ID NLE2 Review

Sorawit Chittrakarn, MD
Infectious disease unit
Prince of Songkla University
Scope of NLE2
Infectious diseases 20/300
 HIV & Opportunistic infections
• Acute retroviral syndrome
• Opportunistic infections
• ARV treatment and side effects
2018
2023
 The Stages of HIV Infection

HHS Panel on Antiretroviral Guidelines for Adults and Adolescents—OARAC. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIVS. [Updated 2023 Mar 23]
The natural history of HIV
 Acute HIV Infection
10-60% are asymptomatic infection
Incubation period: 2-4 weeks ( as long as ten months have been reported)
Features Percent
Fever 75
Fatigue 68
Myalgia 49
Skin rash 48
Headache 45
Pharyngitis 40
Cervical adenopathy 39
Arthralgia 30
Night sweats 28
Diarrhea 27
Daar ES, Pilcher CD, Hecht FM. Clinical presentation and diagnosis of primary HIV-1 infection. Curr Opin HIV AIDS 2008; 3:10.
 Principle of HIV testing

Viral testing
• Plasma HIV RNA: qualitative or quantitative techniques
• p24 antigen (nucleocapsid core)

Antibody testing
• Screening test: 1st – 5th gen ELISA detect IgM, IgG
• Confirmatory test: Western blot, HIV-1/2 differentiation assay
Acute HIV Infection
 HIV Nucleic acid testing

Qualitative NAAT Quantitative NAAT

Report as positive or negative Report as VL copies/mL
RNA or proviral DNA from WBC HIV-1 VL
Sensitivity cutoff 50 copies/mL: 10-15 d
Window period 5-7 d
Ultrasensitive cutoff 1-5 copies/mL: 5 d

https://www.hiv.uw.edu/go/screening-diagnosis/acute-recent-early-hiv/core-concept/all#citations
2019
 Pulmonary OIs
Pulmonary TB Pneumocystis pneumonia (PCP)
CD4 level Any < 200
Clinical S/S Subacute-chronic onset Subacute onset
cough, hemoptysis, night sweat, wt. loss Dry cough, exertional dyspnea
Chest X-ray Patchy, Nodular, Miliary Bilateral fine
Cavity, Pleural effusion interstitial infiltration
Upper lobe predominate (GGO)
Pneumatocele
Pneumothorax

Investigation Sputum AFB +ve Sputum or BAL GMS+ve

Treatment HRZE 6 months TMP-SMX 15-20 MKD x 3wk
2018
 Disseminated Fungal OIs
Cryptococcosis Histoplasmosis Talaromycosis
CD4 level < 100 < 100 < 100
Clinical S/S Asymptomatic cryptococcemia Skin – umbilicated papule Skin – umbilicated papule
CNS & Lung infection Bone, LN, Lung, Fungemia Bone, LN, Lung, Fungemia
Skin – umbilicated papule GI mucosal ulcer
Bone, LN Adrenal gland
Investigation Serum Cryptococcal Antigen +ve Skin scraping or BM biopsy with wright stain
LP with india ink +ve

Molluscum-like lesion Large Intracellular or Extracellular Intracellular or Extracellular Intracellular or Extracellular

Central necrosis Round encapsulated budding yeasts Grape-like, monomorphous Varying in size, round to oval yeast cells
Small round to oval yeast cell central clear septum (Binary fission)
2023
2021
 CNS OIs
Space-occupying lesion Meningitis
Tuberculoma Tuberculous meningitis (more common)
Cryptococcoma Cryptococcal meningitis (more common)
Toxoplasmosis Syphilis
PML Bacteria
Nocardia Virus: CMV, HSV, VZV, HIV
Tan IL, Smith BR, von Geldern G, Mateen FJ, McArthur JC. HIV-associated opportunistic infections of the CNS. Lancet Neurol. 2012;11(7):605-617.
Tan IL, Smith BR, von Geldern G, Mateen FJ, McArthur JC. HIV-associated opportunistic infections of the CNS. Lancet Neurol. 2012;11(7):605-617.
Tan IL, Smith BR, von Geldern G, Mateen FJ, McArthur JC. HIV-associated opportunistic infections of the CNS. Lancet Neurol. 2012;11(7):605-617.
 CNS: Meningoencephalitis
TB meningitis
CD4 level Any
Clinical S/S Subacute Rt.basal gg infarction
Fever, Headache, AOC
Stroke-like (vasculitis)
CN neuropathy (CN 6 & 8)
Other site TB (Lung, LN, Dissem) Basal meningeal
Brain imaging Triad
enhancement
• Basilar meningeal enhancement
• Hydrocephalus Hydrocephalus
• Supratentorial brain parenchyma
and brainstem infarctions
CSF profile Cell count ↑↑ (Lymph, Early -> PMN)
Glu ↓, Protein N/↑
Other CSF AFB +ve (20%)
investigation CSF PCR TB (~ 50-80%) CT with contrast
CSF Culture (< 50%)
Treatment HRZE
Rohlwink UK, Chow FC, Wasserman S, et al. Standardized approaches for clinical sampling and endpoint
ascertainment in tuberculous meningitis studies. Wellcome Open Res. 2020;4:204. Published 2020 Jun 3.
 CNS: Meningoencephalitis
Cryptococcal meningitis Gelatinous pseudocyst (T2 MR)
CD4 level < 100 soap bubble appearance by MRI
(dilation of perivascular spaces due
Clinical S/S Subacute
to mucous gelatinous material
Fever, Headache, AOC
produced by the fungal capsule)
CN neuropathy
Other site (Lung, Skin, BM)

Brain imaging Gelatinous pseudocyst (T2 )

Leptomeningeal enhancement
Hydrocephalus
CSF profile Cell count N / slightly ↑ (Lymph) India Ink counterstain (×40)
Glu N/↓, Protein N/↑ Round yeast cells (some may
Other CSF india ink +ve (Sn 60-80%) showing budding), surrounded
investigation CSF culture (Sn 90%) by a large unstained capsule
CSF cryptococcal Ag (Sn > 95%)
Treatment Ampho B, Flucytosine, Fluconazole
2017
 Opportunistic protozoa

