ID

• IgA blocks viral attachment to mucosal survaces
• Pts with deficiency typically c/o atopic diseases such as asthma, rhinitis, and are Giardia-prone, they can't get rid of Giardia infection
• Do not give IgG immunoglobulin because of anaphylaxis risk due to possible traces of IgA in the immunoglobulin

• C2 is most common in N. American caucasians
• C2 deficiency is suspect if with early onset SLE
• Classical pathway messed up
• Recurrent sinopulmonary infections--encapsulated organisms

• Look for terminal complement deficiency
• Test with CH50 or CH100 to eval function of terminal complement (C5-C9)

• Due to lack of C1 inhibitor
• Present with localized angioedema or abdominal pain with extremity swelling
• Familial pattern

• Less hatn 500 granulocytes
• If with fever -- antibiotics ASAP after cultures done
• Monotherapy: Cefepime, Ceftazidime, imipenem, or meropenem
• Combo therapy: Amingoglycoside + antipseudomonal beta lactam (Ticar/Pip, ceftazidime, cefepime or imipenem/meropenem)
• NEVER ceftriaxone!

• Hypotension/cardiovascular compromise
• Suspected IV catheter-related infection
• Known colonization with MRSA or resistant pneumococcus
• Mucositis
• Recent quinolone prophylaxis

Add Caspofungin or liposomal amphotericin B

Usual post-op nosocomial pneumonias and infections (gram-)

Herpes reactivation

Protozoa (PCP, toxo, Strongyloides), fungi, CMV, Mycobacterium, Listeria, Hepatitis B, Nocardia

Viruses (Varicella zoster, EBV, Hep C)

Cryptococcus neoformans

• "No TB, his cry blasted Coco strongly"
• Nocardia
• TB
• Histoplasmosis
• Cryptococcus
• Blastomycosis
• Coccidiodomycosis
• Strongyloides

• Stap aureus and epidermidis
• Strep pneumo (Pneumococcus)
• Strep pyogenes (Group A)
• Strep agalactiae (Group B)
• Enterococcus

• IV drug users
• Dialysis patients
• Toxic shock syndrome
• Thing of it in a pt with istory or pneumonia and recent influenza

• Strep usually grows in blood culture
• Staph will be high in differential if after surgery especially with prostheses

• Temp > 38.9 C (102 F)
• SBP < 90 mm Hg
• Rash with subsequent desquamation (palms/soles especially)
• Involvement of > 3 organ systems: GI, muscular, mucous membranes, renal, liver, blood, CNS
• Negative serology for RMSF, leptospirosis, measles
• Blood cultures likely positive in Strep, and negative in Staph

Outpt treatment for MRSA is with Clindamycin or Bactrim

• Staph epi is most common
• This is usually resistant to IV Nafcillin, so treat with IV Vancomycin, unless MSSE

• Type 3: most virulent -- associated with M protein (3M is bad)
• If "intermediate resistant" use 3rd generation cephalosporin
• If "highly resistant" to PCN, use 3rd generation cephalosporin or add Vanc to regimen
• If meningitis: Use Vanc (or RIF) + 3rd generation until sensitivities on pneumo are known

• pyogenes (A)
• --GAS, TSS, rheumatic fever, scarlet fever
• agalactiae (B)
• --very young, very old (Alcoholic/DM), wound infection in diabetic foot
• --Major cause of newborn pneumonia and meningitis
• --UTIs in pregnant women
• --Post-partum endometritis/bacteremia

• It is caused by the streptococcal bacteria, which produce a toxin that leads to the hallmark red rash of the illness.
• The rash usually first appears on the neck and chest, then spreads over the body. It is described as "sandpapery" in feel. The texture of the rash is more important than the appearance in confirming the diagnosis.
• The rash can last for more than a week. As the rash fades, peeling (desquamation) may occur around the fingertips, toes, and groin area.

• Rheumatic fever occurs only from pharyngeal strains of GAS
• Post-streptococcal glomerulonephritis can occur even with appropriate therapy
• Post-strep GN can occur from skin or pharyngeal strains
• Treatment of Strep pharyngitis with PCN prevents rheumatic fever

• Sepsis/infection after TURP
• --Tx: Amp/PCN or Vanc are only inhibitory.
• --Add aminoglycoside for synergy with serious infections
• Check Sensitivities for VRE !!!
• --Use daptomycin (Cubicin), quinupristin/dalfopristin (Synercid), or linezolid (Zyvox)

• Diminished cellular immunity syndromes
• --AIDS, lymphoma, leukemia
• --Neonates, elderly, pregnant who like goat cheese or hot dogs
• Tx: IV Amp or pcn +/- aminoglycoside for synergy in severe infections
• --Vanc or TMP/SMX for PCN-allergic pts

• diphtheriae -- causes diphtheria
• -URI
• -Gray-white pharyngeal membrane
• -Hoarseness, sore throat
• -Low-grade fever < 101 F !!
• -Myocarditis/polyneuritis
• -Tx: Erythro or PCN + Antitoxin

• jeikeium (JK) -- IV cathether infections BMT
• -Vanc drug of choice

• Corynebacterium diphtheria
• Tx: Erythro or PCN + Antittoxin

• B. anthracis
• -Cutaneous (95%) and pulmonic (5%)
• -Inoculation from handling hides, wool
• -Painless papule -- painless ulcer -- painless black eschar -- with nonpitting, induration/swelling
• -Tx: Pen G is sensitive (erhtyro/tetracycline)

