Sporotrichosis

Sporofhrix schenckii is a dimorphic fungus found in the natural

environment in the form of mold (hyphae).
It resides on the bark of trees. shrubs. and garden plants. and on
plant debris in soil.
Sporotrichosis is common in gardeners.
The initial lesion. a reddish nodule that later ulcerates.
appears at the site of the thorn prick or other skin injury.
From the site of inoculation, the fungus spreads along the
lymphatics forming subcutaneous nodules and ulcers.
Subsequent papules develop along the route of lymphatic flow.
Adenopathy and systemic signs of infection are usually absent

Candida
Candida colonizes airways and usually does not cause pneumonia
Oral itraconazole is effective against some strains of Candida that
are resistant to fluconazole.

Mucormycosis
This patient is most likely suffering from mucormycosis of the nose
and maxillary sinus.
The most common etiologic agent is Rhizopus.
Poorly controlled diabetes mellitus predisposes to this disease.
Low-grade fever. bloody nasal discharge. nasal congestion. and
involvement of the eye with chemosis. proptosis. and diplopia are
important features.
Involved turbinates often become necrotic.
Invasion of local tissues can lead to blindness., cavernous sinus
thrombosis. and coma.
If left untreated. mucormycosis can lead to death in days to weeks.

NB: H. Influenza and Moraxella catarrhalis are common causes of

bacterial sinusitis.
These usually do not cause necrotic infections.

Invasive aspergillosis
Invasive aspergillosis can involve multiple organ systems
occurs in immunocompromised patients (e.g those with neutropenia.
those taking cytotoxic drugs such as cyclosporine. and those taking
very high doses of glucocorticoids).
Invasive pulmonary disease presents with fever, cough, dyspnea or
hemoptysis.
Chest x-ray may show cavitary lesions.
CT scan shows pulmonary nodules with the halo sign or lesions with
an air crescent.
___________________________________________________
Blastomycosis is endemic in the south-central and north-central US.
Histoplasmosis is most common in the southeastern. mid-Atlantic.
and central US.
Both blasto&histo in both Ohaio &missisipi
Coccidioides is endemic in the southwestern US. as well as Central
and South America(Arizona/California)

BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC

BONE LESIONS:
. Fungal infection of the lung..
. Residence in great lakes, Mississippi, Ohio river & Wisconsin.
. Pulmonary symptoms resembling T.B. & Histoplasmosis.
. ULCERATED SKIN LESIONS & LYTIC BONE LESIONS
(Characteristic!).
. Skin lesions -> Multiple well circuscribed verrucus crusted lesions.
. Bone lesions -> Lytic lesions in the anterior ribs.
. Dx -> Sputum culture -> BROAD BASED BUDDING YEAST.
. Tx -> ITRACONAZOLE or Amphotericin B.

Blastomycosis is endemic in the south-central and north-central US.

It usually affects the lungs. skin. bones. joints. and prostate.
Infection in immunocompetent hosts is uncommon.
Primary pulmonary infection is asymptomatic. or presents with flulike symptoms.
Cutaneous disease is either verrucous or ulcerative.
Verrucous lesions are initially papulopustular, and then progressively
become crusted, heaped up and warty, with a violaceous hue.
These lesions have sharp borders. and may be surrounded by
microabscesses.
Wet preparation of purulent material expressed from these lesions
shows the yeast form of the organism.

Histoplasmosis
. Asymptomatic pulmonary nodule.
. Residence in suburban Mississippi or o"H"io river valleys !
. Absence of any complaints.
. Absence of significant past H/O.
. Absence of any cavitary lesions.
. Calcified nodes in the lung may be seen.

. It is a dimorphic fungus found in soil with high concentration of

bird or bat droppings
. Infection through inhalation of the spores of Histoplasma
capsulatum fungus.
This patient presents with signs/symptoms consistent with
disseminated pulmonary histoplasmosis.
a fungal disease caused by contaminated soil in endemic areas, such
as the Ohio River valley.
Histoplasmosis is fairly self-limiting in immunocompetent people but
can cause significant pulmonary and disseminated disease
in patients with CD4 counts < 1 00/jJL.
These patients typically present with fever. weight loss. night
sweats. nausea. vomiting. and cough with shortness of breath.
Examination findings can include diffuse lymphadenopathy and
hepatosplenomegaly.
Laboratory findings can include pancytopenia (if bone marrow is
involved).
elevated liver function tests. and elevated ferritin
Fluconazole has less activity for histoplasma than does

itraconazole and is not recommended as primary treatment unless

the patient cannot tolerate itraconazole.
Flucytosine is effective against Cryptococcus and Candida but not
against histoplasma.
Metronidazole is effective against amebiasis and other anaerobic
bacterial infections but does not treat histoplasma.
ltraconazole is the preferred antifungal treatment for
histoplasmosis.
__________________________________________________

Influenza
The influenza virus has three different antigenic types: A, B and C.
Influenza A and B produce clinically indistinguishable infections.
whereas type C usually causes a minor illness
This patient presents with signs and symptoms of influenza
pneumonia.
Influenza is characterized by the abrupt onset of fever. chills.
malaise. myalgias. cough. and coryza.
It typically occurs in an epidemic pattern. often in the winter.
On physical exam. patients will often be febrile and may have a
variety of pulmonary findings. including wheezes. crackles. and
coarse breath sounds.
Leukopenia is common and proteinuria may be present.
Chest x-ray may be normal or show an interstitial or alveolar
pattern.
This patient became ill in the winter and has classic symptoms.
laboratory results. and radiographic findings of influenza.
Nasal swabs for influenza antigens are the fastest way to confirm
this diagnosis.
Antiviral treatment must be started within 48 hours to be effective.
Two classes of antiviral drugs are available for the prevention and
treatment of influenza:
1 . Amantadine and rimantadine - these are only active against
Influenza A
2. Neuraminidase inhibitors (i.e .. zanamivir. oseltamivir) - these are
active against both influenza A and influenza B.
Zanamivir is only approved for the treatment, not the
prevention of influenza

The administration of antiviral drugs usually results in shortening of

the duration of symptoms by 2-3 days;
however. the benefit is greatest when the drug is given within the
first 24 to 30 hours in a patient who presents with fever.

