Professional Documents
Culture Documents
Chapter 6: Infectious Diseases
Chapter 6: Infectious Diseases
Chapter 6: Infectious Diseases
Diseases
Specific Diseases
Principles of Antiinfective Therapy Antibiotics
Drug Fever
Specific Antimicrobial Therapy Surgical
Considerations
Necrotizing Infections
Osteomyelitis
Septic Arthritis
Mycology
Viral Diseases
Rickettsial Diseases
Protozoan and Metazoan Infections
INFECTIOUS DISEASE
Specific Diseases
1. VIRAL HEPATITIS: types A, B, non-A, non-B, C, E, and delta
a. Hepatitis B, non-A and non-B cause chronic liver disease that can lead to
cirrhosis
2. AIDS: HIV
a. HIV is one of a number of RNA retroviruses possessing a unique enzyme,
REVERSE TRANSCRIPTASE, which allows the virus to synthesize DNA from
RNA or synthesize DNA backwards; as RNA viruses they can make DNA that
may interfere or incorporate into the DNA of the host cell
b. TARGET-THE IMMUNE SYSTEM:
i. HIV infection follows viral recognition of certain molecular receptors (CD-4)
on the surface of human cells, both the T4 lymphocyte and on the
macrophages and monocytes (This is the key cell surface glycoprotein which
the AIDS virus recognizes and renders those cells carrying this marker
susceptible to infection). As a consequence the HIV infection can lead to
immunodeficiency
ii. With depression of the circulation of the T-helper lymphocyte population,
host response is impaired to a variety of potential pathogens: bacteria,
mycobacteria, viruses, fungi and helminths
iii. It is known that 40-50% of individuals infected with HIV and having less
than 400/mm circulating T-helper cells will develop the manifestations of AIDS
within 2 years, 80-85% will develop manifestations of AIDS if their T-helper
lymphocyte count is less than 200/mm
iv. Also associated with depression of the T-helper lymphocytes, the natural-
killer (NK) lymphocytes' function are also disrupted (these NK cells are
involved in immune surveillance against neoplasms and virusinfected cells)
v. Also associated with depression of the T-helper lymphocytes is depression
of immunoglobulin (antibody) producing B-lymphocyte, which ultimately leads
to the body's decreased responsiveness to vaccines
c. TARGET -THE CNS: HIV also targets the central nervous system leading to a
subacute encephalitis (AIDS encephalitis)
d. CLINICAL MANIFESTATIONS: A classification for the clinical spectrum of HIV
for adults has been proposed by the C.D.C.: thinking of the potential
consequences of the virus infection on a time line
i. GROUP I- Includes people manifesting acute HIV, transient and selflimited,
characterized by fever, rash, malaise, lymphadenopathy. Incubation period 4-
6 weeks after exposure (can be longer). The illness is characterized by
serologic conversion to HIV (+ anti-HIV antibody test)
ii. Group II- Asymptomatic infection with a positive serology and virus culture,
a positive serology but no manifestations of CNS disease (called a Latent
state)
iii. Group III- Persistent generalized lymphadenopathy, palpably enlarged
lymph nodes (> 1 cm) at 2 or more extra-inguinal sites persisting for more
than three months in the absence of any other cause: May have other
manifestations of the disease
iv. GROUP IV- Other diseases; individuals in this group have one or more
significant immunodeficiency or CNS disease, divided into 5 .subgroups
according to manifestations:
Subgroup A: Constitutional disease (fever, weight loss)
Subgroup B: Neurologic disease (progressive dementia, peripheral
neuropathy and myelopathy)
Subgroup C: Infectious diseases (pneumonia, histoplasmosis, herpes
simplex, cryptococcosis, et. al.)