• B. cereus
• -toxin strains produce GI effects
• -trauma to eye, IV catheters
• -Tx: Vanc (or clindamycin) for the trauma/cathether infection

• B. cereus
• Tx: Vanc ( or clindamycin)

• Not spread from person to person (unlike pneumonic plague and smallpox)
• Pneumonia -- widened mediastinum
• Skin lesions, as in ranchers, etc.
• Treatment:
• --Cipro until sensitivities known
• --PCN/Tetracycline also usually effective

• Wound is dirty and either:
• 1. < 3 immunizations, OR
• 2. Immunization history inknown
• --The give TIG + vaccine

• Wond is clean and
• --Immunozations are up to date (<10 years since last) then no treatment
• --Immunizations > 10 years, give Td (Tdap)

• Wound is dirty and
• --Immunizations are up to dare, with most recent < 5 years, then no treatment
• --Immunizations > 5 years, then give Td (Tdap)

Tdap = booster

• C. septicum
• C. bovis

Ceftriaxone

• Risk population: Humoral/complement deficiencies, College students
• Prophylaxis: All household contacts, daycare, "significant others," health care workers with intimate oral contact (intubate, mouth-mouth)
• Meds for prophylaxis: Rifampin, ciprofloxacin (type A), ceftriaxone (pregnant)
• Conjugate vaccine recommended for college freshmen living in dorms and all previously unvaccinated adolescents

• Nesseria meningitis vs. Rocky Mountain Spotted Fever
• -- if they give you geography, it is probably RMSF

PCN

• 2 Vaccines
• 1. Polysaccharide
• --Only for those > 2 years of age, and
• --High risk (functional/anatomic asplenia, terminal complement deficiencies)
• 2. Conjugated, MCV4
• (licensed only for those 11-55 years of age)
• --11-12 year visit, or entry to high school, or 15 years, whichever comes first
• --Students entering college who plan to live in dormitories
• --High risk individuals as above

• Respiratory infections --COPD and Immunodeficient
• Tx: Erythro, tetracycline, Bactrim, amox/clavulanate
• Beta-lactamase producers usually
• Gram-negative, aerobic, oxidase-positive diplococcus

• Nail puncture wound: througha a tennis shoe
• IV drug users: endocarditis/ osteomyelitis
• Diabetics: chronic otitis externa
• Echthyma gangrenosum: round, black, indurated lesion wiht central ulceration = Pseudomonal bacteremia
• Hot tub rash: due to Pseudomonas; self-limited

• Echthyma gangrenosus due to Pseudomonas
• --round, black, indurated lesion with central ulceration

• ETEC: Enterotoxigenic
• Watery diarrhea and "traveler's diarrhea."
• Tx: Bactrim is drug of choice

E. coli

• EHEC: Enterohemorrhagic or STEC (Shiga toxin producing E. coli)
• --O157:H7 induces hemolytic uremic syndrome

• Sources:
• Undercooked beef, unpasteurized mild, apple sause
• Sorbitol-enhanced agar
• Triad: renal faulre, thrombocytopenia with purpura, and hemolytic anemia
• No antibiotics

hearing loss

Azithromycin

• Cat scratch disease
• Caused by Bartonella henselae
• Classic sx in young adults
• Don't aspirate
• Serology is diagnostic
• Tx: none or azithromycin

• Bacillary angiomatosis
• Tx: erythromycin

• Brucella
• Yersinia (plague, enterocolitica)
• Francisella

• Caused by Yersinia pestis
• Pneumonia is biggest concern
• Will present in young people with hemorrhagic pneumonia, high fever
• Is contagious to others, unlike anthrax pneumonia

• a syndrome with Y. enteroclitica or Y. pseudotuberculosis
• Bacteremia in those with sickle cell disease (iron overload states)

• Tularemia
• Reservoirs: Rabbits, deer, ticks
• Mode: Tick bite, eating infected animals, inhalation, self-inoculation
• Ulcero-glandular disease
• Dx: Serology -- don't aspirate
• Tx: Streptomycin, gentamicin, tetracyclines

Y. enterocolitica or Y. psedotuberculosis

Y. enterocolitica has been diagnosed as the cause of bacteremia in sickle cell patients with iron overload

• Tularemia
• This is ulcer-glandular disease
• Found mainly in Arkansas, Missouri, Oklahoma
• Dx by serology -- don't aspirate!
• Tx: Streptomycin, gentamicin, tetracyclines

• 1. Tularemia
• 2. blastomycosis

• R. rickettsii -- RMSF
• Differential diagnosis is meningococcus
• Rash, fever, arthralgias
• Report of tick exposure
• Rash on distal palms, soles; rash maculo-papules to petechiae
• Hyponatremia differentiates this from meningococcus
• Dx: seology, IF staining on bx of petechial lesion
• Tx: Doxycycline, chloramphenicol
• Most cases in N. Carolina, S. Carolina, Georgia, Virginia, New Mexico

• 1. Ehrlichia chaffeensis
• 2. Anaplasma phagocytophila

• Ehrlichia chaffeensis
• Tick borne
• Southeast, South Central, Midwest
• Flu-like illness
• Pancytopenia
• Dx: Serology, morula on smear
• Tx: Doxycycline

