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235 Cards in this Set

  • Front
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Infective Endocarditis -
What is it
Risk Factors
Causes
Infection of endocardium
secondary to infectious causes
MC affects heart valves -
esp. mitral valve

Risk Factors -
dental procedures that cause bleeding
oral & upper respiratory surgery
certain GI procedures
GU surgery
prosthetic heart valves
valvular heart disease
alimentation caths in rt. heart
pressure monitoring caths
IVDU

MCC -
acute - S. aureus
subacute - S. viridans
IVDU - S. aureus
prosthetic valve -
coag-neg. Staph
coexisting GI malignancy -
Strep. bovis

fungal -
Candida
Aspergillus
predisposing factors -
long-term indwelling
IV catheter
immunosup from malignancy
AIDS
organ transplant
IVDU
Infective Endocarditis -
Hx
Fever
chills
weakness
dyspnea
sweats
anorexia
skin lesions
IVDU

in pts. with h/o valve disease
or IVDU -
fever alone should be red flag
Infective Endocarditis -
PE
Fever
heart murmur
Osler's nodes
Janeway lesions
splinter hemorrhages
Roth's spots
Infective Endocarditis -
Dx
Fulfill Duke's criteria:

major criteria -
• pos. BC - 2+ sets
• abnormal echo -
vegetations
paravalvular abscess
new regurg
new partial dehiscence of
prosthetic valve
• TTE - very specific
• TEE - very sensitive

or

1 major and 3 minor
minor criteria -
PE findings
emboli
glomerulonephritis
pos. Rh factor

Other findings -
leukocytosis
left shift
inc. ESR
inc. C-reactive protein
mild anemia
microscopic hematuria
EKG
Infective Endocarditis -
Tx
Tx based on org. & sensitivity
if very ill - empiric
empiric -
antistaph, antistrep & gentamicin
change as soon as know org.

surgery if -
severe CHF from valve incomp
paravalvular leak around
prosthetic valve
fungal endocarditis
persistent bacteremia
despite ABx
extravalvular infection

ABx prophylaxis before:
• dental work -
amoxicillin
if PCN allergy -
clindamycin or
azithromycin, clarithromycin or cephalexin
• urinary or GI procedures -
ampicillin and gentamicin
if PCN allergy -
vancomycin and gentamicin
Candidal Thrush -
What is it
Infection of C. albicans
risk factors -
xerostomia
corticosteroid inhaler use
immune def.
immunosuppressive Tx
leukemia
lymphoma
cancer
diabetes
obesity
pregnancy

can cause skin infections in
noncompromised (diaper rash)
Candidal Thrush -
Hx/PE
White, cream-colored
or yellow plaques
can be scraped off
leaves bleeding surface
freq. complaint of
mucosal burning

oral candidiasis
intertriginous
candidal paronychia
vulvovaginitis - pregnancy, DM
Candidal Thrush -
Dx
Clinical Dx
KOH
Cx - definitive
Candidal Thrush -
Tx
• Hair & nails involved -
can't use topical
must use systemic
• not involved - topical

nystatin
clotrimazole
fluconazole, miconazole
amphotericin


oral nystatin -
4x/day
"swish and swallow"
use for 5-7 days after
lesions disappear
Pneumocystis Carinii Pneumonia
What is it
Org. of low virulence
found in lung of humans
predisposing factor in dev. of PCP -
impaired cell-mediated immunity
Pneumocystis Carinii Pneumonia
Hx/PE
Pneumonia
DOE
dry cough
fever
chest pain

impaired oxygenation
SOB
tachypnea
tachycardia
Pneumocystis Carinii Pneumonia
Dx
• Principle diagnostic test -
bronchoscopy with bronchoalveolar lavage

• CXR -
b/l diffuse perihilar infiltrates
• silver stain and
immunofluorescence
of sputum samples
Pneumocystis Carinii Pneumonia
Tx
TMP-SMX
pentamidine
steroids - adjunct if severe
severe -
PaO2 <70
A-a gradient >35

prophylaxis -
TMP-SMX - oral, #1
dapsone - #2
atovaquone - #3
aerolized pentamidine

prophylaxis can be stopped -
if antiretrovirals raise
CD4 > 200 for >6 mos.
Chlamydia -
What is it
MC bacterial STD in US
Chlamydia trachomatis
can infect genital tract,
urethra, anus and eye
in newborns -
conjunctivitis, pneumonia
coexists or mimics gonorrhea
test for both
Chlamydia -
Hx/PE
Hx -
often asymp
. urethritis -
dysuria
urgency
. mucopurulent cervicitis
vaginal discharge
bleeding
dyspareunia
. salpingitis
. PID -
abdom pain
fever
. nongonocc urethritis - men

PE -
mucopurulent discharge
cervical or adnexal tenderness
penile discharge
testicular tenderness
Chlamydia -
Dx
• Ligase chain reaction test -
of voided urine
• serology-
fluorescent Ab
(swab of male urethra)


(gram stain of discharge -
may show PMNs, but no bact.)
Chlamydia -
Tx
Doxycycline
or azithromycin
pregnant - erythromycin
Chlamydia -
Complications
Chronic infection
pelvic pain
Reiter's syndrome
Fitz-Hugh-Curtis syndrome
PID => infertility
epididymitis
Gonorrhea -
What is it
Gram-neg diplococcus
can infect almost any site in
female repro tract
men - usu limited to urethra
Gonorrhea -
Hx/PE
Greenish-yellow discharge
pelvic or adnexal pain
swollen Bartholin's glands

purulent urethral discharge
dysuria
erythema of urethral meatus
Gonorrhea -
Dx
Swab & culture on
Thayer-Martin medum
gram stain cervical discharge
Cx - most specific test
Gonorrhea -
Tx
single-dose ceftriaxone 250 IM
and doxycycline for 7 days
or
single-dose ceftriaxone 250 IM
and single-dose azithromycin
or
single-dose oral cipro or cefixime

(also treating for chlamydia -
doxycycline or macrolide)

condoms for prophylaxis
Gonorrhea -
Complications
Urethritis
epididymitis
cervicitis
PID
tubo-ovarian abscess & rupture
Fitz-Hugh-Curtis
DGI (Disseminated Gonoc Infec)
persistent infection with pain
Syphilis -
What causes it
Treponema pallidum
spirochete
Syphilis -
Hx/PE
Primary -
10-60 days after infection
chancre (painless ulcer)
near area of contact
spontan heals in 3-9 weeks

Secondary -
1-2 mos. after see chancre
maculopap rash on soles, palms
low-grade fever
headache
malaise
lymphadenopathy
can see alopecia
meningitis, hepatitis &
nephritis may also be seen
very infective 2o eruptions
coalesce => condylomata lata
spontan heals in 2-6 weeks

