Systemic Infectious

Disorders
Bacterial Infections
Food Poisoning and Gastroenteritis
• Definition: diarrhea = a person has to keep going to the bathroom to pass
loose watery bowel movements
• Most diarrhea is a food-borne illness, sometimes it is viral
• Toxic bacteria versus invasive bacterial infection: toxic bacteria have
abrupt onset and the invasive bacteria have a gradual onset and systemic
symptoms
• Toxin-mediated causes:
o Staph aureus from eggs/mayo, ex. picnic
o Bacillus cereus from fried rice
o Enterotoxigenic E. Coli = classic traveler’s diarrhea
o Clostridium perfringens from meat/poultry
o Scombroid from dark meat fish (tuna) ! histamine reaction with
itching and facial flushing
o Ciguatera from carnivorous fish ! neurological symptoms with
neuropathy and tingling
• Invasive bacterial infections causing bloody diarrhea:
o Salmonella from undercooked eggs/chicken/unpasteurized milk
associated with a cafeteria-type outbreak
o Shigella ! from institutionalized patients and poor hygiene !
watery diarrhea that gets worse ! fevers, dysentery, and seizures
(especially in pediatrics)
o Campylobacter (most common) from chicken and natural water
sources ! +/- bloody diarrhea, appendicitis mimic
o Yersinia from farm animals/chickens and person-to-person
transmission ! appendicitis mimic, terminal ileitis, and post-
infection arthritis
o Vibrio parahaemolyticus ! from undercooked seafood generally in
the summer months
o E. Coli O157:H7 ! from raw ground beef or raw milk ! bloody
diarrhea ! HUS (hemolytic uremic syndrome) or TTP (thrombotic
thrombocytopenic purpura)
o Send fecal leukocytes, guaiac the diarrhea (often positive)
o The above infections need antibiotics
• Ask patient about C. difficile risk factors: recent hospitalization, persistent
diarrhea, or recent antibiotic use ! can cause fulminant colitis ! if
suspicious, send C. difficile toxin
 • Treatment: decisions regarding antibiotics
o In otherwise healthy adults with mild diarrhea do not treat with
antibiotics as it is a self-limited illness: focus on dehydration
o Antibiotics will shorten the course of moderate-severe diarrhea by
1-2 days
o Avoid antibiotics, antimotility agents in children or elderly patients
with grossly bloody diarrhea ! may have E. Coli O157:H7 !
increase risk of HUS
o Downside of providing antibiotics: antibiotic resistance and C.
difficile
• Treatment: replacing fluids and electrolytes
o Oral rehydration for mild to moderate cases (1 cup water, 1 tsp salt,
4 tsp sugar)
o Severe cases need IV hydration
• Public Health Emergency: Vibrio cholera
o Vibrio cholera from contaminated food/water supplies often
overseas (ex. Haiti) / in refugee camps
o Epidemics in wartime, overcrowding, famine and poor sanitation
o Produces a toxin that activates adenylyl cyclase in intestinal
epithelial cells of small intestine ! get hypersecretion of
water/chloride and massive diarrhea ! sudden onset “rice water”
diarrhea
o Develop severe hypovolemia and dehydration that can kill elderly
and children = public health emergency
o Hydration is key, especially oral rehydration
o Antibiotics: tetracycline, ampicillin, TMP/SMX, and quinolones !
shortens duration and reduces severity
o Must prevent with clean water and food supply, vaccine available
but need booster every 6 months

Botulism
• Clostridium botulinum: anaerobic, spore-forming bacillus found in soil
• Makes a toxin that inhibits the release of acetylcholine at the
neuromuscular junction
• Three main clinical presentations: foodborne, infant (most common), and
wound
o Foodborne from improperly home canned foods
o Infant botulism from ingestion of honey ! presents with poor
feeding, weak cry, poor head control and loss of facial expression
(bulbar palsies)
o Wound botulism from black tar heroin, skin popping or from a dirty
wound
• Botox uses the same mechanisms and is considered one of the most
powerful neurotoxins that exist ! medical uses include sweating,
strabismus, cervical dystonia and spasms
 • Potentially a bioterrorism agent
• Paralytic disease
• Presentation with the D’s: diplopia, droopy eyes (ptosis), dilated pupils, dry
mouth, dysphonia, and dysarthria
• No mental status change or sensory symptoms
• Symmetric descending muscular weakness ! proximal > distal
• Can get respiratory paralysis
• Diagnosis: Toxin identification
• Differential diagnosis includes
o Guillain-Barre ! distal weakness first +/- paresthesias, CSF protein
high, ascending weakness
o Tick paralysis ! usually ascending weakness, no bulbar
involvement, +tick
o Myasthenia gravis ! pupils spared no autonomic symptoms,
tensilon test can be diagnostic
o Anticholinergics ! pupils dilated but “mad as a hatter” and altered
• Treatment:
o Botulinum antitoxin from the CDC
o Early intubation and supportive care
o Occasionally antibiotics are administered

