Dr.

Ali’s Uworld Notes For Step 2 CK

Infectious Diseases
Fungal Infections

Sporothrix 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. Adenopathy
and systemic signs of infection are usually absent.

Coccidoidomycosis - Coccidioides is endemic in the southwestern US, as well as Central and

South America and causes pulmonary infection. A patient from Arizona/California should make
you think of coccidioidomycosis. Cutaneous findings such as erythema multiforme and
erythema nodosum are common.

Invasive aspergillosis 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.

Mucormycosis - 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.

It requires aggressive surgical debridement plus early systemic treatment with amphotericin B,
which is the only effective drug against this fungus.

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 flu-like 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.

Warty, Verrucous, Violaceous & Heaped Up Skin lesion.

Blastomyces Blasts through Skin, Bones & Joints.

Histoplasmosis is most common in the southeastern, mid-Atlantic and central US. It can
manifest as an acute pneumonia, which presents as cough, fever, and malaise. Other possible
manifestations include chronic pulmonary histoplasmosis and disseminated histoplasmosis
(more common in HIV patients). Skin lesions are uncommon.
HIV

A modified acid-fast stain showing oocysts in the stool is very suggestive of an infection with
Cryptosporidium parvum. This organism can cause severe diarrheal disease in both
immunocompetent and immunocompromised individuals. HIV-infected patients with a more
preserved CD4 count tend to have a self-limiting illness, whereas AIDS patients with CD4 counts
< 180 cells/mm3 tend to have a more persistent clinical course.

HIV Screening –
Vaccinations In HIV - Pneumococcal vaccine is recommended for all HIV-infected patients
whose CD4 count is above 200 cells/microL. Annual influenza vaccination is also recommended
for all HIV-infected patients.

HIV Post-Exposure Prophylaxis - 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 (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).

Esophagitis – Three possible causes of esophagitis in HIV patients are Candida, CMV & HSV.
Candida Esophagitis - The most common cause of dysphagia/odynophagia in an HIV patient is
candida esophagitis. If these symptoms develop, an initial one- to two-week course of empiric
oral fluconazole should be prescribed.

CMV Esophagitis - 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. and 3) presence of intranuclear and
intracytoplasmic inclusions is diagnostic of CMV esophagitis. The treatment of choice is IV
ganciclovir.

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.
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. Cryptosporidium, Isopora belli, Blastocystis, 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 histolitica or Campylobacter.

The etiology must be identified before starting antibiotic therapy. Evaluation of diarrhea in HIV-
infected patients should first begin with include stool culture examination for ova and
parasites and test for C. difficile toxin.
Colonoscopy and biopsy of the mucosa and/or any ulcers are reserved for those with persistent
diarrhea and negative stool examination.

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 CMV Enteritis, the patient presents with the typical
presentation of CMV colitis: chronic bloody diarrhea, abdominal pain and a CD4 count less than
50 cells/~L. 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.

TB in HIV - In HIV-infected patients, tuberculosis carries a very high risk of progression to active
disease. For this reason, all PPD-positive HIV-infected patients should be given prophylactic
treatment. PPD testing is considered positive in HIV patients when there is 5 mm or more
induration within 48-72 hours of intradermal injection of 5 tuberculin units. Isoniazid is the
drug of choice for chemoprophylaxis and is given for 9 months in PPD positive HIV-infected
patients. 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.

Nocardia - Pulmonary cavitation in an HIV-inlected patient can be caused by a number of

different organisms, Including Mycobacterium tuberculosis, atypical mycobacteria, Nocardia,
gram-negative rods, and anaerobes. 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 or
those on high dose steroids. 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-last, filamentous. branching rods are seen in clinical specimens. The treatment of choice is
trimethoprim-sullamethoxazole.

Cavitary Lung Lesions in HIV – Typical & Atypical Mycobacteria & Nocardia.

Histoplasmosis – Histoplasma capsulatum is a dimorphic fungus that is found as a mold in soil.

It is also present in bird and bat droppings and is endemic to the Mississippi and Ohio River
basins. Patients may report a history of exploring caves (associated with exposure to bats) or
cleaning bird cages or coops. Histoplasmosis is fairly self-limiting in immunocompetent people
but can cause significant pulmonary and disseminated disease in patients with CD4 counts <
100/UL. 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.
The most sensitive test to diagnose disseminated histoplasmosis is antigen detection in the
urine or serum.

