Ch.

21–Sk
ina
ndEy
eIn
fec
ti
ons

I
. 21.
1Anatomya ndNor ma l Microbi
ot aoftheSk ina n dEy es
A.Lay
e r
soft heSk i
n
1. Epi dermis-t heout e r
mos tlaye ro fthes kin,an ditisr el
a ti
v el
yt hin.Thee xte ri
ors urfac eoft hee pide rmis,
c all
edt hes t
ratumc orneum, pr i
ma ri
lyc on si
s t
sofde ads k i
nc el
ls.Thisla ye rofde adc el
lsl i
mi tsdir
e ctc ontact
be twe entheout sidewor l
da ndl i
v ec e l
l
s .Thes tr
a t
umc orn eumi srichink eratin,at ough, fibrouspr ote i
nt hat
isa lsofoun dinha i
ra ndn ail
s.Ke ra t
i
nhe lpsma ket heout ers urfa c
eoft hes ki
nr e l
ati
v elyt ougha ndwa terproof
.
Ita l
sohe lpstok ee pthes urfaceo fthes kindr y ,
whi chr educ esmi crobi
a lgr owt h.Howe ve r,somemi crobe s
a res t
il
labletoliveont hes urfac eo ft hes k i
n, ands omeoft hes ec anbes he dwi thde ads k i
nc el
lsint he
pr oces sofde squa ma t
ion,whi chi st hes he ddi nga n dpe e l
ingofs kintha toc cursa san orma lpr
oc e ssbutt hat
ma ybea ccel
e r
atedwhe ninfec t
io nispr e sen t.
2. De rmiscon tai
nsc on necti
vetissuea n de mbe dde ds t
ruc ture ss ucha sbloodv esse l
s, ne rve s,andmus cl
es .
St ructuresc a
ll
e dha i
rfoll
icl
esa reloc a t
e dwi thinthede rmi s, event houghmuc hoft he irs tructur
ec ons i
stsof
e piderma lt
issue.Thede rmisa l
s oc on t
ainst het woma jort ype sofgl an
dsf oun di nhuma ns kin:
a.s we atglands-t ubulargl andst ha tpr oduc es we a t.Pe r
s pir
a ti
on( swe at)prov ide ss omemoi sturet o
t
hee pide r
mi s,whichc a ni ncrea set hepot enti
a lformi c robi
a lgrowt h. Fort hisr ea son ,mor emi c r
obe s
arefoun dont her egi
on soft hes k i
nt hatpr oduc et hemos ts we a t
, suc ha st hes kinoft heun dera r
ms
andg roi
n .Howe ver,i
na dditi
ont owa te r
,s we ata l
s oc on tai
nss ubs t
a nce stha tin hibitmicrobia lgrowth,
sucha ss alt
s,l
y sozyme ,a nda n t
imic robialpe pti
de s.
b.s ebac eousgl ands-a s s ociatedwi t
hha irfoll
icl
e sa ndpr oduc es e bum, alipid-richs ubstanc e
contai
n i
ngpr otei
n sandmi ne ra
ls. Sebuma lsos e rvest opr ote c
tt hes kina ndr e duc ewa terlos s.
Alt
houghs omeoft hel ipidsa n
df att
ya ci
dsi ns e bumi nhibitmic robial growt h, se bumc on t
a i
ns
compoun dstha tproviden utrit
ionf orc e
rtainmi c robe s.
3. Hy pode r
misc on si
stsoff i
brousa nda dipos ec onne cti
vet issue

B.Nor ma l
Mi crobiot aoft heSk in.Thes k i
ni shomet oawi dev ari
etyofn orma lmi cr
obi
ota,c on sisti
ngofc omme nsal
orga n
ismst hatde r
iven utri
ti
onf r
oms kinc e l
l
sa n dse creti
on ss uc ha ss we ata ndsebum. Then orma lmi crobi
otaof
skintendst oi nhibittran si
ent-mi crobec olon i
za t
i
onbypr oduc i
nga n t
imicrobial s
ubstancesa n dout compe t
ingothe r
microbest h atl
a n dont hes ur f
aceoft hes kin.Thishe lpst opr otec tthes kinfrompa thoge n i
ci nfection.Thea vai
labi
li
ty
ofn ut
rie
n tsa ndmoi st
ur epa rtl
ydi ctateswhi chmi cr
oor ga ni
s mswi l
lthriveinapa r
ti
cularregi onoft hes kin.
1. Re l
ativelymoi sts ki
n, sucha st hatoft hen a res( nos tr
il
s)a ndun de rarms ,
hasamuc hdi ff
e rentmi crobi
ot athan
thed rye rs ki
nont hea rms ,legs ,ha nds, andtopoft hefee t.Somea reasofthes kinha v ehi ghe rde nsi
ti
e sof
se bace ousgl a nds.The ses ebum- r
icha reas,whi c hin c
ludet heba ck, t
hefol
dsa tt hes ideoft hen ose,andt he
ba ckoft hen ec k,harbordi st
inc tmi crobialcommun i
ti
est hata reles sdiver
setha nt hos ef oun do notherpa rts
ofthebody .
a. Dr ya nds eba ce ousmos ta bun dantmi crobe stypic all
yfoun da r
eBe taprote oba cte r
iaan d
Pr opion i
bacteria
b . Moi stCor yn eba cteri
um a n dSt aphy l
oc occ usa remos tc ommonba ct
e r
i
af oun d
2. Vi rusesa ndf un giarea lsof oun do nthes ki
n,wi thMa lasseziabe ingt hemos tcommont ypeoff ungusf ound
aspa r
toft hen orma lmic robiota .Ther olea ndpopul a t
i
on sofv i
ruse sinthemi cr
obi ot a
, knowna sv i
rome s,are
stil
lnotwe llun derstood, a ndt he r
ea r
el i
mitati
on st ot hete chn i
que sus edtoide n
tifyt he m. Howe v er
,
Circov i
ridae ,Pa pil
l
oma vi
r i
da e,a ndPol yoma vi
ridaea ppe artobet hemos tcommonr esiden tsint hehe al
thy
sk i
nv i
rome .
C.I
nfec t
ionsoft heSk in.
1. Anoppor t
un i
sticpa thoge nr es i
din ginthes k i
nmi crobiotaofon ei ndivi
dualma ybet rans mittedt oa nother
i
n div
idua l mor es usc epti
blet oa nin f
ec t
ion.Fore xampl e,me thi
cil
li
n-resist
antStaphy l
oc occ usa ur eus(MRSA)
ca nofte nt akeupr es i
den c eint hen a resofhe alt
hc arewor k ersa ndhos pi
talpati
e nt s;
thoughha rmlesson
i
n tact
,he al
thys ki
n,MRSAc a
nc au sei nf
e ct
ionsi fintroduc edi nt
oot he rpart
soft hebody ,a smi ghtoc cur
dur i
ngs urge r
yorv i
aapos t
-sur gicalincisi
onorwoun d.Thi sison er easonwhyc lea ns urgic al
s i
te sares o
i
mpor t
a n t.
 2. I njuryorda ma get ot hes k i
nc ana ll
owmi cro be stoe n terde epe rtissue s,whe r en utri
e ntsa remor ea bun dant,
an dt hee nviron me n tismor ec onduc ivet oba cteri
al growt h.Mi crobe sma yinf
e cts t
ruc ture sinthede rmi s,
suc ha sha i
rfol l
i
clesa n dgl ands ,caus i
n gal oca l
izedin fection ,orthe yma yre acht hebl oods t
rea m, whic hc an
lea dtoas yste mici n f
e ction.
3. I ns omec ases ,i
nfe ctiousmi crobe sc anc a us eav arietyofr a she sorl es i
on stha tdif
fe rint heirphy sical
cha ra cte r
isti
cs .The s er as hesc anbet her e sultofinflamma tionr eac ti
on sordi rectre spon s estot ox i
n s
pr oduc e dbyt hemi c robe s.
D.An atomya ndMi crobiot aoft heEy e
1. Then as olacri
ma ldra i
n ages ystem, whi chs e rvesa sac on duitfort hef l
ui doft hee y
e ,ca l
ledt ears.Te arsflow
fromt hee xtern ale yet ot hen a salca vi
tybyt hel acri
ma l appa ra t
us ,whic hisc ompos edoft hes tructure s
inv ol
ve di ntea rpr oduc ti
on .
Thel ac r
ima lgla nd, abovet hee ye ,secre t
e st earstok eept hee yemoi st.The re
aret wos ma llope n i
n gs ,on eont hein si
dee dgeoft heuppe re yel
ida ndon eont hei ns i
dee dgeoft hel owe r
ey eli
d, ne arthen os e .Ea c hoft heseope n i
n gsi sc al
ledal a crima lpun ctum. Toge t
he r,the sel acri
ma lpun c t
a
col l
ec tte ar
sf romt hee yet hata rethe nc on vey edthr oughl a cri
ma lduc tst oar es ervoirfort earsc all
e dthe
lac r
ima lsac ,alsok n owna stheda c r
oc ys tort earsa c.
2. F romt hes ac, tearfluidf lowsv i
aan a solac ri
ma lduc tt othei nn e
rn os e. Eac hn asolacrima l ductisloc ated
un de rne athth es kina n dpa sse sthrought hebon esoft hef a cein t
ot hen os e.Che mi calsint e a
rs ,suc ha s
de fen si
n s,lactoferrin ,an dl y
soz yme , helpt opr eventc ol oniza ti
onbypa thoge ns .I
na ddi t
ion ,mu c i
nsf acil
it
ate
remov alofmi crobe sf romt hes urf
a ceoft hee ye .
3. Thes urface soft hee ye ba l
landi nnere ye l
ida remuc ousme mbr ane sc all
edc on junc ti
va .Then orma l
con jun ctivalmi crobi otaha sn otbe enwe l
l cha racteri
z e dbutdoe se xi
st.
