INFECTIOUS REVISION NOTES

DAVID HARRISON NOTES

INFECTIOUS DISEASE MAGNETIC LINES

❑ Most common neurological complication seen in HIV patient is Cerebral toxoplasmosis.

❑ Most common Fungal CNS infection: Cryptococcus
❑ Fishy, thin, whitish homogenous vaginal discharge, clue cell present: Gardnerella
vaginalis
❑ Frothy, yellowish discharge: Trichomonas vaginalis
❑ Thick and greenish discharge: Neisseria gonorrhea
❑ White, non-offensive discharge: Candida
❑ Most common cause of viral encephalitis in adult: Enterovirus
❑ Skin hypopigmentation with loss of sensation: Leprosy
❑ Skin hypopigmentation without loss of sensation: Vitiligo/P. versicolor
❑ Campylobacter is usually self-limiting but if severe then treatment with Clarithromycin is
needed.
❑ Abdominal pain due to Campylobacter may mimic appendicitis.
❑ Aerosolized pentamidine is an alternative treatment for Pneumocystis jirovecii
pneumonia but is less effective and has a risk of developing pneumothorax.
❑ Trimethoprim and cotrimoxazole should be avoided in patient on methotrexate
❑ HIV + Neuro symptoms + widespread demyelination: PML
❑ Intensely itchy rash starting on buttock and spreading rapidly up the back and across the
abdomen: Larva Currens, which is pathognomic for Infection with Strongyloidiasis
stercoralis.
❑ Ivermectin is the drug of choice for treatment of strongyloidiasis.
❑ Dilated cardiomyopathy is the most frequent and most severe manifestations of chronic
chagas disease
❑ Treatment of choice for leptospirosis: Benzylpenicillin
❑ History of abdominal pain, gradual onset bloody diarrhoea, and a long incubation period
in a returning traveler is highly suggestive of amoebiasis dysentery.
❑ Patient presenting with vomiting within 6 hours of ingestion of reheated rice is indicative
of Bacillus cereus infection.
❑ Acute toxoplasmosis in the immunocompetent patient can mimic acute EBV infection
(low-grade fever, generalised lymphadenopathy with prominent cervical lymph nodes
and malaise) and should be suspected with negative EBV serology. Pregnancy testing
and counselling is paramount due to the risk of congenital toxoplasmosis
❑ Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present

o thin, white homogenous discharge

o clue cells on microscopy: stippled vaginal epithelial cells
o vaginal pH > 4.5
 o positive whiff test (addition of potassium hydroxide results in fishy odour)

❑ Aspergilloma: Cough + Haemoptysis + rounded opacity and crescent sign on cxr

❑ The BCG vaccine is unreliable in protecting against pulmonary tuberculosis
❑ Shigella infection is usually self-limiting and does not require antibiotic treatment;
antibiotics are indicated for people with severe disease, who are
immunocompromised or with bloody diarrhoea
❑ Fever is a response to cytokines like: IL-1, IL-6 and TNF-alpha
❑ MRI with enhancement of temporal lobe in herpes simplex encephalitis
❑ Fever in injection drug user: Think about Streptococcus pyogen, and S. aureus
❑ Most common cause of PUO: TB, Malaria, Pneumonia, Lymphoma, Temporal
arteritis/polymyalgia rheumatica, Stills disease/Juvenile RA
❑ Initial investigation for any fever: Blood culture and CXR
❑ Injection drug user with bacteremia with S. aureus: Echo should be done to detect
infective endocarditis
❑ Systolic V wave in JVP is seen in case of Tricuspid regurgitation in injection drug user
❑ Empirical therapy in injection drug user: Flucloxacillin, if MRSA, then
Vancomycin/daptomycin.
❑ Reddish nodules or plaques with fever and leukocytosis, in association with
hematological malignancy: Sweet syndrome
❑ Most common pathogen for neutropenic fever: Gram positive organism
❑ Most common regimen for neutropenic fever: Broad spectrum penicillin (piperacillin-
tazobactam). If fever doesn’t resolve within 3-5 days, Empirical caspofungin should be
commenced.
❑ Markers of early fungal infection: Galactomannan, 1,3 Beta D glucan
❑ Fever 1-6 months after post transplantation: Characteristic of Impaired T cell function
and suspect CMV INFECTION and treat with IV ganciclovir/oral valginciclovir
❑ Post transplantation lymphoproliferative disorder (PTLD) is an EBV associated lymphoma
❑ Common cause of blood stream infection: Fig 13.4 (270)
❑ Primary blood stream infection is commonly caused by S. aureus
❑ Fundoscopy should be performed following candida spp. Infection/suspected infectious
endocarditis.
❑ Common cause of endocarditis: S. aureus, V. streptococci, Enterococci (Transesophageal
echo should be done)
❑ Endocarditis caused by S. gallolyticus and Blood stream infection with C. septicum are
both associated with colonic carcinoma and colonoscopy should be done.
❑ Most common cause of catheter induced infection: Coagulase negative Staphylococcus
❑ Infection associated with TPN: Candida
❑ Infection associated with non-sterile infusion equipment: Citrobacter freundii and
pseudomonas flurosans
❑ Infection associated with asplenic individual: S. pneumonia, Capnocytophaga
caniomorsus, Babesia microti
❑ Empirical treatment for necrotising fascitis: Piperacillin-tazobactum plus clindamycin OR
Meropenem + Clindamycin
❑ Hyperbaric oxygen should be given for polymicrobial infection
❑ Noninfectious cause of diarrhea: BOX 13.10
❑ Food associated with gastroenteritis: BOX 13.12
❑ Causes of infectious gastroenteritis: Box 13.9
❑ In EHEC, ANTIBIOTIC SHOULD NOT BE USED.
❑ Antibiotic should be used in Shigella and invasive salmonellosis
❑ Common causes of fever acquired in tropical region: Malaria, enteric fever, viral hepatitis
and dengue
❑ Most common cause of traveler's diarrhea: ETEC
❑ SMALL white spot surrounded by erythema on buccal mucosa: Koplik spot
❑ Immunoglobulin therapy for measles must be given within 6 days of exposure
❑ Fever + maculopapular rash spreading from the face and lymphadenopathy: Rubella
❑ Slapped cheek pattern rash is characteristic of: Parvovirus
❑ High fever/FEBRILE convulsion + maculopapular rash as fever resolves +
hepatitis/encephalitis/pneumonitis: HHV-6
❑ Antivirals are used in uncomplicated chicken pox in adult within 24-48 hours of onset of
vesicles and in all patients with complication and in those who are immunocompromised
including pregnant women regardless of the duration of vesicles.
❑ VZIG should be given within 7 days of exposure
❑ Who develops chickenpox after receiving VZIG should be given anti-viral therapy.
❑ Thoracic dermatomes are most commonly involved in VZV infection.
❑ Geniculate ganglion involvement causes Ramsay hunt syndrome
❑ Stroke like syndrome in shingles especially in an ophthalmic distribution.
❑ Most common complication of chicken pox is secondary bacterial infection from
scratching
❑ Zoster vaccine is a live attenuated vaccine
❑ Fever followed by bilateral tender parotid enlargement +/- meningitis/hearing
loss/pancreatitis/arthritis: Mumps
❑ Complication of EBV: box 13.31
❑ Causes of infectious mononucleosis syndrome: BOX 13.30
❑ Pharyngitis/sore throat + cervical lymphadenopathy + fever + lymphocytosis: EBV
(infectious MONONUCLEOSIS)
❑ Early dx of EBV by Mono spot test (Paul-Bunnel TEST): Detect heterophile antibody
❑ Confirmatory inv of EBV: Specific EBV serology
❑ Complications of CMV:
o Meningoencephalitis
o GBS
o Autoimmune hemolytic anemia
o Thrombocytopenia
o Myocarditis
o Skin eruptions- ampicillin induced rash
❑ ALP level raised in CMV
❑ Dengue warning signs and features of severe dengue: BOX 13.34
❑ Fever + low back pain + abdominal pain + vomiting + conjunctival erythema +
bradycardia + jaundice: Yellow fever
❑ Cause of VHF
❑ Complication of zika virus:
o GBS
o Microcephaly
o Cerebral calcification
o Deafness
o Chorio-retinal scarring
o Joint contracture
o Hydrops fetalis
o Growth retardation

