ANATOMY REVIEW

Skin

MUCUS MEMBRANES
Structure Defenses

PEDIATRIC DIFFERENCES IN THE SKIN

Skin is thinner, more susceptible to irritants and infection Ratio of skin surface area to body volume is greater, allowing greater absorption More susceptible to bacterial invasion Less ability to regulate temperature

IMPETIGO
Most

common bacterial skin infection of childhood

Highly

contagious by Staph aureus or Strep

Caused

NURSING MANAGEMENT OF LESIONS

Gently wash lesions 3 times a day with warm, soapy washcloth, crusts carefully removed

Apply topical antibiotic as ordered

Administer oral antibiotics as ordered Severe infections may need to be treated with IV antibiotics

NURSING CARE FOR A CHILD WITH IMPETIGO

Child can spread impetigo by touching another part of the skin after scratching infected areas Wash the childs hands frequently with antibacterial soap

Distract child from touching lesions

PARENTAL EDUCATION

Good hand washing to prevent spread

Cut childs nails short, wash hands often with anti-bacterial soap Do not share towels, utensils with infected child May return to school or daycare 24 hours after antibiotics started Finish full course of antibiotics (usually 10 days)

STAPH
Staphylococcus aureus, often referred to simply as staph, are bacteria commonly carried on the skin or in the nose of healthy people.

SYMPTOMS OF STAPH INFECTIONS

The symptoms of a staph infection depends on where the infection is. The staph bacteria can cause: Boils an abscess, bump, or swelling within the skin. Also called a furuncle.

Impetigo pustules (bulbous impetigo) or honey colored crusted lesions on the skin

May be caused by staph or other bacteria

In addition to skin infections, the staph bacteria can cause:

Bacteremia a blood infection Deep abscesses an abscess that occurs below the skin surface Endocarditis an infection on the valves of the heart Food poisoning vomiting or diarrhea caused by a staph toxin Lymphadenitis an infection of a lymph gland, which causes it to be red, swollen and painful

Lymphangitis an infection of the lymph channels that drain to lymph glands, causing red streaks in the skin Osteomyelitis a bone infection Paronychia an infection of the skin folds of the nails Scalded skin syndrome Septic arthritis an infection of a joint, like a hip or a knee Styes an infection of the glands on the eyelid Toxic shock syndrome

The Staphylococcus aureus bacteria can also cause less common infections such as pneumonia, ear infections, and sinusitis.

IMPETIGO
Staph aureus Crusted erosions on the arm of a child. The confluence of lesions in the antecubital fossa suggests prior atopic dermatitis at the site that became secondarily infected.

BULLOUS IMPETIGO
Staph aureus

A large, single bulla with surrounding erythema and edema on the thumb of a child; the bulla has ruptured only in the center and clear serum exudes from it.

BACTERIAL SKIN INFECTIONS

1-Acute infections A- Impetigo: 1- Non-bullous impetigo (Impetigo contagiosa )

2- BULLOUS IMPETIGO

Complications: Generally rare and it includes: 1. Spread of infection to other organ as bone (Osteomylitis, joint (septic arthritis) or lung (pneumonia) 2. Acute glomerulnephritis The prognosis is usually good. 3. Rheumatic Fever is very rarely reported 4. Henoch Schoenlein purpura: [acute allergic vasculitis. 5. Staphylococcal Scalded Skin Syndrome (4S syndrome):

TREATMENT OF IMPETIGO

Isolate the infected child. Remove the crust Topical antibiotic as Mupirocin, Bacitracin, Retambulin other agents used topically are tetracycline; gentamycin; soframycin; fusidic acid (act on staph inf.) 4. Systemic Antibioticss are used if - Patient has fever; lymphadenopathy. - Wide spread infection. - Resistant to topical drugs; - Immunosuppressive diseases.

B- Ecthyma

IMPETIGO

Superficial cut. Inf. Staph, gp A strept or both Child, AD

Mx: Remove crust Localized:Topical Abx (bacroban) Severe or Strept (prevent post strept. Glomerulonephritis): Semisynthetic Penicillin : 7-10 d Erythromycine (sensitive) Augmentin (face) 1st generation cephalosporin

Diphtheria and Diphtheria Toxoid

Greek diphtheria (leather hide)

Recognized by Hippocrates in 5th century B.C.

