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Qooba   (ringworm) Qooba   (ringworm)

Qooba (ringworm) - PowerPoint Presentation

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Qooba (ringworm) - PPT Presentation

By tanzeel ahmad Contents History Definition Etiology Epidemiology Pathophysiology Clinical classification ID: 912378

infection tinea skin dermatophyte tinea infection dermatophyte skin humans common clinical trichophyton disease inflammatory treatment scaling nail corporis lesion

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Slide1

Qooba (ringworm)

By

tanzeel

ahmad

Slide2

Contents HistoryDefinitionEtiology

Epidemiology

Pathophysiology

Clinical classification

Differential Diagnosis

Diagnosis

Management

Conclusion

Slide3

Introduction

The first recorded reference to a dermatophyte infection is attributed to

Aulus Cornelius Celsus

, the Roman encyclopaedist, who in his “

De Re Medicina

” written around 30 A.D., described a suppurative infection of scalp that came to be known the

Kerion of Celsus

.

After Celsus it was

Disqoridoos

(

Dioscorides

, 60 A.D.) who gave description of

Qooba

in children

in

his “

De

Materia

Medica

”.

Jalinoos

(

Galenus

of

Pergamon

, 129-200 A.D.) described

Qooba, its

cause and treatment and classified it into acute and chronic in his book “

Mayameer

”.

Slide4

From the 5th to 15th centuries which are considered as middle age,with the advent of Islam, Arabs acquired, collected, translated and documented the knowledge of existing medicine from almost all the famous civilizations especially from the Greek which was based on humoral theory of Hippocrates. Rabban Al-

Tabri

(810-895 A.D.),

Zakaria

Al-

Razi

(850-923 A.D.)

Hasan

Al-

Quamari

(9th Century A.D.)

Abbas

Al-

Majoosi

(930-999 A.D.)

Ibn

Sina

(980-1037 A.D.)

Ahmad Al-

Tabri

(10th century A.D.)

Ismail

Jurjani

(12th century A.D.)

Dawood

Al-

Antaki

(1514-1599 A.D.)

Akbar

Arzani

(17th century A.D.)

Azam

Khan

(19th century A.D.) Almost all the renowned Arab physicians described the disease in their treatises.

Slide5

Historically, medical mycology, specifically relating to human disease, began with the discovery of the fungal aetiology of favus and centred around three European physicians

in the mid-

19th

century:

Robert Remak

,

Johann L.

Scho¨nlein

, and

David Gruby

.

Raimond

Sabouraud

,

a medical

mycologists, began his scientific studies of the dermatophyte around

1890. He

classified the dermatophyte into four genera:

Achorion

,

Epidermophyton

,

Microsporum

and

Trichophyton

,

primarily on the basis of the clinical aspects of the disease, combined with

culture

and microscopic observations. The medium that he developed is in use today for culturing fungi (although the ingredients are modified) and is named in his

honour,

Sabouraud glucose (dextrose) agar

Slide6

In 1934, Chester Emmons modernized the

taxonomic

scheme of Sabouraud He eliminated the genus

Achorion

and recognized only the

three

genera:

Microsporum

,

Trichophyton

and

Epidermophyton

on the basis of mycological principles

.

Slide7

Definition

Qooba

is a roughness which appears over skin surface, associated with

itching, scaling, dryness and some time fish like scales sheds off from them. It may

be of black or red

color

usually periphery is red and occasionally yellowish fluid

discharges from them.

Slide8

The term dermatophytosis refers to superficial infection of skin, nail, and hair due to a group of filamentous fungi, belong to three genera namely Microsporum,

Trichophyton,

and

Epidermophyton

.

The infection commonly referred to as

ringworm

or

tinea

. Infection

is generally cutaneous and restricted to the non living cornified layer of skin because

of the fungi to penetrate the deeper tissue or organs of immunocompetent host. The

atypical lesion of dermatophytosis is an annular scaly patches associated with

erythema and vesicles

.

