Infectious Diseases
Infectious Diseases
Infectious Diseases
Mycoplasma: maculopapular rash, mild tranaminitis, Mild Anaemia d/t cold agglutinins
Coxiella Burnetti: Q Fever (exposure to livestock), Flu like Sx and severe headache
Fungal: Can all present chronically and mimic TB (constitutionalists Sx and cavitary lesions)
Histoplasma:
Soil contaminated by bat and bird droppings: Caves, chicken coops, Ohio/Mississippi River Valleys
Blastomyces:
Inhalation of mould spores in disturbed soil (outdoor occupations), Ohio/Mississippi River Valleys and
Great Lakes; Skin Lesions, osteomyelitis (well circumscribed, lytic lesions)
Coccidiodes:
Soil, SW US and N Mexico (Valley Fever), Erythema nodusum or multiforme, arthralgias, subacute
Tx: Pulm blasto: Itraconazole (histo/coccoi don’t norm need tx); Severe fungal: Amphotericin B
Dx: CXR
False neg CXR in neutropenia, dehydration, PCP infection and disease <24 hrs
Fremitus: Sounds norm only heard in large airways transmitted to periphery in Pneu, same principle for
consolidation
Hemoptysis: MRSA associated necrotising pneumonia: preferentially attacks young pts with influenza
Nosocomial Pneumonia
General Pneu SX: Pleuritic chest pain and cough (productive purulent sputum)
Repositioning of patient can increase V/Q mismatch (gravity), increased intrapulmonary shunt and
worsening hypoxaemia.
Aspiration Pneumonia
Chemical pneumonitis d/t stomach acid can set patient up for bacterial superinfection
Can progress to Empyema: Frank pus aspirated/positive pleural fluid culture, large persistent, air-fluid
layer ——>>>>>>>> Needs chest tube drainage
Management: CAP
CURBS 65:
Confusion, Uremia (BUN>20), RR (>29), BP (BP S<90 OR D<61), 65 (AGE >64)
SCORE OF 3 OR MORE ADMIT
PLUS
New pulm infiltrates; increased resp secretions; systemic sx + Worsened resp status and oxygenation
Prevention of VAP:
Head of bed elevation at 30-45 degrees to reduce retrograde movement of gastric secretions
Limit use of gastric acid inhibition to reduce burden of microorganisms in gastric secretions
Influenza Pneu:
Complication of Influenza in high risk individuals
Buzzwords:
Tularaemia: Gentamycin
Lung Abscess:
Aspiration: Posterior segments of upper lobes and superior segments of lower lobes
——>> septic emboli to lungs —-> multiple periph lung nodules (some w cavitation)
Dx: US neck
Infectious Mononucleosis
Complications:
Autoimmune hemolytic anemia and thrombocytopoenia —> IgM cold Agglutinin 2-3 wks after onset
Tuberculosis
Aerobes
Extrapulmonary TB
Any organ: LNs, pleura, Genitourinary tract, spine, intestine and meninges common
With 3 negative sputum cultures ==> cannot rule out if negative (needs high burden of org)
Initiate empiric tx if high suspicion: RIPE (2 mo) then 4 months of isoniazid w rifampin
The only ppl you give prophylaxis to if in contact with TB are kids <4 (INH for 9 months)
INH: Peripheral neuropathy and sideroblastic anemia (give B6); Hepatitis with mild bump in LFTs
Discontinue RIPE if LFTs rise above 3-5 times upper limit only as all hepatotoxic
Eosinophilia
CXR shows nodular density (upper lobe) with surrounding ground glass opacity (Halo sign)
Triad: Pleuritic chest pain, fever and Hemoptysis (Bronchiecstasis) (Thick brown sputum)
Dx: Positive skin test for Aspergillus; Eosinophilia; Aspergillus IgG; elevated Aspergillus and total IgE
Cavitary lesion +/- mobile (positioning pt) fungal ball (aspergilloma-> Hemoptysis
Acute Bronchitis
Symptomatic tx
Fungi
Histoplasmosis
Most common endemic my obsession in US
TB mimicking Disease
Hilar/Mediastinal LAD
Disseminated disease:
Blastomycosis
Long incubation : 3-6 wks
Skin: Wartlike lesions, painless well circumscribed violaceous nodule/heaped up verrucous lesions,
Meningitis
Kernig sign: hip flexed to 90 degrees —> extending knee stretches meningeal lining of spinal cord
—> pain
Cold hands/feet
Mottled skin/pallor
Bacterial:
CSF cloudy
Aseptic: nonpyogenic
Encephalitis
HSV Encephalitis:
Tx: IV Acyclovir
