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809 Cards in this Set
- Front
- Back
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Variellation
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Using infected lesion to innoculate w/ smallpox
Smallpox develops,but has lower mortality rate that native infection |
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Most important infectious diseases for world medicine
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HIV
TB Malaria 6 million deaths/year 25% of deaths in developing world |
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Vaccination with vaccina
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Live attenuated virus for smallpox immunity
Scar is sign of immunity |
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Dimorphic fungi
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Mycelia, fruiting bodies, spores in environs
Yeast in body |
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Biggest factor increasing life expectancy in US
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Childhood vaccination
Adding 25 years from 1900 to 2000 |
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one DALY
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Loss of one year of time at full health
Metric combines disability and premature mortality |
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Effect of pneumoncoccal vaccination of kids
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Give to kids under 2
Big reduction in invasive pneumococcus in less than 5 Also reduced pneumococus disease in older people who were not vaccinated Herd immunity Reduced carriage in young kids |
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What protects fetus from infections
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Placenta and amnion
Maternal immune system |
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Live attenuated vaccine
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Weakened virus or bacteria
via passage in culture or animal host Immune response depends on replication of live agent in host Induce broad immune response 1 or 2 doses get long immunity No adjuvants or preservativies |
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What else do TB, malaria, HIV cause
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Poverty from loss of work, education
Social instability Political instability Dropping per capita income in subsaharan africa |
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Examples of live vaccines
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Oral poio
rotavirus MMR VZV Live, attenuated nasal influenza Yellow fever vaccine |
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Histoplasma capsulatum
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Intracellular organism
Pathology similar to TB |
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Inactivated vaccines
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Killed whole organisms
or component Immune response generally limited to serum antibody production 3 or more doses required May contain preservatives/adjuvants ammonium to increase immune response non-specifically |
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Gobal anti-AIDS efforts
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HAART for > 6 million
Care for orphans Education |
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Formulations of inactivated vaccines
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Inactivated whole organisms
Toxoids Recombinant antigen Polysaccarides Polysaccharide conjugated to protein carrier |
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Who is at risk for STDs
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Youth
Minorities Multiple sexual partners Socially marginalized Those who live in areas of high prevalence Immigrants from more endemic areas |
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Examples of inactivated vaccines
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Diptheria
Salk poli Influenza HepB H. flu Pneumo conjugate Menigo conjugate HPV vaccine |
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Economic impact of TB
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Avg loss of 3-4 months of work
Cause 12 billion to world |
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Measuring effectiveness of vaccine
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Immunogenicity - measurable immune response - proportion of seroconversion or antibody titer level
Efficacy - calculation of how well vaccine prevents disease |
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Histoplasma geographic
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Mississippi/Ohio River Valley
SE US St Lawrence valley Grows in soil (esp enriched in nitrogren) Soils lacking montmorillonite clay Soil enriched with bird droppings |
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Efficacy
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[1 - (AR immunized)/(AR unimmunized)]x100
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Global effort to Stop TB
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DOTS
w/ political commitment, case-deteciton, standardized treatment w/ supervision, effective drug supply, monitoring system Address HIV/TB, MDR Health care system strengthening Engaging all provider Empowering pts and community |
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Vaccine reactions
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Site reactions
Fever (febrile seizures) Immediate rxns - syncopy, hypersensitivity Neurologic disease |
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Where does baby immunity come from?
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Passive immunity from mother (starts acquiring at 20 weeks and lasts until about 6 months)
Own immune system, active immunity becomes predominant at about 6 months |
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Immunization strategies
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Routine - universal
Limited to persons at higher risk for disease (underlying disease, occupation, travel, post-exposure, disease outbreaks) |
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Impact of malaria
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40% of public health expenditure
50% of admissions and visits Leading cause of mortality <5 1 million deaths a year Dissproportionate effect on pregnant |
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Goal of vaccination
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Reduce disease caused by organism,
not infection by organism |
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Histo in colony
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Moist creamy colonies that produce fuzzy edges in a few days
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Relative contraindications to vaccines
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Live vaccines - pregnancy, immunodeficiency
Allergy to component Previous rxn to vaccine |
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Economic impact of malaria
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Reduced ability to gather crops
25% of family income to prevention |
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Opportunity costs of nosocomial infections
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Other pts cannot get treatment because hospital is full of pts being treated for their nosocomial infections
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Non-tuberculous mycobacterium
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Soil and water organisms
Drinking water contaminant |
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Most important prevent for nosocomial infections
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Hand washing
Also thinking of whether the pt really needs this intervention |
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Pre-travel counseling
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Vector avoidance
Adequate immunization Food/water safety, diarrhea Risk reduction behaviors |
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Criteria for antibiotic prophy
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High risk of infection or potential dire consequences from infection
Causitive agents predictable/limited Period of risks defined and limited Narrow spectrum drug available Evidence of efficacy |
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Histo pathogenesis
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Intracellular growth of tiny yeasts w/in macrophages
Epitheloid granulomatous cellular rxn resembling TB, plus abundant FIBROSIS and rare caseation necrosis Cell mediated immune mechanisms: INFgamma activates macros to kill yeasts, chemokines stimulate cell rxn to wall off infect |
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Routine immunizations
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Recommended for good health home and abroad
HepB, flu, MMR, pneumovax, polio, tetanus, diptheria |
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Congenital causes
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Infections that can go transplacental
Toxoplasmosis Other - (VZV) Rubella CMV Herpes, HepB/C, HIV Enteroviruses Syphilis |
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Recommended vaccines
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To protect traveler to an endemic area
HepA, typhoid, meningococcal, rabies, japanese encephalitis Cholera, plague, BCG, tick-born encephalitis |
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Histoplasma primary infection syndrome
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Frequently asympto or mild
May be flu-like w/ cough, fever, malaise, hilar adenopathy Can lead to mediastinal fibrosis in a sm no of pts- an immunologic reaction containing a few organisms |
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Required immunizations
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Required for entry to country
Designed to protect host country population from importation of disease Ex. Mening and polio for Hajj |
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HIV and STDs
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More likely to contract HIV
ulcers -- skin barrier break inflammation - CD4s to site More likely to transmit HIV shed virus more when STD+ |
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What malarial prophy to use?
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Chloroquine if you can
Mexico, central america, carribean, former soviet union Mefloquine (if no history of psychosis) |
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Reinfection syndrome with Histo
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Exposure to lg numbers of aerosolized spores in a previously infected individualsmay result in febrile illness with ACUTE pulmonary infiltrates
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Febrile illness in an returning traveler?
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Dengue is more common
excpt in subSaharan, central america |
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Congenital infections
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Maternal infection acquired during pregnancy
Earlier is usually worse Acute infection is usually worse that reactivation |
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Diarrhea in travelers
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Mostly bacterial
Common - 60% Prevent with food choices, HepA vaccine, typhoid, cholera Treat with ORS, loperamide, presumptive Abx (azithro, cipro, rifaximin) |
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Mediastinal fibrosis in histo
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Rare complication
Hard to treat because its really an immune reaction, so killing the bug does not help too much Surgery difficult |
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Altitude sickness
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From ascending too quickly
AMS - HA, SOB, diarrhea, anorexia HAPE (high altitude pulmonary edema) - + cough HACE - cerebral edema |
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Geography of TB today worldwide
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Africa > Haiti > Asia > Peru > everywhere else
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Three ways to avoid dying from acute mountain illness
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Recognize early symptoms
Never ascend to sleep at higher altitude with symptoms Descend if symptoms get worse while resting at same altitude |
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Chronic cavitary pulmonary histo
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Progressive fibrous and nodular apical infiltrates, which cavitate
Clinical findings of cough, fever, weight loss in men >40 |
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Avoiding altitude sickness
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Acetazolamide - helps acclimatize and lessens symptoms
Dexamethasone used for rapid, extreme |
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How common is congenital CMV
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1% of newborns
But 9 of 10 are asymptomatic Symptoms: fetal demise, small for gestational age, CNS (microcephaly, calfications), skin, eye (chorioretinitis, cataracts), deafness, hepatitis, limb hypoplasia |
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What illness are you most likely to get abroad?
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Diarrhea
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Disseminated histoplasmosis
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Acute infection disseminates
Immunosuppressed Chronic progressive disease in AIDS |
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Febrile illness in returning traveler by incubation
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< 10 days: dengue, arborovirus, flu
7-28: malaria, leptospirosis, typhoid, HepA/E, chagas >4 weeks: HepB,C, leschmaniasis, brucella, trypanosomiasis |
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Gender and transmission of GC/CT
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GC - male infects female more than female infections male
CT - equal |
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Most important arbovirus worldwide?
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Dengue
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Diagnosing histo
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Culture - yeast form can be grown from respiratory specimens
Yeast converts to mycelia in room temp, characteristic fruiting bodies Macrocondia Biopsy showing intracellular yeast, granulomas, etc Serology - not good for acute Urine - histo antigen in urine useful for active disease, esp in HIV |
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What does dengue have that malaria does not?
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Shorter incubation
Rash Severe myalgias Low WBCs |
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Most common cause of sensorineural hearing loss in infancy?
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Congenital CMV
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What does malaria have that dengue lacks?
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Longer incubation
Evidence of hemolysis, including anemia |
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Urine antigen in histo
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Detection of polysaccarides in urine
Useful in active disease, esp HIV Not going to pos in mild or asymptomatic pulmonary disease |
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Traveler's diarrhea lasting for >4 weeks
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Get stool o and p
Empiric metronidazole, bactrim Giardia E. histolytica C diff Strongyloidies Schisto |
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Non-tuberculous mycobacterium in human infections
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Some are contaminants (gordonae)
Some are real (marinum, avium) Repeated isolation of the same organism points towards real infection |
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Non-infectious cause of traveler's diarrhea
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Unmasked tendency for IBD/S ?
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Therapy of histoplasma
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Not all infections require
AmphoB - severe, progressive forms Itraconaozle - treatment as well as chronic suppression to in immunosuppressed |
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Congenital infections which may seem asymptomatic at birth but reactivate?
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VZV
CMV HSV |
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Geography in blastomyces
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Major river valleys of Midwest
South central US Scattered worldwide Moist soils, river and pond edges Less common than histo |
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Major STD syndromes in males
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Genital ulcers
Urethritis Proctitis Epipidymitis Prostatitis |
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Epi in blastomyces
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M > F
Outdoor occupation risk Dogs can be infected and are symptomatic |
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Blue skin spots on a neonate?
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Can represent extramedullary hematopoeisis
One cause is congenital CMV depression of bone marrow |
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Pathogenesis of blastomycoses
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Extracellular yeast
May also be seen after phagocytosis in macrophages Thick walled yeast with broad based buds Noncaseating, loose granulomas with lots of PMNs Epi hyperplasia prominent |
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Causes of immune deficiency
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Primary
Acquired: Impaired barrier Age Immunoglobulin loss Cancer Infection Autoimmune disease Chronic disease Splenectomy Iatrogenic Pregnancy Stree |
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Blasto skin lesions are mistaken for?
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SCC
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Risk of mother-child transmission of HIV
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Without any treatment
25% during pregnancy and delivery 40-50% with breastfeeding |
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Blastomycoses clinical presentation
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Pulmonary - primary site - most common, sometimes asymptomatic - infiltrate on CXR
Skin - uncommon, looks like SCC Bone - one of the only fungi to go for bone Disseminated - GU, CNS |
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Major STD syndromes in females
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Genital ulcers
Urethritis/cervicitis Vaginitis PID |
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Diagnosing blasto
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Stain of pus/tissue, histopath to show yeast forms
Culture - myceial forms in days to weeks - lollypop hyphae structure (fruiting body) Serology not useful |
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Reducing vertical HIV transmission
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AZT during and after - 68% reduction
Elective CS further decreases (like 3% transmission rate) Single dose nevirapine for laboring mother then infant (nnRTI) is better than AZT |
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Treating blasto
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Amphotericin B for serious/progression
Iatraconazle for others |
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Mycobacterium marinum infection
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Nodules after freshwater scrape
Aquariums |
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Coccidiodes
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Southwestern US, Ca
Dry, alkaline soils Also in Central, SA |
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Peripartum infections
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From maternal colonizers
E. coli Group B strep HSV |
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Valley fever
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Caused by cocciodes
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Genital ulcers
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Breaks in skin
Can be locally painful or itchy May be associated with lymphadenopathy In US Genital herpes > syphilis > chancroid |
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Coccidiodes pathology
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Inhalation of arthrospores
Pulmonary infection w/ possible hematogenous dissemination Granulomatous response Endospores in chacteristic spherules varying in size, no yeast forms In areas exposed to air, pts can have mycelial form in lung |
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Difference between adult and neonate HSV infection
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In neonates disseminated disease is much more common than locally controlled
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Coccidiodes life cycle
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No yeast form
Mycelial form produces athroconidia (like a spore but not) Breathe in Differentiates into spherule Division w/in the spherule makes lots of endospores |
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Why did TB rates drop in US?