Bacterial Sexually Transmitted Diseases

• Chlamydia trachomatis
o Causes urethritis and cervicitis
o Discharge usually watery in men and less painful than gonococcus
in males
o Females usually asymptomatic but can get cervicitis/PID
o Leading cause of infertility
o Can also cause LGV (lymphogranuloma venereum) ! vesicular
lesion or ulcer spreading to nodes (inguinal buboes) and anorectal
involvement possible
o Clinical diagnosis
o Send ELISA/DNA tests to confirm
o Treatment: azithromycin, doxycycline (erythromycin in pregnancy),
treat all partners
• Neisseria gonorrhoeae
o Often coinfection with chlamydia
o Incubation 2-8 days after exposure
o Men: milky discharge, dysuria, couple days later get worse and
discharge changes to yellow
o Women: asymptomatic or dysuria
o Women: PID, infertility
o Conjunctivitis: direct inoculation (adults and neonates) ! copious
purulent discharge
 o Disseminated gonorrhea and bacteremia ! skin lesions =
“gunmetal grey” small hemorrhagic pustules (more common in
women), septic arthritis, and tenosynovitis (provide larger dose of
antibiotics)
o Diagnosis with gram-negative diplococci ! send culture
o Treatment: resistance to penicillin and quinolones so treat with IM
ceftriaxone
o Treat all partners and treat chlamydia too

Syphilis
• Treponema pallidum transmitted via sexual contact or congenitally
• Early stages and late stage
• Primary syphilis:
o Chancre = painless genital ulcer at site of inoculation
o Regional lymphadenopathy
o Heals in 4-8 weeks
o VDRL/RPR are nonspecific (cross reactivity with other conditions)
and often negative in primary syphilis ! send FTA-ABS
(treponemal antibody confirmatory test)
• Secondary syphilis:
o Occurs after untreated primary syphilis, 2-10 weeks later
o Typical rash is on palms and soles
o Kidneys, CNS, liver may be involved, syphilis is the “great imitator”
• Tertiary syphilis:
o Occurs years later
o Gummatous lesions on skin, bone, and viscera
o Cardiovascular involvement
o Neurosyphilis: tabes dorsalis = impaired proprioception, loss of
vibratory sense, demyelination of dorsal columns, chronic
meningitis, dementia
o Argyll-Robertson pupil = small pupils that constrict to near objects
(accommodates) but does not react to bright light
• Treatment
o Benzathine penicillin G 2.4 million units in a single dose, if late
disease need three weekly doses
o Treatment of neurosyphilis: need penicillin every 4 hours x 2 weeks
o Jarisch-Herxheimer reaction occurs with massive destruction of
spirochetes (fever, toxicity)

Meningococcus
• Time sensitive and can have high mortality
• Causes meningitis, bacteremia, meningococcemia, and Waterhouse-
Friderichsen syndrome = rapid hypotension and acute adrenal
hemorrhage
 • Also causes respiratory tract infections (pneumonia, epiglottitis, otitis
media)
• Must recognize the petechial/purpuric rash and treat with ceftriaxone early
= meningococcus until proven otherwise
• Meningitis can lead to permanent neurological sequelae including hearing
loss, visual loss, brain damage
• Chemoprophylaxis = rifampin, Cipro, Ceftriaxone for close contacts only
with droplet contact
• Vaccine has decreased incidence

Atypical Mycobacteria
• Infection with mycobacteria other than tuberculosis
• Mycobacterium avium intracellulare (MAC)
o Affects AIDS patients
o Causes lung disease and bone marrow suppression !
pancytopenia
• Mycobacterium marinum
o Skin infections
o Fish handlers, more common working in aquariums
• Mycobacterium kansasii
o Lung disease
• Mycobacterium ulcerans
o Skin ulcers