4. On es ma l
ls t
udy( pa rtoft heOc ul
a rMi crobi omepr oj ec t
)f oun dt we l
v ege neratha twe r
ec on si
sten t
lypr esent
int hec on j
unc tiva.The semi crobesa rethoughtt ohe l
pde fen dtheme mbr anesa ga i
n stpa thoge ns .Us eof
con tac tlens esc anc aus ec ha ngesi nthen orma lmic r
obi ot aoft hec onjun cti
vabyi ntroduc inga nothe rs urf
ace
intot hen atura lana tomyoft hee ye.
E.I
n f
ect i
onsoft heEy e.Thec on jun cti
vaisaf r
e que nts i
teofi nfec ti
onoft hee ye ;l
ikeot he rmuc ousme mbr a nes, i
tisa l
so
ac ommonpor t
a lofe n tr
yf orpa thoge n s.I
nfl
a mma ti
onoft hec on j
un cti
vai sc al
ledc onjun cti
viti
s, al
thou ghi tis
common l
yk nowna spi nke yebe c auseoft hepi nka ppe a rancei nt hee ye. I
nfec t
ion sofde epe rs t
ruc tures,be nea t
ht he
corne a,
a rele ssc ommon .Con j
un c t
iv
iti
soc cursinmul ti
plefor ms .I
tma ybea cut eorc hr on i
c.Ac ut epu rulent
con j
un c
tiviti
sisa ssoc iatedwi thpusf or ma ti
on ,whi l
ea cutehe mor rha gicc onjun cti
v i
ti
sisa s soc i
atedwi t
hbl ee dingin
thec onjun cti
va .Thet ermbl e pha ri
ti
sre fer
st oa nin fl
amma t
ionoft hee yel
ids ,whi l
ek era t
it
isr eferst oa ninflamma ti
on
ofthec orn ea ;ke ratoc onjun c t
iv i
ti
si sani nfl
amma tionofbot ht hec orn eaa ndt hec on j
un cti
va, andda cryoc ysti
ti
si san
i
n f
l
a mma ti
onoft hel acrima ls act ha tca no ft
e noc c urwhe nan a solac ri
ma lduc tisbl ock ed.

I
I
. 21.2Bact
e r
ia
lIn
fec t
i
on soft heSk i
na n dEy es .
Gr am- po s
it
iveSt aphylococ cuss pp. andSt re
ptococ cuss pp. are
r
espons
ibl
eforma nyoft hemos tc ommons kinin fect
ions.Howe ve r,
ma nysk i
nc onditi
onsa r
en ots t
ri
ctlya s
s oc i
ate dwith
asi
ngl
epathogen.Oppor tun i
s t
icpa thoge nsofma nyty pesma yinf
e ctski
nwoun ds ,andindivi
dualc a
s eswi t
hi de n ti
cal
sy
mptomsma yre s
ultfromdi fferentpa thoge nsorc ombi na
tionsofpa t
hoge n s.
A.Staphyl
ococcal I
nf
e ctionsoft heSk i
n
1. Background
a. St aphy loc occuss peciesa r
ec ommon l
yf oundont hes k i
n,wi hS.
t e
pidermidisan dS. homi nisbe i
ng
prev ale
n tinthen orma lmi crobiota.S.aureusi salsoc ommon l
yf oundinthen a salpa ss
a ge sa n
don
hea l
thys kin,
butpa thoge ni
cs t
rainsareof te
nt hec aus eofabr oadrangeofi nfecti
on softhes ki
na nd
othe rbodys y st
e ms .
b. S. a ureusi squi tec ontagious .I
tiss pr
ea de asi
lythroughs kin-to-ski
nc onta
c t
,a n
dbe caus ema ny
peopl ea rec hron i
cn asa lcarrier
s( asympt oma ti
cindivi
dua l
swhoc ar
ryS. aureusint hei
rn a r
e s )
,the
bac teri
ac a ne asil
ybet ran sferredf r
omt hen os etotheha ndsa n
dthe ntofomi t
e sorot he rin di
vi
dua l
s.
c. Whe nas taphy l
oc occalinfec ti
onde vel
ops ,choiceofme dica t
i
oni simportant.Asdi scuss eda bov e
,
ma n ys t
a phy l
oc occi(sucha sMRSA)a rer esi
stanttos omeorma n
ya nti
bi
otics.Thus ,an t
ibiotic
sen si
tivi
tyi sme a suredt oide nti
fythemos tsuitablean t
ibioti
c .
Howe ver,ev
e nbe f
or erece i
v i
n gthe
resultsofs ens i
ti
vit
ya nalysi
s ,sus pectedS. aureusi n
fe cti
onsa reoftenini
ti
all
ytreatedwi thdr ugs
knownt obee ff
e cti
vea ga i
ns tMRSA, sucha st r
ime t
hopr im- sulfamethoxazole(TMP/ SMZ) ,
cl
inda my c i
n ,
at e t
racycl
ine( dox ycycli
neormi n ocycli
ne )
,orlin ezoli
d.
 d. Thepa thoge n i
c i
t
yofs taphy loc occalinf
ecti
onsisoftene nhancedbyc har
acteri
st
icc hemi cal
s
secret
edbys omes trai
ns. Sta phyl
o coccalvi
rul
encef actor
sincl
udehe molysi
nscall
e ds taphylol
ysins
,
whicha rec ytotox i
cf orma nyt ypesofc el
l
s,i
n cl
udi
n gs ki
ncell
sa n
dwhi t
ebloodc el
ls.Virule
nts t
rain
s
ofS.aure usa rea l
s ocoa gula se -
po s
iti
ve,mea ni
ngthe yproducec oagulase,
apl a
sma -cl
otti
ngpr otei
n
thati
sinvolve di na bs c
es sf orma ti
on .Theyma ya l
sopr oduceleukocidin
s,whichkil
l whitebloodc el
ls
andc anc ontributet othepr oduc t
ionofpusa ndProteinA,whichi n
hibit
spha gocytos i
sbybi ndi
n gto
thecons t
a ntre gionofa n ti
bodi e s.
Somev ir
ul
e ntst
rainsofS. a
ureusa l
soproduceot he rtoxi
ns ,
such
astoxi
cs hoc ks yn dromet oxin -
1.
e. Toc onfi
rmt hec a usa t
i
vea ge ntofas uspect
e dstaphylococcal
s k
ininfecti
on,sample sfromt he
woun da r
ec ultured:
Me
dia S.a ure us S. epi Str
eptoc occus

Gr
amSt
ai
n + + +

Bl
ooda
gar Gr
apecl
ust
ers
,opa
que Gr
apecl
ust
ers
,opa
que Chai
ns,
whi
te
-cr
eam whi
te
-cr
eam Αβγhemol
ysi
s

Ca
tal
aset
est + + -

Coa
gul
aset
est CoPS CoPN

Ma
nit
ols
alta
gar + -

2. Supe r
fici
alStaphy loc occ alI
nfections. S.a ureusi softena ssoc i
a tedwi t
hpy ode rma ,skini nfec t
ion stha ta r
e
purul en t
.Pusf orma ti
onoc cursbe c aus ema nys trai
nsofS. aur euspr oduc eleukoc i
dins, whi chk i
l
l whi teblood
ce l
l
s. The sepur ule n ts ki
ninfe c
ti
on sma yin i
ti
all
yma ni
fe stasf olliculi
tisbutc anlea dtof ur unc les( boils)or
de epe rabsc ess esc alledc arbun cl
e s.Pr ope rhygie neisimpor ta ntt opr e venttheset ype sofs k i
ni nfe cti
on sor
topr ev entthepr ogr es si
onofe xisti
ngi nfe ct
ions.
3. Staphy l
ococ cal sc a l
de ds ki
ns yndrome( SSSS)i sa nothe rs upe rfi
c i
alinfe ct
ionc ause dbyS. aur eust ha ti
s
mos tc ommon lys ee niny oun gc hil
dre n,e spec i
all
yinfan t
s. Ba cteriale xotox i
nsf i
r
s tproduc ee r
y thema
(r
e dn essoft hes k i
n )a ndthe ns everepe e l
ingoft hes k i
n,a smi ghtoc cura f
tersca l
ding. SSSSi sdia gn os edby
ex a
mi n i
ngc ha r
a c te r
isti
csoft hes ki
n( whi chma yr ubof fe as i
ly),us i
n gbl oodt eststoc he c kf ore leva tedwhi te
bloodc ell
coun ts ,c ulturi
ng,a ndot he rme thods .I
n t
rave nousa n t
ibioti
c sa n dfl
uidthe rapya reus eda s
tr
e atme nt
.
4. I
mpe tigo
a .I mpe t
igoc aus esthef orma t
ionofv e si
cles,pus tul
e s, an dpos si
bl ybull
a e,oft
e na roun dthen os ea nd
mout h. Bul laea relarge,flui
d- fi
ll
edbl iste
r sthatme a sur ea tleas t5mmi ndi ame t
e r.I
mpe t
igoc anbe
di
agn os e da se i
thern onbul l
ousorbul l
ous .I
nn onbul l
ousi mpe t
igo, vesicl
esa ndpus tulesr upt ur ea n
d
becomee n crusteds ores .Ty picall
y,thec rustisy e l
lowi sh, oftenwi t
he xuda t
edr ainingf romt heba se
ofthel es ion .I
nbul l
ousi mpe ti
go, thebul laefil
la ndr upt ure ,resultinginlarger,dr aini
n g,e nc r
us te d
l
esions .
b . Es pe ci
a l
lyc ommoni nc hil
dre n ,
impe t
igoi spa rt
icularlyc on ce r
n i
n gbe caus eitishi ghlyc onta gious .