❑ HSV-1 predominantly affect mucocutaneous surface of the head and neck

❑ HSV-2 predominantly affect genital mucosa
❑ Leading cause of sporadic viral encephalitis: HSV-2
❑ HSV encephalitis is diagnosed by positive PCR for HSV in CSF.
❑ HHV-8 is spread by saliva and gay sex

❑ Malignancy associated with HHV-8:

o Kaposi sarcoma
o Primary effusion lymphoma
o Multicentric Castleman’s disease
❑ Major cause of diarrheal illness in young children: Rota virus
❑ Receptor for SARS COV-2: Human Angiotensin Converting Enzyme 2 (hACE2)
❑ Receptor for MERS-COV: DPP4
❑ Most common complication of covid: ARDS
❑ Complication due to covid most commonly in 2nd week
❑ Fever + rash + arthropathy (early morning pain and swelling most often in small joint):
Chikungunya virus
❑ All Infection caused by S. aureus: Fig 13.19
❑ high grade fever + myalgia/headache/sore throat/vomiting + widespread erythematous
blanching rash + hypotension in a menstruating woman with retained tampon:
Staphylococcal toxic shock syndrome
❑ M/A of Clindamycin: Protein synthesis inhibitor
❑ Staphylococcal TSS should avoid using tampons for at least 1 year
❑ Leading cause of bacterial pharyngitis: Streptococcus pyogenes (Group A streptococcus)
❑ Diffuse erythematous blanching rash + coated, red and swollen tongue (strawberry
tongue) + petechial rash in the antecubital fossa: Streptococcal scarlet fever
❑ Influenza like illness + Faint erythematous rash + circulatory shock: Streptococcal toxic
shock syndrome
❑ Streptococcal TSS is treated with judicious fluid resuscitation + Benzylpenicillin and
Clindamycin
❑ Buruli ulcer: Rifampicin and clarithromycin
❑ Tropical ulcer: Penicillin and Metronidazole
❑ Brucellosis: Unpasteurized milk/uncooked meat ingestion + high swinging temp +
headache/myalgia/arthralgia + scrotal pain/abdominal pain/constipation +
splenomegaly/thrombocytopenia
❑ Dx of brucellosis is by culture
❑ Borrelia infection: Red ‘bulls' eye’ macule or papule 2-30 days after tick bite +
fever/headache/regional lymphadenopathy + cranial nerve palsy (Facial nerve palsy) +
peripheral neuropathy/radiculopathy + arthritis/polyneuritis/encephalopathy
❑ Confirmatory investigation for Lyme disease: Immunoblot (Western blot)
❑ Treatment of Lyme disease: 14-day course of Doxycycline or amoxicillin. In pregnant
women, Treat with cefuroxime axetil or azithromycin
❑ Neuroborreliosis is treated with Beta lactam antibiotics (Ceftriaxone)
❑ Leptospira mainly invade: Kidney, liver, meninges and brain.
❑ Only notable sign in Bacteraemic leptospirosis: Conjunctival congestion
❑ Clinical syndrome of leptospirosis: fig 13.26
❑ Investigation of choice for leptospirosis: MAT and it becomes positive by the end of first
week
❑ Laboratory clue to diagnose leptospirosis:
o Polymorphonuclear leukocytosis + thrombocytopenia + elevated creatine kinase
+ raised prothrombin time and liver enzymes
o Blood culture positive if taken before 10 days of illness
o Urine culture positive during 2nd week
o MAT positive by the end of 1st week
o Rapid immunochromatographic test becomes positive in the 1st week
o Detection of leptospiral DNA by PCR in blood in early symptomatic disease and in
urine from 8 day of illness.
❑ Treatment of leptospirosis: Oral doxycycline or IV penicillin
❑ Plague: Caused by Yersinia pestis, a gram-negative bacillus
❑ First sign of plague: Appearance of dead rat
❑ Most common form of plague: Bubonic plague
❑ Most common site of bubo: Groin
❑ Site of entry of plague organism: Skin
❑ Gram staining of Yersinia pestis: Bipolar staining coccobacilli known as safety pin
appearance
❑ Drug of choice for plague: Streptomycin or gentamicin
❑ Clinical clue for plague: Necrotic/purulent/hemorrhagic lesion = oliguria + DIC resulting
in widespread hemorrhage
❑ Listeria meningitis should always be considered in patients with meningitis associated
with brain stem involvement, in elderly and in immunocompromised
❑ Bacterial Meningitis with normal CSF glucose: Suspect Listeria