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Better housing
Better nutrition Disease of poverty |
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Coccidiodies clinical
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Primary pulmonary - Valley fever
febrile illness with highincidence of athralgias Disseminated - bone, skin, meningies higher risk in preg, AAs, Filipino pps AIDS |
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Presentations of neonatal HSV infection
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Skin-eyes-mouth
Disseminated - sepsis, jaundice, coagulopathy CNS only seizures, lethargy, fever Congenital microcephaly, skin scars |
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CXR in cocciodies
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Coin lesion
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Diagnostics to preform on a genital ulcer
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Observe clinical appearance
Direct fluorescence or culture for HSV If not HSV, eval for syph |
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Skin finding in coccidiodies
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Erythema nodosum
Raised tender nodules, shins Immunologic rxn, no organisms here A marker for having immunologically controlled diease |
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Is neonatal HSV dangerous
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Yes.
Mortality from all types except skin/eyes/mouth limited Also disability |
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Coccidiodies diagnosis
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Serology - useful in following progression
Culture - sputum/tissue sample, white fluffy mycelia appear w/in week. Barrel shaped athrospores easily aerosolized (watch out!) Histo - endopsores w/in granulonatous rxn |
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Mycobacterium avium complex infections
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Cervical adenitis in kids
Pulmonary disease in adults Disseminated disease in adults |
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Complement fixation assay in coccidiodies
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High is bad
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Risks for neonatal HSV
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Maternal isolation of HSV
First episode Use of invasive monitors HSV of the cervix C-section reduces risk |
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Coccidioidomycosis Rx
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Most not treated
Ampho B for progressive primary and immunosuppressed Meningitis - itrathecal AmphoB Fluc/iatroconazole for the prevention, less serious |
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Appearance of genital ulcers caused by herpes
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Multiple
Shallow Painful |
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Sporothrix geography
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Worldwide
Rotting wood, sphagnum oss, potting soil, rose plants |
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Treating neonatal HSV
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IV acyclovir
Greatly improves outcomes, higher dose better (esp in disseminated) |
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Sporotrichosis pathology
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Local inoculation, frequently upper limb
Pyrogranulomatous response in dermis Lymphangitic spread |
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What changed HIV mortality rates?
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HAART
Began in 1994 |
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Sporotrichosis appearance
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Cigar shaped
Elongated Difficult to find on biopsy |
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Group B strep proph
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Test mothers in week 35-37
Give intrapartum abx for positive |
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Sporotrichosis clinical
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Cutaneous lymphangitis with nodules
Somtimes has osteoartercular involvement and tenosynovitis Pulmonary, uncommon Disseminated in immunosuppressed Prefers colder body temp sites (skin) |
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Appearance of genital ulcers caused by syph
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Isolated
Heaped up borders Painless |
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Sporothrichosis diagnosis
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Culture - yeast like colonies in a week, convert o mycelia at RT
Cigar shaped yeast, difficult to find on biopsy No useful serology |
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Group B strep in neonate
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Onset < 1 week age
pneumonia, sepsis, meningitis Onset 1 week - 3 months sepsis and meningitis |
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Fruiting body of sporotrix
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Stalks with flowers
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How many people are infection with mycobacterium avium
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30-40% of people have had an asymptomatic infection
Skin tests show |
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Sporotrichosis therapy
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Azole
KI - may work by increasing macrophage intracell killing mecah Local heat |
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Treating group B strep in neonates
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Gentamicin
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Penicillium marneffei
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Emerging disease
SE Asia Respiratory and disseminated systemic infections in immunosuppresed |
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Urethritis in men
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Inflammation of the urethra
Dysuria and urinary frequency Penile discharge CT and GC, herpes Non-gonococcal urethritis |
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Diagnosis of pencilliosis marneffei
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Growth of mold with diffusible RED PIGMENT
Penicillum fruting structures in culture, yeast-like forms with binary fission in tissue |
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What viruses give babies respiratory infections?
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Respiratory syncitial virus
Parainfluenza Influenza Human metapneumovirus Can cause pneumonia/pneumonitis |
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Treating penicilliosis marneffei
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Amph B
Possibly iatraconazole, voriconazole |
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Who has TB in US now?
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> 75% non-white
>50% born outside US |
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How does P marneffi divide in tissue?
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Binary fission of yeasts
Not budding |
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H1N1 and kids
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Higher rates of symptomatic infection and deaths
Hit pregnancy women hard too |
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Penicillium fruiting body
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Paint bring mycoses
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Urethritis and cervicitis in women
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Inflammation of urethra and cervix
Dysuria, urinary frequency, vaginal discharge, bleeding CT and GC, HSV |
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Opportunistic infections
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Take advantage of defect in immune system
Usually not pathogenic |
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What causes auditory tube dysfunction
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viral URI
allergy hypertrophied tonsils/adenoids cleft palate |
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Diagnosing opportunistic infections
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Gold standard is histology
Seeing it causing disease in infection |
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Is NTM protective for TB?
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Yes
Extensive epidemiologic evidence |
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Risks for thrush
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Recent antibiotics
Defects in cell mediated immunity: HIV infection Diabetes Steroid inhaler |
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Different types of otitis media
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Otitis media with effusion (secretory)
chronic - persistant Suppurative otitis media chronic - recalcitrant |
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Confirming diagnosing
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Scrape for KOH
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Vaginitis
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Vaginal discharge and vulvar irritation
Candidiasis > bacterial vaginosis > trich Diagnose with saline wet mount, KOH, whiff test, pH |
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Nystatin
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Swish and spine
Topical antifungal Not going to get to the esophagus |
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Pathophysiology of secretory otitis media
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Obstruction of auditory tube
Accumulation of transudate with negative pressure in middle ear Reduced tympanic membrane mobility |
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Candida diagnosis
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Culture - bottle and agar plates
Gram stains Speciation is desirable for watching out for resistance Take seriously a positive culture from a normally sterile site |
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Impaired barrier defense examples
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Skin abrasion
Loss of normal GI flora IV lines Mucositis Drains |
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CMV comes up with which immune dysfnc?
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T cell
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Patholphysiology of acute suppurative otitis media
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Obstruction of auditory tube
Recent colonization of nasopharynx with pathogenic bacteria Purulent exudate Positive pressure in middle ear -->bulging tympanic membrane |
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Short term neutrophil dysfnc?
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Worry abotu candida
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PID
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Upper genital tract infection in women
Fever, lower ab pain, adnexal tenderness, cervical motion tenderness CT and GC, anaerobes, enteric streptococcal species, gram neg rods |
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Risk factors for disseminated candiasis
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Neutrophil dysfnc
Neutropenia Transplant recipient Leukemia Central line for TPN |
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Etiology of acute suppurative otitis media
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Strep pneumo - 25%
H flu - 20% M. Catarrhalis - 15% No pathogen isolated in 25% |
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HIV and candidiasis
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Mucosal candidiasis (thrush, etc)
It does not disseminate because they have neutrophils |
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Pulmonary disease of MAC
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Chronic process
Often associated with bronchiectasis Diagnosis requires multiple isolation of non-tuberculous mycobacterium |
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Treating disseminated candida
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Antimicrobials - micafungin/caspofungin
or ampho B fluconazole Remove lines Surgery for abscesses |
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Epi of otitis media
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Peak age 6-18 months, rapid decline after age 2
83% of kids have had otitis media by age 3 Risk of recurrence related to age of first infection |
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What do you do when you find yeast in the urine?
|
Change the foley
Cystitis from yeast happens w/ constant foley and long term Abx If changing the foley fails Then start an antifungal |
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Vaginal discharge associated with bacterial vaginosus
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pH > 4.5
Amine odor Clue cells |
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Diagnosing aspergillus
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Histology
Culture sputum (not diagnostic b/c could be colonize, but in right setting) Culture of biopsy specimen Serum galactomannan test |
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Natural history of secretory otitis media
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30% resolve in two weeks
60% in one month 10% are persistent at 3 months |
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Galactomannan test
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Blood test, BAL specimen, CSF
Tests for aspergillous antigen Species specific cell wall antigen |
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Why are mycobacterium so tough to kill
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Triple layer cell wall
Resistant to chemical and mechanical attack Also live in different places - drugs have to get to all those compartments |
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Opportunistic fungi
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Candida
Aspergillus Zygomycoses (Mucor) Cryptococcus |
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Morbidity of persistent secretory otitis media
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Anatomic - glue ear, cholesteatoma
Diminished hearing |
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Pathology in aspergillus
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Vascular invasions
Infarction Necrosis Edema Hemorrhage Culture grows aspergillus fumigatus |
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Vaginal discharge associated with trichomonas infection
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Gray, yellow, white
Frothy or milk-creamy pH > 4.5 |
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Aspergillus host defenses
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Phagocytic cells
and Cell mediated immunity |
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Natural history of acute suppurative otitis media
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75% resolve in 5-10 days w/o therapy
Antibiotics shorten fever and otalgia Chronic suppurative develops in 10%, use of abx is mostly to prevent this |
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Who gets aspergillus?
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transplant patients
HIV patients immune defects |
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Is disseminated MAC in AIDS a reactivation phenomenon?
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Nope
New infection |
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Treating aspergillus
|
Voriconazole is first choice
AmpoB - second line Caspofungin - third line |
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Complication of chronic suppurative otitis media
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Facial nerve paralysis
Mastoiditis which can lead to brain abscess Osteomyelitis of petroid ridge Venous sinus thrombosis, lateral sinus thrombosis hydrocephalus |
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Sinus infection in pt with DKA?
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Worry about mucor
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Vaginal discharge associated with yeast infection
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ph < 4.5
See yeast on mount |
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Zygomycosis (mucor)
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Ubiquitous fungi
Low virulence Opportunistis presumed due to combinationof defects of macros and PMNs serever immuncompromise, DM, lyphoma, leukemia, burns --rare |
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Treating acute suppurative otitis media
|
Observation
Pain control Abx augmentin cefpodox, cefurox, ceftriox amoxicillin clinda/azith w/ allergy Myringotomy |
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Mucor pathology
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Hyphae invade tissue with affinity to blood vessels
Necrosis and thrombosis |
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How common are pediatric GI illnesses
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2-3/per child per year in developed countries
10-18/per child per year in developing (age 0-5) |
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Zygomycosis treatment
|
Surgery is necessary
Reverse underlying problem Medical -- amphoB, posaconazole Prognosis is poor |
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Treatment of persistent secretory otitis media
|
Decongestants don't help
Abx for 2-3 weeks may give partial relief |
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HIV pt with new onset MS change and normal labs?
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Do a spinal tap
Do an MRI Worry about crypto, toxo |
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Proctitis
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Rectal pain or irritation
Purulent discharge Tenismus Constipation Gonorrhea, HSV, CT, others |
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Cryptococcal diagnosis
|
Culture CSF
Cryptococcal antigen (from CSF, blood) Yeast! Elevated opening pressure on spinal tap |
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BCG vaccine
|
Live attenuated M. bovis
Induces a low level mycobacterial infection to vaccinate to TB Replicates locally and disseminates Local scar, parenchymal inflammation Cross protection from TB |
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Does cryptococcus have hyphae?