Subgroup D: Secondary cancers ( Kaposi's sarcoma, non-Hodgkins
lymphoma)
Subgroup E: Other diseases (chronic lymphoid interstitial pneumonitis)
e. CLINICAL MANIFESTATIONS BY ORGAN SYSTEMS:
i. General- fatigue, weight loss, fever and sweats
ii. Dermatologic- rashes (particularly fungal), seborrheic dermatitis, psoriasis,
nail changes and pigmented lesions
iii. Pulmonary- unexplained cough and shortness of breath
iv. Head/ENT- persistent sinus congestion, sore throat, discoloration of the
oral mucosa and tongue
v. Gl- diarrhea
vi. Neurological- headaches difficulty comprehending, behavioral changes,
numbness or tingling
f. TESTING: Seroconversion to a positive HIV antibody test may occur from 4-8
weeks following the acute illness (fever, fatigue, diarrhea, weight loss, night
sweats, and generalized lymphadenopathy).
i. The ELISA (enzyme-linked Immunosorbant Assay) is the primary screening
test to detect the antibody to HIV-1
ii. The Western Blot (Immunoblot) test is used to confirm the validity of the
ELISA test.
iii. A new detection test called the Polymerase Chain Reaction (PCR)
demonstrates amplified proviral DNA in lymphocytes, months to years before
antibody can be detected by ELISA or Western Blot technologies
*Zier BG, Essentials of Internal Medicine in Clinical Podiatry, Philadelphia, Saunders, 1990, pg
327
NOTE* There have been studies proving that 70% of all implants have slime
forming bacteria present in large numbers, yet there is no infection.
Therefore the value as mentioned 102 is only mentioned as a reference
point for the board examinations
NOTE* The 5 cardinal signs of infection are: RUBOR, TUMOR, DOLOR, CALOR,
and FUNCTIO LASEA
ii. Systemic signs consistent with fever > 100 degrees F or 37.7 C, with
lymphadenopathy, lymphangitis, shakes, chills and malaise
iii. Lab Studies- X-rays, Bilaterally (always serve as a base line for future
reference)
Organism Morphology
Gram Positive: Staphylococcus Cocci in grape-like clusters
Streptococcus Cocci In chains
Clostridium Bacilli (rods) with a "racquet shape"
Corynebacterium Rods In "Chinese characters"
Gram Negative: Neisseria Diplococcus (usually
Intracellular)
Note* The current literature states that there is no significant difference in
Pseudomonas Slightly
postoperative infection rates between one dose,curved rod three dose or one
two dose,
Haemophilus/Pasturella Coccold rods
week of prophylaxis
E. Coll/Shigella/Serratla/
Enterobacter/Bacteroldes Straight rods
Strep pyogenes and Pseudomonas.
Best drugs are 1st gen. cephalosporins, vancomycin or clindamycin in the
penicillin allergic patient
d. Antibiotics should be administered no less than 5 minutes before inflation
of the tourniquet and no more than one hour before surgery.
Antibiotics
The best antibiotic is the one that has the narrowest spectrum, the safest,
the cheapest
1. The Penicillins
a. Penicillin G: Parent compound introduced in the 1940's
i. Good gram(+) and weak gram(-) coverage
ii. Fallen out of favor since many resistant strains (Staph 100% Beta
lactamase producing)
iii. 1 mg PenG= 1667 units
iv. Available as Aqueous (10-30 million u/day) and Procaine (600,000 u Q1 2h)
b. Penicillin VK:
i. Used in severe erysipelas and rheumatic fever prophylaxis
c. Methicillin:
i. For PCN-ase resistant organisms
ii. IV form only
iii. Can cause thrombophlebitis
d. Oxacillin/Dicloxicillin/Cloxacillin/Nafcillin: (PRP's)
i. PCN-ase resistant
ii. Good gram(+) coverage
iii. Oral form can cause diarrhea