❑ Diagnosis of listeria is by blood and CSF culture
❑ Most effective regimen for Listeria: IV Amoxicillin/ampicillin + Aminoglycoside
❑ Salmonella typhi mainly localize in the lymphoid tissue of the small intestine
❑ Cause of constipation in enteric fever: Due to swelling of lymphoid tissue around
ileocecal junction
❑ Feature and complication of enteric fever: Box 13.44 and 13.45
❑ Investigation to establish enteric fever: Blood culture
❑ Drug of choice in Enteric fever: Fluroquinolone (Ciprofloxacin) for 14 days
❑ Type of Typhoid vaccine: Tetanus conjugate vaccine containing Vi polysaccharide
conjugated to tetanus toxoid
❑ Rx of tularemia: Parenteral aminoglycosides, streptomycin or gentamicin, with
doxycycline or ciprofloxacin as alternative
❑ Melioidosis: Caused by Burkholderia pseudomallei , a saprophyte found in soil and water
(rice paddy field)
❑ Most common feature of Melioidosis: Pneumonia
❑ Clinical clue for melioidosis: Pneumonia + localised skin nodules and abscess + DM +
Diarrhea + hepatosplenomegaly + cavitary tuberculosis like picture on CXR
❑ Rx of melioidosis: Ceftazidime or meropenem followed by maintenance therapy with
Cotrimoxazole or doxycycline + surgical drainage of abscess
❑ Most common cause of traveler's diarrhea: ETEC
❑ Attachment and effacement lesion: Enteropathogenic E. coli
❑ Stacked brick aggregation to tissue culture cell by microscopy: Enteroaggregative E. coli
❑ Most common cause of antibiotic associated diarrhea: C. difficile
 ❑ Clinical clue to diagnose Diarrhea related organism:

Infection Typical presentation

Escherichia coli Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis Prolonged, non-bloody diarrhea
Cholera Profuse, watery diarrhea without pain or colic
followed by vomiting
Severe dehydration resulting in weight loss
Shooting star on dark field microscopy
Not common amongst travelers
Shigella Bloody diarrhoea
Vomiting and abdominal pain
May rapidly spread among men who have sex
with men
Staphylococcus aureus Severe vomiting
Short incubation period
Campylobacter A flu-like prodrome is usually followed by
crampy abdominal pains, fever and diarrhea
which may be bloody
May mimic appendicitis
Complications include Guillain-Barre
syndrome
Bacillus cereus Two types of illness are seen

❑ vomiting within 6 hours,

stereotypically due to rice
❑ diarrheal illness occurring after 6
hours
Amoebiasis Gradual onset bloody diarrhea, abdominal
pain and tenderness which may last for
several weeks
Incubation period

❑ 1-6 hours: Staphylococcus aureus, Bacillus cereus*

❑ 12-48 hours: Salmonella, Escherichia coli
❑ 48-72 hours: Shigella, Campylobacter
❑ > 7 days: Giardiasis, Amoebiasis

*Vomiting subtype, the diarrheal illness has an incubation period of 6-14 hours
❑ Clostridium difficile clinical clue: Insidious onset + lower abdominal pain + profuse
watery diarrhea/ bloody diarrhea reassembling ulcerative colitis (fever and even toxic
dilatation and perforation) +/- Ileus in pseudomembranous colitis + erythema/white
plaques or an adherent pseudomembrane on rectum seen on sigmoidoscopy
❑ Screening tool to detect C. difficile: Detection of Glutamate dehydrogenase (GDH) in
stool, an enzyme produced by C. difficile
❑ First line antimicrobial for C. difficile: Vancomycin. IV Immunoglobulin/Glucocorticoid is
given in more severe or refractory case
❑ Drug used to prevent recurrence of C. difficile: Bezlotoxumab, a monoclonal antibody
❑ Enzyme that is activated by Vibrio cholera enterotoxin: Adenylate cyclase
❑ Loss of fluid in dilated bowel result in a very intense illness called Cholera sicca, killing
the patient even before GIT symptoms appear
❑ Recommended fluid in Cholera for fluid replacement: Ringer's lactate
❑ Treatment that will reduce the duration of excretion of V. cholera and total volume of
fluid for replacement: 3 days treatment with Tetracycline or single dose of
doxycycline/ciprofloxacin
❑ Antibiotic for Bacillary dysentery: Ciprofloxacin/azithromycin/ceftriaxone