I
mpe t
igoc anbec aus edbyS. a
ur eusa lon e
,bySt rept oc occ uspy ogen esa l
on e,orbyc oin f
e ctionofS.
aureusa n dS. pyoge nes .
c .I mpe t
igoi sof tendia gnos edt hroughobs ervati
onofi tsc hara cterist
icappe aran ce ,althoughc ulture
ands us c e pti
bil
it
yt es t
i
ngma ya lsobeus ed.Topi ca loror alantibioti
ctreatme n tist ypica l
lye ffec t
ivein
tr
ea t
ingmos tc asesofi mpe ti
go. Howe ve r
,ca sesc a us edbyS. pyoge nesc anl ea dtos e r
ious
seque l
a e( pathologicalc onditionsr esulti
n gfromi n fection ,disea se,inj
ury,thera py ,orot h ertra uma )
sucha sa cutegl ome r
ulon ephr i
ti
s( AGN) ,whichi ss e verei nfl
amma ti
onint hek i
dn ey s.
5. Nos oc omi alS. epi der midisIn f
ec t
ions .S. epide r
mi di
si sus ua l
lyaha rmle ssr esi
de ntoft hen orma lsk i
n
mi c
robi ota.Howe v e r,healt
h- car
ewor kersc aninadv ertentl
yt ran sferS. epidermidistome dic alde vice st hat
arein se r
tedintot hebody ,sucha sc athe t
e rs,pros t
he ses,a ndi ndwe ll
i
n gme dicalde vi
c es .
On c eitha s
 bypa ss edthes kinba rri
e r,S. e pide rmi disc anc aus ein fec ti
on si nsidet hebodyt ha tc anbedi ff
iculttot re at.
Li
k eS. a
ur eus ,S. epide rmi disi sr esista nttoma n ya ntibiotics ,an dl oc ali
z edi nfec ti
on sc anbe comes ys temi cif
nottre atedqui ck l
y .Tor educ et her iskofn os oc omi a l(hos pital-
a cqui re d)S. epide rmi dis ,health-carewor ke rs
mus tf ol
lows tri
ctpr oc e dur e sf orha n dli
n ga nds teril
izi
n gme dical de vice sbe for ea nddur ings urgic al
proce dur es.
B.St
rept
ococ calInfec t
ion soft heSk in
1. Bac kgroun d:
a. St reptoc oc cusa regr a m- pos iti
vec oc ci wi t
hami cros copi cmor phol ogyt ha tre sembl esc ha i
n so f
bacte ri
a.Col on i
e sa ret ypic all
ys ma l
l(1–2mmi ndi ame te r
),t r
a n sl
uc e nt,en ti
ree dge ,withas l
ightly
rai
se de l
e va ti
ont ha tc a nbee ithe rn on he mol ytic,a l
pha -he mol y ti
c ,orbe ta-he mol yt
icwh engr ownon
bl
ooda ga r.Addi t
ion all
y ,th eya refa culta ti
v ea n a erobe stha ta rec atal
a se-n ega t
ive.
b. Themos tc lini
c a l
l
yi mpor tan ts tr
e ptoc oc c al spe ci
e si nhuma nsi sS. py oge n es ,alsok nowna sgr oup
As treptoc oc cus( GAS) . S. py oge ne spr oduc e sav a rietyofe xtrace l
lulare n zy me s
,inc l
udin g
str
e ptolysinsOa n dS, hy a l
ur on i
da s e,a nds tre ptok i
n a se. The s ee nzy me sc ana idint ransmi ss iona nd
contributet ot hei nflamma toryr es pon se .S. py oge ne sa lsopr oduc esac a ps ulea ndMpr ot ein, a
str
e ptococ c a lce l
l wa l
l pr ote i
n .The s ev irule nc ef ac torshe lpt heba cte r
iat oa voidpha goc ytos iswhi l
e
provok i
n gas ubs ta nti
a l i
mmun er e spon set ha tc on tri
but e stos ympt omsa ss ociatedwi th
str
e ptococ c a li
n fec t
ion s .
2. Ce l
luli
tis,Erys i
pe l
a s, an dEr ythe maNos odum.
a. Commons trept oc oc c al con diti
on soft hes kini nc l
udec e l
luli
tis, erysipe l
a s,a nde ryt
he man odos um.
i. Ani nfec ti
ont ha tde ve l
opsi nt hede rmi sorhy pode rmi sc anc aus ec e l
lul
iti
s ,whic hpr esen t
s
a sar e dde ne da reaoft hes k i
nt ha tiswa rmt ot het ouc ha ndpa i
n f
ul. Thec ausa ti
vea ge ntis
of te nS. py oge n e s,whi chma ybr ea cht hee pide rmi st hr oughac utora brasion,a l
though
c elluli
tisma ya ls obec aus e dbys t
a phy l
oc oc ci.
i. S.
i py oge ne sc ana lsoc a us ee rys i
pe la s,ac on diti
ont ha tpr e sen tsa sal arge ,i
nte nse l
y
in f
la me dpa tchofs ki
ni nv olvingt hede rmis( oftenont hel e gsorf ace ).The sei nf
e ction sc a n
bes uppur ati
v e ,whi c hr es ul
t sinabul l
ousf or mofe rys i
pe las.
ii
i. St re ptoc oc c al an dot he rpa thoge n sma ya l
soc a us eac on di
tionc allede rythe man odos um,
c ha rac terize dbyi nflamma ti
oni nt hes ubc ut ane ousf a tc ell
soft hehy pode rmi s.I
ts ome t
ime s
r esul t
sf r
omas tre ptoc oc ca li
n fec ti
on , thoughot he rpa thoge nsc a na l
soc a uset hec on diti
on.
Itisn ots uppur a ti
v e,butl e adst or e dn odul e sont hes kin,mos tf reque ntl
yont hes hin s.
b. St reptoc oc ca linfe cti
on sa rebe sttre ate dt hroughi de n t
ifi
c ationoft hes pe ci
ficpa t
hoge nfollowe dby
tr
ea tme ntba se dupont ha tpa rti
c ularpa thoge n ’ss us ce ptibil
ityt odi fferen ta ntibioti
cs .Ma ny
i
mmun ologic al tes t
s ,i
n c lud i
n ga ggl utina t
ionr ea c t
ion sa n dEL I
SAs , canbeus e dt ode tects tre ptoc occi
.
Pen i
c i
ll
i
ni sc ommon l
ypr es cri
be df ort r
e a tme ntofc e ll
uli
tisa n de rysipe l
a sbe c auser e si
sta ncei sn ot
wide spre adi ns tr
e ptoc oc ci atthist i
me .Inmos tpa tients ,e rythe man odos umi ss elf-l
i
mi t
in ga n disn ot
tr
ea tedwi t
ha n ti
mi crobi a ldr ugs .Re comme n de dt re atme ntsma yinc l
uden on ste r
oida lanti-
i
nfl
a mma tor ydr ugs( NSAI Ds ),cool we tc ompr e ss es ,elev ati
on ,a ndbe dr e st.
3. Ne crotizi
n gF a sci
iti
s .
a. St reptoc oc ca linfe cti
on st ha ts tartint hes ki
nc a ns ome ti
me ss pr eade l
s ewhe r
e ,resulti
ngi nar arebut
pote nti
all
yl i
fe -thre aten ingc on diti
onc al
le dn ec rotizingf a sc i
iti
s ,s ome ti
me sr efe rredt oa s“ fl
es h-e ati
ng”
bacte ri
als yn drome .S. py oge n esison eofs ev era lspe c i
e st ha tc anc aus et hisr a r
ebutpot e ntial
ly-
fat
al con dit
ion ; othe rsi n cl
u deKl ebs i
e l
l
a ,Cl os tridium, Es che r
ichi ac oli,S. aur eus ,andAe r
omon as
hydrophi la.
b. Ne croti
zin gf as cii
tisoc cur swhe nt hef as c i
a ,at hinl ay erofc on ne cti
vet iss uebe twe e nthes kina nd
mus c l
e,be c ome sin fec ted. Se verei nva s i
v en e c r
ot i
z i
n gf as ci
iti
sduet oSt re ptoc oc cuspy oge n e s
occur swhe nv irule ncef ac torst ha ta rer e spon s i
blef ora dhe s iona ndi nva sionov er
c omehos t
defen ses .S. py oge nesi nva sinsa llowba c teri
a lc ell
st oa dhe ret ot i
s sue sa nde stablishinfe cti
on .
Bac teri
al prot ea se sun i
qu et oS. py oge n e sa ggr es sivelyin fi
ltratea n dde stroyhos ttissue s,ina c t
ivate
compl eme n t,a ndpr ev e ntn e utrophi lmi gr ationt ot hes it
eofi nfe ct
ion .Thei nfe cti
ona ndr es ulti
n g
ti
ssuede a thc ans pre adv e ryr apidly, asl a rgea re asofs kinbe c omede ta che da nddi e.Tr eatme n t
gene ral
lyr equi re sde br i
de me n t(sur gica lre mov alofde a dori n f
e ctedt iss ue )ora mput ationof
 infec tedl imbst os topt hes prea do fthei nfe cti
on ; sur gical t
re atme ntiss uppl e me ntedwi th
intrav en ousa nti
bi oticsa ndot hert herapi es .
c. Ne c rotiz i
n gf asc i
itisdoe sn ota lwa ysor igin atef romas ki
ni nfec ti
on ;i
ns omec a se s, t
he reisn ok n own
por ta lofe ntry .
Somes tud iesha ves ugge s tedt hate xpe ri
e ncin gabl un tfor cet ra umac a nin creas e
ther iskofde v el
opi ngs tr
e ptoc oc calne c rotizingf a sc i
iti
s.