iv. Requires frequent dosing, Q4-6 hours
e. Ampicillin: Increased gram(-)coverage
i. Not PCN-ase resistant
ii. Used with UTI, typhoid fever and salmonella infections
iii. Used pre-op for endocarditis prophylaxis
iv. Used in combination with aminoglycosides for gram(-) septicemia
f. Carbenicillin: The original anti-pseudomonal penicillin
i. Can be combined with aminoglycoside for pseudomonas infection
ii. Not used much now since has high sodium content, hepatotoxic,
neurotoxic and causes bleeding disorders
iii. Oral form: Geopen (UTI's only)
g. Ticarcillin: A 4th generation penicillin active against pseudomonas
i. 2-4 times more potent than carbenicillin vs pseudomonas
ii. Has increased anaerobic activity
h. Piperacillin: As above, gram(+) 9 (-) activity
i. Azlocillin: As above but superior to ticarcillin/piperacillin vs pseudomonas
aeruginosa
i. Neurotoxic/Hepatotoxic
j. Mezlocillin (Mezlin): A 4th generation penicillin with good gram(-) and
anaerobic activity
i. Can be used for Pseudomonas/B.fragilis
2. The Clavulanates
a. Amoxicillin/clavulanate (Augmentin): Adds clavulanic acid to ampicillin
which inactivates the beta-lactamase enzymes:
i. PCN-ase resistant
ii. Spectrum of activity increased vs gram (-) to include E.Coli & Klebsiella,
also good Staph and Bacteroides coverage
iii. The oral drug of choice for cat, dog and human bites
iv. Dosed at 250-500 Q 8h (for other than endocard prophylaxis)
b. Ticarcillin/clavulanate (Timentin): Has greater gram(-) coverage than any
4th gen. penicillin
i. Has good gram(+) coverage and covers anaerobes well (i.e. B. fragilis)
ii. Good drug for initial therapy for moderate diabetic foot infections
iii. Has high sodium load/use cautiously in hypertensive-renal pt's
iv. Dosed at 3.1 Q 6-8h (3gm ticarcillin + 100mg clavulanate)
3. The Sulbactams
a. Ampicillin/ sulbactam (Unasyn):
i. Similar to Timentin but has much lower sodium load
ii. Adds sulbactam, a beta-lactam inhibitor
iii. 99% coverage against B.fragilis/not good against
pseudomonas and good against enterococcus
iv. Dosed at 1.5-3g Q 4-6h.
NOTE* Unasyn has better gram (+) coverage than Timentin, but weaker
gram (-) coverage 4.
The Tazobactams
a. Piperacillin/Tazobactam (Zosyn)
i. Similar to Timentin in coverage and spectrum
ii. Adds Tazobactum a Beta lactamase inhibitor
iii. Has greater activity than pipericillin
iv. Dosed @ 3.375 gm Q 6 hrs
5. The Cephalosporins
Semi-synthetic compounds derived from the mold, cephalosporum
acremonium. There is a cross reactivity with penicillin allergic patients from
5-20% depending upon the source. As a whole, these antibiotics
are well tolerated, non-toxic and broad spectrum. They are categorized in
generations, which define their spectrum.
NOTE* Zinacef® and Mandol® are better than 1st generation for Staph iii.
coverage
Activity vs gram (-): as with 1st generation (PECK) plus H. flu, Enterobacter &
Neisseria (HENPECK)
c. 3rd generation:
i. Claforan (cefotaxime), Cefobid (cefperazone), Cefizox (cefizoxime),
Rocephin (ceftriaxone), Fortaz (ceftazidime), Suprax (cefixime), Vantin
(cefprodoxime proxetil)
ii. ACTIVITY vs gram (+): variable to both Staph and Strep
iii. Activity vs gram (-): as with 2nd generation (HENPECK) plus Serratia,
Morganella, Providencia, Citrobacter and Pseudomonas
NOTE* ROCHEPHIN HAS THE LONGEST HALF LIFE OF ANY 3RD GENERATION
CEPHALOSPORIN, THEREFORE CAN BE DOSED AT ONCE A DAY.
FORTAZ and CEFOBID HAVE THE BEST ACTIVITY AGAINST PSEUDOMONAS.
