Infectious Diseases

Fungal Infections
Sporothrix schenckii is a dimorphic fungus found in the natural environment in the form of
mold (hyphae). Itresides on the bark of trees, shrubs and garden plants and on plant debris in
soil. Sporotrichosis is commonin gardeners. The initial lesion, a reddish nodule that later
ulcerates, appears at the site of the thorn prick orother skin injury. From the site of inoculation,
the fungus spreads along the lymphatics forming subcutaneousnodules and ulcers. Adenopathy
and systemic signs of infection are usually absent.

Coccidoidomycosis - Coccidioidesis endemic in the southwestern US, as well as Central and

South America and causes pulmonary infection. A patient from Arizona/California should make
youthink of coccidioidomycosis. Cutaneous findings such as erythema multiforme and
erythema nodosum are common.

Invasive aspergillosis occurs in immunocompromised patients (e.g .. those with neutropenia.

those taking cytotoxic drugs such as cyclosporine and those taking very high
dosesofglucocorticoids). Invasive pulmonary disease presents with fever, cough, dyspnea or
hemoptysis. Chest x-ray may show cavitary lesions. CT scan shows pulmonary nodules with the
halo sign or lesions with an air crescent.

Mucormycosis - The most common etiologic agent is Rhizopus. Poorly controlled diabetes
mellitus predisposes to this disease. Low-grade fever, bloody nasal discharge, nasal congestion
and involvement of the eye with chemosis,proptosis and diplopiaare important features.
Involved turbinates often become necrotic. Invasion of local tissues can lead
toblindness.cavernous sinus thrombosis and coma. If left untreated. mucormycosis can lead to
death in daysto weeks.
It requires aggressive surgical debridement plus early systemic treatment with amphotericin B,
which is the only effective drug against this fungus.

Blastomycosis is endemic in the south-central and north-central US. It usually affects the
lungs,skin, bones, joints and prostate. Infection in immunocompetent hosts is uncommon.
Primary pulmonary infection isasymptomatic or presents with flu-like symptoms. Cutaneous
disease is either verrucous or ulcerative.Verrucous lesions are initially papulopustular, and
then progressively become crusted, heaped up and warty,with a violaceous hue. These lesions
have sharp borders and may be surrounded by microabscesses. Wetpreparation of purulent
material expressed from these lesions shows the yeast form of the organism.
Blastomyces Blasts through Skin, Bones & Joints.

Histoplasmosis is most common in the southeastern, mid-Atlantic and central US. It

canmanifest as an acute pneumonia, which presents as cough, fever, and malaise. Other
possible
manifestations include chronic pulmonary histoplasmosis and disseminated histoplasmosis
(more common in HIV patients). Skin lesions are uncommon.
 Human Immunodeficiency Virus

A modified acid-fast stain showing oocysts in the stool is very suggestive of an infection with
Cryptosporidium parvum.This organism can cause severe diarrheal disease in both
immunocompetent and immunocompromised individuals. HIV-infected patients with a more
preserved CD4 counttend to have a self-limiting illness, whereas AIDS patients with CD4 counts
< 180 cells/mm3 tend to have a more persistent clinical course.

HIV Screening :

Vaccinations In HIV
Pneumococcal vaccine is recommended for all HIV-infected patients whose CD4 count is above
200 cells/microL. Annual influenza vaccination is also recommended for all HIV-infected
patients.

HIV Post-Exposure Prophylaxis

Whenever a healthcare worker is exposed to the blood or blood products of HIV-infected
patients, testing forHIV should be performed immediately to establish the person's baseline
serologic status. Repeattestingshould be performed after 6 weeks, 3 months and 6 months.
Once the blood is drawn for baseline serologicalstudies, HIV postexposure prophylaxis should
be started without delay. Prophylaxis includes a combination of two or three drugs. Two
nucleoside reverse transcriptase inhibitors are typically used. If a third drug is used,it is usually
a protease inhibitor. Addition of a third drug increases the efficacy of the two-drug
regimen.Three-drug prophylaxis may be routinely used in all patients, but is particularly
indicated for exposures thatpose an increased risk for transmission(i.e., very low CD4 count,
high viral load, andhigh-risk type of injury such as deep percutaneous injury with a hollow-bore
needle).

Esophagitis Three possible causes of esophagitis in HIV patients areCandida, CMV & HSV.
Candida Esophagitis
The most common cause of dysphagia/odynophagia in an HIV patient is candida esophagitis. If
these symptoms develop, an initial one- to two-week course of empiric oral fluconazole should
be prescribed.

CMV Esophagitis
Ifsymptoms persist despite therapy, endoscopy with biopsy should be performed to investigate
other possible etiologies. HIV patients with severe odynophagia but without oral thrush are
likely to have ulcerative esophagitis, which is most often caused by cytomegalovirus (CMV). The
triad of 1) focal substernal burningpain with odynophagia, 2) evidence of large, shallow,
superficial ulcerations. and 3) presence of intranuclearand intracytoplasmic inclusions is
diagnostic of CMV esophagitis. The treatment of choice is IV ganciclovir.

HSV Esophagitis
Herpes simplex virus (HSV) esophagitis is also a common cause of esophagitis in HIV
patients.The ulcers of HSV esophagitis are usually multiple, small, and well circumscribed and
have a "volcano-like"(small and deep) appearance. Cells show ballooning degeneration and
eosinophilic intranuclear inclusions. Acyclovir is the treatment of choice.
Diarrhea in HIV - Causes of diarrhea in HIV patients include

Non-opportunistic infections (e.g .. Salmonella, Campylobacter, Entamoeba, Chlamydia,

Shigella and Giardia Iamblia).

Opportunistic infections (e.g .. CMV. Cryptosporidium,Isopora belli, Blastocystis, MAC,

Herpes simplex virus, Adenovirus and HIV itself). and

Non-infectious causes (e.g .. Kaposi sarcoma or lymphoma of the Gl tract).

Hematochezia and lower abdominal cramps are usually due to colonic infection with CMV,
Clostridium difficile, Shigella, E histolitica or Campylobacter.

The etiology must be identified before starting antibiotic therapy. Evaluation ofdiarrhea in HIV-
infected patients shouldfirst begin with include stool culture examination for ova and
parasites and test for C. difficile toxin.