C.Ps
eudomon asI n f
e c ti
on soft heSk in
1. Pse udomon asa e rugi nos a ,agr am- n ega t
ive,ox ida s e-pos i
ti
v e ,aerobi cba cil
l
ust ha ti sc ommo nlyf oun din
wa t
e ra n ds oi
l a swe llasonhuma ns kin.P. aerugi n os ai sac ommonc aus eofoppor t
un i
s ti
cin fectionsof
wo un dsa n dbur n s.Itc ana lsoc aus ehott u bra s h, ac on ditionc ha racte ri
z edbyf olli
culiti
st hatf reque ntl
y
aff
li
c t
sus e rsofpool sa n dhott ubs .P. aeruginos ai sa lsot hec aus eofot i
ti
se xte rna( s wimme r’
se ar)
,a n
i
n f
ec ti
onoft hee arc a nal tha tc au se sitching, redn es s,a nddi scomf ort,a ndc anpr ogr e sst of e ver, pain,a nd
swe ll
ing.
2. Wo u ndsi n fe ctedwi thP. a er
ugi n os aha v eadi s ti
n c t
iveodorr e sembl inggr apes odaorf re shc ornt orti
ll
a s.
Thisodori sc aus e dbyt he2- a mi noa ce t
ophe n on et ha tisus e dbyP. a erugin os ai nquor ums e n si
n ga nd
contribut est oi t
spa thoge nicity.Woun dsi nfecte dwi thc ertains t
ra i
n sofP. aerugi n os aa lsopr oduc eabl ue-
gree npusduet ot hepi gme n tspy oc yan i
na ndpy ov erdin ,whi c ha lsoc on tr
i
but et oi t
sv irulenc e.Py ocya nin
andpy ov e rdina res ide rophor e st ha the pP.
l ae rugi nos as urv i
v einl ow- irone nv i
ron me n tsbye nha n ci
ngi ron
uptak e. P. ae rugin os aa ls opr odu c ess e veralot he rv irulen cef a ctors ,i
n cludingphos phol ipa seC( ahe mol ysi
n
capa bleofbr e ak i
n gdownr edbl o o dc ell
s), exoe n zy meS( i
n volve dina dhe r
e nc et oe pithe li
alc ell
s ),and
exotox inA( ca pa bleofc a usin gtis suen ecrosis ).Ot he rv irulen cef ac torsi ncludeas li
met ha ta l
lowst he
bacte ri
umt oa voi dbe i
n gpha goc y ti
z ed,fi
mbr i
a ef ora dhe renc e,a ndpr ote as est ha tc a us et i
ss u eda ma ge P.
.
aerugi nos ac anbede t
e cte dt hr ought heus eofc e tr
imi dea ga r,whi c hiss elec t
ivef orPs e udomon ass pe ci
es.
3. Pse udomon ass pp. tendt ober es i
s tanttomos ta ntibioti
c s. The yof t
e npr oduc eβ- l
ac tama s
e s, ma yha ve
mut ation sa ff
e ctingpor in s( sma l
l ce l
lwa llcha nn e l
s )tha ta ffec ta nti
biot i
cupt a ke, an dma ypumps ome
anti
biot i
c sou toft hec e l
l,c on tr
ibut i
n gt othisr e sista nc e.Pol ymy xinBa n dge ntami c i
na ree ff
e ctive, asa re
somef l
uor oq ui nolon e s.Ot i
ti
se xtern aist ypicallyt rea t
e dwi the ardr opsc onta i
nin ga c e t
ica ci
d, an ti
ba cterial
s,
and/ ors te roidst or e duc ei nflamma ti
on;e ardr opsma ya lsoi n cl
udea ntif
un ga lsbe c aus ef un gi can
some ti
me sc a us eorc on tri
but et oot i
ti
se xterna .Woun din f
e c ti
on sc a us edbyPs e udomon ass pp. ma ybe
tre
a tedwi tht opi c ala nti
bi ofil
ma ge ntst hatdi sruptt hef orma ti
onofbi ofil
ms .
D.Acne
1. Ac nea ff
li
c tsn ear l
y80%oft e en age rsa ndy oun ga dul ts,buti tc anbef oun di ni ndiv i
dua l
sofa l
l age s .
Highe r
i
n ci
de n cea mon ga dol es ce ntsi sduet ohor mon a lcha n ge st ha tc anr e sultinov e rproduc tionofs ebum.
2. Ac neoc c ur swhe nha i
rf ol l
icl
e sb ec omec l
ogge dbys he ds k i
nc ell
sa nds ebum, ca us i
n gn on-in f
lamma t
or y
l
e si
on sc all
e dc ome don es .Come don esc anta k et hef ormofwhi te he ada ndbl a ck he adpi mpl e s.Whi tehe a
ds
arec ov e r
e dbys kin, whe reasbl ac khe adpi mpl e sa ren ot;thebl ac kc oloroc cur swhe nl ipidsi nt hec l
ogge d
fol
li
clebe c omee xpos edt ot hea i
ra ndox idize.
3. Oftenc ome don esl ea dt oi nfe ctonbyPr
i opion iba c t
e ri
uma c n es,agr am- pos i
tive ,n on- spor e-
for mi ng,
aerotole ran ta n ae robicba cil
l
usf o un dons k i
nt ha tc on s ume sc ompon e ntsofs e bum. P. ac ness ec retes
enzy me st ha tda ma get heha irfol l
i
c l
e ,caus i
ngi nflamma toryl e si
on st ha tma yinc ludepa pul es, pus tules,
nodul es ,orps e udoc y sts, depe nd i
n gont he i
rs izea n ds ever i
ty .
4. The rea remul tiplewa yst ogr a dea cn es eve r
ity, butt hr eel e ve l
sa reus ua ll
yc ons ide redba sedont he
numbe rofc ome don e s,then umbe rofi nfl
a mma toryl es i
on s ,a ndt het y pe sofl e sion s.
a . Mi lda cn ei st r
e ate dwi tht opic alage ntst ha tma yi ncludes a l
icy l
ica cid( whi chhe lpst or emov eol d
s kinc e ll
s )orr e ti
n oids( whi chha vemul tipleme cha nisms ,i
n cludin gt her educ t
ionofi n fl
amma ti
o n).
b. Mode r atea cnema ybet r ea t
edwi tha n ti
biot i
c s(e rythr omy cin,c l
inda my cin),a cn ec r
e ams( e.
g.,
be n zoy lpe roxide ),an dhor mon es .
c . Se ver ea c nema yr equi ret reatme ntus in gs tron gme di
c ati
on ss uc ha si s otretinoi n(ar eti
n oidth at
re duc esoi lbuildup, a mon got he re ff
ec ts ,butt ha ta l
s oha ss e ri
ouss idee f
fe ctss ucha s
phot os e ns i
tivi
ty).
d. Ot he rtre a t
me nts ,suc ha sphot ot hera pya n dl ase rthe ra pyt ok i
llba cteriaa ndpos si
blyr educ eoi l
pr od uc tion ,a r
ea lsos ome time sus ed.
E.Ant
hrax
.
 1. Thez oon oticdi s eas ea n t
hr axi sc aus e dbyBa ci
ll
usa n t
hr a ci
s,agr a m- pos i
tive ,en dos por e-formi ng,
fac ultativea na e r
obe .An thra xma i
n l
ya ffec t
sa n i
ma l
ss uc ha ss he e p,goa t
s, ca t
tl
e ,a ndde e r
,butc a nbef ound
inhuma nsa swe ll
.Itisof tent rans mi tt
e dt ohuma nst hroughc on t
a ctwi thin fec t
e da n i
ma l
sora n i
ma l
pr oduc ts, suc ha swool orhi de s.Howe v er, ex pos uret oB. anthr ac i
sc a noc c urbyot he rme an s ,a st he
en dos por esa rewi de spr eadi ns oil
sa n dc ans urv i
vef orl on gpe riodsoft i
me ,some t
ime sf orh u ndr e dsof
ye ars .
2. Thev a stma jor it
yofa nthra xc ases( 95–99 %)oc curwhe na nthra xe ndos por e se ntert hebodyt hr ough
abr as i
on soft hes kin .Thisf ormoft hedi se as ei sc alledc utane ousa nthrax. I
ti sc ha r
a cte r
izedbyt he
forma tionofan odul eont hes kin;thec e ll
swi thint hen odul edi e ,formi ngabl acke scha r, ama s sofde ad
sk i
nt is sue .Thel oca li
zedi n fecti
onc ane v en tua l
lyle adt oba c t
e remi aa nds e pticemi a .I
fun tr
ea te d, cut an eous
an thra xc a nc aus ede athin20%o fpa ti
e nts. On cei nthes kintiss ue s,B. anthr ac i
se ndos por e sge rmi natea nd
pr oduc eac aps ule,whi c hpr e ventst heba c teriafrombe i
n gpha goc yti
z ed, an dt wobi nar ye xo tox inst ha t
ca us ee de maa ndt i
s sueda ma ge. Thef irstoft het woe x otoxinsc on sistsofac ombi na ti
onofpr ote ctive
an ti
ge n( PA)a n da ne nzyma ti
cl etha lfac tor( L F),formi n gl ethal tox i
n( Le TX) .Thes econ dc on sis tsof
pr otec ti
v ea n tige n( PA)a n da ne de maf ac tor( EF ),formi n ge de mat oxin( EdTX) .