Mycobacteria: Tuberculosis (TB)

• Mycobacterium tuberculosis acquired through inhaling droplets
• Public health threat
• Survives in macrophages as a facultative intracellular parasite
• Reactivation more likely in immunocompromised
• During immigration TB is more likely to reactivate
• 1/3 of the world’s population is infected with TB
• Transmission: primary tuberculosis (can appear to be like pneumonia and
may be asymptomatic) ! Latent TB (convert to PPD positive) !
Reactivation TB
• Risk factors: homeless, immunocompromised, history of incarceration,
group living, recently immigrated
• Radiographic findings
o Primary TB can look like any pneumonia or can be atypical
o Reactivation TB may have apical lesions
o Ghon complex = calcified primary focus, Ranke complex = Ghon
complex + calcified hilar lymph node = healed primary TB
• Symptoms
o Most commonly cough
o Also see fever, night sweats, weight loss, hemoptysis
 o Diagnosis: mycobacterial culture/PCR, finding acid fast bacilli on
sputum stain makes you suspect it but it is not diagnostic
• TB is the most common cause of hemoptysis world-wide
• Treatment: INH, rifampin, pyrazinamide, ethambutol
o Respiratory isolation is key
o If PPD positive treat for 9 months
o INH: injuries nerves and hepatocytes ! check LFTs, can cause
neuropathies, can also cause refractory seizures
o Rifampin = orange body fluid
o Ethambutol = optic neuritis (red-green loss)
• Today multi-drug resistant TB does exist

Tetanus
• Clostridium tetani spores are ubiquitous in soil
o In developing countries when the birth is not clean and the umbilical
stumps are exposed ! babies are affected from contamination
• Spores germinate in wounds and bacteria produce a neurotoxin
(tetanospasmin) ! blocks release of GABA/glycine (inhibitory
neurotransmitter) results in unopposed excitatory discharge ! affects
sympathetic and parasympathetic neurons
• Puncture wounds most susceptible
• Pain and tingling at site of inoculation followed by spasticity of nearby
muscle
• Jaw/neck stiffness (lockjaw, trismus, risus sardonicus) and irritability
• Painful tonic convulsions = opisthotonus
• No CNS effect (no mental status changes)
• It is a clinical diagnosis
• Prevention is key
• Tetanus immunoglobulin should be given IM
• Immunization starting in childhood every 5-10 years
• Treatment for disease: supportive care (benzodiazepines, intubation) and
antibiotics

Necrotizing Skin Infections

• Toxin-producing bacteria affecting subcutaneous tissues ! necrotizing
infections
• Cause muscle and fascial necrosis
o Necrotizing fasciitis (fascial planes)
o Myonecrosis (gas gangrene)
o Fournier’s gangrene involves the scrotum, vulvar, and perianal skin
• Maintain a high index of suspicion ! consider with any cellulitis, more
concerning with rapid spread / bullae / crepitus
• Clostridial myonecrosis = gas gangrene
o Rapidly progressive muscle-necrotizing infection
 o Not much skin inflammation but + gas formation (may feel crepitus
or see gas on imaging)
o Recent trauma or surgical wound (diabetics at risk)
o Clostridia produce a toxin that kills muscle and sets up anaerobic
growth
o Onset can be 6-24 hours
o Pain is the earliest symptom (may have pain out of proportion)
o Symptoms: may have tachycardia out of proportion to fever,
temperature not reliable, mental status variable, skin changes
progressive, +/- gas on plain Xray, incision will reveal dead muscle
and foul odor
• Treatment is wide surgical debridement
o Wide surgical debridement
o Anaerobic, gram negative and gram positive antibiotic coverage, ex.
ampicillin + gentamicin + clindamycin (anti-toxin activity)