Colonoscopy and biopsy of the mucosa and/or any ulcers are reserved for those with persistent
diarrhea and negative stool examination.
In an HIV-infected patient, bloody diarrhea and a normal stool examination are highly
suspicious for CMV colitisand warrant a colonoscopy with biopsy. CMV is a common
opportunistic pathogen in HIV-infected patientsand may cause esophagitis, gastritis, colitis,
proctitis or small bowel disease. In CMV Enteritis, the patientpresents with the typical
presentation of CMV colitis: chronic bloody diarrhea, abdominal pain and a CD4count less than
50 cells/~L. Colonoscopy shows multiple mucosal erosions and colonic ulceration. Biopsyshows
the presence of large cells with eosinophilic intranuclear and basophilic
intracytoplasmicinclusions("owl's eye" effect). The treatment of choice is ganciclovir.
Foscarnet is used in case of ganciclovir failure orintolerance.

TB in HIV
In HIV-infected patients, tuberculosis carries a very high risk of progression to active disease.
For this reason, all PPD-positive HIV-infected patients should be given prophylactic treatment.
PPD testing is consideredpositive in HIV patients when there is 5 mm or more induration within
48-72 hours of intradermal injection of 5tuberculin units. Isoniazid is the drug of choice for
chemoprophylaxis and is given for 9 months in PPDpositive HIV-infected patients. Pyridoxine is
added to the regimen to prevent possible neuropathy caused by isoniazid. Pyridoxine does not
prevent isoniazid-induced hepatitis and thus periodic liver function tests shouldbe monitored in
these patients.

Nocardia
Pulmonary cavitation in an HIV-inlected patient can be caused by a number of different
organisms, IncludingMycobacterium tuberculosis, atypical mycobacteria, Nocardia, gram-
negative rods, and anaerobes.Nocardia is a gram-positive, weakly acid-last, filamentous
branching rod found in soil and water. Nocardia(usually N. asteroides) is an important cause of
infection in immunocompromised hosts, such as HIV patientsor organ transplant recipients or
those on high dose steroids. The lung is the most frequently involved organ and infection can
manifest asnodules, a reticulonodular pattern, diffuse pulmonary infiltrate, abscess or cavity
formation. Diagnosis ofNocardia is difficult. A presumptive diagnosis can be made it partially
acid-last, filamentous. branching rodsare seen in clinical specimens. The treatment of choice is
trimethoprim-sullamethoxazole.

Cavitary Lung Lesions in HIV – Typical & Atypical Mycobacteria & Nocardia.

Histoplasmosis
Histoplasma capsulatum is a dimorphic fungus that is found as a mold in soil. It is also present
in bird and bat droppings and is endemic to the Mississippi and Ohio River basins. Patients may
report a history of exploring caves (associated with exposure to bats) or cleaning bird cages or
coops. Histoplasmosis is fairly self-limiting in immunocompetent people but can cause
significant pulmonary and disseminated disease in patients with CD4 counts < 100/UL. These
patients typically present with fever, weight loss, night sweats, nausea, vomiting and cough
with shortness of breath. Examination findings can include diffuselymphadenopathy and
hepatosplenomegaly. Laboratory findings can include pancytopenia (if bone marrow
isinvolved), elevated liver function tests and elevated ferritin.
The most sensitive test to diagnose disseminated histoplasmosis is antigen detection in the
urine or serum.
The treatment of disseminated pulmonary histoplasmosis in HIV patients depends on the
severity of thedisease. Patients with mild-to-moderate disease may be treated with
ltraconazole alone. Patients with moresevere disease (e.g .. high fever . •c 103 .1.F].
laboratory abnormalities, or fungemia) should be initiallytreated with intravenous
liposomalamphotericin B for 2 weeks followed by itraconazole for 1 year. The patientshould
also be restarted on antiretrovirals.

Atypical MAC Infection

Atypical mycobacterial infection is particularly likely if the patient's CD4 count isless than 50
and the patient has no past history of or exposure to tuberculosis. HIV-infected patients with
aCD4 count< 50/mm3 should receive azithromycin as prophylaxis against Mycobacterium
avium complex.

Toxoplasmosis
The most common cause of central nervous system mass lesions in AIDS patients is
toxoplasmosis. The patients present with fever, head ache, seizures & focal neurological deficit.
Brain CT shows single or multiple ring enhancing lesions.Trimethoprim-sulfamethoxazole is
used for prophylaxis of toxoplasmosis, while sulfadiazine and pyrimethamine are used for
treatment purposes.

Brain biopsy is reserved for patients whose lesions do not respond to treatment with
sulfadiazine and pyrimethamine.

Bacillary Angiomatosis
Bartonella henselae and Bartonella quinlana cause bacillary angiomatosis in
immunocompromised individuals. Patients present with cutaneous and visceral angioma-like
blood vessel growths. Bright red, firm, friable, exophytic nodules in an HIV infected patient are
most likely bacillary angiomatosis. Extreme caution must be exercised in biopsying these lesions
because they are prone to hemorrhage. Oral erythromycin is the antibiotic of choice.

Cryptococcal Meningitis
It is an encapsulated yeast. It is a very common cause of meningitis in HIV patients with a low
CD count. The patients usually present with worsening head ache, low grade fever, stiff neck &
lymphadenopathy. CSF shows encapsulated yeasts. Initial inductiontherapy for central nervous
system cryptococcal infection in AIDS patients is IV Amphotericin B plus oral flucytosine.When
there is clinical improvement with induction therapy. amphotericin and flucytosine are
discontinued andoral fluconazole is started as maintenance therapy.
Crystal-induced nephropathy is a well-known side effect of indinavir therapy (indinavir is a
protease inhibitor).It is caused by the precipitation of the drug in the urine and obstruction of
the urine flow. According to onestudy, 8% of the patients treated with indinavir had urologic
symptoms and about 20% had urinary crystalsconsisting of indinavir. Although adequate
hydration may help reduce the risk of nephrolithiasis,indinavir-associated nephrotoxicity has
been described in many well-hydrated patients. Furthermore,thiscomplication may manifest
early in the course of the therapy or develop later. For these reasons,someclinicians
recommend periodic monitoring of urinalysis and serum creatinine levels every three to
fourmonths.