Microsporidium Cryptosporidium Cyclospora Isospora belli

Shape Oval Round Round Oval
Size (μm) 1-2 5 10 20-30
Disease Disseminated disease Watery diarrhea, malabsorption, abdominal pain
Investigation Modified trichrome Stool mAFB
Treatment Albendazole 400 mg ARV TMP-SMX SS (80/400 TMX-SMX SS (80/400
1x2 for 2-4 wk + ARV mg) 2x2 7-10 d mg) 2x2 7-10 d
Microsporidium
2022
2018
2018
2018
 Drug induced nephrotoxicity in HIV
Group Drug Mechanism
NRTI Tenofovir Direct nephrotoxicity
PIs Indinavir, Atazanavir Crystalluria
Antiviral Acyclovir Crystalluria
Cidofovir Direct nephrotoxicity
Foscarnet Direct nephrotoxicity, Crystalluria
Anitibiotic TMP-SMX Direct nephrotoxicity
Aminoglycoside Direct nephrotoxicity
Antifungal Amphotericin B Direct nephrotoxicity
Category Description
TDF nephropathy
Mechanism Inhibit mitochondrial DNA γ-polymerase  oxidative
respiratory chain dysfunction
Risk factor Older age, advanced HIV infection, low BW
HCV coinfection, concurrent nephrotoxic drugs
Concomitant use with ritonavir
Clinical S/S • Acute kidney injury
• Chronic kidney injury
• Tubular toxicity
• Fanconi syndrome (pan-proximal tubule dysfn)
 Sexual Transmitted Infection
Sexually Transmitted Infection Sexually Transmitted Disease
refers to a pathogen that causes refers to a recognizable
infection through sexual contact disease state that has
developed from an infection

Venereal diseases (latin, “venereus” or “venus”, “from sexual love or desire”)

• Older term of sexually transmitted infection

Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Clinical Manifestations in STIs
Genital involvement (oro-ano-genital)
• Anogenital lesion (ulcer, macule, papule, mass)
• Genital Discharge (Urethral / Vaginal discharge)
• Lower abdominal in women pain (PID)
• Testicular pain and swelling (Epididymitis / epididymoorchitis)
• Inguinal bubo
Extragenital involvement
• Disseminated symptoms: direct invasion or immune mediated disease
• Specific organ involvement: CNS, joint, hepatitis syndrome, eye, ano-rectal etc.
Asymptomatic infection: syphilis, other bacterial rectal STI
 Common STD syndromes
Genital
ulcer

Testicular
Urethral
pain &
discharge
swelling

Vaginal
discharge
2018
2021
2020
2021
 Genital ulcer

Pain Genital lesion Number Lymph node Investigation

HSV-1,2 Painful Vesicle Multiple Bilateral Tzanck test +ve
(Herpes simplex) Tenderness, firm NAAT for HSV1,2
Chancroid Painful Indurated Multiple, Unilateral G/S: GNB rods in a
(H.ducreyi) ragged ulcer Kissing ulcer Tenderness, fluctuant chain “school of fish”
Syphilis Painless Clean base ulcer Single Bilateral DF microscopic exam
(T.pallidum) Painless, firm
LGV Painless Variable Single Unilateral NAAT from lesion
(C.trachomatis) Transient Painful, fluctuant
Groove sign +ve
Granuloma Painless Serpiginous, Variable None Edge of lesion scraping
Inguinale "beefy red” or biopsy: Donovan
(K.granulomatis) hypervascular bodies
 Genital Herpes
Category Description
Pathogen HSV-1,2
Symptoms Multiple, painful, superficial, vesicular or ulcerative
lesions with erythematous base
+/- tender bilateral LN
Diagnosis Tzanck smear: multinucleate giant cells (Sn 30-80%)
Virologic test (PCR, Direct fluorescent antibody)
Serologic test (type-specific anti-glycoprotein G)
Treatment Acyclovir 400 mg 1x3 7-10 days
Partners Current sex partners should be examined, if infected, treated

CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Chancroid
Category Description kissing lesions Ragged ulcer
Pathogen Haemophilus ducreyi
Symptoms Painful, indurated, ragged genital ulcers
Multiple or kissing lesions
Tender suppurative inguinal LN (50%), unilateral
Diagnosis Gram stain: small gram-ve rods in a chain "school of fish“
Culture (Sn<80%)
NAAT: very high Sn & Sp
Treatment Azithromycin 1 g po x 1 dose
Ceftriaxone 250 mg IM x 1 dose
Ciprofloxacin 500 mg po bid x 3 d
Partners Treat the partners if sexual contact ≤10 d preceding patient
symptom onset (regardless of symptoms)

CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Lymphogranuloma Venereum (LGV)
Category Description 1st stage
Ragged ulcer
Pathogen Chlamydia trachomatis serovars L1, L2, L3
Symptoms 1st stage: 3-30 d post infection; painless genital ulcer with
spontaneous heal, ± urethritis
2nd stage: 2-6 wks later; enlarged inguinal LN with bubo formation
(M>F), ± proctitis ± constitutional symptoms 2nd stage: Groove sign +ve
3rd stage: perirectal fistula, stricture, rectal stenosis, penile
distortion (saxophone penis)
Diagnosis NAAT from genital/rectal/pharyngeal swabs or discharge from LN Separation of femoral & inguinal
Treatment Preferred: Doxycycline 100 mg 1x2 for 21 days LN by inguinal ligament
Alternative: Azithromycin 1 g once weekly for 3 weeks*
3rd stage
Partners Treat the partners if SI ≤60 d preceding patient’s symptom onset
(regardless of partner’s symptoms)
If asymptomatic : doxycycline 100 mg 1x2 for 7 days

1. CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
2. O'Byrne P, MacPherson P, DeLaplante S, Metz G, Bourgault A. Approach to lymphogranuloma venereum. Can Fam Physician. 2016 Jul;62(7):554-8.
 Granuloma Inguinale (Donovanosis)
Category Description
Pathogen Klebsiella granulomatis
(Sporadic cases reported in India, South Africa, and South America)
Symptoms Painless, slowly progressive ulcerative lesions on genital/perineum
Lesions are highly vascular (beefy red appearance) and can bleed
No regional lymphadenopathy
Diagnosis Edge of lesion scraping or biopsy: Donovan bodies*
NAAT
Treatment Preferred: Azithromycin 1 gm once weekly or 500 mg daily
Alternative: Doxycycline 100 mg 1x2, TMP-SMX (160/800) 1x2
Duration at least 3 weeks and all lesions have completely healed
Partners Current sex partners should be examined and, if infected, treated
* Donovan bodies (numerous bacilli in the cytoplasm of macrophages shown by Giemsa or Wright stain)

CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
2022
 Condyloma Acuminata
(anogenital wart)
Category Description
Pathogen Human papillomavirus (HPV)
90% are caused by nononcogenic HPV types 6 or 11
Although coinfection with other high-risk types of HPV* is common
Symptoms Single or Multiple, Cauliflower-shaped or fungating lesion
Color varies; white, skin-colored, erythematous, violaceous
Location: vulva, penis, groin, perineum, anal skin or perianal skin
Associated Anogenital cancers (anal, vulvar, vaginal, cervical CA)
malignancy Head and neck cancers
Diagnosis Clinical diagnosis (most cases)
Biopsy (in atypical features or to rule out malignancy)
Treatment Guided by wart size, number, and anatomic site; patient preference;
cost of treatment; convenience
No single treatment is ideal for all patients or all warts
Prevention HPV vaccine, External condom, Limited number of sex partner
*High-risk HPV types include types 16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 70
CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Condyloma Acuminata
(anogenital wart)

1. CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
2. N Engl J Med 2023; 388:1790-1798
2020
2019
 Syphilis
Primary syphilis (chancre)
• Represents an initial local infection
• Appear 10-90 days (mean 21 days) after exposure
• Appearing at the site of inoculation
• Painless, solitary, indurated, clean base (98% specific, 31% sensitive)
• Common sites: on glans, corona, labia, fourchette, or perineum
• Localized painless adenopathy, often bilateral
• Heal spontaneously within 3-6 wks even without treatment

1. Syphilis. BMJ 2019;365:l4159

2. Mandell, Douglas, and Bennett’s principles of infectious disease 8th edition
3. Ramoni S, Cusini M, Gaiani F, Crosti C. Syphilitic chancres of the mouth: three cases. Acta Derm Venereol. 2009 Nov;89(6):648-9.
4. Ramos, Mauro & Nicola, Maria & Bezerra, Natália & Sardinha, José & Sampaio, Julia & Schettini, Antonio. (2022). Genital ulcers caused by sexually transmitted agents. Anais Brasileiros de Dermatologia. 97. 10.1016/j.abd.2022.01.004.
 Syphilis
Secondary syphilis Plantar rash with
hyperkeratosis
• Systemic with widespread dissemination of the spirochete
• Symptoms appear 2 weeks to 6 months (mean 2-12 weeks)
after exposure. Can be concurrent with chancre
• Fever, headache, malaise, anorexia, sore throat, myalgias Patchy alopecia Oral mucous patch Condyloma lata
• Generalized painless lymphadenopathy
• Rash: Diffuse, symmetric red or reddish-brown MPE involving
the entire trunk and extremities, including the palms and soles
(classic)
Condyloma lata Pustular form
• Other type: papulosquamous, annular, or pustular lesion
• Vesicular and bullous lesions are never seen !!
• Mucous patch, Condylomata lata
• Non-scarring, Moth-eaten alopecia (Reversible with Rx)
• Hepatitis, Synovitis, osteitis, and periostitis

1. Syphilis. BMJ 2019;365:l4159

2. Mandell, Douglas, and Bennett’s principles of infectious disease 8th edition
 Sy Treatment
Treatment Early syphilis Late syphilis Neuro/ocular/otosyphilis
(primary, secondary, early (late latent ≥1 y, tertiary,
latent <1y) unknown duration)
Preferred BPG 2.4 mU IM single dose BPG 2.4 mU IM wkly x 3 *** Aqueous crystalline peniciilin
G 18-24 mU/d x 10-14 d
Alternative (EU) • Procaine penicillin 600,000 U • Procaine penicillin • Procaine penicillin 2.4 mU
IM OD x 10-14 d 600,000 U IM OD x 21 d IM OD + probenecid 500
• Doxycycline 200 mg/d x 14 d • Doxycycline 200 mg/d x mg oral qid x 10-14 d (US,
• Ceftriaxone 1 g IV OD x 10 d 28 d EU)
• Ceftriaxone 2 g IM/IV OD
x 10-14 d
Pregnancy* BPG 2.4 mU IM single dose BPG 2.4 mU IM wkly x 3 *** Aqueous crystalline peniciilin
(US, EU) • Consider additional dose 1 wk G 18-24 mU/d x 10-14 d
later **

* Pregnant penicillin-allergic patients with syphilis need to be desensitized to penicillin and treated with a penicillin-
based regimen. There are NO OTHER OPTIONS (not even ceftriaxone)
**Preferred additional dose if there are sonographic evidences of placental/fetal infection
***Interval should not > 9 days (acceptable 10-14 d for non-pregnancy)  repeat full course Rx if delay
2018
2022
2017
2019
 Urethral discharge

Urethritis
Gonococcal urethritis (GU) Nongonococcal urethritis (NGU)
• Neisseria gonorrhoeae (1st) • Chlamydia trachomatis (2nd)
• Mycoplasma genitalium (3rd)
S/S: dysuria (painful urination), pruritus, burning, & DC per meatus
• Acute, frankly purulent urethral discharge  suggestive of GU
• Mucoid, scanty discharge, meatal erythema  suggestive of NGU
Gonorrhea Chlamydia
• Painful genital ulcer  genital HSV
• Conjunctivitis  adenovirus
• 10% GU & 42% NGU are asymptomatic

CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Gonorrhoea
Category Description
Pathogen Neisseria gonorrhoeae
Symptoms Men : urethritis, epididymitis
Women : cervicitis, PID, Fitz-Hugh-Curtis syndrome, Bartholin abscess
Disseminated gonococcal infection (DGI): Triad of Polyarthritis,
Tenosynovitis & hemorrhagic vesiculopustular lesion
Diagnosis Gram stain: GNDC intracellular
C/S: Thayer-Martin agar, transport rapidly
NAAT : gold standard (highest sensitivity)
Evaluation for co-infection : C.trachomatis, HIV, Syphilis
Treatment

• Genital, Preferred Ceftriaxone 500 mg IM single dose (1 gm if BW ≥150 kg)

Pharynx, Alternative (no reliable in pharyngeal GC)
Rectal GC • Gentamicin 240 mg IM + azithromycin 2 gm po single dose
• Cefixime 800 mg PO single dose
• DGI Ceftriaxone 1-2 gm IV/IM OD ≥ 7 days Fitz-Hugh-Curtis: fibrinous exudate
("violin string" adhesions), affecting
the anterior surfaces of the liver
CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Chlamydia trachomatis
Category Description Reactive arthritis
Pathogen C. rachomatis, obligate intracellular small gram-negative bacteria
Symptoms Mostly asymptomatic
Females: cervicitis (vg d/c and bleeding, purulent endocervical dc), PID
Male: urethritis (mucoid or watery urethral discharge), epididymitis
Both sexes
• Conjunctivitis: serovars D-K, by direct inoculation with genital fluid
• Proctitis: serovars D-K, MSM > female, Receptive anal SI
• LGV: serovars L1-3
• Reactive arthritis : triad of arthritis, uveitis, and urethritis or cervicitis
Diagnosis NAAT (gold standard)
Treatment Doxycycline 100 mg bid for 7 days
Alternative Rx
• Azithromycin 1 gm orally in a single dose
• Levofloxacin 500 mg orally od for 7 days

CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
2018
 Epididymitis or Epididymoorchitis
Epididymitis or Epididymoorchitis
Pathogen Common: N. gonorrhoeae and C. trachomatis
Enteric pathogen (risk: insertive anal sex, BPH obstructive uropathy, post prostate bx, post vasectomy)
Less common: Mycoplasma genitalium
Rare : TB, Brucella
S/S Localized testicular pain with tenderness and swelling on palpation (epididymitis)
Testicular pain and swelling (epididymo-orchitis)
Positive Prehn sign (manual elevation of the scrotum relieves pain)
Diagnosis Based on history and physical examination
R/O testicular torsion (need sx emergency) eg. ultrasound in acute, unilateral, painful scrotal swelling
Objective evidence of urethral inflammation (criteria for urethritis)
Urine NAAT for N. gonorrhoeae and C. trachomatis
Urine bacterial culture to evaluate for the presence of genitourinary organisms
Treatment STI risk who do not practice insertive anal sex (cover GC + Chlamydia)
• CRO 500 mg IM once + doxycycline 100 mg 1x2 for 10 days
STI risk who practice insertive anal sex (cover GC, Chlamydia + enteric pathogen)
• CRO 500 mg IM once + levofloxacin 500 mg 1x1 for 10 days
Low risk for STIs e.g. post prostate biopsy, vasectomy (cover only enteric pathogen)
• Levofloxacin 500 mg 1x1 for 10 days
CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
 Parasitic disease

Protozoa Helminths Ectoparasite

Kingdom –Protista (unicellular) Kingdom –Animalia (multicellular) Kingdom –Animalia (multicellular)

Arachnida: Tick, Mite

Sporozoa Insecta: Flea, Lice
Sarcodina Mastigophora Ciliophora Nematodes Platyhelminth Other: Mosquitoes, Sandfly
(adult stage not (round worms) (flatworms)
(amoeba) (flagellates) (ciliates)
motile)

Giardia Balantidium Plasmodium Intestinal Tissue

E.histolytica Trichomonas Cestodes Trematodes
Toxoplasma (tapeworm, ribbon-
Leishmania Microspodium (Flukes, leaf shaped)
Trypanosoma like chain of segments)
Cryptosporidium Ascaris Filariasis
Cyclospora Trichuris
Isospora Hookworm
Enterobius Intestinal Tissue Intestinal Tissue
Trichinella
Strongyloides
Taenia spp. Cysticercosis Opisthorchis Schistosoma
Fasciola Paragonimus
Fasciola
 Stool wet mount
1. A drop of saline or Lugol’s iodine is placed over a
clean microscopic slide
2. With an applicator stick, pick up a small portion of
the stool and mix the drop of saline (or iodine)
3. Cover the sample with the help of cover slip
4. Under the microscope examine the smear, initially at
low power 4X and then focus on at 10X objectives

Lugol iodine help to stains the some cyst’s nuclei of protozoa

such as E.histolystica and easily seen under microscope.
* Disadvantage: Lugol’s kill the motile parasites trophozoite.
Intestinal nematode Transmission Disease Investigation Treatment
Ascaris lumbricoides Feco-oral route Mostly asymptomatic Stool wet mount
(ingestion of eggs) Lung: Loffler syndrome
GI: abdominal discomfort, gut
obstruction, biliary obstruction
Adult worm migrate from mouth or nose

Trichuris trichiura Feco-oral route Mostly asymptomatic Stool wet mount

(whipworm) (ingestion of eggs) Chronic colitis
Rectal prolapse (children) Albendazole 400
mg PO once

Enterobius vermicularis Feco-oral route Anal pruritis Scoth-tape technique Mebendazole

(pinworm) (ingestion of eggs) 500 mg PO once

Necator americanus & Penetration of skin Chronic blood loss  IDA Stool wet mount
Ancylostoma duodenale by filariform larvae
(hookworm)

Strongyloides stercoralis Penetration of skin Mostly asymptomatic Stool wet mount Ivermectin 200
by filariform larvae Skin: larva currens mcg/kg/day x 2
GI: abdominal pain, diarrhea days, repeat next
Lungs: pneumonitis 2 wk
Intestinal nematode Transmission Disease Investigation Treatment
Capillaria philippinensis Feco-oral route Watery diarrhea, abd pain, borborygmi Stool wet mount Albendazole 400
(ingestion of Malabsorption syndrome: weight loss, mg/day orally for
infective larvae in muscle wasting, weakness, edema 10 days
freshwater fish)
 Tissue nematode Transmission Disease Investigation Treatment
Trichinella spiralis Feco-oral route 1st week: Enteral phase Eosinophilia Albendazole or
(Ingestion of meat • Encysted larvae are liberated from the Muscle enzyme ↑ Mebendazole
containing encysted meat by gastric juices Muscle biopsy
larvae ) • Adult worms that burrow into the
intestinal mucosa
• Abd pain, N/V, and diarrhea

2nd week: Parenteral phase

• newborn larvae enter the lymphatic
vessels and then enter the bloodstream
• Muscle pain, swelling, weakness
• Facial and periorbital edema, fever, rash
Wuchereria bancrofti Mosquitoes Lymphatic filariasis Thick & Thin blood Diethylcarbamazine
Brugia malayi • Lymphedema of the legs, arms, breasts smear (DEC)
• Lymph scrotum (W.bancrofti)
 Trematode Transmission Disease Investigation Treatment
Diphyllobothrium Feco-oral route Asymptomatic Stool wet mount Praziquantel
latum (ingestion of cysts in Diarrhea, Abdominal discomfort 10 mg/kg single
(fist tapeworm) freshwater fish) Megaloblastic anemia (B12 deficiency) dose
• Anemia, Pancytopenia, Glossitis
• Progressive weakness, ataxia, and
paresthesia

T.saginata Feco-oral route Taeniasis Stool wet mount Praziquantel

(beef tapeworm) (ingestion of • Mostly asymptomatic 10 mg/kg single
cysticerci in meat) • Intermittently, patients may pass dose
T.solium proglottids in the stool
(pork tapeworm) • nausea, anorexia, or epigastric pain

Cysticercus cellulosae Feco-oral route Neurocysticercosis Brain CT or MRI Albendazole 1-2 wk

