Pneumonia
Types
1. CAP
a. Within community or first 72hrs of hospitalization
b. Can be typical or atypical
c. MCstrep pneumoniae
2. Nosocomial pneumonia
a. Occurs during hospitalization after first 72hrs
b. MCGram rods (E coli, pseudomonas) and S. aureus
Prevention
1. Influenza vaccinegive to ppl at risk; healthcare workers
2. Pneumococcal vaccinefor pts > 65yo and those at risk (heart disease, cochlear
implants, SCD, pulm disease, DM, asplenic)
Typical CAP
1. Common agents
a. S. pneumoniae (60%)
b. H. influenzae
c. Aerobic gram rods (Klebsiella, enterobacteriaceae)
d. S. aureus
2. Features
a. Sx
i. Acute onset of fever, chills
ii. Productive coughthick, purulent sputum
iii. Pleuritic chest pain (suggests pleural effusion)
iv. Dyspnea
b. Signs
i. Tachycardia, tachypnea
ii. inspiratory crackles, bronchial breath sounds, tactile/vocal fremitus,
dullness on percussion
iii. pleural friction rub
c. CXR
i. Lobar consolidation
Atypical CAP
1. Common agents
a. Mycoplasma (MC)
b. Chlamydia pneumonia or psittici
c. Coxiella burnetii (Q fever)
d. Legionella
e. Viruses: influenza (A, B) adenovirus, RSV
2. Features
a. Sxs
i. Insidious onset
ii.
iii.
b. Signs
i.
ii.
c. CXR
i.
ii.
Dry cough
Fever (usually without chills)
Pulse-temp dissociation: nl pulse but high temp
Whhezing, rhonchi, crackles
Diffuse reticulonodular infiltrates
Absent or minimal consolidation
3. Dx
a. CXR
i. After tx, CXR improvement shows after a few wks
b. Pretx sputum for Gram stain and cultureto determine Abx resistance
c. Special stains if suspect:
i. Acid-fast stainTB
ii. Silver stainfungi, P. carnii (immunosuppressed)
d. Ur Ag is suspect legionella
i. Ag persist in urine for wks (even after tx started)
Tx of CAP
1. May need to hospitalize if mod-high severity
2. Abx
a. < 60 yo
i. macrolides (azithromycin or clarithromycin)
ii. or doxy
iii. or quinolones
b. > 60 yo or if comorbidities or if tx with Abx in last 3 mo
i. quinolone
ii. or 2G or 3G cephalosporin
c. hospitalized
i. quinolone
ii. or macrolide + 3G cephalosporin
Tx of hospital acquired pneumonia
1. 3G cephalosporin
2. or carbapenam
3. piperacillin/tazobactam
4. no macrolides
complications
1. pleural effusion
2. pleural empyema (rare)
3. acute resp failure
TB
1. Ppl with primary TB are noncontagious
MOA
1. Primary TBinhale bacilli, Mo ingest them, granuloma formation
2. Secondary TB (reactivation)hosts immunity is weakened
a. Apical/posterior lungs
3. Extrapulm TB
Features
1. Primary TB
a. Asymptomatic
b. If incomplete immune response, then pulm and constitutional sxs may develop
progressive primary TB
2. Secondary TB
a. Constitutional sxs (night sweats)
b. Dry cough purulent hemoptysis (if really adv)
c. Apical rales
Dx
1. CXR
a. Upper lobe infiltrates with cavitations
b. Possible
i. pleural effusion
ii. Ghon complex, Ranke complex: shows healed primary TB
2. Sputum studies
a. Culturetakes 4-8wks
b. PCR rapid
c. Acid fast bacillishows mycobacteria
3. PPD test
a. Test for primary TB
Tx
1. Active TB
a. Maintain in isolation until sputum is negative for AFB
b. 2 mo of RIPE, then 4 mo of RI
2. ptx for latent TB
a. INH for 9 mo
Influenza
1. Fever, chills, malaise, headache, nonproductive cough, sore throat
2. Supportive tx mainly
3. NA inhibitor (zanamivir or oseltamavir) given if severe disease/high risk of
complications and within first 48hr
Tx
1. Bacterial meningitis
