Infectious Disease

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Robert Pa:cton PA-C, M.P.A.S.

Robert Paxton graduated from the University ofNebraska-Lincoln with aBachelor's degree in biology, which was followed by two years of infectiousdisease research and teaching microbiology. He received his Masters ofPhysician Assistant Studies from Marquette Universrty. He currently worksfor a private infectious disease practice at St. Joseph's Regional MedicalCenter in Milwaukee,'WI. Mr, Paxton is an adjunct clinical professor andclinical preceptor for Marquette University, where he teaches a series oflectures on infectious disease. He is a member of the American Academy ofPhysician Assistants (AAPA) and the Wisconsin Academy of PhysicianAssistants (V/APA).

CME ResourcesCertification & Recertification Exam Review

Certifrcation & Recertification Exam ReviewCME Resources

Infectious Disease TopicsRobert Paxton PA-C, MPAS

i)Selected f@Eections-Know the etiology, presentatior5 evaluation, and treatment

-Ei$spl4smosis-Blastomycosis-eoscidioidomycosis-Pneumocystosis

r-eSplococcus-A€Ergillosis-Candidiasis

2) Selected fulozoal[shc]tions-Know the etiology, presentation, evaluation, and treatment

-Bebeliosis-Malaria-T6-ropiasmosis

3)Selected Yiral Iq&ctions-Know the etiology, preser$ation, evaluation, and treatment

-Human Hslpesviruses-!MV-roIV-8-vzv

-Rabies --Sin Nombre Virus (Hantavirus)-Iff-Severe Acute Respiratory Syndrome-Igst Nile Virus

4) Selected Brcketlsial Infeqtions-Know the etiology, presentation, evaiuatioq and treatment

-Rocky Mountain Spotted Fever (Rickettsia)-Eillichio s is (E hr I i chi a)

5) S elected Bacterial Infections-Know the etiology, presentatioq evaluation, and treatment

-Tetanus-Botulism-Lyme Disease

6)Selected "@gJoos"-Know the etiology, presentation, evaluation, and treatment

-Anthrax-Suu[Po*

7) Selected Sexuaiiy Transmitted Diseases-Know the eti6G,ffintation, evaluatiorq and treatment

-Bacterial Vaginosis- Trichomonal Vaginitis-Chlamydial Urethritis / Cervicitis-Lyrnpho granuloma venereum-Gonorrhea-}IPV-HSV-Chancroid-Granuloma inguinale-Syphilis-Molluscum Contagio sum-Pelvic Inflammatory Disease

8 ) S elect ed O&redic.l*nfections-Know the etiology, presentation, evaluation, and treatment

-Osteomyelitis *-Infectious arthritis -

9)Selected Cardiac Infections-Know the etiology, presentatiorl evaluation, and treatment

- Spontaneous Bacterial Endocarditis-Rheumatic Heart Disease-Pericarditis

1 0) Seiected Neurolo gicai Infections-Knowffilogy, presentation" evaluation, and treatment

-Meningitis-Encephalitis

1l)Selected Skin & Soft Tissue Infections-Know the etiology, presentation, evaiuation, and treatment

-Erysipeias-Cellulitis-Cutaneous abseesses (folliculitis, furuncles, carbuncles)-Necrotizing soft tissue infections (necrotizing fasciitis, Fournier' sgangrene, clo stridial myonecrosis)' -Bite wound infections

1 2) S elected Etiolo gies of Infectious Diarrhea-Know the etiology, presentation, evaluatiorq and treatraent

-Non-Inflammatory Diarhea-Viral infections (Norwalk Virus, Norovirus)-Protozoal infections (Giardia, Cryptosporidium)-Bacterial infections (5. aureus, B. cereus, V. cholerae)

-Inflammatory Diarrhea-Protozoal infections (8. hi stolytic a)-Bacterial infections (E. coli 0157:H7, C. dfficile, Shigella,Campyl obacter, Salmonella)

StaphylococcusCoaoulase positive

S, aureusCoaoulase negative

S. epidermidisS, saprophytras

Streptococcus5. pneumoniaeLancefieid orouos

Group A: S. pyogeneGroup Bz S, agalactiaeGroup CGroup D: S, bouisGroup FGroup G

Strep viridans

Notes:Group A (5. pyogenu\ strep throat, necrotizing fasciitis f'flesh-eating bacteriaf, rheurnatic heart diseaseGroup B (5. agaladiae): perinalal strep, colonizer of vaginal canal, neonatal sepsisGroup C, F, G: Not as commDn as Group A, B, and DGroup D: used to include enteromccus, now ju$ .1liarzrs, If found in blood is thought to indicate colon cancerStrep viridans: 5, millen, S. anginosis, S. sativariuslEhrtis found in mouth, teethjupper respiratory tmct.Associated with endocarditis

RespiratoryHaemophilus influenzaeMonxella ahrrhalis

Non-FermentersPseudomonasAanetobaclerStenotrophomonas

Enterics-" E mli* Proteus- Klehsiella

EnterubaderSeratiaSalmonella

.. YersiniaCrtrobaderShigella

vaqinitis f UrS",\Vaginal pH @ 4.0 (Lactobacillus)

Trichomonasvepinalis

Bacterial vaginosis Candida albicans Cervicitis

Manifeststions Yellow-Green DiCFrothy D/CCopious D/CMalodomus D/C"Strawberrv vasina"

GralshDlCHomogeneous D/COcc. Frothy DiC

PruritusErythematous vulvaand vaginaThick/Crcamy D/CDvsnareunia

Less D/C(DMucopumlentD/CSponingafter intcrcourse

pH > 5.5 -5.0 > 4-5 -4-7 <4.5 7.4WetMount Motile richomonads

on NaCI slideManyWBCs

"Clue Cells"