The common acute life-threatening reactions associated with HIV therapy include:
1. Didanosine-induced pancreatitis
2. Abacavir-related hypersensitivity syndrome
3. Lactic acidosis secondary to the use of any of the NRTis
4. Stevens-Johnson syndrome secondary to the use of any of the NNRTis
5. Nevirapine-associated liver failure

Bacterial Pneumonia in HIV - Suspect bacterial pneumonia in an HIV-infected patient who

presents with acute onset, high-grade fever andpleural effusion. Pneumococcus is the most
common cause of pneumonia in HIV patients who have a CD count more than 200. Due to
theirimpaired humoral immunity, HIV patients are susceptible to infection by encapsulated
organisms in general,so other encapsulated bacteria should also be considered in the
differential.
 Viral Infections

The incidence of influenza rises greatly during the fall and winter months especially mid January
(epidemic). The onset of symptomsis typically abrupt and includes: fever, chills, malaise,
headache, coryza, non-productive cough, sore throat,muscle aches and occasionally nausea.
The influenza virus has three different antigenic types: A, B and C.Influenza A and B produce
clinically indistinguishable infections, whereas type C usually causes a minorillness. The
diagnosis is usually made clinically in the setting of an epidemic; however, rapid laboratory
testsfor influenza antigens from nasal or throat swabs are now widely available. The infection is
self-limiting inmost healthy individuals with a typical duration of 1-7 days. Many patients are
treated with bed rest and simple analgesics (e.g .. acetaminophen).

For the treatment of Influenza A, use Amantadine, rimantadine & Neuraminidase Inhibitors like
Oseltamivir & Zanamivir.

For the treatment of Influenza B, use only Neuraminidase Inhibitors like Oseltamivir &
Zanamivir.

Nasal swabs for influenza antigens are the fastest way to confirm this diagnosis.

The administration of antiviral drugs usually results in shortening of the duration of

symptoms by 2-3 days. The Advisory Committee on Immunization Practices (ACIP)concludes
that benefit from antiviral drug therapy has only been demonstrated in otherwise healthy
patientstreated within two days of the onset of illness.

Post-influenza Staphylococcus aureus Pneumonia The patients initially present with a

syndrome consistent with influenza, which improves after several days of medication (e.g ..
oseltamivir). They then developed a new pneumonia less than two weeks after the initial
presentation. S. aureus is a relatively uncommon cause of community acquired pneumonia. It
most often affects hospitalized patients, nursing home residents, injection drug users, patients
with cystic fibrosis or people with recent influenza infection. Gram-positive cocci in clusters are
seen on gram stain. S. aureus is known to cause post-viral URI necrotizing pulmonary
bronchopneumonia with multiple nodular infiltrates that can cavitate to cause small abscesses.
This looks on the X rays as multiple thin walled cavities.

A good hint is a person recovering from a simple URTI now has productive cough with blood.

Antibiotics should only be used if a secondary bacterial infection is suspected. One

shouldconsider this diagnosis if the fever persists for more than 4 days, along with a productive
cough and white cellcount > 10,000/cmm.

Rubella Vaccination & Pregnancy - If a woman becomes pregnant earlier than three months
after rubella immunization,reassurance is the appropriate step. Previously, women of
childbearing age were advised to avoid conception for at least threemonths after rubella
immunization; however, there have been no case reports to date of congenital
rubellasyndrome in women inadvertently vaccinated during early pregnancy. In fact, the
Advisory Committee on Immunization Practices (ACIP) has reduced the recommended waiting
time for conception from 3 months to 28 days.
Herpes Simplex Virus (HSV) encephalitis - HSV most frequentlyaffects the temporal lobes of
the brain. As a result, features such as bizarre behavior and hallucinations maybe present. The
disease is usually abrupt in onset, with fever and impaired mental status. Meningeal signsare
frequently absent. Cerebrospinal fluid (CSF) findings are nonspecific with low glucose levels
andpleocytosis. The diagnostic test of choice is CSF polymerase chain reaction (PCR) for herpes
simplex virus DNA,not viral culture! However, whenever there is a suspicion of HSV
encephalitis, IV acyclovir should bestarted without delay. Waiting for the result of the PCR or
viral culture is not necessary. Treatment should be started immediately.

Herpes Zoster aka Shingles - Shingles is caused by reactivationof the varicella-zoster virus.
Following the primary infection (chicken pox), the virus remains latent in thedorsal root ganglia.
A decrease in cell-mediated immunity (e.g. older age, stressful situation, HIV, lymphoma)can
allow the virus to reactivate and spread along the sensory nerve. This accounts for the typical
unilateral,dermatomal distribution of the pain and rash; T3 to L3 are the most frequently
involved dermatomes. Patientsoften develop pain or discomfort in the affected area before the
onset of rash. Valacyclovir is the drug of choice for treating herpes zoster. However, acyclovir
is less expensive and is also effective. Early antiviraltherapy reduces the duration of rash and
associated pain and is also thought to reduce the likelihood ofdeveloping postherpetic
neuralgia.

Infectious Mononucleosis - these patients presents with fever, sore throat, malaise, jaundice,
and mild hepatosplenomegaly consistent withlikely infectious mononucleosis (IM). The clinical
features of IM include fever, sore throat, toxic symptomsand symmetrical lymphadenopathy
involving the posterior cervical chain of lymph nodes more frequently thanthe anterior chain.
Inguinal and axillary lymphadenopathy can also be present. Other physical findings include
pharyngitis, tonsillitis, and tonsillar exudates. Mild palatal petechiae may be found, butthis
non-specific signmay also be seen in streptococcal pharyngitis. Tonsillar enlargement can cause
airway compression.Hepatitis and jaundice are present in a small percentage of cases. The
findings of hepatosplenomegaly,malaise and fatigue and generalized lymphadenopathy tend to
favor IM and are notcommonly seen in other bacterial causes such as streptococcal pharyngitis.
The diagnosis of IM is confirmed by the presence of atypical lymphocytosis and anti-
heterophile antibodies (Monospot), which typically indicate EBV associated disease. One of the
hematological complications of IM isautoimmune hemolytic anemia and thrombocytopenia,
which is due to cross reactivity of the EBV-inducedantibodies against red blood cells and
platelets. These antibodies are lgM cold-agglutinin antibodies known as anti-i antibodies,
which lead to complement-mediated destruction of red blood cells (usually Coombs'-
testpositive). The onset of the hemolytic anemia can be 2-3 weeks after the onset of the
symptoms. even though the initial laboratory studies may not show anemia or
thrombocytopenia. Contact sports should be avoided to prevent the chances of splenic rupture.
When rupture occurs, the mortality is significant. Hematological studies reveal leukocytosis
with variant lymphocytes (atypical lymphocytes - convoluted nuclei and highly vacuolated
cytoplasm).