• Anaplasma phagocytophila
• Human granulocytic ehrlichiosis
• Same disease but live in neutrophils, not macrophages
• Northeast, North Central, California

• Gram variable
• Tx: Metronidazole (Flagyl)
• Responsible for vaginosis
• Clue cells
• This is from a pt's pap smear

• Beaded, branching, filamentous, and weakly acid-fast
• Lung infection usually first -- cavity
• Progresses to brain abscess
• Tx: bactrim or high-dose sulfas
• --Minocycline
• --Amikacin + imipenem

• Cryptosporidium
• Self-limited in normal host
• Lasts 1-2 weeks
• Chronic in AIDS patients, may persist indefinitely
• Tx: Nitazoxanide or paromomycin +/- azithromycin
• Small and round (compared to Isospora belli which is big and oval

Isospora belli

• Gram-positive bacilli
• Anaerobic infection
• Sulfur granules = clusters of organisms
• Cervicofacial swelling from dental source
• Causes PID if IUD present
• Can cause (rare) chronic neutrophilic meningitis
• Tx: PCN/amp or tetracycline

• Chlamydia psittaci
• Q fever

• Pt with exposure to birds, esp. poultry
• Pneumonia + splenomegaly
• Myalgia, rigors, fever to 105

• Common in adolescents
• Community-acquired pneumonia
• Person-person spread (not birds)
• Wheezing prevalent
• Tx: e-mycin or tetracyclines

• Chancres develop at the site of inoculation, on average, 21 days after exposure
• Incubation period can range from 10-90 days
• Skin lesions are painless
• 20-30% will be RPR/VRDL negative at this stage

• Hematogenous dissemination of T. palladium
• Fever, malaise, generalized lymphadenopathy are often present
• Rash--macular, papular, annular, or follicular
• Alopecia, condylomata lata, mucous patches

• Syphilis
• This is a symptom of neurosyphilis

• VDRL or RPR for initial screen
• Confirm + test with either:
• --FTA-ABS or
• --MHA-TP
• Darkfield microscopy showing T. palladium from a clinical specimen

Meningovascular syphilis

Parenchymatous syphilis

• Early (primary, secondary, or latent <1 year): Pen G benzathine 2.4 million units IM X 1
• --doxycycline 100 mg PO bid X 14 days

• Late (> 1 year's duration, CV, gumma, late-latent): Pen G benzathine 2.4 million U IM q week X 3
• --doxycycline 100 mg PO bid X 4 weeks

Neurosyphilis: PCN G 2-4 million U IV q 4 X 10-14 days

• Contact with infected animals
• "Swimming with your dog," but may also be from rat feces or urine
• Mild to severe disease

• Biphasic:
• --Early disease: BC (+) (first week, then it's late after)
• --Late disease : Urine (+)
• Treatment: PCN or doxycycline

• Borrelia burgdorferi
• Transmitted by the Ixodes scapulars tick or Ixodes pacificus
• Think Martha's Vineyard or Connecticut, Wisconsin, California
• Dx: Erythema migrans is pathognomonic
• Don't do serology

• Early: Rash with fever, HA, lymph nodes
• Weeks to months later:
• --Meningitis and/or neuritis. Peripheral neuropathy or Bell's Palsy, or foot drop
• --Cardiac--> heart block
• --Arthritis

• Lyme disease
• The rash is erythema migraines. This rash is pathognomonic.
• No serology indicated.
• Treatment:
• --Early: Doxycycline (amoxicillin also) but doxy is 1st choice)
• --Meningitis or carditis: Ceftriaxone
• --Arthritis or isolated Bell's palsy: Doxycycline
• Treat for at least 2 weeks
• Prophylaxis for hikers/campers: not indicated

Candidiasis

• Terbinafine
• --for fingernails -- 250 mg daily by mouth for 6 weeks
• --for toenails -- 250 mg daily by mouth for 12 weeks

Clinical trials show terbinafine is superior to itraconazole and griseofulvin

prednisone and itraconazole

• Characteristic radiographic picture with the fungus ball changing position in an epithelial-lined cavity or in an air-fluid level
• Cavities are secondary to previous or concomitant tuberculosis, histoplasma, or bronchiectasis
• Hemoptysis -- sometimes life-threatening-- is the hallmark
• Tx: In cases complicated by severe hemoptysis, surgery may be required to remove the aspergilloma and stop the bleeding. Observation only if asymptomatic.

• Can be due to hyphen colonization of bronchopulmonary tree
• Inhalation associated with dyspnea, wheezing, cough, rales
• X-ray: diffuse nodular infiltrates
• Treatment is steroids + itraconazole
• Diagnosis: sputum exam or BAL maybe + but view with caution. Correlate with x-ray and clinical history. Conversely, in a severely immunocompromised pt, finding the hyphae in nasal mucous membranes could be very serious
• Most recommended histology or microscopy
• -- Galactomannan antigen detection is promising. Released during growth of hyphae
• Serology: + in 90% of aspergillomas and 70% of ABPA --- DO NOT USE in invasive disease diagnosis

• Acute pulmonary cryptococcosis in immune-competent: Not treatment
• Acute pulmonary cryptococcosis in immune-compromised: Ampho B +/- flucytosine for 1 month
• Meningitis: Ampho B 0.7 mg/kg/d for 2 weeks + flucytosine 100 mg/kg (levels needed) in 4 divided doses, followed by oral fluconazole for 6 weeks (levels needed)
• HIV pts need maintenance tx with fluconazole