The treatment of disseminated pulmonary histoplasmosis in HIV patients depends on the

severity of the disease. Patients with mild-to-moderate disease may be treated with
ltraconazole alone. Patients with more severe disease (e.g .. high fever > 39 .5•c [> 103 .1.F].
laboratory abnormalities, or fungemia) should be initially treated with intravenous liposomal
amphotericin B for 2 weeks followed by itraconazole for 1 year. The patient should also be
restarted on antiretrovirals.

Atypical MAC Infection - Atypical mycobacterial infection is particularly likely if the patient's
CD4 count is less than 50 and the patient has no past history of or exposure to tuberculosis.
HIV-infected patients with a CD4 count< 50/mm3 should receive azithromycin as prophylaxis
against Mycobacterium avium complex.

Toxoplasmosis - The most common cause of central nervous system mass lesions in AIDS
patients is toxoplasmosis. The patients present with fever, head ache, seizures & focal
neurological deficit. Brain CT shows single or multiple ring enhancing lesions. Trimethoprim-
sulfamethoxazole is used for prophylaxis of toxoplasmosis, while sulfadiazine and
pyrimethamine are used for treatment purposes.

Brain biopsy is reserved for patients whose lesions do not respond to treatment with
sulfadiazine and pyrimethamine.

Bacillary Angiomatosis - Bartonella henselae and Bartonella quinlana cause bacillary

angiomatosis in immunocompromised individuals. Patients present with cutaneous and visceral
angioma-like blood vessel growths. Bright red, firm, friable, exophytic nodules in an HIV
infected patient are most likely bacillary angiomatosis. Extreme caution must be exercised in
biopsying these lesions because they are prone to hemorrhage. Oral erythromycin is the
antibiotic of choice.

Red drug for red lesions.

Cryptococcal Meningitis – It is an encapsulated yeast. It is a very common cause of meningitis
in HIV patients with a low CD count. The patients usually present with worsening head ache,
low grade fever, stiff neck & lymphadenopathy. CSF shows encapsulated yeasts. Initial
induction therapy for central nervous system cryptococcal infection in AIDS patients is IV
Amphotericin B plus oral flucytosine. When there is clinical improvement with induction
therapy. amphotericin and flucytosine are discontinued and oral fluconazole is started as
maintenance therapy.

Crystal-induced nephropathy is a well-known side effect of indinavir therapy (indinavir is a

protease inhibitor). It is caused by the precipitation of the drug in the urine and obstruction of
the urine flow. According to one study, 8% of the patients treated with indinavir had urologic
symptoms and about 20% had urinary crystals consisting of indinavir. Although adequate
hydration may help reduce the risk of nephrolithiasis, indinavir-associated nephrotoxicity has
been described in many well-hydrated patients. Furthermore, this complication may manifest
early in the course of the therapy or develop later. For these reasons, some clinicians
recommend periodic monitoring of urinalysis and serum creatinine levels every three to four
months.

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
Bacterial Pneumonia in HIV - Suspect bacterial pneumonia in an HIV-infected patient who
presents with acute onset, high-grade fever and pleural effusion. Pneumococcus is the most
common cause of pneumonia in HIV patients who have a CD count more than 200. Due to their
impaired humoral immunity, HIV patients are susceptible to infection by encapsulated
organisms in general, so other encapsulated bacteria should also be considered in the
differential.

Viral Infections –

The incidence of influenza rises greatly during the fall and winter months especially mid January
(epidemic). The onset of symptoms is typically abrupt and includes: fever, chills, malaise,
headache, coryza, non-productive cough, sore throat, muscle aches and occasionally nausea.
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. The
diagnosis is usually made clinically in the setting of an epidemic; however, rapid laboratory tests
for influenza antigens from nasal or throat swabs are now widely available. The infection is self-
limiting in most healthy individuals with a typical duration of 1-7 days. Many patients are
treated with bed rest and simple analgesics (e.g .. acetaminophen).

For the treatment of Influenza A, use Amantadine, rimantadine & Neuraminidase Inhibitors like
Oseltamivir & Zanamivir.