Young Patient + Sore Throat + Cervical Lymphadenopathy + Hepatosplenomegaly = IM

CMV Mononucleosis - A patient with a mononucleosis-like syndrome, a lack of pharyngitis and

cervical lymphadenopathy on exam, atypical lymphocytes and a negative heterophile antibody
(monospot) test most likely has CMVmononucleosis. Atypical lymphocytes are large basophilic
cells with a vacuolated appearance. In contrastto EBV-associated infection, CMV mononucleosis
usually presents without pharyngitis and cervicallymphadenopathy.

Condylomata acuminata (anogenital warts) are caused by the human papilloma virus. The
characteristiclesions are verrucous, papilliform, and either skin-colored or pink. This is in
contrast to the lesions ofcondyloma lata, which are flat or velvety. Systemic symptoms are
usually absent.
There are three treatment options for condyloma acuminata:

1. Chemical or physical agents (e.g., trichloroacetic acid, 5-florouracil epinephrine gel,

and podophyllin)
2. Immune therapy (e.g., imiquimod, interferon alpha)
3. Surgery (e.g., cryosurgery, excisional procedures, laser treatment)

The choice of treatment depends upon the number and extent of lesions. Podophyllin is a
topical antimitoticagent that leads to cell death. It is teratogenic and thus contraindicated in
pregnancy. Its other adverseeffects include local irritation and ulceration.
 Protozoal Infections

Malaria is a protozoal disease caused by genus plasmodium, which is a RBC parasite and is
transmitted bythe bite of infected Anopheles mosquitoes. It is the most important parasitic
disease and is endemic in mostof the developing countries of Asia and Africa. Four species of
Plasmodium P. Vivax, P. falciparum, P.ovale and P. malariae can cause malaria. Most of the
deaths are due to falciparum malaria whereas vivaxand ovale are responsible for several
relapses.Cyclical fever is hallmark of malaria and it coincides with RBC lyses by the parasites.
Fever occurs every 48hours with P. vivax and P. ovale and every 72 hours with P. malariae,
whereas periodicity is generally notseen with P. falciparum. The typical episode consist of a cold
phase characterized by chills and shivering, followed by a hot phase characterized by high grade
fever, followed 2-6 hours later by a sweating stagecharacterized by diaphoresis and resolution
of fever. Nausea, vomiting, headache, anorexia, malaise andmyalgia are commonly seen. In
people from endemic areas, anemia and splenomegaly are common findings.Vitals would show
hypotension and tachycardia.

COLD followed by HOT followed by WET

All travelers to malarious regions should be prescribed antimicrobial prophylaxis. Chloroquine-

resistant Plasmodium falciparum is particularly common in Sub-Saharan Africa and the Indian
subcontinent (e.g .. India, Pakistan and Bangladesh). Mefloquine is the drug of choice for
chemoprophylaxis against chloroquine-resistant malaria. To be effective, prophylaxis should
be started one week before travel and continued until four weeks after departure from an
endemic area.

The use of primaquine (both for prophylaxis and treatment) is indicated in settings where
malaria is due to Plasmodium vivax or Plasmodium ovale; these organisms cause persistent
infection in the liver
Babesiosis - Suspect babesiosis in any patient from an endemic area who presents with a tick
bite. This illness is causedby the parasite Babesia and is transmitted by the Ixodes tick.
It is endemic in the northeastern UnitedStates. Following a tick bite, the parasite enters the
patient's RBCs and causes hemolysis. Clinicalmanifestations vary from asymptomatic infection
to hemolytic anemia associated with jaundice,hemoglobinuria, renal failure, and death. Unlike
other tick-borne illnesses, rash is not a feature of babesiosis,except in severe infection where
thrombocytopenia may cause a secondary petechial or purpuricrash. Clinically significant illness
usually occurs in persons over age 40 orimmunocompromised individuals.
It is more commonly seen in patients with functional asplenia or splenectomy.
Definitive diagnosis can be made from a Giemsa-stained thick and thin blood smear. Laboratory
studies maydemonstrate intravascular hemolysis, anemia, thrombocytopenia, mild leukopenia,
atypical lymphocytosis,elevated ESR, abnormal liver function tests, and decreased serum
complement levels. The two most widelyused drug regimens are quinine-clindamycin and
atovaquone-azithromycin.

Cystecercosis - It is a parasitic disease caused by the larval stage of the pork tapeworm Taenia
solium. It iscontracted when a person consumes T. solium eggs excreted by another person.

Humans are the only definitive host for T. solium, meaning that only humans can become
infected with the adult tapeworm. The adult tapeworm lives in the upper jejunum and excretes
its eggs into the person s feces (intestinal infection). If an animal consumes these eggs, it
becomes an intermediate host, with larvae encysting in its tissues.
The most common intermediate host is a pig. Then, when humans consume larvae in meat
such as infected., undercooked pork, they can once again develop intestinal infection with the
adulttapeworm. However, if a person (rather than a pig) consumes the T. solium eggs excreted
in human feces, Cysticercosis results. After ingestion, the embryos are released in the intestine
and the larvae invade the intestinal wall. They disseminate hematogenously to encyst in the
human brain, skeletal muscle, subcutaneous tissue or eye. (Note that cysticercosis is not
contracted by eating infected pork. so people who do not eat pork canstill be affected.)