• Dx: Culturing the organism
• Tx: Lymphocutaneous
• --SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
• --Treat 4 weeks after lesions healed
• --Itraconazole is better than SSKI

• Sporotrichosis
• SSKI five drops tid PO increased by 1 drop/day to total daily dose 120-150 drops/day
• --Treat 4 weeks after lesions healed
• --Itraconazole is better than SSKI

• Pseudallescheria boydii, like aspergillus but resistant to Ampho B
• Treat with miconazole

• Cat is definitive host
• Dx: Acute IgM antibody +
• 4 types:
• --Asymptomatic or mild symptoms: self-limited
• --Pregnancy-acquired: Congenital infection > later in pregnancy
• --CNS disease: Multiple lesions (MRI > CT)
• --Ocular toxo: Yellow-white cotton patches

• Acid-fast positive on smears
• Raspberries, basil seasoning, snow peas
• Tx: Bactrim

• Affects RBCs
• 4 types:
• - P. vivax
• - P. ovale
• - P. malariae
• - P. falciparum
• Big trouble in asplenic patients
• Asia and Africa have chloroquine resistance

• Most fatal of the 4 types
• Widespread chloroquine resistance
• Blood smear: Banana gametocyte
• -More than one infected RBC on slide
• -Multiple parasites in one RBC
• -Other forms: few parasites and hard to find
• -Schizonts NOT seen on smear --- if so, it is a non-falciparum form of malaria

• Treatment(oral):
• --Quinine sulfate + doxycycline X 7 days
• --Atovaquone/proganil (Malarone) X 3 days
• --Mefloquine (Lariam) X 2 doses

• Treatment (IV if too sick to take oral)
• --IV quinidine until pt can take oral

• If in chloroquine-sensitive area -- use chloroquine
• No steroids for cerebral malaria!

P. vivax

P. malariae

• P. vivax and ovale (VOdka goes into the liver)
• Give Primaquine to avoid relapse

P. vivax, ovale, malariae

• Mefloquine (or chloroquine if in sensitive area) 1/week for 1-2 weeks before arrival and continue 4 weeks after leaving area, or
• Doxycycline q day for 1 day before until 4 weeks after travel, or
• Atovaquone/proguanil (Malarone) q day 1 day before until 7 days after travel

• Primaquine given last 2 weeks of prophylaxis after travel to P. vivax or ovale area
• Pyrimethamine-sulfadoxine (Fansidar) associated with Stevens Johnson syndrome
• Primaquine induced hemolytic anemia in G-6-PD deficiency (SCREEN)

• Intra-RBC protozoan: Maltese cross pattern
• Febrile hemolytic anemia
• Ixodes tick from rodents, deer
• Nantucket in summer/fall
• Fever, sweats, myalgias, chills
• Hemoglobinuria: predominant sign
• Emotional lability is common
• Mild: Clindamycin + quinine or atovaqoune + Azithromycin
• Severe: Exchange transfusion, then antibiotics

• Entamoeba histolytica
• Mainly Texas, Mexico, Oklahoma
• Fecal-oral transmission
• Water and food sources
• Institutionalized, immigrants, gay men
• Liver aspirate: No ameba or WBCs; "anchovy paste"
• Diagnosis:
• -Diarrhea -- check stool antigen
• -Liver abscess: check serology; stool usually negative
• Treatment:
• Metronidazole or Tinidazole
• *Paromomycin or iodoquinol for intraluminal treatment is also given at the end of therapy for invasive disease

• Campers, travelers, children in daycare, gay, IgA deficiency, hypogammaglobulinemia
• Infects the duodenum but 75% asymptomatic
• Acute: watery, smelly diarrhea, flatulence
• Chronic: Flatulence, sulfurinc belching, soft stools
• Dx: Fresh stool O&P, Giardia-specific antigen on stool, string test
• Treatment: Metronidazole, tinidazole, albendazole, furazolidone

• African: Sleeping sickness
• --Trypanosoma brucei
• --Tsetse fly

• American: Chagas disease due to T. cruzi
• -Self limited usually but can affect:
• 1. Cardiac (heart block--CHF)
• 2. GI (achalasia, megaesophagus, megacolon)
• 3. CNS

Chagas disease

• Sand fly is the vector
• Cutaneous (L. major / L. tropica, military in Iraq)
• -Occurs on exposed areas of skin
• -Begins as a red papule that enlarges to form a PAINLESS ulcer with granulomatous tissue at the base and raised, heaped-up margins
• -No surrounding induration
• -Localized adenopathy can occur
• Visceral leishmaniasis = kala-azar
• -GI symptoms: Big liver and spleen

Treatment: Sodium stibogluconate (antimony), meglumine, or Amphotericin B

Leishmaniasis

• Treatment:
• Sodium stibogluconate (antimony)
• meglumine
• Amphotericin B - now the drug of choice

Cryptosporidium

Pinworm (Enterobius)

Hookworm (Necator)

• The only helminthic organism that replicates in the human body
• Persists for decades
• Think about this in old pt with neutropenia, now with abdominal pain and diarrhea
• Typical scenario: Veteran from WWII gets neutropenic from chemo, and becomes will with recurrent severe Strongyloides
• Treatment: Ivermectin or thiabendazole

