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MD2 Intersession 1 > Skin, Soft Tissue, Bone and Joint Infections > Flashcards

Skin, Soft Tissue, Bone and Joint Infections Flashcards

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1
Q

What do the clinical manifestations of skin and soft tissue infections include?

A 
Erythema
Warmth
Tenderness
Systemic symptoms
- Chills
- Fever
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2
Q

What is the differential diagnosis for unilateral leg erythema, swelling, and tenderness, of rapid onset?

A 
DVT
Cellulitis
Localised infection
Eczema/contact dermatitis
Compartment syndrome
Necrotising fasciitis
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3
Q

What is the relevance of cracked heels and tinea between the toes in skin and soft tissue infections?

A

Candida and cracked skin allow entry of bacteria into dermal layer

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4
Q

What is cellulitis?

A

Acute inflammatory process involving skin and soft tissues

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5
Q

What are the features of cellulitis?

A

Spreading, erythematous rash
Most cases involve lower limbs
Almost always unilateral - if not, limbs have different pattern
Chills and fevers may precede localising symptoms and signs
Red, warm, tender rash
Often associated with lymphangitis

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6
Q

What can happen in severe or protracted cellulitis?

A

Abscess - rare
Bullae
Vesicles

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7
Q

What are the risk factors for cellulitis?

A 
Lymphatic stasis
Peripheral oedema - with skin breaches
Trauma
IV drug use
Ulcers
Wounds
Dermatophytic infections
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8
Q

What pathogens usually cause cellulitis?

A 
Group A Streptococcus
- Potential to rapidly go to necrotising fasciitis
- Most likely cause
Other Strep
Staph aureus
Coagulase -ve Staph
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9
Q

How is cellulitis diagnosed?

A 
Usually clinical - epidemiology and history important clues to underlying microbiology
Swab pus, if present
Blood cultures indicated for
- Fever
- Extensive cellulitis
- Immunosuppression
- Lack of response to empiric therapy
- Suspicion of unusual pathogen
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10
Q

When is imaging helpful in the diagnosis of cellulitis?

A

Ultrasound to differentiate DVT

MRI/CT if suspicion of necrotising fasciitis/pyomyositis

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11
Q

Which pathogens are likely to cause skin infections in IV drug users?

A

Typical cellulitis pathogens

Oral flora

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12
Q

Which pathogens are likely to cause skin infections post burns?

A

Typical pathogens
Pseudomonas aeruginosa
Enterobacteriaeciae
Acinetobacter spp

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13
Q

Which pathogens are likely to cause skin infections in immunocompromised hosts?

A 
Typical pathogens
Gram -ve bacteria
Fungi
Viruses
Mycobacteria
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14
Q

Which pathogens are likely to cause skin infections in seawater exposure?

A

Vibrio spp

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15
Q

Which pathogens are likely to cause skin infections in freshwater or mud exposure?

A

Aeromonas spp

Mycobacterium marinum

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16
Q

Which pathogens are likely to cause skin infections due to dog or cat bites?

A

Typical pathogens
Oral Streptococci
Oral anaerobes

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17
Q

Which pathogens are likely to cause skin infections due to human bites?

A

Typical pathogens

Oral flora

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18
Q

What is the management of cellulitis?

A 
Oral preparations
Di/flucloxacillin
- Good for Staph and Strep
- Doesn't cover MRSA, Gram -ves, anaerobes
Penicillin
- Staph pyogenes cultured/suspected
Cephalexin
- For hypersensitivity to penicillins
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19
Q

For whom should IV antibiotics in the treatment of cellulitis be reserved?

A

High fever
Systemic toxicity
Facial cellulitis

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20
Q

How long does cellulitis take to resolve?

A

7-10 days to start
2 weeks to fully
Therefore don’t need to treat with antibiotics until redness gone

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21
Q

What is the adjunctive and preventative management for cellulitis?