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No
Its a thick walled yeast with a capsule |
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Prostatitis
|
Dysuria, frequency, perineal or lower back pain, fever
GC, CT, enteric gram negs |
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Why high opening pressure in crypto menigitis?
|
Gums up the ventricles
Cannot resorb CSF appropriately |
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MTB complex
what is in it? where did they evolve from? |
MTB = M. tuberculosis, M. bovis, BCG
Thought to evolve from non-pathogenic soil-living mycobacterium |
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Crypto on CSF
|
Elevated opening pressure
May be decreased glucose, increased preotin, low WBC India ink positive |
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Epididymitis
|
Unilateral scrotal pain and swelling
Dysuria GC, CT, enteric gram negs |
|
|
Crypto antigen test
|
Latex agglutination
Blood or CSF Sensitive and specific Titer indicative or burden of disease |
|
|
What is the other use for BCG?
|
Intravesicular for immune stimulation in bladder cancer
|
|
|
How do you get crypto?
|
Pigeon poop inhalation
Initially typically assymptomatic Walled off by macros in lung Disease due to reactivation Cell medated immunity important, can occur in competent hosts Can disseminated, predilicaiton for the CNS |
|
|
Preferred diagnositic for trichomonas
|
NAAT
Transcription mediated amplification |
|
|
Clincal crypto
|
Lung
Skin - umblicated lesion Disseminated |
|
|
How do you lose immunoglobulins?
|
Nephrotic syndrome
Enteropathy |
|
|
Treatment for crypto
|
Mild - fluconazole
Serious - amphotericin B and flucytosine + 6 weeks of fluconazole Improve immune status in AIDS, prevent immune reconstitution inflammatory syndrome Increased intracranial pressure serial lumbar puncture to remove CSF lumbar drain placement more permanent shunt may be necessary |
|
|
Exam of woman with symptomatic trich infection
|
Red blotches
|
|
|
Prognosis of crypto meningitis
|
Depends on underlying illness
Reversibility of the immune suppression Residual defects: CN palsy, decrease mental fnc, hydrocephalus, visual loss |
|
|
Efficacy of BCG?
|
Probably 50-75%
Greatest efficacy against childhood progressive and TB meningitis Reduces death > disease TST will turn positive Duration thought to be 10-15 years But some studies show longer |
|
|
HPV course
|
Median duration is 8 months
90% clear w/in two years |
|
|
How is TB spread?
|
Usually adult with a cavitary lesion cough out droplet nuclei
These dry out and float around A previously naive kid breaths one in And TB has spread 1 active case causes 10 new a year 30-50% of family contacts infected |
|
|
Liklihood of getting HPV during lifetime?
|
1 in 2
|
|
|
What BCG protect against
|
MTB
NTM leprosy Buruli ulcer (M. ulcerans) |
|
|
HPV test?
|
Only off PAP
|
|
|
HIV life cycle
|
Enveloped RNA virus
Binds to CD4 Reverse transcriptase makes DNA DNA integrates Translated into RNA Some of which is translated Others get packaged with proteins Buds off |
|
|
Genital HSV
|
80% is HSV2, 20% HSV1
Risk associated with lifetime sexual partners and race |
|
|
BCG side effects
|
Prolonged drainage and ulceration at site (BCG-itis)
Adenitis Rare osteomyelitis Disseminated BCG can occur in kids with unknown HIV |
|
|
How common is HSV-2
|
1 in 4 > 30
25-65% of pregnant women |
|
|
TB cases worldwide
|
6-8 million new cases/year
2-3 million deaths/year |
|
|
Clinical features of HSV
|
Initial episode may asymptomatic/widespread ulcers/systemic symptoms
Latency in ganglia Genital ulcers, urethritis, pharyngitis Neonatal disease, encephalitis |
|
|
Where does antigen go in TST?
|
dermally
|
|
|
Diagnosing HSV
|
Viral culture
Direct florescence antibody PCR for DNA in CSF Type specific serology |
|
|
What cancers are immunosuppressive?
|
Leukemia
Lymphoma Multiple myeloma |
|
|
Do condoms work to prevent herpes?
|
60% risk reduction
|
|
|
TST in active TB
|
80% have >15-17mm
False negative rate in immunosuppressed Repeated in 2 weeks 75% of FN turn positive |
|
|
Chlamydia trachomatis
|
Obligate intracellular bacteria
Causes mucosal inflammation Very difficult to culture |
|
|
MTB and host response
|
Macrophage ingest MTB
Presents to CD4 T cell T cell elaborates Il-2 (self expander) and INFgamma (macrophage activator) Activated macrophages have better chance at killing TB But it still fights back |
|
|
Where is chlamydia in US?
|
South
Women 15-30 (?reporting bias) |
|
|
Causes of positive PPD
|
MTBC - including BCG (but only for a few years, rarely >10 mm in adults, sometimes gets boosted)
NTM infection False positives |
|
|
Chlamydia clinically
|
60-70% asymptomatic
Urethritis, cervicitis, proctitis, epididymitis, PID, reactive arthritis |
|
|
Sepsis definition
|
Toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection
AKA SIRS w/ infection |
|
|
Chalmydia disease in kids
|
Inclusion conjunctivitis
Interstitial pneumonia |
|
|
TST positivity
|
> 5 mm in HIV, transplant, known infection
> 10 mm in immigrants, IDU, high risk settings (jails), chronic disease > 15 mm in everyone else |
|
|
Diagnosing chlamydia
|
Nucleic acid amplification technique
Females: vaginal swab > cervical swab > urine Male: urethra, first catch urine These are in high 90s for sens Can do rectal swabs, but not FDA approved |
|
|
Genetics and TB
|
Variant in phagolysosomal regulation (NRAMP1) found in West Africans seems to increase susceptibility
Variate in Vit D receptor seems to be protective against disease |
|
|
Diagnosing gonorrhea
|
Gram stain of male urethra
Nucleic acid amplification technique Urethra, cervix, urine All > 90% sens Culture from multiple sites onto special media |
|
|
How effective is treating latent TB?
|
INH for 9 months - 90%
INH for 6 months - 70% |
|
|
Treating chlamydia
|
Azithromycin
1 dose of 1 gram PO second line doxy Partner treatment |
|
|
Prognosticating in HIV
|
CD4 - current immune status
HIV viral load - predictor of progression CD4 + viral load - good predictor of medium term prognosis w/o therapy |
|
|
Preventing chlamydia
|
Screening sexually active women <35, pregnant women in third trimester, all other in high risk settings
Treat, test for success, treat partners Condoms |
|
|
Common cause of TB in chickens?
|
MAC
|
|
|
N gonorrhea virulence
|
Papilla adhere to warm moist mucosal surfaces
|
|
|
Natural history of TB
|
Organism inhaled
Ingested by alvelolar macrophages Transient bacteremia Granuloma formation in lung (+/- other sites) Stable or reactived |
|
|
Where in US is gonorrhea
|
South
15-30 year olds |
|
|
PPD
|
purified protein derivative from MTB used to detect delayed hypersensitivity in person with latent/active TB
With primed myco immunity, CD4s rush to site -- causes induration |
|
|
Gonorrhea clinically
|
90% of women asymptomatic vs 5% men
Mucosal infections: urethritis, cervicitis, epididymitis, proctatitis, pharyngitis, conjunctivitis Invasive: PID, perihepatic (FHC), disseminated bacteremia, septic arthritis |
|
|
What infections are immunosuppressive?
|
HIV
CMV EBV hepatitis |
|
|
Gonorrhea resistance issues
|
Increased resistance to cipro, pen, tetracycline
|
|
|
Ways TB plays out
|
Infection and control by immune system in 2-10 weeks never to reactive in 90%
10% who have active disease every Half: Active disease in two years in Half: Reactivation disease at some point in life in 5% |
|
|
Gonorrhea treatment
|
IM ceftriaxone (IV higher dose for PID, disseminated)
+ azithromycin for chlamydia Always test for HIV, syph |
|
|
Responding to epidemic
|
Clinically - what is the syndrome
Epi - how is it being spread Diagnostically - what is the cause Public health - how can this be stopped/prevented |
|
|
Preventing GC
|
Test sexually active women and men at risk
Retest after 3 months Treat partners Condoms |
|
|
Molecular epi of TB
|
Possible to get a DNA fingerprint of each strain by digestion then probing for the insertion sequence
Can compare to other strains in population - new or reactivation |
|
|
Vaccine preventable STDs
|
HepA - sexually active MSM
HepB - sexually active (except exclusively female-female), known sexual contact of HepB+ HPV |
|
|
Medical treatments causing immunosuppression
|
Corticosteroids
TNFalpha inhibitors Chemo Radiation Anti-metabolites Anti-calcineurins Anti-lymphocyte (ex. rituximab) |
|
|
Bacterial vaginosis
|
Shift from normal vaginal bacteria to more anaerobes
|
|
|
Reactivation or new TB frequency?
|
In US, 60% of new onset active TB is reactivation
In endemic areas, there is more new infection |
|
|
Source of HIV
|
Non-human primates
Probably several transmissions in history HIV-1 - chimpanzees HIV-2 - sooty mangabee First transmission probably 1930s |
|
|
Latent infection with TB
|
No symptoms
CXR may show small calcification (Ghon complex) Not contagious |
|
|
How does infection in immunosuppressed patient differ?
|
Rapid progression
Few signs/symptoms Unusual sites of infection Unusual bugs |
|
|
Active TB
|
Tuberculous pneuomia
Cavitary Milliary Extra-pulmonary |
|
|
Causes of pyogenic meningitis
|
Bacteria: group B strep, H flu, strep pneumo, N. meningitidis, listeria
Fungi: histoplasma, cocciodomyces, cryptococcus neoformans Ameba: Nagleria |
|
|
Disseminated TB
|
TB bacteremia seeds lungs and organs
Miliary lesions in bilateral lungs and other places |
|
|
What to look at in a immunosuppressed patient with an infection?
|
Clinical signs
Immune state Exposures (contacts, geography, insect bites, hospitalizations, latent infections, blood transfusions) |
|
|
Scrofula
|
Lymphatic TB
Tuberculous adenitis Can also be caused by non-TB myco May result in a chronic draining sinus |
|
|
Risk activities for contracting HIV
|
Receptive anal sex, needle share
0.5-3% chance/activity Occupational needle stick 0.3% Receptive vaginal sex 0.1% Oral sex <0.1% |
|
|
Pott's disease
|
Skeletal TB (TB osteomyelitis)
Characterized by destruction of vertebral body and extension across vertebral disc Cause of spinal deformity |
|
|
Chronic diseases causing immunosuppression
|
Malnutrition
Diabetes Chronic renal disease Chronic liver disease |
|
|
Healed active TB
|
Apical scarring or calcification on Xray
|
|
|
Upper GI syndrome
symptoms and etiology |
Prominent N/V
Rapid onset Etiology: Viral (norovirus, rotavirus) Heavy metals Preformed toxins |
|
|
Risks for developing active TB
|
HIV
Poverty - crowding, malnutrition Immune suppression Diabetes Old age Alcoholism |
|
|
IRIS
|
Immune reconstitution inflammatory syndrome
As immune system of previously compromised patient is restored, reaction to the many infections the patient now has can be dagnerous |
|
|
HIV and TB
|
HIV increases risk of active TB because of CD4 role in controlling mycobacterium
TB makes HIV worse, accelerating course, seems to increase production of HIV in mononuclear cells (via TNF) |
|
|
Rate of vertical transmission in HIV?
|
25% untreated in US, 35% untreated in Africa
8% with AZT 1% with current meds |
|
|
TB in early and late HIV
|
TB w/ CD4 > 200
mostly pulmonary disease with apical infiltrates 80% skin test positive TB w/ CD4 <200 hilar nodes, effusion, disseminated disease 20-40% skin test positive |
|
|
Treating infection in immunosuppressed patient
|
Early empiric Abx use
Reduce immunosuppression (watch out for IRIS) Tailor based on diagnostics Treat for a long time (slower response than with a normal immune system) |
|
|
Diagnosing active TB
|
AFB smear - positive in 50%
Culture - takes weeks, positive in 80%, can test for drug susceptibility Nucleic acid amplification: rapid 1-2 day method confirms in 65%, some can also test for resistance |
|
|
SIRS
|
2 or more of
T > 38.5 or <35 HR >90 RR >20 or PaCO2 <32 WBC >12K, <4K, or > 10% bands |
|
|
Standard treatment for active TB
|
Directly observed therapy with 4 drugs
Rifampin Isoniazid Pyrazinamide Ethambutol x 2 months Followed by 2 months of rifampin/INH |
|
|
Infections associated with T cell defects
|
Thrush
PCP Severe HSV and VZV reactivation Other indolent infection with an opportunist |
|
|
Rifampin effects in TB
|
Cidal for intracellular organisms
Orange urine Influenza syndrome Hepatitis Drug interaction |
|
|
AIDS epidemiology in US
|
M>W
Most diagnoses between age 25-44 Recently falling in whites but rising in blacks More diagnoses in the South |
|
|
Isoniazid effects in TB
|
Cidal for extracellular organisms
Hepatitis Neuropathy Mild CNS effects B6 deficiency |
|
|
Infections associated with Ig defects
|
Encapsulated organisms (strep pneumo, H, flu) causing pneumonia, bacteremia
Chronic GI infections Giardia |
|
|
Pyrazinadine effects on TB
|
Acts on intracellular organisms
GI, hepatitis, rash, arthralgias, increased uric acid |
|
|
Lower GI syndrome
|
Acute infectious diarrhea
Less than 2 weeks in duration >2 unformed stools/day Fecal/oral Most commonly food born spread |
|
|
Ethanbutol effects on TB
|
Static
Helps prevent resistance Optic neuritis, rash |
|
|
Infections associated with complement defects
|
Neisseria
severe, recurrent |
|
|
Response to treatment in TB
|
Untreated mortality is >25%
In HIV- patients, 80% sputum culture neg at 2 mos, negligible mortality In HIV+ patients, 80% sputum culture neg at 2 mos, 25-40% 1 year mortality |
|
|
Current most frequent ways to contract HIV now
|
Male to male sexual
Heterosexual sexual Injection drug use |
|
|
MDR TB
|
Rifampin and Isoniazid resistant
Resistant chromosomally mediated Most likely in patients with prior (inadequate treatment) More common in Russia, South Africa, Asia, DR, Argentina 1% in US |
|
|
Interferon gamma release assay
|
Specific MTB antigens added to serum sample
Release of interferon gamma show memory |
|
|
Infections associated with integument defects
|
Recurrent cutaneous infections
staph aureus, streph, GNRs |
|
|
MDR TB mortality
|
30-40% overall
80% in HIV |
|
|
Osteomyelitis
|
Infection and destruction of bone
|
|
|
XDR TB
|
MDR plus resistance to a fluroquinolone and an injectable (streptomycin, amikacin, capremyocin)
|
|
|
Preventing infections in patients with Ig immune deficiency
|
Early antibiotics
IvIG |
|
|
Diagnosing latent TB infection
|
Skin test - positive at 2-10 weeks
watch out from cross rxns, immunosuppression Interferon gamma release assay - as sensitive, but more specific than TST, blood test where you stimulated with TB specific antigens |
|
|
Preventing infections in patients with splenectomy
|
Vaccination against encapsulated organisms
Early abx |
|
|
What size TST means you have latent TB?