METHICILLIN RESISTANT STAPH AS WELL AS GROUP D STREP
(ENTEROCOCCI) ARE RESISTANT TO ALL CEPHALOSPORINS
6. Other Beta-Lactams:
a. Imipenem/Cilastatin (Primaxin): Is an extremely potent antibiotic with the
broadest spectrum of an available beta lactam including anaerobic coverage/
most expensive antibiotic on the market. Cilastatin is added to prevent renal
hydrolysis (destruction of imipenem)
i. May be the drug of choice in severe/limb threatening diabetic infections ( as
initial therapy) other than clinda/genta/ampi
ii. Major therapeutic use for Gram (+) cocci and aerobic gram (-) bacilli
iii. A 3% cross sensitivity with penicillin allergic patients
Dosed at 0.5-1 gram Q 6h IV up to 4gm/day
b. Azreonam (Azactam): Is ONLY effective against gram (-) aerobes, including
P. aeruginosa
i. Can be combined with clindamycin in penicillin allergic patients when
gram(+)and anaerobes are suspected
7. Quinolones:
a. Ciprofloxacin (Cipro):
i. Its main benefit is it's p.o. gram (-) coverage
ii. Can be used for methicillin resistant staph but should be combined with
rifampin (300 mg BID) in the treatment of these infections
iii. Contraindicated in its use with children as it can cause cartilage
degeneration
iv. Can be combined with clindamycin (Cleocin) or metronidazole (Flagyl) in
the treatment of diabetic foot infections
v. Oral therapy for osteomyelitis when caused by Pseudomonas
vi. Rarely a first line antibiotic
b. Ofloxacin (Floxin):
i. As with the above, but with better gram (+) coverage
ii. Dosed for soft-tissue infections at 400 mg Q 12 h
8. Aminoglycosides:
a. Streptomycin: (used in treatment of TB)
b. Kanamycin (used as an irrigant)
c. Gentamycin: used with methylmethacrylacte beads (PMMA) for
osteomyelitis and in triple antibiotic therapy for serious infections
d. Potentially ototoxic in patients with renal problems
NOTE* Gentamycin is a good drug for use with PMMA because of its good
water solubility, heat stability, and broad antibacterial spectrum. Most
studies have fabricated PMMA beads utilizing 1-2 g of antibiotic powder
to 40-60 g of PMMA
d. Tobramycin (less ototoxic than gentamycin)
e. Amikacin (reserved for serious infections against aminoglycoside resistant
organisms)
f. As a group these antibiotics have well documented toxicities
(ototoxicity/hepatotoxicity). g. They are essentially anti-gram negative
agents, but do have gram positive coverage. When using these antibiotics it
is beneficial to, have an ID consult and you should perform peak/trough
serum levels as well as creatinine clearance and BUN tests (if BUN elevated
increase time span between doses or lower the dose)
NOTE* Aminoglycosides (gentamycin/tobramycin) must be monitored to keep
the peak level just below 10 micrograms/ml and the trough level below 2
micrograms/ml and Amikacin peak at 20-30 µ/ml and trough less than 10
µ/ml. The peak should be drawn within 30 minutes after infusion of the drug
and the trough level should be determined by drawing another blood sample
15 minutes prior to the next dose. The calculated dose of aminoglycosides
should be given Q 12 or 24 h (never Q 8)
9. Other antibiotics:
a. Vancomycin:
i. Indicated in penicillin allergic patients or those patients needing coverage
against gram (+) organisms, including methicillin resistant Staph
ii. It is possibly nephrotoxic and should be monitored carefully
iii. Red neck syndrome occurs if infused too quickly (not an allergy)/severe
hypotension can result
iv. Oral form is for pseudomembranous colitis only
NOTE* Peaks and troughs for vancomycin can be done. The peak is 20-30,
and the trough is <10
b. Clindamycin:
i. It is used extensively for anaerobic infections and in the penicillin allergic
patient for gram (+) coverage
ii. Can cause pseudomembraneous colitis
c. Tetracycline:
i. A broad spectrum antibiotic used for rocky mountain spotted fever,
Lyme disease, and H. pylori infection
ii. To be avoided in children and pregnant/ nursing mothers (brown
teeth)
d: Metronidazole (Flagyl):
i. An amebicidal drug also with excellent anaerobic coverage
ii. Can be combined with Cipro for more complete coverage
e. Erythromycin, clarithromycin (Biaxin), azithromycin (Zithromax)
Drug Fever
Fever is considered to be drug induced if no other infections or noninfectious
cause is present on the basis of clinical or laboratory evidence, if there is no
known underlying disease or condition, if the temperature elevation is
temporarily associated with the administration of a "sensitizing" medication
and if the fever disappears within 72 hours of discontinuation of the
medication.