[stippled epithelialcellslFewWBCs@Tirt6-st",-#fzAmme odor whenKOH aoolied

Sporcs urdHyphae on KOHModerare WBCs

lfany WBCs-.*No orEsntsmsOn lifet MouaB

i- cenrEeErEs { G- , \

80 ToAsymptomaticPurulentvaginal D/CDysuriaPIDPharyngitiVArthritis

80%AsymptomaticCervicitisUrethral syndromePIDConjunctivitis

HSY-Z: - &5-90YoFint episode - worsttFever*Malaise*Headache*Mlalgias

PrimaryChancre (l-5 wks)SecondaryRashLymphadenopathyCondyloma lataTertiary 6 -20 yrs)CV; gNS

Intracellular(columnar/transitional)DNA probc;(Urine LCR/PCR)

Tzanck smearCulturesDNAprobc

Ciprofloxacin 500mg po

,,or:=,,\a$sxackf 400mg PoPLUS

f;-ithromrcin I Gm po

Doxycycline l00mgBID X 7 days

Acyclovir orFamciclovir orValcyclovir

+Suppressive Tx:6)Vyear;

Penicillin G+/-Tetrarycline

Jarisch-HeaheimerFebrile reactionPCN Tx

Note:

Genital WareCondyloma accuminata (Human Papillomavirus)Pink to white "frondlike" Issions; solitary or in clustersAssociated cervical dysplasia (HPV 16, 18, 31, 35)

Overview of Infectious Disease

.=#_>= Ft}rD6AC t-Selecte(Fungallnlectron\ " i ,-rlffi::_Ta{\,:in'ffH ffih, f)c:L rnl-"*fl€ Y Jd'zo't tP't-linked to bird droppings or bat guano exposure along Ohio River Valley-most infections are asyrnptomatic pulmonary infections ---disserninated disease common in AIDS / immunocompromised states-diagnose with biopsy and urinary testk-treat with amphotericin B products or itraconazole

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O":i - [r ,\t-u- n;,ilr2)Blastomycosis

-caused by Blastomyce s dermatitidis-linked to soil exposure along Ohio River Valley, especialiy dust exposure L(construction or excavation) ! r

-most infections are asymptbmatic puhngnary infectio* 'L"\*c,r-'

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-disseminated disease cornmon in AIDS / immunocompromised states-diagnose with biopsy and culture-treat with amphotericin B products or itraconazoie

3)Coccidioidomycosis'caused by Coccidioides immitis-linked to geographical exposure history (southern California -> Texas)

-called San Joaquin Valley Fever-40% present with influenza-like illness

-erythema nodo sum common-diagnose with serology-treat with amphotericin B products

kr 3lPneumocystosis k-caused by Pneumocystis jiroveci (calrtntt for boards)-common n ruOS (< ZOO Cn+ ) / immunocompromised states-present with fever, dyspnea, nonproductive cough

-physical exam not usualiy consistent with degree ofhypoxemia-diagnose with CXR (interstitial infiltrates), sputurn, or bronchoscopy-treat with TMP-SI/D( or atovaquone

-use prednisone if PaOz <7A mmHg

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4)Cryptococeus-caused by Cryptococcus neoformans

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-common in AIDS / immuqgco_mpromised states

-diagnose with CSF and serum serology-India ink may be positive

-treat with amphotericin B products or fluconazole

-may present with altered mental status changes, headache, or meningismus

S)Aspergillosis-caused

'\lspergillus fumigatu, mostiy

-many disease entities-allergic bronchopulmonary aspergillosis, aspergiliom4 and invasiveaspergillosis

-invasive aspergillosis most common in patients with prolonged neutropeniadiagnose with tissue biopsy

-treat with amphotericin B products or voriconazole

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6)Candidiasis-corrmon normal flora but opporlunistic infection possible . \ ,1r.,r) il,;tt,"t-categorized as C. albicans or non-albicaf Canafia--_=). \.: lc1 1'-sibr''

-diagnosis of invasive disease requires tissue biopsy or evidence of retinal disease

-C. albicans responds to fluconazole-non-albicans Candida may respond to fluconazole (some species are resistant)

-vaginal candidiasis-presents with wlvar itching. ery4hema. and white. cwdy discharge-KOH shows hlphae-treat with *gW cream X 1-7d or fluconazole 100-200 mg PO Xl

-esophageal candidiasis-may present with substernal odynophagia, GE reflux, or nausea with orwithout substernal pain-diagnose wirh EGD (with biopsy) vety ptt;'"L\-treat with fluconazole

-other Candidal diseases-Candidal funguria-Candidalfungemia(oftenline-associated) - Ya,a.-l nhior.J. ls ncuq- r. r'*Tdla"/

-choreoretinitis / endophthalrnitis-hepato splenic candidiasis-endocarditis

?oi^- ou \-Selected Protozoal lnfections

1)Babesiosis-caused by Babesia microti-same distribution and transmission as Lyme disease-Dresents as'North American Malaria"

2)Malaria-caused by Plasmodiury-ygg*2-_ryalariae, P. ovale, P. falciparum

-P. falciparu4lqgs!:yizulelr}= Fa\ crp.ri*r : trr.:cixc\-most common in tropical regions (travel history)-transmitted by female Anopheles mosquito-presents with periodic chills -> fever -> sweats

-qod (tertian) with P. vivax, P. ovale, P. falciparum-q3d (quartan) with P. malartae

-may also have FIA, myalgi4 splenomegaly-anemia and leukopenia common-diagnose with thick / thin blood smears-prophylaxis for travelers vital

.ir -chloroquine (if no P. falciparum resistance in travei area)

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rJcis'n\J-mefloquine, doxycycline, atovaquone, or primaquine (if P. falcip arumresistance)

-treatment depends on piasmodium species and resistance in travel area

3)Toxoplasmosis kt,)s I in, Uter\-caused bV !e49pbsm%g!4it-transmitted by eating contaminated food, or handling cat litter-usually an asymptomatic primary infection-reactivation in AIDS (< 100 CD4 eells) / immunocompromised states-present with progressive HA, AMS changes, or new-onset seizure-diagnose with serology, biopsy, imaging

-head CT shows ring-enhancing mass lesions-treat with pyrimethamine and sulfadiazine

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-s.t*.t.afiffit.tioo, \---rjffi.*,-Herpes Simplex Virus 1& 2 (HSV) ) STDs-Varicella Zoster Virus (VZV)