3. Le ssc ommon ly,a nthra xinfe ct
ionsc a nbei n it
iate dt hroughot he rpor t
a lsofe ntrys uc ha sthedi ge s t
ivet ract
(ga stroin testin al anthr ax)orr espirator yt rac t(pul mon arya nthra xori nha l
a t
i
ona nthr ax).Ty picall
y , ca sesof
no nc ut ane ousa n t
hr axa remor edi ff
icul ttot re att ha nthec utan eousf or m. Themor tal
ityr atef or
ga stroi ntes t
ina l anthr axc a nbeu pt o40%, e v enwi tht r
e at me nt.Inha l
ati
ona n thrax ,whi choc cu rswhe n
an thra xs por e sa rei nha l
ed, i
nit
ial
lyc a us esi n fl
ue nz a-li
kes y mpt oms ,butmor t
a l
it
yr a t
e sa r
ea ppr ox ima tely
45 %i nt rea t
e di n divi
dua l
sa nd85 %i nt hos en ott r
e ated. Ar elati
v elyn ewf ormoft hedi se ase, i
n je ction
an thra x,ha sbe e nr epor tedi nEur opei ni n trav enousdr ugus ers; i
toc curswhe ndr ugsa rec o nta mi n ate dwi t
h
B. an thr ac i
s.Pa tientswi t
hi n j
ec ti
ona nthr axs hows ign sa n ds ympt omsofs e ve r
es ofttiss uei nfe c t
iont ha t
differc l
ini
c all
yf romc utane ousa nthr ax. Thisof tende l
ay sdi agn os isa ndt r
e atme nta ndl e adst oahi gh
mor talit
yr ate.
4. B. an thr ac i
sc olon i
e sonbl ooda garha v ear ought ex t
ur ea nds e rra t
e de dge st ha te ve ntua l
lyfor ma n
un dul atingba n d. Br oa ds pe ctruma nti
bi oticss uc ha spe n ici
ll
in,e rythromy cin, andt e tr
a cy cl
inea reof ten
effe ctivet rea tme n t
s .The rei sav ac cinea va i
lablef orB. a nthrac is,butc ur r
e ntlyitison l
ya dmi nis tere dt oa t
ri
s ki ndividua ls .
F
. Ba
c t
eri
alCon jun c ti
vit
is
1. Ba cte rialc on jun c ti
viti
s( pink ey e)isac on dit
ionc ha ra cterize dbyi nflamma ti
onoft hec on jun cti
v a, ofte n
ac compa n i
e dbyadi s cha r
geofs ti
c kyf luid( de s cri
be da sa cutepur ulentc on jun cti
viti
s).Con jun c ti
v i
tisc a n
affec ton ee y eorbot h, an di tus uall
ydoe sn ota f
fe ctv i
s i
onpe r
ma ne ntl
y. Bac terialcon jun ctivi
ti
si smos t
common l
yc aus edbyHa emophi l
usi nflue nz ae ,butc a na lsobec a us edbyot he rs pe ci
e ss uc ha sMor axe l
la
ca tarrha l
is, S.pn e umon iae, andS. aur eus .Thec aus ativea ge ntma ybei dentifi
e dus i
n gba cterial cultur es ,
Gra ms tai
n ,a nddi agn os ti
cbi oc he mic al,a nti
ge nic,orn uc l
e i
ca ci
dpr of i
let estsoft hei sola tedpa thoge n.
Ba cte ri
a lc on j
un ctivi
tisisv e ryc ontagi ous ,be i
n gt ran smi ttedv i
as e c reti
on sfromi n fecte di ndivi
dua l
s, buti tis
alsos elf-l
imi ti
n g. Ba cte ri
alc on j
un cti
v i
tisus ua ll
yr es olve sinaf ewda ys,butt opi c alan t
ibioticsa res ome time s
pre sc ri
be d. Be c a us et hisc on dit
ioniss oc on ta gious ,me dic alatte nti
oni sr ecomme nde dwhe ne v eriti s
sus pe c ted. I
n div i
dua lswhous ec onta ctl en se ss houl ddi s c onti
n uet he i
rus ewhe nc on j
un c t
ivi
tisi ss us pe cted.
Ce r
ta i
ns ympt oms ,s ucha sbl urredv i
s i
on , ey epa i
n ,a ndl i
ghts en siti
v i
ty,c anbea ss ociate dwi ths e r
ious
con dition sa n dr equir eme dic alatten t
ion .
2. Ne wbor nswhos emot he rsha vec erta i
ns e xua ll
yt ran smi ttedi nfec ti
on sa r
ea tr i
skofc on tractingopht ha lmia
ne on ator umori n cl
us i
onc on j
un cti
v i
tis, whi c ha r
et wof or msofn eon at
a lcon jun ctivit
isc on tracte dt hrough
expos ur et opa thoge nsdur i
n gpa ss aget hr ought hebi rthc an al
. Gon ococ cal opht ha lmian eon ator umi s
ca us edbyNe i
s s eri
agon orrhoe a e,theba cte ri
umt ha tca us est heSTDgon orrhe a .I
n cl
us ion( c hlamy di al)
con jun c t
iviti
si sc aus e dbyChl amy di at rac homa ti
s, t
hea n a erobic ,obl i
ga te,i
n trace l
lularpa rasi
tet ha tc a us es
theSTDc hla my dia.Mos thos pital
sa rer e quir edbyl a wt opr ov i
det hispr even tati
vet r
e atme nttoa l
lin fants ,
be ca us ec on j
un ctivi
tisc aus e dbyN. gon orrhoe ae ,C. trac homa tis,orot he rba c t
e r
iaa c quire ddur ingav a ginal
de l
ive ryc a nha v es e ri
ousc ompl icati
on s .Ifun t
re ated, thei n fecti
onc ans pr eadt ot hec or ne a,re sul ti
n gin
ulce rationorpe rfora ti
ont ha tc anc a us ev i
s i
onl ossore ve npe rma ne ntbl i
ndn e ss.Ass uc h,ne o na tal
con jun c t
iviti
si st re ateda ggr essivelywi t
hor a lori ntra ven ousa ntibiot i
cst os topt hes pre adoft h ei nfe ction .
 Ca u sati
vea ge n tsofi ncl
us i
onc onjun ct
i
v i
ti
sma ybei de n t
i
fi
e dus ingba ct
eri
a lculture s,Gr ams tain,and
diagn osti
cbi oc he mic al
,an t
igeni
c,orn uc l
ei
ca c i
dpr ofil
et ests.
G.Tr a c homa ,orgran ularc on j
un ct
ivit
is,i
sac ommonc a useofpr e v
e ntabl
ebl i
n dn esstha tisr arei ntheUn it
edSt ates
butwi des preadinde ve lopingc oun tr
ies,
e special
lyinAf ric
aa ndAs i
a.Thec on di
ti
oni sc a us edbyt hes a mes pecies
tha tc ause sn eona t
a li
n clusionc onjuncti
vi
tisininfant
s ,Chla my diatrachoma ti
s .C.trachoma ti
sc anbet ransmitted
ea sil
yt hroughf omi tess ucha sc ontaminatedtowe ls,be dli
n en s,andc l
othinga nda lsobydi re ctcon tactwithinfec
ted
i
n dividuals. C.tr
ac homa tisc ana l
s obes pre adbyf l
i
e stha ttran sf
erin f
ec t
edmuc ousc on t
a i
n i
n gC. tr
a choma t
i
sf r
om
on ehuma nt oa nothe r.InfectonbyC.
i t
rachoma ti
sca use sc hronicc onjunctivit
is,whichl e adst ot hef orma t
ionof
ne croticfolli
clesan ds c arri
n gintheuppe re yel
i
d. Thes c arstur nthee ye l
ashe sinwa r
d( ac on di
tionk nowna stri
chia
sis
)
an dme c
ha ni
calabr asi
onoft hec ornealea dstobl i
ndn ess.An tibi
oticss ucha sa zi
thromy cina ree ffe
c ti
veint r
ea t
i
ng
trac homa ,andout c ome sa regoodwhe nt hedise a
sei st r
e atedpr ompt ly.
H.Ke ra ti
ti
sc a nha vema n yc aus es,butba ct
e ri
alke r
ati
tisi
smos tf r
eque ntl
yc aus edbySt aphy loc occuse pidermidis
an d/ orPs e udomon asa eruginos a.Contactlensus ersa repa rti
cul
a r
lya tri
skf ors uc ha ni nfec t
ionbe c auseS.
epide r
midisa ndP. a er
ugi nos abot ha dherewe l
ltothes urf
ac eoft hel enses .Riskofi nfec ti
onc anbegr e a
tl
yr educed
bypr ope rc areofc on tac tlensesa n davoidingwe ari
n gle nsesov e r
n i
ght.Be ca uset hei nfectionc anquic kl
yleadto
bli
n dn ess, prompta nda ggr essi
vet reat
me n twithan ti
bi
ot i
csi simpor tant.Thec aus ati
vea ge ntma ybei dentif
i
edus i
ng
ba cte r
ialcultures,Gr ams t
ain,anddi agnosticbiochemi ca l
,an t
igenic,orn ucleica ci
dpr ofilet estsoft hei sol
ated
pa thoge n.
I
. Biofil
msa ndI nf
e ct
ion soft heSk ina ndEy e sWhi l
eb iofi
l
msma yde ve l
opi not herpa rtsoft hebody ,theya ree s
pe ci
al
ly
releva nttos ki
ninfec t
ions( sucha st hosec ausedbyS. aureusorP. aeruginos a)be caus eoft he i
rpr eval
e ncein
chron i
cs kinwoun ds .Biofil
msde v el
opwhe nba c t
eri
a( ands ome t
i
me sf ungi)a ttacht oas urfac ea ndpr oduc e
extra cell
ularpol yme ri
cs ubs tances( EPS)inwhi c hcellsofmul ti
pleor ganismsma ybee mbe dde d.Whe nabi ofi
l
m
de velopsonawoun d, i
tma yi nterf
erewi t
ht hen aturalhe al
ingpr oce ssa swe l
l asdiagn os i
sa ndt reat
me nt.