4. Gram (-): When a gram stain is received and initial therapy is to be started
prior to a C & S the following should be considered: Cipro 750 mg Q1 2h,
Azactam 1 gm Q8h IV, Gentamicin 3-5 mg/kg _IV following a loading dose,
Timentin and Fortaz 1-2 gms Q8h IV, Zosyn (tazobactam/piperacillin) 3.375
gm Q6 IV
Surgical Considerations
Probably the single most important factor in the control of a postoperative
infection is local care of the wound. Unless all areas of abscess formation and
pus are drained and devitalized tissue excised the adjunctive therapy of moist
dressings, antibiotics etc., will be of little value. The exception to this is a
rapidly ascending cellulitis without areas of abscess formation in which
surgical debridement would be of no value.
1. Outline of General Surgical Principles: try not to use tourniquets, try
using regional anesthesia and not local anesthesia which can spread the
infection:
a. Sterile skin prep of foot
b: If a post-op infection, release all skin sutures
c. Explore the extent and depth of the infection, breaking up any loculations if
present, not extending into uninvolved areas
d. If the infection has gone below the subcutaneous layer explore and remove
any deep sutures or necrotic tissue, opening the wound to the deepest
portion of the infection
e. If the infection penetrated the joint capsule, the capsule must be opened, if
an implant is used it must be removed, the bone and cartilage must be
carefully inspected to determine the involvement
f. If an infection extends proximal and distal to a joint both the proximal
phalanx and metatarsal neck must be explored
g. If osteotomies have been done external fixation devices should be
removed
h. Once the extent of the infection is determined all devitalized soft tissue
and bone must be removed
i. Samples of deeper tissue and bone, if excised, should be submitted to
pathology for microscopic .examination as well as to microbiology for culture
and sensitivity tests
j. All implant material when removed should be sent to microbiology for
culture and sensitivity tests in order to isolate organisms which may be firmly
attached to the device and not found within the soft tissues k. The wound
should then be copiously lavaged with large volumes of 1% Betadine solution
followed by sterile saline or Ringer's lactate
l. The wound should be packed open with 1/4 or 1/2 inch iodoform gauze for
hemostasis and drainage and covered with gauze soaked in sterile saline or
Ringers lactate. When this dries it acts as a mechanical debriding agent
m. Immobilize and elevate the extremity
n. Keep extremity warm (can use Microtemp heating unit at 102°F)
o. Post surgically, the packing should be changed on a daily basis, and as the
wound starts to granulate less and less packing is necessary p. When
granulation tissue has completely filled the defect, closure of the wound is
attempted, however, for small to moderate surface defects, delayed primary
closure with skin adhesive strips to gradually bring the skin edges together is
attempted within three days after surgical debridement
q. If repeated cultures are negative and clinical appearance of the wound is
clean and well granulated, then the patient can return to the operating room
for irrigation and resuturing of the wound, which is attempted within 4-5 days.
This type of delayed primary closure should be avoided if the defect is large
and/or if the suture closure places excessive tension on the wound
r. If the defect is large the patient may undergo skin grafting when conditions
are right
Necrotizing Infections
The classification of necrotizing infections is difficult. Prompt and oftentimes
empirical medical and surgical therapy must be initiated to save life and limb.
Even with early intervention the rate of amputation and mortality is high, with
all of these patients having some underlying predisposition: trauma, surgery,
burns, malignancy, diabetes mellitus, immunosuppression, human bite
wounds, injection injuries, puncture wounds and PVD.