a. Empiric Abxstart immediately after LP is performed (if CT scan must be
performed/ there are delays in performing LP, then can give Abx firstagent can
still be identified from CSF)
b. IV Abx
c. Steroidsif cerebral edema
d. Vaccination
i. Adults > 65 yo for S. pneumoniae
ii. Asplenic pts for S. pneumoniae, N. meningitidis, H. influenzae
iii. Immunocompromised pts for meningococcus
e. Ptx (rifampin or ceftriaxone) for close contact of pts with meningococcus
2. Aseptic meningitis
a. Supportive
b. Analgesics for fever reduction
Encephalitis
1. Inflammation of brain parenchyma; may be seen simultaneously with meningitis
Cause
1. Virus
2. Bparenterally or sexually
3. Drequires the outer envelope of hepB sAg for replication
a. Co-infection with HBV
b. Or superinfection in chronic HBV carrier
4. Cparenterally
5. B,C,Dcan progress to chronic
Features
1. Classification
a. Acute (<6mo)
b. Chronic (>6mo)
2. Jaundice
3. Dark-colored urineconjugated hyperbilirubinemia
4. RUQ pain
5. N/V
6. HM
Complications
1. Hepatic encephalopathyasterixis, palmar erythema
2. Hepatorenal syndrome
3. Bleeding diathesis
Dx
1. PCR
2. LFTs
3. Ags, Abs
a. Aanti-HAV Ab
b. B
i. HBsAg
ii. HBeAg
iii. Anti-HBs Ab
iv. Anti-HBc Abimportant during window period (sAg is disappearing and
sAb not yet seen)
v. Viral PCR
c. Canti-HCV Ab, viral PCR
d. Danti-HDV Ab
Tx
1. A, E: supportive
2. Chr BIFN-alpha or lamivudine
3. Chr CIFN-alpha or ribavirin
Botulism
1. Ingestion of preformed toxins by spores of C. botulinum. (inactivated toxins by cooking
at high T), wound contamination
Features
1. N/V, diarrhea
2. Symmetric, descending flaccid paralysis; starts w/ dry mouth, diplopia, dysarthria
Dx
Intra-abd abscess
1. CausesSBP, pelvic infxn, pancreatitis, perforation of GI tract, osteomyelitis of vertebral
bodies with secondary extension
2. DxCT or US
3. Txdrainage, broad spectrum Abx
b. UTI criteria
i. Bacteriuria: >1 organism per oil-immersion field. Bacteruria without
WBCs may reflect contamination.
ii. Pyuria: > 10 leukocytes/uL is abnl
3. Urine gram stain
4. Urine cultureneeded if sxs are not typical of UTI, if complicated infxn suspected,
persistent sxs despite tx
5. Blood cultures
Complications
1. Complicated UTI
a. Any UTI that spreads beyond the bladder
b. Any UTI caused by structural abnl, metabolic disorder, neurologic dysfxn
2. UTI during pregnancyrisk for preterm labor, low birth weight
3. Recurrent infxns
Tx
1. Acute uncomplicated cystitis
a. Oral TMP/SMX (3d)
b. Nitrofurantoin (7d)CI if pyelonephritis suspected
c. Fosfomycin (one dose)CI if pyelonephritis suspected
d. quinolones, Cipro (3d)
e. phenazopyridineurinary analgesic
2. pregnant women with UTI
a. ampicillin, amoxicillin, oral cephalosporin for 10d
b. avoid quinolones (can cause fetal arthropathy)
3. UTIs is men
a. Tx as uncomplicated UTI but for 7d
4. Recurrent infxns
a. If relapse occurs within 2wks of cessation of tx, continue tx for 2 more wks +
obtain urine culture
b. If pt has 2+ UTIs/yr, then ptx
i. Single dose of TMP/SMX after sex or at first sign of sxs
ii. Low dose TMP/SMX for 6 mo
Pyelonephritis
1. Infxn of upper tract
Features
1. Fevers, chills, flank pain
2. Possible sxs of cystitis
3. Possible sxs of N/V/diarrhea
4. CVA tenderness
5. Possible abd tenderness
Dx
1. UA
a. Pyuria, bacteriuria, leukocyte casts
b. Possible hematuria, proteinuria (cystitis also shows this)
2.