Early latent -
no symptoms
pos serology
first yr of infection

Late latent -
no symptoms
pos or neg serology
> 1 yr of infection
1/3 will progress to tertiary

Tertiary -
3-20 yrs after init infection
not contagious
gummas
Tabes dorsalis
Argyll Robertson pupil
CV -
aortitis
aortic root aneurysms
aortic regurg
Syphilis -
Dx
• Best diagnostic in primary -
dark-field microscopy
• secondary -
RPR/VDRL
Syphilis -
Tx
• primary & secondary -
IM PCN
2.4 million units/wk
primary - 1 wk
secondary - 3 wks
• tertiary -
IV PCN
10-20 million units/day x 10D
• PCN allergic -
primary & secondary - doxy
tertiary or pregnant - desensitize

Jarisch-Herxheimer -
> 50% of pts.
fever
headache
sweating rigors
temp exacerbations of lesions
6-12 hrs post Tx
Histoplasmosis -
What is it
Dimorphic fungus
environment - mold (mycelial)
yeast in body
endemic - MS River, OH
self-limited flu-like Sxs
mediastinal fibrosis
residual scar tissue

chronic cavitary disease -
if obstructive lung dis.

disseminated histoplasmosis -
esp. in immune compromised
infants
fatal if untreated

risk factors -
AIDS
spelunking
bird and bat feces
Histoplasmosis -
Hx/PE
Acute infection -
arthralgia
erythema nodosum
erythema multiforme

chronic infection -
low-grade fever
anorexia
weight loss
night sweats
productive cough
Histoplasmosis -
Dx
. polysaccharide Ag detection
fast test for Dx and
monitoring relapse
. complement fixation Ab
of 1:8 of 1:16
. silver stain on Bx
bone marrow, l. node, liver
. bronchoalveolar lavage
. CXR
. chest CT
Histoplasmosis -
Tx
amphotericin B
ketoconazole
Coccidioidomycosis -
What is it
Dimorphic fungi
environment -
breaks up into arthroconidia
spherules in tissue
endemic - SW, S. CA
can present as flu-like
or acute pneumonia
if disseminates, can involve -
bone, meninges, skin
the "great imitator"
incubation period is 1-4 weeks
after exposure
Coccidioidomycosis -
Hx/PE
Fever
headache
anorexia
chest pain
cough
dyspnea
night sweats
arthralgias
Coccidioidomycosis -
Dx
. Precipitin Ab -
rise within 2 weeks
disappear after 2 mos.
. complement fixation Ab -
rise at 1-3 mos.
. culture -
sputum
wound exudate
joint aspirate
. CXR
. consider -
bronchoscopy
fine-needle Bx
open lung Bx
pleural Bx
Coccidioidomycosis -
Tx
Ketoconazole or
fluconazole
amphotericin B
Cryptococcosis -
What is it
C. neoformans
encapsulated yeast
in soil with pigeon droppings
can cause asymp pulmon infect
affects meninges
defining opportunistic
infection for AIDS
Cryptococcosis -
Hx/PE
Meningitis -
frontal or temporal headache
fever
impaired mentation
no meningismus

pneumonia -
nonproductive cough
SOB
fever
Cryptococcosis -
Dx
. LP with init eval by india ink
. then cryptococcal Ag testing

. worse prognosis -
high opening pressure
high Ag titer
low CSF cell count

. fungal culture
. latex agglutination test
. CT - if neuro deficits

. fungal meningitis -
CSF glucose dec.
protein inc.
leukocyte count high
lymphocytes predominate
Cryptococcosis -
Tx
IV Amphotericin - 2 wks.
then oral fluconazole for life

prophylaxis -
fluconazole not recommended
effective, but incidence of
meningitis too low
Anthrax -
What is it
B. anthracis
forms spores
gram positive rods
occupational hazard for
veterinarians & farmers
animal wool/hair, hides,
bone meal products
biological weapon
MC - cutaneous
inhalational - most deadly
intestinal
Anthrax -
Hx/PE
Cutaneous -
1-7 days after skin exposure
and penetration of spores
MC - exposed upper ext
pruritic papule
in 24-48 hrs forms ulcer
with edematous halo
in 7-10 days => black eschar
regional lymphadenopathy
Anthrax -
Dx
Aerobic culture
gram stain of ulcer exudate
Anthrax -
Tx
Meningeal anthrax -
PCN - meningeal dose
doxycycline
chloramphenicol
quinolone 1-2 wks (PCN allerg)

ciprofloxacin prophylaxis -
postexposure prophylaxis
60 days to prevent
inhalational anthrax
Lyme Disease -
What is it
Borrelia spirochete
Ixodes tick
usu seen in summer months
endemic - NE, Pacific, NmidW
MC vector-borne dis. in NA
Lyme Disease -
Hx/PE
Rash
fever
malaise
headache
myalgias
joint pain
often recent h/o camping,
hiking in endemic areas
tick needs 24 hours of attachment to transfer Borrelia

primary -
Erythema migrans
eryth macule or papule
at tick-feeding site
slowly expands
central clearing
"bull's eye"

secondary -
migratory polyarthropathy
neuro - Bell's palsy - MC
meningitis
myocarditis
MC - AV heart block

tertiary -
arthritis
subacute encephalitis

severe arthritis -
HLA-DR2
Lyme Disease -
Dx
rash
1 late manifestation
lab confirms org.

ELISA -
pos = exposure, not active dis
Western Blot - to confirm
Lyme Disease -
Tx
Doxycycline - minor Sxs
IV ceftriaxone - major Sxs
Rocky Mt Spotted Fever -
What is it
Rickettsia rickettsii
dermacentor tick
invades endothel lining of cap
=> small-vessel vasculitis
rapidly fatal if untreated
Rocky Mt Spotted Fever -
Hx/PE
Headache
fever
rash - before 6th day

macular pink rash
starts at wrists, ankles
maculopapular and darker
petechial/purpuric as spreads
spreads centripetally (in)
=> palms & soles

in severe cases -
altered mental status
DIC
Rocky Mt Spotted Fever -
Dx
Clinical
confirm -
complement fixation test
Weil-Felix test
Rocky Mt Spotted Fever -
Tx
Doxycycline
UTIs -
What is it
Causes
Cystitis
pyelonephritis
perinephric abscess