1. Necrotizing Fasciitis: Widespread necrosis of subcutaneous tissue
YOU MUST TREAT THIS WITHIN 48 HRS
a. Signs and Symptoms:
i. Fever, tachycardia, anemia, shift left and > bilirubin
ii. Hot/edematous/indurated/erythematous extremity
iii. The skin is shiny and smooth with vescicles & bullae filled with a
reddish-brown fluid
iv. Cutaneous anesthesia
v. Later: Tissue slough with grey necrotic subcutaneous fat and fascia b.
Causative organisms- Strep predominates
c. Diagnosis:
i. Extensive necrosis of the superficial fascia
ii. Toxic reaction/altered mental states iii. Absence of muscle involvement
iv. Absence of clostridium as the primary organism
v. No major vascular occlusion is present
d. Differential diagnosis- Lymphangiitis, Clostridial gas gangrene,
synergistic (the aerobes help the anaerobes proliferate) necrotizing
fasciitis/cellulitis and progressive bacterial synergistic gangrene
e. Treatment:
i. Stabilize the patient medically
ii. Penicillin/Gentamycin/Clindamycin or Primaxin
iii. Aggressive incision and drainage with multiple incisions
iv. Daily irrigation and packing
Osteomyelitis
1. Definitions:
a. Osteomyelitis- infection of bone (chronic OM & acute OM, the distinction of
which will determine treatment regime)
b. Sequestrum- dead necrotic bone separated from the affected bone
c. Involucrum- a chronic process where new bone is laid down around dead
bone
d. Cloaca- an opening in along the cortex from where the pus drains
e. Rarefaction- localized loss of bone density (earliest radiological finding
when 30-50% of the osseous mineralization has been lost)
f. Bone abscess ( Brodie's abscess)- localized focus of infection within bone
usually found in the metaphyseal region of tubular bones, but can be
occasionally found in the diaphysis (Chronic/subacute OM)
f. Chronic Sclerosing Osteitis (Garre's)- a low grade infection causing sclerotic
reaction without destruction or sequestration
2. Classifications:
a. Hematogenous (AHO)- a form of OM caused by spread of bacteria via the
bloodstream, originating within cancellous bone, which will result in
radiographic findings that start inside the bone and eventually work out to the
cortex and periosteum. Seen mostly in the metaphyseal region in children
with open epiphyseal plates, occurring most commonly in the calcaneous
and femur. In adults it is most commonly seen in the metatarsal heads
b. Direct Extention- is secondary to trauma or surgery, will first effect the
periosteum, then the cortex and finally the marrow. Proteolytic enzymes
destroy Sharpey's fibers
c. Contiguous- is the spread of infection from contiguous soft tissue to the
underlying bone, also will first effect the cortex and finally the marrow
d. Vascular insufficiency
a. Symptoms (AHO):
i. Local warmth over the infected area
ii. Pain and tenderness on ambulation and palpation
iii. Pseudoparalysis (often the only complaint in kids) and possible subtle gait
changes
iv. Palpable swelling if the infection has ruptured the cortex into the
periosteum
v. Ulceration or soft tissue lesion(s) may produce contiguous OM
vi. Concurrent infection: Measles/chicken pox may give strep AHO.
Middle ear infections may give hemophilus/pneumococcus/staph
AHO
b. History & Physical: In pediatric AHO recent infections may be implicated as
causative pathogens
c. Laboratory Exams:
i. Same basic studies as with management of inpatient infection
ii. Leukocytosis or a shift left is not commonly seen in acute or chronic OM
iii. Sed Rate is usually increased (a nonspecific exam useful to monitor the
response to treatment)
d. Radiographs:
i. Always take bilateral x-rays for comparative purposes
ii. The lytic process in bone is not visable on x-ray until at least 30%50% of
the osseous mineralization of the area has been lost
iii. The first bone changes occur 10-14 days following the onset of symptom
iv. Baseline radiographs must be taken- (look at the soft tissue first, may find
edema in the contiguous soft tissues, with swelling of one tissue layer as
compared to another)
v. Three stages of soft tissue changes have been discribed in children with
AHO: small deep local. soft tissue in region of metaphysis, swelling of muscles
and obliteration of lucent plane between them and superficial subcutaneous
soft tissue edema which occurs 3 days after onset of symptoms (if aspirate
bone during this phase, should be able to extract pus).