Febrile neutropenia
Over the past decade. there has been a shift from gram-negative to
gram-positive bacteria being the most frequent cause of neutropenic
infection.
considered a medical emergency; thus. empiric antibiotics should be
started immediately.
Empiric therapy should be broad-spectrum and should cover
Pseudomonas aeruginosa.
Either monotherapy or combination therapy can be employed.
Monotherapy consists of ceftazidime. imipenem. cefepime. or
meropenem.
Combination therapy is equally effective. and consists of an
aminoglycoside plus an anti-pseudomonal beta-lactam.

infectious mononucleosis
"the kissing disease" and "glandular fever."
fever, sore throat, malaise, jaundice, and mild hepatosplenomegaly
consistent with likely infectious mononucleosis (IM).
The clinical features of IM include fever, sore throat, toxic
symptoms. and symmetrical lymphadenopathy involving the posterior
cervical chain of lymph nodes more frequently than the anterior
chain.
Inguinal and axillary lymphadenopathy can also be present.
Other physical findings include pharyngitis, tonsillitis, and tonsillar
exudates.

Mild palatal petechiae may be found, but this non-specific sign may
also be seen in streptococcal pharyngitis.
Tonsillar enlargement can cause airway compression.
Hepatitis and jaundice are present in a small percentage of cases.
The findings of hepatosplenomegaly, malaise and fatigue. and
generalized lymphadenopathy (as seen in this patient) tend to favor
IM and are not commonly seen in other bacterial causes such as
streptococcal pharyngitis.
The diagnosis of IM is confirmed by :the presence of atypical
lymphocytosis and anti-heterophile antibodies (Monospot). which
typically indicate EBV associated disease.
Heterophile antibodies are sensitive and specific for IM.
The EBV-specific antibody test is used in patients with suspected
IM and a negative heterophile antibody test
These antibodies generally appear within one week of the onset of
symptoms, and may persist in low levels for up to one year.
However, these antibodies sometimes may not appear until later in
the course of the illness.
For this reason, a negative heterophile antibody test in the first
few weeks of illness does not rule out the diagnosis of IM.
Atypical lymphocytes are seen in the peripheral smear of patients
with IM, but are nonspecific.
They may also be present in patients with toxoplasmosis, rubella,
roseola, viral hepatitis, mumps,CMV, acute HIV infection, and
some drug reactions
One of the hematological complications of IM is autoimmune
hemolytic anemia and thrombocytopenia. which is due to cross
reactivity of the EBV-induced antibodies against red blood cells and
platelets.
These antibodies are lgM cold-agglutinin antibodies known a anti-i
antibodies.
which lead to complement-mediated destruction of red blood cells
(usually Coombs'-test positive).

The onset of the hemolytic anemia can be 2-3 weeks after the
onset of the symptoms. even though the initial laboratory studies
may not show anemia or thrombocytopenia (as in this patient).
This patient is most likely suffering from infectious mononucleosis.
and splenic rupture is a serious potential complication.
All patients with splenomegaly should avoid excessive physical
activity. particularly contact sports. until their spleen regresses in
size and is no longer palpable (usually after one to three months).
Posterior cervical lymphadenopathy and a maculopapular rash may be
seen in infectious mononucleosis
Leukocytosis is common.
In infectious mononucleosis. rash often develops after the
administration of ampicillin.

Primary HIV infection causes a febrile illness that can closely

resemble infectious mononucleosis.
The key distinctions between the two are that rash (unless
antibiotics have been administered) and diarrhea are LESS common
in infectious mononucleosis and the finding of a tonsillar exudate is
uncommon in primary HIV.

Nocardia
Nocardia is a gram-positive, weakly acid-last, filamentous branching
rod found in soil and water.
Nocardia (usually N. asteroides) is an important cause of infection in
immunocompromised hosts, such as HIV patients or organ transplant
recipients.
The lung is the most frequently involved organ. and infection can
manifest as nodules. a reticulonodular pattern. diffuse pulmonary
infiltrate. abscess. or cavity formation.
Diagnosis of Nocardia is difficult.

A presumptive diagnosis can be made it partially acid-Fast,

filamentous. branching rods are seen in clinical specimens.
The treatment of choice is trimethoprim-sulfamethoxazole.

Rubella & measles

The characteristic rash of rubella is erythematous and
maculopapular.
It starts on the face and progresses to the trunk and extremities.
Prodromal symptoms include fever. lymphadenopathy. and malaise.
Occipital and posterior cervical lymphadenopathy are suggestive of
the diagnosis.
Adult women usually have associated arthritis. which is another
diagnostic clue.
Some patients may have mild coryza and conjunctivitis.
__________________________________________________
The characteristic rash of measles is also erythematous and
maculopapular. and similarly progresses from the head to the trunk
and extremities.
There is usually a prodrome of fever. cough. coryza. and
conjunctivitis.
The presence of Koplik's spots is suggestive. Arthritis is not
commonly seen.
________________________________________________
The rash of chicken pox is pruritic and usually develops after a
prodrome of fever and malaise.
The lesions appear in consecutive crops. so lesions of several
different stages are often visible on examination (i.e .. papular.
vesicular. and crusted lesions).