|
Depends on who you are
>5 mm for HIV+, immunosuppressed, known TB contact >10 mm for recent immigrant from endemic area, worker in high risk area, IDU, diabetic, hemoglobinopathies, gastrectomy >15 mm for persons w/o risk |
|
|
How are women getting HIV?
|
85% heterosexual contact
15% IDU |
|
|
Treating latent TB
|
To prevent reactivation possibility
INH x 9 months (or 6 months) (or rifampin for 4 months) |
|
|
Preventing infections in patients with neutrophil defects
|
GCSF
Antibiotics Antifungals |
|
|
Infection control in TB
|
Negative pressure rooms
Adequate ventilation Masks Consider BCG in endemic areas |
|
|
Dysentery
|
Frequent, small, painful stools containing blood/mucus
Implies invasion of bowel mucosa |
|
|
Why is TB seen in the upper lobes?
|
Strict aerobe
|
|
|
Progressive neurologic deficits in an immunosuppressed patient?
|
Do an MRI
Subcortical periventricular white matter disease Progressive multifocal leukoencephalopathy - JC virus |
|
|
Risk of developing reactive TB in pt with HIV?
|
8-10% per year
|
|
|
In US, what proportion of HIV pts are getting treatment?
|
About half
25% do not know they do not have disease 25% not in care |
|
|
TB in HIV general principles
|
High rate of reactivation
High rate of extrapulomonary/disseminated disease Same immediate response to TB treatment, but much greater 1 year all cause mortality Leading cause of death in HIV infected patients |
|
|
Why do you have to treat longer in immuncompromised patients with infections
|
Host response in much weaker
Organism may be normally indolent ones and it can take a long time to kill those |
|
|
How much TB diagnosis is clinical?
|
20% have neither a positive sputum nor culture
|
|
|
Septic shock
|
Sepsis + systolic <60
|
|
|
Treating TB in HIV+ patients
|
RIPE + antiretroviral therapy (within 2-8 weeks)
IRIS in 10-30% |
|
|
When do you have to worry about reducing immunosuppressive treatment because of an infection
|
Transplant -- don't want to lose the organ
Other times when steroids are doing important things? |
|
|
Preventing TB in the US
|
TB skin testing and treating latent disease
|
|
|
Public health implications of 25% of HIV population in US being undiagnosed?
|
Transmission from these individuals accounts for 54% of new infections
|
|
|
Ghon complex
|
Site of primary TB infection
Peripheral focus in the lung parenchyma and central draining LN |
|
|
Outer retinal necrosis
|
Weird VZV thing
With meningoencephalitis |
|
|
Controlled disease in TB pathologically
|
Granulomas that are fibrotic, calcified
Still have small numbers of bacteria |
|
|
Norovirus
Symptoms |
Nausea, cramps
Diarrhea - predominant in adults Vomiting - predominant in kids Duration 12-60 hours, incubation 1-2 days |
|
|
TB molecular pathogenesis
|
Taken up by macrophages using mannose and complement receptors
Multiplies in vacuoles Resists phagosome/lysosme fusion (acidification) Organisms travel in monocytes to other organs |
|
|
Who is more likely not to get tested early in HIV course
|
18-35 years
Heterosexual Less educated African American or Hispanic |
|
|
Immune reaction to TB cytokines
|
Initially IFNgamma - activating macrophages to improve killing of TB
Secondly TNFalpa - recruitment of more lymphocytes and macrophages to form a granuloma Controls, but does not eradicate the infection |
|
|
Causes of asceptic meningitis
|
Viruses
Drugs Malignancy |
|
|
Damage caused by immune response to TB
|
Tissue necrosis from granuloma formation
Caseation necrosis at center of granuloma Liquifaction necrosis is a great media for TB to grow in |
|
|
Diagnostic testing define
|
Test performed because of symptoms
|
|
|
Langhans cells
|
Giant cells associated with TB granulomas
Characteristically have peripherally located nuclei |
|
|
Most frequent foodborne illness in US
|
Norovirus
|
|
|
Controlled disease in TB pathologically
|
Granulomas that are fibrotic, calcified
Still have small numbers of bacteria |
|
|
Screening
|
Test performed on everyone in a population
|
|
|
TB molecular pathogenesis
|
Taken up by macrophages using mannose and complement receptors
Multiplies in vacuoles Resists phagosome/lysosme fusion (acidification) Organisms travel in monocytes to other organs |
|
|
SIRS causes
|
Infection
Tissue damage (ie pancreatitis, burns) Immunologic (lupus, anaphylaxis) Others - thyroid storm |
|
|
Immune reaction to TB cytokines
|
Initially IFNgamma - activating macrophages to improve killing of TB
Secondly TNFalpa - recruitment of more lymphocytes and macrophages to form a granuloma Controls, but does not eradicate the infection |
|
|
Targeted testing
|
Test performed based on membership in high risk group
|
|
|
Damage caused by immune response to TB
|
Tissue necrosis from granuloma formation
Caseation necrosis at center of granuloma Liquifaction necrosis is a great media for TB to grow in |
|
|
This is probably a norovirus outbreak...
|
>50% of patient are vomiting
Lasting 12-60 hours Incubation 24-48 hours Stool negative for bacteria/parasites |
|
|
Langhans cells
|
Giant cells associated with TB granulomas
Characteristically have peripherally located nuclei |
|
|
Opt-out screening
|
Test all patients except those who refuse
|
|
|
Liquifaction necrosis in TB leads to
|
Growth medium for TB
Cavitary lesions that erode into brochial tree -- spread Erosion into blood vessels --dissemination |
|
|
Is pneumonia a big deal in the US?
|
8th leading cause of death
|
|
|
Acid fast
|
Staining with carbol fuchsin dye
Acid alcohol decolorization Still colored = acid fast |
|
|
What type of testing gets highest takes in HIV?
|
Opt-out testing
|
|
|
Auramine
|
fluroescent dye used to detect acid fast bacilli more easily
|
|
|
Controlling an norovirus outbreak
|
Diagnose with PCR on cultures
Stop group activities Hand hygiene |
|
|
Renal TB
|
Unilateral involvement
Replacement of cortex by caseating granuloma Can light up on xray from calcification "sterile" urine culture |
|
|
Criteria that justify routine screening of patients
|
Serious health disorder can develop before symptoms develop
Treatment works better before symptom onset Reliable, inexpensive, acceptable screening test Costs of screening are reasonable in relationship to anticipated benefits |
|
|
TB meningits
|
Basilar granulomatous inflammation
Few MTB actually in the CSF, hard to diagnose |
|
|
Sepsis epi
|
Rising incidence
700K cases/US/year Mortality is not improving: 10-30% |
|
|
TB in culture
|
Slow growth of typical rough colonies on complex medium
May take three weeks More rapid growth in broth Identified by hybridization probe |
|
|
Diagnostic testing in HIV
|
ELISA positive in chronic infection
confirm with western blot against AntiB against: p24, gp41, gp120/160 2+ = pos 1 = intermediate Acute - use viral load RNA |
|
|
Rotavirus clinical syndrome
|
Severe diarrhea in kids <2 years
Highly contagious Inclubation 2 days, illness 4 days Survives well on surfaces |
|
|
Intermediate western blot with positive ELISA in HIV means?
|
Either false positive
In process of seroconversion HIV-2 |
|
|
Mollert's syndrome
|
Recurrent asceptic meningitis
Recurrent herpes simplex |
|
|
Recommendations for HIV testing
|
Routine, voluntary HIV screening for adults 13-64 in health care settings, not based on risk
Repeat screening at least annually with known risk Special counseling not necessary for testing |
|
|
Diagnosing and preventing rotavirus
|
Diagnose via ELISA
Prevent with vaccine |
|
|
Risk of HIV from screened blood
|
1/500K
|
|
|
Sepsis pathogenesis
|
Pathogen triggers innate immune response
Tries to contain invader w/coagulation and kill it via cytokine storm SEs: Systemic hypotension - end organ damage Systemic coagulation - DIC |
|
|
Risk of HIV positive needle stick w/o prophylaxis
|
3/1000
|
|
|
Rotavirus epidemiology
|
Most death in:
South Asia Western/Eastern Africa 3.5 million cases/year in US |
|
|
Stages of HIV infection
|
Infection - macrophage trophic phenotype infects infects macs and DCs using CD4, CRC5, spreads via nodes
Seroconversion - burst of viremia w/ mono-like illness in 50%, CD8s and Abs push viral load lower Clinical latency with ongoing depletion of CD4 cells AIDS - shift to CD4 and CXR4 - CD4 T lymphocyte massive depeletion |
|
|
How does infection get into bone
|
Hematogenous route or by innoculation from a contiguous source of infection like a penetrating route
|
|
|
Sourc/recipient factors that affect risk of transmission of HIV
|
Viral load
Mucosal lesions Recipient susceptibility Viral fitness |
|
|
Normal enteric flora
|
>99% anaerobic bacteria
Clostridia, bacteriodes, lactobacillus E. coli, klebsiella, enterococcus, proteus Work synergistically with innate immunity Loss of normal flora shifts towards gram neg aerobes and yeast |
|
|
How does HIV find a T cell
|
Randomly happens upon it
But once it is...golden for the virus |
|
|
Lungs is sepsis
|
Frequently get hurt
Acute respiratory distress sydrome |
|
|
T cells and HIV
|
Massive depletion of CD4 T cells
60-90% w/in first two weeks Most never come back Particularly vulnerable - activated, memory, HIV-specific Die via activation and subsequent apoptosis, CD8 killing infected cells, direction cytotoxicity, apoptosis |
|
|
Who has defects in normal GI flora
|
Newborns
Pts on antibiotic Pts on chemotherapy |
|
|
Symptoms of acute HIV infection
|
Fever
Fatigue Rash HA Lymphadenopathy Mylagias Thrombocytopenia Leukopenia Nausea Aseptic meningitis Oral/genital ulcers Abnormal LFTs |
|
|
Most common meningitis pathogens from 0-2 months
|
Group B strep
E. coli Listeria |
|
|
Counts in acute HIV infection
|
Can by thrombocyptopenic, leukopenic
Viremia peaks high, CD4s drop Both recover somewhat (CD4s in blood recover more than in gut) |
|
|
Non-inflammatory infectious diarrhea
|
Enterotoxin mediated
Watery diarrhea with no fecal WBCs Effecting proximal small bowel Vibrio cholera ETEC C. perfringens Bacillus cereus Rotavirus Giardia Cryptosporidium |
|
|
When does ELISA become positive in HIV infection
|
3-6 months
Not during initial high viremia This test is looking for antibodies |
|
|
Sepsis
the good vs the bad |
Vasodilation
Improves tissue circulation vs lowers systemic BP Increased cap perm Improved immune cell diapedesis vs lower systemic BP Cytokine storm Recruit immune cells vs bystander damage Sympathetic storm Keeps brain and heart perfused vs tissue ischemia Activation of the clotting cascade Wall off damage vs embolism, ischemia |
|
|
Chronic HIV infection
|
Largely asymptomatic
A little fatigue, weight loss Insidious and constant loss of CD4+ cells Bone marrow is compensating by producing lots |
|
|
Inflammatory infectious diarrhea
|
Toxin/invasion mediated
Dysentery w/ fecal WBCs Effecting terminal ileum/colon Shigella Salmonella non-typhi Campylobacter EHEC EIEC Yersina enterolitica Vibrio parahemolyticus C. diff Entamoeba histolytica |
|
|
How many novel HIV viruses arise per virus each day?
|
1 billion different genomes
RT is mutation prone Leads to viral evolution in patient and population |
|
|
Acute bronchitis
|
Acute cough illness
Acute inflammatory condition of the tracheobronchial tree that does not involve parenchyma Almost always viral <3 weeks No other significant symptoms |
|
|
Viral loads in HIV
|
Show how fast disease in progressing
<1000 good >100K bad |
|
|
Penetrating infectious diarrhea
|
Enteric fever w/ fecal WBCs
Effects distal small bowel Salmonella typhi Yersinia enteroliticia |
|
|
CD4 counts in HIV
|
Show how depleted the immune system is
>800 good <200 bad |
|
|
What kills you in sepsis?
|
Multiorgan failure
|
|
|
Health risks in chronic HIV disease with good CD4 counts
|
Co-infection with HepB and C, HSV, VZV, CMV, candida
Psychiatric disease Cardiovascular disease (meds and inflammation) Cancer (HPV, EBV, others) |
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Food borne illness epi
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More common and dangerous in old and young
Salmonella, campy, shigella are most common |
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What is AIDS?
