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14. Infectii cutanate

14. Infectii cutanate

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Published by: Medical Books Romanian on Oct 20, 2011
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Capitolul
14
---------------------------------------------------------
.-
INFECTIICUTANATE~IALEpARTILORMOl
Prof.Dr.RODICAPASCUMecanismeledeapiirareaorganismuluiuman
cuprind0multitudinedefactori,careinterfereazacucapacitateaagentilorpatogenideainvadagazda.Factorii,careconferapleliicapacitateadeaparareantllnfectloasai
~Integritateaanatomicii
constituieceamaiimportantabarieranaturalaincaleaagentilorpatogeni.Capacitateadepenetrareaunormicroorganismeprinpieleaintactasemanifestarar,comparativcupielealezata,Majoritateamicroorganismelorpatrund
in
pieleprinpenetrareaacesteiadecatreunvectorsauprinleziunipreexistente(eczema,traumatism)sauprindiverseplagi.Liniacontinuadeapa-rareategumentuluiprezintaanumitepuncteslabelanive-luIfoliculilorpilo~isialorificiilorglandulare.sudo-riparesisebacee,carereprezintafrecventportideintrarepentrustafilococisistreptococi.
®
Structurapluristrati{icataaepidermei
areunrolim-portant.Eliminareastraturilorsuperficialecolonizatecugermenipatogenisireinnoireacontinuaaacestoraconstituieunproces"mecanic"de"autosterilizare".Unstratcomosmaidezvoltatofera
rezistenta
maimarelapiitrunderea
agentilor
patogeni,comparativcuuntegumentiritatcareestemaivulnerabil.
(9
pH-ulacidalpielii
(intre3-5)sisecretiaseboreicareprezintafactoriprotectoriantllnfe<ill.0~i.
0
seriedeagentipatogeni(dermatofitii)colonizeazapielea,candpH-uloptimalacesteiasemodifica.AcidifiereapH-uluiestecon-feritadeprezentaunoracizigra~inesaturati(aciduloleic)siaacizilorformicsilactic,careprotejeazapieleafatadeinfe£liilefungice..Sebumulcontine,deasemenea,acizigrasiesterificatisiare
0
actiuneprotectoareantibacteriana.
@
Microjlorasapro{itii
(comensuala)intra
in
competitiecuflorapatogenasiconstituieunmijlocprotectoralpielii,faladereceptoriicelularisisecretiaunorprodusidecata-bolismtoxiciaigermenilorpatogeni.Starilededismicro-bismconsecutiveantibioticoterapieilaunelepersoanecon-duelaaparitiadeinfectiicumicroorganismecomensuale(Candida).
(!JJ
CeluleleLangerhans
dinpielefacpartedincelulelefixetisulare,careaurolfagocitar.
4:J
Celuleleimunocompetente
(macrofage,limfociteT,limfo-cite
B)
dinstrahl!ileinferioarealepieliiauroldeaparareantiinfectioasa,
INFECTIISTREPTOCOCICECUTANATESIALEPARTILORMOI
Infectiilecutanatesialepartilormoisuscitauninteresdeosebitinpracticamedicalaprin:a)incidentacrescuta;b)etiologiafermatademaimultegrupuridestreptocociCA,B,C,D,L,G),cuproprietatipatogenicediferentiate;c)manifestariclinicedegravitatesiprognosticdiferit;d)capacitatealordeainducecomplicatiipostinfectioase.
Etiologie,
epidemiologie,patogenie
Etiologie.Dominastreptocociigrupabili,inprincipal
Streptococcuspyogenes(grupA);
mairar,suntimplicatistreptocociidegrupB,C,D,L,G.Streptocociide
grupA.llu
0virulentacrescuta,datoriticapsuleideacidhialuronic,pr~nejM(actiuneantiopso-nizanta)sia~igenelorT~i
B.
Tulpinilede
Str.pyogenes,
 
Infectiicutanatesiale
parti/ormoi
123
caredeterminainfectiicutanate
difera
prinunelecarac-teristicibiologice,fatadecelecareproducanginelestrep-tococice.StreptocociicareproducinfectiicutanateapartinunorserotipuriTsiinnumarmairedusunorserotipuriM(2,49;55,57,60),dincareunelesuntnefritogene(risedeinducereaglomerunonefriteiacutedifuze),Streptocociide
grupB:jiD
facpartedinfloraorganismului,putand
fi
izolati
dill
tractulgenitallafemeie,deundeacestiapotinfectanou-nascutiiillcursulnasterii.Maipot
fi
izolatisidinsecretiiuretrale,rect,faringesidepetegumente.