-Chickenpox ) Peds-Herpes Zoster (Shingle$ ) ID

-Ebstein-Barr Virus (EBV) + ENT-Cltomegalovirus (CIvfD ) ID-Human Herpes Virus 6 (HHV-6) ) Peds

-etiology of roseola (exanthema subitum)-Human Herpes Virus 7 (HHV-7) ) Peds

-? etiology of roseola (exanthema subitum) also-Human Herpes Virus 8 (HHV-8) ) ID

-? etiology of Kaposi's sarcolna

2)Herpes Zoster (Shingles)-caused by VaricellaZoster Virus (VZY-transmission is mostly respiratory, but direct contact with vesicular or pustularlesions may result in transmission ) initial infection

-primary infection is chickenpox!-VZV remains dorrnant in dorsal root ganglia of nerve ) reactivationdisease ) shingles

'f -shingles tends to occur as people age and cell-mediated immunitywanes ) shingles in a patient <50 yrs. should make you considerHIV infection

-presentation typically prodromal qanptoms (burning, tingling) in region ofsensory nerve distribution ) vesicular eruption typically of 1-3 dermatomes

-may disseminate in immunocompromised patients-recurrent vesicular outbreaks in the same spot ) HSV (more likely)

-post-herpetic neuralgia is the most common long-term complication-clinical diagnosis followed by Tzanck smear / immunofluorescent antibodystaining-treatment

-miid to moderate disease ) -cyclovir (PO)-severe disease ) acyclovir (IV)

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3)Cytomegalovirus./ -caused by Cytomegalovirus (CIvIV)

-transmission is sexual, congenital, transfusio4 transplantation and person-to-person (respiratory secretions)-primary infection presents similar to infectious mononucieosis-especialiy severe in AIDS (< 50 CD4 cells) / immunocompromised states

-CMV retinitis (blindness)'GI CMV (ulcers esophagus -> anus)-Pulmonary CMV ("pneumonia")

-diagnose with PCR and biopsy -_ c:"fr\ v PC il* \ ettlt-treat with gangiclovir lr r1,.*:lr-, Frffi F\f.T\,f;flff'nLL

3)Hrrv-8-causes Kaposi's sarcoma-present with red-purple macules, papules, nodules, or patches, throughout thebody-comrnon inAIDS patients /CIA ",.oJ,lca'.,

Acjn-treat by trying to reconstitute the immune system

4)Rabies-caused by a rhabdovirus

-noirodents / lagomorpfrs traUUitsl -""t-;;;; crith,;*re'L"c- (:ar'n ^;"1

's.p"6 '}_''-usually there is a bite history

-scratches from rabid animals are 50x less Iikely to transmit rabies

-nr.r.n; owed by paresthesias-later manifestations include extreme behavior, convulsions, and seizures-prevention is the goal

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1H'ffirffi$,#tr#;ffiH:y;;ffi lt:;f Tl::;5)Sin Nombre Virus

-causes Hantavirus Pulmonary Syndrome-most cases in "Four-Corners" states-transmitted by inhalation of rodent urine / feces-present with flu-like illness, foliowed quickiy by shock and ARDS-treat with ?? (? ribavirin)

6)Human Immunodeficiency Virus-Epidemiology

-arr)'one who is sexuall)' active or injects drugs is at risk for HIV infection-in the US, HIV 1$ seen in gay merq then IVDU, blood transfusion

recipients, and hemophiliacs-globa[y 35-40 million infected (most in developing countries)

-HiV is a retrovirus-uses reverse transcriptase to change viral RNA -> viral DNA

-Acute HIV Syndrome-"mononucleosis-like illness" usually more severe and more likely to need

hospitalization-rash 40-80o/o (no exposure to aminopenicillins)-mucocutaneous ulceration is distinctive feature

-diagnose *jl FjY RNA*I (viral load) i lcc;; ',n J'h€ Scrna,i-treat with HAART

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-ELISA= srreeningtest - 4"71i"\y affstrcet-WB : confirmatory tesf-.-.---_

-ELISA + wB {ge2lesg4qt-HIV viral load (measures copies/ml)

-don't use as screening tool (unless AHS suspected)-used to test for neonatal HIV

- Symptomatic HIV infection-CD4 count and disease risk

- >500 (lymphadenopathy)-200-500 (pulmonary TB, bacterial pneumonia, herpes zoster,NH-lymphom4 Kapo si sarcoma)-100-200 (PCP)- 5 0- 1 00 (CIvIV retinitis, toxoplasmo sis, cryptococcus)- <50 (MAC, CNS iymphom4 PNtr-)

-Antiretroviral options-nucleoside reverse llnnscriptase inhibitors (NRTIs)

-zidovudine (AZT), lamivudine (3 TC), enrtricitabine (FTC),didanosine (ddl), zalcitabine (ddc), stavudine (d4T), abacavtr(ABC), tenofovir

-non-nucleoside reverse transcripase inhibitors $INRTIs)-nevirapine, delavirdine, efavirenz

-protease inhibitors (PIs)-saquinavir, ritonavir, indinavir, nelfnavir, amprenavir /fo samprenavir, lopinavir, atazarovu

-fusion inhibitors (enfuviride I T-20)

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-Antiretroviral Ciass Specific SE-NRTis

-AZT: bone uvurow suppression-ddl, ddc, d4T : peripheral neuropathy / pancreatitis-ABC = hypersensitivity r>ar. (never rechallenge)

-NNRTIS-all cause rash-efavirenz causes CNS disengagement (vivid dreams)

-PIs-all cause NAIID and "lipodystrophy / metabolic SE" \-indinavir causes nephrolithiasis \ a* s\)\6( \:e f,at . f r,,\ ."15)

-Highly Active Antiretroviral Therapy G{AART)-combination therap), with 3 drugs is standard of care X-druss of choice

(-zNRtts+1PI\-2NRTIs+lNNRTI-2 NRTIs * abacavir-1 NRTI + 1 NNRTI +1 PI

-Opportunistic infections requiring prophyiaxis-pneumocyctosis (CD4 < 200)