❑ Diphtheria clinical clue: sore throat with a 'diphtheric membrane' - grey, pseudo
membrane on the posterior pharyngeal wall + bulky cervical lymphadenopathy + may
result in a 'bull neck' appearance + neuritis e.g., cranial nerves + heart block
❑ Infection with C. diphtheria: Spread by respiratory droplet
❑ Husky voice and high-pitched cough in laryngeal diphtheria: Urgent tracheostomy
should be done
❑ Early cause of death from diphtheria: Acute circulatory failure
❑ Neurological involvement of diphtheria: Palatal palsy + difficulty in reading small print
(paralysis of accommodation)
❑ Complication of diphtheria:
o Laryngeal obstruction
o Myocarditis
o Peripheral neuropathy
❑ Anthrax clinical clue: painless black eschar (cutaneous 'malignant pustule', but no pus)
+ typically, painless and non-tender + may cause marked oedema + anthrax can cause
gastrointestinal bleeding
❑ Treatment of anthrax: Ciprofloxacin until penicillin susceptibility is confirmed
❑ Prophylaxis for anthrax: Ciprofloxacin for 2 months with 3 doses of vaccine

❑ Leprosy clinical clue: Patches of hypopigmented skin typically affecting the buttocks,
face, and extensor surfaces of limbs + sensory loss
❑ M. leprae has tropism for: Schwan cell and skin macrophage

❑ Most common skin lesion in leprosy: Macule or plaques

❑ “Glove and stocking” sensory neuropathy is common in: Lepromatous leprosy
❑ Cardinal feature of leprosy: Box 13.47
❑ Difference between tuberculoid and lepromatous leprosy: Box 13.48
❑ After 3 days of chemotherapy patient is not infectious in leprosy
❑ Confirmatory test for leprosy: SLIT SKIN SMEAR to detect acid fast bacilli
❑ Characteristic feature of borderline leprosy: Annular lesion
❑ Regimen in leprosy: Box 13.51
❑ Reaction in leprosy: Box 13.49
❑ Most common tick-borne infection: Rickettsial fever
❑ Rickettsia producing lesion in:
o Skin
o CNS
o Heart
o Lungs
o Liver
o Kidney
o Skeletal muscle

❑ Target organ in epidemic typhus: Brain

 Disease Cause Vector Notes
Rocky Mountain Rickettsia ricketsii Tick Headache and fever
spotted fever are common

Rash starts on the

peripheries (wrist,
ankles) before
spreading centrally.
It is initially
maculopapular
before becoming
vasculitic

Q fever Coxiella burnetti No vector No rash but causes

pneumonia
Endemic typhus Rickettsia typhi Flea Rash starts centrally
then spreads to the
peripheries
Epidemic typhus Rickettsia prowazekii Human body louse
Ehrlichliosis Ehrlichia Tick

❑ Features of rickettsia: Box 13.52

❑ Mx of Rickettsial fever: Tetracycline/Doxycycline/Chloramphenicol. Louse borne
typhus and scrub typhus treated with single dose doxycycline
❑ Treatment of Q fever: Doxycycline
❑ Treatment of Q fever endocarditis: Prolong therapy with Doxycycline and rifampicin or
ciprofloxacin with hydroxychloroquine
❑ Cat scratch disease: By Bartonella henselae, vector is Flea
❑ Trench fever: Bartonella quintana, Vector is Lice
❑ Oroya fever and verruga peruana (Carrion's disease): Bartonella bacilliformis, vector is
sand fly
❑ Treatment of Bartonella spp.: Macrlides or tetracycline
❑ Most common cause of avoidable blindness: Chlamydia trachomatis
❑ First affected site in trachoma: Conjunctiva of the upper lid
❑ Characteristic feature of trachoma: Early follicles
❑ Chlamydial infections: Box 13.54
❑ Treatment of trachoma: Single dose Azithromycin
❑ SAFE strategy for trachoma control: Surgery, Antibiotics, Facial cleanliness and
Environmental improvement
❑ Most common and most dangerous organism for Malaria: Plasmodium falciparum
❑ Sexual form of malarial parasite: Gametocyte
❑ Which stage of malaria invade red blood cell: Merozoite
❑ Which stage of malaria accumulate in salivary gland: Sporozoite
❑ Cause of fever in malaria: Rupture of schizont and release of merozoite into the blood
❑ Malaria species that remain in liver as dormant: P. vivax and P. ovale
❑ Name of dormant stage of malaria: Hypnozoite
❑ Malaria species that don't have persistent exo-erythrocytic phase but causes
recrudescence of fever: P. falciparum, P. knowlesi and P. malariae
❑ Malaria species that invade young cell: P. vivax and P. ovale. P. falciparum invade rbc of
all ages.
❑ Protective mutations against P. falciparum:
o Sickle cell (Hb)
o Thalassemia
o G6PD deficiency
o HLA-B53

❑ P. falciparum does not grow well in red cell that contain Hb F, C or especially S
❑ Hb S heterozygotes are protected against lethal complications of malaria
❑ P. vivax cannot enter red cell that lack the Duffy blood group
❑ Life cycle of malaria parasite: Fig 13.36
❑ Malaria parasite in pregnancy bind with placental protein chondroitin sulphate A
❑ Previous splenectomy increases the risk for severe malaria
❑ Feature of severe malaria:

o schizonts on a blood film

o parasitaemia > 2%
o hypoglycaemia
o acidosis
o temperature > 39 °C
o severe anaemia
o complications as below

❑ Complications

o cerebral malaria: seizures, coma

 o acute renal failure: blackwater fever, secondary to intravascular hemolysis,
mechanism unknown
o acute respiratory distress syndrome (ARDS)
o hypoglycemia
o disseminated intravascular coagulation (DIC)