SIRS, Sepsis, & Septic Shock

Definitions
• SIRS, sepsis and septic shock are on a continuum of disease
• SIRS = systemic inflammatory response syndrome with two or more of the
following
o Tachycardia
o Tachypnea
o Hyper/hypothermia
o High or low WBC or bandemia
• Remember that SIRS is nonspecific and can be a result of burns,
pancreatitis, trauma, and many other conditions
• SIRS + infection = sepsis
• Sepsis = life threatening organ dysfunction due to a dysregulated host
response to infection (no more “severe sepsis”)
• Septic shock = profound circulatory, cellular and metabolic abnormalities
that substantially increases mortality
• The Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3)
o Sepsis I–II = suspected infection + SIRS
o Sepsis-III = suspected infection + qSOFA + SOFA
o qSOFA = quick SOFA and signs of poor perfusion
o qSOFA criteria: abnormal mental status, RR≥22 or SBP≤100, and
>1: sepsis (mortality ~10%) ! as meet larger number of criteria
mortality increases
• Lactate is a good marker for poor perfusion, if level >2 concern for septic
shock if it does not clear when repeating the level
 • If patients are refractory to IV fluids and remain hypotensive requiring
vasopressors = septic shock

History, Research, & Future

• Surviving sepsis campaign in the early 2000’s
o Early recognition and aggressive resuscitation is key
o Antimicrobial + adequate tissue oxygenation and perfusion
o Early and adequate fluid resuscitation
• ProCESS Trial 2014: A Randomized Trial of Protocol-Based Care for
Early Septic Shock
o Multi-center RCT – 31 sites
o Just over 1300 patients
o ED patients > 18 meeting at least 2 criteria for SIRS
o Refractory hypotension or serum lactate > 4 mmol/L
o Compared EGDT (early goal directed therapy) vs. protocol-based
standard therapy vs. usual care (around 450 patients/group)
o Primary outcome: in-hospital death at 60 days
o Result: No difference (21% vs. 18.2% mortality vs. 18.9% mortality)
• ARISE Trial 2014: Goal-Directed Resuscitation for Patients with Early
Septic Shock
o Multi-center RCT – 51 sites
o 1600 patients
o ED patients with suspected/confirmed infection and at least 2
criteria for SIRS
o Evidence of either refractory hypotension or hypoperfusion
(lactate>4)
o Compared EGDT vs. usual care
o Primary outcome: Mortality at 90 days
o Result: No difference (18.6% mortality vs. 18.8%)
• ProMISE Trial 2015: Trial of Early, Goal-Directed Resuscitation for Septic
Shock
o Demonstrated probability of survival for patients with severe sepsis
receiving EGDT and those receiving usual care at 90 days
o Result: No difference between usual care and EGDT
• Surviving sepsis campaign 2015: Updated Bundles in Response to New
Evidence
o Measure lactate level
o Blood cultures before antibiotics
o Broad-spectrum antibiotics
o Give 30 cc/kg crystalloid for hypotension or lactate > 4 mmol/L
o Keep MAP > 65 (vasopressors if no response to initial fluid)
o Re-measure lactate if initial lactate elevated ! poor prognostic sign
if not improving
o Re-assess and document volume status and tissue perfusion
 • Sepsis bundles, alerts, and early aggressive therapy can lead to
decreased mortality

