Infections of Liver

Ascending
Cholangitis
Liver
Abscess
Amebiasis Echinococcus
Buzzword
Bloody Diarrhea
Flask-shaped Ulcers
Anchovy Paste Abscess
Eat RBCs
Sheep
Presenting S & S
Fever/RUQ
Jaundice
ACUTE ONSET
Fever/RUQ
Anorexia
Wt. Loss
N/V
RUQ Hepatomegaly
First Step
Serology to r/o Amebiasis Serology to r/i Amebiasis CT
Next Step
U/S
CT

Imaging
Right Lobe Abscess Single/Multiple Cysts
Tests

Organism
E. Coli E. Coli
B. Fragilis
S. faecalis
E. histolytica E. granulosus
Tx
Decompression
Drainage
Zosyn
PC Drainage
Metronidazole
Ceftriaxone
Metronidazole
Paramomycin
PC Drainage
Albendazol
Associated DZ
Anaphylaxis from cyst
rupture











Liver Tumors

Multiple Liver Masses: think mets from GI, Lung, Breast.colonoscopy!

AFP to follow HCC (usu. solitary mass)

































OPHTHO

1. Retinitis in HIV Patients
CMV: PAINLESS, fluffy/granular retinal lesions near the retinal vessels + assoc. hemorrhages (usu cause conjunctivitis/keratitis); MCC
serious ocular complication in HIV+ pts

HSV/VZV: EYE PAIN + Mild CONJ rapid progressive visual loss; marked keratitis, widespread pale peripheral retinal lesions and central
necrosis of retina (HSV HURTS)

Candida Endophthalmitis: esp with dissem infection

2. Eye infections
dacryocystitis: infection of lacrimal sac (infants adults over 40); sudden onset of pain/redness in medial canthal region +/- purulent d/c; can
go to fever, elev wbc; MCC S. aureus, BHStrep

Chalazion: hard, painless lid nodule + lid discomfort; chronic granulomatous inf of meibomian gland

Hordoleum: abscess over upper/lower eyelid, localized red, tender swelling over eyelid, MCC staph

Episcleritis: infection of episcleral tissue b/t conjunctiva/sclera; acute onset of mild/mod discomfort, photophobia, watery d/c; bulbar
conjunctival injection

Orbital Cellulitis: inf posterior to orbital septum, unilateral, mc in children, abrupt onset fever, proptosis, EOM restricition, swollen/red
eyelids














Arthritis

Septic: fever, knee pain, WBC really high
GC Septic Arthritis: asymmetric polyarthritis (assoc w/ tenosynovitis + rash) purulent monoarthritis

Group Descriptive Name of Group Laboratory Findings Common Cause

OA
Overview: Osteoarthritis, also referred to as degenerative joint disease, occurs as a result of degeneration of the articular cartilage, with a gradual onset of symptoms after 40
years of age.
Pathogenesis of primary osteoarthritis: Normal articular cartilage undergoes turnover; however, in osteoarthritis, this turnover does not occur. Osteoarthritis is due to wear and
tear and other factors, including genetic factors. Osteoarthritis can also be secondary, as a result of trauma and other causes.
Joints involved: Weight bearing, including hips and knees; lower lumbar and cervical vertebrae; and proximal and distal interphalangeal joints.
Morphology of osteoarthritis (Figure 19-9 A and B)
Gross
o Eburnation: Term for thickened and polished subchondral bone.
o Subchondral cysts: Synovial fluid leaks through defects in cartilage and into underlying bone.
o Osteophytes: Include bony excrescences at the distal interphalangeal joint (Heberden nodes) and the proximal interphalangeal joint (Bouchard nodes).
o Joint mice: Loose fragments of cartilage and/or bone in the joint cavity.
Radiographic findings: Joint space narrowing, subchondral sclerosis and cysts, and osteophyte formation.
Microscopic: Fibrillation of the cartilage (i.e., splitting of cartilage)

Aching pain, decreased mobility, mild and brief (< 30 minutes) morning stiffness; pain with movement and remission of pain with rest, joint
crepitus, and theater sign (pain and knee joint locking when arising from a prolonged seated position). With progressive disease, pain
occurs at night and with rest. Patients can have symptoms due to compression of nerves.

