Case ILA Final Answers

8/3/2019 Case ILA Final Answers

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Presented by :Dermatology

andParasitology

Departments


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A previously imprisoned, 30 years oldmale patient has been released from jail

since two weeks. He developed severenight itching, resulting in extensivescratching till bleeding specially in the

inter-digital spaces, peri-umbilicaland medial aspect of the thighs.


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Examination revealed the following lesions:Multiple linear scratch marks

Papules

Pustules


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Lesions were distributed in the following areas The web space between the fingers

Peri-umbilical region

Anterior axillary fold Medial aspect of the thigh


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What is the probablediagnosis?


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Scabies


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What is scabies?


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Scabies is a transmissible ectoparasiticskin infestation caused by infestation withand sensitization to adult female of

Sarcoptes scabiei. It is characterized bysuperficial burrows , intense pruritus(itching) and secondary bacterial infection


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What is Sarcoptes scabiei?


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Sarcoptes scabieiis a small arthropodebelonging to class ARACHNIDA; orderACARINA

It is a small mite having an unsegmentedrounded or oval body, 4 pairs of legs,and tegument covered with bristles.

ARTHROPODA

CRUSTACEA ARACHNIDA INSECTA

SCORPIONIDA ACARINA

TICKS MITES

S scabeii


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What is the life cycle

of Sarcoptes scabieimite ?


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When the impregnated female tunnels into thestratum corneum of the skin and deposits eggs

in the burrow , which hatch in 3-10 days, thelarvae move on the skin and then mature intoadult mites. The adult mites live 3-4 weeks inthe host's skin.


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What is the mode of

transmission ofinfection?


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Scabies is transmitted readily, often throughoutan entire household, by skin-to-skin contact

with an infected person


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In what special situations

could scabies spread?


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Scabies spreads among overcrowded

poor population, with poor hygienicconditions


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What are the usual sites

of infestation withSarcopetes scabeii

mite?


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The usual sites involved are theinter-digital spaces, ulnar, aspect of

the arm, elbows, axilla, groin, breast,umbilicus shoulder, back andbuttocks.


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What is the characteristiclesion for scabies?


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Itchy skin burrows (tunnels) are characteristic

for scabies.


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How are skin tunnels

formed?


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Sarcopetes scabeiipenetrates the horny layerof the skin and keeps on burrowing in the

epidermis, resulting in the formation oftunnels. As the mites feed on the tissues,they deposit minute faecal pellets believed to

provoke the characteristic vesiculations of theskin and the severe pruritis.

epidermis

Fecal pellets


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When does itchingoccur?


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Severe itching is intensified at night. It isenhanced by warmth and perspiration of the

affected area. Warmth initiates an acidicsecretion which intensifies the irritation.


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Why does itching occur?

(Factors reponsible foritching)


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mites wandering within the skin

Presence of the eggs and the mite excretaproduce a massive allergic response which, inturn, produces more itching.

Both type I and type IV hypersensitivity reactionsoccur which take about one month forsensitization after initial infestation yet upon re-infection only 24 hrs are needed to produceclinical symptoms of intense itching.


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What is the mostcommon complication?

P l d d b i l


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Pustules, due to secondary bacterialinfection introduced by intense skin

scratching caused by itching, oftencomplicate the lesion.


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If pus was seen oozing from the

previous lesion,what is the mostcommon complication that may occur?


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I-Secondary bacterial infections:

1-Impetigo.

2-Cellulitis. 3-Mixed bacterial infection.

II-Hypersensitivity& allergic reactionswhich complicated by secondary

bacterial infections


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What are the most

common organisms to be

involved ?


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1-Impetigo caused by Streptococcus group A.

2- Cellulitis caused by Streptococcus group A.

3-Mixed bacterial infection by : Gram positive cocci; Staphylococcus aureus.

Streptococcus group A.

Gram negative bacilli ; enterobacteriaceae eg.

Escherichia coli , proteus. Gram negative bacilli eg. Pseudomonas aeruginosa .

Anaerobic bacteria eg. Peptostreptococci .


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Describe the mainlines of laboratorydiagnosis of theseorganisms?


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1-Specimen: Pus swab( Precautions forspecimen collection should be regarded)

2-Smears : Gram stained smears to detect the

presence of bacteria and pus cells. 3-Culture & biochemical testing to identify the

organism.

4-Antibiotic susceptibility testing to detect theappropriate antibiotic to be prescribed

by the physician to treat such a condition.


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How can you reach a

proper diagnosis?

History: low hygienic conditions over crowdening contact with infected


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History: low hygienic conditions, over-crowdening, contact with infectedperson

Complaint: Characteristic nocturnal itching, vesiculations, papules.

Examination: Site of the lesion: inter-digital spaces, ulnar aspect of the arm, elbows, axilla,

groin, breast, umbilicus, shoulder, back and buttocks Character of the lesions: scratch marks, burrows, vesiculations, and sometimes

pustules.

Diagnosis confirmation:1. Skin scrapping: tunnels scrapping with a sharp needle. The scraped

material is cleared in 10% potassium hydroxide and examined

microscopically to detect the mite.2. Skin biopsy
http://cmr.asm.org/content/vol20/issue2/images/large/zcm0020722000008.jpeg


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How can this case be

managed?


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MANAGEMENT

CAUSATIVETREATMENT

SYMPTOMATICTREATMENT

COMPLICATIONTREATMENT

SOOTHING CREAMMEDICATED SOAP

EURAXCREAM ANTIBIOTICS

PREVENTREINFESTATION

Topical treatment


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Topical treatment

Eurax (crotamiton)

Cream or lotion.

Acaricidal & inhibits the growth of bacteria. It has also antipruriticproparty.

Apply on the skin, paying particular attention to skin folds and webs inbetween the fingers and toes for 5 consecutive days.

Oral treatmentIvermectin

The drug is given orally.

It targetsthe parasite's CNS resulting in its paralysis.

Soothing cream for itching

Topical corticosteroides and antihistamines.


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Medicated Soap

Scrub the whole body using lifa and soapcontaining sulfur for 5 consecutive days.

AntibioticsIn severe cases of scabies wherepustules, antibiotic therapy may be

considered (after performing culture andsensitivity)

Prevent re-infestation


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How could we preventre-infection or cross

contamination?


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Maintenance of good personal hygiene

Patients' clothes and bed sheets should besterilized by boiling during the course oftreatment.

Avoidance of contact with infested persons.

All family and close contacts should be treated

at the same time . Treatment must be thorough and simultaneous .


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