The localized forms of skin and subcutaneous fat infections in newborns.

Lecturer: Sakharova Inna.Ye., M.D.,

Ph.D

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Plan of the lecture:

1. Contributory etiological factors of local infections in newborns.

2. Skin and mucoses diseases.

3. Subcutaneous fat diseases.

4. Umbilical wound infection.

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Anatomico-physiological peculiarities of newborns skin:

Thin, tender epidermisWeak intercellular connectionUnderdeveloped basal membraneInsufficient development of collagen and elastic fibersIncreased content of hyaluronic acid, hyaluronidaseGood skin vascularity (blood and lymphatic)Presence of brown fat (1-3 %)

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Protective factors

Antenatal: The placenta filters out most organisms (but not rubella virus, HIV, Toxoplasma, CMV and Treponema pallidum)

Amniotic fluid contains lysozyme  and other antibacterial agents to reduce the risk of infection

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Postnatal: Breast feeding:

- breast milk has IgG, IgM, IgA, macrophages and lysozymes

- lactoferrin and transferrin protect against gram negative organisms

- breast feeding contribute to the growth of Lactobacillus and inhibits E.coli

Good baby-minding

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Conjunctivitis Gonococcal conjunctivitis is a serious acute inflammation which may damage the cornea leading to blindness. Clinical features - rapid onset with red swollen mucus membranes and a copious purulent discharge.  Diagnostics - Gram stain of a conjunctival smear; culture for confirmation and antibiotic susceptibility testing.Treatment - instillation of Penicillin eye drops (20,000 IU/ml). Sometimes 100,000 IU/kg/daily IM or IV for 7 days in severe gonococcal conjunctivitis. 

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Thrush Moniliasis is caused by the fungus Candida albicans and commonly affects the mouth or the nappy area.  Clinical features - Small white patches are found on the tongue and may spread to the inside of the cheeks and lips.  These white plaques resemble curds of milk but are difficult to remove.  The underlying mucosa is inflammed and sucking is often painful.  The diagnosis is proved by microscopy.Treatment: Hexetidine (Stomatidin) for local application, Nystatin 1 ml (100,000 IU) per os 4 times per day 7-10 days; phluconasol 3 mg/kg/daily 10-15 days. For nursins mother mycostatin should be applied to the nipples.

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Impetigo

Ethiology - gpoup A streptococcus (rarely gpoup B,C and G) and Staphylococcus aureusClinical features

Papule —> evanescent vesicle —> pustule that enlarges —> breaks down over 4-6 days —> seropurulent discharge that dries to form typical thick golden-yellow crust

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Treatment of impetigo

1st generation cephalosporin ( Keflex®) 20-50 mg/day, penicillinase-resistant penicillin (Dicloxacillin) or amoxicillin with clavulanic acid (Augmentin®)– Lyncomycin, Clindamycin for penicillin allergic patient or in the case of osteomyelitisTopical antibiotics (mupirocin) less effective becouse of fail to eradicate skin colonization or prevent new lesion formation

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VesiculopustulosisEthiology - Staphylococcus aureus

Clinical features – Evanescent vesicles (a few mm in diameter —> first transparent, later muddy content —> break down over 2-3 days —> small erosions, than crusts which disappear without pigmentation

Localization - skin of buttocks, hips, inguinal folders, head

Treatment usually local – chlorhexidine, fucorcin, brilliant green.

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Pemhigus bullosa (Pemphigus neonatorum)

Benign course – on the background of erythematous patches appearance of vesicles and small bullae (d = 0,5-1 cm). The localization in lower abdominal part, on extremities. There are erosions, but there is no crusts on the site of bullae. Worsening of general condition of baby can have place, subfebrile temperature. Nikolsky's sign is negative.

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Nikolsky's sign is a condition caused by a staphylococcal infection in which the superficial layers of skin slip free from the lower layers with a slight rubbing pressure. Large areas of the skin will blister and peel away leaving wet, red and painful areas.