Epidemiologie.
Infectiilecutanateprodusedestrepto-cocipiogenisuntfoarteraspandite.
Sursadeinfectie
0
constituiebolnaviicuafectiunistreptococice(angine,infectiisupurativecutanate).Inspitale,reprezintasursepotentialedeinfectiebolnaviicuplagisiarsurisuprainfectate,nou-nascutiicuinfectiialeplagiiombilicale.Purtatoriinazaliauomareimportantaepidemiologica,acestiaeliminade80deorimaimultistreptococidecatpurtatoriifaringoamigdalieni.
Rezistenta
streptocoeilorB-bemoliticigrup
A
inmediulexternesterelatiV!iTIcata.Inproduselepatologice(puroi,sange),eirezistamaimultezile,iarlailltunericsiumidi-tatesepotconservamillmulte
hIDj
Patogenie.
Streptoeocii
proyju
dinf9carediverse
(rinita,anginastreptococica,otite)sau
din
mediulambiant
sipatrundintegumenteprintr-o
solutiedecontinuitate,
plaga,Multiplicarealorarelocillvasele~ispatiilelimfaticealed~provocandunprocesinflamatorlocaldermiticsausUJ2urativ.Uneori,serozitateaprovoacaclivajulsupe!-ficialalpielii,buleepidermicesauzonedenecroza.Inerizipel,stEeptocociiproducunplacardderrniticcucaracterinflamatorsiinfiltratieintensalamarginileacestuia.Propa-gareainfectieisefacedinaproapeillaproape.Placarduldermiticaparedepredilectieinzoneleundeexistsstazalim~auedemcronicdeex.,postrnastectomie.FactoriiIaVorizantisuntv~1ajnaintata"bolilecronice(diabetulza-harat),micozelesieczemeleinterdigitale~seconstituieconsecutiveatrunderiistrepto-Eocilorins1E!..turiJebipodeoulllui,undeformeazaprocesesupurative,labcese.!flegmoane.Lacopilulmic,celulitaesteprodusamaifrecventdestreptococjdegnip.B,~G.
LimfangitaacutiLeste
consecintamultiplicariisipropagariistreptococilorillvaselelimfaticespreganglioniiregionali.
Imvetigo
survinemaifrecventLacopilulmicinconditiiprecaredeigj.enii.Existadatecaresugereaza
Gil
tulpinileimpetiginoaseprezintaanurniteparticularitati,princonti-nutulmareinlipidedinmembranapereteluicelular,illconditiiordinaredecrestere.Histopatologic,seformeazaveziculo-pustuleunilocularesuperficialeillepiderm.Caldurasiurniditatealocalainfluenteazadezvoltareaprocesuluiinfectios.
Ectima
(ulceratiecircularaindurata)seproduceprin
-
\U?rainfectie.custreptococdegrupAauneiescoriatiisauauneim~einsecta,Factoriifavorizantisunt:igienadefectuoasa,iarlaadultterenuldiabetic.
Suprain[ixtiapliigilorchirurgicale
:ji
arsurilor
custrep-tocbc~-hemolitic-grupA,provenitdelapurtatorifaringieni,nazali,analiesterelativfrecventa,Lanou-nascutisilapersoanelecuimunodepresie,suprainfectiacustreptococigrupBaparemaifrecventdecatlaaltecategoriidepacienti.
Fasciitanecrozantiitir;;!
aparelaimunodeprimati,pro-dusade
0
ascciese
Qe
gweni,dincareeelputinunuleste~naerob(Bacteroidessp.,Peptostreptococcussp.)asociatcugermenifacultativianaerobi(streptococinon-A)sienterobacterii(E.coli,Enterobacter,Proteus,Klebsiella).Principaliifactoriderisc'suntvarstailla:inW"a,ii1.1lillodepre~
§ill.
Debuteazadupaplagicontuze,interventiicfuIUfglcaleabdominale,perforatiiintestinale(diverticulita,cancerdecolonsausindromarterialobstructivperiferic).Acestifac-torideprimafunctiilefagocitaresialtereazaraspunsulimunalgazdei,influentandinfectiilerninorespreunasevera.
Fasciitanecrozantiitip
2aparelapersoaneimunocom-pefente.EsteprodusadestreptococivirulentidegrupA
(nu:c
sauD),caetiologieunica,sauinasocierecu~lococcusaureus.Principalacauzadeterminanta
0
constituieaugmentareavirulenteiunortulpinidestreptococigrup
A.