I
I
I
. 21. 3Viral
In f
e cti
on soft heSk i
na ndEy es .Unti
l r
e cently,i
twa sthoughtt hatthen orma lmi crobiotaoft hebodyc on sist
ed
pri
ma r
i
lyofba c t
e ri
aa nds omef un gi.Howe v
e r
,ina dditi
ont oba cteri
a, thes ki
nisc olon i
ze dbyv i
rus es ,
a ndr ec en ts tudies
suggestthatPa pill
oma vir
ida e,Poly oma vi
ridaea ndCi r
c oviri
daea l
soc ontri
butet othen orma l
sk i
nmi crobiota. Howe ver,
somev i
rusesa ssoc i
atedwi ths kina repa thogen i
c,a ndt he sev ir
us esc a nc a
us edis ease swi t
hawi dev a ri
etyof
presen
tati
ons .
A.Pa pill
oma s
1. Pa pil
loma s(wa r
ts)a rethee xpressionofc ommons kinin f
e ct
ionsbyhuma npa pil
loma vi
rus( HPV)a n da r
e
tr
a nsmi t
tedbydi rectc on t
act.The r
ea r
ema nyt ype sofHPV, andt heyl eadt oav ari
etyofdi ffer
e nt
pres entati
ons ,sucha sc ommonwa rt
s ,pl
a ntarwa rt
s, f
latwa r
ts,andf i
li
formwa rt
s.HPVc a na lsoc aus e
sex uall
y-t
rans mittedge ni
talwa rts
,whi chwi l
lbedi scusse di nUroge nitalSy st
emI nfections. Va ccinationi s
ava i
labl
ef ors omes trainsofHPV.
2. Ins omec ases ,t
hei mmun es ystemma ybes tron ge nought opre ventwa rt
sf romf or mingort oe radic ate
esta bl
ishedwa rt
s .Howe ver,treat
me ntofe st
a bl
ishe dwa rtsistypical
lyr equired.The rea r
ema nya vail
a b l
e
tr
e atme ntsforwa rts,andt heire f
fecti
ve nes sv ari
e s.Commonwa rt
sc a nbef r
oz enof fwi t
hl iquidn itroge n
.
Topi calappli
c ati
on sofs a l
icyl
i
ca c
idma ya lsobee ff
ec t
ive. Otheropt i
on sa ree l
e ctr
os urge ry( burning) ,
cure t
tage( cutti
n g),ex ci
sion,paint
ingwi thc antharidi
n( whi chc ause sthewa r
ttodi es oi tc anmor ee a sil
ybe
remov ed),l
as ertreatme n ts
,treatme ntwi thbl eomy ci
n,c he micalpe el
s ,andi mmun othe rapy
B.Or a lHerpe s
1. An otherc ommons kinv i
rusishe rpe ss i
mpl exv i
rus( HSV) .HSVha shistorical
lybe endi vi
de di nt
ot wot ypes ,
HSV- 1a ndHSV- 2.HSV- 1ist ypical
l
yt rans mittedbydi rec toralcon t
a ctbe twee nindividua l
sa ndisus ua l
ly
ass ociatedwi thor alhe r
pe s.HSV- 2i sus ua l
lytran smitteds exual
lya ndist ypicall
ya ss ociatedwi thge n i
tal
herpe s.Howe ver,bot hHSV- 1a ndHSV- 2a rec apa bleofi nfecti
nga n ymuc ousme mbr a ne,a ndt hei n cidence
ofge n i
talHSV- 1a n dor alHSV- 2infe cti
on sha sbe enin crea si
nginr ece ntye ar
s .
2. Infe cti
onbyHSV- 1c ommon l
yma ni
fes t
sa sc olds oresorf everbli
s t
e r
s ,usua l
l
yonora roun dt hel i
ps .HSV- 1is
hi
gh l
yc ontagious ,withs omes tudi
e ss ugge s t
ingt hatupt o65%oft heUSpopul ati
oni sin f
e cted; howe ver
,
ma n yinfect
e dindividua l
sa rea sympt oma t
ic.Mor e over,thev i
rusc anbel atentforlon gpe ri
ods ,re si
din gi nthe
tr
ige minalne rvega ngl i
abe twe enrec urri
ngbout sofs ympt oms .Re currenc eca nbet ri
gge re dbys tre sso r
env i
ronme n
ta lconditions( systemicora ff
e cti
n gthes ki
n). Whe nles i
on sa repre sen t
,the yma yb li
s ter, break
ope n, a
n dcrus t.Thev i
rusc anbes pre adt hroughdi r
e ctc on t
act,evenwhe napa ti
en tisa sy mpt oma tic.Whi l
e
 thel ips , mout h, a ndf ac ea ret hemos tc ommons i
te sf orHSV- 1i nfec t
ion s ,l
e sion sc ans pre a dtoot he ra re a
s
oft hebody .
3. HSV- 1i n f
e c t
ion sa rec ommon lydia gn os e df romt he i
ra ppe ara nce ,althoughl abor a t
or yt es ti
n gc a nc on f
irm
thed ia gn os is.The rei sn oc ur e ,buta ntivir
a l me dica ti
on ss uc ha sa c yclov i
r ,pe nc i
c l
ovir, f
a mc iclov i
r,a nd
va l
a cy clov ira reus edt or educ es ympt omsa n driskoft ran smi s si
on .Topi ca lme dication s,s uc ha sc rea ms
wi t
hn - doc os an ol an dpe nci
c lov i
r,ca na ls obeus e dt or educ es ympt omss uc ha si t
chi ng, bur ning, an dt in gli
ng.
C.Roseol
aa ndF i
f t
hDi se as e
1. Ros e ola ,s ome time sc all
e dr os eolai nfan tumore x anthe ms ubi tum( “s udde nr a sh” )
,isami ldv iralinfe ction
us ua l
lyc a us edbyhuma nhe rpe sv i
rus -6( HHV- 6)a n doc cas i
on al
lybyHHV- 7. I
ti ss pre adv iadi r
e ctc on tac t
wi t
ht hes ali
vaorr e spi ratorys e cr
e ti
on sofa ninfec tedi n dividua l,oftent hroughdr ople ta eros ols. Ros e olai s
ve ryc ommoni nc hildre n,wi ths ympt omsi nc l
udin gar un n yn os e,as oret hr oa t,an dac ough, alon gwi th( or
foll
owe dby )ahi ghf ev er( 39.4º C) .Aboutt hreet of iveda ysa ft
e rthef ev ers ubs i
de s, ar as hma ybe gint o
appe a ront hec he sta n da bdome n .Ther a sh, whi chdoe sn otc aus edi s comf ort,in i
t
iallyfor msc hara cte ristic
ma cul est ha ta ref latorpa pul e sth ata ref irma nds li
ght l
yr a i
se d; somema culesorpa pul e sma ybe
sur roun de dbyawhi ter i
ng. Ther a shma ye ventua l
lys pre adt ot hen ec ka nda rms ,a nds ome time sc on tin ues
tos pr e a dt ot hef a cea n dle gs .Th edi a gn os isisge n era l
lyma deba s eduponobs e rv
a tionoft hes ympt oms .
Howe v e r,itispos siblet ope rfor ms erol ogi cal testst oc on fi
rmt hedi agn os i
s.Whi letre a t
me n tma ybe
rec omme n de dt oc on trolthef e ver,thedi s ea seus ua l
lyr e solve swi t
houtt reatme n twi thinawe e ka fte rthe
feve rde ve l
ops .F ori ndiv i
dua lsa tpa rti
c ularr i
sk ,suc ha st hos ewhoa rei mmun oc ompr omi s ed, thea ntivira l
me dic ationga nc iclov i
rma ybeus e d.
2. Fifthdi se a se( a l
s ok nowna se ryt
h emai nfe cti
os um)i sa not he rc ommon ,highlyc onta giousi l
lnes st ha tc a uses
adi s ti
n c tra sht ha tisc ri
ticaltodi agn os i
s .
a .F ifthdi s ea sei sc aus e dbypa r vov irusB19a ndi st r
a ns mi tt
e dbyc on ta ctwi thr e spiratorys ec re ti
on s
froma ni n fec tedi ndiv i
dua l.Infec ti
oni smor ec ommoni nc hil
dr ent hana dul t
s. Whi l
ea ppr oxima te l
y
20%ofi ndi vidua lswi llbea s ympt oma ti
cdur i
n gi nfe cti
on ,othe rswi llexhibi tcol d-li
kes ympt oms
(he ada c he , fev er,an dups ets toma ch)dur ingt hee arlys tage swhe nt hei ll
ne ssi smos ti nfec t
ious .
Se v era lda y sl ater,adi sti
nc tr edf a c i
al r
a sha ppe ars ,ofte nc all
e d“ sl
a ppe dc he e k”r ash. Wi thinaf ew
da y s,as e con dr ashma ya ppe a ront hea r
ms , l
e gs ,c he st,ba ck ,orbut toc ks. Ther a shma yc omea n
d
gof ors ev era lwe eks ,butu sua l
lydi s appe a rswi t
hi ns e ve nt ot we n ty-on eda ys ,gr adua ll
ybe c omi n g
l
a c yina ppe a r
a n cea si tre ce de s .
b .I nc hildre n ,thedi se as eus ua ll
yr es olve soni t
sownwi thoutme dica lt
r eatme ntbe yon ds ympt omr el
ief
asn e ede d. Adul tsma ye x pe ri
e n cedi ffere nta n dpos siblymor es e ri
ouss ympt oms .Ma nya dul tswi t
h
fi
fthd ise as edon otde vel
opa nyr a shbutma ye x pe r
ie nc ejoin tpa i
na nds we ll
ingt ha tla stss e v era l
we ek sormon ths .I
mmun oc ompr omi s edi ndiv i
dua l
sc a nde ve l
ops eve rea n
e mi aa ndma yn ee dbl ood
tran sfus ion sori mmun eg lobul inin jec ti
on s.Whi let her as hist hemos ti mpor ta ntc ompon en tof
dia gn os i
s( es pe cial
lyi nc hildre n),thes ympt omsoff i
fthdi s ea sea ren ota lwa ysc on sisten t
. Se rologi cal
tes ti
n gc anbec on duc tedf orc on fi
rma t
ion .