rubella immunization.
If a woman becomes pregnant earlier than three months after
rubella immunization.
reassurance is the appropriate step.
Previously. women of childbearing age were advised to avoid
conception for at least three months after rubella immunization;
however. there have been no case reports to date of congenital
rubella syndrome in women inadvertently vaccinated during early
pregnancy.
In fact. the Advisory Committee on Immunization Practices (ACIP)
has reduced the recommended waiting time for conception from 3
months to 28 days

CMV
CMV pneumonitis should be considered in the differential diagnosis
of any bone marrow transplant (BMT) recipient with both lung and
intestinal involvement.
Risk factors include certain types of immunosuppressive therapy,
older age, and seropositivity before transplantation.
The median time of development of CMV pneumonitis after BMT is
about 45 days (range of two weeks to four months).
Typical chest x-ray findings include multifocal diffuse patchy
infiltrates.
High-resolution CT scan shows parenchymal opacification or multiple
small nodules.
Bronchoalveolar lavage is diagnostic in most cases.
Other than pneumonitis, CMV infection in post-BMT patients also
manifests as upper and lower gastrointestinal ulcers , bone marrow
suppression. arthralgias. myalgias. And Esophagitis
Consider cytomegalovirus ( CMV) infection in a patient with
mononucleosis-like symptoms. Atypical lymphocytes on the blood
smear. and a negative monospot test.

 Unlike EBV-associated mononucleosis.

Sore throat and lymphadenopathy are uncommon in CMV infection.

(GVHD)
The most common organ involved in graft-versus-host disease
(GVHD) is the skin;
skin rash is almost always seen.
The other organs commonly involved include the intestine, liver, and
lung.
Lung involvement is seen in chronic GVHD and manifests as
bronchiolitis obliterans.

tests for HIV

ELISA is the preferred screening test for HIV infection because
its sensitivity is greater than 99.9%.
Western blot is a confirmatory test for HIV infection. Its
specificity is greater than 99.99% when combined with ELISA.
HIV viral load is an indicator of disease progression.
Very high viral loads (>100,000 copies/ml) is associated with a poor
prognosis.
Absolute CD4 count is an indicator of disease progression.
The risk of AIDS-opportunistic infections is high when the CD4
count is less than 200 cells/jJL.
Patients with a CD4 count below 200 cells/jJL should be
started on antiretroviral therapy.
P24 antigen assay is not used for screening purposes.

Whenever a healthcare worker is exposed to the blood or blood

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

The common acute life-threatening reactions associated with HIV

therapy include:
1 . didanosine-induced pancreatitis
2. abacavir-related hypersensitivity syndrome
3. lactic acidosis secondary to the use of any of the NRTis
4. Stevens-Johnson syndrome secondary to the use of any of the
NNRTis
5. nevirapine-associated liver failure
6.Crystal-induced nephropathy is a well-known side effect of
indinavir therapy.

. Bacillary angiomatosis
Bright red. firm. friable. exophytic nodules in an HIV infected
patient are most likely bacillary angiomatosis.
Bacillary angiomatosis is caused by BARTINELLA .
A Gram-negative bacillus.
Diagnosis is made via tissue biopsy and microscopic identification of
organisms and the characteristic angiomatous histology.
Extreme caution must be exercised in biopsying these lesions
because they are prone to hemorrhage.
BA can be treated with a variety of antibiotics which lead to
involution of the lesions.
Oral erythromycin is the antibiotic of choice

Kaposi sarcoma
The cutaneous lesions of Kaposi sarcoma are asymptomatic, elliptical,
and arranged linearly.
Commonly involved regions include the legs, face, oral cavity, and
genitalia.
The lesions begin as papules, and later develop into plaques or
nodules.
The color typically changes from light brown to violet.
There is no associated necrosis of the skin or underlying structures.
In the US, this disease is most commonly seen in homosexual HIV
patients.
Kaposi sarcoma in HIV patients is caused by human herpesvirus 8.

Pneumocystis
Pneumocystis may cause nodular and papular cutaneous lesions of the
external auditory meatus in immunocompromised (HIV) patients.
With use of trimethoprim-sulfamethoxazole. Pneumocysfis infection
is highly unlikely.
Although initiation of antiretroviral treatment is indicated.
it is important to treat the PCP first.

Failure to start treatment in patients with PCP is associated with

almost 100% mortality. HAART is usually started after the acute
episode is over.
Encapsulated bacteria, especially Pneumococcus, are the most
common cause of pneumonia in HIV patients.
Oral trimethoprim-sulfamethoxazole (TMP-SMX) is effective in
preventing Pneumocystis pneumonia (PCP) in transplant patients.
It may also prevent toxoplasmosis, nocardiosis, and other infections
(e.g., urinary tract infections and pneumonia).
All post transplant patients should receive prophylaxis with
TMP-SMX.
Ganciclovir or valganciclovir can be used to prevent CMV
infections
Diarrhea in HIV
Causes of diarrhea in HIV patients include non-opportunistic
infections (e.g .. Salmonella. Campylobacter. Entamoeba. Chlamydia,
Shigella. and Giardia Iamblia).
opportunistic infections (e.g .. CMV. Cryplosporidium./sopora belli.
8/aslocyslis. MAC. Herpes simplex virus. Adenovirus. and HIV itself).
and non-infectious causes
(e.g .. Kaposi sarcoma or lymphoma of the Gl tract).
Hematochezia and lower abdominal cramps are usually due to colonic
infection with CMV. Clostridium difficile. Shigella. E hislofylica. or
Campy/obacter.
In an HIV-infected patient. bloody diarrhea and a normal stool
examination are highly suspicious for CMV colitis and warrant a
colonoscopy with biopsy
CMV is a common opportunistic pathogen in HIV-infected patients
and may cause esophagitis. gastritis. colitis. proctitis. or small bowel
disease.