Evolutiarapidasideosebitdeseverasedatoreazaprodu-ceriisi!!.dromuluidesoc.toxicstreptococic~ilipsapolimorfo-nuclearelorlalocuLin:fuctiei,explicataprinurmatoarelemecanisme:@)exotoxinastreptococicacreeazaconcentratiicitotoxice,care~producdistructiitisulare;~)leucocitelesunt"s;:shestrate"
in
vaseleadiacente~culuiin~piditateaconstituiriinecrozeloresteconsecintainsuficienteivasculareprogresive~iformariinecrozelorischemice.Streptolizina
0
stimuleazaproducereaselectineiE,afactoruluideactivarealplachetelorICAM-lsiactivareareceptorilorgranulocitelor(CD11
b/CD
18),conducandlaaderentapolimorfonuclearelorlaendoteliu,iardupacatevaorelaaparitia
citotoxicitatii,
Evolutiaesterapidasprenecrozeextinsealete~utuluisuhcutanat~ide-alungulfasciilQr.
Gangrena'Fournier
este
0
formaparticularadefasciitanecrozanta,cunoscutasubnumelede
·gangreniiscr;;t{JJ
.-
treptococidi
Etiologiaestefermata
am
enterobacterii(E.coli,Klebsiella,enterocoei),illasocierecuanaerobi(Bac-teroides,Fusobacterium,Clostridium,streptococianaerobisistreptococidegrupA).Principaliifactoripredispozantisunt:diabetulzaharat,traumatismelelocale,parafunosis,incontinentaurinara,infectiileperianale~iperirectale,chi-rurgiazoneiperineale,circumcizia.Debuteazainitialca
0
celulitalocalizatalapoartadeintrare~iseextindepanalanivelulfasciilor.
Purpurafulminans(gangrenosa).
Mecanismuldeprodu-cereestecoagulareaintravascularadiseminata,Apareillin-fectiacustreptococf3-hemoliticgrupAsiillsepticemiidealteetiologii.
Sindromulde:joctoxicstreptococic(ToxicStreptococicSyndrome).
Aparemalaleslavarstnici~iimunodeprimati,Poartadeintrareamicroorganismuluiestecutanata,
 
124
Baliin
ec
ioase
vaginalasaufaringiana,deundeprocesuldisemineazahematogen.Sindromulestedeterminatdetoxineleeritro-geneA,BsauC,produsedes~ptococull3-hemoliticgrupA(serotipuri1,3,12si38aleproteineiM).Suntimplicatesi2exotoxinepirogene(SSAsifactorulmitogen),careactioneazacasuperantigeneactivatoarealelimfocitelorT,cuproduceredecitokine,caredeclanseazasocul.Strepto-cociidegrupAdeterminasintezaunormaricantitatideTNF-alpha,iarsuperantigenulSPEA(exotoxinastrepto-cocilorde
grUD
A)inducesintezadeTNF-beta,carepro-voacahipotensiune.
SiiiPtococii~hemoliticinon-A
(C,G,
B,LsiD-S.bovis)
suntmairarsemnalatiinetiologiainfectiilorcutanate.Totusi,seconsiderainprezent
eli
infectiileprodusedeacestiatrebuiereconsideratesitratatecuaceeasiseriozitatecaaceleaprodusedestreptocociidegrupA,avand
in
vedereasociereaacestora
in
etiologiaunorcelulite,
in
supra-infectareaunorleziuniischemicesidezvoltarearezistenteilamultipleantibiotice.
Streptococul~hemoliticgrupA
isimentinesensibi-
litatealabetalactamine,macrolide,clindamicina,
StreptocociidegrupB,
C,
D,L,
Gpotfimultirezistentisisetrateazaconformantibiogramei(betalactamineasociatecuaminozide).
Tablouriclinice
Impetigo.Esteceamaifrecventaformaclinicade
infec-fiestreptococicdcutanatii.
Estefoartecontagioasa,inmediUlfamiliarsauincolectivitatiledecopii.Debuteazaprinaparitiaunui
placarderitematopapulos,
caretrecerapid
in
v~ii,
initialculi"hjdclar,apoitulbure,reZiifta
0
pustulii
careseacoperade
crustemelicerice.
Leziunilesunts~cialesiaparpetegumenteleregiuniiperioronazale,inzoneIeparoasesilaextremitati.Prinautoinoculare(prurit),procesulseextindesiinaItezone.Prinspalare,seformeazaeroziunieritematoasezemuinde.Evolutiacarac-teristicaesteinplacarderotunde.Frecvent,se...asoclazaa~a
regioaala,
DlferentiereatablouluideeelstafilococicsebazeazapeleziunilePJlstuJoase,purulentedeladebut,situatein
jurul
unci
portideintrare.Stareageneralaabolnavului
t!lt
estemodificatii.Ectima
(impetigoulceros-necrozan~L
Estefrecventalacopiisivarstnici.Tabloulclinicesteasernanatorcuimpe-trgo,darleziuneaeste~ineJlid,e.rm.