For the treatment of Influenza B, use only Neuraminidase Inhibitors like Oseltamivir &
Zanamivir.

Nasal swabs for influenza antigens are the fastest way to confirm this diagnosis.

The administration of antiviral drugs usually results in shortening of the duration of

symptoms by 2-3 days. The Advisory Committee on Immunization Practices (ACIP) concludes
that benefit from antiviral drug therapy has only been demonstrated in otherwise healthy
patients treated within two days of the onset of illness.

Post-influenza Staphylococcus aureus Pneumonia – The patients initially present with a

syndrome consistent with influenza, which improves after several days of medication (e.g ..
oseltamivir). They then developed a new pneumonia less than two weeks after the initial
presentation. S. aureus is a relatively uncommon cause of community acquired pneumonia. It
most often affects hospitalized patients, nursing home residents, injection drug users, patients
with cystic fibrosis or people with recent influenza infection. Gram-positive cocci in clusters are
seen on gram stain. S. aureus is known to cause post-viral URI necrotizing pulmonary
bronchopneumonia with multiple nodular infiltrates that can cavitate to cause small abscesses.
This looks on the X rays as multiple thin walled cavities.
A good hint is a person recovering from a simple URTI now has productive cough with blood.

Antibiotics should only be used if a secondary bacterial infection is suspected. One should
consider this diagnosis if the fever persists for more than 4 days, along with a productive cough
and white cell count > 10,000/cmm.

Rubella Vaccination & Pregnancy - 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.

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. Waiting for the result of the PCR or
viral culture is not necessary. Treatment should be started immediately.
Herpes Zoster aka Shingles - Shingles is caused by reactivation of the varicella-zoster virus.
Following 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
postherpetic neuralgia.

Infectious Mononucleosis - these patients presents with 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 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. 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 as 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. Contact
sports should be avoided to prevent the chances of splenic rupture. When rupture occurs, the
mortality is significant. Hematological studies reveal leukocytosis with variant lymphocytes
(atypical lymphocytes - convoluted nuclei and highly vacuolated cytoplasm).

Young Patient + Sore Throat + Cervical Lymphadenopathy + Hepatosplenomegaly = IM

CMV Mononucleosis - A patient with a mononucleosis-like syndrome, a lack of pharyngitis and

cervical lymphadenopathy on exam, atypical lymphocytes and a negative heterophile antibody
(monospot) test most likely has CMV mononucleosis. Atypical lymphocytes are large basophilic
cells with a vacuolated appearance. In contrast to EBV-associated infection, CMV
mononucleosis usually presents without pharyngitis and cervical lymphadenopathy.

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. Systemic symptoms are
usually absent.
There are three treatment options for condyloma acuminata:

 1. Chemical or physical agents (e.g., trichloroacetic acid, 5-florouracil epinephrine gel,

and podophyllin)
 2. Immune therapy (e.g., imiquimod, interferon alpha)
 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.

Protozoal Infections –

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 P. Vivax, P. falciparum, 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.

COLD followed by HOT followed by WET

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). 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.

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
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 or immunocompromised individuals.
It is more commonly seen in patients with functional asplenia or splenectomy. 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.

Cystecercosis - It is a parasitic disease caused by the larval stage of the pork tapeworm Taenia
solium. 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 tapeworm. The adult tapeworm lives in the upper jejunum and excretes
its eggs into the person’s 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, sub-Saharan 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.

Trichinosis - Also known as trichinellosis, It is a parasitic infection caused by the roundworm

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.

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.

Febrile Neutropenia - Neutropenia is defined as an absolute neutrophil count (AN C) <

1500/microl. Susceptibility to infection increases when ANC falls below 1000/microl; ability to
control endogenous flora is lost and risk of death is markedly increased when the ANC falls
below 500/microl. Fever in a neutropenic patient is defined as a single temperature reading of
greater than 38.3C (100.9F) or a sustained temperature of greater than 38C (100.4F) over one
hour. Bacteria, fungi, and viruses can all cause infection in neutropenic patients. Bacterial
infections are the most common and are frequently caused by endogenous skin or colon flora.
Over the past decade, there has been a shift from gram-negative to gram-positive bacteria
being the most frequent cause of neutropenic infection.
Febrile neutropenia is 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.

