nocturnal carnivores (painful venom wounds)
Millipedes Diploda Harmless vegetarians (emit toxic substance that may produce blistering & pigmentation, eye irrit)