In this case. the patient presents with the typical presentation of

CMV colitis: chronic bloody diarrhea. abdominal pain. and a CD4 count
less than 50 cells/IJL.
Colonoscopy shows multiple mucosal erosions and colonic ulceration.
Biopsy shows the presence of large cells with eosinophilic
intranuclear and basophilic intracytoplasmic inclusions ("owl's eye"
effect).
The treatment of choice is ganciclovir.
Foscarnet is used in case of ganciclovir failure or intolerance.

This HIV-infected man is suffering from unexplained fever and

cough.
The differential includes Mycobacterium avium complex,
Mycobacterium tuberculosis, disseminated cytomegalovirus
infection, and non-Hodgkin's lymphoma.
Clarithromycin, in combination with ethambutol, is used as treatment
for Mycobacterium avium complex infection.
Pulmonary cavitation in an HIV-inFected patient can be caused by a
number of different organisms. Including:Mycobacterium
tuberculosis, atypical mycobacteria, Nocardia, gram-negative rods,
and anaerobes.
HIV patients are at high risk for tuberculosis. A positive PPD test
(skin induration of greater than 5 mm in HIV patients) requires
prophylaxis with isoniazid (and pyridoxine) for 9 months.
Pyridoxine is added to the regimen to prevent possible neuropathy
caused by isoniazid.
Pyridoxine does not prevent isoniazid-induced hepatitis. and thus
periodic liver function tests should be monitored in these patients.

Peripheral neuropathy may present as tingling in the extremities.

numbness and ataxia. It is a known side effect of isoniazid.
For this reason. all patients who are started on anti-tubercular
therapy are also started on vitamin supplements.
especially pyridoxine ( 1 0 mg/day).
If the peripheral neuropathy has already developed.
the dose of pyridoxine is increased to 1 00mg/day.

dysphagia/odynophagia in an HIV patient

The most common cause of dysphagia/odynophagia in an HIV patient
is candidal esophagitis.
If these symptoms develop. an initial one- to tvvo-week course of
empiric oral fluconazole should be prescribed.
If symptoms persist despite therapy, endoscopy with biopsy should
be performed to investigate other possible etiologies.
HIV patients with severe odynophagia but without oral thrush are
likely to have ulcerative esophagitis. which is most often caused by
cytomegalovirus ( CMV).
The triad of :
1) focal substernal burning pain with odynophagia,
2) evidence of large, shallow, superficial ulcerations.
3) presence of intranuclear and intracytoplasmic inclusions is
diagnostic of CMV esophagitis.
The treatment of choice is IV ganciclovir.
HIV-infected patients who develop esophagitis are first
started on fluconazole directed against candidiasis
Failure to respond to a 3-5 day course of oral fluconazole
warrants further investigation with endoscopy.

Herpes simplex virus (HSV) esophagitis

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

herpes simplex virus (HSV) encephalitis.

HSV most frequently affects the temporal lobes of the brain.
As a result features such as bizarre behavior and hallucinations may
be present.
The disease is usually abrupt in onset. with fever and impaired
mental status.
Meningeal signs are frequently absent.
Cerebrospinal fluid ( CSF) findings are nonspecific. with low glucose
levels and pleocytosis.
The diagnostic test of choice is CSF polymerase chain reaction (PCR)
for herpes simplex virus DNA. not viral culture!
However. whenever there is a suspicion of HSV encephalitis.
IV acyclovir should be started without delay. B4 PCR

zoster
Shingles is caused by reactivation of the varicella-zoster virus.
Fallowing the primary infection (chicken pox).
the virus remains latent in the dorsal root ganglia.
A decrease in cell-mediated immunity (e.g. older age, stressful
situation, HIV, lymphoma)
can allow the virus to reactivate and spread along the sensory nerve.

This accounts for the typical unilateral, dermatomal distribution of

the pain and rash; T3 to L3 are the most frequently involved
dermatomes.
Patients often develop pain or discomfort in the affected area
before the onset of rash.
Valacyclovir is the drug of choice for treating herpes zoster.
However, acyclovir is less expensive and is also effective.
Early antiviral therapy reduces the duration of rash and associated
pain. and is also thought to reduce the likelihood of developing post
herpetic neuralgia.
Postherpetic neuralgia can be prevented and/or treated with
tricyclic antidepressants such as amitriptyline or nortriptyline along
with acute antiviral therapy.

bacterial meningitis.
The most appropriate empiric antibiotic regimen is vancomycin.
ceftriaxone. and ampicillin.
Vancomycin + ceftriaxone is ideal for community-acquired bacterial
meningitis in adults and children since it covers the three most
frequent etiologic agents: Streptococcus pneumoniae. Haemophi/us
inf/uenzae. And Neisseria meningitidis

Ampicillin is included in the empiric regimen to cover Listeria

monocyfogenes. which is also an important cause of meningitis in
patients older than 55.
Other patients who are at risk for Listeria meningitis include
immunocompromised patients, patients with malignancies (especially
lymphoma). and patients taking corticosteroids

IV cefotaxime + ampicillin is the ideal antibiotic regimen for patients

less than three months of age.
IV ceftazidime + vancomycin is the ideal antibiotic regimen for
hospitalized patients who develop meningitis. especially after
neurosurgery.
These drugs cover Pseudomonas and Staphylococcus aureus.
respectively.