Overview: Rheumatoid arthritis is an autoimmune disorder with an unknown antigenantibody combination. Patients with HLA-DRB1*0401 and *0404 alleles have increased
incidence of disease. Rheumatoid arthritis occurs in 1% of the population. Most patients are 4070 years of age. It is more common in females than males, with a ratio of 3:1.
Joints affected: Metacarpophalangeal and proximal interphalangeal joints, and feet, wrist, ankle, elbows, and knees.
Morphology of rheumatoid arthritis
Gross: Edematous and thick synovium (pannus); surface is rough, with projections.
Radiographic finding: Osteopenia; bony erosion with narrowing of joint space.
Microscopic: Increased number of B cells and T cells, vessels, fibrin, and neutrophils form the pannus. Rheumatoid nodule consists of central fibrinoid necrosis rimmed
with histiocytes and lymphocytes; located in areas subject to pressure and can be in viscera.
Clinical presentation of rheumatoid arthritis
Symptoms: Morning stiffness for > 1 hour, three or more affected joints, and arthritis of the hands with symmetric involvement of joints. Systemic signs such as weight
loss, fatigue, and fever may be present.
Signs: Warm tender joints; radial deviation of wrist and ulnar deviation of phalanges; swan neck deformity, Dupuytren contracture, boutonnire deformity; and
stiffness after inactivity.
Laboratory findings: Rheumatoid factor (IgM versus Fc portion of IgG) is positive in 7080% of patients.
Complications of rheumatoid arthritis: The pannus erodes cartilage and may bridge bones, causing ankylosis (Figure 19-10). Extra-articular manifestations are not unusual. The
triad of rheumatoid arthritis, leukopenia, and splenomegaly is referred to as Felty syndrome. Pulmonary involvement may cause pleural effusions, interstitial fibrosis, or nodular
disease (Caplan syndrome). Anemia of chronic disease is common.


Feature Osteoarthritis Rheumatoid arthritis
Joints affected Weight-bearing (hips, knees); PIP, DIP MCP, PIP, feet, wrists, ankles, elbow, knees
Morning stiffness < 30 minutes > 1 hour
Symptoms Pain occurs with movement and is better after rest Stiffness and pain are worst after inactivity
Physical examination Heberden and Bouchard nodes Rheumatoid nodules; radial deviation of wrist and ulnar deviation of phalanges

Ankylosing Spondylitis
Basic description: HLA-B27-associated seronegative spondyloarthropathy related to Reiter syndrome and psoriatic arthritis, and characterized by inflammation of axial joints
(e.g., spine and sacroiliac joints).
Epidemiology: Second and third decades of life; prevalence in males more than females, with ratio of 3:1.
Important point: Approximately 90% of patients have HLA-B27.
Clinical presentation of ankylosing spondylitis: Gradual onset of back pain, loss of mobility, and tenderness on palpation of the sacroiliac joints. Sacroiliitis with pseudo-
widening and eventual fusion of sacroiliac joints, and prominent involvement of spine with squaring and fusion of the vertebrae (bamboo spine). Erythrocyte sedimentation rate
is elevated.
Gout
Basic description: Arthritis due to deposition of uric acid crystals.
Types of gout
Primary gout: About 8590% of total number of cases of gout. Results from an unknown enzyme deficiency that causes either increased production of uric acid or
normal production of uric acid with decreased excretion. Most patients with primary gout have normal production with decreased excretion of uric acid.
Secondary gout (causes)
o Increased nucleic acid turnover (e.g., in leukemia).
o Chronic renal disease.
Risk factors for gout: Increasing age, alcohol use, obesity, thiazide diuretics (thiazide diuretics completely inhibit secretion of uric acid).
Pathogenesis of gout
Urate crystals are precipitated in the synovium; trauma leads to their release into the synovial fluid. The uric acid crystals are chemotactic for neutrophils, and they
activate complement.
Uric acid levels must be elevated for 2030 years to cause gout.
Forms of gout
Acute arthritis: Occurs as a result of the neutrophilic infiltrate associated with uric acid crystals in the joint.
Chronic tophaceous arthritis: Urates coat the surface of synovium and deposit within synovium, which causes hyperplasia of synovium.
Tophi: Term for aggregates of urates rimmed with macrophages, lymphocytes, and giant cells (Figure 19-11). Tophi form in tendons and ligaments.
Gout nephropathy
o Formation of uric acid stones, which can precipitate pyelonephritis.
o Deposition of uric acid crystals in interstitium.