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Pemhigus bullosa (Pemphigus neonatorum)

Malignant course – big number of bullae (d = 2-3 cm – “phlyctenae”). Nikolsky's sign is positive. Expressed intoxication, febrile temperature, leukocytosis. Often can be development of sepsis.

Treatment of pemhigus bullosa

Pricking of bullae, local aniline dye (spiritus aethilicus based).

Antibiotics, infusion therapy, vitamins, immunoglobulins, plasma.

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Staphylococcal scalded skin syndrome (SSSS) or Ritter's disease

or Exfoliative dermatites

Ethiology- Staphylococcus aureus. Clinical features –

Fever Erythema which spreads to cover most of the body Skin slips off with gentle pressure leaving wet red areas (Nikolsky sign is positive) Large areas of skin peel or fall away (exfoliation or desquamation) PainSevere general condition of newborn

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Treatment of Ritter's disease :

Penicillinase-resistant antistaphylococcal antibiotics given IV must be started immediately. Nafcillin (UNIPEN) 12.5 to 25 mg/kg IV q 6 h for newborns > 2 kg is given until improvement is noted, followed by oral cloxacillin 12.5 mg/kg q 6 h. Corticosteroids are contraindicated. Topical therapy and patient handling must be minimized.Local 1-2 % aniline dye (water based) on healthy skin, on affected areas – brilliant green, 0,1 % AgNO3 0,5 % KMnO4.

Infusion therapy, vitamins, immunoglobulins, plasma.

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Necrotic phlegmona of newborns

Ethiology – staphylococci

Appearance of dense, compact red spot on the small part of skin

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I stage – initial

II stage – alternative-necrotic

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III stage – exfoliative

IV stage - reparation

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Cellulitis is an acute inflammation of the dermis and subcutaneous fat caused by infection with staphylococcus, streptococcus.

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Symptoms of cellulitis :Localized skin redness or inflammation that increases in size as the infection spreads, fever

Pain or tenderness of the area

Skin lesion or rash (macule): sudden onset, usually with sharp borders, rapid growth within the first 24 hours

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Omphalitis

Catarrhal omphalitis – delayed epithelization, serous discharge, absence of intoxicationPurulent omphalitis

- Purulent or malodorous discharge from the umbilical stump

- Periumbilical erythema, lymphangitis- Edema - Tenderness- Trombophlebitis and trombophlebitis as

complications

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o Treatment of purulent omphalitis - parenteral antimicrobial coverage for gram-positive and gram-negative organisms. A combination of an antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended.

o Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, with antimicrobial therapy directed at anaerobic organisms as well as gram-positive and gram-negative organisms. Metronidazole or clindamycin may provide anaerobic coverage.

o Topical therapy with anilin dye, bacitracin ointment

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Phungus (granuloma)

In delayed healing of umbilical wound under the crust can appear granulations up to 1-3 cm in diameter.

For treatment 5 % Ag NO3 solution can be used

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Table. Infectious Causes of Vesicles or Pustules in the Newborn

Class Cause Distinguishing features

Bacterial Group A or B StreptococcusListeria monocytogenesPseudomonas aeruginosaStaphylococcus aureusOther gram-negative organisms

Other signs of sepsis usually presentElevated band count, positive blood culture; Gram stain of intralesional contents shows polymorphic neutrophils

Fungal Candida Presents within 24 hours after birth if congenital, after one week if acquired during deliveryThrush is commonPotassium hydroxide preparation of intralesional contents shows pseudohyphae and spores

Spirochetal

Syphilis RareLesions on palms and solesSuspect if results of maternal rapid plasma reagin or venereal disease research laboratory test positive or unknown

Viral CytomegalovirusHerpes simplexVaricella zoster

Crops of vesicles and pustules appear on erythematous baseFor herpes simplex and varicella zoster, Tzanck test of intralesional contents shows multinucleated giant cells

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