❑ Thick film: Diagnosis of low level parasitemia, all stage of parasites is seen
❑ Thin film: Essential to confirm the diagnosis, quantify parasite load
❑ Malaria treatment: Box 13.57
❑ Treatment of choice in complicated P. falciparum malaria: IV Artesunate (Side effect:
Late hemolysis)
❑ RDT for malaria OptiMAL detects: Plasmodium LDH of P. falciparum and P. vivax
❑ RDT for malaria Parasight-F detects: P. falciparum histidine-rich protein (HRP)
❑ Chloroquine may cause irreversible retinopathy
❑ Radical cure: Primaquine or tafenoquinewhich destroys the hypnozoites phase in liver
(For vivax and ovale)
❑ Severe hemolysis develops in those who are G6PD deficient in non-falciparum malaria
❑ Chemoprophylaxis of malaria: Box 13.58
❑ African trypanosomiasis: Trypanosoma brucei gambiense and Trypanosoma
rhodesiense

❑ Clinical clue for African trypanosomiasis:

o Trypanosoma chancre - painless subcutaneous nodule at site of infection
o intermittent fever
o enlargement of posterior cervical lymph nodes
o later: central nervous system involvement e.g somnolence, headaches, mood
changes, meningoencephalitis
❑ Clinical clue for American trypanosomiasis:
o an erythematous nodule at site of infection and periorbital oedema are
sometimes seen. Chronic Chagas' disease mainly affects the heart and
gastrointestinal tract

o myocarditis may lead to dilated cardiomyopathy (with apical atrophy) and

arrhythmias
o gastrointestinal features include megaesophagus and megacolon causing
dysphagia and constipation
❑ Site of sexual cycle for toxoplasmosis: Small intestinal epithelium of domestic cat

❑ Clinical clue for toxoplasmosis:

o Localized or generalized painless lymphadenopathy
o Cervical lymph node primarily involved
 o Palpable spleen
o Malaise/fever/fatigue/muscle pain/sore throat/headache

❑ Result of congenital infection by toxoplasma: Retinochoroiditis

❑ Long term Sequelae of Congenital toxoplasmosis:
o Retinochoroiditis
o Microcephaly
o Hydrocephalus

❑ Treatment of toxoplasmosis: Usually self-limiting. In severe case, Sulfadiazine,

Pyrimethamine and folinic acid. In pregnant women, Spiramycin is given until term.
❑ First sign of Kala azar: High fever with chills and rigo

❑ Clinical clue for Kala azar:

o High fever with chills and rigor
o Then become afebrile for weeks to months
o Again, relapse of fever
o Quick development of splenomegaly
o Moderate hepatomegaly
o Lymphadenopathy
o Anemia + Pancytopenia
o Bleeding from retina, GIT tract and nose
o Hypoalbuminemia presenting as pedal edema, ascites and anasarca

❑ Dominant feature of kala azar: Pancytopenia

❑ Chief immunoglobulin in kala azar: Ig G
❑ Most efficient means of diagnosis: Demonstrations of amastigote form (LD body) in
splenic smear.
❑ First line treatment of kala azar: Liposomal amphotericin B
❑ Pathogenic stage of amoebiasis: Cyst
❑ Flask shaped ulcer in sigmoidoscopy: Amoebiasis
❑ Amoebic liver abscess is usually found in right hepatic lobe
❑ Clinical clue for Amoebic liver abscess: Swinging temperature + sweating + enlarged
tender liver + cough + pain in the right shoulder
❑ Confirmatory investigation for amoebic abscess: USG
❑ Treatment of Amoebiasis: Oral metronidazole/tinidazole/ornidazole
❑ Drug to eliminate luminal cyst of amoebiasis: Diloxanide furoate or paromomycin
❑ Classes of helminths that parasitizes human: BOX 13.60
❑ Treatment of giardiasis: Single dose of Tinidazole/ Metronidazole for 10 days/
Nitazoxanide for 3 days
❑ Infective stage of ancylostomiasis/hookworm: Filariform larva
 ❑
Worm Notes Treatment
Strongyloides stercoralis Larvae are present in soil and Ivermectin and -bendazoles
gain access to the body by are used
penetrating the skin A course of two doses of
ivermectin.
Features include diarrhoea, For strongyloidiasis hyper
abdominal pain, infection syndrome,
papulovesicular lesions Ivermectin is given for 5-7
where the skin has been days
penetrated by infective larvae
e.g. soles of feet and
buttocks, larva currens:
pruritic, linear, urticarial rash,
if the larvae migrate to the
lungs a pneumonitis similar
to Loeffler's syndrome may
be triggered
Enterobius vermicularis Threadworm infestation is -bendazoles
(pinworm) asymptomatic in around 90% A single dose of
of Mebendazole/albendazole/p
cases, possible features yrantel pamoate/piperazine
include perianal itching, and repeated after 2 weeks
particularly at night; girls may
have vulval symptoms

Diagnosis may be made by

the applying sticky plastic
tape to the perianal area and
sending it to the laboratory
for microscopy to see the
eggs
Ancylostoma duodenale, Larvae penetrate skin of feet; -bendazoles
Necator americanus gastrointestinal infection → Single dose albendazole is
(hookworms) anaemia + eosinophilia the treatment of choice
Thin-shelled ova
Loa loa Transmission by deer fly and Diethylcarbamazine
mango fly

Causes red itchy swellings

below the skin called 'Calabar
swellings', may be observed
when crossing conjunctivae
Trichinella spiralis Typically develops after -bendazoles
eating raw pork Mebendazole

Features include fever,

Onchocerca volvulus
Wuchereria bancrofti
periorbital oedema and
myositis (larvae encyst in
muscle)
Causes 'river blindness'. Ivermectin single dose
Spread by female blackflies repeated at 3 months
Snowflake deposit are seen intervals
at the edge of cornea
Features include blindness, rIVERblindness = IVERmectin
hyperpigmented skin and
possible allergic reaction to
microfilaria
Transmission by female Diethylcarbamazine
mosquito

Causes blockage of
lymphatics → elephantiasis
Toxocara canis (dog Transmitted through Diethylcarbamazine
roundworm) ingestion of infective eggs.