• Clonorchis sinensis: Chinese Liver Fluke
• -Far East, raw fish, biliary obstruction
• Schistosoma haematobium: Bladder
• Schistosoma mansoni: Africa, Mid East, S. America
• S. japonicum: Asia

• Acute schistosomiasis: Katayama fever
• -2 months after inoculation
• -Fever, lymphadenopathy, diarrhea, eosinophilia, HSM
• -complications: cirrhosis/esophageal varices
• Dx: eggs in stool (or bladder -- S. haematobium)
• No stigmata of alcoholic cirrhosis
• Tx: Praziquantel is DOC for any schistosoma infection

• Stat ophthalmology consult. Start IV acyclovir stat

• Primary infection
• --Fever, HA, myalgias, and lymphadenopathy can occur with initial genital infection
• Clinical course shortened with acyclovir

• Treatment:
• Primary: Acyclovir 400 mg tid X 10 days
• Recurrent: Acyclovir 400 mg tid X 5 days
• Immunocompromised host: IV acyclovir 5-10 mg/kg q 8 h x 7 days
• Encephalitis: IV acyclovir 10 mg/kg q8h X 14-21 days
• If resistant HSV: Foscarnet recommended

• Most serious neonatal infections occur in infants whose mothers acquired asymptomatic primary infection with HSV-2 late in their pregnancy
• Women with active genital herpes at the end of pregnancy should have C-section

Give IV acyclovir

• Normal adolescent/adult, pregnant, pneumonia:
• -Acyclovir 800 mg PO 5X/day for 7 days
• ==> decreases new lesions, pain
• -Acyclovir 10 mg/kg IV q8h X 5 days
• ==> better healing, reduced postherpetic neuralgia from 119 days to 63 days compared to placebo
• -Valacyclovir 1000 mg 3x/day x 5 days
• ==> Reduces posherpetic neuralgia

Immunocompromised: 10 mg/kg IV q8h

Zoster vaccine (Zovirax) now approved for those > 60 years of age

Okay to go to work as long as they can cover the lesions

This is CMV and they need to see an ophthalmologist ASAP

EBV

HTLV-1

Cough, coryza, conjunctivitis

HHV-8

Rubella

• Mumps.
• Watch out for orchitis if occur after puberty

• Type A H1N1 is resistant to oseltamivir (Tamiflu-oral)
• Zanamivir (Relelenza - inhalation powder) is still effective for both A and B

• Any prior hx of PCP
• Adult, HIV-infected: CD4 < 200 or < 15%

• Use Bactrim DS 1 tab PO daily (preferred), or 3X per week.
• --If can't tolerate Bactrim, use Dapsone 100 mg once daily.
• --Check for G6PD deficiency if using dapsone
• -- Aerosolized pentamidine 300 mg via Respirgard II inhaler monthly

Test for G6PD deficiency

• Can discontinue PCP prophylaxis if:
• -On antiretroviral therapy, the pt has had a rise in CD4 cell cont to > 200 cells/uL for more than 3 months

Prophylaxis should be restarted if the CD4 cell count fall below 200 cells/uL or if PCP occurs while on anti-retroviral therapy at a CD4 cell count > 200 cells/uL

• 5 mm induration is considered a +PPD
• However, due to altered immune response, a neg. PPD never rules out infection

• Active disease: 4 drugs unless in MDR area
• --4 drugs (INH, RIF, PZA, ETH) for 8 weeks
• --then 2 drugs (INH/RIF) for 18 weeks

• Positive PPD only:
• --INH for 9 months or
• --RIF for 4 months (use this only in the case where you think the patient was exposed to INH-resistant Mycobacterium)

• Become prevalent when CD4 , 50 mm
• Fever, night sweats, wt loss, diarrhea, abode pain
• HSM, LFT abnormal, low WBC or pancytopenia
• Dx: Blood culture +, BM, tissue

• Tx: Clarithromycin (or azithromycin) + ethambutol + rifabutin (reduce dose if on PI) x 12 months
• --Start anti-HIV therapy as well 1-2 weeks into therapy (if naive).
• --Watch out for immune reconstitution inflammatory syndrome (IRIS)
• ==>fever, malaise, weight loss, worsening respiratory symptoms, increase in lymph node size

Prophylaxis: azithromycin q week or clarithromycin once daily for CD4 < 50

IRIS (immune reconstitution inflammatory syndrome)

• 1. AIDS-defining opportunistic infection
• 2. CD4 count < 350 cells
• 3. Pregnant women
• 4. Persons with HIV-associated nephropathy
• 5. Persons co-infected with hep B

• Anemia: reduce dose and/or epos
• Neutropenia: reduce dose and/or G-CSF
• Myositis: gait disturbance/loss of mm mass
• --"rugged red fibers" w/ increase CPK: Stop ZDV

• Painful peripheral neuropathy: reduce dose
• Pancreatitis: discontinue drug if occurs
• Retinal depigmentation with ddI

• 3TC acts as reverse transcriptase inhibitor
• Is incorporated in viral DNA and acts as chain terminator
• An extremely potent antiviral agent
• Pancreatitis is biggest concern
• Emtricitabine (FTC) -- similar agent

• Biggest concern:
• -Hypersensitivity reaction:
• 1. Fever, chills
• 2. Rash
• 3. Flu-like illness
• -If any of these occur on therapy, you must STOP
• -Now screen for HLA-B*5701
• -And never re-challenge pt: causes death

Efivarenz (Sustiva)

• HIV RNA > 400 copies after 24 weeks of therapy or
• HIV RNA > 50 copies after 48 weeks or
• Repeatedly detectable HIV RNA level after prior suppression or
• Drug toxicity

• If the answer is YES to these 2 questions, then give postexposure prophylaxis
• --Is the fluid bloody?
• --Is the skin integrity compromised?
• Give prophylaxis if yes to both, and no prophylaxis if yes to only 1 of 2.

