Doctors Network

Fungal infections

Fungi (introduction)

Study of fungi is mycology.
All fungi are eukaryotic and its cell wall is composed of chitin,mannan and glucan.
Ergosterol is the major membrane sterol.
Hyphae is the filamentous cellular units of moulds and mushrooms (it can be septate and non-septate)
Pseudo-hyphae: C.albicans

Dimorphic fungi:

Fungi which can convert from hypheal to yeast or yeast-like form.

Fungi which are in the from of mold in cold is thermally dimorphic.

Imp dimorphic fungi:

Histoplasma
Sporothrix
Coccidioides
Blastomyces

Superficial fungal infections

Malassezia furfur
Cutaneous fungal infection
Yeast skin infection
Dermatophytes

Candidiasis (Moniliasis)

Is an infection caused by the yeast Candida albicans, or occasionally by other species of Candida.
C.albicans is an oval yeast 2-6 x 3-9 mm in size, which can produce budding cells, pseudohyphae and true hyphae.
It most commonly causes superficial infections of the skin and mucous membranes.
Can also involve internal organs as in septicemia, endocarditis and meningitis (particularly in AIDS patients and in patients in intensive care units).
Candida albicans occurs as a normal commensal in humans and colonizes the gastrointestinal tract, vagina, intertriginous skin and the bronchial tree.

Clinical syndromes of candidiasis

Oral candidiasis
Candida intertrigo (flexural candidosis)
Vulvovaginitis (vulvovaginal thrush)
Candidal balanoposthitis
Napkin candidosis (diaper rash)
Candida paronychia

Oral candidiasis

can occur in infants (oral thrush),
immunocompromised patients,
patients wearing dentures (denture stomatitis),
smokers & those applying intraoral steroid medications (mouthwashes,inhalers).
Sharply defined patch of curd-like white pseudomembrane, which, when removed, leaves an underlying erythematous base.

Candida intertrigo (flexural candidosis)

Usually affects the skin folds in obese subjects.
Typical lesions are moist, erythematous eroded areas with a fringed irregular edge and pustular or papular satellite lesions beyond the margins.

Vulvovaginitis (vulvovaginal thrush)

Itching, soreness and dusky red erythema of the vaginal mucosa and the vulval skin with a thick curdy white discharge per vagina.
More common in pregnancy.

Candidal balanoposthitis

Is more commonly seen in the sexually active uncircumcised men or in patients with diabetes.
The sexual partners are usually carriers of candida.
Tiny papules or pustules develop on the glans penis a few hours after intercourse, and rupture, leaving a peeling edge, with mild soreness and irritation.

Napkin candidiasis (diaper rash)

Moist skin of the buttocks and genitalia infants and can cause disease in the napkin area when it is wet and occluded.
The affected area may show erythema with subcorneal pustules and satellite lesions.

Candida paronychia

Candida is the most common cause of chronic paronychia.
condition is commonly found among those whose hands are frequently immersed in water (cooks, housemaids, washermen).

Management of candidal infections

Remove the susceptibility factors. For example, maintenance of oral and dental hygiene and keeping the affected sites dry.

Topical therapy

Clotrimazole, miconazole, econazole, nystatin, natamycin. These drugs are used in the form of creams, lotions, gels, mouth paints or lozenges.

Oral therapy

The most useful treatments are with fluconazole (100-400 mg/day) and itraconazole (100-200 mg/day).

Intravenous therapy

Amphotericin B and fluconazole are mainly used for systemic infections.

Dermatophytes

These are filamentous fungi and are monomorphic.
It infect only skin, hair/nail.(Only superficial)
Dermatophytic infections are known as Tineas or Ringworms.
These belong to three genera. They are:

Trichophyton: Infects skin, hair and nails.
Microsporum: Infects skin and hair.
Epidermophyton: Infects skin and nail.

Cutaneous infections:

Tinea capitis: ringworm of scalp
Tinea barbae: ringworm of the bearded region
Tinea corporis: infection of the glaberous skin
Tinea cruris: jock itch
Tinea pedis: athlete’s foot

Tinea capitis

Ringworm of the scalp in which the essential feature is invasion of hair shafts by a dermatophyte fungus.

Have a distinct predilection for the hair shaft.

Cause: M. audouinii, T. schoenleinii and T. violaceum

Clinical feature

The appearance vary from a few dull grey, broken-off hairs with a little scaling, detectable only on careful inspection, to a severe, painful, inflammatory mass covering most of the scalp.
In all types, the cardinal features are partial hair loss with inflammation of some degree.

Tinea capitis

Tinea barbae

Ringworm of the beard and moustache areas of the face with invasion of coarse hairs. It is thus a disease of the adult male.