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HIV infection plus bad outcome
CD4 <200 Opportunistic infection Other AIDS defining condition |
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Most common meningitis pathogens from 2 months - 2 years
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W/o vaccines:
H. flu Strep pneumo N. meningitidis W/ vaccines N. meningitditis |
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What does a patients virus look like when then get to AIDS?
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Diverse population
Viruses has been replicating in them for average 7-8 years |
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Food borne illness with highest mortality?
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Listeria has highest case fatality rate
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Why does antiretroviral therapy sometimes fail to restore CD4 counts?
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Bone marrow exhaustion
Premature shortening of telomeres |
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Where did infection start in sepsis
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Pneumonia (40%)
Primary bloodstream (20%) UTI/pyeloneph Cellulitis Peritonitis Other |
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What happens at CD4<50
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Disseminated illness with weird viruses
MAC - wasting CMV - blindness Cryptococcus Kaposi's sarcoma |
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Upper GI syndrome < 2 hours after eating
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Heavy metal contamination
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PCP in HIV
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Pneumocysitis jirovecii pneumonitis
<200 CD4s Insidious onset of breathlessness Bilateral infiltrates on CXR Diagnosed by induced sputum, bronchoscopy Prevent/Treat with TMP/SMX also steroids |
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What increases changes of osteomyletitis
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Trauma
Ischemia Foreign bodies |
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Toxoplasmosis in HIV
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Represents reactivation in seropositive patients
CD4 <100 Focal CNS symptoms Ring enhancing lesions on imaging Diagnose by biopsy or treat and see what happens Treat with pyramethamine + sulfadiazine |
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Upper GI syndrome 1-6 hours after eating?
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Staph aureus
B. cereus |
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Cryptococcus meningitis in HIV
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Fever, malaise, ?HA, menginismus
CD4 <50-100 High pressure LP, cryptococcal Ag in CSF Treat with AmB + flucytisine then fluconazole for prophylaxsis |
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What kind of organisms cause sepsis?
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Gram pos and Gram neg > Fungi
Staph and E. coli are most common pathogens |
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MAC in HIV
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Mycobacterium avium complex
CD4 <50 Wasting, fevers, lymphadenopathy, GI sx Diagnose with blood cultures Treat with 2-3 drugs for many months Only cure is an immune system |
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Lower GI syndrome 8-14 hours after eating?
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C. perfringens
B. cereus |
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CMV of the eye in HIV
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CD4<50
Floaters, blind spots, visual changes Whitish exudates and hemorrhages Irreversible blindness if untreated Ganciclovir IV and IO |
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Most common meningitis pathogens
5-60 years |
N. meningitidis
Strep pneumo |
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Kaposi's sarcoma
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HIV patients with CD4<50
HHV8 Purplish bumps, sometimes lymphadenopathy, fever, cough HAART, chemo |
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Lower GI syndrome > 14 hours after eating?
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V. cholera
ETEC/EIEC Shigella |
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Viral set point in HIV
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Viral load one year after infection
Fortells speed of progression to AIDS |
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Treating sepsis
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Keep patient alive
Fix the infection -find it, drain pus, give Abx remove lines, caths, devices Address coagulation defects Support organ perfusion ICU, NS IV, norepinephrine |
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Leading cause of death in HIV positive patients worldwide
in developed nations? |
TB
Liver disease |
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Upper/lower GI syndrome > 14 hours after eating?
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Salmonella non-typhi
Vibrio parahemolyticus |
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HIV and hep B and C
|
Share some risk factors
HIV infection makes Heps worse Less likely to spontaneously clear More frequent and faster hepatic decompensation |
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Pathogenesis of pneumonia
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Microbial invasion of lower respiratory tract (usually from aspiration)
Local inflammation Systemic spread can occur |
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Treatment and prophylaxsis of MAC in AIDS
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Treat with chlarithromycin, ethambutol, rifabutin
CD4 <50 prophylax with azithromycin or riabutin |
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Food contaminants causes extraintesttinal symptoms
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Scrombotoxin <2 hours til onset
Shellfish toxin <2 hours Mushroom toxin - early or hours later Ciguatoxin - 1-6 hours later Clostridium botulinum - >14 hours |
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Empiric antibiotic therapy in sepsis
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Vanco + something broad
Ceftriaxone, meropenem |
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Food borne contaminants with low innoculum needed
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Shigella
Giardia Cryptosporidium STEC (EHEC with shiga toxin) Norovirus |
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Most common meningitis pathogens
> 60 years |
Strep pneumo
Listeria |
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Food borne contaminants with high innoculum needed
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Salmonella
Campylobacter Cholera ETEC - really need to drink this to get it |
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Pressors
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Norepinenphrine
alpha and beta action - improves pumping and vasoconstricts increasing pressure Dopamine Vasopressin Phenylephrine |
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Salmonella non-typhi species
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S. enteritidis, s. typhimurium, s. paratyphi, s. cholerasius
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Result of untreated chronic osteomyletitis
|
Ischemic necrosis of bone
Separation of large devascularized fragments (sequestra) |
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Salmonella non-typhi syndrome
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Gasteroenteritidis with sudden onset of nausea, crampy abdominal pain, diarrhea, fever
6-48 hours after ingesting contaminant |
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Giving steroids in sepsis
|
Decreases 28 day mortality in
Relative adrenal dysfunction Severe sepsis If given early Maybe |
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Salmonella non-typhi virulence
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Pili adhere to small bowel
Enterotoxin stimulates fluid production |
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Most common meningitis pathogens
in immunocompromised |
Listeria
Cryptococcus neoformans |
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Salmonella non-typhi sources and diagnosis
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Animal reservoirs
eggs, fruit, vegetables Diagnosis : stool culture |
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How to fix coagulation defect in sepsis
|
In severe sepsis can give recombinant activated protein C
Can give in severe sepsis, may decrease 28 day mortality, will also increase risk of bleeding No role in less severe sepsis |
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Salmonella typhi appearance
|
Gram negative, flagellated
Facultative anaerobe |
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Impetigo
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Infection of the epidermis
Staph aureus, strep pyogenes Vesicles --> pustules w/ honey colored crust Usually on faces of kids Treat with dioxacillin, cephalexin (pen if known to be strep) |
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Salmonella typhi syndrome
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Systemic illness
Insidious onset of malaise, myalgias, HA, high prolonged fever Most have diarrhea Rose spots Temperature pulse dissociation Case fatality 1-30% |
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How to keep the patient with sepsis alive?
|
ICU
Mechanical ventilation Tight glucose control Renal replacement Decrease iatrogenic harm by reducing overventilation, using sterile technique Use an algorithim |
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Salmonella typhi transmission and pathogenesis
|
Human reservoir only
Human fecal contamination is source Invades small bowel mucosa (can perforate) Spread to blood and lymphatics Chronic carrier state - lives in biliary tree |
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Most common meningitis pathogens
in basilar skull fracture |
Strep pneumo
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Diagnosing salmonella typhi
|
Blood cultures
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What do you do when a patient has sepsis?
|
Start treating/evaluating immediately
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Campylobacter syndrome
|
Incubation 1-7 days
12-24 hour prodrome of HA, myalgias, fever, then acute diarrhea w/ >10 loose stools, non-bloody stools/day Lasts 5-7 days |
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Involucrum
|
New bone formed when pus break through the cortex and forms a subperiosteal abscess
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Campylobacter site and reservoir
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Invades ileum, colon
Animal reservoirs, also water, unpasteurized milk - a lot like salmonella |
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Changing epi of meningitis
|
Vaccines for kids against H flu and strep pneumo
Now average age is now 40 |
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Campylobacter diagnosis
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Stool culture
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How does the bacteria get to the lower respiratory tract?
|
Microaspiration
Aspiration Inhalation Hematogenous |
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Shigella clinical syndrome
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Malaise, HA, abdominal pain
High fever, acute, blood dysentery Incubation 6-72 hours |
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Pathophysiology of bacterial meningitis
|
Nasopharynyx colonization
Mucosal disruption before humoral immunity sets in Leads to bacteremia Encapsulated bacteria marginate in cerebral vessels PMNs respond, damaging the BBB |
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Shigella micro
|
Gram neg rod
Facultative intracellular Human reservoir S. dystenteriae, S. flexneri, S. sonnei, S. boydii |
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How do bacterial in osteomyelitis evade immune system?
|
Adhering to damage bone
Entering persisting in osteoblasts Biofilm |
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Shigella at risk groups
|
Children in daycare
MSM poor sanitation |
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Symptoms of meningitis arise from
|
Decreased cerebral blood flow
Caused by bacterial replication -->cytokine response --> inflammation --> cerebral edema and vasculitis |
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Shigella pathogenesis
|
Superficial destruction of colonic epithelium
Toxin - shiga- damages vascular endothelial cells |
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Acute bronchitis treatment
|
Beta agonist, education
Maybe antitussives Do not treat with antibiotics - many randomized trials have shown no benefit |
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Frank blood in diarrhea
|
Think Shigella, EHEC
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What is special about bacteria that cause meningitis?
|
They all have capsules
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EHEC
|
Enterohemorrhagic E. coli
Median incubation 3-4 days Cytotoxin causes bloody stool if this is shiga toxin -- STEC Transmitted via consumption of undercooked, contaminated meat |
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Pathologic appearance of acute osteomyelitis
|
Organisms
PMNs Congested or thrombosed blood vessels |
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EIEC
|
Enteroinvasive E. Coli
Invasive of bowel wall Closely related to Shigella Incubation 2-3 days |
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Virchow-Robin space
|
Enlarged perivascular space around blood vessel where it enters the brain
These are the main site of inflammation/infilitrate during meningitis |
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EAEC
|
Enteroaggregative E. Coli
Persistent diarrhea in kids In US, but not commonly |
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Role of inflammation in pneumonia?
|
Increased capillary permeability
Neutrophilic infiltrate Good for fighting bacteria Also clogs airways and impairs gas exchange |
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EPEC
|
Enteropathogenic E. coli
Pediatric diarrhea, hospitalized infants < 4 months Insidious onset after days of poor feeding Adheres to microvilli and destroys them |
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Viral diseases limited to CNS
|
Enteroviruses (polio, coxsacki, echo)
Arbroviruses |
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Cholera
|
Non inflammatory toxin acts on small bowel
Increases cAMP Isotonic fluid loss Profuse, rice water diarrhea for 5 days |
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Pathologic appearance of chronic osteomyelitis
|
Necrotic bone (no living osteocytes)
Mononuclear cells Granulation and fibrous tissue hallmark is dead bone |
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Vibrio parahemalyticus
|
24 hours after eating poorly cooked seafood
Explosive water diarrhea, low grade fever |
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Viral diseases with CNS and systemic
|
Mumps
Herpes simplex Varicella zoster Adenovirus EBV parvovirus b19 Lymphocytic choriomeningitis virus |
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Yersinia enterolytica
|
Fever and abdominal cramps in 24-48 hours
Some have n/v Adults - appendicitis like Kids - diarrhea Lasts 1 day to 4 weeks |
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Transient bacteremia
|
Brief bacteria in the blood
Asymptomatic Occurs during normal daily activities: tooth brushing, bowel movements Manipulation of infected tissues |
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Yersinia enterolytica culture
|
Flat, colorless/pale pink
1-2 mm in diameter Lactose neg |
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Enteroviruses pathophysiology
|
Ingestion
Infects oropharynx/GI tract Minor viremia Lymphoid organs infected Major viremia--symptoms CNS, myocardium, etc infection |
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Clostridium botulinum
|
N/V/D
Descending flaccid paralysis 18-36 hours after consumption Toxin inhibits ACh release from nerves Associated with canned food |
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Epi of osteomyelitis
|
Can occur at any age
M 2 > 1 F Continuous focus infections in abnormal bone more in older (diabetes, orthopedic surgery, peripheral vascular disease) Hematogenous is normal bone more common in kids, elderly (vertebral), IDU |
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Clostridium botulinum complications
|
Respiratory paralysis
Need for weeks-months of ventilation |
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Meningitis symptoms signs in neonates
|
Irritablity, lethargy
Poor feeding Vomiting Seizures Temperature Instability Tense fontenelle CN palsy Maybe nuchal rigidity |
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Listeria monocytogenes
|
Incubation is 2-6 weeks
Fever, abdominal pain, watery diarrhea, myalgias, meningitis in infants, elderly, immunocompromised |
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Risk factors for developing pneumonia?
|
Immunosuppression
Aspiration risks Endotracheal tubes Decreased saliva Mucociliary elevator dsfnc Endobronchial lesions CF Alcohol |
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Treat listeria with?