-TMP-SlvD(-toxoplasmosis (CD4 < 100)

-TMP.SVD(-Myeobacterium avium compiex (CD4 < 50)

-azithromycin or clarithromycin-HIV and pregnancy

-ACTG 076 reduced transmission rate from 23% -> 8% (66% reduction)-Protocoi

1)PO AZT 100 mg 5x/d at week 14 until onset of labor2)MT 2 mgkg load, then 1 mg&g until delivery3)8-12 hrs. after birth give AZT syrup 2 mgkg q6 for the 1$

6 weeks of life

7)Severe Acute Respiratory Syndrome (SARS)-caused by a "new" coronavirus (SARS-CoV)-transmitted by respiratory secretions & fomites-most cases in Hong Kong, Singapore, Hanor, and Toronto-presents with IJRTI qrrnptoms + dry cough and hypoxemia-diagnose : clinical picttxe plus risk factors-treatment is multifactorial

-CAP treatment + ribavirin * steroids

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8)West Nile Virus-WNV is a Arbovirus

-WNV is in the family Flaviviridae-ls case in US + NYC '99

->3000 cases with>170 deaths-WNV predominately spreads b/t birds and mosquitos

-humans / other mammals are "dead-end" hosts-most will have an asym,ptomatic or mild viral illness

-1 in 5 deveiop a mild febrile illness-1 in 150 develop meningitis, encephalitis, or both

-present with meningitis / encephalitis-muscie weakness ) flaccid paralys

-diagnose with CSF studies-IgM antibody capture ELISA for WNV

-fiert?2 (? Ribavirin + interferon a2b)

ankles and then spreading centrallytreat with doxycyciine L,ORrtj-\ + Aroxut L

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-Selected Rickettsial Infectionsl)Roclry Mountain Spotted Fever (RMSF)

-caused by Rickettsia rickettsii-transmitted by tick bite-presents as "influenzal" prodrome, followed by F/C, HA, myalgias

-red macular rash appears b/t 2od -> 6th da]t of fever. 1$ on the wrists and

2)Ehrlichiosis-Ehrlichia chaffeenis causes human monocytic ehrlichiosis (HME)

-transmitted by Lone Star Tick- Ehrlichia phago cyt ophila causes human granulocytic ehrlichio sis (HGE)

-llansmitted by Ixodes bite-presents iike RMSF, except the rash is less cofirmon

-rash involves trunk, spares hands / feet-diagnose with leukopenia, thrombocytopeni4 and elevated ALT / AST-treat with doxycycline

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-Selected Bacterial Infections

-caused by a neurotoxin elaborated by Clostridium tetani-associated with puncture wounds, but any wound is prone (iaceration, decubiti,

etc.)-frequently present withjaw or neck stiffiress and dysphagia

-h;perreflexia and muscle spasm iater-jaw muscle spasm = trismus

-prevent with vaccination +/- TIG-treatment (actual infection)

-Td + TIG + Penicillin G 24 mu/d

2)Botulism-caused by a neurotoxin elaborated by Clostridium botulinum \-associated with home-canned food products and honey (infants) /up f" \Z rno's )-present with sudden onset of dipiopia, dry moutlr, dysphagia, dysphoni4 and

muscle weakness -> respiratory paralysis-treat witir6--_t6)

3)Lyme Disease-caused by Botelia burgdorferi-common in NE and upper midwest and transmitted by tick bite-chamcterized in stages

l)Early infection: Stage 1 (localized infection)-eMhema chronicum migrans (60-80% of cases)

-small red papule -> centrifugal spread -> central clearing-F/C, myalgias / artlralgias, fatigue common

2)Early infection: Stage 2 (disseminated)-neurological synptoms (Bell's palsy)-cardiac s;nnptoms (AV block)

3)Late infection: Stage 3 (persistent)-chronic arthritis (monoarticular or asymmetric oligoarticularinvolving large joints)

-diagno se with serology-treat with doxycycline, ceftriaxone, or amoxiciliin depending on stage

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1)Anthrax

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-caused by Bacillus anthracis-transmitted naturaliy via exposure to infected animals or via inhaiation of sporesas "bioweapons"

-tlrree fonns of antlrraxi)cutaneous (most commoq e4posure to wool)2)GI (very rare, eating undercooked contaminated meat)3 )inhalational (mo st deadiy)

-Inhalational anthrac-usually present with flu-iike illness-inhaled spores cause mediastinitis / hemorrhagic l].mphadenitis

-widened mediastinum on CXR-usually do not present with pneumonia

-treat with ciprofloxacin and vaccinate'-

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2)Smallpox-caused by Variola major-eradicatedfr;;i*;iigao * \cr;t c*se- rv-'' Crzrrr'rt?''-transmitled by respiratory secretions and cutaneous contact-presents as flu-like illness, followed by rash (oral mucos4 face, UE / LE ->spreads centraliy to the trunk)

'lesions proeress from macules -> papules -> vesicles -> eschars (all insame stage of development)

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F.*trd Sr4re' Transmitted Infectionsl)Bacterial Vaginosis

-pollrnicrobial vaginal infection ) not felt to be a STI-an overgrowth of Gardnerella vaginalis and other anaerobes-ctue celts are epitneUal c-associated with increased malodorous gray discharge

-may be frothy-treatment options

-metronidazole 29 PO Xl-metronidazoie 500mg PO BiD X 7d-metronidazole vaginal cream BID X 5d-ciindamycin vaginal cream QD X 7d

+ (+) "Wh_iff'test

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2)Trichomonal Vaginitis-caused by Trichomonas vaginalis-presents with vaginal pruritis and a malodorous frothy, yellow-green discharge-cervical petechiae ) strawberr.y cervix-trichomonads are seen on wet prep-treat with metronidazole 29 PO Xl

-check for other STIs-treat partners and educate to refrain from sex until infection treated

I X \use-3)Chlamydial Urethritis / Cenricitis

-caused by Chlamydia trachomatis-most common STD-75-90% of cases are asymptomatic ) recommended to screen all women <25 yrsand in other asymptomatic women at increased risk-presentation depends on sex