(ingestion of eggs) • IICP, Seizure, Focal NS deficit + corticosteroid
Extraneural cysticercosis
• muscle / subcutaneous tissue involvement Contraindication
• Mostly asymptomatic - No viable cyst
(only calcified)
- Brain edema
- Untreated
hydrocephalus
 Cestode Transmission Disease Investigation Treatment
Opisthorchis viverrini Feco-oral route Acute infection Stool wet mount Praziquantel (25
(Ingestion of • RUQ pain, N/V, diarrhea, weight loss mg/kg for 1-2days)
freshwater fish) • fever, ascites, hepatomegaly
Chronic infection
• Chronic inflammation of bile duct walls
• Biliary obstruction
• Cholangiocarcinoma
Fasciola hepatica Feco-oral route Acute (liver) phase Stool wet mount Triclabendazole
(Ingestion of free • Fever, RUQ pain, Hepatomegaly, (10 mg/kg for 1-2
swimming cercariae Urticaria, +/- Jaundice days)
on aquatic vegetation) Chronic (biliary) phase
• Usually asymptomatic / subclinical
• Inflammation and intermittent
obstruction of bile ducts
Paragonimus Feco-oral route Pulmonary paragonimiasis Sputum wet mount Praziquantel
westermani (Ingestion of • Recurrent blood-tinged sputum or (75 MKD in 3
crustacean containing Hemoptysis divided doses, for 3
metacercariae) • CXR: patch/nodule/calcification, cavity, days)
mass like lesion, pleural effusion
 Ectoparasite Transmission Disease Investigation Treatment
Sarcoptes scabiei Contact transmission Classic scabies Lesion Scrapings Permethrin cream
(person-person or • Pruritus, and usually worse at night with 10%KOH Benzoyl benzoate
formites) • PE: Multiple small, erythematous preparation Ivermectin
papules, often excoriated and burrows
• Typical location: sides & webs of
fingers, flexor of wrist, extensor of
elbow, axillary folds
Crusted scabies
• Occur in CMIR defect
• Psoriasiform hyperkeratotic popular
burrow
lesions at scalp, face, neck, hand, feet
Pthirus pubis Contact transmission Pediculosis Pubis Demonstration of Permethrin cream
(crab or pubic louse) (person-person) • itching in the pubic region lice or nits (louse Malathion
• Lice and nits observed on pubic hair eggs) Ivermectin
2023
 Taeniasis
Category Description
Pathogen Taenia saginata (beef tapeworm)
Taenia solium (pork tapeworm)
Transmission Feco-oral route, ingesting meat containing cysticerci
Clinical S/S Most human carriers = asymptomatic
May notice proglottids in their stool
Nausea, anorexia, or epigastric pain
Investigation Direct stool exam: round egg with double-walled and
radially striated membrane

Treatment Praziquantel 10 mg/kg PO single dose

 Cysticercosis
Category Description
Pathogen Only Taenia solium (pork tapeworm)
Transmission Feco-oral route, ingestion of T.solium eggs
(contaminated food by human feces)
Clinical S/S Neurocysticercosis (NCC)
• Depend on the number, location of cysticerci and the
degree of associated inflammatory response
• Seizure, Headache, Focal NS deficit
Extraneural cysticercosis
• Muscle or subcutaneous tissue involvement
• Cardiac involvement
Investigation CT scan and MRI brain for NCC
Treatment • Untreated hydrocephalus, cysticercal encephalitis, or
calcified lesions only: C/I for antiparasitic therapy
• 1-2 viable cysts: albendazole 10-14 days
• > 2 viable cysts: albendazole + praziquantel 10-14 days
 Cysticercosis
Category Description
Pathogen Only Taenia solium (pork tapeworm)
Transmission Feco-oral route, ingestion of T.solium eggs
(contaminated food by human feces)
Clinical S/S Neurocysticercosis (NCC)
• Depend on the number, location of cysticerci and the
degree of associated inflammatory response
• Seizure, Headache, Focal NS deficit
Extraneural cysticercosis
• Muscle or subcutaneous tissue involvement
• Cardiac involvement
Investigation CT scan and MRI brain for NCC
Treatment • Untreated hydrocephalus, cysticercal encephalitis, or
calcified lesions only: C/I for antiparasitic therapy
• 1-2 viable cysts: albendazole 10-14 days
• > 2 viable cysts: albendazole + praziquantel 10-14 days
2023
2019
2023
 Eosinophilic meningitis
Definition: ≥ 10 eosinophils/mL in the CSF or ≥ 10% eosinophils in the total CSF leukocyte count
Angiostrongylus cantonensis Ganthostoma spinigerum
Transmission Eating raw or undercooked snails or slugs Eating undercooked fish, poultry, or snake meat
crab or freshwater shrimp
Clinical features Excruciating headache Meningoencephalitis, Radiculomyelitis
Ocular involvement Ocular involvement
Intermittent subcutaneous migratory swelling
CSF findings Usually cloudy but not turbid or xanthochromia Xanthochromic or bloody CSF
Brain imaging Unremarkable Areas of hemorrhage or hemorrhagic tract
Treatment Mainly supportive • Cutaneous: Surgical removal + Alben 3 wk
Analgesic, corticosteroid, CSF release • CNS: Supportive treatment
+/- albendazole (not use alone, weak)
2022
 Malaria
Category Description
Pathogen Plasmodium (falciparum, vivax, ovale, malariae, knowlesi)
Vector Female mosquitoes of the genus Anopheles
Epidemiology Thai – Myanmar and Thai – Cambodia borders
Clinical S/S Uncomplicated malaria (non-specific)
• Fever, Headache, Vomiting, Diarrhea, Chill, Myalgia
• Febrile paroxysms (occur later in the course of infection)
Severe malaria
• Generalized weakness, Coma, Seizure
• Non-cardiogenic pulmonary edema
• Hypoglycemia, Severe anemia, DIC, AKI, Jaundice
• Metabolic acidosis, Shock
Investigation Thick and thin blood smear
2017
 Intestinal Capillariasis
Category Description
Pathogen Capillaria philippinensis
Transmission Feco-oral route, eating undercooked fish
Clinical S/S Chronic watery diarrhea, abdominal pain
weight loss, malabsorption, and wasting
Electrolyte abnormalities and protein loss
Investigation Direct stool exam: peanut-shaped egg with
flattened bipolar plugs, striated shell