Slide9

Etiology

The

cause of

Qooba

is similar to that of the

sa’fa

; that is the

haad

(sharp),

harrif

(astringent) or pungent fluid which is mixed with

ghaleez

saudavi

madda

(viscous melancholic humour) more viscous than the matter of

jarab

(scabies). And it

may be due to

balgham

maleh

(saline phlegm) which is burnt and converted into

sauda

(melancholic

homour

).

Slide10

Dermatophytosis is colonization of keratinized tissues, the hairs, nails, and stratum corneum of skin by dermatophytes.Dermatophyte:

the term dermatophyte is defined primarily

by functional

characteristics and not by strict

taxonomical criteria.

A dermatophyte is a

hyalo

hyphomycete, morphologically and

physiologically

related fungi, and possesses

keratinophilic

and

keratinolytic

properties i.e. they rely on keratin and invade keratinized tissues and degrade them,

and consequently cause communicable skin infection in humans and/or in

animals

.

Slide11

Ecology: The dermatophytes and their congeners have long been divided into three ecological groups, based on their reservoir and habitat;

Anthropophilic

(humans),

Zoophilic

(animals),

and

Geophilic (soil).

Slide12

Ecology of Common Human Dermatophyte SpeciesspeciesNatural habitatincidence

Epidermophyton floccosum

Humans

Common

Trichophyton rubrum

Humans

Very Common

Trichophyton

interdigitale

Humans

Very Common

Trichophyton tonsurans

Humans

Common

Trichophyton

violaceum

Humans

Less Common

Trichophyton

concentricum

Humans

Rare*

Trichophyton

schoenleinii

Humans

Rare*

Trichophyton

soudanense

Humans

Rare*

Microsporum audouinii

Humans

Less Common*

Microsporum

ferrugineum

Humans

Less Common*

Trichophyton

mentagrophytes

Mice, rodents

Common

Microsporum canis

Cats

Common

* Geographically restricted.

Slide13

Epidemiology

The high prevalence of superficial mycotic infections shows that 20-25% of the world’s population has skin mycoses, making these one of the most frequent form of infection.

Dermatomycoses

, the most common of mycotic infections, occur worldwide. There has been a steady rise in the incidence of cutaneous fungal infections and an increasing rate of treatment failure or relapse among mycotic patients undergoing treatment. Almost every human alive will be infected by at some point over the course of his or her lifetime.

Slide14

Tinea or ringworm are among the most common and widespread endemic infectious diseases. In some geographic areas or environments more than 30% of the population is affected. Therefore, dermatophytoses poses a considerable worldwide health problem. Prevalence of various species varies from country to country but Trichophyton rubrum is the most common dermatophyte of tinea pedis, tinea

ungium

, tinea cruris, and tinea corporis worldwide.

In India, superficial infection of skin, nails, hair account for 8-10% of all skin outpatient attendance. Tinea cruris and corporis are the commonest varieties seen in India, followed by Tinea pedis, capitis, barbae, unguium and manum in descending order of frequency. Etiologically, T. rubrum tops the list followed by

T.

mentegrophyte

and

E. Floccosum, T.

verrucosum

, M. canis

and

M.

gypseum

.

Slide15

Host Factors;Race: All races, clinical varieties and prevalence depend mainly on environmental factors.Age: The different incidence of ringworm between various age groups and sex is thought to be due to different rates of physical activities and exposure to risk factors and of sebum production, and fluctuation of immunity with old age.

Children below the age of 12 years-Tinea capitis.

Adults are more susceptible to

onychomycoses

.

Sex:

Dermatophyte infections are in general less prevalent in females, more common in males.

Socioeconomic Status:

The prevalence of tinea capitis is closely related with socioeconomic status and life style and commonly occurred under poor hygienic conditions

Slide16

Customs and Habits: Vegetable oils were believed to be a protective factor for acquiring tinea capitis. Mustard oil used in North and North-east India for hair dressing was found to have an inhibitory effect on fungi affecting scalp.وسببها حرافة الاغذیة وادمان اكل ما غلظ كلحم البقر والباذىجانEnvironmental Factors: Raised CO2 tension is known to facilitate

arthroconidial

formation, also aids in adhesion or penetration. Moisture is also important for the

germination of arthroconidia on

keratinocytes

.