-men present with urethral discharge of mucopwulent / purulent materiafdysuria, or urethral pruritis

-accounts for 35-50% ofcases ofnongonococcal urethritis-women present with uethritis, bartholinitis, cervicitis ) characterized bydysuria, abnormal vaginal discharge, or post-coital bleeding

-may also present with upper genital tract infections (endometritis,salpingo-oophoritis, or PID) ) characteruedby irregular uterine bleedingand abdominal / pelvic discomfort

Note: both sexes can present with reactive arthritis /tenosynovitis or Reiter's syndrome (urethritis, conjunctivitisoarthritis, & mucocutaneous lesions)

-diagnose with PCR or LCR of discharge or wine-sensitivity 80-91% (range depends on type of material collected)-specificity 95-1A0%-new home kits based on this technology are available

-treat with azithromycin 19 PO Xl-check for other STIs-treat parlners and educate to refrain from sex until infection treated

4)Lymphogranuloma venereum t St"a-" OH\an^v J" \-caused by Chlamydia trachomalls serovars Ll-L3-starts as a painless mucosai lesion ) lyrrphatic spread ) inguinal bubo )draining sinus tracts-treat with do>rycycline 100mg BID PO I'zld

-check for other STIs-treat partners and educate to refrain from sex u:rtil infection treated

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5)Gonotlhea-caused by Neis s eria gonomhoeae (GN-diplqgocd-can infect any mucocutaneous surface (oral, urethnal, vagina[ anal)-presents with yellow, creamy, profuse discharge-Fitz-Hugh-Curtis syndrome ) perihepatic gonorrhea

-present with fever & RUQ pain-extension of infection from fallopian tubes ) peritoneum & liver capsule

-diagnose with LCR of discharge or urine-treat I25mgIM Xl or FQ plus azithromycin 1g PO Xl

empiricaily treat chlamydia also-check for other STIs-treat partners and educate to re ain from sex until infection treated

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6)Human Papillomavirus-HPV causes genital warts and cervical / anorectal dysplasia / neoplasia

-HPV 6 and 11 most commonly cause external genital warts ) low risk forneoplasia LU$ r* rg = LtL,t: RISV<-HPV 16, 18, 31, 33, 35 most common for cervical dysplasia * high risk

-appear as an exophytic growth, often pink or white-solitary lesions or clustered lesions-usualiy not painful, pruritis common

-anorectal warts = condylomata acuminata-diagnose with biopsy l-atA-treat with ablation, imiquimod (Aldara), podofilox, or TCA

-check for other STIs

7)Herpes Simplex Virus 'R*.\'s' Pt \sy-HSV predominantly causes oral / genitdl ulcers

-HSV-I ) oral (can cause genital)-cold / fever sore-85% of US population has serologic evidence

-HSV-2 ) genital (can cause oral)-25% of US population has serologic evidence

-genital ulcers present as grouped, pain-firl vesicies-fever, adenopathy, and urinary s;nnptoms possible

-outbreaks often recurrent (remain dormant in sensory ganglion)-new guidelines recommend culture to differentiate HSV-1 from HSV-2

-HSV-2 much more likely to have recurrent lesions-can also cause

-ocular disease-meningoencephalitis-esophagitis / proctitis-HSV-i is associated with Bell's Palsy

13

-clinical diagnosis confirmed with Tzanck smear, DF,\ serology, PC& or culture-Tzanck ) intranuclear inclusions & multinucleated giant celis-PCR important for CSF studies

-treat with acyclovir, valacyclovir, or famciclovir-6/yr. try suppressive therapy-treatment does not eradicate disease

-check for other STIs-valacyclovir (Valtrex) approved for decreasing risk of transmission

8)Chancroid-caused by Haemophilus ducrey, ( .\t C fV )

-GN coccobacillus-painfi.rl genital ulcer (chancre) with fluctuant inguinal adenitis-treat with ceftriaxone 250mg IM Xl or azithromycin 1g PO Xl

-check for other STIs

9)Granuloma inguinale *'hrn**rri,"r!*b(:r}'g\-caused by Calymmatobacterium granulomatis-chronic, relapsing, granulomatous anogenitai infection

-painftl infiltrated nodules ) uicer with red &iable base of granulationtissue

-diagnosis: Donovans bodies seen on $/right or Giemsa stains-treat with doxycycline 100mg PO BID X 21d or TMP-S}vD( DS PO BID X 3-4wks.

-check for other STIs

l0)Syphilis'Jertc-hr} "Teczl1nr

-caused by Trepanema pallidum-clinical stages

-Primary syphilis (painless ulcer at site of exposure : chancre)-Secondar.y syphilis (generalized maculopapular rash (even palms / soles)

-Tertiary syphilis (infiltrative tumors (gummas), aortitis, neurosyphilis)-diagnosis

-screening: VDRL or RPR-confrmatory: ETA:ABS or MHA-TP

-more sensitive & specific

:qlays positive for life-.tle4,wtrh jienici[in>

-gpe of penicillin and duration oftreatment depend on stage of syphilis-check for other STIs

1,4

-.-.'-.-.'.---..=..