Toxic Shock Syndrome

Definitions
• Toxin-mediated SIRS
• Peaked in the 1980’s with tampon use
• Menstruation still most common setting but nonmenstrual is just less than
half, ex. wound packing or nasal packing
• About 200 cases a year
• Definition of toxic shock syndrome:
o Fever of at least 102F
o Rash: Diffuse macular erythroderma (appearance of a sunburn)
o Desquamation: 1-2 weeks after onset, particularly palms and soles
o Hypotension: SBP < 90 for adults (<5% for kids)
o Multisystem involvement of at least 3: GI, muscular, mucous
membranes, renal, hepatic, hematologic, CNS
• Streptococcal and staphylococcal causes
• Staphylococcal features:
o 15-35 years old
o Usually female
o Pain is rare
o Hypotension in 100% of cases
o Erythroderma is very common
o Renal failure is common
o Bacteremia in low percent of cases
o Tissue necrosis is rare
o Occurs from tampons and packing
o Thrombocytopenia is common
o Mortality is <3%
o Does not require a positive culture
• Streptococcal features:
o 20-50 years old
o Either sex
o Pain is common
o Hypotension in 100% of cases
o Erythroderma is less common
o Renal failure is common
o Bacteremia in 60% of cases
o Tissue necrosis is common
o Occurs from cuts, burns, varicella
o Thrombocytopenia is common
o Mortality is 30-70%
o Requires a positive culture
Fungal Infections
Candida Albicans
• Risk factors: immunocompromised (diabetes, HIV, chemotherapy,
antibiotics, steroids, indwelling lines)
• Types of disease
o Cutaneous
o Mucosal/genital
o Fungemia
o Endocarditis
o Hepatosplenic
• Features of cutaneous disease
o Diaper dermatitis
o Red with defined margins, satellite lesions are characteristic
o Kids/adult (with diabetes) may develop candida dermatitis in moist
areas (pannus, breasts)
o Treatment: topical antifungals
• Mucosal disease: mouth/esophagus
o Thrush = candida of the mouth; white plaques that can be scraped
off
o Esophagitis: odynophagia (like GERD), painful swallowing
especially in immunocompromised patients
o Treatment: thrush ! liquid antifungals (swish and spit); esophagitis
(diagnostic on endoscopy) ! oral fluconazole; amphotericin B if
recurrent/resistant
• Mucosal disease: vulvovaginal/genital candidiasis
o Most women have it at least once
o Occurs in extremes of age, pregnancy, diabetes (especially males),
steroids, HIV (may be their presenting symptom)
o Also occurs after taking a course of antibiotics which can offset the
flora in the vagina
o Presents with itching, burning, white cottage-cheese discharge
o Men can get balanoposthitis ! check blood sugar
o Treatment: topical antifungals or oral fluconazole
• Fungemia
o Life threatening, may be secondary to indwelling catheter
o Treatment: amphotericin B
o If disseminated, may add flucytosine or fluconazole ! some
patients need lifelong preventive therapy after one infection
o Hepatosplenic disease and organ infiltration
o Leukemia, lymphopenia
o May present with RUQ pain, increased LFTs
o Diagnosis: multiple low density defects seen, need biopsy
Cryptococcus Neoformans
• Encapsulated yeast found in soil with dried pigeon poop
• Transmitted through inhalation
• Pulmonary and CNS disease
• Meningitis most commonly presents with mental status changes, cranial
nerve/visual abnormalities (not typical neck stiffness)
• Diagnosis: cryptococcal antigen in CSF/serum, india ink stain also helpful
• Treatment: oral fluconazole x 10 weeks, if severe, amphotericin B

Histoplasmosis
• A dimorphic fungus in soil with bird or bat poop ! inhaled, occurs in
spelunkers
• Endemic in many areas: Ohio and Mississippi River Valleys
• Most infections are asymptomatic unless immunodeficient
• Can occur in epidemics when soil is upturned
• Disseminated histoplasmosis may be fatal in weeks, presents with fever,
cough, mouth ulcers, weight loss, retinal deposits
• Chronic progressive pulmonary disease occurs in older patients with
COPD ! develop calcified nodes
• If HIV, risk is highest as CD4 < 100
• Chest XRay may have military infiltrates
• Treatment: long term itraconazole, amphotericin B

Parasites
Toxoplasmosis
• Toxoplasma gondii (a protozoa)
• Infects warm-blooded animals, mostly cats
• Transmitted from raw meat (pork) and cat feces
• Primary infection usually mild
• In HIV it reactivates and causes an encephalitis and focal brain lesions,
can also affect retina
• Treatment: pyrimethamine
• Can also cause congenital syndrome in non-infected mother with primary
infection
o In early pregnancy it is worse
o Causes premature birth, eye, CNS, skin problems, jaundice, and
splenomegaly
o Avoid cat feces in pregnancy

Malaria
 • Presents with fever and shaking chills and a history of travel to an
endemic region
• P. falciparum (worst type), P. ovale, P. vivax, and P. malariae
• 1500 cases diagnosed in US each year
• Female Anopheles mosquito is a vector
• Infects the red blood cells
• Clinical characteristics
o Irregular and cyclical fevers
o Anemia, headache, chills, lethargy, abdominal pain
o P. falciparum can cause severe organ damage and death
o Acute falciparum infections – cerebral malaria / edema /
encephalopathy, hypoglycemia (kids), pulmonary edema and DIC
• Diagnosis: order thick and thin blood smear, Giemsa or Wright stain
• Treatment:
o Chloroquine
o Chloroquine resistance is common: can give quinine and
doxycycline
o Falciparum needs IV quinine (causes profound hypoglycemia !
frequent glucose checks)