Maximum number of cases of dermatophytic infection occurs during rains.

و هو مرض خریفى

Associated diseases

: Susceptibility to persistent dermatophyte infection has been associated with a number of underlying conditions such as DM, Cushing’s syndrome and Lymphoma, frequent usage of antibiotics, immunosuppressive drugs, and organ transplantation

Slide17

Agent factors;Virulence of infecting organism: The geophilic and zoophilic infections are usually of inflammatory type and are seen only sporadically in humans. Infections produced by zoophilic are inflammatory and short lasting in humans. Anthropophilic species produce mild but chronic infection.

The degree of inflammatory response depends in part on the site of infection (large follicles of scalp and beard are associated with an intense reaction) and the immune status of host.

T.

mentagrophytes

var

mentagrophytes

produce marked inflammatory reaction.

T.

mentagrophytes

var

interdigitale

produce non-inflammatory reaction.

Competing organism and co-pathogen:

Staphylococcus aureus acts as a

copathogen

, increases the degree of inflammation in dermatophyte infection.

Slide18

PATHOPHYSIOLOGYTabiyat (Natural Power) is the driving force which pulls out the morbid matters from Aazae

Raeesa

(Principal Organ) and expels them toward the surface of skin. This morbid matter is composed of

Akhlate

Harra

wa

Lateefa

(Hot and Thin Humours) mixed with

Akhlate

Arzia

Ghaleeza

(Thick and Earthy Humour). Due to this duplicity in the nature of

Akhlat

, the disease spreads in both directions. The disease spreads rapidly due to the

Hiddat

(acuteness) and

Latafat

(thinness) of

Madda

(Matter), while the spread is slow owing to the thickness and tardiness of

Madda

. Moreover, the disease both fulminates and heals faster if there is preponderance of

Akhlate

Harra

in the causative material while it develops and heals slowly if

Akhlate

Arzia

are in excess.

Slide19

The factors that play a crucial role apart from the fungal inoculums are: (a) Trauma and maceration, (b) Increased hydration of skin. invasion of stratum corneum of the scalp skin is an absolute necessity to cause actual hair infection. Minor trauma assists inoculation, which is followed, after approximately 3 weeks, by clinical evidence of hair shaft infection.Kligman divided the infection into the following stages:1. Period of incubation 2. Period of enlargement3. Refractory period 4. Stage of involutionSkin:

During the incubation period of 1-3 weeks, the dermatophyte grows in stratum corneum with minimal clinical signs of infection Once the infection is established in stratum corneum, two factors are important in determining the size and the duration of lesion: 1. The rate of growth of organism 2. The epidermal turnover rate.

Slide20

The fungal growth rate must equal or exceed the epidermal turnover rate or the organism will be shed quickly. During the stage of enlargement, there is spread of the fungus from the site of inoculation in a radial fashion producing clinical symptoms of an expanding ring with a central clearing.For unknown reasons, the fungus ceases to grow after the clinical lesion has reached a certain size. Following this, the infection may spontaneously terminate. These are the stages of refractory period

and of

involution

. It appears that the inflammatory response at the periphery of lesion stimulates an increased epidermal turnover in an effort to shed the organisms. The central area of clearing means that the newly healed skin which has recovered from the dermatitic reaction is resistant to further infection. Hence, clinically the lesion appears annular with an elevated, red and infiltrated border often containing papulovesicles.

Slide21

ImmunologyThe disease process in dermatophytosis is greatly influenced by the host reaction to the dermatophyte involved. Immunity to dermatophytosis in humans varies considerably with each species and with the individual host involved.There are two major classes of dermatophyte antigens: glycopeptides preferentially stimulates cellmediated

immunity

(CMI)

and humoral immunity. Keratinase, produced by the dermatophytes to enable skin invasion, elicit delayed-type hypersensitivity

(DTH)

responses. The classical studies in human volunteers suggested that CMI is the major immunological defence in clearing dermatophyte infection.

Slide22

Clinical Presentation and ClassificationIbne Sina

classified it according to its cause, disease pattern and appearance, and included it in seasonal disease that occurs in spring

1.