vi. Additional radiographic findings are: periosteal elevation, metaphyseal
destruction (children), regional osteoporosis, sequestrum and involucrum.
vii. Radiographic findings in chronic OM are:
thickened/irregular/sclerotic bone, elevated periosteum, chronic draining
sinus and sequestrum
e. Aspiration (bone/joint biopsy): Confirms the diagnosis, identifies the
organism and aids in determining the treatment plan.
f. Blood Cultures:
i. Are positive in 50% of cases of septic arthritis and osteomyelitis.
ii. The joint fluid in septic arthritis is sterile in 30% of the cases- look at the
blood cultures.
g. Wound cultures:
i. Sinus tract cultures frequently yield gram(-) organisms which are not
responsible for the underlying bone infection.
ii. If Staph aureus is cultured out, there is a 50% chance that this organism is
producing the associated osteomyelitis.
h. Bone cultures:
i. Take specimens for gram stain, aerobic, anaerobic, fungal and acid
fast cultures
ii. Take a specimen for histology
i. Bone Scans:
i. In most patients with osteomyelitis, bone scintograms become positive
within 48-72 hours after onset of clinical symptoms (precedes the x-ray
changes by 10-14 days)
ii. Predominant scintigraphic finding is a "hot spot" (increased tracer
localization)
iii. The exception to this are "cold spots" which is due to NO delivery of the
tracer due to necrosis or a fulminating destructive osteomyelitis not
accompanied -by significant reparative processes
99m Technetium MDP: is currently the most frequently used radionuclide
It is renally excreted, has a half-life of 6 hours, deposits more in trabecular
than cortical bone and provides more anatomic information with less time,
exposure and expense than Gallium 67 imaging. 99m TC MDP may continue to
show abnormal isotope accumulation after infection subsides as a result of
continued bone repair.
Three Phase Bone Scan: is used to differentiate OM from cellulitis.
Phase 1- at time of injection shows an immediate radionuclide angiogram or
dynamic blood flow, OM and cellulitis both show increased uptake at this
point.
Phase 2: 5-10 minutes after injection looking for focal increases (blood pool
image) cellulitis and OM are still positive at this point.
Phase 3: 4 hours after injection (delayed static scan), cellulitis becomes
quiescent at this point.
j. Gallium 67: Almost all IV injected Gallium binds to transferrin, with 1/3
excreted by the G.I. tract and 1/3 by the kidneys. More tracer is localized in
the metaphyseal area. Imaging is done 48 hours after tracer administration.
Resolution of anatomical detail for bone lesions is considerably less with
Gallium than with 99m TC MDP, with higher radiation exposure. This scan is
preferred to 99m TC MDP in evaluating the response to treatment and is not
as dependant on blood flow. More specific in differentiating. bone tumors
from osteomyelitis and more reliable in assessing subacute and chronic
infections.
k. Multiple Tracer Studies: When both types of study are needed the bone
scan scan should precede the Gallium scan by 24 hours. The following lists
some scenarios when multiple studies are used:
(+) 99m Tc MDP & (+++) Ga67= infection in the presence of an implant
l. 111 Indium White Cell Scanning: This scan is much more specific for
infection. With this scan, white blood cells are labeled with the tracer (Indium)
and injected intravenously. This technique was developed to detect leukocyte
accumulation at sites of inflammation and abscess formation. Scans are
performed 24 hours after injection. A positive scan is defined as a focal
accumulation of leukocytes that is higher than in the surrounding bone. This
technique is reserved for complicated posttraumatic or post-surgical patients
with equivocal conventional bone scans, in cases where 99m TC MOP
scanning reveals false positive results because of rapid turnover. Therefore, it
may be more accurate in detecting acute infections.