Epidemics described in 6th century C. diphtheriae described by Klebs in 1883 Toxoid developed in 1920s

CORYNEBACTERIUM DIPHTHERIAE

Aerobic gram-positive bacillus Toxin production occurs only when C. diphtheriae infected by virus (phage) carrying tox gene If isolated, must be distinguished from normal diphtheroid

DIPHTHERIA CLINICAL FEATURES

Incubation period 2-5 days (range, 1-10 days)

May involve any mucous membrane

Classified based on site of infection Anterior nasal Tonsillar and pharyngeal Laryngeal Cutaneous Ocular Genital

PHARYNGEAL AND TONSILLAR DIPHTHERIA

Insidious onset of exudative pharyngitis

Exudate spreads over 2-3 days and may form adherent membrane Membrane may cause respiratory obstruction Fever usually not high but patient appears toxic

DIPHTHERIA COMPLICATIONS

Most attributable to toxin Severity of generally related to extent of local disease

Most common complications are myocarditis and neuritis Death occurs in 5%-10% for respiratory disease

DIPHTHERIA ANTITOXIN

First used in 1891 Produced in horses

Used only for treatment of diphtheria

Neutralizes only unbound toxin

DIPHTHERIA EPIDEMIOLOGY

Reservoir

Human carriers Usually asymptomatic Respiratory Skin and fomites rarely Winter and spring

Transmission

Temporal pattern

Communicability

Up to several weeks without antibiotics

DTAP, DT, AND TD

Diphtheria 7-8 Lf units Tetanus 5-12.5 Lf units

DTaP, DT
Td (adult)

DTDTaP, DT 2 Lf units and pediatric DT used 5 Lf units Pertussis vaccine through age 6 years. Adult Td used for persons 7 years and older Td (adult) aP, DT

Pertussis vaccine and pediatric DT used through age 6 years. Adult Td Td (adult) used for persons 7 years and older.

DIPHTHERIA TOXOID

Formalin-inactivated diphtheria toxin

Schedule Three or four doses + booster Booster every 10 years

Efficacy Approximately 95% Duration Approximately 10 years Should be administered with tetanus toxoid as DTaP, DT, or Td

Routine DTaP Primary Vaccination Schedule

Dose
Primary 1 Primary 2 Primary 3 Primary 4

Age
2 months 4 months 6 months 15-18 months

Interval
--4 wks 4 wks 6 mos

CHILDREN WHO RECEIVE DT

The

number of doses of DT needed to complete the series depends on the childs age at the first dose: if first dose given at <12 months of age, 4 doses are recommended if first dose given at >12 months, 3 doses complete the primary series

ROUTINE DTAP SCHEDULE CHILDREN <7 YEARS OF AGE

Booster Doses

4-6 years, before entering school

11-12 years of age if 5 years since last dose (Td) Every 10 years thereafter (Td)

Routine Td Schedule Persons >7 years of age

Dose Primary 1 Primary 2 Primary 3 Interval --4 wks 6-12 mos

Booster dose every 10 years

DIPHTHERIA AND TETANUS TOXOIDS ADVERSE REACTIONS

Local reactions (erythema, induration) Exaggerated local reactions reactions (Arthus-type) Fever and systemic symptoms uncommon Severe systemic reactions rare

DIPHTHERIA AND TETANUS TOXOIDS CONTRAINDICATIONS AND PRECAUTIONS

Severe allergic reaction to vaccine component or following prior dose Moderate to severe acute illness

CORYNBACTERIUM DIPTHERIAE
Gram-positive irregular bacilli Virulence factors assist in attachment and growth.

diphtherotoxin
2

exotoxin

part toxin part B binds and induces endocytosis; part A arrests protein synthesis

39

40

EPIDEMIOLOGY AND PATHOLOGY

Reservoir of healthy carriers; potential for diphtheria is always present Most cases occur in non-immunized children living in crowded, unsanitary conditions. Acquired via respiratory droplets from carriers or actively infected individuals

41

EPIDEMIOLOGY AND PATHOLOGY

2 stages of disease: 1. Local infection upper respiratory tract inflammation
sore throat, nausea, vomiting, swollen lymph nodes; pseudomembrane formation can cause asphyxiation
2.