1-6 months opportunistic: CMV, Aspergillus, TB ——> in setting of high dose immunosuppressives
Management
Prophylactic/Tx amoxicillin/clavulanate
Avoid closure
Suppurative Parotitis
Retrograde seeding of bacteria from oral cavity: Staph Aureus, oral flora
Ludwig Angina
Ear pain
Anti viral tx (valcyclovir) can shorten course of acute shingles and reduce risk of PHN
Chikungunya Fever
Aedes mosquito
Severe polyarthralgias
Tx: Supportive
Leprosy
Nearby nerves often become hairless, nodular and tender ----->> Loss in sensory and motor function
Lepromatous form: Thickened forehead etc (leonine facies) -> d/t no Th1 response
Schistosomiasis
Tx: Praziquantel
Tick-borne paralysis
CSF normal
Leukopenia/thrombocytopoenia
Bartonella Henselae
Lyme Disease:
Early localised (days to 1 month): Erythema Migrans, fatigue, headache, myalgias, arthralgias
Heart block, meningitis, Facial N Palsy (often bilateral), Carditis (AV Block)
Tx: Mild/Skin disease —> Oral Abs —> Amoxicillin/ Doxy if >8 yrs
Malaria
Tx: Chloroquine preferred in non resistant areas; artemisin based combo tx;
Africa: P falciparum
Neutropenia Fever
Medical Emergency
NB Neutropoenic pt may not mount a fever with sepsis d/t decreased inflamm cytokines
Rash on wrists and ankles (palms and soles), fever and headaches
Tick bite, no rash, headache, fever, headache, low Plts and WBC, increased ALT
Trim-Sulfa
Parvovirus B19
Transient red cell aplasia
Hepatic Infections
Eggshell calcification on CT
Botulism
Preformed toxin required to infect adult -> inactivated at temperatures of 100 degrees Celsius
4Ds: Dry mouth, diplopia and/or dysarthria, limb paralysis occurs later
DX: Toxin
Wound Botulism
Fever and leukocytosis Within ~10 days (cf hours in food borne)
Dx: CT or US
Salmonella
Typhoidal: Typhoid fever (GI Sx less so)
Contaminated food/water
Non typhoidal: GI Sx
Entamoeba Histolytica
R lobe cystic lesion d/t greater portal blood supply; raised ALP
Giardiasis
Tx: Tinidazole (recommended for pts at high risk of disseminated disease or symptomatic pts)
Untreated can lead to chronic carriage and malabsorption in some —-> Vit def etc
Risk Factors:
Pregnancy
Uncircumcised males
Suprapubic tenderness
UTI in pregnancy: Preterm labour, low birth weight and others, esp in late pregnancy
Complicated UTI
Any UTI that spread beyond bladder/associated factors that increase the risk of antibiotic resistance or
treatment failure
Pyelonephritis
Younger men
Irritating voiding Sx
Fever uncommon
Pts frequently have sxs of recurrent UTIs that transiently improve with Abs
Dull, poorly localised pain in lower back, perineal, scrotal or suprapubic region
Acute Epididymitis
Age <35 STI eg chlamydia
Epididymis oedema
Chylamydia
Complications:
Gonorrhea
Usually asymptomatic in F but symptomatic in MEN
Purulent discharge, dysuria, erythema and edema of urethral meatus, increased frequency
Fever, arthlagias, tenosynovitis (hands and feet) and pustular lesions on hands
Complications:
Salpingitis, turbo-ovarian abscess, Fitz-Hugh-Curtis Syn (perihepatitis, Increased LFTs, RUQ pain)
Dx: Gram stain
Urethritis in Men
Dx: UA; Gram stain & Culture; NAAT —->> ‘culture negative’ likely chlamydia
——>>> as not recoverable on conventional culture nor Gram stained (use NAAT)
4 phases of infection:
Primary infection
Persistent LAD
Constitutional sx
AIDS
Dx: PCR RNA viral load test; P24 Ag Assay (viral load)
Tx: Antiretrovirals
Triple drug regimen HAART targets HIV rep at 3 different points in rep process:
Abacavir: Hypersensitivity: rash, fever, n/v, muscle aches, SOB in first 6wks
Post exposure prophylaxis: AZT, Lamivudine and nelfinavir for 4wks (Triple Drug Therapy)
Pneumonia
PCP
CD4 <200
Elevated LDH
Bilateral diffuse symmetrical Infiltrates on CXR ——>> Bronchoscopy with BAL to visualise bug
TB
Screen all newly dx HIV for latent TB
HIV pts can have false negative PPD d/t low CD4
Diarrhoea
CMV
CD4 <50
MAC
CD4 <50
Cryptosporidium
CD4 <50
Neurological signs
MRI shows diffuse brain atrophy, ventricular enlargement and increased white matter intensity