Damwi

(

Ratab

): That oozes , but it is easily curable.

2.

Saudawi

(

Yabis

): It is produced by

sauda

, which is formed by the

ihteraq

(combustion) of

balgham

maleh

(saline

phleghm

).

3.

Mutaqashshir

: It is characterized by scaling due to extreme dryness. It may be deeply seated sometime and resembles

Barse

aswad

, or it may appear like slough

..

4

.

Ghair

mutaqashshir

: It does not scale.

5.

Saee

Khabees

: It is of spreading in nature, and malignant i.e. not easily curable.

Slide23

6.Waqif: It is localized and does not spread.7.

Haad

: It is of short duration, acute in condition, and easily curable.

8.

Raddi

: it is malignant in prognosis i.e. not easily curable.

All

these conditions develop due to the

hiddat

,

khabasat

,

latafat

, and

kasafat

of causative matters.

Slide24

Anatomical Classification 1. Glabrous skin (tinea corporis, tinea cruris, and tinea faciei)2. Skin rich in terminal hair follicles e.g. scalp and beard (tinea capitis, tinea barbae)

3. Highly keratinised skin e.g. palms, soles (tinea pedis and tinea manum)

4. Nail infections (

onychomycosis

)

Involved site -Clinical type

Anatomo

clinical classification

Glabrous skin T. corporis I. limited to keratinized structure

Groin T. cruris (Tinea corporis, cruris, pedis etc.)

Hair/scalp T. capitis II. Perforating dermatophytoses

Face T. facie (P

erforating folliculitis, Kerion, Favus)

Hands T. manuum III. actively invading dermal tissue

Nails T. unguium (Dermatophytic

granuloma

)

Feet T. pedis IV. Generalized dermatophytosis

Beard area T. barbae (Dermatophytic disease)

Slide25

Clinical ManifestationsThe clinical features of dermatophyte infections results from a combination of keratin destruction and an inflammatory host response. The atypical lesion of dermatophytosis is an

annular scaling patch

with a

raised margin

showing a variable degree of

inflammation

, the

centre

usually being

less inflamed

than the edge. The wide variation in clinical presentation depends upon the

species

and probably the strain of fungus concerned,

size of

inoculum

,

site

of body infected and

immune

status of the host.

Tinea Corporis:

circular, marginated pink, erythematous patch, raised edge, The advancing border is more or less scaling, but in inflammatory forms crusts, vesicles, papules or even pustules can develop.

Slide26

Tinea Cruris: The lesions can begin unilateral, but very soon both groins are affected. Patches with erythema with central clearing. Extends both distally on the medial part of the thighs, and proximally to the lower abdomen and pubic area, the perineum and buttocks. The peripheral activity is characterised by fine scaling and the presence of some papules, vesicles and pustules. itching or a burning sensation and by rubbing and scratching, lichenification or impetiginisation.Tinea

Faciei

:

Erythematous, scaling, pruritic lesions on the face; discrete, raised, scaling borders, flat erythematous patches. Itching and burning.

Tinea Capitis:

The infection may range from mild, almost subclinical, with slight erythema, patchy areas of scaling, dull gray hair stumps to a highly inflammatory reaction with folliculitis, kerion formation, extensive areas of scarring, sometimes accompanied by fever, malaise, and regional

lymphadenopathy

.

Slide27

Tinea Barbae: As with tinea corporis, ranging from lesion with follicular pustules to non inflammatory scaly patches.Tinea Mannum: usually unilateral, the right hand affected > left. Lesion on the dorsum appears similar to those of tinea corporis. This presents a diffuse hyperkeratosis, with accentuation of fissuring in the palmer crease. Inflammatory vesicular, pustular.

Tinea Pedis:

Most inflammatory reactions result in vesicular-bullous or even pustular lesions. Lack of inflammation is characterised by pink to red discoloration and diffuse scaling. dryness, scaling and fissuring or by white, moist maceration. Irritation and itching.

Tinea Unguium:

thickening of the horny layer, raising the free edge of the nail plate, destruction of nail plate and separation of nail from nail bed. Discoloration ranges from white to brown. The nail crumbles, disappears, leaving a thickened, abnormal nail bed retaining

keratotic

nail debris.