The most common manifestations of cysticercosis are neurologic. Neurocysticercosis (NCC) is

characterized by multiple, small (usually <1 cm),fluid-filled cysts in the brain parenchyma.
These cysticerci have a membranous wall and often demonstrate a characteristic invaginated
scolex on neuroimaging. Interestingly, NCC is the most common parasitic infection of the brain,
and is most prevalent in the rural areas of Latin America, sub-Saharan Africa, China, southern
and Southeast Asia and Eastern Europe, particularly where pigs are raised and sanitary
conditions are poor. Humans with cysticerci are deadendhosts. Eighty percent of
neurocysticercal infections are asymptomatic and are accidentally found on brain autopsy.

Trichinosis - Also known as trichinellosis, It is a parasitic infection caused by the roundworm

Trichinella. It is acquired by eating undercooked pork that contains encysted Trichinella larvae.
The diseaseoccurs in three phases. The initial phase occurs in the first week of infection when
the larvae invade theintestinal wall. This phase manifests as abdominal pain,nausea, vomiting
and diarrhea.

The second phase begins in the second week of infection. It reflects a local and systemic
hypersensitivity reaction caused by larval migration, with features such as "splinter"
hemorrhages. conjunctival and retinal hemorrhages, periorbital edema and chemosis. As the
larvae enter the patient's skeletal muscle during the third phase, muscle pain, tenderness,
swelling and weakness occur. Blood count usually shows eosinophilia.
Cutaneous larva migrans , or creeping eruption, is a helminthic disease caused by the infective-
stage larvae ofAncylostoma braziliense, the dog and cat hookworm. Infection occurs after skin
contact with soil contaminated with dog or cat feces containing the infective larvae. This
disease is prevalent in tropical andsubtropical regions, including the southeastern United
States. People involved in activities on sandy beachesor in sandboxesare particularly at risk.
Initially, multiple pruritic, erythematous papules develop at the site oflarval entry, followed by
severely pruritic, elevated, serpiginous, reddish brown lesions on the skin, whichelongate at
the rate of several millimeters per day as the larvae migrate in the epidermis. It is most
commonlyseen in the lower extremities, but the upper extremities can also be involved.

Febrile Neutropenia - Neutropenia is defined as an absolute neutrophil count (AN C) <

1500/microl. Susceptibility to infection increases when ANC falls below 1000/microl; ability to
control endogenous flora is lost and risk of death is markedly increased when the ANC falls
below 500/microl. Fever in a neutropenic patient is defined as a single temperature reading of
greater than 38.3C (100.9F) or a sustained temperature of greater than 38C (100.4F) over one
hour. Bacteria, fungi,and viruses can all cause infection in neutropenic patients. Bacterial
infections are the most common and are frequently caused by endogenous skin or colon flora.
Over the past decade, there has been a shift fromgram-negative to gram-positive bacteria being
the most frequent cause of neutropenic infection.

Febrile neutropenia is considered a medical emergency; thus, empiric antibiotics should be

startedimmediately. Empiric therapy should be broad-spectrum and should cover
Pseudomonas aeruginosa. Eithermonotherapy or combination therapy can be employed.
Monotherapy consists of ceftazidime, imipenem, cefepime or meropenem. Combination
therapy is equally effective and consists of an aminoglycoside plusan anti-pseudomonal beta-
lactam.

Malignant Otitis Externa - The typical symptoms of malignant otitis externa are ear discharge
and severe ear pain. The pain oftenradiates to the temporomandibular joint and consequently
causes pain that is exacerbated by chewing.Worsening of the disease despite the use of topical
antibiotics is an important indicator of the condition'smalignant nature. Examination shows the
presence of granulation tissue in the external auditory meatus.Diabetes mellitus and other
immunosuppressive conditions are important risk factors. The most frequent causative
organism is Pseudomonas aeruginosa,which is implicated in more than 95% of cases.

Nail Puncture Osteomyelitis - Although Staphylococcus aureus is the most common cause of
osteomyelitis in children and adults.Pseudomonas aeruginosa is a frequent cause of
osteomyelitis in adults with a history of a nail puncture wound (especially when the puncture
occurs through rubber-soled footwear). The patients presents with localpain and swelling. fever
and an increased white cell count. Blood cultures may reveal the infectingmicroorganism;
otherwise, a bone biopsy is required. Plain radiographs take about 2 weeks or more to show
evidence of the disease. Treatment is with oral or parenteral quinolones and aggressive
surgical debridement.
Erysipelas is a specific type of cellulitis. It is characterized by inflammation of the superficial
dermis,thereby producing prominent swelling. The classic finding is a sharply demarcated,
erythematous, edematous,tender skin lesion with raised borders. The onset of illness is abrupt
and there are usually systemic signs Including fever and chills. The legs are the most frequently-
involved site. The most likely causative organism is group A beta-hemolytic streptococcus (S.
pyogenes).

T a elle Dia hea - Diarrhea in travelers is most commonly due to contaminated food and
water. Although a variety of agents (e.g .. bacteria. viruses. parasites) are possible,
enterotoxigenic E. coli (ETEC)is the most frequent cause of traveler's diarrhea.
Bloody Diarrhea WITHOUT Fever - Diarrhea has a wide differential diagnosis. Not all causes of
which are infectious. The presence of abdominal pain and lack of fever in a patient without a
travel history makes Enterohemorrhagic E. coli (EHEC) the most likely diagnosis.. Abdominal
tenderness with an absence of fever is most suggestive of infection with Enterohemorrhagic E.
coli (EHEC). Shigella, Salmonella and Campylobacter can also cause bloody diarrhea but often
result in fever and/or lackof abdominal pain. EHEC is different from other strains of E. coli
because it produces a Shiga toxin that causes its propensity to cause bloody diarrhea. The most
common serotype of EHEC in the US is 0157:H7. Most cases are caused by ingestion of
undercooked ground beef, although it is not uncommon for patients to not remember a
particular exposure. Potential complications include development of Hemolytic-Uremic
Syndrome (HUS) or Thrombotic Thrombocytopenic Purpura (TTP). A stool culture could be
considered toconfirm the diagnosis and determine antibiotic susceptibilities.

Diarrhea due to Vibrio parahaemolyticus is usually transmitted by the ingestion of seafood.