• If urine exposure: NO
• If intact skin exposure: NO
• Prophylaxis: ZDV, 3TC, +/- lopinavir / ritonavir for 4 weeks

• D4T/ddI
• efavirenz

• ZDV to mothers starting between 14 and 34 weeks gestation 100 mg PO 5x daily
• Intrapartum ZDV IV loading dose 2 mg/kg starting in labor and continued at 1 mg/gk/hour until delivery
• Oral ZDV in infants beginning 8-12 hours after birth to age 6 weeks at 2 mg/kg/dose q 6 hours
• Treat the mother as though she is not pregnant; Give her 3-drug or more therapy!

• Surgery indications:
• -Fistulas
• -Abscess
• -Pericarditis
• -Persistent fever
• -CHF = most common cause of death
• -Recurrent embolic phenomenon (2 strokes)
• -Conduction disturbances

Viridans streptococci

• Bacterial endocarditis
• Order blood cultures

• Inflammation of the brain
• Sx: Fever, HA, stiff neck, confusion, bizarre behavior, focal signs, seizures

• Acute
• -Usually symptoms less than 1 day (within hours frequently)
• -Fever, HA, lethargy, stiff neck
• -If non-focal exam, go directly to LP (no need for CT head)
• -Immediate lumbar puncture
• -Empiric antibiotics if LP abnormal

• Usually 7 days to 2 months in duration
• Unilateral HA frequently
• Focal neurologic signs and/or seizures
• CT/MRI
• Lumbar puncture if imaging study OK
• Empiric therapy based on findings

Vanc/Gent/Ampicillin

• 500-10,000 WBC/uL
• > 90% neutrophils
• < 40 mg/dL glucose
• > 150 mg/dL protein

• Gram-positive diplococci = S. pneumoniae
• -Ceftriaxone or cefotaxime + vancomycin until sensitivities known
• -If PCN-sensitive, switch to IV PCN
• -Data now support dexamethasone

• N. meningitidis
• Treat with IV PCN or ceftriaxone/cefotaxime

• Listeria
• Treat with Ampicillin and gentamicin

• H. influenzae
• Dexamethasone followed by or concomitantly with ceftriaxone or cefotaxime

Ceftriaxone, ceftazidime, or cefepime (if pseudomonas a concern, use the latter 2)

deafness

• Rifampin for children < 18 years of age
• Ceftriaxone for pregnant women
• Ciprofloxacin is an acceptable alternative to rifampin in non-pregnant adults

Rifampin

Lymphocytic choriomeningitis virus

amebic meningitis

• nocardia
• actinomyces
• fungi

6th nerve palsies

Bell's palsy or foot drop

• Diagnose with CT scan
• Stereotactic biopsy is indicated today
• No LP!
• Most common empiric treatment: 3rd generation cephalosporin + metronidazole and surgical drainage if possible

• Shigella
• Salmonella
• Campylobacter jejuni
• Yersinia enterocolitica
• Amebic

Campylobacter jejuni

Yersinia enterocolitica

• Etiology: Neisseria gonorrhea
• Small, non-motile, Gram-negative diplococci
• Thayer-Martin or chocolate agar
• Virulence factor involved in pathogenesis

• 1-3% of patients
• Leading cause of acute septic arthritis in young adults
• Local infection 7-30 days before dissemination
• Menstruation may trigger dissemination
• Terminal complement deficiencies at increased risk

• Subacute in onset
• Migrating polyarthralgia
• Pustular skin lesions
• Tenosynovitis

• Septic arthritis
• endocarditis
• meningitis
• pneumonitis
• osteomyelitis

• Fitz-Hugh-Curtis syndrome occurs almost exclusively in women.
• Usually caused by gonorrhoea (acute gonococcal perihepatitis) or chlamydia bacteria, which cause a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, causing infection and inflammation.
• Occasionally, this inflammation can cause scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver.
• Sx: acute onset, upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder following an episode of PID

• Gram stain showing typical intracellular Gram (-) diplococci
• Women have to be diagnosed through culture

• Ceftriaxone 125 mg IM x 1 dose (only one approved for pharyngeal gonorrhea)
• Cefixime 400 mg PO x 1 dose

Spectinomycin 2 g IM x 1 dose (if has anaphylactic reaction to cephalosporin). This is no longer available except on Board exams

• Ceftriaxone 1 g IV q day x 7-10 days or for 2-3 days followed by either:
• -Cefixime 400 mg PO bid or
• -Cefpodoxime 400 mg PO bid
• ==> complete 7-10 day total therapy

Ceftizoxime or Cefotaxime may also be used for IV therapy followed by same drugs above.