Diptherotoxin production and toxemia

target organs primarily heart and nerves

42

DIAGNOSTIC METHODS
Pseudomembrane and swelling indicative Stains Conditions, history Serological assay

43

TREATMENT AND PREVENTION

Antitoxin Penicillin or erythromycin Prevented by toxoid vaccine series and boosters

44

BORDETELLA PERTUSSIS

http://www.hhmi.princeton.edu/sw/2002/psidelsk/Microlinks.htm

OUTLINE
Bordetella Pertussis microbiology Whooping Cough/Pertussis Vaccine Current problems with B. pertussis

BORDETELLA PERTUSSIS BASICS

Aerobic, Gram negative coccobacillus Alcaligenaceae Family Specific to Humans Colonizes the respiratory tract

Whooping

Cough (Pertussis)

http://microvet.arizona.edu/Courses/MIC420/lecture_notes/bordetella_pertussis/ gram_pertussis.html

TRANSMISSION
Very Contagious Transmission occurs via respiratory droplets

http://www.universityscience.ie/imgs/scientists/whoopingcough.gif

http://www.ratbags.com/rsoles/history/2000/12december.htm

VIRULENCE

Steele, R.W. Pertussis: Is Eradication Achievable. Pediatric Annals. Aug 2004. 33(8):525-534

ADHESIONS
Filamentous hemagglutinin Pertactin Fimbriae

http://www.rivm.nl/infectieziektenbulletin/bul1306/kinkhoest.jpg

http://www.my-pharm.ac.jp/~yishibas/research/Pertussis1.jpg

TOXINS
Pertussis Toxin Adenylate Cyclase Toxin Tracheal cytotoxin Dermonecrotic toxin Heat-labile toxin

www.ibl.fr/u447/u447.htm

PERTUSSIS TOXIN
Colonizing factor and endotoxin Cell bound and extracellular

gsbs.utmb.edu/ microbook/ch031.htm www.med.sc.edu:85/ ghaffar/pertussis.jpg

ADENYLATE CYCLASE TOXIN

Invasive toxin Activated by host cell calmodulin Impairment of immune effector cells

Babu et al., 2001

THE BVG LOCUS

Controls expression of virulence factors Encodes BvgA, BvgS and BvgR

BvgA-BvgS

signal transduction system

Babu et al., 2001

WHOOPING COUGH
Also known as Pertussis Outbreaks first described in the 16th Century Major cause of childhood fatality prior to vaccination

paaap.org/immunize/ course/slide27.html

CLINICAL FEATURES
Incubation period 4-21 days 3 Stages

1st

Stage- Catarrhal Stage 1-2 weeks 2nd Stage- Paroxysmal Stage 1-6 weeks 3rd Stage- Covalescent Stage weeks-months

http://www.cdc.gov/nip/publications/pertussis/chapter1.pdf

PERTUSSIS INFECTION

gsbs.utmb.edu/ microbook/ch031.htm

DIAGNOSIS
Isolation by culture PCR Direct fluorescent antibody Serological testing

http://medinfo.ufl.edu/year2/mmid/bms5300/images/d7053.jpg

TREATMENT

Antibiotic therapy
Erythromycin
Azithromycin

and clarithromycin

http://www.aboutthatbug.com/AboutThatBug/files/CCLIBRARYFILES/ FILENAME/0000000032/033_lg.jpg

http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/macrohd.htm

PERTUSSIS VACCINE
1st Pertussis vaccine- whole cell Acellular vaccine now used Combination vaccines

http://www.tdh.state.tx.us/immunize/providers.htm

http://www.nfid.org/publications/clinicalupdates/pediatric/pertussis.html

VACCINE PROBLEMS
Complications/Safety Multiple administration Waning adolescent and adult immunity Strain Variability

http://www.healthcareforhoosiers.com/Member/vaccineschedule.html

CONCLUSIONS

Reemerging in adult and adolescent populations as worldwide vaccination rates increase

High

vaccination rates not enough Better vaccine development needed

Cutaneous Anthrax

Back

Cutaneous Anthrax

View Table
The primary lesion of cutaneous anthrax is a painless, pruritic papule that appears one to seven days after inoculation. Within one to two days, small vesicles or a larger, 1- to 2-cm vesicle forms that is filled with clear or serosanguineous fluid. As the vesicle enlarges, satellite vesicles may form.

Fitzpatricks Dermatology in General Medicine. Fifth Edition. Freedberk IM, Eizen, AZ, Wolff, K, Austen KF, Goldsmith LA, Katz SI, Fitzpatrick TB (eds.). New York: The McGraw Hill Companies, Inc; 1999.

Fluid within the vesicles may contain numerous, large gram-positive bacilli. As the lesion matures, a prominent, non-pitting edema surrounds it. Eventually, the vesicle ruptures, undergoes necrosis, and enlarges, forming an ulcer covered by the characteristic black eschar. Symptoms include low-grade fever and malaise. Regional lymphadenopathy is present early on.