Tick Borne Illnesses

Lyme Disease
• Borrelia burgdorferi transmitted to humans through Ixodes tick
• Most common vector-borne disease in the US
• Most common in the North East part of the US
• Often the tick bite history is absent
• 3 stages of disease
• Stage 1
o Early, localized (7-10 days after a bite)
o Erythema migrans (EM) with a bull’s eye appearance
o EM is the most common sign of Lyme Disease and usually begins
as a small erythematous papule or macule that appears at the site
of the tick bite and then enlarges
o EM can appear anywhere on the body and most commonly on the
groin, axilla, waste, back, legs, and head or neck
o About 2/3rds of EM will be solid erythematous lesion and not a
bull’s eye appearance
• Stage 2
o Early disseminated (days to weeks later)
o Skin, CNS, MSK systems, cardiac
o Multiple often smaller EM lesions
o Cardiac: heart block; CNS: Bell’s palsy, meningitis
• Stage 3
o Later persistent and disseminated (months to years)
 o Joint pain (most often in knee), synovitis, subacute encephalopathy
• Diagnosis: antibodies through ELISA
• Half will be antibody negative if tested early (clinical diagnosis)
• Treatment: Doxycycline x 14 days
• Prevention (single dose doxy) ! not recommended for routine use

Rocky Mountain Spotted Fever

• Rickettsia rickettsia, transmitted by wood tick
• Most common in Eastern US
• 2-14 days after exposure get viral syndrome
• Rash starts on wrists/ankles and spreads to extremities and trunk
• Rash is also on the palms and soles
• Late findings: hepatosplenomegaly, myocarditis, ARDS, and DIC
• On labs: elevated WBC, low platelets, may see hyponatremia, hematuria
• Treatment: doxycycline
• Complications: seizures, neurological deficits
• Prevention is key (stay covered with protective clothing)

Ehrlichiosis
• 2 forms: human monocytic (HME) and human granulocytic (HGA)
• High risk populations similar to Lyme Disease (frequent contact with
wildlife or live near rural, wooded areas)
• Clinical presentation: abrupt onset of fever, headache, myalgias, and
shaking chills
• History of tick exposure
• Rash may or may not be present
• Associated with optic neuritis, ARDS, meningitis, pancarditis, renal failure
and DIC
• Order special testing (PCR, antibody)
• Treatment: doxycycline or tetracycline

Viruses
Epstein-Barr Virus
• Transmitted via saliva
• Infectious mononucleosis most common (AKA “kissing disease”)
• Triad: pharyngitis (exudative), lymphadenopathy (posterior cervical
adenopathy), fever
• May see soft palate petechiae
• Also involved in Burkitt’s lymphoma, nasopharyngeal carcinoma
• Incubates for several weeks ! patient extremely fatigued
• Splenomegaly in 50% of the cases ! counsel patient on no contact sports
to avoid splenic rupture
 • Maculopapular/petechial rash in 15% ! increases to 90% if given
amoxicillin
• Complications: secondary bacterial pharyngitis, splenic rupture,
pericarditis, encephalitis
• Diagnosis: clinical but can see atypical lymphocytes
o May get hemolytic anemia/thrombocytopenia
o Heterophile antibodies, monospot test
o Can have false positive RPR or VDRL test in 10% of cases
o Can get elevated LFTs ! hepatitis
• Treatment: symptomatic treatment, no aspirin
• No contact sports

Influenza
• Orthomyxovirus
• Three strains: A, B, and C, type based on surface antigens (hemagglutinin
and neuraminidase)
• Type A is the most common and more pathogenic
• Genetic drift and shift (re-type flu vaccine yearly): antigenic shift is from
major mutations; minor mutations cause antigenic drift
• Clinical presentation: sudden onset fever, sore throat, headache, myalgias,
nonproductive cough
• Most common cause of death = secondary pneumonia
• Lasts a few days to a week
• Treatment
o No more amantadine/rimantadine (resistance and only active
against A)
o Neuraminidase inhibitors (zanamivir or oseltamivir) ideally given
within 48 hours of symptom onset, also give to patients being
hospitalized, activity against A and B
• Mortality highest in the very young and the very old
• Vaccinate yearly: vaccine criteria becoming more inclusive

Parainfluenza
• Associated with pediatric URIs
• Causes croup and bronchiolitis
• Barking cough = croup
• Steeple sign = subglottic edema seen on chest XRay ! narrow airway
from edema
• Treatment: cool mist, steroids