Other signs andsymptoms include fever, abdominal cramps, and nausea. These clinical features
develop after an incubationperiod of four hours to four days. V. parahaemolyticus can cause
either watery or bloody diarrhea.
Staph aureus Food Poisoning - The abrupt onset of nausea and vomiting is most likely due to
the intake of a preformed toxin or chemical irritant. Because the cause of illness is a preformed
exotoxin, there is no person-to-person transmission. But large outbreaks can occur if many
people ate the same contaminated food. Illnesses secondary to preformed toxins are
characterized by a rapid onset of symptoms (usually less than 6 hours) and often involve
vomiting. Staphylococcus aureus and Bacillus cereus both produce a preformed toxin. Clues to
the specific etiology lie in the types of foods consumed. Poultry and egg products, meat and
meat products,salads made with mayonnaise (egg. Tuna, chicken,potato or macaroni
salad),cream-filled pastries and milk and dairy productsare foods frequently incriminated in
staphylococcal food poisoning. The most frequently tested food item is a mayonnaise-
containing food like potato or macaroni salad.

Bacillus Cereus Food Poisoning - For the USMLE, suspect Bacillus cereus whenever you read
about a patient who eats rice and subsequentlydevelops nausea and severe vomiting. Bacillus
cereus produces a heat-stable toxin in inadequatelyrefrigerated cooked rice. Because the illness
is due to a preformed toxin, symptoms of nausea and vomitingappear quickly after
consumption of the contaminated food (between one and six hours after ingestion). Aside
from preformed toxins, chemical irritants also produce abrupt-onset nausea and severe
vomiting.

Actinomycosis is an infection caused by Actinomyces israelii. These anaerobic,Gram-

positiveBranching bacteria can present with an infection in the cervicofacial, thoracic or
abdominal region. Cervicofacial actinomycosis classically presents as a slowly progressive, non-
tender indurated mass, which evolves into multiple abscesses, fistulae and draining sinus
tracts with sulfur granules which appear yellow.The treatment is high-dose penicillin for 6-12
weeks.
Leprosy is a chronic granulomatous disease that primarily affects the peripheral nerves and
skin. It is causedby Mycobacterium Leprae. In the early part of the disorder, it may present as
an insensate, hypopigmented plaque. Progressive peripheral nerve damage results in muscle
atrophy with consequent cripplingdeformities of the hands. The most common affected sites
are the face, ears, wrists, buttocks, knees andeyebrows. Diagnosis is made by demonstration
of acid-fast bacilli on skin biopsy.

Lyme Disease Tick Management –

Most patients who have Lyme disease do not recall about any tick. Patients who traveled to a
Lyme-endemic area and saw an Ixodes scapularis tick attached to their body have to follow a
certain protocol to decrease the risk of Lyme disease transmission. The tick should be removed
as soon as possible. The risk ofdeveloping a tick-borne disease is low if the tick is attached for
<24 hours. The technique recommended bythe Centers for Disease Control and Prevention is to
grasp the tick with tweezers as close to the skin as possible and then remove the tick using
steady upward pressure. Some studies suggest that mouthparts thatbreak off and remain in
the skin can be left alone because the infective body of the tick is no longer attached.

Patients should be advised to seek medical attention if a "bull's eye rash" (erythema migrans)
develops overthe next month. One dose of doxycycline should be administered if all criteria for
prophylaxis are met (table).

Patients traveling to tick-infested areas should be advised to wear permethrin-treated pants

and long-sleeved shirts, to apply insect repellents to the skin, and to check the entire body for
ticks.

Doxycycline is an excellent treatment option for most patients as it has the advantage of
simultaneouslypreventing or treating coexisting human granulocytic anaplasmosis, an infection
also carried by Ixodus scapularis.However,doxycycline is contraindicated in young children as
well as pregnant and lactating women because itcan cause permanent discoloration of teeth
and retardation of skeletal development in exposed children andfetuses. Oral amoxicillin is the
treatment of choice in pregnant and lactating women as well as children age <8 years.

In severe cases of facial palsy, the cornea may be at risk of dryness and abrasions due to poor
eyelid closure and reduced tearing. Artificial tears should be used during the day in addition to
ophthalmic ointments and eye patching at night

Ehrlichiosis is a category of tick-borne illness that iscaused by one of three different species of
Gram-negative bacteria, each with a differenttick vector. It isendemic in the southeastern,
south-central, mid-Atlantic, and upper Midwest regions of the US, as well asCalifornia. It usually
occurs in the spring or summer. The incubation period varies from one to three weeks.
Clinical features include fever, malaise, myalgias, headache, nausea, and vomiting. There is
usually no rash;hence, its description as the "spotless Rocky Mountain spotted fever." Labs
often show leukopenia and/orthrombocytopenia, along with elevated aminotransferases.
Suspect ehrlichiosis in any patient from an endemic region with a history of tick bite, systemic
symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases. The drug
of choice is doxycycline.
Syphilis - Primary syphilis presents with a painlesschancre that resolves in 3-6 weeks and can
recur weeks to months later as secondary syphilis. In secondarysyphilis,the rash typically starts
on the trunk and extends to the periphery, including the palms and soles.
Generalizedlymphadenopathy is very common.Secondary syphilis requires a high index of
suspicion for a clinical diagnosis. Initial testing is with a nontreponema!test (e.g .. RPR or VDRL)
with positive results confirmed with a specific treponema test (e.g .. FTA-ABStest). Treatment
involves 3 doses of benzathine penicillin, each given weekly. Patients occasionallydevelop the
Jarisch-Herxheimer reaction (acute febrile reaction with headaches and myalgias) in the first
24hours of therapy. Alternative regimens include doxycycline or azithromycin in penicillin-
allergic patients.
If you find out that a patient has one STD, there is a chance that he might also have other
STDs because of his high risk activities. Screen the patient for HIV with ELISA, RPR, pap smear
and hepatitis B surface antigen testing also be performed (with the patient's consent).

Vs

Rocky Mountain spotted fever (RMSF) is a tick-borne illness that requires rapid initiation of
antibiotics to prevent mortality. The rash usually begins as a maculopapular eruption on the
wrists and ankles that spreads to the trunk, extremities, palms and soles around day 5 of the
illness. Patient's often have asevere headache and diffuse myalgias.

Rocky Mountain spotted fever usually does not produce bacterial meningitis and has CSF
findings more consistent with a viral meningitis picture.