Streptoeoeiide_grupA
producleziuneadenovosauinfecteazaleziunipreexistente(muscaturadeinsecta;excoriatii).LeziunicuaspectasernanatorpotfiprodusedeinfectiicuPseudo-monas,incursulbacteriemiei.Sediulleziunilorseaflapee.xtre'mitatileinferioare.Aspectiifestede
'!:!ceratie
cumar-ginisupradenivelate,acoperitede
cruste
galben-verzuicareseextindinderm,delimitatedeun~euviolaceu,culim-fadenopatieregionala.Laimunodeprimati(SIDA),seasociazabacteriemia.GlomerulonefritaaC'ltaPQststn~pto-cocicapoateconstitui()"c~mplicatie,cande~esteprodusadestreptococicuserotipuri2,49,55,57,60aleproteineiM.Suprainfeetareaplagiloreustreptoeoeipoartanumele
de~i'/l!!etigi~iza~e.
Suprainfectareap?at~ave~locl~nivelulplagilorc~,eczemelor,leziunilordinvaricelasaudeherpeszoster.--_~ntertrigo.
Dermitdinflamatorieaplicilor,
favorizatade'contactulpermanenta2suprafetecutanatecuhiperhi-drozasimaceratie(pliurilesubmamare,interfesiere~iretro-auriculare).
Etiologia
poatefimultipla:streptococi,entero-bacterii,piocianic,Candida,dermatofiti,
l'actorlljavorizanji:
igienamediocra,obezitatea,diabetul,corticoterapia.Aspectulestede
roseata
lanivelulpliului,frecventulceratinzonacentrala,
cu
depozltalbiciospeintreagasuprafala,'inconju-ratade
0
reactieinflamatoriesidemicivezicule.Bolnaviiacuzapruritsiarsurilanivelulleziunilor.Erizipelul.Este
0
clermoepidermitiiacutaIocalizata,careaparesecundaruneiinfectiicu
Streptococcuspyogenes,
favorizatade
0
stazavenoasii~ilimfatica.Caracterulintensinflamatoralleziunilor,casifrecventarecidivelor,sugereazaosensibilizar.e.laantigenelestreptococice.Suntafectatestructurilesuperficialealetegumentelorsilimfaticelesu-p-erhclale.
Incubatia
ested0zile(maximum8).
Oebutul
estebrusccu.lli:llii,frisoane,varsaturi,mialgii,Dupa12-48ore,apareun
placarderitematos
strafiiCItOr,cald,userindurat,cumarginiusorreliefate,netconturat,denumitbureletdedelimitare.Peplacard,aparfrecventflictenesuperficiale.cuuncontinutclarsauusorgalbiu.Acoperisulepidermicalacestorase
rUj)e
usor,lasandsasescurgacontinutul,careseconcentreazasubformaunorcrustemelicerice.Informelemaisevere,straturilesuper-ficialealeplacarduluisenecrozeaza,constituinderizipelulnecroticsaugangrenos.Tesutulsubcutanatestesediulunui
edem,
careuneoriiaproportiiconsiderabile.Placardulare~utiecentrifuga
"in
patadeulei",centrulramanemaiputintumefiat,maisterssimaipalid.Labolnaviinetratati,placardulseextindesiinaIteregiuni(eratic,serpiginossaumigrator).Seinso-testedefebra,tahicardie,tulburiiridigestivesinervoase(agitatie,~),oligurie,splenomegalie.~
Adenopatiaregionalii,
sensibilalapalpare,precedeapa-ritiaplacardului.~
Evolutiabolii
dureaza8-12zile,uneorichiarmaimult,InIipsatratamentuluiantibiotic.Subterapiecuantibioticeevolutiaestefavorabilain~Dupaboala,apare
0
fw
descuamaresi
0
pigmentaretrecatoare
ill
zonaplacardului-.-Leucocitozacuneutrohhesicrestereavlfezelde
'sedi-
mentareahel!ill!!ilor.
Formeclinice:
-
-Erizipelul{elei:
Placardulareunaspectcaracteristic
HI
"l!ripideflutur(siseinsotestede
0
adenopatieregionaU(antetragiana),users,~ibilalapalpare.Focarulstrepto

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