Microscopic morphology: Uric acid crystals are needle shaped and have strong negative birefringence when polarized.
Clinical presentation of gout
Important point: About 50% of the time, the first attack of gout occurs in the first metatarsophalangeal joint. The next joints involved are those in the instep, ankle, and
heel.
Stages of gout in order of occurrence
o Asymptomatic hyperuricemia
o Acute gouty arthritis
o Asymptomatic period between acute attacks; then chronic tophaceous gout.
Diagnosis of gout: Joint aspiration with identification of needle-shaped, negatively birefringent crystals in synovial fluid.
Conditions associated with gout
Lesch-Nyhan syndrome: Characterized by hyperuricemia, gout, mental retardation, and self-mutilation; caused by hypoxanthine guanine ribosyl-transferase deficiency
(HGPRT).
Saturnine gout: Caused by lead poisoning, and is characterized by gout, renal failure, and microcytic anemia. It is classically associated with homemade whisky
(moonshine) made from stills containing lead or old car radiators.
Calcium Pyrophosphate Crystal Deposition (Pseudogout)
Epidemiology: Older than 50 years of age; occurs in patients with degenerative joint disease.
Microscopic morphology: Rhomboid positively birefringent crystals examined under polarized light.
Clinical presentation of pseudogout
Mimics osteoarthritis.
Affects large joints, such as the knee.

Table 42. Fever and Arthritis.
Active infection
o Septic arthritis
o Disseminated gonococcal infection
o Endocarditis
o Acute viral infections
o Mycobacterial
o Fungal
Post infection
o Reactive arthritis (particularly in its early phases)
o Acute rheumatic fever and poststreptococcal arthritis
Not due to infection
o Systemic lupus erythematosus
o Drug-induced lupus
o Still disease
o Gout
o Pseudogout
o Inflammatory bowel disease
o Paraneoplastic arthritis
o Acute sarcoidosis
o Systemic vasculitis
o Familial Mediterranean fever and other inherited periodic fever syndromes
Common Causes of Acute Monoarthritis.
Cause Example
Bacterial infection of the joint Nongonococcal: especially, Staphylococcus aureus, -hemolytic streptococci, Streptococcus pneumoniae, gram-negative organisms
Cause Example
space Gonococcal: often preceded by a migratory tenosynovitis or oligoarthritis associated with characteristic skin lesions
Crystal-induced arthritis
Gout (monosodium urate crystals)
Pseudogout (calcium pyrophosphate dihydrate crystals)
Trauma Hemarthrosis

Table 45. Differential Diagnosis of Acute Inflammatory Oligoarthritis.
Infection
o Disseminated gonococcal infection
a

o Nongonococcal septic arthritis
o Bacterial endocarditis
b

o Viral
c

Post infection
o Reactive arthritis
b

o Rheumatic fever (poststreptococcal arthritis)
d

Spondyloarthropathy
o Reactive arthritis
b

o Ankylosing spondylitis
b

o Psoriatic arthritis
b

o Inflammatory bowel disease
b

Oligoarticular presentation of rheumatoid arthritis, systemic lupus erythematosus,
a
adult-onset Still disease, relapsing polychondritis,
a
or other polyarthritis
Gout and pseudogout
Table 46. Differential Diagnosis of Acute Polyarthritis.
Common
o Acute viral infections
o Early disseminated Lyme disease
o Rheumatoid arthritis
o Systemic lupus erythematosus
Uncommon or rare
o Paraneoplastic polyarthritis
o Remitting seronegative symmetric polyarthritis with pitting edema
o Acute sarcoidosis, usually with erythema nodosum and hilar adenopathy
o Adult-onset Still disease
o Secondary syphilis
o Systemic autoimmune diseases and vasculitides
o Whipple disease
Acute Monoarthritis