A 
Management of lower limb ulcers and oedema/venous insufficiency
- Dressings
- Compression stockings
- Leg elevation
- Diuretics
Keep skin hydrated = emollients
Assess for and manage tinea pedis
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22
Q

What is chronic lymphoedema?

A

When lymphatic load exceeds transport capacity of lymphatic system

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23
Q

What are the risk factors for chronic lymphoedema?

A 
Trauma, especially recurrent
Malignancy, and its treatment
- Keep in people who've had all lymph nodes removed in arm
Chronic venous insufficiency
Obesity
Inflammatory disorders
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24
Q

What are the features of chronic lymphoedema?

A

Tight, swollen legs > discomfort
Chronic condition compared to cellulitis
May become super-infected

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25
What is the management for chronic lymphoedema?
Exercise - gentle resistance training Compression bandaging Massage Meticulous skin and nail care
26
Which conditions can be misdiagnosed as cellulitis?
``` Acute contact dermatitis Septic bursitis Septic arthritis DVT Gout Thrombophlebitis Lipdermatosclerosis/venous insufficiency/varicose eczema ```
27
What are the features of acute contact dermatitis?
Dry/erythematous/eczematous skin | Exposure to irritant/caustic chemical
28
What is the treatment for acute contact dermatitis?
Avoid causative agent Topical steroids Emollients
29
What are the features of septic bursitis?
``` Commonly affects prepatellar and olecranon bursae Pain Tenderness Erythema Warmth Preceding local trauma Usual pathogen = Staph aureus ```
30
What is the treatment for septic bursitis?
Treat as per cellulitis | Surgical drainage if severe
31
What are the features of septic arthritis?
``` (Usually) single swollen, painful joint Warmth Erythematous Restricted movement +/- fevers ```
32
What is the management for septic arthritis?
Surgical washout Deep specimens for culture and susceptibility testing IV antibiotics
33
What is a differential diagnosis for septic arthritis?
Gout - Moderately high WCC - Urate crystals
34
What are the features of DVT?
``` Swollen, tender, erythematous limb Risk factors - Immobilisation - Recent surgery - Obesity - Previous venous thromboembolism - Trauma - Malignancy - Pregnancy - OCP use ```
35
What is the management for DVT?
Confirm diagnosis with ultrasound | Anticoagulation
36
What are the features of gout?
Urate crystal deposition often over MTP joint | Acute and chronic arthritis +/- tophi
37
What is the management of gout?
Diagnosis: urate crystals from aspirated joint/bursa Treatment - Acute - NSAIDs - Colchicine - Glucocorticoids - Chronic: allopurinol > decreases serum uric acid
38
How can you differentiate between gout and cellulitis?
Gout responds to treatment faster than cellulitis If start cellulitis and gout treatment at same time, gout responds in 48 hours Not certain that it's gout, but more likely to be gout
39
What are the features of thrombophlebitis?
Inflammation and thrombus within vein
40
What is the management for thrombophlebitis?
Diagnose clinically/with ultrasound | Treatment: symptomatic +/- compression/anticoagulation
41
What are the features shared by lipodermatosclerosis, venous insufficiency, and varicose eczema?
``` Chronic Absence of fever and heat Circumferential and usually bilateral, compared to cellulitis Limb - Discomfort - Pain - Swelling May see - Oedema - Pigmentation - Venous ulcers - Varicose veins ```
42
What are differential diagnoses for a history of painful, swollen, erythematous limb, where the important clinical features are - Haemodynamic instability - Pain as dominant feature
Necrotising fasciitis Pyomyositis Streptococcal necrotising myositis Clostridial necrotising cellulitis = gas gangrene ALL severe, rapidly progressing, potentially fatal infections
43
What other features in the history, other than the presenting complaint, can help differentiate the cause of an infection involving deeper tissue planes?