D.Vi
ra
l Conjun ctiv i
tis
1. Likeba c terialc on jun c ti
v i
ti
sv i
ra li
nfe ction so fthee yec a nc aus ei nfl
a mma tionoft hec on jun ctivaa nddi s c ha r
ge
fromt hee ye. Howe v er, vi
ral c onjun ctivitist en dst opr oduc eadi scha rget ha tismor ewa teryt ha nt het hic k
disc ha rgea ss oc iate dwi thba cteri
a lc on jun c t
ivit
is.Thei n fectioni sc on t
a giousa ndc ane as i
lys pr eadf romon e
ey et ot heot h erort oot heri ndi vi
dua lst hr oughc on tac twi the yedi s cha rge .
2. Vira lc on jun ctiviti
si sc ommon lya ss oc i
a tedwi thc oldsc a use dbya de n ov i
rus e s;howe v er,othe rv ir
us e sc a n
alsoc a us ec o njun c ti
v i
tis.I
ft hec aus a ti
vea ge ntisun ce rtain, ey edi scha r gec anbet es tedt oa i
di ndi a gn os is.
An tibiot i
ct rea tme ntofv i
ralc on junc ti
v i
ti
si si n eff
e ctive, an ds ympt omsus ua ll
yr es olvewi thoutt reatme n twi t
hin
awe ekort wo .
3. He rpe si nfe ction sc aus e dbyHSV- 1c ans ome t
ime ss pr ea dt ot hee y ef romot he ra rea soft hebody , wh i
c h
ma yr e sul tink era toc on junc ti
v i
tis.Thisc on dit
ion ,ge ne rall
yc alledhe rpe sk e rati
tisorhe rpe ti
ck era t
iti
s ,a ff
e c t
s
thec on j
un cti
v aa ndc or n ea,c a usi
n gi rri
ta t
io n,e xce sst e ar s,an ds en si
tivityt olight .De e pl es i
on si nthec or n e
a
ma ye ve ntua ll
yf orm, lea dingt obl indn e s s.Be caus ek era ti
tisc a nha ven ume rousc aus e s,labor ator yt es ti
n gis
ne ce ss a ryt oc on fir
mt hedi a gn osiswhe nHSV- 1i ss us pe cte d; on cec on f
irme d, an t
i
v i
ra lme dica ti
on sma ybe
pr esc ribe d.
I
V. 21.4My cos esoft heSk in .Ma nyf un ga linfe cti
on soft hes k i
ni n v olvef un githa ta ref oun di nt hen orma ls k i
nmi crobiota.
Someoft he sef un gi ca nc a us ei n fecti
onwhe nthe yga ine ntryt hr oughawoun d; othe rsma i
n l
yc aus eoppor tun i
sti
c
i
nfe
c ti
onsini mmun oc ompr omi s e dpa tien ts.Ot he rf unga l pa thoge nspr i
ma ri
lyc a us ei nfec t
ioni nun us ua ll
ymoi s t
env
ironme n t
st ha tpr omot ef un ga lgrowt h; f
ore xa mpl e ,swe atys hoe s,c ommun a ls howe rs, andl oc kerr oomspr ovide
exc
e l
lentbre edin ggr oun dst ha tpr omot et heg rowt ha n dt ran smi s s i
onoff un ga l pa thoge n s. Fun ga li
n f
e c ti
on s,a l
soc al
l
e d
mycos es,ca nbedi vide di ntoc las sesba s edont he irinva siven e ss . My c os e stha tc aus es upe rfi
c i
al i
n f
e ction soft he
epi
de r
mis, ha i
r,a ndn ail
s ,a rec all
e dc ut an eousmy c ose s. My c os e st ha tpe n etra tet hee pide rmi sa ndt hede r
mi stoi nfect
deepertis
s ue sa rec a l
leds ubc ut an eousmy c ose s. My cos e st ha ts pr ea dt hroughoutt hebodya rec a l
leds y stemic
mycos es.
A.Ti neas .
1. Ag roupofc ut a neousmy c os esc all
e dt i
ne asa rec a us e dbyde rma tophy tes ,fun ga lmol dst ha tre quir
ek e rat
i
n,
apr ote i
nf oun di ns kin,ha i
r, an dn ai
ls,forgr owt h. The r ea r et hre ege n eraofde rma tophy te s, allofwhi chc a n
ca us ec ut an eousmy cos es :Tr i
c hophy ton, Epi de rmophy ton , an dMi cros por um. Tin easonmos ta r
e asoft he
bod ya rege n er all
yc all
e drin gwor m, butt i
n ea sins pe c i
ficl oc ati
on sma yha vedi s t
inc t
iven ame sa nd
sy mpt oms .
2. De rma tophy tesa r
ec ommon lyf oun di nt hee n vi
r on me n ta n di ns oi l
sa nda ref r
e que n tl
yt ran sfe r
re dtot hes ki
n
viac on ta ctwi thot he rhuma nsa n da nima ls .Fun ga l s por e sc ana l
s os pre adonha i
r.Ma nyde rma tophy tes
growwe llinmoi st,da rken v i
ron me nts. Fore xa mpl e ,t i
n e ape dis( a thlete ’
sf oot )c ommon l
ys pr eadsi npubl ic
showe rs,a ndt hec a us ati
vef un gi growwe l
lint heda rk, moi stc on fi
n e sofs we a tys hoe sa nds ocks .Li
k ewise,
ti
n eac ruris( joc ki tch)of t
e ns pre adsi nc ommun a lli
v i
n ge n vir
on me ntsa ndt hrive sinwa rm, mo i
st
un de rga rme nts .
3. Ti ne asont hebody( tineac or por i
s )of tenpr oduc el e sion st ha tgr owr adi all
ya n dhe altowa rdst hec enter.Thi
s
ca us est hef orma t
ionofar e dr i
n g,lea dingt ot hemi slea din gn ameofr ingwor m.
4. Us ingaUVl ampa swe l
lasdi re ctmi cr osc opice v alua tionofs pe c ime nsf roms kins cra pings , hair,orn ail
sc an
alsobeus e dt ode tec tfun gi.Ge nera l
ly,the ses pe c i
me nsa repr e pa redi nawe tmoun tus ingapot assium
hy dro xides olut i
on( 10%–20%a qu e ousKOH) ,whi c hdi s solv est hek e ra ti
ninha ir,na i
l
s ,a nds kinc e l
l
st oa l
low
forv isua li
za ti
onoft hehy pha ea ndf un ga lspor e s. Thes pe cime nsma ybegr ownonSa bour au dde xt
ros eCC
(chlor amphe n i
c ol/c yc l
ohe x ami de ),as e l
ec t
ivea ga rt ha ts uppor tsde rma t
ophy tegr owt hwhi lei nhibi
ti
ngt he
growt hofba c te ri
aa nds apr ophy ti
cf un gi.
5. Va riousa n ti
fun ga l trea t
me ntsc anb ee ff
ec ti
v ea ga i
n s ttine a s.Al l
y l
a mi neoi n
tme n t
st ha tinc ludet erbinafi
nea re
common l
yus e d; mi c on azolea n dc l
ot ri
ma zo l
ea rea lsoa va i
lablef ort opi c altrea tme n t
, andgr ise ofulvi
ni sus ed
ora l
ly.
B.Cut ane ousAs pe rgil
los is.
1. An ot he rc aus eofc uta neousmy cos esi sAs pe rgill
us ,age n usc on sistingofmol dsofma nydi fferentspe cies,
someofwhi chc aus eac on diti
onc a l
leda s pe rgil
los is. Pr ima ryc ut an eousa spe rgil
los i
s, i
nwhi cht hei nfecti
on
be ginsi nt hes kin,isr a rebutdoe soc cur .Mor ec ommoni ss e con da ryc utane ousa spe rgil
los i
s ,inwhi cht he
i
n fectionbe ginsi nt her e spirator ys y stema nddi s se mi na tess ys temi c all
y .Bothpr ima rya nds e con dary
cut an eousa spe rgil
los i
sr es ultind isti
nc ti
vee s cha rst ha tf orma tt hes it
eors i
te sofi nfe cti
on .
2. Pr i
ma ryc ut an e ousa spe r
gi l
los i
su sua ll
yoc cur sa tthes iteofa ni njurya n dismos tof te nc aus edby
As pe rgill
usf umi ga tusorAs pe rgill
usf la v
us .Itisus ua ll
yr epor te di npa ti
e ntswhoha veha da ni njurywhi le
wor k i
n gi na na gr i
c ultura l
orout do ore nviron me n t.Howe ve r,oppor tun isticinfec ti
on sc a na ls oo ccurinhe al
th-
ca res e tti
ngs , of t
e na tthes i
t eofi n t
r ave nousc athe te rs ,ve n i
pun ctur ewoun ds , orina ssoc iationwi thbur ns,
sur gica lwoun ds ,oroc cl
us ivedr e ssing.
3. Cut a ne ousa s pe r
gi l
los i
sisdi agn o se dus ingpa t
ie nthi stor y, culturing, his topa thologyus ingas k i
nbi ops y.