Hantavirus
• Spread by aerosolized rodent excretions, ex. sweeping out tent or cabin
• HPS = hantavirus pulmonary syndrome (sin nombre virus)
 • Presents with tachypnea, hemoconcentration, thrombocytopenia,
leukocytosis
• ARDS like picture that is deadly
• Treatment = supportive

Herpes Family
• HHV 1 – 2: Herpes simplex 1 and 2
o HSV – humans only
o Transmitted by close contact, direct inoculation
o HSV-1: 85% of US population
o HSV-1: classically stomatitis (cold sores), fever, decreased PO
intake, corneal ulcers (no steroids)
o Whitlow = vesicles on digits (do not I&D)
o HSV-1 and 2 can be both on the mouth or genitals
o HSV-2: 25% of US population
o HSV-2: classically on the anus and genitalia
o Before lesions erupt sensation of burning, stinging and malaise
o Genital lesions are painful and worse in primary outbreak
o Females tend to have more severe disease and may involve the
cervix
o Lesions can coalesce
o Genital herpes at the time of birth is dangerous for mother and
baby
o HSV-2 has a higher rate of dissemination and C-section is usually
recommended if active outbreak
o HSV-2 treatment: antivirals and suppressive therapy
o Remains latent in dorsal root ganglion
o Reactivation with stress, immunocompromised, trauma
o Can also cause encephalitis
o Diagnosis: clinical (Tzanck smear, culture)
• HHV 3 – Varicella zoster (VZV)
o Highly contagious (even the day before the rash appears)
o Incubates 10-20 days
o Not a big deal in kids but bad in adults and immunocompromised
o Lesions are at different stages of healing (some crusted, some
fresh)
o Lesions appear in crops
o “Dew drops on a rose petal”
o Mucous membranes can be involved
o Different from smallpox where lesions are all at same stage
o Most infections have some systemic viral-type symptoms (low
grade fever, myalgias)
o Severe infections may involve lung and brain
o Clinical diagnosis
o Treatment: supportive, prevent bacterial superinfection,
immunocompromised: acyclovir
 o Vaccine in wide use now
o Zoster is reactivation of dormant VZV ! shingles
o Zoster is a painful eruption, usually in a dermatomal pattern (may
cross regions especially in immunocompromised patients)
o Thoracic and lumbar areas most common
o Trigeminal nerve (CN V) eruptions can involve the eye (herpes
ophthalmicus: dendritic branches on fluorescein stain)
o Ramsay-Hunt Syndrome – zoster oticus = Bell’s palsy + ear pain /
zoster
o Hutchinson’s sign at tip of nose ! herpes ophthalmicus has or may
develop
o Postherpetic neuralgia debilitating, steroids may prevent, most
common in elderly, treatment of neuropathic pain: TCA, capsaicin,
narcotics, gabapentin
• HHV 4 – Epstein-Barr
• HHV 5 – CMV
• HHV 6 and 7 – Roseola (pediatric disease)
o Sixth disease/exanthema subitum
o 6 months – 2 years
o Sudden high fever ! a few days later getting better and rash starts
o Rash begins on trunk and goes to head and neck
o Rash not itchy
o Common causes of febrile seizure
o Treatment: no aspirin
• HHV 8 – Kaposi’s Sarcoma (AIDS)