Malignant Otitis Externa - The typical symptoms of malignant otitis externa are ear discharge
and severe ear pain. The pain often radiates to the temporomandibular joint and consequently
causes pain that is exacerbated by chewing. Worsening of the disease despite the use of topical
antibiotics is an important indicator of the condition's malignant nature. Examination shows the
presence of granulation tissue in the external auditory meatus. Diabetes mellitus and other
immunosuppressive conditions are important risk factors. The most frequent causative
organism is Pseudomonas aeruginosa, which is implicated in more than 95% of cases.

Nail Puncture 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). The patients presents with local pain and swelling.
fever and an increased white cell count. Blood cultures may reveal the infecting microorganism;
otherwise, a bone biopsy is required. Plain radiographs take about 2 weeks or more to show
evidence of the disease. Treatment is with oral or parenteral quinolones and aggressive
surgical debridement.

Erysipelas is a specific type of cellulitis. It is characterized by inflammation of the superficial

dermis, thereby producing prominent swelling. The classic finding is a sharply demarcated,
erythematous, edematous, tender skin lesion with raised borders. The onset of illness is abrupt
and there are usually systemic signs Including fever and chills. The legs are the most frequently-
involved site. The most likely causative organism is group A beta-hemolytic streptococcus (S.
pyogenes).

Traveller’s 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 (ETEC) is the most frequent cause of traveler's diarrhea.
Bloody Diarrhea WITHOUT Fever - Diarrhea has a wide differential diagnosis. Not all causes of
which are infectious. The presence of abdominal pain and lack of fever in a patient without a
travel history makes Enterohemorrhagic E. coli (EHEC) the most likely diagnosis.. 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.

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.

Staph aureus Food Poisoning - The abrupt onset of nausea and vomiting is most likely due to
the intake of a preformed toxin or chemical irritant. Because the cause of illness is a preformed
exotoxin, there is no person-to-person transmission. But large outbreaks can occur if many
people ate the same contaminated food. Illnesses secondary to preformed toxins are
characterized by a rapid onset of symptoms (usually less than 6 hours) and often involve
vomiting. Staphylococcus aureus and Bacillus cereus both produce a preformed toxin. Clues to
the specific etiology lie in the types of foods consumed. Poultry and egg products, meat and
meat products, salads made with mayonnaise (egg. Tuna, chicken, potato or macaroni salad),
cream-filled pastries and milk and dairy products are foods frequently incriminated in
staphylococcal food poisoning. The most frequently tested food item is a mayonnaise-
containing food like potato or macaroni salad.

Bacillus Cereus Food Poisoning - For the USMLE, 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). Aside
from preformed toxins, chemical irritants also produce abrupt-onset nausea and severe
vomiting.

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. Cervicofacial actinomycosis classically presents as a slowly progressive, non-tender
indurated mass, which evolves into multiple abscesses, fistulae and draining sinus tracts with
sulfur granules which appear yellow. The treatment is high-dose penicillin for 6-12 weeks.

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.

Lyme Disease Tick Management –

Most patients who have Lyme disease do not recall about any tick. Patients who traveled to a
Lyme-endemic area and saw an Ixodes scapularis tick attached to their body have to follow a
certain protocol to decrease the risk of Lyme disease transmission. The tick should be removed
as soon as possible. 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.

Patients should be advised to seek medical attention if a "bull's eye rash" (erythema migrans)
develops over the next month. One dose of doxycycline should be administered if all criteria for
prophylaxis are met (table).

Patients traveling to tick-infested areas should be advised to wear permethrin-treated pants

and long-sleeved shirts, to apply insect repellents to the skin, and to check the entire body for
ticks.
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 Ixodus 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.