Bacterial infection of the joint
space
Nongonococcal: especially, Staphylococcus aureus, -hemolytic streptococci, Streptococcus pneumoniae, gram-negative organisms
Gonococcal: often preceded by a migratory tenosynovitis or oligoarthritis associated with characteristic skin lesions
Crystal-induced arthritis
Gout (monosodium urate crystals)
Pseudogout (calcium pyrophosphate dihydrate crystals)
Trauma Hemarthrosis






























Arthritis Acute/Chronic INF/Non-INF Joints involved Presentation Test Tx Other Findings
Osteoarthritis

Chronic (DJD) NON
50-2000 WBC
<30% N
Wt-bearing, Hips/knees
Lumbar/cervical
PIP/DIP
MTP

Aching pain
Decreased mobility
<30m stiff in morning
Pain with movement
Pain remits w/ rest,
Joint crepitus
theater sign
Pain occurs at night
and with rest. Patients
can have symptoms
due to compression of
nerves.

Best Initial Tests
XR of joint


Rheumatoid

Chronic
(sxs > 6wks)
5000-50,000 WBC Symmetric

MCP swelling/pain
Boutonnierre Deformity
Swan Neck Deformity

Ulnar Deviation of
Fingers
Bakers Cyst
C1/C2 subluxation
Small Joints later
Knee later


Older women

Diagnostic Criteria (4+):

- Morning stiffness > 1 hr
- 1+ affected joints
- Symmetric Hand Joints
- (+)RF or anti-CCP
- CRP/ESR elevation
- Rheumatoid Nodules
- XR showing erosions

Systemic signs (weight loss,
fatigue, and fever possible)

Best Initial Tests
XR/RF/CCP/ESR/CRP

- RF+ (only 80%)

- Anti-CCP = most
accurate (>95% sp)
NSAIDs (any) +
Steroid bridge until
DMARDs started

Methotrexate
- best tolerated
- if fail, add others
- BMS
- Pneumonitis

Biologics (+/- MTX)
Infliximab (TNF)
Adalimumab (TNF)
Etanercept (TNF)

Hydroxychloroquine
- mild disease
- RETINOPATHY
(eye exams yearly)

Sulfasalazine
- BMS

Others:
- Rituximab (cd20)
- Anakinra (IL-1)
- Leflunomide (il-6)
- Abatacept (Tc)


Cardiac: pericarditis,
valve dz

Lung: Pleural Effusion
with very low glucose,
lung nodules

Blood: Normocytic,
Normochromic
Anemia

Nerve: Mononeuritis
Multiplex

Skin: Nodules

Felty Syndrome:



GC Septic Arthritis
Septic: fever,
knee pain, WBC
really high
Acute
GC Septic
Arthritis:
asymmetric
polyarthritis
(assoc w/
tenosynovitis +
rash)
purulent
monoarthritis

young, sexually
active =
Neisseria

Gout Chronic warm, painful,
swollen joint + LG
fever

10000 50000

Reactive arthritis
I Noninflammatory arthritis 502000 WBC/mm3; < 30% neutrophils Osteoarthritis
II Mildly inflammatory arthritis 09000 WBC/mm3; < 20% neutrophils Systemic lupus erythematosus
III Severely inflammatory arthritis 100160,000 WBC/mm3; 70% neutrophils Gout
IV Purulent arthritis 150250,000 WBC/mm3; 90% neutrophils Bacterial infections















Hypocalcemia

Calcium Ionized Calcium Phosphate PTH S&S
Hypoalbuminemia decreased unchanged
Malabsorption low low
PseudoHypoPTH low high
Renal Failure low high high