Slide28

Slide29

Slide30

Slide31

Slide32

LABORATORY DIAGNOSIS Direct Microscopic Examination: Direct examination is essential, as it allows the clinician to start treatment, pending culture. Although false-negative results have been reported in 5–15% of cases in routine practice. Correct visualization of the fungal elements requires the dissociation of collected material. The specimen is placed on a glass slide to which one or 2 drops of a 10%-20% KOH solution is added and a cover slip applied and allowed to remain at room temperature for 15-20 min. This allows KOH to dissolve the keratinous material, leaving hyphae and spores more easily visible. The dermatophytes appear as hyaline, septate, branched or unbranched hyphae. The presence of septate hyphae confirms the diagnosis of tinea.

Stains and Fluorochromes (Woods light examination)

Visualization of fungal elements at direct examination is sometimes difficult. Staining can increase sensitivity of direct examination by facilitating the visualization of fungal structures. Various stains which can be associated to clearing agents may be used

.

Slide33

Culture: Culture is a valuable and often obligate complement to direct examination. The most common medium used for isolating dermatophytes is Sabouraud’s peptone-glucose agar. Various formulations of this medium are commercially available; some have additives that inhibit bacterial and non dermatophyte growth. A dermatophyte test medium (DTM) indicator can also be used. The latter has the added advantage of a phenol indicator that turns red in the alkaline environment produced by dermatophytes.Sabouraud’s

dextrose agar at pH 5.6 containing;

1. Glucose - 4% (40gm) 2. Peptone - 1% (10gm)

3. Agar - 2% (20gm) 4. Distilled water -1000ml is routinely used.

The specimens are inoculated onto the slanted surface of the culture media tubes. The tubes are incubated at room temperature (25-30c) and cultures are held for a maximum of 3-4 weeks.

Slide34

Management Treatment of

Qooba

basically depends on the causative substances i.e.

Akhlat

(humours), clinical presentation, severity and duration of disease. Both, local and systemic therapy is advised for the treatment, following the principle

of

nuzj-wa-istifragh

(concoction and removal of morbid substance and fluid) to normalize the

humors

and maintaining their equilibrium for health.

Therapy should be constituted of drugs that have the effects of

Tahleel

,

Taqtee

,

Izabat

and

Talteef

for

ghaleez

madda

(thick morbid matter) along with

Taskeen

and

Tarteeb

for

haar

and

raqeeq

madda

(hot and thin morbid matter).

Inspite

of the drug therapy, there are some regimens as advised in the treatment of this disease.

Ibne

Sina

advised

leech therapy

and dietary recommendation, providing moist and wet environment, and avoiding dryness to come in contact, and

hammam

.

Ibne

Sina

held leeching better than drug therapy and

hammam

is a good option for treatment. As a prophylaxis as well as treatment,

luk

maghsool

in

sibra

(aloe) along with

matbookh

rehani

(decoction) can be used

Slide35

A-Jinse Damwi: Perform fasd

(

venesection

) on a nearest vein for removal of morbid matters.

Ghassal

(detergent)

advia

should be applied locally.

Leech

should be applied if these regimens fail.

B-

Jinse

Ratoobi

:

Use

matbookh

aftimoon

(decoction) and

ayarij

faiqara

for the removal of morbid fluid.

Gargle:

make a decoction of

Maveezaj

,

Aqarqarha

in honey water and gargle it.

Tila

:

Aqlimia

zahab

and

hadtal

should be ground in

gulnar

and

gule

surkh

, mixed into vinegar and applied locally on lesions as a

tila

.

C-

Jinse

Saudawi

:

This is the worst among all the types of

Qooba, which does not

respond treatment and does not heal easily. Use decoction of

matbookh

aftimoon

and

laughazia

with

aabe

halela

siyah

and

zabeeb

.

Perform

fasd

(

venesection

) of

vareede

basaleeque

(

basalic

vein).

Tila

:

fats of ducks and cocks, wax, and oils should be applied regularly