Tre atme nti nvol ve st heus eofa nti
fun ga lme dica ti
on ss uc ha sv or icon az ole( pre ferredf ori nv as i
ve
as pe rgil
los i
s )
, i
tr acon azole, an da mphot er
ic i
nBi fi t
r ac on a zol eisn ote ff
e ctive.F ori mmun os uppr es s
e d
i
n dividua lsorbur npa tients, me dicationma ybeus e da n ds urgic al ori mmun othe r
a pyt rea t
me n t
sma ybe
ne ede d.
C.Ca ndidias i
soft heSk i
na ndNa il
s.
1. Ca n didaa lbica n sa n dot he ry e as tsint hege nusCa n didac anc aus es kini nfection sr eferredt oa sc utaneous
ca ndidia si
s .Ca n didas pp. ar es ome ti
me sr es pon s i
bl ef ori n tertrigo, age ne r
a ltermf orar as ht ha toc cursi na
sk i
nf old, orot he rloc ali
zedr as he so nt hes k i
n .Ca ndi dac a na l
s oi nfec tt hen a i
ls, caus i
n gt he mt obe come
ye l
lowa ndha rde n.
 2. Ca ndidiasisoft hes kina ndn ai
lsisdi agnos edt hroughc l
ini
ca lobs ervati
ona ndt hroughc ult
ur e,Grams t
ain,
andKOHwe tmoun ts .Susc eptibil
i
tyte sti
ngf ora nti
-fun ga lage ntsc ana lsobedon e. Cut ane ousc an didi
a si
s
canb etrea tedwi t
ht opica lors ystemi ca zolea nti
funga l me dication s
.Be ca usec a ndidia si
sc a nbe come
invasive,pa tient
ss ufferi
ngf romHI V/ AIDS, ca
n cer,orot herc on diti
onst hatc ompr omi set hei mmun es ystem
ma ybe nefitfrompr ev enti
vet r
ea t
me nt.
Az ol
es, suc ha sc l
otri
ma zole,econ az ol
e ,f
lucon azole ,
k et
oc on azole,
andmi con a zole
;nysta ti
n;terbinafi
n e;andn aft
if
inema ybeus e df ortreatme nt.Long- termt r
e atme ntwi th
me dica t
ion ss ucha sitracon azoleork etoc onazolema ybeus e df orc hronicin f
ec t
ion s.Re pe atinfectionsof t
en
occur ,butt hisriskca nber educ e dbyc a reful
lyfoll
owi n gt re
a tme ntrecomme nda t
ion s, avoidinge xce ssi
ve
mois ture,ma int
ai
n i
nggoodhe alth,practi
c i
n ggoodhy gie ne,an dha v
inga ppr opriatec lothing( i
n cl
udin g
footwe ar)
D.Sporot
ri
chosis
1. Wh er easc utaneousmy cose sa res uperficial
,subc utan e ousmy cosesc a ns preadf romt hes kintode epe r
ti
ssue s .
Int empe rater egions ,t
hemos tc ommons ubc uta neousmy cosisisac on dit
ionc all
e ds porotrichosis,
caus edbyt hefungusSpor othrixs che n
k ii
a ndc ommon l
yk nowna sros ega rde ner’sdi s e
a seorr os et horn
diseas e.Spor ot
ri
chos isisof tenc on t
racte da f
terwor ki
n gwi ths oi l
,plant
s ,ort i
mbe r,
a st hef un gusc a nga in
entryt hroughas ma l
l woun ds uc ha sat horn-prickors pl i
nt
e r
. Spor otri
chos i
sc ange ne ral
lybea voide dby
we ari
n ggl ov esandpr otecti
v ec l
o t
hingwhi l
ega r
de ninga ndpr ompt l
yc l
e an i
nga n ddis infectinga nywoun ds
susta i
n e
ddur i
ngout doora c ti
vit
ies.
2. Spo rothrixin f
e c
ti
on sin i
ti
all
ypr es enta ss ma ll
ulce r
si nt hes kin, butthef un gusc ans pr eadt ot helympha ti
c
systema nds ometi
me sbe y ond. Whe nt hei nf
e cti
ons pre ads,n odul esappe ar,bec omen ec roti
c,andma y
ulcerate.Asmor elymphn ode sbe comea ffected, absc e ssesa n dulc er
a ti
onma yde ve lopov erala rgera rea
(oft
enonon ea rmorha n
d). I
ns e verec as es,t
hei n f
e cti
onma ys preadmor ewi de l
yt hr oughoutt hebody ,
alt
ho ught hi sisrelat
ive l
yun c ommon .
3. Spo rothrixin f
e c
ti
onc anbedi agn ose dba se duponhi stol ogi
ce xa minati
onoft hea ffec tedt i
s sue.It
s
ma cros copi cmor phol ogyc a nbeobs er
v edbyc ulturi
n gt hemol donpot atode x t
ros ea gar,a ndits
micros copi cmor phol ogyc a nbeobs ervedbys t
ainingas l
i
dec ulturewi thlactophe nol cottonbl ue.Tr eatme nt
withitracon azol
eisge neral
lyr ec omme nde d.

V. 21.
5Pr otozoana ndHe l
mi n
thicInfec ti
on soft heSk i
na ndEy e s
A.Ac a
n thamoebaI nfecti
ons
1. Ac ant
ha moe baisage nusoff ree -
li
vingpr otozoa na moe ba et ha tarec ommoni ns oilsa n dun chlori
nated
bodiesoff reshwa ter.(
Thi sison ere asonwhys omes wimmi ngpool sa retreatedwi thc hlori
ne.)Thege nus
contai
n saf ewpa ras i
ti
cs pe ci
es ,someofwhi chc anc aus ei nf
e cti
on softhee yes ,skin ,andn ervouss y st
e m.
Suchi nfecti
onsc ans ome time st ravelan da f
fectot herbodys ys tems .Ski
ni nfecti
on sma yma ni
fe stas
absces ses,ulcer
s ,andn odul es.Whe na can t
ha moe ba ein f
e ctthee ye,causingin fl
a mma tionoft hec orn e
a ,t
he
condit
ioni scall
edAc antha moe bak eratit
i
s .
2. Wh i
leAc a nt
ha moe bak erati
tisisinit
ial
lymi ld,i
tc anle adtos e v
e rec ornealda ma ge ,visioni mpa i
rme n
t,ore ven
bli
ndnes sifl
e f
tun t
rea t
ed. Similartoe yei nfect
ionsi nvolvi
n gP. a e r
uginosa,Ac an tha moe bapos esamuc h
great
e rri
s ktowe are r
sofc ontac tl
e nsesbe causet hea moe bac ant hri
veint hes pac ebe twe enc ontact
l
e nsesa ndthec orne a.Preve nti
ont hroughpr ope rc ontactle nsc a
rei simpor t
an t.
3. Ac ant
ha moe bac ana ls
oe nterthebodyt hroughot he rpa t
hwa ys ,
includi
ngs ki
nwoun dsa n dther espirat
ory
tra
ct.I
tus ua l
l
ydoe sn otc aus edi seasee xceptini mmun oc ompr omi sedindivi
dua ls;howe ver,i
nr areca ses,
theinfecti
onc ans preadt ot hen e r
vouss ys t
em, res ul
tinginaus uall
yf at
alc ondit
ionc a l
ledgr anuloma tous
amo ebice ncepha l
i
tis(GAE)
B.Loiasis
1. Thehe lmin hL
t oaloa ,al
sok nowna st heAf r
i
ca ne yewor m, i
san ema t
odet hatc a nc a usel oi
asis,adise ase
endemi ct oWe sta ndCe ntralAfrica.Thedi sea sedoe sn otoc c urout si
det hatre gione xc eptwh enc a
rriedby
tra
velers.The r
eise videnc etha tindivi
dua lge neti
cdi ff
e r
en ce sa ff
ec tsuscept i
bil
i
tyt ode velopi
ngl oiasi
sa f
ter
i
n f
ecti
onbyt heL oaloawor m.
2. Thepa ras i
teisspre adbyde e r
fl
ies( ge nusChr ys ops )
, whichc anin gestthel ar
va ef roma ninfectedhuma nv i
a
abloodme al
.Whe nt hede erf
lybi t
esot he rhuma ns, i
tde pos it
st hel arv
aein tothe irbloods tre
ams .Aft
e rabout
fi
vemon thsinthehuma nbody ,somel arvaede v el
opi n t
oa dultwor ms ,whic hca ngr owt os everal
centi
me te r
sinlengtha n dli
v efory ea r
si nthes ubc ut aneoust i
ss ueoft hehos t
.
3. Then ame“ ey
ewor m”all
udestothev i
si
blemigrat
i
onofwor msa c
rossthec onjunc t
iv
aoft hee ye.
Adult
wormsl i
veinthes ubcuta
neoustissuesandc antr
avela
ta bout1c mpe rhour.The yc anoftenbeobs erv
ed
whe nmigrat
ingt hroughthee y
e,ands ome t
i
me sunderthes ki
n;i
nfact
,thi
sisge neral
lyhowt hediseaseis
dia
gn osed.
4. Wo r
msc anbes ur gi
call
yremovedf r
omt heeyeorthesk i
n,butthi
strea
tme nton lyrel
ievesdiscomfor
t;it
doesn otcur
et hei nfect
i
on,whichinvol
vesma nyworms. Theprefer
redtreat
me ntisdiet
hylcar
ba mazi
n e
,but
thi
sme dicat
i
onpr oducess ev
eresidee f
fect
sinsomeindivi
duals
, s
ucha sbra i
ninflamma t
iona ndpossibl
e
deathinpati
entswi t
hhe a
vyinf
ecti
on s.
Albendazol
eisal
sos ome ti
mesus edifdiethylcar
bama zi
n ei
sn ot
appropri
ateorn ots uccessf
ul
.I
flef
tun t
reat
edforma nyye ar
s,l
oi
a s
iscanda ma get hek i
dneys,heart
,and
l
ungs ,t
houghthe sesymptomsa rerare.