Treatment Albendazole 400 mg/day orally for 10 days

Mebendazole 200 mg orally twice daily for 20 days
2017
 Strongyloides hyperinfection
Category Description
Pathogen Strongyloides stercoralis
Transmission Direct penetration of human skin
Risk factors Corticosteroid, HIV, Malignancy, Transplantation
Clinical S/S • GI: Abdominal pain, watery diarrhea,
constipation anorexia, weight loss
• Lung: Dyspnea, cough, wheezing, chest pain,
hemoptysis
• Skin: Larva curren, Petechial and purpuric
rashes, Thumbprint sign of periumbilical purpura
Investigation Direct stool exam: strongyloides larva
Sputum or GI aspirate wet mount: larva
CXR: bilateral or focal interstitial infiltrates
Treatment Ivermectin 200 mcg/kg/d
 Strongyloides hyperinfection
Category Description
Pathogen Strongyloides stercoralis
Transmission Direct penetration of human skin
Risk factors Corticosteroid, HIV, Malignancy, Transplantation
Clinical S/S • GI: Abdominal pain, watery diarrhea,
constipation anorexia, weight loss
• Lung: Dyspnea, cough, wheezing, chest pain,
hemoptysis
• Skin: Larva curren, Petechial and purpuric
rashes, Thumbprint sign of periumbilical purpura
Investigation Direct stool exam: strongyloides larva
Sputum or GI aspirate wet mount: larva
CXR: bilateral or focal interstitial infiltrates
Treatment Ivermectin 200 mcg/kg/d
 Larva migrans
• Pruritic, raised, serpiginous rash
• Slow rate of progression (< 1-2 cm per day)
• Localized on the lower legs and buttocks
• Animal vector hookworms e.g. Ancylostoma
braziliense, Ancylostoma caninum, and
Uncinaria stenocephala
Larva currens
• Linear to serpiginous, erythematous urticarial lesion
• Rapid progression (5-15 cm per hour)
• Preferentially localized around the buttocks,
perineal area, or abdomen
• Strongyloides stercoralis
CNS infection
2023
2023
 TB meningitis
TB meningitis
CD4 level Any
Clinical S/S Subacute Rt.basal gg infarction
Fever, Headache, AOC
Stroke-like (vasculitis)
CN neuropathy (CN 6 & 8)
Other site TB (Lung, LN, Dissem) Basal meningeal
Brain imaging Triad
enhancement
• Basilar meningeal enhancement
• Hydrocephalus Hydrocephalus
• Supratentorial brain parenchyma
and brainstem infarctions
CSF profile Cell count ↑↑ (Lymph, Early -> PMN)
Glu ↓, Protein N/↑
Other CSF AFB +ve (20%)
investigation CSF PCR TB (~ 50-80%) CT with contrast
CSF Culture (< 50%)
Treatment HRZE
Rohlwink UK, Chow FC, Wasserman S, et al. Standardized approaches for clinical sampling and endpoint
ascertainment in tuberculous meningitis studies. Wellcome Open Res. 2020;4:204. Published 2020 Jun 3.
2022
 Rabies
Category Description
Pathogen Lyssaviruses (Rabies virus)
Reservior Domestic dogs (US: bats, raccoons, skunks, and foxes)
Transmission Exposure to saliva from an animal bite or non-bite
Symptoms Prodrome
• low-grade fever, malaise, myalgias, weakness
• Paresthesia radiating proximally from the affect limb
Encephalitis
• fever, hydrophobia, pharyngeal spasms, dysphagia
• agitation and combativeness, fluctuating consciousness,
hallucination, autonomic instability
Coma & Death
Investigation PCR for rabies (Saliva, skin, serum, CSF)
MRI: increase T2 signaling in hippocampus, hypothalamus
Treatment Supportive care
2022
2022
2018
2018
2021
2023
 Streptococcus suis
Category Description
Pathogen Streptococcus suis
Reservoir Pig (Colonize in nasopharyngeal and GI tract)
Epidemiology SEA (1st China, 2nd Vietnam, 3rd Thailand)
Risk factors Raw pork consumption, Pig related occupation
Symptoms Meningitis, Bilateral SNHL
Skin: Petechiae, purpura, and ecchymoses (purpura
fulminans)
Bacteremia, Acute and Subacute IE
Septic arthritis, Spondylodiscitis
Investigation G/S: Gram positive cocci in pair, chain
HC and CSF Culture
Treatment Penicillin, Ceftriaxone or Vancomycin
+/- Adjunctive dexamethasone
2022
2022
2023
2021
 Herpes encephalitis
Category Description
Pathogen HSV-1 >> HSV-2 (<10%)
Pathogenesis CNS invasion via the CN V or olfactory tract
Epidemiology All age group, severe in children and the elderly
Symptoms Acute onset
Fever, headache, seizures, focal NS deficit
Cognitive, behavioral, and personality changes
Investigation • Lymphocytic pleocytosis, Protein ↑, Glu N, RBC ↑
• CSF PCR for HSV +ve
• CT brain (Sn 50%): hypodensity in the medial parts
of the temporal lobe and the insular cortex
• MRI (Sn 80-90%): Hyperintense lesions on T2-wt. in
the mesiotemporal and orbitofrontal lobes
Treatment Acyclovir (10 mg/kg) IV q 8 hours for 14-21 days
2023
2019
 Meningococcal disease
Category Description
Pathogen Neisseria meningitidis
Risk factor Nasopharyngeal carriage, complement def, HIV
Symptoms Meningitis, Meningococcemia
Petechial rash & Purpura fulminans, DIC, Shock
Investigation CSF Profile: PMN predominate, Glu ↓↓
CSF G/S: Gram negative diplococci
HC (Sn 50-60%), CSF Culture (Sn 80-90%)
Treatment Ceftriaxone 2 gm IV q 12 hr for 7 days
Prevention Droplet precaution, 24 hr after institution of effective ATB
Antimicrobial prophylaxis I/C
• >8 hours contact while in close proximity (<3 feet)
• Household members, roommates, intimate contacts
• Directly exposed to the patient's oral secretions
2021
2018
Gastroenteritis
2023
2021
 Hemolytic uremic syndrome (HUS)
Category Description
Pathogen Shiga toxin-producing Escherichia coli (STEC)
Transmission Feco-oral route
• fresh produce (ready-to-eat salads, fruit, sprouts)
• uncooked or unpasteurized products
• Non-beef meats
Pathogenesis Bacterial Stx injures endothelial cells
Clinical S/S Prodrome: abdominal pain, vomiting, bloody diarrhea
1 wk later triad of MAHA, thrombocytopenia, and AKI
Investigation Stool culture or Stool PCR for Shiga toxins
Hemolytic anemia with red cell fragmentation
Treatment Supportive: IV fluid, monitor
Avoid ATB !!
• ATB-induced injury to the bacterial membrane favors
the acute release of large amounts of toxins
• ↑ risk of full-blown HUS by 17-fold
2017
2021
 Clostridioides difficile infection
Category Description
Pathogen Clostridioides difficile
Obligate anaerobe, GPB, spore-forming
Transmission Feco-oral route by ingestion of spores
Pathogenesis Disruption of the microflora (by antibiotic treatment)
Clinical S/S Watery diarrhea
Abdominal pain and cramping
Severe: ileus, toxic megacolon
Investigation EIA for toxin A,B: Sn ~ 50%, Sp 99% Pseudomembranous
Stool GDH: Sn 95%, Sp 90% colitis (PMC)
PCR for C.diff toxin B: Sn 95%, Sp 95% Adherent, yellowish
Treatment Non-fulminant disease white plaques on the
• Vancomycin 125 mg PO 1x4 for 10 days intestinal mucosa
• Metronidazole 500 mg PO 1x3 for 10-14 days
Fulminant disease
• Vanco 500 mg PO 1x4 + Metro 500 mg IV q 8 h
• Rectal vancomycin 500 mg in NSS 100 mL (if ileus)
SSTI & Gas gangrene
2022
2020
2023
2020
2021
Necrotizing soft
tissue infection

Lancet Infect Dis. 2023 Mar;23(3):e81-e94.