{)Molluscum Contagiosu\-caused by an unclassified poxvirus-can be acquired by direct contact (including sexually) or by contact by infectedmaterials (i.e. towels)-lesions begin as papules ) pearly, umbilicated nodules 2-10mm in diameter, witha central caseous plug that can be readily expressd

-lesions are most corxron on trunk, genitalia, and proximal extremities and

are typically in a cluster of 5-20 nodules-treatment

-mild disease ) will resolve on their own 2-12 months after developmenteven without treatment)-extensive or disfiguring disease ) ablative therapy (i.e.liquid nitrogen,laser)

I2)PeMc Inflammatory Disease (PID) b"t\ tta^Li\ fiY = Lp<>v'n1 -

-PID is a term used to describe ascending infection of the endometriurn, faliopiantubes, and other peivic structures

-i.e. describes salpingitis, tubo-ovarian abscess, pelvic peritonitis, andendometritis

-risk factors include multiple sexuai partners, frequent sexual partners, and newsexual parlners within the last 30 days-po lynicrobial infectio n (l{. Sgf-rrr ho e a e, C-,Xsehenati s, My c opl as m a /Ur e apl as ma, Enter ob act eriac e ae, mixed anaerobes and siraptococci;-present with lower abdominal pain, adnexal / cervicai motion tenderness )mmrmum crrterra

-fever and vaginal discharge also possible-diagnosis is really ciinical with supportive lab tests / imaging

1r,-\ .v -laboratory findings are nonspecific (leukocytosis)

t - I .+ r \ ^ \ c, -US to rule out tubo-ovarian abscessI * -i^ n.)F '-' -laparoscopy most sensitive method of diagnosis ) perform if diagnosis

^n /2 Y rz't\ \' uncertain

15

-Selected elt&Edic Infections \1)d;eoffi-infla:nmation of the bone / bone ma:row-hematogenous seeding conrmon in children

-most commonly metaphysis of iong bones-contiguous spread common in adults

-often from a soft tissue infection (i.e. DM ulcer)-S. azreus is most common overall cause (esp. hematogenous)

-contiguous-focus is oft en poiymicrobial-Salmazrel/a spp. more common in sickle cell patients

-presentation is variable depending on site of infection-diagnose with iabs, imaging (nay, bone +/- WBC scans, CT, or MRI), and bonebiopsy with histopathology and cultures-always r/o tumor-treat with ABX and surgery

2)Infectious Arthritis-inflammation of a joint from a pyogenic organism

from a transient bacteremia

rpresent with single, hot, swollenjoint-rlo rheumatic disease-diagnose with joint aspiration

-l[ gorzorrftoea most common cause in young. sexually active people-represents dis semi4alg[gggo co ccal disease (DGI)-present with feverfmigralgglpolyarlhralgias, tenosynovitis, and dermatitis-find primary gonococcal focus

-treatment depends on organism

f\-r., uUlri! ni,r.f i't1,,1

-{Yri-r'\L\.{:' 11Ll f

*

16

I Endocarditis (SBE)-microbial infection of the lining ofthe heart ) characteristic lesion is avegetation, which is most commonly found on vaivular structures-etiologic agents F-.:.r

-native valve: f,riridanslstrep, S. aureus, and Enterococci-prosthetic valve

early infections (<2 months after valve)

;-coagglasq(-) staph

l-E6*,d'-Iate infection: resembles native vaive

-other organisms (HACEK)-Haemophilus p ar ainfluenzoe / aphr ophilus-Actino b acillus actinomycet emc omitans-C ar di o b act er ium homini s-Eikenella corredens C.l - t<;n -c\\a)-Kingella bingae

-often present with febrile illness lasted for days to weeks, often with nonspecificsymptoms (cough, dyspne4 arthralgias, diarrhe4 abdominal / flank pain

-90% have murmurs (development of CFIF is most common complicationand death from SBE)-40% have systemic emboli (spleen ) renal > cerebral / ophthajmic /mesenteric / coronary)-25% have characteristic peripherai lesions

-petchiae of paiate, coqiunctiv4 beneath fingemails-subungal (splinter hemorrhages) - 7 Llrr<\r:r Wc,.', \-Osler nodes (painful, violaceous raised lesions of fingers / toes)-Janeway iesions (painless erythematous lesions of palms / toes)-Roth's spots (retinal exudative lesions)

-diagnose withblood cultures, EKG, CXR, labs (CBC, ESR UA), echo (TEEmore sensitive than TTE)-Duke Criteria is used for diagnostic criteria-treatment

-empiric therapyi)nafciliin + ampicillin + gentimicin OR2)vancomycin + gentimicin

-Selected

t7

2)Pericarditis-acute inflammation of the pericardium-may be infectious (echoviruses & coxsackieviruses) or systemic disease (AMI,neoplasnr, radiation" sarcoid, lupus, IBD, medications)-typicatly present with chest pain, often pleuritic and postural

-often relieved by sitting and leaning forward)-pericardial friction rub is classic

-EKG shows generalized ST & T wave changes ) begin with diffirse ST elevation

followed by return to baseline & then T wave inversion-treatment is multifactorial

-NSAIDS or prednisone for s1'rnptomatic relief-identify and treat the cause

3)Acute Rheumatic Fever (RF)-the nonsupportive complications of S. pyogenes (GAS) infection are acute

rheumatic fever and acute glomeruionepluitis-incidence has dramatically decreased since introduction of penicillin and

improved socioeconomic status in the US-clinical manifestations are multiple, but varied and several criteria must be met toestablish a definitive diagnosis

-2 n:urjor manifestations or 1 major and2 minor manifestations plus

evidence of antecedent GAS infection-major manifestations ) arthritis > carditis > S1'ndenham's chorea

> subcutaneous noduies-minor manifestations ) fever, arthralgias, heart block, increased

WBC/CRP/ESR-murrnurs of mitral stenosis and aortic stenosis are cluonic , manifestations of RF

ical Infections1)Meningitis

-defined by the presence of bacteria within the subarachnoid space causing

inflammation with resuitant inflammatory consequences-mortaiity is organism dependent

-5. pneumoniae 2AYo mortalitY-N. meningitides <lATo mortality-H. influenzae SYo mortality

-transmitted by respiratory droplets or mucosa-to-mucosa spread

-most organisms gain access to CNS via bloodstream and choroids spread

-other routes include1)contiguous spread (sinusitis or otitis medra)

2)post-operative infection or trauma3)indwelling devices

18

$-'., ^,li-)'.ftu'

Nl'\v

-Classificationl)Acute Meningitis

-most cofiImon, medical emergency-rapid onset of symptoms-classified into bacterial & aseptic

-"aseptic" meningitis usually indicates arboviruses

(arthropod-borne) and enteroviruses (coxsackieviruses / echovirus)

2)Chronic Meningitis-symptoms may be present for months / years (ex. TB &neurosyphiiis)