|
Ampicillin
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Meningitis signs and symptoms in kids and adults
|
fever, HA, n/v, stiff neck, lethargy/confusion
Nuchal ridigity, Kernig's, Brudzinski's |
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Giardiasis
|
Bloating, abdominal discomfort and distention, diarrhea
Last 1-8 weeks Incubation 9 days Risk groups: hikers, childcare, MSM |
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Epi of hematogenous osteomyelitis
|
Kids
1 in 1000 neonates Children <13, 1 in 5000 |
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Cryptosporidium GI syndrome
|
Diarrhea, abdominal pain, HA, fever
Incubation 7 days, lasts 10-12 Immunocompromised |
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Meningitis signs and symptoms in the elderly
|
Confusion
Obtundation May not have a fever |
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Diarrhea in hiker?
|
Giardia
|
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|
How to rule out pneumonia in case of bronchitis?
|
CXR - gold standard
Normal vitals and no localizing lung signs Sputum is not predicitve |
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Diarrhea in international traveler?
|
ETEC
|
|
|
Labs in meningitis
|
CSF - WBC/diff, glucose, protein, gram stain, culture
Blood culture Serum Na (looking for SIADH) |
|
|
Diarrhea in amphibian lover?
|
Salmonella
|
|
|
Overview of contiguous focus osteomyelitis
Origin, RR, sites, population |
80% of cases
Origin of infection - punctures, bites, surgical procedures, trauma Risk factors - pvd, dm Sites: feet, hands, tibia, femur Who? Adults with diabetes |
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|
Diarrhea from anal sex?
|
Shigella (GC, HSV, CT, TP)
|
|
|
Neuroimaging in meningitis
|
Usually done
Usually normal early Not really necessary for diagnosis |
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|
Diarrhea on cruise ship?
|
Norovirus
|
|
|
Symptoms of pneumonia
|
Fatigue, cough, myalgia, fever, dyspnea
Pleurisy is uncommon, but a clue if present Does it hurt to take a deep breath? think inflammatory disease of the lung |
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|
Diarrhea from playing with toddlers?
|
Rotavirus
|
|
|
Complications of bacterial meningitis
|
Subdural effusion
Hydrocephalus Infarction 2/2 vascular insufficiency |
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|
GI illness after raw oysters?
|
V. parahemolyticus
|
|
|
Overview of hematogenous osteomyelitis
|
20% of cases
Origin of infection is blood Risks - endocarditis, bacteremia, sickle cell disease, previous bone damage Sites: Kids: tibia, femur, humerus Eldery/IDU: vertebra |
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|
GI illness after raw cookie dough?
|
Salmonella non-typhi
|
|
|
Prognosis of bacterial meningitis
|
Adults: strep 22% death, N. men 13%)
Kids: strep 8%, N men 8% H. flue 4% 85% who recover are wnl Other have deafness, cognitive impairment, spasticity/paresis, seizure disorder |
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GI illness after raw hamburger?
|
EHEC
|
|
|
Erysipelas
|
Infection of epidermis and dermis
Mostly caused by group A strep Sharply demarcated raised epithelium Pea d'orange Systemic symptoms, very painful Treat with pen |
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|
GI illness after fresh salsa?
|
Hep A
|
|
|
How to treat bacterial meningitis
|
Antibiotics (ceftriaxone, vanco)
Corticosteroids Fluid management Hearing evaluation |
|
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GI illness after leftover fried rice?
|
B. cereus
|
|
|
History of kids with osteomyeltis
|
Limp
Often no apparent source of bacteremia Frequent h/o blunt trauma resulting in interosseos hematoma or vascular obstruction |
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GI illness after unpasteurized cheese?
|
Listeria
|
|
|
History clues for unusual causes of pneumonia
|
TB risk factors
Travel history Animal exposure Mold exposure |
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|
GI illness after canned veggies?
|
C. botulinum
Also prominent would be the paralysis |
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|
Most common pathogen in osteomyelitis- all comers
|
Staph aureus
|
|
|
Diarrhea in AIDS
|
Cryptosporidium
Microsporidium Cylcospora Isospora |
|
|
Acute bronchitis pathogens
|
>90% viral
Rhinovirus Coronovirus, adenovirus, RSV, parainfluenza, <10% bacterial Mycoplasma pneumoniae, chlamydia pneumonia, bordetella pertussis |
|
|
Frequent rice-water stools?
|
Cholera
|
|
|
Pathogens in vertebral osteomyeltiis in elderly
|
Staph aureus
E. coli Proteus |
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Infectious cause of abdominal bloating?
|
Giardia
|
|
|
PE in pneumonia
|
Fever, hypotension, tachycardia, tachypnea, hypoxia
Asymmetric lung exam: Dullness to percussion Crackles, egophony, whispered pectoriloquy MS changes in elderly, respiratory compromise, shock |
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Infectious cause of appendicitis syndrome?
|
Yersina enterolitica
|
|
|
Pathogen to consider in IDU osteomyeltis
|
Pseduomonas
|
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|
What do fever and severe abdominal pain in presence of diarrhea imply?
|
Invasive disease
(Salmonella, shigella, campy) |
|
|
Pneumococcus
Appearance |
Streptococcus pneumoniae
Gram positive Lancet shaped diplocci Numerous capsule types - important virulence factor, vaccine target Greening of blood agar in culture - alpha hemolytic |
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Infectious cause of tenesmus?
|
Shigella
|
|
|
Pathogen associated with osteomyelitis in sickle cell disease
|
Salmonella
|
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|
Diagnostic testing in diarrhea
|
Fecal WBCs
Then stool culture O and P If all neg and symptoms persist, consider scope |
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Egophony
|
Have patient say E, if it sounds like A in your stethoscope, its a consolidation
|
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Culturing vibrio
|
Requires TCBS agar
|
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Pathogens for osteomyelitis in babies
|
Neonates - group B strep, gram negatives
Babies - H flu |
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Culturing Yersinia
|
Requires cold enrichment
|
|
|
When to treat acute bronchitis with antibiotics?
|
If it goes on for >2 weeks
Know exposure to a pathogen Bordetella pertussis specific diagnosis w/ nasopharygneal specimen M. pneumoniae IgM Chlamydia - no specific test Use macrolide (azithro, clarithro, etc) |
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Diagnosing C diff
|
Toxin testing
|
|
|
Signs and symptoms of hematogenous osteomyelitis
|
Fever, chills, malaise
Restriction of movement Difficulty weight bearing, ambulating Local pain and tenderness Local edema, erythema, warmth |
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|
Treating acute GI illness
|
REHYDRATE
Antibioitics only if severely ill, immunocompromised, fever and bloody stool |
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|
Whispered pectrolioquy/Tactile fremitus
|
Sounds are transmitted better through solids
"The boy is fine" or "toy boat" |
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Histamine fish poisoning (scromboid)
|
Causes mouth/throat burning, flushing, dizziness, n/v/d
5- 60 minutes later Lasts for a few hours Happens in coastal states |
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Vertebral osteomyeltis
|
Hematogenous
Starts at end plate and goes across disc Usually lumbar or thoracic |
|
|
Ciguatera poisoning
|
Fish toxin
Numbness and tingling of lips and extremities V/wateryD, cramps 1-6 hours later Lasts for days - months Florida and Hawaii |
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Cellulitis
|
Infection involving epidermis, dermis, subcutaneous tissue
Spreading painful erythema w/ indistinct borders May be patchy May form necrotic bullae Risk for systemic spread via lymphatics, blood |
|
|
Paralytic shellfish poisoning
|
Paresthesias of mouth and extremities
Vertigo, HA, N/V/D 5 min- 4 hours after eating mollusks Lasts hours-days Occurs in the coastal states |
|
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Risk factors of vertebral osteomyelitis
|
>50
Sickle cell disease DM Hemodialysis Endocarditis IDU Nosocomial bacteremia Long term vascular access UTI Preceding blunt trauma |
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|
Neurotoxic shellfish poisoning
|
Coastal florida
Less bad version of paralytic shellfish poisoning |
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Lab findings in pneumonia
|
WBC increased or decreased
Left shift Hypoxia Sputum cultures -- plausible pathogen? Blood cultures Respiratory virus studies |
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Tetrodoxin poisoning
|
Neurotoxin
Lethargy, paresthesias, dysphagia Japanese puffer fish Onset 10 min - 3 hours Lasts a few days |
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|
H/P in vertebral osteomyeltiis
|
Back pain/neck pain
Percussion tenderness of spine w/ paraspinal muscle spasm Fever in 50% Constitutional symptoms May have history of recent rigors |
|
|
Hemolytic uremia syndrome
|
Hemolysis and renal failure
Occurs as Shigellla or EHEC diarrhea is starting to resolve 8-13% of cases Fever, leukocytosis, thrombocytopenia More in kids/elderly 4% fatality |
|
|
Pharyngitis
symptoms |
Slow onset
Mild nasal discharge Scratchy throat - slighty erythematous Dry cough Glassy nasal mucosa No fever |
|
|
Campylobacter post infectious complication?
|
Guillaine barre
1-3 weeks later |
|
|
Imaging in vertebral osteomyelitis
|
Irregular erosions of adjacent endplates
Narrowing of disc space CT or MRI may show nearby abscess |
|
|
Reactive arthritis diarrhea pathogens
|
Salmonella
Yersinia Campy Shigella |
|
|
What is sputum good for in pneumonia?
|
Sometimes you see a plausble pathogen + WBCs
|
|
|
Most frequent cause of diarrhea worldwide?
|
ETEC
|
|
|
Osteomyelitis and DM
|
Usually small bones of the feet
Trauma/pressure sores/ulcers with contiguous spread Poor tissue perfusion impairs normal healing Good environment for anaerobes |
|
|
Top 5 foodborne pathogens
|
Salmonella
Norovirus Shigella C perfringens Staph aureus |
|
|
Intermittent bacteremia
|
Symptomatic
Occurs with infection and obstruction (like pyelonephritis, cholecystitis) or undrained abscesses |
|
|
What food gets contaminated with staph
|
Ham
Poultry Mayo Cream pastry |
|
|
Pathogens of continuous focus osteomyelitis
|
Stap aureus predominant
30-50% polymicrobial 30% include gram neg aerobes Bites, dental/sinus, peripheral vascular, deep punctures -- anaerobes |
|
|
What food gets B cereus
|
Fried rice
Vegetable Beans |
|
|
Ring-like lesion on chest xray in pneumonia
|
Abscess
|
|
|
What food gets C perfringens
|
Beef
Poultry Legumes Gravy |
|
|
Pathogen for osteomyelitis after nail through shoe?
|
Pseudomonas
|
|
|
Treating shigella
|
Ampicillin
TMP/SMX, cipro in resistance Don't give antimotility |
|
|
Pharyngitis causes
|
human rhinovirus>other respiratory viruses>>bacteria
|
|
|
Treating salmonella typhi
|
Ampcillin
TMP/SMX Cipro Or prevent with live oral vaccine |
|
|
Eikenella corodens
|
Human bite pathogen
|
|
|
Treating salmonella non-typhi
|
Usually you don't
Can use TMP/SMX or cipro in vulnerable patients |
|
|
Who does not get as many symptoms from pneumonia?
|
Symptoms can be blunted in immunocompromised
These are also the people most likely to get pneumonia |
|
|
Treating C diff
|
Metronidazole
Vanco if not responding |
|
|
Pasturella multocida
|
Cat bite pathogen
|
|
|
Treating yersinia enterolitica
|
Tetracycline
TMP/SMX |
|
|
Fasciitis
|
Infection of the fascia
|
|
|
Sings of continuous focus osteomyelitis
|
W/ normal vascular fnc
Erythema, swelling, pain, purulent sinus tract No/little fever W/vascular insufficiency Foot skin ulcer/cellulitis Often no pain (neuropathy) |
|
|
Types of pneumonia
|
Community acquired
Nosocomial Ventilator associated Aspiration Immunocompromised |
|
|
If you really want to look at a diabetic foot ulcer?
|
Use an MRI
|
|
|
What causes the symptoms in viral pharyngitis?