In severe cases of facial palsy, the cornea may be at risk of dryness and abrasions due to poor
eyelid closure and reduced tearing. Artificial tears should be used during the day in addition to
ophthalmic ointments and eye patching at night

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.
Suspect ehrlichiosis in any patient from an endemic region with a history of tick bite, systemic
symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases. The drug
of choice is doxycycline.
Syphilis - Primary syphilis presents with a painless chancre that resolves in 3-6 weeks and can
recur weeks to months later as secondary syphilis. In secondary syphilis, the rash typically
starts on the trunk and extends to the periphery, including the palms and soles. Generalized
lymphadenopathy is very common. Secondary syphilis requires a high index of suspicion for a
clinical diagnosis. Initial testing is with a nontreponema! 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.
If you find out that a patient has one STD, there is a chance that he might also have other
STDs because of his high risk activities. Screen the patient for HIV with ELISA, RPR, pap smear
and hepatitis B surface antigen testing also be performed (with the patient's consent).

Vs

Rocky Mountain spotted fever (RMSF) is a tick-borne illness that requires rapid initiation of
antibiotics to prevent mortality. The rash usually begins as a maculopapular eruption on the
wrists and ankles that spreads to the trunk, extremities, palms and soles around day 5 of the
illness. Patient's often have a severe headache and diffuse myalgias.

Rocky Mountain spotted fever usually does not produce bacterial meningitis and has CSF
findings more consistent with a viral meningitis picture.

Vs
Rubella - 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.

Vs

Chicken Pox - 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).

Uncomplicated Pyelonephritis Management - After 48-72 hours of parenteral therapy for

uncomplicated pyelonephritis, the patient can be usually switched to an oral agent. Oral
therapy is more convenient and less expensive; if the results of antibiotic susceptibility testing
are known, the appropriate antibiotic can be easily chosen.

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 home-slaughtered 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.

Pig farmers are at high risk for Neurocysticercosis.

Sheep farmers are at high risk for Hydatid Cysts.

The commercial sex worker is at high risk for perihepatitis from gonorrhea and numerous other
sexually-transmitted diseases.

Dog Bite Post Exposure Prophylaxis - A dog bite may result in rabies, which is a fatal disease.
For this reason, all physicians should understand the guidelines for post-exposure rabies
prophylaxis. Post-exposure prophylaxis, when indicated, consists of both active and passive
immunization.
In any dog bite, an attempt is made to capture the dog.

 1. If the dog is not captured, it is assumed rabid, and post-exposure prophylaxis is

indicated.

 2. If the dog is captured and does not show features of rabies, it is kept for observation
for the development of rabies for 10 days. If the dog develops any features of rabies,
post-exposure prophylaxis should be started immediately. The dog's diagnosis is
confirmed by fluorescent antibody (FA) examination of the brain.

 3. Post-exposure prophylaxis should be started immediately for exposures involving the

head and neck.

Diabetic Foot Ulcers - Chronic foot ulcers are frequently found in patients with diabetes.
Diabetic patients are prone to developing foot ulcers due to a combination of arterial
insufficiency and peripheral neuropathy. Because of poor tissue perfusion, the immune system
has difficulty combating infection in the region surrounding the ulcer. Thus, the open ulcer is an
ideal site for entry of bacteria and infection of the soft tissue can easily spread to include the
neighboring bone. Such contiguous spread is the most likely pathogenic mechanism of
osteomyelitis in patients with arterial insufficiency, such as those with diabetes.
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.

Staph aureus Endocarditis – Staphylococcus aureus is a leading cause of bacteremia both in the
community and hospital setting. Patients who are more likely to have S. aureus bacteremia
include intravenous drug users, patients with skin infections, and patients with an infected
medical device (e.g., prosthetic valve). Patients with HIV infection are also at increased risk of S.
aureus bacteremia. Patients with tricuspid valve endocarditis, which specifically occurs in
intravenous drug users, are prone to septic embolism to the lungs, which typically presents
with pleuritic pain and multiple cavitating lung nodules on x-ray.

In cases of suspected IE, 1st draw blood for C & S and then start emperic antibiotic therapy.
When culture results become available, antibiotics can be changed if they are not appropriate.

Endocarditis -
IE in IVDU
Meningococcal Meningitis – These patient presents with sudden onset of fever, stiff neck,
headache, nausea, and myalgias, worrisome for bacterial meningitis. The hypotension,
tachycardia, myalgias, and purpuric skin lesions suggest meningococcal meningitis with
meningococcemia, which can develop within several hours of the initial meningitis. Myalgias
more commonly occur in meningococcal meningitis than other bacterial causes and can be
more intense and painful than the myalgias caused by viral influenza.