Causes: T. mentagrophytes and T. verrucosum

Clinical features

The affected men are commonly farm workers
The clinical picture in these is that of a highly inflammatory pustular folliculitis.
Hairs of the beard or moustache regions are surrounded by red inflammatory papules or pustules, usually with exudation or crusting.
Many hairs within the affected areas are loose and easily removed with the forceps without causing pain.

Tinea barbae

Tinea corporis

Dermatophytic infection of the glaberous skin, but can occur in any part of the body.

Cause:

Microsporum canis
Trichophyton verrucosum

Clinical features

The lesions are erythematous, annular and scaly with a well defined edge with central clearing.
May be single or multiple and are usually asymmetrical.
Steroid use: leads to disguising and worsening of the signs.

Tinea corporis

Tinea cruris

Infection of the groins by a species of dermatophyte.

Cause:

T. rubrum is the main cause;
T. mentagrophytes var. interdigitale and
E. fl occosum

Clinical features

Itching is a predominant feature.
The lesions are erythematous plaques, curved with sharp margins extending from the groin down the thighs.

Tinea cruris

Tinea pedis

Infection of the feet or toes with a dermatophyte fungus.

Causes:

T. rubrum,
T. mentagrophytes var. interdigitale and
E. floccosum

Clinical features

The most common form of tinea pedis is an intertriginous dermatitis characterized by peeling, maceration and fissuring affecting the lateral toe clefts, and sometimes spreading to involve the undersurface of the toes.
This picture may be produced by any of the three species.
Itching is a common complaint in warm weather. The condition is highly persistent.
In T. rubrum infections, a scaling hyperkeratotic variety, which is particularly chronic and resistant to treatment and which affects the soles, heels and sides of the feet, is often found. The affected areas are pink and covered with fine silvery white scales. If the foot is extensively involved, the term ‘moccasin foot’ or dry-type infection are sometimes applied.
In T. mentagrophytes vesiculation or frank blistering is commonly seen.

Tinea pedis

In all cases of suspected dermatophytic infection:

Skin scrapings/ nail clippings
Woods light examination
Direct examination
Fungal culture

Treatment

Topical

Terbinafine or miconazole cream

Systemic

terbinafine, griseofulvin or itraconazole

Congenital Talipes Equinovarus(Clubfoot)

The term talipes is derived from of the Latin words for ankle(talus) & foot (pes).

The term refers to the gait of severely affected
patients, who walked on their ankles.

Clubfoot is a severe fixed deformity of the foot characterized by fixed ankle plantar flexion (equinus), inversion of the subtalar (talocalcaneal) joint (varus), and medial subluxation of the talonavicular and calcaneocuboid joints (adductus)

Etiopathogenesis

Idiopathic majority , some secondary to muscle pathology
All the tissues of the foot i.e. bone, joint,ligaments and muscles have developmental abnormality
Bone: smaller in size, neck of talus is angulated so that head of talus is directed downwards and medially. Calcaneum is small and concave medially
Joints: equinus deformity occurs primarily at ankle joint. Inversion deformity occur in subtalar joint. Adduction occurs in midtarsal joints
Muscles and tendons: muscles of calf are underdeveloped.
Capsule and ligament: all the ligamentous structure on the postero-medial side of the foot shortened
Skin shows adaptive change
Callosities and bursae over bony prominences on the lateral side

Congenital Talipes Equinovarus

Bilateral in 60%.
General examination to rule out other deformities
Normally, the foot of newborn can be dorsiflexed until the dorsum touches the anterior aspect of shin of tibia
Components of the deformity:
Equinus.
Varus.
Adduction.

X-ray

AP view and a lateral view in a position of maximum dorsiflexion.
Kite angle is the angle subtended by the long axes of the calcaneus and the talus on the AP view.
This angle is normally between 20 and 40 degrees.
In the clubfoot, this angle is less than 20 degrees with relative parallel alignment of the talus and calcaneus.
The relationship of the talus and calcaneus should also be assessed on the lateral view. Again, in the clubfoot, this shows relative parallel alignment compared with the normal foot

Treatment

Nonoperative :

Best results are achieved with early manipulation.
(as early as first week of life) and serial casting (changed every 2 week). Adduction deformity is corrected first followed by inversion and then equinus deformity. If this sequence is not followed rocker bottom foot may result

Wearing Of Dennis-Browne(DB) splints for maintenance.

Good results may be achieved if previous technique is applied.

Operative Technique :

In less than 3 years only soft tissue release may be sufficient while older children require bony operations.
Indicated for manipulation failure cases, recurrence and neglected cases
Posteromedial soft tissue release (PMSTR)
Tendon transfer
Dwyer’s osteotomy- open wedge osteotomy of calcaneus
Dilwyn-Evan’s procedure : PMSTR with calcaneo-cuboid fusion
Wedge tarsectomy
Triple arthrodesis

What are the clinical manifestations of spongiform encephalopathies?