N Engl J Med 2017; 377:2253-2265
 Clostridial gas gangrene
Category Description
Pathogen Clostridium perfringens, anaerobic, spore-forming, GPB
Pathogenesis Traumatic wounds with vascular compromise
(particularly deep penetrating injuries) create an
anaerobic environment
Symptoms Sudden onset, severe pain at the site of trauma
Skin rapidly change: pale -> purple-red discoloration
Skin bullae, necrosis, crepitus
Signs of systemic toxicity -> shock & multiorgan failure
Investigation Imaging: gas in deep tissues
Surgical exploration: muscle that does not bleed or
contract when stimulated
G/S from bullae: Gram positive bacilli, no leukocyte
Aerobic and anaerobic tissue culture
Treatment Prompt, aggressive surgical debridement Large GPB and the
Antibiotic therapy absence of leukocytes
• PGS 4 mU IV q 4 h + Clindamycin 900 mg IV q 8 h
 Vibrio vulnificus
Category Description
Pathogen Vibrio vulnificus, gram-negative curved rod
found in salt water and brackish water
Transmissio Consumption of undercooked seafood (esp. oysters)
n Contact of an open wound with salt water
Risk factors Cirrhosis, heavy alcohol use, hereditary hemochromatosis
Clinical S/S Primary septicemia
Wound infection: mild cellulitis  NSTI
Diarrhea
Investigation Blood cultures
Culture of hemorrhagic bullae or wound culture
Treatment Severe infection
• Ceftriaxone + Doxycycline or Fluoroquinolone
• Surgical debridement
Mild infection & no risk factor for severe disease
• Monotherapy: Doxycycline or Fluoroquinolone
2018
 Deep vein thrombosis
Homans' sign
Acute pharyngitis
2023
2022
2018
 Infectious mononucleosis (IM)
Category Description
Pathogen EBV (HHV-4) primary infection
Epidemiology Childhood – young adult (15-24 yo)
Symptoms Fever, pharyngitis, lymphadenopathy
Splenomegaly, hepatomegaly
Palatal petechiae, jaundice, Rash
Investigation CBC: Mono- lymphocytosis with atypical lymphocyte
Heterophile antibodies +ve
EBV-specific antibogies +ve
• Viral capsid antigen, Early antigen, Nuclear antigen
Plasma PCR for EBV
Treatment • Symptomatic treatment Differential diagnosis
• Corticosteroid only in complicated case (upper • Acute retroviral syndrome
airway obstruction, massive splenomegaly) • Acute toxoplasmosis
• No role of antiviral treatment • GAS pharyngitis, Other viral pharyngitis
Heterophile antibodies
• Reactive heterophile Ab s in a patient with a compatible
syndrome  Diagnostic for EBV infection EBV Early Antigen (EA)
• Con Sensitivity 80%, False positive in HIV infection, • appears in the acute phase of illness
leukemia, lymphoma, SLE • disappear after recovery

Viral Capsid Antigen (VCA) EB Nuclear Antigen (EBNA)

• VCA IgM: appears early in EBV infection • EBNA IgG: appear 6-12 wks after onset, +ve for life
• VCA IgG: positive for life
2023
2023
2020
2019
 Pertussis (Whooping cough)
Category Description
Pathogen Bordetella pertussis
Epidemiology Infant & children, ↑ Adult
Transmission: respiratory droplets
Symptoms Catarrhal phase (1-2 wk)
• nonspecific symptoms (resemble URI)
Paroxysmal phase (1-6 wk)
• paroxysmal cough (severe, vigorous coughs that occur
during a single expiration)
• follow with a "whooping" sound
Convalescent phase (2-3 wk)
• Gradual ↓ in the frequency and severity of cough
Complication otitis media, pneumonia, apnea, encephalopathy
Sequelae of severe cough: subconjunctival hge, rib fx etc.
Investigation Culture or PCR for B.pertussis
Treatment Azithromycin 500 mg d 1, 250 mg 1x1 days 2 - 5
Clarithromycin 500 mg PO 1x2 for 7 days
TMP-SMX 1 DS PO 1x2 for 14 days
2018
 Diphtheria
Category Description
Pathogen Corynebacterium diphtheriae
Epidemiology Childhood – young adult, Lack of immunization
Transmission: direct or via airborne droplet
Symptoms • Sore throat, malaise, cervical lymphadenopathy
• Pseudomembrane @ tonsillopharyngeal area (gray-
white exudate, adheres tightly, bleeds with scraping)
• Bull neck appearance: massive swelling of the tonsils,
uvula, submandibular region, and anterior neck
• Complication: UAO, Myocarditis, Peripheral neuritis
Investigation Culture or PCR for C.diptheriae
Toxin detection: Elek test, EIA, PCR for toxin gene
Treatment Antibiotic
• Erythromycin 500 mg 1x4 for 14 days
• Penicillin G 1.2 mU IM Q 24 hr
Diphtheria antitoxin (DAT)
Airway management
Fever with rash
2022
2021
 Zoster
Category Description
Pathogen VZV (HHV-3) Reactivation
Risk factors Old age & immunocompromised patient
Symptoms Uncomplicated HZ (Immunocompetent)
• Group of vesicle along the distribution of dermatome

Disseminated HZ (immunocompromised)
• Generalized skin eruptions, occur outside of the
primary dermatomes
• Visceral involvement: meningoencephalitis, hepatitis,
pneumonitis
Investigation Tzanck smear: multinucleated giant cell
PCR for VZV
Treatment Non-severe: Acyclovir 800 mg PO 1x5
Severe or IC host: Acyclovir 10 mg/kg IV q 8 h
Ramsay Hunt syndrome (CVII palsy + ear pain + vesicle)
• Acyclovir + Prednisolone 1 MKD for 5 days
2022
 Chikungunya
Category Description
Pathogen Chikungunya virus
Transmission Mosquitoes: Aedes aegypti & Aedes albopictus
Symptoms Acute onset, fever, malaise
Arthralgia, Arthritis: symmetrical, distal > proximal
Skin: macular or maculopapular rash
Investigation RT-PCR for chikungunya virus RNA (< 7 days)
Chikungunya IgM (≥ 5 days)
Treatment Supportive care
Arthritis: Paracetamol, NSAIDs
2022
Acute febrile illness
2021
2021
 2021