HIV
• Human retrovirus that requires reverse transcriptase
• More than 40 million infected worldwide and mostly in Africa
• HIV primarily infects the CD4 helper T cells (T4 antigen)
• Macrophages serve as a reservoir of virus
• Transmitted through bodily fluids
• Acute HIV infection frequently missed – typical viral syndrome, ex.
pharyngitis, fatigue, fever, lymphadenopathy, myalgias
• Spectrum: time from infection to symptomatic disease averages 10 years
but quite variable
• AIDS = CD4 count < 200 or development of AIDS defining condition
(ADC)
• As CD4 count drops, incidence of opportunist infection rises
• Examples of ADC: candidiasis of bronchi, trachea or lungs, Zoster,
cervical cancer, Lymphoma, CMV, Kaposi sarcoma, Toxoplasmosis of the
brain, and common infections
• CD4 count and typical illness
 o 200-500: Salmonella, C difficile colitis, Kaposi’s sarcoma, TB
(**note that with TB and AIDS can have a negative chest XRay),
candidiasis
o 100-200: Progressive multifocal leukoencephalopathy (PML),
Pneumocystis jiroveci (PCP) pneumonia, histoplasmosis,
coccidioidomycosis
o 50-100: Toxoplasmosis, Cryptococcus, CMV (retinitis)
o <50: mycobacterium avium complex (MAC) ! pancytopenia, bone
marrow suppression, affects the lungs
• Treatment
o NRTI (nucleoside reverse transcriptase inhibitor), ex. Zidovudine
(AZT), Lamivudine (Epivir), side effects: peripheral neuropathy,
hepatitis, rash
o NNRTI (non-nucleoside RTI), ex. Nevirapine (Viramune), Efavirenz
(Sustiva), side effects: rash
o PI (protease inhibitor), ex. Ritonavir (Norvir), Indinavir (Crixivan),
side effects: headache, GI, Crixivan: kidney stones
o Entry Inhibitor, ex. Fuzeon, side effects: injection site pain, allergic
reaction
• Adherence to treatment is difficult but important ! if go off of therapy
resistance can develop
• PEP is important and should be started within 72 hours of exposure
• Chance off contracting HIV from a needlestick is 0.3%
• Antiretroviral therapy in pregnancy is important ! decreased transmission
• As CD4 count goes down, prophylaxis regimens start
• Pulmonary presentations
o CD4 > 500: encapsulated bacteria, TB, malignancy
o CD4 < 500: PCP, fungal, CMV, lymphoma, Kaposi Sarcoma
o PCP = Pneumocystis jirovecii, which is the most common
opportunistic infection in AIDS
o PCP = non-productive cough, fever (FUO), dyspnea on exertion
o PCP chest XRay: batwing appearance on imaging with bilateral
perihilar infiltrates
o Other PCP pearls: LDH elevation is sensitive but not specific,
diagnosis: bronchoalveolar lavage
o PCP treatment: Bactrim DS, steroids (PaO2<70 or A-a gradient >
35), if sulfa allergy: Pentamidine 2nd line (side effects include
hypoglycemia, hypotension) and inhaled form (watch for
pneumothorax)

Rabies
• Transmitted via infected animal saliva to CNS
• Dogs (not common in the US), bats (most common in US), skunks, foxes,
raccoons, coyotes, (not rodents or lagomorphs: rabbits)
• Incubation 3-7 weeks
 • Pain/paresthesias at site, restless, seizures, thick saliva
• Hydrophobia (painful spasms caused by drinking water)
• Definitive diagnosis: suspected animal’s brains are tested
• No treatment (give rabies immunoglobulin)
• Immunization of pets
• If bitten, local wound care
• Post-exposure vaccination with rabies immunoglobulin (in wound and at
distant site) and HDCV = human diploid cell vaccine (4 injections on days
0, 3, 7, 14)
• Pre-exposure vaccinations of high risk jobs (vets, handlers)

Measles (Pediatric Disease)

• AKA Rubeola
• Paramyxovirus
• Fever, cough, coryza, conjunctivitis
• Koplik’s spots (not always seen)
• Rash starts on head and spreads
• Rash stains (fades from pink to brown)
• Can present with diarrhea/pneumonia/encephalitis/corneal complications

Rubella (Pediatric Disease)

• German measles
• Rash appears on face and spreads to trunk and limbs
• Usually fades in 3 days
• Viral symptoms
• Uncommon in infants and people over 40
• Bad in pregnant women ! congenital rubella syndrome

Biological Warfare
Anthrax
• 3 forms: cutaneous (direct contact contaminated hides), GI (least
common) and pulmonary/inhalations (wool-sorter’s disease from inhaled
spores)
• Not transmitted person to person
• Incubation 2-4 days
• Cutaneous eschar, fever, mediastinitis with widened mediastinum on
chest XRay
• Treatment: doxycycline or ciprofloxacin

Smallpox
• Smallpox virus
 • Transmitted by airborne droplets and direct contact
• High fever ! vesicular rash in centrifugal distribution (from face
downwards ! legs last)
• Lesions at similar stage of development
• Treatment: early vaccination, supportive care

Botulism
Plague
• Yersinia pestis
• AKA The Black Death
• Gram negative bacillus
• Animal reservoirs (most commonly rodents)
• Transmitted by infected fleas but also person to person
• Three main types
o Bubonic
o Pneumonic
o Primary septicemia
• Treatment: streptomycin or gentamicin