cystitis -
very common
affects women > men
E. coli - 80%
• due to -
urinary stasis
foreign body
tumor
stones
stricture
BPH
neurogenic bladder
honeymoon cystitis
• major cause -
catheters
risk related to length (time) of catheterization
UTIs -
UTI bugs
SEEKS PP
S. saprophyticus
E. coli
Enterobacter
Klebsiella
Serratia
Proteus
Pseudomonas
UTIs -
Cystitis
Hx/PE
Dysuria
urgency
frequency
hematuria
low-grade fever
suprapubic pain
PE - suprapubic tenderness

kids - bedwetting
infants -
poor feeding
recurrent febrile episodes
foul-smelling urine
UTIs -
Dx
Best init. test - UA
look for:
WBC = #1
RBC
protein
bacteria

if nitrites - gram neg.
inc. urine pH - Proteus
WBC < 5 is normal

UC > 100,000 colonies confirmatory
not always necessary if -
have Sxs and pos. UA
UTIs -
Tx
Uncomplicated cystitis -
TMP-SMX or any quinolone for 3 days
DM - 7 days
pregnant - no quinolones


elderly, comorbid dis. or
acute toxicity -
admit
IV ciprofloxacin or
ampicillin & gentamicin

recurrent UTIs -
prophylaxis ABx
Pyelonephritis -
What is it
Ascending UTI that has
reached renal parenchyma

More common in -
women
pregnancy
childhood
after catheterization or instrumentation

if immunosuppressed -
prone to Candida

due to obstruction from -
strictures
tumor
stones
bph
neurogenic bladder
vesicoureteral reflux
Pyelonephritis -
Hx/PE
Costovertebral angle tenderness
flank pain
fever/chills
n/v
dysuria
frequency
urgency
Pyelonephritis -
Dx
Clean-catch urine for -
UA, UC, sensitivity
>100,000 colonies suggestive
US - to r/o obstruction

WBC casts
leukocytosis
UC

radiology if -
pregnancy
h/o urolithiasis
prior GU surgery
recurrent pyelonephritis
prepubescent age
fever > 5-7 days without
appropriate med eval
elderly

IVP - #1 choice (if not pregn)
US - safe in pregnancy
CT -
if nondiagnostic IVP & US
if don't respond to therapy
after 3 days of Tx
Pyelonephritis -
Tx
Any ABx or gram neg rods
10-14 days
(fluoroquinolone
TMP-SMX
ampicillin
gentamicin
3rd gen cephalosporin)
Sepsis -
What is it
Systemic infection plus
a reaction called
Systemic Inflammatory Response
Syndrome (SIRS)
Sepsis -
What causes SIRS
A release of many mediators
into the blood that
activate inflammatory and
coag pathways
Sepsis -
What is severe sepsis
Sepsis and signs of failure
of at least 1 organ
Sepsis -
What is septic shock
Sepsis-induced
severe sepsis
organ hypoperfusion
hypotension (systolic BP < 90)
poor response to
init fluid resus
most cases -
hosp.-acq. gram neg bacilli
or gram pos cocci

gram-pos shock -
secondary to fluid loss
caused by exotoxins

gram-neg shock -
caused by vasodilation
due to endotoxin (LPS)
Sepsis -
What causes septic shock in
neonates
Group B strep
E. coli
Klebsiella
Sepsis -
What causes septic shock in
kids
H. influenzae
pneumococcus
meningococcus
Sepsis -
What causes septic shock in
adults
Gram-pos cocci
aerobic bacilli
anaerobes
Sepsis -
What causes septic shock in
IV drug users
S. aureus
Sepsis -
What causes septic shock in
asplenic pts.
Pneumococcus
H. influenzae
meningococcus
(in other words,
encapsulated organisms)
Sepsis -
Hx/PE
Hx -
abrupt onset of fever & chills
often hyperventilation
altered mental status

PE -
fever
tachy
tachypnea
in septic shock -
may start as warm shock
warm skin and extremities
=> cold shock
cool skin and extremities

petechiae or ecchymoses - DIC
elderly pt. with
altered mental status -
consider urosepsis
Sepsis -
Dx
WBCs initially dec.
WBCs inc. in 1-4 hrs.
with inc. PMNs - esp. bands
thrombocytopenia
BC
UC
sputum
CXR
coag studies
DIC panel
Sepsis -
Tx
May need ICU admission
treat aggressively
maintain BP
IV fluids
pressors
ABx
treat underlying cause
Pneumonia -
What is it
Infection of lung parenchyma/alveoli
has inflammatory exudate

• only cause of death in top 10
from infectious disease
• not nec. to have
predisposing condition
• but predisposed if -
cigarettes
DM
alcoholism
malnutrition
immunosuppression
bronchial obstruction (tumor)
neutropenia, steroids => aspergillosis
Pneumonia -
Categories of "typical" and
"atypical"
Typical -
bacteria from nasopharynx

Atypical -
from org. inhaled from envi
hard to see on gram stain
not susceptible to ABx that
act on cell wall (B-lactams)
RSV
adenovirus
mycoplasma
legionella
chlamydia
Pneumonia -
What is aspiration pneumonia
Secondary to inhaling
a large amount of
oropharyngeal secretions
into larynx and lwr resp tract

aspiration of small amount
in pts with impaired
pulmonary defenses

MCC of death in pts. with
dysphagia due to
neurologic d/o
Pneumonia -
What is chemical pneumonitis
Secondary to inhaling
gastric contents
causes chemical injury to lung
Pneumonia -
Hx
Mycoplasma Hx
Legionella Hx
PCP Hx
Productive cough -
green or yellow sputum
rust-colored = pneumococcus
currant jelly = klebsiella
hemoptysis
dyspnea
fever/chills
night sweats
pleuritic chest pain

atypical organisms present -
more gradual onset
dry cough
headaches
myalgias
sore throat
pharyngitis

• Mycoplasma -
dry cough
sore chest
bullous myringitis
anemia (from hemolysis from
cold agglutinins)
rare to be inpatient/need to admit

• Legionella -
confusion
headache
lethargy
diarrhea
abdom pain

• PCP -
marked dyspnea
DOE
chest soreness
cough
HIV+
Pneumonia -
PE
Decreased or
bronchial breath sounds
crackles (rales)
wheezing
dullness to percussion
egophony
tactile fremitus

elderly, COPD or DM -
may have minimal signs on PE
Pneumonia -
Dx
• CXR - initial test
• sputum Cx -
most specific diag. for lobar
(atypicals don't show up on
gram stain or regular Cx)
• invasive tests sometimes to confirm
• open lung Bx - most specific

• Mycoplasma -
Ab titers
cold agglutinins - limited
• Legionella -
special Cx media:
charcoal yeast extract
urine Ag tests
direct fluorescent Ab
Ab titers
• PCP -
bronchoalveolar lavage
increased LDH
• Chlamydias, Coxiella, Coccidio -
Ab titers