|
Immune response
|
|
|
Diabetes and osteomyelitis implications
|
6-10% of diabetics will have an amputation
|
|
|
Causes of community acquired pneumonia
|
Atypicals - not as severe illness
Strep Pneumo - more severe illness Respiratory viruses |
|
|
Labs in osteomyelitis
|
Elevated ESR (lasts longer)/CRP (rises first)
Blood cultures + in 1/3 of hematogenous in kids + in 25% of vertebral |
|
|
Upper vs lower tract UTIs
|
Upper:
Kidney and ureters Pyelonephritis Lower: Bladder, urethra Cystitis Urethritis Prostatitis |
|
|
What's not great about ESR in osteomyelitis
|
Greatly influenced by RBCs, plasma constituents
Changes more slowly than CRP ESR is a lower values - less discrimination |
|
|
Most common causes of bad community acquired pneumonia
|
Strep pneumo
Legionella Gram negs Staph aureus |
|
|
Monitoring response in osteomyelitis
|
CRP initially and should normalize before treatment is over
|
|
|
Transmission of pharyngitis
|
Hand to hand or fomites for HRV and coronavirus
|
|
|
Cultures in osteomyelitis
|
Need FNA or biopsy
Skin ulcer/tract cultures are not good enough Do aerobic and anaerobic |
|
|
Causes of hospital acquired pneumonia
|
Most common staph
Gram negatives (pseudomonas, klebsiella, e coli) |
|
|
Xray in osteomyelitis
|
Early on just soft tissue swelling
Periosteal rxn seen 10 days in Lytic in 2 to 6 weeks Sens 60/ Spec 70 Clearly shows bony changes (like fractures, prior surgery) Foreign bodies, gass |
|
|
Myositis
|
Infection of the muscle
Pyomyositis is almost always Staph aureus Can be strep as a complication of nec fac With gas production think Clostridia |
|
|
Radionuclide scans, 3 phase bone scan
|
All three phases are increased in osteomyeltis
More sens/spec than xray Not good in diabetic foot osteo though |
|
|
How does ventilator acquired pneumonia differ from just hospital acquired?
|
More resistant gram negatives
SPACE bugs Stenophromonas Pseudomonas Actinobacter |
|
|
Scintigraphy
|
Labeled WBCs
Accumulate in areas of infection Can be difficult to distinguish bone from soft tissue, combo with bone scan is good Sens/spec but not often done |
|
|
Group A strep pharyngitis
|
Exudates on an erythematous pharynx
Enlarged and tender anterior cervical LNs Abrupt onset severe pharyngitis Fever Transmitted by saliva or nasal discharge |
|
|
Best imaging for osteomyelitis
|
MRI
Bone signal change, cortical bone interruption, soft tissue edema around bone CT has a role in chronic |
|
|
Aspiration pneumonia causes
|
Often polymicrobial
Beware of anaerobes |
|
|
When are you most sure its not osteomyelitis
|
Able to probe exposed bone and get negative culture
90% specific` |
|
|
Continuous "high grade" bacteremia
|
Endovascular infection
Endocarditis, infected arterial aneurysm, infected grafts and shunts |
|
|
Duration of treatment in osteomyelitis
|
4 to 6 weeks
Can transition to home IV once stable Better to be using long acting agents then (vanco, ceftriaxone, erbepenem) Kids can go to orals after 5 to 10 years |
|
|
Pneumonia causes only in immunocompromised
|
HIV: PCP, cryptococcus, mycobacteria
BMT: Aspergillus, molds, Nocardia |
|
|
When to do surgery in vertebral osteomyelitis
|
Spinal instability
New or progressive neurologic deficits Large soft tissue abscesses Failure of medical therapy |
|
|
Diagnosing strep pharyngitis
|
Clinical and microbiologic
Clinical - 20% of kids carry this Tonsillar adenopathy, anterior cervical LNs, fever Microbiologic - need to not miss this Rapid enzyme immunoassay 80-90% sens, 95% spec Culture 90-95% sense |
|
|
Treating chronic osteomyelitis
|
Combined surgical and medical approach
Need to debride necrotic bone and any abnormal soft tissue Then treat for 4 to 6 weeks |
|
|
Treatment for community acquired pneumonia, mild
|
Azithromycin
w/ Doxycycline as second line Covers atypcials and most strep pneumo |
|
|
Treatment of contiguous osteomyelitis with vascular insufficiency
|
Debridement
Revascularize limb if large arteries are involved |
|
|
Staph aureus skin infections
|
Abscess formation -folliculitis, furuncles, pustules
Locally necrotizing infections Toxins - scalded skin, TSS Spreading infections - cellulitis |
|
|
Malignant otitis externa
|
Destruction of the floor of the external canal
Ear pain and chronic discharge >60, DM Pseudomonas is most common pathogen treat with debridement and high dose Abx |
|
|
Treatment for community acquired pneumonia, admitted to floor
|
Azithromycin + Ceftriaxone
Cover resistant strep pneumo, and atypicals Second line: levofloxacin, moxifloxacin |
|
|
Mandibular osteomyelitis
|
Usually with lack of medical care, alcohol, tobacco
Mixed infections - viridans, eikenella corrodens, oral anaerobes May need surgery to r/o malignancy and debride enough |
|
|
Why treat strep pharyngitis?
|
To prevent rheumatic fever
Glomerulonephritis, etc |
|
|
Skeletal TB pathology
|
Caseating granulomas
Not a lot of bacteria May take 6 weeks to culture |
|
|
Treatment for community acquired pneumonia, admitted to unit
|
Vanco/ceftriazone/azithromycin
Need to cover MRSA |
|
|
Pneumococcus
Where? |
Bacterial pneumonia, otitis, meningitis
Can be normal oral flora |
|
|
Treatment for hospital acquired pneumonia
|
Vanco/ceftriaxone
Cover MRSA, anerobes -atypically not necessary Second line is vanco/amp/sb |
|
|
Mononucleosis pharyngtitis
|
Mostly EBV (CMV, toxo, primary HIV)
Abrupt onset severe systemic symptoms (fever, malaise, fatigue) and headache Also have sore throat Generalized adenopathy, enlarged spleen |
|
|
Treatment of ventilator acquired pneumonia
|
Vanco/piperacillin/tazobactam
Gets MRSA and resistant gram negs Can add quinolone Second line is ceftaz instead of pip/tazo |
|
|
Strep infections of the skin
|
Most commonly s. pyogenes
Can cause glomerulonephritis Other beta hemoytic strep also cause skin infections (but not glomerulonephritis) Group B - primarily in immunocompromised host |
|
|
Signs of failing pneumonia treatment
|
Fevers, worsening dyspnea
Consider: a resistant bug, empyema, metastatic infection, wrong diagnosis, non-compliance |
|
|
Mononucleosis transmisison
|
Usually not from known cases
20% of adults are shedding EBV at any time Direct person-person -- never cultured from fomites |
|
|
How to prevent pneumonia?
|
Flu shot
Pneumoccal vaccine HIV dx and treatment TB control |
|
|
How to do a blood culture?
|
Skin prep w/ EtOH, iodophor, chlorhexadine
10-20 mls of blood anaerobic and aerobic cultures Best to get at least two sets better for sensitivity and specificity |
|
|
Is microaspiration bad?
|
Not usually
Its pretty common and does not usually causes disease Pneumonia arises with excessive invasion and failure of defenses |
|
|
Complications of mononucleosis
|
Airway obstruction
Severe thrombocytopenia Hemolytic anemia Give steroids for these |
|
|
Cardinal finding in pneumonia
|
Infiltrate on chest xray
|
|
|
Ulcerated and nodular skin lesions
|
Anthrax
Syphilis Fungal Mycobacterial |
|
|
When to treat pneumonia
|
Clinical syndrome
+ CXR showing infiltrate |
|
|
Diagnosing mononucleosis
|
Do it to avoid further diagnostic workup
Atypical lymphcytosis (peaks in week 2) Plts <140 in 50% of cases Monospot tests for heterophile antibody (+ in EBV) --90% sens in adults, reduced in kids Test for anti-EBV antibodies |
|
|
Travel to the midwest + pneumonia
|
Histoplasma
|
|
|
Symptoms of upper tract infection
|
Fever
Flank/CVA pain N/V Sepsis |
|
|
Pneumonia after spelunking
|
Histoplasma
|
|
|
Pharyngitis work up
|
If common cold presentation -- supportive care and RTC
Abrupt onset and systemic > pharygnitis -- flu in flu season, EBV otherwise -- supportive Abrupt onset and pharyngitis > systemic -- group A strep workup |
|
|
Pneumonia after bird exposure
|
Cryptococcus
|
|
|
Cellulitis predisposing factors
|
Trauma
Obesity Edema, lymphedema Chronic venous insufficiency Fissured toe-webs, athletes foot Impaired lymphatic drainage Other skin lesion |
|
|
Pneumonia after exposure to sheep placenta?
|
Q fever
|
|
|
Sinusitis
|
Infection of one or more of the paranasal sinuses
Viral Bacterial Fungal -- most in immunocompromised |
|
|
Pneumococcal vaccine
|
Vaccine against major serotypes of pneunococcus
All Kids - 7 valent conjugate vaccine At risk adults - 23 valent polysaccaride vaccine |
|
|
Interpretation of blood cultures
|
Normal skin flora are usually contaminants
True pathogens are rarely contaminants Contaminents are less likely to be found in multiple cultures, also more likely to be found in a clinical situation which does not finish |
|
|
Bacterial factors leading to pneumonia
|
Adherence to epithelia
Ability to invade Avoidance of phagocytosis --ie survival in macrophages |
|
|
Viral rhinosinusitis
|
viral sinusitis as part of the spectrum of the common cold
|
|
|
Particle size effects in pneumonia
|
Clearance of smaller particles is better
larger may be lodged in alveoli Inorganic inhaled material may impair phagocytic killing |
|
|
Microbio of cellulitis
|
Strep pyogenes is most common
associated with lymphangitis Staph aureus after a penetrating trauma |
|
|
Host factors effecting pneumonia development
|
Problems with mucocillary elevator
Pulmonary edema Loss of cough reflex Immunosuppression |
|
|
Acute community acquired bacterial sinusitis
|
Bacterial sinusitis with symptoms for less than a few weeks
Bacteria introduced by sneezing, coughing, nose blowing Usually from URI |
|
|
Pathologic types of pneumonia
|
Lobar - anatomic segment
Bronchopulmonary - pathcy Interstitial - invovlement of both lungs interstially |
|
|
Pneumococcus vs strep viridans
|
Strep pneumo is optochin sensitive
|
|
|
Pathologic progression of lobar pneumonia
|
Congestion (edema, serous exudate)
Fibrin deposition and polymerization from activation of complement/coagulation casacde Cellular infiltrate (PMNs, RBCs, macros) Hepataziation (infiltrates fill space) Resolution (macros clear infiltration) |
|
|
Chronic sinusitis
|
Bacterial or fungal sinusitis lasting more than a few weeks
|
|
|
Pathogen of lobar pneumonia
|
95% pneumococcus
|
|
|
Dog/cat bite + cellulitis
|
Pasturella multocida
|
|
|
Red vs gray hepatization
|
In lobar pneumonia pathology
Red first -- RBCs predominate Gray after - WBCs predominate |
|
|
Acute community acquired bacterial sinusitis pathogens
|
S. pneumoniae
H. flu M. catarrhalis - peds |
|
|
Bacterial pathogens causing a patchy (bronchopulmonary) pneumonia
|
Staph, strep (including pneumococcus)
Gram negatives More frequently disruptive of tissue |
|
|
Infective endocarditis
|
Localized microbial infection of cardiac valve or mural endocardium
|
|
|
Necrotizing pneumonia
|
Organism elaborate toxins
Tissue destroyed Scarring, not resolution Usually patchy Ex. Klebsiella, Staph aureus, other gram negs, weird strep pneumo |
|
|
Clinical presentation of acute community acquired bacterial sinusitis
|
Rhinorrhea, nasal obstruction, facial pressure, headache, cough
Purulent drainage from middle meatus Pain will palpation Reduced transillumination |
|
|
Complications of bacterial pneumonia
|
Empyema
Lung abscess Hematogenous spread |
|
|
Freshwater injury + cellulitis
|
Aeromonous hydrophilia
|
|
|
Interstitial pneumonia
|
Atypical pathogens
Viral, mycoplasma, chlamydia Damage to epithelium, inflammation w/in alveolar walls, exudate (hyaline membranes) |
|
|
Complications of bacterial sinusitis
|
Subdural empyema
Brain abscess Pott's puffy tumor Orbital cellulitis Cavernous sinus thrombosis Meningitis |
|
|
CXR is interstitial pneumonia
|
Fluffy interstitial infiltrates
|
|
|
Symptoms of lower tract infection
|
Dysuria
Frequency Urgency Suprapubic pain |
|
|
Influenza A pathology
|
Superficial necrosis of respiratory epithelium
Submucosal mononuclear infiltrate Fibrin in bronchi |
|
|
Treating bacterial sinusitis
|
ABx for 10 days
Amoxicillin-clavulanate, cefuroxime, cefpodoxime, moxifloxicin Antihistamines, nsaid No role for decongestants, steroids |
|
|
Interstitial pneumonia pathology
|
Interstitial inflammation
Air spaces preserved with widened alveolar septa Mononuclear infiltrate |
|
|
Salt water/raw oysters + cellulits
|
Vibrio vulnificus
|
|
|
Avian influenza pathology
|
Cytokine craze
Alveolar damage Macrophage infiltrate TNFalpha + |
|
|
Diagnosing bacterial sinusitis
|
Difficult
Bacterial vs allergic -- sneezing, itchy eyes, previous history Bacterial vs viral -- high fever, unilateral pain, facial tenderness, redness, swelling or does not get better in expected time CT to support |
|
|
How to sample lower respiratory tract for culture
|
Sputum- always going to mixed with pharynx, mouth
Tracheal aspirate - endotracheal tube Bronchoalveolar aspirate - bronchoscope mini BAL - catheter, semi-quantitative - ventilator assoc Lung biopsy |
|
|
Vegetation
|
Infected platelet rich thrombus
|
|
|
Why would you need to do a lung biopsy in pneuomia
|
If you really needed to know what this was
Bronchoscopes only get little pieces and might not reach to lesion |
|
|
CT finding in bacterial sinusitis
|
Air fluid line with flat meniscus
--shows presence of thin fluid Not just mucosal thickening (could also be viral) |
|
|
Calcofur white stain
|
Stains fungal cell walls
Also a few other organisms |
|
|
Lymphangitis
|
Infection spreading via lymphatics
|
|
|
How long does it take the culture to go positive in pneumonia pathogens?