• Choose 1 of these 2 regimens:
• 1. Cefoxitin 2 gm IV q 6 or cefotetan 2 gm IV q 12 + doxycycline 100 mg IV q 12 until improved followed by doxycycline 100 mg PO bid to complete 14 days

or

2) Clindamycin 900 mg IV q 8 + gentamicin 2 mg/kg IV x 1 followed by gent 1.5 mg/kg IV q 8 until improved followed by doxycycline 100 mg PO bid to complete 14 days

(Alternative: Ampicillin/sulbactam 3 gm IV q 6 + doxycycline 100 mg q 12)

Ceftriaxone 250 mg IM x 1

or

Cefoxitin 2 gm IM + probenecid 1 gm x 1 dose

PLUS

Doxycycline 100 mg bid x 14 days +/- metronidazole 500 mg bid x 14 days

• Surgical emergencies (appendicitis, etc.) cannot be excluded
• Suspected pelvic/tubo-ovarian abscess
• Pregnancy
• Uncertain diagnosis
• N/V precluding oral therapy
• Failure to respond to oral agents in 24-48 hours

• Chlamydia cause 2/3 of epididymitis in young women
• Chlamydia in 30-60% of women co-infected with GC
• Chlamydia in 1/3 of cervix and/or fallopian tubes of laparoscopically verified PID

• Less dysuris, less d/c than GC in general
• Urinary frequency, irritation can be present
• Leukocyte urethral exudate with > 4 PMNs on Gram stain of urethral swab without organism is correlated with chlamydial NGU

• Mucopurulent cervicitis
• -Yellow or creamy d/c from cervix
• -Gram stain + for WBCs
• -Similar symptoms to GC
• - > 10 PMNs/HPF on Gram stain smear of cervical mucous correlates with Chlamydia if GC if ruled out
• PID -- probably as common as GC as cause

• 3 days to 3 weeks after exposure, get a small painless vesicle or papule/ulcer at the site of initial contact (1/3 of patients only)
• 2-6 weeks after exposure, regional lymphadenopathy develops. Painful periadenitis occurs with matted nodes and inflamed overlying skin. Suppuration occurs with fistula formation (heals after several months).
• LGV 2nd stage:
• -Fever, chills, HA, myalgias
• -Can get aseptic meningitis, meningoencephalitis, conjunctivitis, hepatitis, arthritis
• LGV 3rd stage:
• Chronic ulcerative/infiltrative local structures, fibrosis, strictures, impaired lymphatic flow with resulting genial elephatiasis

• Diagnosis:
• -Culture
• -Detection of elementary bodies by Giemsa, etc. or
• -IF staining with monoclonal antibody: Most sensitive
• -Chlamydiazyme and MicroTrak: rapid assays for detection of Chlamydia in clinical specimens
• -Serologic 4-fold rise in antibody titer or +IgM

• Urethritis, cervicitis, conjunctivitis, proctitis
• --Azithromycin 1 gm x 1 dose or doxycycline 100 mg PO bid x 7 days
• ----Ofloxacin 300 mg bid x 7 days or e-mycin 500 mg qid x 7 days or levofloxacin 500 mg x 7 days

• Pregnant: Azithromycin 1 gm x 1 or amoxicillin 500 mg tid x 7 days
• --Erythromycin 500 mg PO qid x 7 daus (not estolate form)

• LGV: Doxycyline 100 mg PO bid x 21 days
• --Erythromycin 500 mg qid x 21 days

• Incubation period: median 5-7 days
• Begins as small tender papule with surrounding erythema at site of contact
• Evolves to pustule which erodes and ulcerates
• Ulcers are painful
• Tender regional lymphadenopathy in 50%

• Treatment:
• Azithromycin 1 gm PO x 1
• Ceftriaxone 250 mg IM x 1
• Ciprofloxacin 500 mg PO bid x 3 days
• Erythromycin 500 mg PO tid x 7 days

Treat sexual partners also

Chancroid

• Treatment:
• Azithromycin 1 gm PO x 1
• Ceftriaxone 250 mg IM x 1
• Ciprofloxacin 500 mg PO bid x 3 days
• E-mycin 500 mg PO tid x 7 days

Chlamydia

• Diagnosis: Culture of ulcer base with swab or aspirated from inguinal nodes or buboes
• --Gram stain shows gram (-) coccobacilli ("school of fish")
• Differential: LGV, HSV, syphilis, granuloma inguinale

• Etiology: Klebsiella granulomatosis
• --gram-negative bacillus
• Mildly contagious, requires repeated exposures
• Tx: Doxycycline

colposcopy

• For females ages 9-26 years
• Works for HPV types 6, 11, 16, 18
• Series of 3 shots over 6 months

• Etiology: Trichomonas vaginalis
• 50% are asymptomatic
• Accounts for 25% of symptomatic vulvovaginitis in U.S.
• Found in 13-58% of male partners, no symptoms
• Copious, malodorous, yellow-green vaginal d/c most commonly seen
• Intense vaginal pruritus in 25-50%
• Vulvar, labial, vaginal mucosal edema and erythema may be seen
• Men: asymptomatic
• Diagnosis: Wet mount 75% sensitive.
• --PAP, Giemsa, acridine orange stains also
• --Culture available; 48 hours anaerobic incubation
• Treatment: Metronidazole 2 gm x 1 or 500 mg bid x 7 days
• Treat sexual partners

• No treatment of sex partners necessary
• Treatment:
• Metronidazole cream
• Clindamycin cream or PO
• Metronidazole 500 mg bid x 7 days