6. Contiguous Osteomyelitis:
a. Most common form of OM seen in podiatry.
b. Chronic ulcerations may frequently lead to contiguous OM.
c. May develop when an infection arises in an area adjacent to bone in which
a malignancy is present or bone has received radiotherapy.
d. Staph aureus is the most frequent pathogen.
8. Chronic Osteomyelitis:
a. Long standing OM is associated with sequestration.
b. Indolence of the infection is sometimes related to the suppressive effects
of antibiotics in low doses.
c. Staph aureus is the most common pathogen.
d. The phalanges and metatarsal heads are the most common sites. e. The
sed rate is elevated in 57% of these patients. f. Increased warmth over the
infected area found in 94% patients.
g. Pathogens residing in the "dead bone" if not removed along with the
sequestra, can cause acute flare ups as late as 50 years after the initial
episode.
NOTE* Oral antibiotic therapy prescribed after the original puncture wound
may contribute to a later OM infection
Septic Arthritis
1. Occurs most commonly in infants and children
2. Adults will generally have an underlying disease
3. Pathogens vary according to the age of the patients with S. aureus
predominating in all age groups
a. H. influenza 2nd most common organism in patients under 2
b. N. gonorrhea 2nd most common organism in adolescents
c. Enterobacter and pseudomonas 2nd most common organisms in patients
older than 50
4. Diagnosis is made via sterile aspiration of pus with a positive gram stain
and C&S.
Mycology
1. Superficial Mycoses
a. Tinea Versicolor
b. Candidiasis
c. Onychomycosis
d. Tinea capitis
e. Tinea corporis
f. Tinea pedis
g. Tinea cruris
h. Trichomycosis axillaris
Viruses are the smallest and most simple biologic units that can manifest the
essential aspects of a living substance. Some important facts about viruses
are:
They are composed of an outer coat of protein and an inner core of nucleic
acid
The viruses reproduce heritable characteristics in a predictable manner
during multiplication and demonstrate genetic continuity
A virus infected cell is immune to reinfection by the virus and also immune
to infection from other viruses usually related to the one which infected it
The virus infected cell can support the reproduction of the virus which
entered it and may produce new virus particles in a relatively short time
The most common form of damage in cells supporting viral reproduction is
a cytopathic effect which leads to deterioration and results in death and
disintegration
Viruses are classified according to the target organ and similarity of action.
They are:
1. The pox group (vaccinia and smallpox)
2. Neurotrophic viruses (poliomyelitis, rabies, and arthropod-transmitted
encephalitis including Japanese, St. Louis encephalitis, equine encephalitis
and aseptic meningitis)
3. Viseotrophic viruses (yellow fever, infectious hepatitis and homologous
serum hepatitis)
4. The herpes group
5. Varicella and herpes zoster
6. The myxoviruses (mumps and influenza)
7. The lymphogranuloma psittacosis group
8. Miscellaneous viruses (measles, rubella, Coxsackie viruses, the common
cold, warts, etc.)
9. Bacteriophage
Rickettsial Diseases
Rickettsial diseases are caused by intracellular microorganisms which are
classed between bacteria and viruses, and have characteristics of both. These
pleomorphic, cocco-bacillary organisms can cause acute, febrile, self-limited
symptoms usually accompanied by a skin rash. The group of diseases
includes typhus, Rocky Mountain spotted fever, tsutsugamushi, and Q fever.
Diagnosis is via serologic testing (the Weil-Felix test is useful)
1. Protozoan infections
a. Amoebic dysentery
b. Malaria
c. Trypanosomiasis
d. Leishmaniasis
e. Toxopiasmosis
NOTE* Stool examination for the egg larvae and the organisms themselves
are diagnostic for some intestinal protozoa and metazoa. Blood smears
using special staining techniques aid in the diagnosis of some protozoan
infections. Some special stains can detect protozoa in tissue biopsies