Features include visceral

larva migrans and retinal
granulomas

VISCious dogs → blindness

Ascaris lumbricoides (giant
roundworm)
Eggs are visible in faeces
May cause intestinal
obstruction and occasional
migrate to lung (Loffler's
syndrome)
-bendazole
A single dose of
Albendazole/pyrantel
pamoate/Ivermectin

❑ Anemia and heart failure associated with hookworm infection: respond to oral iron
❑ Clinical feature of strongyloidiasis: Box 13.61
❑ Pathogenicity of filarial parasites: Box 13.62
❑ Wuchereria bancrofti
o Parasitic filarial nematode
o Accounts for 90% of cases of filariasis
o Usually diagnosed by blood smears
 o Usually transmitted by mosquitos
o Treatment is with diethylcarbamazine
Cestodes (tapeworms)
Worm
Echinococcus granulosus
Taenia solium
Notes Treatment
Transmission through -bendazoles
ingestion of eggs in dog
faeces. Definite host is dog,
which ingests hydatid cysts
from sheep, who act as an
intermediate host. Often
seen in farmers.
Features include liver cysts
and anaphylaxis if cyst
ruptures (e.g. during surgical
removal)
Often transmitted after -bendazoles
eating undercooked pork.
Causes cysticercosis and
neurocysticercosis, mass
lesions in the brain 'swiss
cheese appearance'
Trematodes (flukes)

Worm Notes Treatment

Schistosoma haematobium
Mature in portal vein
Paragonimus westermani
Clonorchis sinensis
Hosted by snails, which Praziquantel
release cercariae that
penetrate skin.
Causes 'swimmer's itch' -
frequency, haematuria. Risk
factor for squamous cell
bladder cancer
Caused by undercooked Praziquantel
crabmeat, results in
secondary bacterial infection
of lungs
Caused by undercooked fish Praziquantel

Features include biliary tract

inflammation. Known risk
factor for
cholangiocarcinoma
Fasciola hepatica (the liver May cause biliary obstruction Triclabendazole
fluke)
❑ Most common and first symptom of schistosomiasis: Painless terminal hematuria
❑ Association of S. haematobium: Squamous cell carcinoma of bladder
❑ Only natural host of S. haematobium: Human
❑ Granulomas are composed of:
o Macrophage
o Eosinophils
o Epithelioid cell and
o Giant cell around an ovum
❑ Most serious site of egg deposition S. haematobium: CNS
❑ DX of Trichinosis: Biopsy from the deltoid or gastrocnemius muscle after the 3rd week of
symptoms may reveal encysted larvae
❑ Most common linear lesion seen in travelers: Cutaneous larva migrans (Intensely itchy,
linear, serpiginous lesion)
❑ Most common site of CLM: Foot
❑ Rx of CLM: 15% THIBENDAZOLE cream or single dose of Albendazole
❑ Major etiological agent for bile duct cancer: Clonorchis sinensis and Opisthorchis felineus
❑ Drug of choice for taenia solium: Praziquantel
❑ Drug of choice for taenia saginata: Praziquantel
❑ Ingestion of T. solium tapeworm ova: Cysticercosis
❑ Common location of growth of cysticercosis:
o Subcutaneous tissue
o skeletal muscle
o Brain
❑
❑ Clinical clue for cysticercosis:
o Epilepsy, new onset focal seizure starting in adult life in endemic area
o personality change
o Staggering gait
o signs of hydrocephalus
❑ Treatment of parenchymal neurocysticercosis: Albendazole/Praziquantel + Prednisolone
❑ Treatment of hydatid cyst: Albendazole compaired with PAIR (Percutaneous puncture,
aspiration, injection of scolicidal agent and re-aspiration)
❑ Classification of fungi: Fig 13.62
❑ Severe oropharyngeal and esophageal candidiasis is seen with T-cell immunodeficiency,
including HIV infection and Anti IL-17 therapy.
❑ Most common cause of systemic candidiasis: C. albicans
❑ Main predisposing factor of acute disseminated candidiasis: Central venous catheter

❑ Factors predisposes to acute disseminated candidiasis:

o Central venous catheter
o Recent abdominal surgery
o Total parenteral nutrition
o Recent antimicrobial therapy
o Localized candida colonization
❑ Candida endophthalmitis is seen occasionally in injection drug user
❑ Treatment of candidiasis: IV/Oral Fluconazole
❑ Hepatosplenic candidiasis/Chronic disseminated candidiasis:
o Persistent fever + neutropenia despite antimicrobial therapy and neutrophil
recovery
o Abdominal pain
o Raised ALP
o Multiple lesions in abdominal organs (Liver, kidney or spleen) on radiological
imaging

❑ MRI brain showed a space occupying lesion with surrounding edema: Cryptococcal
disease
❑ Histopathological examination of the lesion stained with Grocott’s stain show
encapsulated cyst: Cryptococcal disease
❑ Treatment of cryptococcosis: Liposomal amphotericin B
❑ Cryptococcosis is acquired by inhalation of yeast, most commonly disseminate in CNS
and skin
❑ Most common predisposing factor of Mucormycosis:
o profound immunosuppression from neutropenia and hematopoietic stem cell
transplantation
o Uncontrolled DM
o Iron chelation therapy
o Severe burn