. CBC -
leukocytosis
left shift
. sputum gram stain & culture-
ID org.
ID ABx susceptibility
good sputum sample -
many PMNs (> 25 cells/hpf)
few epith cells (< 25/hpf)
. BC
. ABG
. for recurrent pneumonias -
consider underlying dis.
Pneumonia -
Outpt community-acq < 65 y/o
otherwise healthy
What are pathogens
S. pneumoniae
M. pneumoniae
Chlamydia
H. flu
viral
Pneumonia -
Outpt community-acq < 65 y/o
otherwise healthy
What is init coverage
In uncomplicated cases,
tx on outpt basis
erythromycin
tetracycline

smokers with H. flu -
clarithromycin
azithromycin
Pneumonia -
Outpt community-acq > 65 y/o
or with comorbidity
What are pathogens
S. pneumoniae
H. flu
E. coli
Enterobacter
Klebsiella
S. aureus
Legionella
viruses
Pneumonia -
Outpt community-acq > 65 y/o
or with comorbidity
What is init coverage
Require admission
cefuroxime (2nd gen cephalo)
TMP-SMX
amoxicillin
if atypicals suspected -
add erythromycin
if pt has obstructive dis. -
add pseudomonal coverage
Pneumonia -
Community-acq req. admission
What are pathogens
S. pneumoniae
H. flu
anaerobes
aerobic GNRs
Legionella
Chlamydia
Pneumonia -
Community-acq req. admission
What is init coverage
Cefotaxime or
ceftriaxone (2nd or 3rd gen)
or
B-lactam with B-lactam inhib
if atypicals suspected -
add erythomycin
Pneumonia -
Severe community-acq req. ICU
What are pathogens
S. pneumoniae
H. flu
anaerobes
aerobic GNRs
Mycoplasma
Legionella
Pseudomonas
Pneumonia -
Severe community-acq req. ICU
What is init coverage
Erythromycin
macrolide
and antipseudomonal agent
and aminoglycoside
Nosocomial pneumonia -
(hospitalized > 48 hrs or in
long-term care fac. > 14 days)
What are pathogens
E. coli
Enterobacter
Klebsiella
Pseudomonas
S. aureus
Legionella
mixed flora
Nosocomial pneumonia -
(hospitalized > 48 hrs or in
long-term care fac. > 14 days)
What is init coverage
3rd gen cephalosporin with
anti-pseudomonal activity
and gentamicin
Pneumonia -
Who gets pneumococcal vaccine
> 65 y/o
any serious lung, cardiac,
liver, renal disease
immunocompromised
splenectomized
sickle cell
DM
leukemia
lymphoma

60-70% effective
redose in 5 years if -
severe immunocompromised
original vaccine at < 65 y/o
Tuberculosis -
What is it
Mycobacterium tuberculosis
most cases of symptomatic TB -
reactivation of old infection
remain confined to lung
common cause of FUO
MC site of extrapulmonary
infection -
lymph nodes (adenitis)

most significant defect
associated with reactivation -
impaired T cell-mediated
cellular immunity

risk factors -
immunosuppression
alcoholism
preexisting lung dis.
immigrants from
developing nations
DM
advancing age
homelessness
manourishment
crowded living conditions
prisoners
nursing home residents
health care workers
sick contacts
Tuberculosis -
Hx/PE
Cough
hemoptysis
weight loss
night sweats
dyspnea
fever
cachexia
hypoxia
tachy
lymphadenopathy
abnormal lung sounds
(positive Babinski -
when affects spine)
Tuberculosis -
Dx
• CXR - best init test
• AFB stain -
allows for specific Dx
need 3 neg. for >90% sensitivity
• Cx -
the most specific
need for sensitivity testing
• pleural Bx -
most sensitive test

• if AFB stain unrevealing -
thoracentesis
gastric aspirate (kids)
Bx (extrapulmonary organ)
needle aspiration (extrapul)
LP (if meningitis)
Tuberculosis -
PPD test
Length of induration measured
at 48-72 hrs.
BCG vaccine- PPD pos. for 1 yr

2-stage testing -
no recent PPD test
have reactivity < 10mm
2nd test within 2 weeks

Pos. results indicated by -
5 mm -
HIV
close TB contacts
steroid use
organ transplant recipient
abnorm CXR -
old, healed TB

10 mm -
homeless
recent immigrant
IVDU
chronic illness
residents of health &
correctional institutions
healthcare workers
immunocompromised other than in "5mm" group

15 mm -
everybody else

if pos. PPD -
get CXR
abnormal CXR -
get 3 AFB
if pos. AFB - Tx
if neg. AFB -
latent TB
INH and B6 for 9 mos.
("prophylaxis")

if pos. PPD -
get CXR
normal CXR -
latent TB
INH and B6 for 9 mos.
("prophylaxis")
Tuberculosis -
Tx
• All cases reported to local
& state health depts.
• respiratory isolation

Directly Observed Therapy -
• rifampin (RIF)
ethambutol (ETB)
pyrazinamide (PZA)
INH & B6
for 2 months (until know sensitivity)
• ETB & PZA discontinued
cont. RIF & INH for 4 more mos.
• if sensitivity not known -
give ETB

• TB meningitis -
Tx 12 mos.
TB meds and steroids
• TB pericarditis -
TB meds and steroids
• TB in pregnancy - Tx 9 mos.
• TB in osteomyelitis & HIV -
Tx 6-9 mos.

• pregnant -
no pyrazinamide
no streptomycin
• all but streptomycin => liver toxicity
RIF - stains contacts and underwear
ETB - optic neuritis
=> color blind
PZA - benign hyperuricemia
don't Tx unless gout Sxs
Fever of Unknown Origin (FUO)-
What is it
MCC
Risk factors
Temp > 38.3 for 3 weeks
undx after 3 outpt visits
or 3 days of hospitalization

MCC - infections & cancer
autoimmune dis. (15%)

Risk factors -
recent travel
immune deficiency
drug abuse
Fever of Unknown Origin (FUO)-
Hx/PE
Fever
headache
myalgia
malaise
Fever of Unknown Origin (FUO)-
Dx
CBC with diff
BC
ESR
CXR
PPD
CT & MRI - if malig or abscess suspected
specific tests if infectious
or autoimmune suspected
Fever of Unknown Origin (FUO)-
Tx
If severely ill -
empiric broad-spectrum ABx
stop if no response
Neutropenic Fever -
What is it
One oral temp of 38.3
or 38.0 > 1 hr.
in neutropenic pt.