3 )Meningo encephalitis-refers to infections that involve the CSF, leptomeninges, and brain

parenchyma itself4)Parameningeal infections

-includes subdural empyema / epidural abscess I &an abscess

-etioiogies depend on age of patient r. , -" r.l \-0-4 weeks ) S. agalactiae (GroupB strep), E. cali, ListeriafVros"-\ -ra*'\'l-)

-4-12 weeks-) as above PLUS H. influenzae,.S' pneumoniae,

\J{,nslagli4qyt-3months-lSytt ) H. inJluengpA.S. pneumoniae, N' meningitides- i 8-50yrs ) S. pneumoniae W..-usntrtgztjdeD->50yrs ) S. pneumoniae, N. meningitides, Listeria

-classic presentation include fever, FlA, neck stiffiress (85% of patients)

-NA/ and variable rates of confusion are also common

-check for nuchal rigidrty (turn head side-to-side, then flex and observe fordiscomfort)

-Kernig & Brudzinski are less sensitive tests-CSF examination is the key

-check opening PSI, cell count / differential, glucose, protein, gram stain Iculture

-bacteriai antigen studies indicated when patients have been

pretreated with ABX-CT's ofthe head are overused

-When should you order a CT?anyone with increased ICP as manifested by signifieantpapilledema, dilated nonreactive pupil, ocuiar motion abnormalities,

drowsiness / stupor, bradycardia / HTN OIEJM 2001;345:1727-33)-treatment (for community-acquired acute meningitis)

-empiric ) vancomycin + ceftriaxone a7- Ugp4iffial L7-ftrnct-modrfy therapy based on culture results-dexmethasone may also be added

-g*ii"'""''

l9

-Anatomic & Clinical Classification of Skin & Soft Tissue Infections

Note: from Curent - Diagnosis & Treatment in Infectious Disease p. 178

Rjp@laslrpeligoFof[a$EsgctarnaRrunorlssls

Cdlulilis

l,lecrotizingedb

lt{tonecrods(cbsnidal andnondositfat)

f,W-,r--".:::::....-.*.=i=__-g+;_ _ri' -:- ---tat---ffi

-i\,'S. rrt\'\'

,lis*-J-.-d:l-

-t-_:-lr-l4-(,') t

W

'9/,;*q-,i

ffiTs Sqnfe€

20

-Selected Skin & Soft Tissue Infectionsl)Impetigo ) Peds

2)Erysipelas-infection of the epidermis / dermis-usually caused by S. pyogenes (GAS) Fe*\ dlsue .r F<eI cI&SL-seen as red, gJistening, and demarcated

-treat with antistaphylococcal ABX-see ABX lecture notes

3)Cellulitis-infection of the epidermis / dermis / CT-present with F/C, erythema, and induration

-ervthema is iess intense than erysipelasIlrmon

-caused by S. pyogenes or S. aureus-treat with anti-staphylococcal ABX

-see ABX iectures

4)Cutaneous AbscesseS,. * ", Z ;| .

-Folliculitis L-c'rt5-infection of the hair foilicle and apocrine glands

-often on the face, buttocks, extensor surfaces-presents as small, tender, er;'thematous papuies, often topped a by central

pustule-usually caused by S. aureus-treat with warm

"o*pr.rr.s and topical mupiricin C ts".d'\'t\* ")

-IIot Tub Folliculitis-acquired from contaminated pools / hot tubs r !, t >-t \-eaisedby P. aeluqinosa L^nsr ctrvJ.:,\\\ r*Vrl'>c'r^e' $., t<'\\ flir'J(-present *itn@to-"times tendet plpgr. )- pustule-treat with warm compresses and anti-pruritis meds

-ABX not indictated"TY'. cf,r,r ar ie;';*ri'"''*' ) k't\ psduLlbY]ad^t'l

-Furuncles @oils) \1U bL ?- \ f-often secondary to foliiculitis ) spreads to subcutaneous tissue

-present as firm, tender, erythematous nodules that become fluctuant-common on neck, axillae, buttocks-usually caused by S. aureus-treat with I&D and anti-staphylococcal ABX (or based on culture results)

21

-Carbuncles ,-7 (.,taner'"> frS''g-

-multiple abscesses separated by CT, extending into subcutaneous fat inareas ofthick, inelastic skin (neck, back, thighs)

-basically a collection of furuncles-fever and constitutional slmptoms are comrron-usually caused by S. aureus-treat with I&D and antistaphylococcal ABX (or based on culture results)

Dt/ ^b'>(

S)Necrotizing Soft Tissue Infections-Necrotizing fasciitis

-infection that progressively destroys the subcutaneous fascia / fat with lmuscle sparing C{lesr r,r}un1) ft;;, 6rp ft sv1,{\^tot'.ir.

-)-classically caused by S. pyogenes (iff-iy 10%) +most are polymicrobiai-present like cellulites" but exam finding (s)'stemic toxicity. pain) are out ofproportion-extensive debridement is key

-broad-spectrum ABX are secondary

-Fournier's Gangrene-polymicrobial necrotizing fasciitis of the scrotum +/- perineunr penis. orabdominal wall-often in diabetics-extensive debridement is key

-broad-spectrum ABX are secondary

-Clostridial Myonecrosis (Gas Gangrene) &"p:-d" nn0sc\es-infection that progressively destroys the subcutaneous fascia, fat, andmuscle-usualiy caused by C. pe$"ingens-often from traumatic wounds or enteric surgery-present acutely with severe pairl systemic toxicity, +/- crepitus-extensive debridement is key

-broad-spectrum ABX are secondary

22

-Bite wound Infections A*r-*.sl^-often from dogs (lacerations) > cats (punctures) > humans (occlusions)

-infecting organisms can be from the environment, victim's skin, or the "normal" flora ofthe biter

-often polymicrobial in nature-usually caused by Staphylococcus spp., Sneptococcus spp., various anaerobes

-unique organisms-doss / cats ) Pasteurella multocida-hvmans ) Eikenella conodens

-treat with ABX +/- srugery (if compiications)