Vs

Rubella - The characteristic rash of rubella is erythematous and maculopapular. It starts on the
face and progresses to the trunk and extremities. Prodromal symptoms include fever,
lymphadenopathy and malaise. Occipital and posterior cervical lymphadenopathy are
suggestive of the diagnosis. Adult women usually have associatedarthritis, which is another
diagnostic clue. Some patients may have mild coryza and conjunctivitis.

Vs

Chicken Pox - The rash of chicken pox is pruritic and usually develops after a prodrome of fever
and malaise. The lesions appear in consecutive crops. So lesions of several different stages are
often visible on examination (i.e .. papular. vesicular. and crusted lesions).
Uncomplicated Pyelonephritis Management- After 48-72 hours of parenteral therapy for
uncomplicated pyelonephritis, the patient can be usually switched to an oral agent. Oral
therapy is more convenient and less expensive; if the results of antibiotic susceptibility testing
are known, the appropriate antibiotic can be easily chosen.

Echinococcosis is a parasitic disease caused by tapeworm echinococcus. Four species of

Echinococcus can produce infection in humans.The two most common being E. granulosus.
causing cystic echinococcosis and E. multilocularis, causing alveolar echinococcosis.
The majority of human infections are due to sheep strain of E. granulosus,for which dogs and
other canidsare the definitive hosts and sheep are the intermediate hosts; humans are the
dead- end accidentalintermediate host.

It is most commonly seen in areas where sheep are raised (sheep breeders are thus at high
risk) and transmission is seen when dogs living in close proximity of humans are fed the viscera
ofhome-slaughtered animals. The infectious eggs excreted by dogs in the feces are passed on to
other animalsand humans. After ingestion of eggs by humans, the oncospheres are hatched and
they penetrate the bowelwall disseminating hematogenously to various visceral organs, leading
to formation of hydatid cysts. The liver, followed by the lung, is the most common viscus
involved; however, any viscera can be involved. Hydatid cystis a fluid-filled cyst with an inner
germinal layer and an outer acellular laminated membrane. Germinal layer gives rise to
numerous secondary daughter cysts.

Pig farmers are at high risk for Neurocysticercosis.

Sheep farmers are at high risk for Hydatid Cysts.

The commercial sex worker is at high risk for perihepatitis from gonorrhea and numerous
othersexually-transmitted diseases.

Dog Bite Post Exposure Prophylaxis - A dog bite may result in rabies, which is a fatal disease.
For this reason, all physicians should understand theguidelines for post-exposure rabies
prophylaxis. Post-exposure prophylaxis, when indicated, consists of bothactive and passive
immunization.
In any dog bite, an attempt is made to capture the dog.

1. If the dog is not captured, it is assumed rabid, and post-exposure prophylaxis is

indicated.

2. If the dog is captured and does not show features of rabies, it is kept for observation
for the development of rabies for 10 days. If the dog develops any features of rabies,
post-exposure prophylaxis should be started immediately. The dog's diagnosis is
confirmed by fluorescent antibody (FA) examination of the brain.

3. Post-exposure prophylaxis should be started immediately for exposures involving the

head and neck.
Diabetic Foot Ulcers - Chronic foot ulcers are frequently found in patients with diabetes.
Diabetic patients are prone to developingfoot ulcers due to a combination of arterial
insufficiency and peripheral neuropathy. Because of poor tissueperfusion, the immune system
has difficulty combating infection in the region surrounding the ulcer. Thus, theopen ulcer is an
ideal site for entry of bacteria and infection of the soft tissue can easily spread to include the
neighboring bone. Such contiguous spread is the most likely pathogenic mechanism of
osteomyelitis inpatients with arterial insufficiency, such as those with diabetes.

Hematogenous spread is the most likely pathogenic mechanism of hematogenous

osteomyelitis, which is typically observed in children
Direct inoculation of pathogenic bacteria during trauma may be responsible for post-traumatic
osteomyelitis.

Staph aureus Endocarditis – Staphylococcus aureus is a leading cause of bacteremia both in the
community and hospital setting. Patients who are more likely to have S. aureus bacteremia
include intravenous drug users, patients with skin infections, and patients with an infected
medical device (e.g., prosthetic valve). Patients with HIV infection are also at increased risk of S.
aureus bacteremia. Patients with tricuspid valve endocarditis, which specifically occurs in
intravenousdrug users, are prone to septic embolism to the lungs, which typically presents with
pleuritic pain andmultiple cavitating lung nodules on x-ray.

In cases of suspected IE, 1st draw blood for C & S and then start emperic antibiotic therapy.
When culture results become available, antibiotics can be changed if they are not appropriate.

Endocarditis -
IE in IVDU-
Meningococcal Meningitis – These patient presents with sudden onset of fever, stiff neck,
headache, nausea, andmyalgias, worrisome for bacterial meningitis. The hypotension,
tachycardia, myalgias, and purpuric skin lesions suggest meningococcal meningitis with
meningococcemia, which can develop within several hours ofthe initial meningitis. Myalgias
more commonly occur in meningococcal meningitis than other bacterialcauses and can be more
intense and painful than the myalgias caused by viral influenza.
The CSF findings of elevated white blood cell (WBC) count, elevated protein level, and
decreased glucoselevel are indicative of bacterial meningitis. Viral meningitis may present with
similar symptoms but is usuallynot associated with purpura. The CSF findings also tend to show
normal glucose, mild elevation of protein(usually < 150 mg/dL), and WBC count <250/cmm. This
patient has CSF findings consistent with bacterialmeningitis and the hypotension and skin
lesions most consistent with disseminated meningococcemia.

Meningitis Rx –
Cat-scratch disease is caused by Bartonella henselae. The condition may be transmitted by a
cat scratch,cat bite, or flea bite. It is commonly seen in young, immunocompetent individuals.
Cat scratch diseasetypically presents as a localized cutaneous and lymph node disorder near the
site of the inoculum, with veryrare involvement of the liver, spleen, eye, or central nervous
system. A local skin lesion evolves throughvesicular, erythematous, and papular phases, but can
be pustular or nodular. The hallmark of cat scratchdisease is localized, regional
lymphadenopathy, which is tender and may be suppurative. The diagnosis isclinical, although a
positive B. henselae antibody test or a tissue specimen demonstrating a positiveWarthin-Starry
stain supports the diagnosis. A short course of antibiotics is recommended. Five days of
azithromycin has been found to be particularly effective.