38.3 C = 101 F
38.0 C = 100.4 F
Neutropenic Fever -
Hx/PE
Cmn in pts. undergoing chemo
ANC nadir 7-10 days post chemo
if severely neutropenic -
inflammation may be min. or 0

pain at MC infected sites -
skin
eye
peridontium
pharynx
lungs
lwr esoph
abdomen
perineum
anus
Neutropenic Fever -
Dx
Thorough PE
NEVER do rectal exam
CBC with diff
BC
BUN/Cr
transaminases
CXR - if resp signs
CT - to check for abscess
Neutropenic Fever -
Tx
Empiric ABx
Tx algorithm
Congenital Infections -
Common sequelae
Can occur at any time during
pregnancy, labor, delivery

common sequelae -
premature delivery
CNS abnorm
jaundice
anemia
hepatosplenomegaly
growth retardation
Congenital Infections -
What are they
(mnemonic)
TORCHeS
Toxoplasmosis
Other
Rubella
CMV
Herpes
Syphilis
Congenital Infections -
Toxoplasmosis
How transmitted
Specific findings
Transplacental - rare
primary infection -
consumption of raw meat -
undercooked pork & lamb
contact with cat feces

Specific findings -
intracranial calcifications
chorioretinitis
hydrocephalus
ring-enhancing lesions on
Head CT

immunocompetent - usu asymp
best diag. test -
visualize parasite in tissue or fluid
MC - serology
Congenital Infections -
Other (TORCHeS)
What are they
HIV
parvovirus
Varicella
Listeria
TB
malaria
fungi
Congenital Infections -
Rubella
How transmitted
specific findings
Transplacental transmission
in 1st trimester

Specific findings -
rubella
r - r p
b - c d
l - m m

purpuric blueberry muffin Rash
PDA
Cataracts
Deafness
Mental retardation
Microcephaly
Congenital Infections -
CMV
How transmitted
specific findings
CMv is MC congenital infection
transplacental transmission

Specific findings -
petechial rash
periventricular calcifications
Congenital Infections -
Herpes
How transmitted
specific findings
Intrapartum transmission if
mom has active lesions

Specific findings -
skin, eye and mouth infections
life-threatening CNS/systemic
infection
Congenital Infections -
Syphilis
How transmitted
specific findings
Intrapartum transmission

Specific findings -
maculopapular skin rash
lymphadenopathy
hepatomegaly
"snuffles" - mucopur rhinitis
osteitis

In childhood, late congen -
saber shins
saddle nose
CNS involvement
Hutchinson's triad -
peg-shape upr central incisors
deafness
interstitial keratitis
(photophobia, lacrimation)
Congenital Infections -
Dx
Serologic testing -
rubella
toxoplasmosis
HSV

UC - CMV

syphilis -
dark field exam - skin lesions
material serum

test cord blood for inc. IgM

viral isolation
amniocentesis - PCR for CMV
antigen detection

all ill newborns -
BC
LP
empiric ABx
Congenital Infections -
Toxoplasmosis
Tx
Pyrimethamine
sulfadiazine
spiramycin (if 3rd trimester)
Congenital Infections -
Syphilis
Tx
PCN
Congenital Infections -
HSV
Tx
Acyclovir
Congenital Infections -
CMV
Tx
Ganciclovir
Congenital Infections -
Toxoplasmosis
Prevention
Avoid exposure to cats &
cat feces during pregnancy
women with primary infection -
pyrimethamine and
sulfadiazine
in third trimester -
spiramycin
Congenital Infections -
Rubella
Prevention
Immunize before pregnancy
consider abortion if
infected or exposed
vaccinate mom after delivery
if titers remain negative
Congenital Infections -
Syphilis
Prevention
PCN in pregnant women who
test pos.
Congenital Infections -
CMV
Prevention
Avoid exposure
Congenital Infections -
HSV
Prevention
C-section if lesions present
at delivery
Congenital Infections -
HIV
Prevention
AZT - pregnant with HIV
C-section
AZT prophylaxis - infant
no breast-feeding
Osteomyelitis -
What is it
Three types:
• acute hematogenous -
kids
long bones of lwr ext
MC - staph
• secondary to contig infection -
recent trauma
placement of prosthesis
MC - polymicrobial
MC single org. - staph
• vascular insufficiency -
>50 y/o
DM or PVD
repeated minor trauma
not noticed cuz of neuropathy
small bones of lwr ext
MC - polymicrobial
MC single org. - staph
Osteomyelitis -
Common Pathogens
Most people - staph
IVDU - staph or pseudomonas
SCD - salmonella
hip replaced - s. epidermidis
foot puncture wound - pseudomonas
chronic -
staph, pseudomonas,
enterobacter
Osteomyelitis -
Hx/PE
Fever
localized bone pain
localized warmth,
tenderness,
swelling,
erythema
limited ROM
Osteomyelitis -
Dx
• XR - initial test
periosteal elevation - 1st abnorm
• technetium bone scan
MRI - better differentiation
• ESR -
nonspecific
can follow during Tx
• Bx and Cx -
best diagnostic
most invasive
Osteomyelitis -
Tx
Depends on isolate

oxacillin/nafcillin
and
aminoglycoside or 3rd gen ceph
until specific Dx

chronic -
12 wks of IV therapy
then 8-12 wks orally
Osteomyelitis -
Complications
Chronic osteomyelitis
soft tissue infection
sepsis
septic arthritis

chronic osteomyelitis with
draining sinus tract
=> squamous cell ca
(Marjolin's ulcer)
HIV -
What is it
Risk factors
Retrovirus
targets and destroys CD4+

CD4+ count = marker for
extent of disease progression
viral load = indicates rate

Risk factors -
MC risk - IVDU
2nd MC risk - homosexuality
unprotected sex
maternal HIV infection
needle sticks
mucocutaneous exposure
receipt of blood products
HIV -
Hx/PE
Primary infection often asymp
may present with flu-like Sxs
Later -
night sweats
weight loss
thrush
cachexia
complications correlate with
CD4+ count
HIV -
Dx
ELISA -
high sensitivity
moderate specificity
detects anti-HIV ab
can take up to 6 mos. to
appear after exposure

Western blot -
confirmatory
low sensitivity
high specificity

viral load
PPD with anergy panel
VDRL
CMV serology
toxoplasmosis serology
HIV -
Tx
Tx During Pregnancy
Tx for Needlesticks
• Start when -
CD4+ <350 or
viral load >55,000 (PCR-RNA)
2 rev. trans. + prot. inhib
or 2 rev. trans. + 2 prot. inhib
or 2 rev. trans. + efavirenz

• adequate Tx -
viral load dec. 50% in 1st mo.