@o)orunasyn(IV)-Ceffioxhe p/ars ciindamycin or metronidazole-do4ycycline or TMP-SIvD( or FQ

plusclindamycin or metronidazole

-Infectious Diarrhea-Divided nto 2 classes

-Non-Inflarnmatory Diarrhea-Characterized by

l)large volume, watery stool2)no blood / PMNs3)nausea / flu-like sym.ptoms common

-DifferentialDiagnosis /r .\

-viral infections (Norwalk Virus, Norovirus) ( Lrvtt' 3Y"o ) )

-protozoal infections (Giardia, Crypotosporidium)-bacterial infections (5. aureus, B. cereus, V. cholera)

-Anti-peristaltic agents are ok-l*\ t'J6rm;J,[xr' '

-Inflaffinatory Diarrhea-Characterized by

l)small volume, frequent bioody / mucosy stools2)many PMNs3)fever / chills and crampy abdominal pain common

-Differential Diagno sis

-protozoal infections (E. histolytic a)-bacterial infections (E. coli A157, C. dfficile, Shigella,

)k -No *?;:#';i:':;::( *' ne I t a)

na-/.)

-Non-Infl ammatory Infectious Diarrheal)Viral Infections

-Norwalk Virus & Norovirus (Norwalk-like Virus)-causes "Winter Vomitinf Disease"-acquired via contaminated food I H20 or person-to-person contact-most common cause of gastroenteritis in the US-present with N/VID and abdominal pain that lasts 1-3 days

-low-grade / transient fever possible-treat supportively with rehydration (ORT)

2)Protozoal Infections-Giardiasis

-caused by Giardia lanfilia-most common oarasitic etioloqv of infectious diarrhea in

,n.-u,-associated rvith camping / hiking

-fecal- oral transmission-affects the SI and may oause diarrhea

-most causes asymptomatic-may have acute or chronic diarrhea or a malabsorption

$Yndmne -) F rttY Gfi,D[ '#-diagnose with O&P & stool EIA (serology)_treat with metronidazoie Dx e _gluj\ f-t A

-Cryptosporidiosis-caused by Cryptosporidiunt panwn-fecal-oral transmission-affects the colon and causes "cholera-1ike" diarrhea-self-limiting in immunocompetent patients; severe in AIDSpatients-diagnose with O&P & stool EIA (serology)-treatment is based on immune status

-non-AIDS : nitazoxanide-AIDS: paromomycin + azithromycin

24

3)Bacterial fnfections- Stap hylococcu s flurn es

-exotoxin is released into a food product (mayonnaise) that is theneaten

@-treat supportively Stap^ au1 Yr.,.',jS

pld.+, s."L^,{V.A,*tCb jn SD-bDwvlc

-Bacillus cereus-exotoxin is released into a food product (rice) that is then eaten

-"food-poisoning,,-treat supportively

-Cholera ( Cystc, r'<r t\n"'FliF.;t't" R^*\-caused by T'ibrio cholerae-occurs in epidemics under conditions of inadequate sanitation-transmitted by contaminated food / water-presents with rice water stool-diagnose with stool culture-treat with Fe & rehydration

_-.-t_---._ *\

[ -tnflammatoryhnfectious Diarrhea1)Protozoattnje*ions

-caused by Entamoeba histolytica-fecal-oral transmission mostiy in tropics-causes most disease in the coion / liver

-colonic disease ) recurrent diarrhea / abdominal pain-hepatic abscesses ) ferrer, hepatomegaly, pain, andlocalized tenderness

-diagnose with O&p, serology, and imaging-treat with metronidazole +/- paromo*y"io ia.pending on diseaseseverity / state)

-&ain abscess if indicated

25

u .\""whu'-.2)Bacterialrnfection, ?So/' eF^\ \jo"')y ('

-Escherichia coli O157:H7-serot)?e of E. coli producing "shiga-toxins"-associated with undercooked hamburger, unpasteurized miik /juice, and raw fruit / vegetables-infection may be asymptomatic or present with bloody diarrheaand HUS

-afebrile plus bloody diarrhea ) E.coli (until provenotherwise)-hemolytic uremic syndrome (I{US) =

-ARF + thrombocylopenia + hemolytic anemia-treatment is supportive ) ABX are controversial

TX ; Abx. &o,olo\a.,e-

-Cbnrtdium ilfficite $F l'+irx fx-produces an enterotoxin (toxin A) and a cytotoxin (toxin B)-associated with all ABX

-pick ciindamycin on the boards-variety of syndromes are possible

-asymptomatic infection ) diarrhea ) PMC ) toxicmegacolon ) fulminant colitis

-present with fever, abdominal cramping I pwn, and watery diarrhea-diagnose with stool FIA

]f -treat *itrrffiffia"o-i6pnd place in contact isolation

-Shigellosi, DoY Ccartl-caused by multipie shigella species

-5. sonnei > S. .flexnerz > ,S. dysenteriae (in US)-associated with day-care outbreaks-presents abrupti)'with biood)' diarrhea, abdominal pai4 tenesmus,

qxicity

-Campylobacteriosis 6rnL-\ 3 sh'ry'\ rcJ-caused by Campylobacter jejuni-presents with fever, watery-bloody diarrhea, and abdominal pain-most common bacterial cause of infectious diarrhea in the US-associated with raw / poorly cooked chicken-treat with erychromycin

26

-Salmonellosis-salmonella species cause 2 main clinical patterns

-enteric fever (,Salnonella \pht)-gastroenterrtis (Salmanella tlphinruriuw, among other

species)-transmitted by ingestion of the organism, usually fromcontaminated food or drink

-associated with eggs

-enteric fever is a ciinical syndrome characterized by constitutionalsymptoms, GI syrnptoms, and by HA

-any salmonella species can cause enteric fever, lcntt S' Whiis most common

-typhoid fever: enteric fever 2' to .9. f,.f:&l-GI symptoms may be marked constipation or "pea soup"diarrhea-rose spots may be present (2-3 mm papule on trunk usually)

-treat with FQ or ceftriaxone if severe disease

-vaccine available