Diarrhea
Diarrhea in travelers is most commonly due to contaminated
food and water. Although a variety of agents (e.g .. bacteria.
viruses. parasites) are possible. enterotoxigenic E. coli is the
most frequent cause of traveler's diarrhea.
It is a rare cause of diarrhea in the US
Abdominal tenderness with an absence of fever is most
suggestive of infection with Enterohemorrhagic E. coli
(EHEC).
Shigella. Salmonella. and Campylobacter can also cause bloody
diarrhea but often result in fever and/or lack of abdominal pain.
EHEC is different from other strains of E. coli because it produces
a Shiga toxin that causes its propensity to cause bloody diarrhea.
The most common serotype of EHEC in the US is 0157:H7.
Most cases are caused by ingestion of undercooked ground beef,
although it is not uncommon for patients to not remember a
particular exposure.
Potential complications include development of Hemolytic-Uremic
Syndrome (HUS) or Thrombotic Thrombocytopenic Purpura (TTP).
A stool culture could be considered to confirm the diagnosis and
determine antibiotic susceptibilities.

 suspect Bacillus cereus whenever you read about a patient who

eats rice and subsequently develops nausea and severe
vomiting.
Bacillus cereus produces a heat-stable toxin in inadequately
refrigerated cooked rice.
Because the illness is due to a preformed toxin symptoms of nausea
and vomiting appear quickly after consumption of the contaminated
food (between one and six hours after ingestion).
A side from preformed toxins. chemical irritants also produce
abrupt-onset nausea and severe vomiting.
Staphylococcus aureus toxin is present in foods such as dairy.
salad. meat. and eggs.
Symptoms include nausea. vomiting. diarrhea. and abdominal pain.
Because S. aureus food poisoning is also due to a preformed toxin.
symptom-onset is rapid. usually within one to six hours after
ingestion.
Clostridium perfringens is a spore-forming organism.
Its spores germinate in foods such as meats. poultry. or gravy.
Ingestion of such food results in watery diarrhea due to production
of toxin in the gut.
Symptom onset is later than with preformed toxins (8-14 hours
after ingestion).
Diarrhea occurs with ingestion of a large number of organisms.

Diarrhea due to Vibrio parahaemolyticus is usually transmitted by

the ingestion of seafood.
Other signs and symptoms include fever, abdominal cramps, and
nausea.
These clinical features develop after an incubation period of four
hours to four days.
V. parahaemolyticus can cause either watery or bloody diarrhea.

Shigella is a very common cause of dysentery in the US, and is

actually the second most common cause of food-borne illness.
Dysentery due to Shigella usually occurs in daycare centers or other
institutional settings.

Pseudomonas aeruginosa
The presence of gram-negative bacilli in the sputum of an intubated
intensive care unit patient with fever and leukocytosis should make
you think of possible Pseudomonas aeruginosa infection
ttt
Fourth generationcephalosporins (i.e .. cefepime)
aztreonam.
ciprofloxacin.
imipenem/cilastatin.
tobramycin.
gentamicin.
amikacin.
Piperacillin-tazobactam

osteomyelitis
Although Staphylococcus aureus is the most common cause of
osteomyelitis in children and adults.
Pseudomonas aeruginosa is a frequent cause of osteomyelitis in
adults with a history of a nail puncture wound (especially when the
puncture occurs through rubber-soled footwear).
Hematogenous spread is the most likely pathogenic mechanism of
hematogenous osteomyelitis, which is typically observed in children.
Direct inoculation of pathogenic bacteria during trauma may be
responsible for post-traumatic osteomyelitis

In diabetic patients, the pathogenic mechanism of osteomyelitis

adjacent to a foot ulcer is contiguous spread of infection.

Leprosy
Leprosy is a chronic granulomatous disease that primarily affects
the peripheral nerves and skin.
It is caused by Mycobacterium leprae.
In the early part of the disorder.
it may present as an insensate. Hypopigmented plaque.
Progressive peripheral nerve damage results in muscle atrophy. with
consequent crippling deformities of the hands.
The most common affected sites are the face. ears. wrists.
buttocks. knees. And eyebrows.
Diagnosis is made by demonstration of acid-fast bacilli on skin biopsy

early syphilis
Dark field microscopy is especially useful in diagnosing primary
syphilis, and visualization of the spirochetes confirms the diagnosis.
This patient's syphilis infection suggests that he may be involved in
high-risk sexual activity, also putting him at risk for HIV exposure.
After proper counseling, HIV screening using ELISA should be
offered.
The drug of choice for early syphilis is benzathine penicillin G. and a
single IM dose is sufficient.
For those patients who are allergic to penicillin.
doxycycline or tetracycline can be given for 14 days.
A single dose of oral azithromycin can also be used. but resistance
to azithromycin has been reported.

Secondary syphilis
Secondary syphilis requires a high index of suspicion for a clinical
diagnosis.
Initial testing is with a non treponema! test (e.g .. RPR or VDRL). with
positive results confirmed with a specific treponema test (e.g ..
FTA-ABS test).
Treatment involves 3 doses of benzathine penicillin. each given
weekly.
Patients occasionally develop the Jarisch-Herxheimer reaction
(acute febrile reaction with headaches and myalgias) in the first 24
hours of therapy.
Alternative regimens include doxycycline or azithromycin in
penicillin-allergic patients
Some superficial scaling can be present in secondary syphilis. which
can be confused for psoriasis.
Psoriasis usually involves the elbows and knees and is not associated
with systemic symptoms and lymphadenopathy

hereditary hemochromatosis.
Patients with hemochromatosis and cirrhosis are at increased risk of
infection with Listeria monocytogenes.
Possible explanations include increased bacterial virulence in the
presence of high serum iron and impaired phagocytosis due to iron
overload in reticuloendothelial cells.
Iron overload is also a risk factor for infection with Yersinia
enferocolifica and septicemia from Vibrio vulnificus, both of which
are iron-loving bacteria