3.
4.
5.
6.
Tx
1. Uncomplicated pyelonephritis
a. Oral Abx if pt can take oral rx
i. Gram - : TMP/SMX or quinolone for 14d
ii. Gram + cocci : amoxicillin
iii. Single dose of ceftriaxone or gentamicin is given initially before starting
oral tx
b. Repeat urine cultures 2-4d after cessation of rx
2. If pt is ill, elderly, pregnant, unable to take oral rx
a. Hospitalize and give IV fluids
b. Abx
i. Broad spectrum (initially): IV ampicillin + gentamicin/Cipro
ii. If blood cultures are -, tx with IV Abx untile afebrile for 24hrs; then give
oral Abx for 14d
iii. If blood cultures are +, tx with IV Abx for 2-3 wks
Prostatitis
MOA
1. Ascending infxn from urethra
2. May occur after urinary cath
3. Otherdirect or lymphatic spread from rectum
4. Hematogenous spread (rare)
Features
1. Acute prostatitis
a. Fever, chillspts may appear toxic
b. Irritative voiding sxsdysuria, frequency, urgency
c. Perineal pain, low back pain, Ur retention
2. Chronic prostatitis
a. Aymptomatic. Do not appear ill. Fever uncommon
b. Recurrent UTIs with irritative voiding/obs urinary sxs
c. Dull, poorly localized pain in lower back, perineal, scrotal, suprapubic region
Dx
1. DRE
a. Acute: boggy, tender prostate
b. Chronic: enlarged, nontender prostate
2. UAnumerous WBCs present in acute bacterial prostatitis
3. Urine culturesalways positive in acute prostatitis
4. Chronic prostatitispresence of WBCs in expressed prostatic secretions suggests dx;
Urine cultures + in chr bacterial prostatitis vs in nonbacterial prostatitis.
5. Obtain CBC, blood cultures if pt appears toxic or suspected sepsis
Tx
1. Acute prostatitis
a. If severe and pt appears toxic, then hospitalize + IV Abx
b. If mild, then oral Abx for 4-6 wks
i. TMP/SMX or quinolone + doxy
2. Chr prostatitis
a. Quinolone
STIs
Genital warts
1. Caused by HPV
2. MC STD
Chlamydia
1. MC bacterial STD; Chlamydia trochomatis
2. Intracellular organism
3. Likely co-infected with gonorrhea
Features
1. Asymptomatic
2. Symptomatic
a. Mendysuria, purulent urethral d/c, scrotal pain/swelling, fever
b. Womenpurulent urethral d/c, intermenstrual/postcoital bleeding, dysuria
Dx
1. No serologic tests
2. Culture, PCR
Tx
1. Azithromycin (oral 1 dose) or doxy (oral for 7d)
2. Tx sexual partners
Gonorrhea
1. N. gonorrheae (gram -, intracellular diplococci)
2. Likely co-infxn with chlamydia
Features
1. Men
a. Asymptomatic
b. dysuria, purulent urethral d/c, scrotal pain/swelling, fever
2. Women
a. Mostly asymptomatic
b. purulent urethral d/c, intermenstrual/postcoital bleeding, dysuria
3. disseminated gonococcal infxn
a. fever, arthralgias, tenosynovitis (of hands/feet)
b. migratory polyarthritis/septic arthritis, endocarditis, meningitis
c. skin rash
Dx
1.
2.
3.