• viral sensitivity/resistance monitoring -
meds failing/not suppressing


PREGNANCY -

• if low CD4+ or high load -
3x's antiretrovirals as nonpregnant pt.
• C-section -
only if CD4+ & viral load not controlled
• all get AZT
• start AZT by 14th week
• AZT => transient anemia
• no efavirenz - teratogen


Postexposure Prophylaxis
(Needlestick) -
AZT + lamivudine + nelfinavir
for 4 weeks
HIV -
PCP

CD4+ Level at Presentation
Tx
CD4+ <200

TMP-SMX
pentamidine
steroids - if severe

prophylaxis -
TMP-SMX - orally, #1
dapsone - #2
atovaquone -#3
pyrimethamine - aerolized, #4

prophylaxis may be discontinued
if antivirals raise CD4 >200
for more than 6 mos.
HIV -
Mycobacterium Avium Complex

CD4+ Level at Presentation
Tx
CD4+ <50

clarithromycin and ethambutol

prophylaxis -
azithromycin - orally once a week
or clarithromycin BID
rifabutin - alternative

prophylaxis can be stopped if
antiretrovirals raise
CD4 >100 for several months
HIV -
Toxoplasma

CD4+ Level at Presentation
Tx
CD4+ <100

pyrimethamine and sulfadiazine
(clindamycin is substitute
for sulfadiazine if sulfa-allergy)

prophylaxis -
TMP-SMX
dapsone/pyrimethamine
HIV -
TB
Indication for prophylaxis
Medication
PPD > 5mm

INH x 9 mos. or
rifampin + pyrazinamide or
rifabutin + pyrazinamide
HIV -
Candida
Indication for prophylaxis
Medication
Multiple recurrences

Fluconazole or
itraconazole
HIV -
HSV
Indication for prophylaxis
Medication
Multiple recurrences

Acyclovir or
famciclovir or
valacyclovir
HIV -
Pneumococcus
Indication for prophylaxis
Medication
All patients

Pneumovax
HIV -
Influenza
Indication for prophylaxis
Medication
All patients

Influenza vaccine
Otitis Externa -
What is it
Common etiologic agents
"Swimmer's ear"
inflammation of skin lining
ear canal and surrounding
soft tissue

from moisture -
=> maceration of skin
breeding ground for bacteria

from trauma -
usu from objects for cleaning

Pseudomonas
Enterobacteriaceae
Otitis Externa -
Hx/PE
Pain
pruritus
possible purulent discharge

pain with movement of
tragus/pinna
edematous, eryth ear canal
Otitis Externa -
Dx
Clinical
gram stain & culture if
suspect fungal
CT if pt. looks toxic
Otitis Externa -
Tx
Eardrops -
polymyxin B
neomycin
hydrocortisone

acute - dicloxacillin

DM -
at risk for malignant OE
at risk for osteomyelitis of skull bone
admit
IV ABx
Encephalitis -
What is it
Inflammation of the brain
meninges and parenchyma
MCC - viral infection
MC virus - HSV
Encephalitis -
Hx
Can have any level of neuro deficit
any level of focal deficit
1st clue -
altered mental status, fever, headache

nuchal rigidity
mild lethargy
confusion
stupor
coma
Encephalitis -
PE
Focal neuro signs -
hemiparesis
focal seizures
autonomic dysfunction

inc. ICP
SIADH
Encephalitis -
Dx
CT or MRI
HSV affects temporal lobe
LP - key to Dx
PCR - eliminates need for Bx
Encephalitis -
Tx
HSV - immediate IV acyclovir
CMV - ganciclovir or foscarnet
HIV - if suspect resistant HSV
foscarnet
Meningitis -
What is it
Risk factors
Infection of leptomeninges
most cases - sporadic

• contiguous local spread -
otitis media
mastoiditis
sinusitis
dental infections

• spreads hematogenously -
endocarditis
pneumonia

• S. aureus - surgery
cryptococcus - <100 T cells
RMSF
Lyme
TB
syphillis
• Listeria -
immune defects, esp. T cell
HIV
steroids
leukemia
lymphoma
chemo
neonates & elderly -
they have dec. T cell function
Meningitis -
Hx/PE
Fever
malaise
headache
neck stiffness
photophobia
altered mental status
seizures

MC focal neuro deficits -
visual fields
CN

MC long-term damage - CN8

signs of meningeal irritation-
Kernig and Brudzinski
often absent in < 2 y/o
Meningitis -
Dx
LP - to establish Dx
CSF Cx - most accurate test
cell count & differential -
most useful

CT best init test if -
papilledema
focal motor deficits
severe abnorm in mental status
give ceftriaxone prior

if 20-30 min. delay in LP -
best init step -
ceftriaxone or cefotaxime
add ampicillin if suspect Listeria
Meningitis -
Tx
Empiric - ceftriaxone or cefotaxime
Listeria - add ampicillin
Staph after surgery - vanco
PCN resistant - vanco
Lyme - ceftriaxone
Syphllis - PCN
TB - steroids (adults)
viral - no proven useful Tx
cryptococcus - amphotericin, then lifelong fluconazole if also HIV pos.


contacts of pts. with
meningococcal meningitis -
rifampin prophylaxis
Meningitis -
Complications
Tx
Hyponatremia -
admin fluids
monitor sodium concentration

Seizures -
benzos
phenytoin

Subdural effusions -
may be seen on CT
50% of infants with
H. influenzae meningitis
no Tx necessary

Cerebral edema -
presents with loss of
oculocephalic reflex
IV mannitol

Subdural empyema -
presents as intractable Szs
surgical evacuation

Brain abscess -
surgical drainage

Ventriculitis -
presents as:
worsening clinical pic
yet improved CSF findings
need ventriculostomy,
possibly intraventricular ABxs
Sinusitis -
What is it
Risk factors
Infection of sinuses due to
undrained collection of pus
MC infected - maxillary

Risk factors -
barotrauma
allergic rhinitis
viral infection
asthma
smoking
nasal decongestant overuse
Sinusitis -
Acute sinusitis
Definition
MC associations
Sxs last < 1 mo.