Intermittent catheterization
Intermittent catheterization is associated with a significantly lower
risk of urinary tract infections (UTI) as compared to the use of
indwelling catheters in patients with spinal cord injuries.
Although each passage of the catheter can introduce bacteria into
the bladder, indwelling catheters carry a greater risk of infection.
This is due to the ability of bacteria to form a biofilm along the
catheter wall that can reach the bladder within 24 hours of
insertion.
Generally, the longer the catheterization, the greater the risk of
bacteriuria.
Application of antibacterial creams to the urethral meatus or
antibacterial washes of external genitalia are not helpful in
decreasing the incidence of bacteriuria or the risk of UTI.

infective endocarditis
Staphylococcus aureus is the major cause of acute infective
endocarditis in IV drug abusers.
Injection drug users are prone to get tricuspid endocarditis caused
by S. aureus. Fragments of the vegetation can embolize to the lungs,
causing the characteristic nodular infiltrate with cavitation.
Staphylococcus epidermidis is the most frequent cause of
infective endocarditis in patients with prosthetic valves.
Staphylococcus saprophytic usually causes urinary tract
infections in young woman.
Enterococcus is an important but less frequent cause of
infective endocarditis.
Streptococcus bovis endocarditis is associated with colorectal
cancer. Colonoscopy should be pursued For further evaluation

 Viridans group streptococci are a frequent cause of subacute

bacterial endocarditis (SBE) in patients with preexisting
valvular disease.
Viridans group streptococci (most commonly S. mulans) are the
most common cause of endocarditis following dental
procedures
Four members of the viridans group cause IE: Streptococcus mitis,
S. sanguis, S. mulans, and S. salivarius.
S. mulans also causes dental caries.
Mitral regurgitation is the most common valvular abnormality
observed in patients with infective endocarditis not related to IV
drug abuse
Whenever an infective endocarditis is suspected empiric antibiotics
should be administered after drawing the blood for culture
Vancomycin is the initial empiric antibiotic of choice
Gentamycin is often added to regimens for endocarditis because of
its synergistic effect.

Actinomycosis
Actinomycosis is an infection caused by Actinomyces israelii.
These anaerobic. Gram-positive. Branching bacteria can present with
an infection in the cervicofacial. thoracic. or abdominal region.
The infected area usually begins to drain fluid containing sulfur
granules. which appear yellow.
The treatment is high-dose penicillin for 6-12 weeks
Hyperbaric oxygenation is not used to treat actinomycosis.
Hyperbaric oxygen (HBO) therapy is generally used to treat the
"bends" from deep sea diving, carbon monoxide poisoning , slowhealing ulcers.

Lyme
The risk of developing a tick-borne disease is low if the tick is
attached for <24 hours.
The technique recommended by the Centers for Disease Control and
Prevention is to grasp the tick with tweezers as close to the skin as
possible and then remove the tick using steady upward pressure.
Some studies suggest that mouthparts that break off and remain in
the skin can be left alone because the infective body of the tick is
no longer attached.

Crushing, twisting, or puncturing the tick may increase the risk of

infection by releasing infectious fluids from its body into the skin
and is therefore discouraged.

erythema migrans (EM)

EM is pathognomonic for Lyme disease.
It is the only manifestation that allows for clinical diagnosis without
laboratory confirmation.
Blood cultures for B burgdorferi are not available in most clinical
laboratories and are not recommended.
Doxycycline is an excellent treatment option for most patients as it
has the advantage of simultaneously preventing or treating

coexisting human granulocytic anaplasmosis, an infection also carried

by I. scapularis.
However. doxycycline is contraindicated in young children as well as
pregnant and lactating women because it can cause permanent
discoloration of teeth and retardation of skeletal development in
exposed children and fetuses
Oral amoxicillin is the treatment of choice in pregnant and lactating
women as well as children age <8 years.
The rash and constitutional symptoms should resolve within 3 weeks
of treatment.
Pregnant patients should be reassured that Lyme disease is not
known to cause congenital anomalies or fetal demise.

Malaria
Malaria is a protozoal disease caused by genus plasmodium. which is a
RBC parasite and is transmitted by the bite of infected Anopheles
mosquitoes.
It is the most important parasitic disease and is endemic in most of
the developing countries of Asia and Africa.
Four species of Plasmodium. viz. P. falciparum. P. vivax. P.ovale. and
P. malariae can cause malaria.
Most of the deaths are due to falciparum malaria whereas
vivax and ovale are responsible for several relapses.
Cyclical fever is hallmark of malaria and it coincides with RBC lyses
by the parasites.
Fever occurs every 48 hours with P. vivax and P. ovale and
every 72 hours with P. malariae.
whereas periodicity is generally not seen with P. falciparum.
The typical episode consist of a cold phase characterized by chills
and shivering.
followed by a hot phase characterized by high grade fever. followed
2-6 hours later by a sweating stage characterized by diaphoresis

and resolution of fever. Nausea. vomiting. headache. anorexia.

malaise and myalgia are commonly seen.
In people from endemic areas. anemia and splenomegaly are common
findings.
Vitals would show hypotension and tachycardia.
All travelers to malarious regions should be prescribed antimicrobial
prophylaxis.
Chloroquine-resistant Plasmodium falciparum is particularly
common in Sub-Saharan Africa and the Indian subcontinent
(e.g .. India. pakistan. and Bangladesh).
It is not common in the US.
Mefloquine is the drug of choice for chemoprophylaxis against
chloroquine-resistant malaria.
To be effective. prophylaxis should be started one week before
travel and continued until four weeks after departure from an
endemic area.
Chloroquine is the drug of choice for chemoprophylaxis in regions
with chloroquine-sensitive malaria.
while mefloquine is given in areas endemic for chloroquine-resistant
Plasmodium falciparum.
The use of primaquine (both for prophylaxis and treatment) is
indicated in settings where malaria is due to Plasmodium vivax or
Plasmodium ovale; these organisms cause persistent infection in the
liver.
Fansidar is not used for prophylaxis of malaria because of the
serious side effects
(Stevens-Johnson syndrome and toxic epidermal necrolysis)
associated with it.

