Essay Example on Diagnosing a superficial skin infection must be approached in a systematic Manner

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The first branch point is to determine the extent of penetration of the infection is it localized to the dermal layer or does the infection extend into the subcutaneous tissue The former leads one to an erysipelas diagnosis while the latter is indicative of a cellulitis infection On inspection it is difficult to assess the depth of infection so classic signs are looked for Erysipelas is indicated as a well demarcated erythematous painful lesion with high fevers and chills commonly present Usually erysipelas results as a consequence of lymphatic obstruction local trauma or abscess or fungal infections Ms V had signs that were dissimilar to this presentation and as such an alternate to erysipelas was considered Cellulitis is an acute inflammatory skin condition characterized by localized pain erythema swelling and heat with or without signs of fever It is important to distinguish a purulent infection from a non purulent one as that is key to identifying the most common pathogens Staphylococcus aureus purulent and Streptococcus pyogenes non purulent Ms V s presentation was non purulent and the blood cultures came back positive for S pyogenes Cellulitis usually presents unilaterally so a bilateral involvement should raise flags for other possible etiologies namely necrotizing fasciitis toxic shock syndrome and gas gangrene 3 The absence of any major systemic symptoms along with the clinical presentation of a subacute progression led to a low clinical suspicion of these alternate diagnoses despite Ms V having bilateral leg swelling S pyogenes are a catalase negative coagulase negative Lancefield Group A bacteria that are non spore forming cocci Histology frequently shows them in pairs or chains S pyogenes has a variety of virulence factors that makes it pathogenesis so widespread 



The outermost capsule is made of hyaluronic acid which has a chemical structure similar to human connective tissue This enables the bacteria to escape host recognition and allows for evasion by macrophages and neutrophils The major virulence factor is the M protein which has been largely associated with community based streptococcus infections The M protein binds to the host fibrinogen and blocks complement binding to the peptidoglycan layer of the bacterium Although antibodies may develop to a specific M protein there are more than 80 serotypes of the protein making it difficult to establish immunity to S pyogenes infection Increasing the invasive capacity of S pyogenes is mediated largely by its capsular polysaccharide C substance which is composed of a branched polymer of L rhamnose and N acetyl D glucosamine The pathophysiology of host cell damage and inflammatory response is similarly exhaustive in nature 2 hemolysins Streptolysin O and Streptolysin S are implicated in tissue damage Streptolysin O is highly immunogenic and is more helpful in assessing other S pyogenes infections apart from cellulitis Streptolysin S damages neutrophils and mediates organelle damage which is the relevant pathogenesis for cellulitis and systemic inflammatory responses Ms V s subacute presentation plus marked widespread edema can raise a concern for toxic shock syndrome TSS if improvement does not occur within one week Streptococcal TSS encodes certain factors that function as superantigens they induce a rapidly elevated febrile response proliferation of T cells and promote the release of cytokines such as TNF IL 1B and IL 6 This widespread nonspecific T cell proliferation is a cause of serious concern as patients who develop TSS must be treated aggressively Death is a likely complication as mortality rates can vary from 30 70 Monitoring Ms V s clinical improvements is essential to her diagnosis As per the guidelines for skin and soft tissue infection by the Infectious Diseases Society of America Ms V s infection is on the severe scale as evidenced by the progression of edema and extent to which the edema presents 



Additionally her hospitalization makes her susceptible to MRSA infection and a MRSA specific antibiotic regimen must be included in her treatment plan Vancomycin plus either piperacillin tazobactam or imipenem meropenem has a strong moderated recommendation for an empiric regimen of severe infections A strong high recommendation is for treatment duration of 5 days but treatment should continue past this if the infection has not improved Furthermore elevation of the affected area and treatment of other factors such as edema is recommended Because Ms V s edema is widespread a diuretic should be included in the regimen taking care to note her renal impairment and adjusting the drug and dose accordingly Ms V s presentation is not classic for a cellulitis infection however the proposed pathogenesis is most likely when considering all the possible risk factors along with the patient s recollection Ms V states she was near her grandchildren while on vacation and was aware of the flu going around the area and attributes her cause of infection to those factors She also had a solitary case of diarrhea vomiting and nausea It is hard to assess the cause of these findings especially because they were standalone factors But Ms V s likely etiology of an infectious cause where she does not remember a bruise or injury at the site can be likely as that is the most likely proposed mechanism for S pyogenes infections that cause cellulitis Additionally the positive blood cultures for S pyogenes indicates an infectious process although repeat cultures should be attained for establishing strength of association This likelihood of an infectious cause coupled with negative tests for other severe but likely etiologies such as DVT or emboli from endocarditis makes this treatment plan highly tailored for Ms V s presentation a favorable prognosis


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