``` Recent surgery Crushing/penetrating trauma Chronic skin ulceration Debilitating illness Immunocompromise Elderly Diabetes Lymphoedema ```
44
What is the difference between type I and type II necrotising fasciitis and gas gangrene?
Type I = polymicrobial | Type II = mono-microbial
45
When is type I necrotising fasciitis or gas gangrene more likely?
``` Post surgery Peripheral vascular disease Diabetes Decubitus ulcers = pressure sores Spontaneous mucosal tears of GI/GU tract ```
46
What are the common causative agents of type II necrotising fasciitis or gas gangrene?
``` Strep pyogenes Clostridium spp Vibrio vulnificus Aeromonas hydrophila MRSA ```
47
What are the features of necrotising fasciitis and gas gangrene?
``` Necrosis of - Skin - Subcutaneous tissue - Muscle Prompt surgical review +/- intervention needed if - Skin sloughing - Purple bullae - Marked oedema - Systemic toxicity Surgical exploration can be life-saving ```
48
What are potential markers of deep-seated infections?
``` Severe pain out of proportion with other clinical findings Systemic toxicity - Hypotension - Tachycardia - High fever Gas in soft tissues - Crepitus O/E - Seen on x-ray/CT Clinical deterioration Progressive skin necrosis Bullae Elevated CK > muscle destruction ```
49
What is the management for deep-seated soft tissue infections?
``` Empirical antibiotics - Meropenem - Vancomycin - Clindamycin Surgical debridement ```
50
What are the differential diagnoses for a painful, swollen joint?
``` Septic arthritis Traumatic effusion Haemarthrosis Gout/pseudogout Adjacent osteomyelitis Bursitis/cellulitis ```
51
What are the risk factors for septic arthritis?
``` Local trauma Age >80 Rheumatoid arthritis Prosthetic joint Recent joint surgery Skin infection IV drug use Prior intra-articular steroid injection ```
52
What is the pathogenesis of septic arthritis?
Mostly blood-borne Direct inoculation less common Bacteria invade cartilage > cause micro-absecesses > cartilage destruction if no prompt, appropriate treatment
53
What are the investigations required for septic arthritis?
Prompt joint aspiration - >50 000 WCC Blood cultures in acute cases Synovial biopsy in sub-acute/chronic disease WCC, ESR, and CRP likely to be elevated CT/MRI may be helpful in assessing degree of joint damage
54
What is the treatment for septic arthritis?
Joint washout for acute, purulent arthritis Empiric antibiotics to cover Gram +ve pathogens - Flucloxacillin/cephazolin Don't delay starting treatment Minimum 6 weeks of antibiotics - Minimum 2 weeks IV initially - 4 weeks oral
55
Is osteomyelitis always acute?
No, can be either acute or chronic
56
What is the pathogenesis of osteomyelitis?
``` Contiguous spread from adjacent - Skin - Soft tissue - Joint Haematogenous seeding - Common in children ```
57
What is the treatment for osteomyelitis?
Prolonged antibiotics Make every effort to ID putative organism before starting therapy - Difficult to get microbiological sample
58
What are the features of osteomyelitis associated with prosthetic devices?
Coagulase -ve Staph become more important Foreign body removal needed to achieve cure Complicated management
59
What are the features of osteomyelitis associated with trauma, bites, and penetrating wounds?
Infections from bites and punch wounds commonly polymicrobial Appropriate debridement Consider infected fracture site when osteomyelitis secondary to trauma
60
What are the features of osteomyelitis associated with neuropathy and/or vascular isufficiency?
Common complication in deep foot ulcers, especially in vascular insufficiency and/or diabetic peripheral neuropathy Commonly polymicrobial Osteomyelitis confirmed if surgical probe ID's bone at ulcer base
61
What are the features of osteomyelitis associated with skull base osteomyelitis?
Often associated with ear disease Risk factors - Chronic otitis - Diabetes
62
What is the management of osteomyelitis?
``` Immobilisation Analgesia IV antibiotics directed towards pathogen Prolonged course - Relapse rates high if patients under-treated ```

MD2 Intersession 1 (5 decks)

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