4.
tx
1. ceftriazone (IM); also effective against syphilis
2. if disseminated, hospitalize + ceftriazone (IV or IM for 7d)
HIV/AIDS
Features
1. primary infxn
a. mono-like syndrome 2-4 wks after HIV exposure
2. asymptomatic infxn (seropositive but no clinical sxs)
a. CD4 count nl (>500)
b. Longest phase
3. Symptomatic HIV infxn (pre-AIDS)
a. Persistent generalized LAN
b. Localized fungal infxns
c. Recalcitrant vaginal yeast and trichomonal infxns in women
d. Oral hairy leukoplakia
e. Skinseborrheic dermatitis, psoriasis exacerbations, molluscum, warts
f. Constitutional sxs
4. AIDS
a. CD4 < 200 cells/mm3
b. Or AIDS-defining illness
Dx
1. PCR RNA viral load test
2. P24 Ag
3. Seroconversion (3-7wks after infxn)
a. ELISAhigh sensitivity
b. WB, if positive ELISA
Tx
1. HAART: 2 NRTIs + 1 other (NNRTI or protease inhibitor)
a. Continue HAART during pregnancy
b. Monitor HIV viral load
2. OIs
a. PCP
i. CD4 < 200
ii. Sxsdyspnea, dry cough, fever
iii. Tests: CXR (bilateral infiltrates), LDL (high), ABG (hypoxia or increased
A-a gradient), sputum stain, BAL
iv. TxTMP/SMX (or dapsone/pentamidine/atovaquone)
b. Toxoplasmosis
i. CD4<100
ii. TxTMP/SMX (dapsone + pyrimethamine + leucovorin)
c. Mycobacterium avian complex
i. CD4<50? Or 100?
ii. Txazithromycin or clarithromycin (or rifabutin, which promotes Cyp
metabolism of ARTs)
d. TB
i. TxINH + pyridoxine (9mo)
3. Vaccines
a. No live vaccines
b. Influenzaq1yr
c. Pneumococcal polysaccharide vaccine (pneumovax)q5yr
d. HepB (if not Ab positive)
Herpes simplex
MOA
1. HSV replicates in dermis/epidermis travels via sensory nerves to DRG latent infxn
of DRG
Features
1. HSV-1
a. Primary infxn usually asymptomatic
b. If symptomaticsystemic sxs (fever, malaise), oral lesions
c. a/w Bells palsy
2. HSV-2
a. Primary infxn causes severe, prolonged sxs; recurrent episodes are milder, shorter
b. Painful genital vesicles or pustules, tender inguinal LAN, vaginal/urethral d/c
3. Disseminated HSV
Dx
1. Obtain tissue cx if wound, ulcer, or site of infxn
2. Obtain plain film, MRI if suspicion for deeper infxn
Tx
1. IV Penicillin or cephalosporin until signs improve. Then, oral Abx for 2wks
Erysipelas
1. Cellulitis confined to dermis and lympahtics
2. Well-demarcated, red, painful lesion
Tx
1. If uncomplicatedIM/oral penicillin or erythromycin
2. If complicated (sepsis, subQ spread, necrotizing fasciitis)tx as like cellulitis
Necrotizing fasciitis
1. MCstrep pyogenes, C perfringes
Features
1. Fever/pain out of proportion to appearance of skin
2. Thrombosis of microcirculation tissue necrosis, discoloration, crepitus, cutaneous
anesthesia
a. Different from DVTrestricted to posterior calf, Doppler US confirmatory
Tx
1. Surgical exploration, excision of tissue
2. Broad-spectrum Abx
Lymphadenitis
1. Inflammation of LN(s) caused by local skin or soft tissue bacterial infxn
Features
4. Plain films
a. By first 10 dperiosteal thickening or elevation
b. Lytic lesionsif advanced
5. Radionucleotide bone scansnonspecific (metastatic disease, trauma, overlying soft
tissue inflammation)
6. MRImost effective to dx, determine extent of disease
Tx
1. Blood cx
2. IV Abx for 4-6wks; Abx is agent dependent
Acute infectious arthritis
MOAagents enter joint via
1. Hematogenous spreadMC
2. Contiguous spread from another locus
3. Traumatic injury to joint
4. Iatrogenic
Acute bacterial
1. S. aureus
2. N. gonhorreae
3. Pseudomonas or Salmonellaif hx of SCD, immunodeficiency, IV drugs