MC associated with -
S. pneumonia
H. influenza
Moraxella catarrhalis
viral infection
Sinusitis -
Chronic sinusitis
Definition
Sxs persist > 3 mos.
often ongoing low-grade
anaerobic infections

DM -
mucormycosis can start in
nose and maxillary sinuses
Sinusitis -
Hx/PE
Fever
facial pain
can radiate to upper teeth
nasal congestion
headache
headache worse when lean forward

tenderness
erythema
swelling over affected area
purulent discharge

in chronic -
pain may be absent

febrile ICU pts. -
may have occult sinusitis
esp. if intubated or have NGT
Sinusitis -
Dx
• Obvious cases -
no XR before Tx
• maxillary sinus XR - best init test
air-fluid levels
opacification
• coronal CT -
greater detail
• sinus puncture -
if don't respond to Tx
freq. recurrences
confirms bacteria
Sinusitis -
Tx
Mild or acute uncomplicated -
decongestant
(oral pseudoephedrine or
ozymetazoline spray)

severe pain & discolored discharge -
amoxicillin - best initial
amoxicillin-clavulanate -
if recent amoxicillin use
or don't respond
or 2nd or 3rd ceph OK to use
Sinusitis -
Complications
Osteomyelitis of frontal bone
meningitis
orbital cellulitis
cavernous sinus thrombosis
abscess of epidural or
subdural spaces
Acute Pharyngitis -
What is it
Etiologies
Usu self-limited
must differentiate strep
from other causes
MC - viral causes

Grp A B-hemolytic strep
Grp C B-hemolytic strep
N. gonorrhoeae
C. diphtheria
M. pneumonia

rhinovirus
coronavirus
adenovirus
HSV
EBV
CMV
influenza
coxsackie
Acute Pharyngitis -
Hx/PE
Typical of strep -
sudden-onset sore throat
pharyngeal erythema
fever
ant. cervical lymphadenopathy
soft palate petechiae
headache
vomiting
scarlatiniform rash
tonsillar exudate -
EBV can give exudate
mild S. pyogenes may not
Acute Pharyngitis -
Dx
Clinical
rapid group A strep Ag detect
throat culture

pos. rapid group A strep Ag -
equivalent to pos. Cx
neg. test - confirm with Cx
Acute Pharyngitis -
Tx
Reduce symptoms -
fluids
rest
antipyretics
salt-water gargles

PCN V po x 10 days or
PCN G benzathine M x 1 dose

if allergic to PCN -
macrolides
oral, 2nd gen cephalosporins
Acute Pharyngitis -
Complications
Nonsuppurative -
acute rheumatic fever
poststrep glomerulonephritis

suppurative -
cervical lymphadenitis
mastoiditis
sinusitis
otitis media
retropharyngeal or
peritonsillar abscess

peritonsillar abscess -
odynophagia
trismus (lockjaw)
muffled voice
u/l tonsil enlargement, erythema
uvula & soft palate deviate away
Tx -
intraoral US or CT
Cx abscess fluid
drain
PCN or erythromycin
elective tonsillectomy later
Lymphogranuloma Venereum -
What is it
Contagious STD
Chlamydia trachomatis
Lymphogranuloma Venereum -
Hx/PE
Lesion ulcerates & heals
u/l inguinal lymph nodes enlarge
=> draining buboes
scar formation
fever
joint pains
headache
Lymphogranuloma Venereum -
Dx
Clinical exam and Hx
high or inc. Ab titer
isolate Chlamydia from bubo pus
Lymphogranuloma Venereum -
Tx
Doxycycline
erythromycin - alternative
Chancroid -
What is it
Haemophilus ducreyi
gram neg rod
Chancroid -
Hx/PE
Small, soft, painful papules
become shallow ulcers
have ragged edges
vary in size & coalesce
inguinal lymph nodes enlarge
Chancroid -
Dx
Clinical
gram stain with Cx to confirm
PCR
Chancroid -
Tx
Azithromycin single dose
or ceftriaxone 250 IM one dose
erythromycin x7D (alternative)
cipro x3D (alternative)
Genital Herpes -
What is it
HSV-2 (85%)
HSV-1 can be seen
Genital Herpes -
Hx/PE
Vesicles erode
painful, circular
with red areola
can have inguinal lymphadenopathy
relapses
Genital Herpes -
Dx
Tzanck smear and Cx
Genital Herpes -
Tx
Acyclovir
famciclovir or
valacyclovir
Granuloma Inguinale -
What is it
Chronic granulomas
spread by sexual contact
Donovania granulomatis
Calymmatobacterium granulomatis
Granuloma Inguinale -
Hx/PE
Painless, red nodule
develops into elevated granuloma
heals slow
scars form
Granuloma Inguinale -
Dx
Giemsa or Wright stain
Donovan bodies - confirm
punch Bx
Granuloma Inguinale -
Tx
Doxycycline or TMP/SMZ
erythromycin (alternative)
Genital Warts -
What are they
HPV 6 & 11
Genital Warts -
Hx/PE
Soft, moist, pink or red
grow fast
cauliflower appearance
condylomata acuminata
Genital Warts -
Dx
Clinical
must differentiate between -
warts and c. lata of syphilis
Genital Warts -
Tx
Remove -
curettage
sclerotherapy
trichloroacetic acid
cryotherapy
podophyllin
laser
imiquimod (immune stimulant)
Perinephric Abscess -
What is it
Causes
Not common
• pyelonephritis => abscess
rupture into perinephric space
• caused by -
any factor predisposing to pyelonephritis
stones - #1
structural abnorm
trauma
recent surgery
DM
• "SEEKS PP" pathogens
MC - E. coli
then Klebsiella,
Proteus
S. aureus - hematogenous
Perinephric Abscess -
Hx/PE
Insidious
2-3 wks of Sxs before 1st visit
fever
flank pain
abdom pain
palpable abdom mass
persistence of pyelonephritic Sxs even tho Tx for pyelonephritis
Perinephric Abscess -
Dx
UA/UC - init. tests
fever, pyuria & neg. UC or
polymicrobial UC - suggestive
US - best init. scan
CT or MRI - better imaging
Bx - nec. for definitive bacterial Dx
Perinephric Abscess -
Tx
Abx for gram neg rods
drainage (usu percutaneous)

ex. -
3rd gen ceph
antipseudomonal PCN
ticarcillin/clavulanate
often with aminoglycoside
Brain Abscess -
What is it
• Bacteria spread from contiguous infections -
dental infections
otitis media
mastoiditis
sinusitis
• spread hematogenously -
endocarditis
pneumonia
• Toxoplasmosis can reactivate
if CD4 <100

MC have Strep
then Bacteroides,
Enterobacteriae,
Staph,
polymicrobial
Brain Abscess -
Hx/PE
MC Sx - headache
fever
focal neuro
seizures
Brain Abscess -
Dx
CT with contrast - init test
MRI - more accurate
bacteria -
Bx for gram stain and Cx
Brain Abscess -
Tx
HIV -
90% Toxo or lymphoma
empiric Tx to establish Dx
if respond to sulfadiazine and pyrimethamine,
continue Tx