Babesiosis
Suspect babesiosis in any patient from an endemic area who
presents with a tick bite.
This illness is caused by the parasite Babesia and is transmitted by
the Ixodes tick. It is endemic in the northeastern United States.
Following a tick bite, the parasite enters the patient's RBCs and
causes hemolysis.
Clinical manifestations vary from asymptomatic infection to
hemolytic anemia associated with jaundice, hemoglobinuria, renal
failure, and death.
Unlike other tick-borne illnesses, rash is not a feature of babesiosis,
except in severe infection where thrombocytopenia may cause a
secondary petechial or purpuric rash.
Clinically significant illness usually occurs in persons over age 40,
patients without a spleen, or immunocompromised individuals.
Definitive diagnosis can be made from a Giemsa-stained thick and
thin blood smear.
Laboratory studies may demonstrate intravascular hemolysis,
anemia, thrombocytopenia, mild leukopenia, atypical lymphocytosis,
elevated ESR, abnormal liver function tests, and decreased serum
complement levels.
The two most widely used drug regimens are quinine-clindamycin and
atovaquone-azithromycin (QC/AA)

Ehrlichiosis, or "spotless Rocky Mountain spotted fever,"

Ehrlichiosis is a category of tick-borne illness that is caused by one
of three different species of Gram-negative bacteria, each with a
different tick vector.
It is endemic in the southeastern, south-central, mid-Atlantic, and
upper Midwest regions of the US, as well as California.
It usually occurs in the spring or summer.
The incubation period varies from one to three weeks.
Clinical features include fever, malaise, myalgias, headache, nausea,
and vomiting.
There is usually no rash; hence, its description as the "spotless
Rocky Mountain spotted fever."
Labs often show leukopenia and/or thrombocytopenia, along with
elevated aminotransferases.
Whenever ehrlichiosis is suspected, treatment should be started
without delay
the drug of choice is doxycycline.

Q fever
Q fever is a zoonosis caused by Coxiella burnefii.
The main sources of human infection are infected cattle, goat, and
sheep.
People at risk include meat processing workers and veterinarians.
Infection due to C. burnefii occurs in most areas of the world.
Manifestations of Q fever may include a flu-like syndrome,
hepatitis, or pneumonia.
TTT:DOXYCYCLINE

Cysticercosis
Cysticercosis is a parasitic disease caused by the larval stage of the
pork tapeworm Taenia solium.
Pig farmers are at high risk for neurocysticercosis
It is contracted when a person consumes T. solium eggs excreted by
another person.
Humans are the only definitive host for T. solium. meaning that only
humans can become infected with the adult tape worm.
The adult tape worm lives in the upper jejunum and excretes its eggs
into the persons feces (intestinal infection).
If an animal consumes these eggs. it becomes an intermediate host.
with larvae encysting in its tissues.
The most common intermediate host is a pig.
Then. when humans consume larvae in meat such as infected.
undercooked pork. they can once again develop intestinal infection
with the adult tapeworm.

However. if a person (rather than a pig) consumes the T. solium eggs

excreted in human feces.
Cysticercosis results After ingestion.
the embryos are released in the intestine and the larvae invade the
intestinal wall.
They disseminate hematogenously to encyst in the human brain.
skeletal muscle. subcutaneous tissue. or eye. (Note that
cysticercosis is not contracted by eating infected pork. so people
who do not eat pork can still be affected.)
The most common manifestations of cysticercosis are neurologic.
Neurocysticercosis (NCC) is characterized by multiple. small
(usually < 1 cm). fluid-filled cysts in the brain parenchyma.
These cysticerci have a membranous wall and often demonstrate a
characteristic invaginated scolex on neuroimaging.

Interestingly. NCC is the most common parasitic infection of the

brain. and is most prevalent in the rural areas of Latin America. subSaharan Africa. China. southern and Southeast Asia. and Eastern
Europe.
particularly where pigs are raised and sanitary conditions are poor.
Humans with cysticerci are deadend hosts.
Eighty percent of neurocysticercal infections are asymptomatic. and
are accidentally found on brain autopsy.

Hydatid cysts
Echinococcosis is a parasitic disease caused by tapeworm
echinococcus.
Four species of Echinococcus can produce infection in humans.
the two most common being E. granulosus. causing cystic
echinococcosis. and E. multilocularis. causing alveolar echinococcosis.
The majority of human infections are due to sheep strain of E.
granulosus.
for which dogs and other canids are the definitive hosts and sheep
are the intermediate hosts; humans are the dead- end accidental
intermediate host.
It is most commonly seen in areas where sheep are raised (sheep
breeders are thus at high risk) and transmission is seen when dogs
living in close proximity of humans are fed the viscera of homeslaughtered animals.
The infectious eggs excreted by dogs in the feces are passed on to
other animals and humans.
After ingestion of eggs by humans. the oncospheres are hatched
and they penetrate the bowel wall disseminating hematogenously to
various visceral organs. leading to formation of hydatid cysts.
The liver. followed by the lung. is the most common viscus involved;
however. any viscera can be involved.

Hydatid cyst is a fluid-filled cyst with an inner germinal layer and

an outer acellular laminated membrane. Germinal layer gives rise to
numerous secondary daughter cysts.

trichinosis
(also known as trichinellosis). a parasitic infection caused by the
round worm Trichinella.
It is acquired by eating undercooked pork that contains encysted
Trichinella larvae.
The disease occurs in three phases.
The initial phase occurs in the first week of infection when the
larvae invade the intestinal wall.
This phase manifests as abdominal pain. nausea. vomiting. and
diarrhea.
The second phase begins in the second week of infection.
It reflects a local and systemic hypersensitivity reaction caused by
larval migration. with features such as "splinter" hemorrhages.
conjunctival and retinal hemorrhages. periorbital edema. and
chemosis.
As the larvae enter the patient's skeletal muscle during the third
phase. muscle pain. tenderness. swelling. and weakness occur.
Blood count usually shows eosinophilia.