Features
1. Joint swollen, warm, painful
2. Limited ROM
3. Constitutional sxs
Dx
1. Joint aspiration
a. WBC count with differential
b. Gram stain
c. Cultureaerobic, anaerobic
d. Crystal analysis
e. PCRif gonococcal suspected but negative stain/cx
2. Blood cx (usually negative in gonococcal)
3. High ESR, CRP
Tx
1. Abx STAT (start even when cx, other labs are pending)
2. Drainage of joint as long as effusion persists
Zoonoses and arthropod-borne diseases
Lyme disease
1. Caused by the spirochete Borrelia burgdorferi
2. Transmitted by ticksIxodidae scapularis
Features
1. Stage 1localized infxn
a. Erythema migransskin lesion at site of tick bite; large, painless, welldemarcated targetoid lesion
b. If multiple lesionshematogenous spread
2. Stage 2disseminated infxn
a. Spreads via blood, lymphatics
b. Intermittent flu-like sxs, headaches, neck stiffness, fever/chills, malaise, MSK
pain
c. may also develop
i. meningitis (Brudzinski, Kernig sign negative), encephalitis
ii. cranial neuritis (bilateral facial n. palsy)
iii. peripheral radiculoneuropathy (motor or sensory)
iv. cardiac sxs (AV block, pericarditis, carditis)
3. stage 3persistent infections
a. arthritisusually affects the large joints (knee)
b. chr CNS disease
c. acrodermatitis chronica atrophicans (rare)red/purple plaques/nodules on
extensor surfaces of legs
dx
1. clinical dx.
2. Labsconfirmatory
a. ELISA to detect serum IgM and IgG
b. WB to conform +/0 ELISA
Tx
1. Early, localized
a. If confined to the skin, 10d of Abx
b. If evidence of spread, 30d of Abx
i. doxy (CI in pregnant women, kids <8yo) or amoxicillin/cefuroxime (or
erythromycin)
2. if facial n palsy, arthritis, cardiac disease tx for 30-60d
a. if meningitis or CNS complications IV Abx for 30d
RMSF
1. caused by intracellular Rickettsia rickettsii
2. transmitted via tick bites
features
1. onset of sxs 1wk after tick bite
2. sudden onset of fever, chills, malaise, N/V, myalgias, photophobia, headache
3. papular rash appears 5d after fever; rash starts PERIPHERALLY CENTRALLY
a. papular maculopapular petechial
dx
1. clinical
2. labshigh LFTs, thrombocytopenia
tx
1. doxy; give IV if pt is vomiting
2. CNS manifestations or pregnant ptgive chloramphenicol
Malaria
Features
1. Fevers, chills, myalgias, headache, N/V, diarrhea
2. Fever pattern
a. P. falciparumfever constant
b. P. ovale, P. vivaxfever spikes q48 hr
c. P. malariaefever spikes q72 hr
Dx
1. Peripheral blood smear with Giemsa stain
Tx
1. Quinine + tetracycline (or atovaquone-proguanil + doxy)
2. Additionally, in P. vivax and P. ovale, relapses occur due to dormant hypnozoites in liver.
Add primaquine
3. Ptxmefloquine (has replaced chloroquine)
Rabies
Features
1. Incubation period of months
2. Sxs
a. Pain at site of bite
b. Prodromal sxssore throat, fatigue, headache, N/V
c. Encephalitisconfusion, combativeness, hyperactivity, fever, seizures
d. Hydrophobiainability to drink, laryngeal spasm with drinking, hypersalivation
e. Possible ascending paralysis
Dx
1. Virus or viral Ag in infected tissue or salive
2. Negri bodies (eosinophilic inclusion bodies found in cytoplasm of nerve cells containing
rabies virus)
3. PCR for virus
Tx
1. Clean wound
2. If known rabies exposure, do both:
a. Passive immunizationgive human rabies Ig in the wound + gluteal region
b. Active immunizationgive antirabies vaccine
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