The CSF findings of elevated white blood cell (WBC) count, elevated protein level, and
decreased glucose level are indicative of bacterial meningitis. Viral meningitis may present with
similar symptoms but is usually not associated with purpura. The CSF findings also tend to show
normal glucose, mild elevation of protein (usually < 150 mg/dL), and WBC count <250/cmm.
This patient has CSF findings consistent with bacterial meningitis and the hypotension and skin
lesions most consistent with disseminated meningococcemia.

Meningitis Rx –
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.

The tuberculin skin test is used to screen asymptomatic patients for infection with
Mycobacterium tuberculosis. It is performed by injecting a small amount of M. tuberculosis
purified protein derivative (PPD) into the skin and measuring the amount of induration at 48-72
hours. The degree of induration considered "positive" depends upon the patient's pretest
probability of having tuberculosis. The classification is given below:
1. Induration > 5 mm is considered positive in:
• HIV-positive persons
• Individuals with recent contact with a TB-positive person
• Individuals with signs of TB on chest x-ray
• Organ transplant patients, patients on immunosuppressive therapy

2. Induration> 10 mm is considered positive in:

• Individuals who have recently emigrated from a location where TB is endemic
• Injection drug users
• Residents/employees of high-risk settings (e.g. prisons, homeless shelters)
• Patients with diabetes, chronic kidney disease, hematologic malignancies, or fibrotic
lung disease
• Children less than 4 years of age, teens exposed to high-risk adults

3. Induration> 15 mm is considered positive in:

• Healthy individuals with no risk factors for TB infection.

So, if a healthy person with PPD less than 15 mm comes to clinic, you don’t do any further
investigations. Just observe.

A patient who has a positive PPD test should have a chest x-ray to evaluate for active
pulmonary tuberculosis. Patients with a positive PPD but without signs of active TB on chest x-
ray should be treated for latent TB infection. Treatment is a nine-month course of INH plus
pyridoxine (vitamin B6).

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 (10 mg/day). If the
peripheral neuropathy has already developed, the dose of pyridoxine is increased to 100
mg/day. Hepatitis is another known side effect of isoniazid.

Latent TB Rx -
Bite Inujury - 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.

Post Transplant Management - Oral trimethoprim-sulfamethoxazole (TMP-SMX) is effective in

preventing Pneumocysfis pneumonia (PCP) in transplant patients. It may also prevent
toxoplasmosis, nocardiosis, and other infections (e.g., urinary tract infections and pneumonia).
All posttransplant patients should receive prophylaxis with TMP-SMX. Ganciclovir or
valganciclovir can be used to prevent CMV infections. These patients should also be vaccinated
against influenza, pneumococcus, and Hepatitis B.

Bone Marrow Transplant - 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.

BMT + Pneumonia + Abdominal Complains = CMV Pneumonitis.

Pneumocystis pneumonia (PCP) caused by the organism now called Pneumocystis jiroveci, is
seen in the immediate post-transplant period. But its incidence has fallen dramatically with the
routine use of prophylactic trimethoprim-sullamethoxazole during the pre-transplant period.
PCP usually does not cause diarrhea.

Hospital Acquired Pneumonia - 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. P. aeruginosa is one of the most commonly
considered gram-negative aerobic bacilli in the differential diagnosis of gram-negative
infections, and is a common cause of gram-negative nosocomial pneumonia. Nosocomial
Pseudomonas infections have been linked to a number of environmental sources, including
contaminated water faucets, respiratory therapy equipment, therapy pools and plant products
(flowers, vegetables). Intravenous antipseudomonal antibiotic therapy should be started as
soon as possible. Fourth generation cephalosporins (i.e .. cefepime) have been used
successfully for treatment. Other effective medications include aztreonam, ciprofloxacin.
imipenem/cilastatin, tobramycin, gentamicin and amikacin. Piperacillin-tazobactam is also
highly effective.

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 enferocolitica and septicemia from
Vibrio vulnificus, both of which are iron-loving bacteria.

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.

Toxic Shock Syndrome

Necrotizing Fasciitis –
Splenic Abscess

Upper Respiratory Tract Infections

Parvovirus B19