❑ Treatment of mucormycosis: High dose lipid formulated amphotericin B

❑ Treatment of histoplasmosis: Itraconazole

❑ HIV infects cell bearing CD4 receptor:

o T helper lymphocytes
o Monocyte-macrophage
o Dendritic cell
o Microglial cell

❑ Co receptor of HIV: CCR5/CXCR4

❑ Predominant opportunist infection in PLWH: Consequence of impaired cell mediated
immunity
❑ Most clinically useful laboratory indicator of the degree of immunosuppression: CD4
count
❑ Viraemia is measured by: Quantitative PCR or HIV RNA, known as viral load.
❑ For monitoring response to ART therapy: Check viral load
❑ Early dx of HIV: Detecting HIV RNA by PCR or p24 anti-genaemia
❑ Median time from infection to development of AIDS: 9 years
❑ Pulmonary infiltrate + CD4 countless than 350/mm3 : Pulmonary TB most likely
❑ Pulmonary infiltrate + CD4 less than 50/mm3 : PCP and TB likely
❑ CD4 count and risk of common HIV associated disease: Box 14.8
❑ Most common cause of morbidity and mortality in PLWH: TB
❑ Presentation and D/D of weight loss: Fig 14.3
❑ Poor prognostic feature of Kaposi sarcoma:
o Visceral involvement
o Edema
o Ulcerated lesion
o B symptoms: Fever, night sweats and weight loss
❑ Kaposi sarcoma lesions typically have a red purple color caused by HHV-8
❑ Treatment of common opportunistic infection: Box 14.10
❑ Blue black discoloration of nails: Zidovudine/HIV
❑ Biopsy of ulcers showing Owl’s eye inclusion body: CMV colitis
❑ Prominent feature of MAC infection: Fever
❑ Confirmatory investigation for cryptosporidiosis: Duodenal biopsy
❑ Most common sites of concomitant extrapulmonary TB: Pleura and lymph node
❑ Clinical clue to dx PCP:
o Progressive dyspnea with a duration of less than 12 weeks
o Dry cough
o Fever
o Chest x-ray showing bilateral interstitial infiltrate spreading out from hilar regions
o CT showing typical ground glass interstitial infiltrate
o Pneumatocele may rupture and result in Pneumothorax
❑ Diagnosis of PCP: Dx made with silver stain, PCR or immunofluorescence of
bronchoalveolar lavage or induced sputum.
❑ Treatment of PCP: High dose co-trimoxazole + systemic glucocorticoid if hypoxic
❑ Disseminated endemic mycoses caused by:
o Histoplasmosis
o Coccidioidomycosis
o Emergomycosis
o talaromycosis

❑ HIV associated neurological involvement: Fig 14.11

❑ PML is caused by JC virus
❑ Vision is impaired in PML due to involvement of occipital cortex
❑ Diagnostic of CMV encephalitis: Detection of CMV DNA in CSF
❑ Most common cause of space occupying lesion in AIDS: Toxoplasmosis
❑ Characteristic finding of Cerebral toxoplasmosis: Multiple space occupying lesion with
ring enhancement on contrast and surrounding edema + Positive IgG antibody to
toxoplasma
❑ Definitive investigation of cerebral toxoplasmosis: Brain biopsy
❑ Characteristic finding on Primary CNS lymphoma: Single homogenously enhancing,
periventricular lesion with surrounding edema
❑ Definitive investigation for primary CNS lymphoma: Brain biopsy
❑ Most common cause of meningitis in AIDS patient: Cryptococcal neoformans
❑ Most common cause of myelopathy in HIV infection; Cord compression from tuberculous
spondylitis

❑ Clinical clue for CMV polyradiculitis:

 o Painful legs
o Progressive flaccid paraparesis
o saddle anesthesia
o Absent reflex
o sphincter dysfunction

❑ Clinical clue to diagnose CMV retinitis:

o Painless progressive visual loss
o Vitreous is clear
o Hemorrhage and exudate on retina often with sheathing of vessels
o Starts unilaterally and then becomes bilateral

❑ Diagnostic of CMV retinopathy: Detection of CMV DNA by PCR of vitreous fluid

❑ Treatment of CMV retinopathy: Ganciclovir or Valganciclovir (Lost vision does not
recover)
❑ Clinical clue to dx HIV retinopathy: Cotton wool spot
❑ Clinical clue to dx ocular toxoplasmosis: Vitritis and retinitis without retinal hemorrhage

❑ Most common disorder causing severe thrombocytopenia: Immune mediated platelet

destruction resembling ITP
❑ Most common manifestation of DILS (Diffuse infiltrative lymphocytosis syndrome):
Bilateral parotid enlargement
❑ AIDS defining cancer:
o Kaposi sarcoma
o Cervical cancer
o Non-Hodgkin lymphoma
❑ Opportunistic infection reduced by cotrimoxazole: Box 14.14
❑ M/A of anti-retro viral drug: Box 14.16
❑ First line ART: Bictegravir/Dolutegravir + Tenofovir + Emtricitabine/Lamivudine
❑ Most important measure of ART efficacy: Viral load, should repeat after 4 weeks of
starting ART
❑ C/S is associated with lower risk of mother to child transmission than vaginal delivery
❑ HIV is transmitted by breastfeeding
❑ Pre-exposure prophylaxis of HIV: Daily tenofovir + Emtricitabine
❑ Post exposure prophylaxis: (Tenofovir + Emtricitabine + Darunavir/Dolutegravir)
Ineffective if given 72 hours after exposure
❑ GENITAL ULCER:
❑ Most common cause of genital ulceration: Genital herpes

❑ Painful ulcer:
o Herpes simplex: Oro genital ulcer + Vesicular eruption
o Chancroid: No vesicular eruption
o Bechet's disease: Oro genital ulcer + Joint pain + rash + thromboembolism
o Malignancy: H/O chemo/radiotherapy
❑ Painless ulcer:
o Syphilis:Painless Lymphadenopathy
o LGV: Painful Lymphadenopathy
o Granuloma inguinale

❑ Discharge:

▪ Vaginal discharge:
o Candidiasis: Curdy white discharge + itching + low vaginal pH + vulval burning +
external dysuria + superficial dyspareunia(Fluconazole)
o Trichomoniasis: Frothy yellowish/Greenish discharge + itching (Metronidazole)
o Bacterial vaginosis: No itching + white homogenous discharge + high vaginal pH
+ Fishy/unpleasant odor + worse after sexual intercourse and during
menstruation + clue cell on microscopy (Metronidazole)
o Aerobic vaginitis: Purulent vaginal discharge
▪ Most common treatable STI causing vaginal discharge: Trichomoniasis

▪ Urethral discharge:
o Gonorrhea: Thick purulent discharge
o Chlamydia: Thin purulent discharge / clear

❑ Genital warts: Known as Condylomata acuminata

▪ Cause:
▪ HPV- 6& 11: Benign
▪ HPV - 16, 18 ,33: Cervical cancer

♦ Features:
o Small fleshy protuberance, slightly pigmented
o May bleed or itch
♦ D/D: Molluscum contagiosum & Skin tag
♦ Management: Topical self-administered treatments commonly prescribed for use at
home include:
o Podophyllotoxin, 0.5% solution or 0.15% cream (contraindicated in pregnancy)
o Catephen
o If topical therapy fails, ablative therapy is performed like Cryotherapy,
hyfrecation & Surgical removal

❑ HSV:
o 2 strains:
o HSV 1 & HSV 2
o HSV 1: Oral ulcer & HSV 2: Genital ulcer
o Irritable vesicles
o Enlarged tender inguinal lymph nodes

♦ Dx: By PCR - Detection of DNA

♦ Mx: Oral acyclovir

❑ Chancroid:
o Hemophilus ducreyi (Gram negative bacillus)
o Erythematous papule, pustule & ulcer on external genitalia
o Single or multiple painful genital ulcers associated with unilocular painful
inguinal lymph node enlargement
♦ Dx by Microscopy & culture of scraping from ulcer
♦ Treatment: Azithromycin/Ceftriaxone/Ciprofloxacin

❑ Bechet's disease:
o Multisystem vasculitis disorder
o Associated with HLA-B5, HLA B51
o Autoimmune mediated
♦ Triad: Oral ulcer + Genital ulcer + Anterior uveitis
♦ Dx by Positive Pathergy test.
❑ Syphilis:

♦ Primary features
o chancre - painless ulcer at the site of sexual contact
o local non-tender lymphadenopathy
o often not seen in women (the lesion may be on the cervix)

♦ Secondary features - occurs 6-10 weeks after primary infection

o systemic symptoms: fevers, lymphadenopathy
o rash on trunk, palms and soles
o buccal 'snail track' ulcers (30%)
o condylomata lata (painless, warty lesions on the genitalia)
Tertiary features:
o Gummas (granulomatous lesions of the skin and bones)
o ascending aortic aneurysms
o general paralysis of the insane
o Tabes dorsalis
o Argyll-Robertson pupil

Features of congenital syphilis: Penicillin is the drug of choice

o blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars

o rhagades (linear scars at the angle of the mouth)
o Keratitis
o saber shins
o saddle nose
o deafness

❑ Commonest late manifestation of untreated syphilis is involvement of ascending aorta

and sometimes the aortic arch.

Ankle jerk absent but planter exaggerated:

o Conus medularis
o Motor neuron disease
o Friedrich ataxia
o Subacute combined degeneration of spinal cord
o Tabes dorsalis

♦ Investigation:
o Nonspecific:
• VDRL - Becomes negative after treatment
• RPR (Rapid plasma reagin)
o Specific:
• TPHA - Remains positive throughout life even after treatment. positive for syphilis &
Yaws
• TPPA
• FTA-ABS
• EIA for IgG and IgM

♦ Mx: Benzyl penicillin IM 2-4 lakhs unit/ Doxycycline

❑ Jarisch - Herxcheimer reaction:

• Fevef + Rash + Tachycardia + Hypotension (after 1st dose of Antibiotic)

• Cause: Release of Endotoxin within few hours following bacterial death

❖ Present in:
o Syphilis
o Rickettsial fever
o Q fever
o Lyme disease

♦ No treatment is needed

❑ Lymphogranuloma venereum: Small, painless, transient ulcer with painful, unilateral,

matted, suppurative inguinal or femoral lymph node
o Chlamydia trachomatis
o Gay men, especially in HIV positive men

• 3 stages
• Pathognomic sign: Groove's sign positive
 ♦ Treatment: Doxycycline/Erythromycin
❑ Gonorrhea:

• Neisseria gonorrhea (Gram negative Diplococcus)

• Male: Mucopurulent / purulent urethral discharge (thick)
• Female: Pus from urethra, para urethral duct, Bartholin duct

♦ Local Complications:
• Urethritis
• Epididymitis
• Salpingitis: Infertility

♦ Disseminated gonococcal infection:

1. Tenosynovitis
2. Migratory polyarthritis
3. Dermatitis (Maculopapular / Vesicular)

♦ First choice antibiotic: IM Ceftriaxone single dose

❑ Chlamydia:
o Obligate intracellular, most prevalent STD in UK
o Investigation of choice: Nucleic acid amplification test (NAAT)
o Thin purulent urethral discharge
♦ First choice antibiotic: Doxycycline

❑ Granuloma inguinale:
o Klebsiella granulomatis (Donovan bodies)
o Painless ulcer
o Inguinal lymph node enlarged: Abscess / ulcer
o Microscopy: Intracellular bipolar staining Donovan bodies
♦ Treatment: Azithromycin/Doxycycline/Ceftriaxone

❑ Proctitis:
♦ STIs that can cause proctitis:
o Gonorrhea
o Chlamydia
o Herpes
o Syphilis

❑ A definitive diagnosis of PID can only made by laparoscopy