Dx Clinical w neuropsychological testing
Memory Problems or gait disturbance: AIDS Dementia complex
Multiple ring enhancing lesions: Toxo —> preference for basal ganglia
Tx: HAART
Seizure with de ja vu aura and 500 RBCs in CSF: HSV encephalitis (acyclovir)
Meningoencehalitis: Crytococcus
CD4 <100
PML
Hemisensory Loss, visual impairment, Babinski:
—> motor deficits (focal arm/leg weakness or hemiparesis), ataxia and vision abnormalities
MRI shows well delineated, asym (not diffuse) white mater lesions
HBV
Meningococcus (A,C,W,Y) ages 11-18; large groups living in close proximity; splenic/complement def
Pneumococcus: PCV13 once then PPSV23 8 wks later, 5 years later and at age 65
If CD4 <200 use recombinant inactivated but immune response likely blunted
Do not instigate HAART in setting of acute infection —->> immune reconstitution syndrome
Delay for several wks
Opportunistic prophylaxis
Use TMP/SMX
CD4 <100:
Toxoplasmosis: TMP/SMX
Herpes Simplex
HSV1 lesions of oropharynx: Most ppl acquire in childhood (80% have HSV1)
Transmitted via contact with active ulcerations or shedding from mucous membranes
Herpes labialise (cold sores) most common on lips, painful, heal in 2-6 wks
Most transmission d/t asym viral shedding so abstinence when no outbreak not effective
Disseminated HSV
Immunocompromised usually
Congenital malformations, intrauterine growth retardation (IUGR), chorioamnionitis and even death
Dx: Tzanck smear quickest test, use Wright stain -> Multinucleated giant cells.
Tx: No cure
Primary stage:
Chancre: PAINLESS, hard, crater like (indurated) lesion with clean base
Highly infectious
Secondary stage: Maculopapular rash most common —>> extends to palms and soles
Flu like,
Epitrochlear LAD
Condylomata Lata: Raised, gray/white lesions that develop on mucosal surfaces (mouth, perineum)
Contagious stage
Neurosyphilis: Dementia, personality changes and tabes dorsalis (post column degeneration)
Serology: Nontreponemal tests: RPF (high FN), VDRL (most common). Both +ve in SLE
Tx: Benzathine penicillin (one IM) -> Oral doxycycline for 2 wks if penicillin allergy
PAINFUL genital ulcers: deep with ragged borders and soft, friable purulent base + yellow/grey
exudate
Satellite lesions poss
Unilateral tender inguinal LAD (BUBOES) appear 1-2 wks after ulcer, may suppurate
Dx: Clinically
Tender Inguinal LAD (fluctuated Adenitis buboes) a few wks later (usually unilateral)
Poss constitutional sx
Dx: Serology
Tx: Doxycycline
Dx via examination
Nodules coalescing in PAINLESS granulomatous ulcers-> nodules burst creating fleshy oozing lesions
No LAD!
Biopsy contains Donovan bodies (bipolar staining with safety pin appearance)
Constitutional sx poss
Vaccines
Live attenuated CI in those on immunosuppressives like TNF Antagonists eg adalilmumab for IBD
HPV
Typically asymp and nontender but pruritic, friable lesions may occur
Pts with chronic tobacco use or immunosuppression (HIV) have elevated risk
Dx is clinical
Tx: Topical agents that chemically injure lesion (trichloroacetic acid, podophyllin resin) or
AnoGenital warts in children usually self resolving -> Query sexual abuse in ages >4 to adolescences
Toxins/Poisons
Cyanide toxicity
Nitroprusside use in HTN emergency -> Metabolised to nitric oxide and cyanide ions
Prolonged infusions or high doses increase risk as does renal insufficiency (CKD)
Pulse oximetry usually normal as oximetry does no ddx between oxyHb and carboxyHb
Cerebral hypoxia sx: headache, dizziness, confusion, DROWSINESS, seizure and coma
==> So large oxygen saturation gap (>5% diff bet O2 sat on pulse oximetry & ABG)
Normal PaO2
Tx: methylene blue; high dose ascorbic acid if methylene CI (eg G6PD)
Sx of myocardial ischemia:
Arsenic Poisoning
Organophosphate Poisoning
Muscarinic sx
Sulfasalazine: TNF & IL1 suppressor —-> hepatotoxic; stomatitis; hemolytic anemia
Lead Poisoning
Opiate withdrawal -> First few days of life and can last 4 wks
Medication if refractory
Salicylate Intoxication
Near norm pH