• Pregnant
• Neutropenic
• Transplant patients

• Acute: S. aureus
• -IV drug abuser: Pseudomonas, MRSA
• -SS patient: Salmonella, S. aureus
• -Negative bone scan excludes osteomyelitis
• -Sinus drainage does not correlate with organism in wound (except S. aureus)
• Prosthetic joint - Staph epi, chronic, do joint aspiration

UTI

This organism is found throughout the world and is endemic in the United States. Wound infection with RGM is uncommon but can be catastrophic if not recognized and treated appropriately. The most distinguishing characteristics of the infections are nodules, often purple in color, and chronic abscess or sinuses. Skin and subcutaneous infections with RGM should be strongly considered in clinical situations demonstrating chronic purulent drainage, a lack of a convincing pathogen on routine culture, and association with implanted prosthetic devices. A lack of response to treatment and the failure to isolate a convincing pathogen should prompt further diagnostic evaluation consisting of staining and special culturing for mycobacteria followed by sensitivity testing to determine the appropriate antimicrobial therapy.

gram-negative bacillus

Gram-positive rods

• Treatment depends on the immune status of the host. Immunocompetent patients generally require no specific therapy because the disease is self-limited. If symptoms persist beyond several weeks, a course of nitazoxanide can be tried because it has been shown to hasten symptom resolution and clear oocysts from the stool. Immunocompromised patients, such as those with HIV infection, respond poorly to nitazoxanide, paromomycin, trimethoprim-sulfamethoxazole, and metronidazole. For these patients, initiation of highly active antiretroviral therapy to induce immune reconstitution is critical for controlling the cysts.
• Proper hygiene is essential to decrease person-to-person spread of Cryptosporidium. Boiling or filtering of tap water may decrease the incidence of infection in immunocompromised hosts but is not routinely recommended. Persons who are immunocompromised should also limit time in public swimming pools, water parks, and lakes.

• Immediate vaccination of close contacts (ring vaccination) is the appropriate response to a community outbreak of smallpox.
• Acyclovir has no effect against variola, and cidofovir has not been tested as a prophylactic agent for this infection. Passive immunization with hyperimmune globulin is an effective prophylaxis for smallpox, but supplies are too limited to be of practical use in epidemic-control efforts.

• After needlestick injury, injured persons should immediately wash the area with soap and water and report to the employee health department or specified area for needlestick evaluation. Baseline serologies and postexposure HIV prophylaxis should be done immediately, with follow-up serologies done as indicated.
• Recommendations for postexposure HIV prophylaxis are based on severity of exposure and the source HIV class. Severity is divided into two categories: less severe is defined as exposure to a solid needle with superficial injury; and more severe is defined as exposure to a large-bore hollow needle, deep puncture, visible blood on device, or needle used in a patient’s artery or vein. An HIV class 1 exposure is defined as exposure to an asymptomatic source or to a source in whom the viral load is low (for example, <1500 HIV RNA copies/mL). An HIV class 2 exposure is defined as exposure to a source with symptomatic HIV infection, AIDS, acute seroconversion, or a known high viral load.
• For low-risk exposure, prophylaxis with two nucleosides is recommended.
• Severe exposure and the source’s class is 2; therefore, the recipient of the needlestick should be offered postexposure prophylaxis with three or more antiretroviral agents.

Clinical features include tremores, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.

• fever
• hemicranial headache
• language and vehavioral abnormalities
• memory impairment
• cranial nerve deficits
• seizures

Intravenous acyclovir is the treatment of choice for immunocompromised patients with disseminated herpes zoster infection.

• If malaria is acquired in Africa, the likelihood that it is Plasmodium falciparum is at least 3:1
• P. falciparum infections have a clinical onset beyond 2 months after exposure in only 5% of cases; therefore, patients with symptoms lasting beyond 2 months after return from travel are unlikely to have P. falciparum infection
• Peripheral Blood Smear Findings Likely for P. falciparum Infection
• Level of parasitemia is >2%
• Only ring forms are present
• Banana-shaped gametocytes are seen
• Erythrocytes of all sizes are infected
• Numerous multiply infected erythrocytes are seen
• Erythrocytes contain no Schüffner granules

Variant Creutzfeldt-Jakob disease (vCJD) is characterized by early-onset psychiatric symptoms suggestive of depression, an earlier age of onset than CJD, an absence of periodic sharp waves on electroencephalogram, and presumptive diagnosis by tonsillar biopsy.

Brain biopsy

In patients with encephalitis caused by flaviviruses (such as West Nile virus), the detection of cerebrospinal fluid (CSF) IgM antibodies is considered diagnostic of neuroinvasive disease.

Clinical features of neurologic infection with West Nile virus include tremors, myoclonus, parkinsonism, and poliomyelitis-like flaccid paralysis that may be irreversible.

• Foscarnet is the drug of choice for treating acyclovir-resistant genital herpes simplex virus infection.
• Resistance should be suspected if herpetic lesions do not resolve within 7 to 10 days after the initiation of adequate antiviral therapy. Resistance is most commonly reported for acyclovir, but this may simply be because acyclovir has been available for clinical use longer than the other drugs in this family. If resistance is suspected, a viral culture should be obtainedand the specimen submitted for in vitro susceptibility testing; the correlation between in vitro resistance and clinical response is good.