The tuberculin skin test is used to screen asymptomatic patients for infection with
Mycobacteriumtuberculosis. It is performed by injecting a small amount of M. tuberculosis
purified protein derivative (PPD)into the skin and measuring the amount of induration at 48-72
hours. The degree of induration considered"positive" depends upon the patient's pretest
probability of having tuberculosis. The classification is givenbelow:

1. Induration > 5 mm is considered positive in:

HIV-positive persons
Individuals with recent contact with a TB-positive person
Individuals with signs of TB on chest x-ray
Organ transplant patients, patients on immunosuppressive therapy

2. Induration> 10 mm is considered positive in:

Individuals who have recently emigrated from a location where TB is endemic
Injection drug users
Residents/employees of high-risk settings (e.g. prisons, homeless shelters)
Patients with diabetes, chronic kidney disease, hematologic malignancies, or fibrotic
lung disease
Children less than 4 years of age, teens exposed to high-risk adults

3. Induration> 15 mm is considered positive in:

Healthy individuals with no risk factors for TB infection.

So, if a healthy person with PPD less than mm comes to clinic ou don t do an further
investigations. Just observe.

A patient who has a positive PPD test should have a chest x-ray to evaluate for active
pulmonarytuberculosis. Patients with a positive PPD but without signs of active TB on chest x-
ray should be treated forlatent TB infection. Treatment is a nine-month course of INH plus
pyridoxine (vitamin B6).

Peripheral neuropathy may present as tingling in the extremities, numbness and ataxia. It is a
known side effect of isoniazid. For this reason, all patients who are started on anti-tubercular
therapy are also started on vitamin supplements, especially pyridoxine (10 mg/day). If the
peripheral neuropathy has already developed, the dose of pyridoxine is increased to 100
mg/day.Hepatitis is another known side effect of isoniazid.
Latent TB Rx -

Bite Inujury - A clenched fist injury is a bite wound to the hand incurred when a person's fist
strikes an opponent's teeth(also known as a "fight bite"). Amoxicillin-clavulanate is the
antibiotic of choice for prophylaxis and treatmentof infections caused by a human bite. These
infections are usually polymicrobial, and thus coverage for Grampositives, Gram negatives, and
anaerobes should be provided. Clavulanic acid is a beta-lactamase inhibitorand is helpful
against beta-lactamase-producing anaerobes.

Post Transplant Management - Oral trimethoprim-sulfamethoxazole (TMP-SMX) is effective in

preventing Pneumocysfis pneumonia (PCP) in transplant patients. It may also prevent
toxoplasmosis, nocardiosis, and other infections (e.g., urinary tract infections and pneumonia).
All posttransplant patients should receive prophylaxis with TMP-SMX. Ganciclovir or
valganciclovir can be used to prevent CMV infections. These patients should also be vaccinated
against influenza, pneumococcus, and Hepatitis B.

Bone Marrow Transplant - CMV pneumonitis should be considered in the differential diagnosis
of any bone marrow transplant (BMT)recipient with both lung and intestinal involvement. Risk
factors include certain types of immunosuppressivetherapy, older age, and seropositivitybefore
transplantation. The median time of development of CMVpneumonitis after BMT is about 45
days (range of two weeks to four months). Typical chest x-ray findingsinclude multifocal diffuse
patchy infiltrates. High-resolution CT scan shows parenchymal opacification ormultiple small
nodules. Bronchoalveolar lavage is diagnostic in most cases. Other than pneumonitis,
CMVinfection in post-BMT patients also manifests as upper and lower gastrointestinal ulcers,
bone marrow suppression, arthralgias, myalgias andesophagitis.

BMT + Pneumonia + Abdominal Complains = CMV Pneumonitis.

Pneumocystis pneumonia (PCP) caused by the organism now called Pneumocystis jiroveci, is
seen in the immediate post-transplant period. But its incidence has fallen dramatically with the
routine use of prophylactic trimethoprim-sullamethoxazole during the pre-transplant period.
PCP usually does not cause diarrhea.
Hospital Acquired Pneumonia - The presence of gram-negative bacilli in the sputum of an
intubated intensive care unit patient with fever andleukocytosis should make you think of
possible Pseudomonas aeruginosainfection. P. aeruginosa is one ofthe most commonly
considered gram-negative aerobic bacilli in the differential diagnosis of gram-
negativeinfections, and is a common cause of gram-negative nosocomial pneumonia.
Nosocomial Pseudomonasinfections have been linked to a number of environmental sources,
including contaminated water faucets, respiratory therapy equipment, therapy pools and plant
products (flowers, vegetables).Intravenous antipseudomonal antibiotic therapy should be
started as soon as possible. Fourth generationcephalosporins (i.e .. cefepime) have been used
successfully for treatment. Other effective medicationsinclude aztreonam, ciprofloxacin.
imipenem/cilastatin, tobramycin, gentamicin and amikacin.Piperacillin-tazobactam is also
highly effective.

Patients with hemochromatosis andcirrhosis are at increased risk of infection with

Listeriamonocytogenes. Possible explanations includeincreased bacterial virulence in the
presence of high serum iron and impaired phagocytosis due to ironoverload in
reticuloendothelial cells. Iron overload is also a risk factor for infection with Yersinia
enferocoliticaand septicemia from Vibrio vulnificus, both of which are iron-loving bacteria.

Intermittent catheterization is associated with a significantly lower risk of urinary tract

infections (UTI) ascompared to the use of indwelling catheters in patients with spinal cord
injuries. Although each passage ofthe catheter can introduce bacteria into the bladder,
indwelling catheters carry a greater risk of infection. Thisis due to the ability of bacteria to form
a biofilm along the catheter wall that can reach the bladder within 24hours of insertion.
Generally, the longer the catheterization, the greater the risk of bacteriuria.
Toxic Shock Syndrome :

Necrotizing Fasciitis –
Splenic Abscess

Upper Respiratory Tract Infections

Parvovirus B19