Ascariasis
Ascariasis can also present with intestinal symptoms and
eosinophilia. but the triad of periorbital edema. myositis. and
eosinophilia is most suggestive of trichinellosis.
Ascariasis more often presents as a lung phase with non-productive
cough followed by an asymptomatic intestinal phase.
Symptoms of ascariasis often result from obstruction caused by the
organisms themselves. such as small bowel or biliary obstruction.

E histolytica
E histolytica is a parasite that cause bloody diarrhea. but it can
usually be diagnosed by visualization of trophozoites on stool
examination.
Colonoscopy shows the presence of 'flask-shaped' colonic ulcers.
Inclusion bodies are not seen.

Cutaneous larva migrans

Cutaneous larva migrans, or creeping eruption, is a helminthic disease
caused by the infective-stage larvae of Ancylostoma braziliense,
the dog and cat hookworm.
Infection occurs after skin contact with soil contaminated with dog
or cat feces containing the infective larvae.
This disease is prevalent in tropical and subtropical regions, including
the southeastern United States.
People involved in activities on sandy beaches or in sandboxes are
particularly at risk.
Initially, multiple pruritic, erythematous papules develop at the site
of larval entry, followed by severely pruritic, elevated, serpiginous,
reddish brown lesions on the skin, which elongate at the rate of
several millimeters per day as the larvae migrate in the epidermis.
It is most commonly seen in the lower extremities, but the upper
extremities can also be involved.

Cat scratch disease

Cat-scratch disease is caused by Bartonella henselae.
The condition may be transmitted by a cat scratch, cat bite, or flea
bite.
It is commonly seen in young, immunocompetent individuals.

Cat scratch disease typically presents as a localized cutaneous and

lymph node disorder near the site of the inoculum, with very rare
involvement of the liver, spleen, eye, or central nervous system.
A local skin lesion evolves through vesicular, erythematous, and
papular phases, but can be pustular or nodular.
The hallmark of cat scratch disease is localized, regional
lymphadenopathy, which is tender and may be suppurative.
The diagnosis is clinical, although a positive B. henselae antibody
test or a tissue specimen demonstrating a positive Warthin-Starry
stain supports the diagnosis.
A short course of antibiotics is recommended.
Five days of azithromycin has been found to be particularly
effective.
NBs:
Prednisone is used to treat aphthous ulcers
Polyvalent pneumococcal vaccine is recommended in all children
and adults with HIV infection and a CD4 count above 200
cells/microL.
Tuberculosis can also cause a draining infection in this region.
which is called scrofula; therefore. an acid-fast stain must be
done to rule out TB.
Combination therapy with intravenous ceftriaxone and
vancomycin is the empiric treatment for bacterial meningitis.
Drug eruptions can present as morbilliform. urticarial.
papulosquamous. pustular. and/or bullous lesions.
Most drug eruptions are not associated with sore throat and
lymphadenopathy.

 The patients with uncomplicated pyelonephritis can be usually

switched to an oral antibiotic after 48-72 hours of parenteral
therapy
The commercial sex worker is at high risk for perihepatitis
from gonorrhea and numerous other
sexually-transmitted diseases
Streptococcus pneumoniae is the most common pathogen
causing pneumonia in nursing home patients
only S. aureus is known to cause post-viral URI necrotizing
pulmonary bronchopneumonia with multiple nodular infiltrates
that can cavitate to cause small abscesses
Because patients with PID are at increased risk for other
STDs, most physicians advise that HIV, RPR, pap smear and
hepatitis B surface antigen testing also be performed (with the
patient's consent).
When there is a history of IV drug abuse, hepatitis C serology
should also be obtained.
A clenched fist injury is a bite wound to the hand incurred
when a person's fist strikes an opponent's teeth (also known as
a "fight bite").
Amoxicillin-clavulanate is the antibiotic of choice for
prophylaxis and treatment of infections caused by a human
bite.
These infections are usually polymicrobial, and thus coverage
for Gram positives, Gram negatives, and anaerobes should be
provided.

 Clavulanic acid is a beta-lactamase inhibitor and is helpful

against beta-lactamase-producing anaerobes
Brown recluse spider bites are characterized by a papule with
erythema at the site of the bite followed by severe ulceration.
Condylomata acuminata ( anogenital warts) are caused by the
human papilloma virus. The characteristic lesions are
verrucous, papilliform, and either skin-colored or pink.
This is in contrast to the lesions of condyloma lata, which are
flat or velvety.
There are three treatment options for condyloma acuminata:
o 1 . Chemical or physical agents (e.g., trichloroacetic acid,
5-florouracil epinephrine gel, and podophyllin)
o 2. Immune therapy (e.g., imiquimod, interferon alpha)
o 3. Surgery (e.g., cryosurgery, excisional procedures, laser
treatment)
The choice of treatment depends upon the number and extent
of lesions.
Podophyllin is a topical antimitotic agent that leads to cell
death.
It is teratogenic and thus contraindicated in pregnancy.
Its other adverse effects include local irritation and
ulceration.

Proteus species produce urease. which makes the urine

alkaline. This infection is particularly common in patients who
live in long-term care facilities and have chronic indwelling
catheters.
Candida, Pseudomonas. and Klebsiella infections are also
common in patients with chronic indwelling catheters but they
do not produce alkaline urine.

 E. coli is the most common cause of UTis. but it does not

produce urease and thus does not alter the normal acidic pH of
urine.