1. Creutzfeldt-Jakob disease CJD :85% cases are sporadic; 15% are familial

2.Middle age to elderly patients

3.Rapidly progressing dementia

4.Memory loss with startle myoclonus or other involuntary movements

5.Typical EEG changes

6.Death within 6-12 months.

Approach to limping child

Differential diagnoses:

0 to 5 years old

Septic arthritis
Osteomyelitis
Transient hip synovitis
DDH
Perthes disease
Toddler's fracture
Nonaccidental injury (child abuse)
Tumors (ALL)
Neuromuscular disorders (cerebral palsy, Duchenne's Muscular Dystrophy)
Discitis
Juvenile rheumatoid arthritis

5 to 10 years old

Septic arthritis
Osteomyelitis
Transient synovitis
Perthes
Limb length difference
Tumor (ALL, Ewing sarcoma, benign bone tumors)
Neurologic disorders (hereditary motor sensory neuropathy)
Discitis
Juvenile rheumatoid arthritis

10 to 15 years old

Osteomyelitis
Slipped capital femoral epiphysis (SCFE)
Tumor (osteosarcoma, Ewing's sarcoma, benign bone tumors)
Perthes disease
Hip dysplasia
Idiopathic chondrolysis

History

Acuteness of onset, pain, history of trauma or injury, constitutional symptoms such as fever, malaise, chills; early morning stiffness and motor milestone development (walked by 15-18 months).
Past medical history, Birth history and any previous surgery, injuries, or illnesses.
Family history of childhood lower extremity conditions such as developmental dysplasia of the hip (DDH).

Physical examination

An antalgic gait is characterized by a decreased stance period on the affected limb as well as a trunk shift over the affected limb during stance.
Evaluation for limb length difference: palpate the anterior superior iliac spine (ASIS) with the patient standing. Then, with the patient supine, compare lengths of the lower extremities with the legs extended. Also, compare lengths of the femurs by flexing the hips and comparing the relative heights of the knees.
Physical exam should also include the back, sacroiliac (SI) joints, and abdomen as well as the entire extremity involved.
Palpate the entire length of the limb.
Range of motion of the hip, knee, and ankle joints. Particular attention should be paid to any erythema, warmth, joint effusion, or focal tenderness.
A thorough neurologic examination should also be completed.

Investigation

Radiographic evaluation. Anteroposterior (AP) and lateral plain radiograph (x-ray) of the entire length of bone involved, including joint above and below the area of concern. Referred pain describes pain attributed to one site or location by the patient but the source of the pain is at a different site (e.g., knee pain in a patient with an SCFE involving the hip joint).
Laboratory studies. Complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). If rheumatologic conditions or spondyloarthropathies are being evaluated, include rheumatoid factor (RF), antinuclear antibody (ANA), anti-streptolysin (ASO) titer, Lyme titer, and HLA B-27.
Additional imaging studies.
Magnetic resonance imaging (MRI). Very sensitive and specific. Able to identify areas of bone marrow edema, soft tissue edema, or fluid collections such as abscesses.
Ultrasound. Useful to look for hip joint effusions, subperiosteal or soft-tissue abscesses. May also help guide aspiration of hip joint or soft tissue abscess.
CAUTION: If septic arthritis is suspected, a joint aspiration should be performed without wasting time waiting for the availability of other additional imaging studies.

Ulnar tunnel syndrome

Motion:

> Dorsiflexion- 0-50

Palmarflexion 0-60

Radial deviation 0-15

Ulnar deviation 0-50

Supination/Pronation 75-80 each

ULNAR TUNNEL SYNDROME

Compression of sensory, motor or both in Guyons canal at wrist

Guyons canal fibro-osseous triangular space ulnar aspect of volar wrist, roof volar carpal ligament and pisohamate ligament, lat. Wall TCL and hook of hamate, medial wall pisiform and fibrous structures

Ulnar nerve and artery

Causes- SOL like ganglions, aneurysms, lipoma

# hook of hamate, repeated trauma vibration tools, long distance cyclists

Symotoms – numbness and tingling ring and little finger, weakness of intrinsic muscles, pain at wrist

Sensory deficit – sparing of dorsal hand

Motor – weak intrinsics, clawing, Froments sign, confrontation test, Egawa test

Diagnosis – history, clinical tests, Tinels sign, Nerve Conduction study

Treatment – Cessation of provocative activities, NSAID, Local steroid injection, Surgery

CARPAL TUNNEL SYNDROME

Compression of median nerve at wrist in carpal tunnel

Carpal tunnel three sides by carpal bones, roof by Transverse Carpal Ligament

Causes– Secondary, Idiopathic

Clinical features:

aching and burning pain along median nerve distribution, night symptoms, aggravated by elevation, repetitive activities and prolonged wrist flexion, clumsiness of hand, female predominance

Physical signs :

Sensory loss, Motor weakness and atrophy