IFA for murine typhus

2022
2020
2022
 Scrub typhus
Category Description
Pathogen Orientia tsutsugamushi
obligate intracellular, gram-negative coccobacilli
Transmission Chigger bites
Symptoms Fever, headache, myalgia, N/V, Diarrhea
Macular, or maculopapular rash
Eschar: painless nonpruritic lesion with a central tough
black area surrounded by an erythematous region
Hepatomegaly, Splenomegaly
Complication Lung: Pneumonitis, ARDS
Cardio: Myocarditis
Neuro: Aseptic meningitis, Encephalitis, Seizure
KUB: AKI
Investigation Indirect fluorescent antibody (IFA) – fold 4 rising Ab
PCR for O.tsutsugamushi (blood, eschar)
Treatment Mild disease: monotherapy doxycycline, azithromycin
Severe disease: doxycycline (prefer IV) Am J Trop Med Hyg. 2007 May;76(5):806-9.
2018
2018
 Leptospirosis
Category Description
Pathogen Leptospira interrogans, spiral-shaped GNB
Transmission Contact with urine-contaminated soil or water
• Animal reservoir: Rodent (main), domestic mammals
• Organisms can survive for days to months
Symptoms Anicteric leptospirosis
• Septicemic phase: fever, chill, myalgia (calve & back),
conjunctival suffusion
• Immune phase: fever, aseptic meningitis, uveitis
Icteric leptospirosis (Weil's disease)
• fever, jaundice, renal failure, pulmonary hge, ARDS
Investigation Indirect fluorescent antibody (IFA) – fold 4 rising Ab
Blood, Urine, CSF PCR
Treatment Mild disease: doxycycline, azithromycin
Severe disease:
• Penicillin G 1.5 mU IV q 6 hr
• Ceftriaxone 1 gm IV q 24 hr
2023
 Tetanus
Category Description
Pathogen Clostridium tetani, Obligately anaerobic, soil bacterium
GPB with terminal spore (drumstick shape)
Risk factor Penetrating injury resulting in the inoculation of C.
tetani spores + Lack of immunization
Pathogenesis Tetanospasmin prevents the presynaptic release of
inhibitory neurotransmitters GABA  loss of inhibition
Symptoms Generalized tetanus
• Trismus (lockjaw), Risus sardonicus
• Pharyngeal and laryngeal spasms
• Opisthotonos (generalized spasm with flexion of the
arms and extension of the legs)
Investigation Diagnosis based on clinical signs and symptoms
Treatment Wound debridement
ATB: Metronidazole or Penicillin G IV
Tetanus antitoxin (Ig) & Active immunization
Supportive rx: control muscle spasm & autonomic dysfn
2022
 Mump
Category Description
Pathogen Mump • Obscure the angle of
Transmission Respiratory droplets, direct contact, or fomites the mandible
Symptoms Common age 2-9 yo. • orifice of Stensen's
Prodrome: fever, headache, myalgia, fatigue duct is erythematous
Parotitis, unilateral or bilateral and enlarged
Complication Epididymoorchitis – most common complication
• Occurs among postpubertal males (age 20-30 yo)
• Symptoms occur 5-10 day after onset of parotitis
Aseptic meningitis, Encephalitis, SNHL
Investigation RT-PCR for mumps RNA (serum, buccal swab)
Mumps IgM positive
Treatment Supportive care (self-limited), No antiviral treatment
Prevention MMR vaccine (0.5 ml SC) 2 doses, 4 weeks apart
PEP: within 72 hours of exposure (if no C/I)
2021
2022
2021
HBV serology (basic)
 HBV serology interpretation
HBsAg Anti-HBs Anti-HBc (total) Anti-HBc (IgM) Interpretation
Positive Negative Positive Positive Acute infection
Positive Negative Positive Negative Chronic infection
Negative Positive Positive Negative Past infection
Negative Positive Negative Negative Vaccinated
Negative Negative Positive Negative Past infection with anti-HBs fallen
“Low level” chronic infection
Resolving acute infection
False positive anti-HBc
 • Past infection with anti-HBs fallen “Low level” chronic infection
• False positive anti-HBc

Past infection with anti-HBs fallen False positive anti-HBc

Clin Infect Dis. 2018 Jan 6;66(2):317-318.

2021
2017
2021
2019
2018
 2015 vs 2023 ESC IE Prophylaxis
2015 ESC 2023 ESC

No longer recommend the use of

clindamycin for antibiotic prophylaxis
(mainly related to C. difficile infections)
2018
 Fungi

Yeast Mold Dimorphic fungi

- Talaromyces spp.
- Histoplasma spp.
Non-encapsulated Encapsulated Septate Non-Septate
hyphae hyphae
- Candida spp. - Cryptococcus
- Malassezia - Rhodotorula
- Trichosporon

Dematiaceous Hyaline Mucorales Entomophthorales

(Black molds) septate
- Apophysomyces
- Alternaria - Aspergillus - Saksenea
- Curvularia - Fusarium - Cunninghamella
- Exophiala - Scedosporium - Mucor
- Cladophialophora - Lomentospora - Rhizopus
- Coniosporium - Acremonium - Rhizomucor
- Cyphellophora - Lichtheimia
- Fonsecaea (Absidia)
- Phialophora - Actinomucor
- Rhinocladiella
 Aspergillosis
Category Description
Pathogen Aspergillus spp. (A.fumigatus, A.flavus, A.niger etc.)
Transmission Inhalation of spore
Risk factors Severe and prolonged neutropenia, high dose steroid,
HSCT, SOT, COPD, ICU admission
Symptoms Pulmonary aspergillosis
• fever, chest pain, shortness of breath, cough
• CXR: single or multiple nodules, patchy or segmental
consolidation, peribranchial infiltration
Investigation Galactomannan antigen detection
Culture
Histopathology (gold standard)
Treatment Voriconazole, Posaconazole, Isavuconazole
Amphotericin B narrow, septate hyphae with acute-angle branching with
dichotomous branching
 Mucormycosis
Category Description
Pathogen Mucorales e.g. Rhizopus, Mucor, Rhizomucor etc.
Transmission Inhalation of spore
Risk factors DM esp. DKA, iron overload, SOT, HSCT, Glucocorticoid
Symptoms Rhino-orbital-cerebral mucormycosis
• Rhino: nasal congestion, purulent nasal discharge
• Orbit: periorbital edema, proptosis, blindness Black eschar (necrosis of tissues after vascular invasion by the
fungus) the nasal mucosa, palate, or skin overlying the orbit
• CNS: headache, CN palsy, cavernous sinus thrombosis
Investigation Endoscopic evaluation of the sinuses
Tissue biopsy and culture for fungus
Treatment Control risk factor + Surgical debridement + Anti-fungal

broad, nonseptate hyphae with right-angle branching

2022
2017
Anti-TB side effects

แนวทางการควบคุมวัณโรคประเทศไทย พ.ศ. 2564

Drug induced hyperuricemia

PZA strongly associated with

hyperuricemia and gout attack

EMB – Less effect

Rheumatology (Oxford). 2017 May 1;56(5):679-688.

2021
2017
2021
 Melioidosis
Category Description
Pathogen Burkholderia pseudomallei
Epidemiology SEA (Thailand esp. NE) & Northern Australia
Risk factors Soil exposure
T2DM, CKD, Renal stone, Thalassemia disease
Symptoms “The great imitator”
• Bacteremia, Pneumonia (40-60%)
• Liver abscess, Splenic abscess (10-33%)
• Other: septic arthritis, skin abscess, KUB, CNS etc.
Investigation G/S: GNB with bipolar staining
Culture (gold standard for Dx)
Serology: Not recommend for Dx in Thailand
• High background Ab in an endemic region
• Cross-reactivity to avirulent soil Burkholderia species
Treatment Initial phase ≥ 2 wks of Ceftazidime
Maintenance phase 12-20 wks of TMP-SMX