Differential Dx - Ecthyma

View Table

Cutaneous anthrax Lesion located most commonly on upper extremities (especially the hands), neck, or face Systemic manifestations include fever, malaise, regional lymphadenopathy Ecthyma Lesions located most commonly on lower extremities Systemic symptoms unusual Ecthyma gangrenosum Associated with neutropenia May be associated with Pseudomonas bacteremia

Differential Dx Brown Recluse

View Table

Cutaneous anthrax Painless lesion Necrosis of skin and subcutaneous tissue occurs late and gradually

Brown Recluse Spider Bite Bite lesion becomes painful Necrosis of skin and subcutaneous tissue occurs early and quickly

Differential Dx Sweets

View Table

Cutaneous anthrax Solitary lesion Painless lesion Necrotic ulceration Formation of black eschar Characteristic massive edema surrounds the lesion

Sweets Syndrome Multiple lesions most common Painful or tender lesions Edema within the lesions

Differential Dx Orf Virus

View Table

Cutaneous anthrax Lesion forms black eschar surrounded by massive edema

Orf Virus Infection Lesion forms crusts, scabbing

PEDICULOSIS CAPITIS

PEDICULOSIS CAPITIS (HEAD LICE)

Lice infection transmitted by direct contact with infected persons or indirect contact with contaminated objects Lice can live on a human host consuming scalp blood and lay eggs Lice can live off of human for 48 hours without blood

Nits (eggs) capable of hatching for 10 days

CLINICAL MANIFESTATIONS

Nits are visible on hair shafts close to scalp usually behind ears and at nape of neck, difficult to remove

Once hatch crawling causes intense pruritis (itchy scalp)

MANAGEMENT -THREE GOALS

1.

Kill the active lice using pediculicide OTC products (Kwell, Nix, Rid)

Kwell is neurotoxic for infants RID is safe and effective, must treat hair again 1 to 2 weeks after initial treatment

NIX kills head lice and eggs with 1 treatment, may have residual activity for 10 days

MANAGEMENT - THREE GOALS

2.

Remove nits Inspect childs hair with fine-toothed comb Comb nits out when hair is wet (apply vinegar water mixture prior to combing)

MANAGEMENT-THREE GOALS
3.

Prevent spread or recurrence Treat environmental objects Examine and treat family members Vacuum carpets Check child for reinfestation 7 to 10 days after treatment Wash all bedding, hats in hot water and high dryer setting Notify school if reoccurs

SCABIES

Mite infection-burrow under skin Spread by skin to skin contact

Female mite burrows under skin and lays egg

Hatch in 3-5 days and cause severe intense itching Secondary infections (impetigo, cellulitis) common

CLINICAL MANIFESTATIONS

Intense, severe pruritis esp. at night Papular-vesicluar rash mainly in wrists, fingers, elbows, axilla and groin May see a faint burrow pattern

MANAGEMENT

Elimite- prescription Application applies neck to toe and must remain on for 8-12 hours Family members even if asymptomatic and day time contacts should be treated

Wash all bedding, clothing in hot water similar to that for pediculosis

TINEA

COMMON TYPES OF TINEA INFECTION

Tinea capitis (scalp) Tinea cruris (groin, buttocks, and scrotum) Tinea corporis (trunk, face, extremities) Tinea pedis (feet)

TINEA CAPITIS

Erythema papular rash of scalp

Patches of alopecia
Treated with topical and oral antifungals

TINEA CORPORIS

Single circular 1 scaly plaques

Erythema to pale pink/white Topical antifungals, continue to treat one week after rash gone

TINEA CRUIS

Warm moist environment promotes fungal growth Common in adolescent male

Topical antifungal Loose clothing

TINEA PEDIS

Sweaty feet promotes growth

Barefoot in common wet areas (pools,lockeroom) Topical antifungal

Fresh socks, toss old shoes

NURSING CONSIDERATIONS ALL TINEA INFECTIONS

All members of the family and household pets should be assessed for fungal lesions
Person-to-person transmission is cause Treat all asymptomatic family members for recurrence Good hygiene helps in prevention Dont share towels, clothing, hats, etc

PINWORMS

Intestinal worms- live in rectum of humans Female worms leave rectum at night to lay eggs on surrounding skin Eggs can survive in bedding and clothing for 2 weeks Spread by ingesting eggs Medicines kill worms curable