Other Tx - based on etiology
Bronchitis -
What is it
Infection limited to bronchial tree
Caused by -
S. pneumonia
H. influenza
Moraxella
viruses
MC causative factor - cigarettes
acute and chronic form
chronic can => COPD
Bronchitis -
Hx/PE
Cough
sputum
discolored sputum = bacteria
may have low-grade fever
most are afebrile
Bronchitis -
Dx
Clinical
CXR - 1st test
normal CXR confirms!
Bronchitis -
Tx
Mild -
no Tx needed
usually from virus
resolves spontaneously

severe -
amoxicillin,
doxycycline
or TMP-SMZ

repeated infection
or not responding -
amoxicillin/clavulanate,
clarithromycin,
azithromycin,
oral 2nd or 3rd gen cephalo
or new fluoroquinolones
Lung Abscess -
What is it
Necrosis of pulmonary parenchyma
caused by bacterial infection

90% - anaerobes involved
Staph
E. coli
Klebsiella
periodontal disease
predisposition to aspiration
noninfectious causes -
pulmonary infarction
cancer
vasculitis (Wegener's)
Lung Abscess -
Hx/PE
Fever
cough
chest pain
foul-smelling sputum
chronic course
Lung Abscess -
Dx
CXR
CT
Bx - for specific bact. Dx
sputum for gram stain & Cx -
will NOT show causative org.

common sites of aspiration -
lower lobes - if upright
post. segment of rt. upr lobe -
if supine
Lung Abscess -
Tx
Clindamycin - empiric
PCN - alternate empiric
Impetigo -
What is it
Skin infection
mainly kids
S. pyogenes
S. aureus (bullous)

untreated =>
lymphangitis
a. glomerulonephritis
cellulitis
furunculosis
Impetigo -
Hx/PE
Superficial
pustular
oozing, crusting, draining of lesions

• common on -
arms, legs, face
• may follow trauma to skin
• maculopapular => vesicles
Impetigo -
Tx
Oral 1st gen ceph or
ox-, clox-, or dicloxacillin
mild -
topical mupirocin or bacitracin
PCN-allergy - macrolide
Erysipelas -
What is it
Superficial cellulitis
S. pyogenes
Erysipelas -
Hx/PE
B/L
shiny, red, edematous
face, arms, legs
Erysipelas -
Tx
If can't tell from cellulitis-
1st gen cephalosporin
oxa-, cloxa, dicloxacillin

if sure Strep -
PCN
Tinea Versicolor -
What is it
Skin infection
Malassezia furfur
(Pityrosporum orbiculare)
Tinea Versicolor -
Hx/PE
Tan, brown, white lesions
coalesce
chest, neck, abdomen, face
lesions do not tan
Tinea Versicolor -
Tx
Topical selenium sulfide,
ketoconazole,
oral itraconazole
Scabies -
What is it
Parasitic skin infection
Sarcoptes scabiei
(itch mite)
transmitted skin-to-skin contact
Scabies -
Hx/PE
Digs into skin at skin folds
burrows
pruritis
flexor surfaces of -
wrists
finger webs
axillary folds
areola (women)
genitals (men)
Scabies -
Dx
See in scrapings (mineral oil)
Scabies -
Tx
Permethrin
lindane (Kwell)
Pediculosis -
What is it
Skin infestation by lice
• Head -
pediculus humanus capitis
• Body -
pediculus humanus corporis
Pediculosis -
Hx/PE
Itching
excoriation
secondary bacterial infections
Pediculosis -
Dx
Direct exam of hair-bearing surfaces
Pediculosis -
Tx
Permethrin
lindane (Kwell)
Molluscum Contagiosum -
What is it
Skin-colored, waxy,
umbilicated papule
poxvirus
Molluscum Contagiosum -
Hx/PE
Small papules
central umbilication
anywhere on skin
asymptomatic

adults -
usually by venereal contact
genitals, pubic area
Molluscum Contagiosum -
Dx
Appearance
giemsa stain -
large cells with
inclusion bodies
Molluscum Contagiosum -
Tx
Freezing
curettage
electrocautery
cantharidin
Gas Gangrene
(Clostridial Myonecrosis) -
What is it
Wounds contaminated by
Clostridium perfringens
not common
inc. in wartime
trauma (50%)
shrapnel
MVA
postop
nontraumatic
uterine gangrene -
was complication of
improper abortion
Gas Gangrene
(Clostridial Myonecrosis) -
Hx/PE
<1-4 days of incubation -
pain, edema
=> hypotension
tachycardia
fever
crepitation
renal failure
Gas Gangrene
(Clostridial Myonecrosis) -
Dx
Gram stain -
pos. rods, no WBC
Cx - not diagnostic
gas bubbles on XR - not diag.
diagnostic -
direct visualization
pale, dead muscle
brown, sweet-smelling discharge
Gas Gangrene
(Clostridial Myonecrosis) -
Tx
High-dose PCN
PCN-allergy - clindamycin
surgical debridement
or amputation
hyperbaric O2 - controversial
Septic Arthritis -
What is it
Infection due to any agent
MC - bacterial
rickettsia, virus, spirochete
may also cause
gonococcal and nongonococcal

• nongonococcal -
any previous damage to joint
OA, RA
previous surgery
prosthesis placement
IVDU
gout
sickle cell
gram pos -
S. aureus (60%)
Strep (15%)
gram neg (15%)
polymicrobial
Septic Arthritis -
Hx/PE
• Gonococcal -
polyarticular 50%
tenosynovitis
migratory polyarthralgia
petechiae & purpura

• nongonococcal -
monoarticular
swollen, tender
erythematous
dec. ROM
usually knee
Septic Arthritis -
Dx
• gonococcal -
hard to Cx
Cx sites other than knee -
greater yield

• nongonococcal -
synovial fluid aspiration:
Cx
gram stain
cell count -
high
mainly PMN
low glucose
Septic Arthritis -
Tx
• gonococcal -
ceftriaxone

• nongonoccocal -
good empiric -
staph/strep & gram-neg. drug
nafcillin or oxacillin &
aminoglycoside or 3rd gen ceph
Myocarditis -
What is it
Associated with every group of
infectious agent
MC - Coxsackie B
also noninfectious -
radiation
drugs
collagen vascular dis.
hyperthyroidism
Myocarditis -
Hx/PE
Any presentation possible
MC - dyspnea & fatigue
can be asymp,
subclinical,
or rapid progression to death

PE -
normal or
S3 and murmurs
Myocarditis -
Dx
Any EKG abnormality
MC - ST-T changes
any type of heart block possible
cardiac enzymes may be inc.
Ab titers may be inc.
viruses may be isolated -
stool
saliva
NPA

endomyocardial Bx -
best diag. test
Myocarditis -
Tx
Viral -
supportive
most spontan resolve
no steroids (damaging)

other Tx depends on agent