|
Bacteria - 1-5 days
Myco/chlamydia - 5-10 days Fungi - 5 days - 5 weeks Mycobacteria 10 days to 3 weeks |
|
|
What increases pen resistant pneumocci carriage in kids?
|
More antibiotic use
Personally and in community |
|
|
Diagnosing legionella
|
Urine and respiratory specimens
Looking for antiens |
|
|
Group A strep
Appearance |
Streptococcus pyogens
Gram positive cocci in chains Beta hemolytic (complete hemolysis) |
|
|
Diagnosing histoplasma pneumonia?
|
Urine antigen positive in disseminated disease
|
|
|
Causes of common cold
|
Rhinovirus
Coronovirus Adenovirus Parainfluenza virus Influenza A and B |
|
|
Diagnosing pneumocystis pneumonia
|
Organisms only deep in lung (BAL or induced sputum)
Silver impregnation stain or immunoflourescent stain (more sens) |
|
|
Periorbital cellulitis may indicate
|
Sinus disease
|
|
|
Diagnosing viral causes of pneumonia
|
Use respiratory specimens
PCR, Immunoflorescence and enzyme assays |
|
|
Causes of pharyngitis
|
Rhinovirus
Adenovirus Parainfluenza virus Influenza A and B Coxsackievirus A EBV CMV HIV RSV Groups A, B, G strep N. gonnorhea Mycoplasma pneumonia Chlamydia pneumonia H. flu Strep pneumoniaa Moraxella catarrhalis |
|
|
At a reference lab you could get what to help diagnose a pneumonia?
|
Amplification assays for many pathogens
|
|
|
Acute endocarditis
|
Caused by invasive organisms
Rapidly progressive |
|
|
How to maximize success in culturing for pneunomia
|
Culture the best specimen you get
Don't culuture if there are > 10 squamous cells/LPF or if the sputum gram stain is negative |
|
|
Causes of acute bronchitis
|
Rhinovirus
Adenovrius Influenza A and B RSV M. pneumoniae Chlamydia pneumonia H. influenzae Strep pneumo Moraxella catarrhalis |
|
|
Chronic bronchopulmonary pneumonia pathogens
|
Nocardia
Actinomyces Granulomatous - TB, mycobacterium Fungal : crypto, histo, blasto |
|
|
Diagnosis of cellulitis
|
Clinical appearance
Blood cultures - + in 5% Aspiration of inflammed skin really better to use a bullae Punch biopsy with culture (20-30%) |
|
|
Most common cause of the common cold?
|
Human rhinovirus
|
|
|
Complicated UTI
|
Presence of:
Obstruction - anatomic or foreign body Function disruption of urinary flow (neuromuscular dysfunction) Immune abnormalities |
|
|
How are cold viruses transmitted?
|
Rhinovirus - mostly hands, can live on fomites for a bit
Flu/paraflu/coxsackie -- aerosols Not saliva |
|
|
Recurrent cellulitis
|
Associate with chronic lymphatic/venous obstruction
Usually strep pyogenes Represents colonization Chronic suppression with Pen VK can be helpful |
|
|
Treating the common cold
|
Nasal: ipatropium bromide, cromolyn sdoium decrease discharge and rhinorrhea
Sore throat- ibuprofen, warm saline gargles Cough: antitussives Systemic: ibuprofen, rest Not: Abx, VitC, echinacea, antitussives, expectorants, glucocorticoids, zine |
|
|
Subacute endocarditis
|
Caused by low-grade pathogens
Symptoms usually present for weeks to months before diagnosis |
|
|
Complications of the common cold
|
Sinusitis, mostly viral
Otitis media, mostly in kids Lower respiratory tract infection |
|
|
Paronychia
|
Painful infection of nail bed or margin
S. aureus commonly Treatment: Moist heat, drainage prn, oral antibiotic for systemic symptoms or large lesions |
|
|
Group A strep pharyngitis epi
|
5-15% of adult pharyngitis
20-30% kids |
|
|
Beta hemolytic streps
|
A, B, C, G
|
|
|
Treating group A strep pharyngitis
|
10 fold reduction in acute rheumatic fever if Abx started w/in 9 days and continued for 10 days
Use penicillin (erythro in allergic) |
|
|
Folliculits
|
Pustular hair follicle infection
No systemic toxicity Staph aureus Treat with topical muprocin or polymixin B-neomycin-bacitracin |
|
|
Pathogenesis of sinusitis
|
Blocking of ostia
In chronic they remain blocked |
|
|
Nonbacterial thrombotic endocarditis
|
Sterile vegetations
Seen in connective tissues diseases, malignancy |
|
|
Pathogens in chronic sinusitis
|
Strep pneumo
H. flu Staph aur Anaerobic gram + Gram neg rods |
|
|
Recurrent furunclosis is associate with?
|
Nasal staph carriage
|
|
|
Gold standard for diagnosing bacterial sinusitis?
|
Aspiration and culture
|
|
|
Acute vs chronic UTI
|
Acute - treated and symptoms/bacterial resolve
Chronic -- treated and symptoms resolve but bacteria continues |
|
|
Acute bacterial sinusitis natural history and complications
|
Spontaneous resolution in 40-50%
Maxillary/frontal - subdural empyema, pott's puffy tumor, meningitis Ethmoid - orbital abscess, cellulitis Sphenoid - cavernous sinus thrombis, meningitis |
|
|
Treatment of furuncle
|
Moist heat
Drainage of large lesions Oral antibiotic for systemic symptoms, large lesions, lesions on face |
|
|
Acute endocarditis
|
Normal or abnormal valves
Acute onset, hectic pace, early complications Virulent organisms (S. aureus, beta-hemolytic strep, pneumococcus) |
|
|
Sporotrichosis
|
Painless pustule that ulcerates
Secondary lesions along lymphatics Gardeners and farmers |
|
|
What differentiate group A strep from other beta hemolytics?
|
Ability to cause late sequela:
rheumatic fever acute glomerulonephritis |
|
|
Infection with mycobacterium marinum
|
Contact with aquariums and freshwater
Small papule that ulcerates Lymphangitic spread |
|
|
Subacute endocarditis
|
Usually occurs at abnormal valves
Subacute onset over months Insidious course Less virulent organisms: viridans strep, coagulase-neg staph |
|
|
Cutaneous anthrax
|
Painless papule
Associated edema, regional lymphadenopathy Papule w/erythema --> vesicle/bullae --> black from hemorrhage--> ulcerate to form eschar Often, several pearl-like satellite vesicles develop Necrotic area--but not painful |
|
|
Recurrent UTI
|
Reinfection with different bugs occuring frequently
Relapse - persistant bacteria in UT leads to repeated symptomatic episodes |
|
|
Loxocelism
|
Painful
Spider bites Necrotic lesions without much surrounding edema |
|
|
Native valve endocarditis epidemiolgy
|
2-6/100K person-years
M>W, 50% older than 55 Predisposing risk factors IDU Mitral valve prolapse Degenerative valve disease Rheumatic heart disease Poor dental hygiene Long term hemodialysis Previous endocarditis |
|
|
Secondary infections complicate these skin lesions
|
Eczema
Lacerations Decubitus ulcers (bowel flora) Human bites Animal bites Surgical wounds Burns |
|
|
Group A strep
Where? |
Pharyngitis and skin infections
Low rate of carriage orally in kids in winder |
|
|
Infection associated with puncture through sneaker
|
Pseudomonas aeruginosa
|
|
|
Endocarditis pathogenesis
|
Damaged endocardial surface
High velocity flow Passage of blood from high pressure to low pressure Localized thrombosis ensues serving as a nidus for infection during transient bacteremia Platelet-fibrin layers form barrier between bacteria and neutrophils Allows for bacterial growth |
|
|
Skin infection with foul smelling gas in tissues
|
Clostridia
|
|
|
Urosepsis
|
Sepsis syndrome 2/2 infection of urinary tract
|
|
|
Secondary bacterial infections associated with lacerations and punctures are caused by
|
Staph and strep usually
Can be caused by environmental contaminants Enterobacteraciae Pseudomonas Aeromonas Vibrio vulnificus |
|
|
Microbiologic causes of endocarditis
|
Viridans strep
S. aureus especially in nosocomial , IDU Coagulase neg staph - often iatrogenic Enterococci esp w/ bladder outset obstruction Polymicrobial = IDU |
|
|
Secondary infection of human bite
|
Staph, strep, Eikenella corrondens, oral anerobes (Fusobacteria, Prevotella)
Often on the hand, so can be complicated by tenosynovitis, arthritis, osteomyelitis Treat with ampicillin/sulfbactam (amoxicillin/clavulanate), cefotetan |
|
|
Types of group A strep?
|
Many
Different in their M proteins -- cell wall protein |
|
|
How to triage cellulitis of hands or face?
|
Admit them
|
|
|
Most common pathogens in native valve endocarditis
|
Community acquired - strep viridans > staph species
IDU - Staph majority also sometimes see fungi |
|
|
Secondary infections of animal bites
|
Often polymicrobial
S. aureus, beta hemolytic strep Pasturella Capnocytophaga --can cause sepsis in immunocompromised host Treat with amoxicilin/clavulanate or ampicillin/sulfbactam |
|
|
Ascending lower UTI risk factors
|
Maternal history of UTIs
1st UTI < 15 New sexual partner Condom/diaphragm use Spermicides Catheterization |
|
|
Secondary infections of decubitus ulcers
|
Sacral
--polymicrobial bowel flora need deep cultures can invade bone Heel Stap and strep |
|
|
Most common pathogens on replacement valve endcarditis
|
<12 months out - coag-neg staph
>12 months out - strep viridans |
|
|
Necrotizing faciitis
|
Rapid progression
Necrosis of subcutaneous tissues and overlying skin Systemic toxicity Causes by group A strep or polymicrobial aerobic/anerobic May need MRI/exploratory surgery to differentiate from cellulitis |
|
|
Treating beta hemolytic strep?
|
Penicillin works
Except for enterococci |
|
|
Clues that this skin infection is from an anaerobe
|
Gas production (crepitus or seen on imaging)
Foul odor Tissue necrosis Rapid spread through tissue planes Gram stain showing mixed organisms |
|
|
Culture negative endocarditis
|
Not common
Usually seen after recent antibiotic use Sometimes difficult to culture organisms Bartonella - cat scratch, trench Q fever Abiotrophic strep HACEK orgnanisms Chalmydia Legionella Brucella Fungi |
|
|
Hematogenous UTI pathogenesis
|
Seeding during bacteremia
Usually staph aureus |
|
|
HACEK
|
Hemophilus
Actinobacillus Cardiobacterium hominis Eikenella Kingella |
|
|
Group B strep
|
Several species - strep agalactiae
Usually beta hemolytic Female genital tract Neonatal sepsis, meningitis Sensitive to penicillin |
|
|
Clinical presentation of subacute bacterial endocarditis
|
Fever in 95% of pts
Anorexia, weight loss, malaise, night sweats Myalgias - 50% of patients Heart murmur Embolic stimata Splenomegaly |
|
|
Host defenses against UTIs
|
Urine - osmolarity, pH, organic acids
Anti-adherence Mechanical effect of urine flow Immune system: bacteriosidals, cytokines, PMNs |
|
|
Skin signs of infective endocarditis
|
Splinter hemorrhages (red -->brown)
Conjunctive petichiae Osler's nodes - painful subq nodules often on pulp of thenar eminence Janeway lesions - nontender erythematous lesions on palms or soles Petichiae |
|
|
Viridans streptococci
appearance |
Gram positive cocci in chains or pairs
Many are alpha hemolytic Optochin insensitive |
|
|
Roth spots
|
Sign of SBE
Retina - oval white areas surrounded by hemorrhage |
|
|
Epidemiology of UTIs
|
Infants: 1-2% prev -- M=F
School age: 0.5-5% - F>M Adult: 20% - F 30x M Geriatric: 20-40% - M>F Increasing with age Old men - BPH alters urine flow Old women - loss of fnc |
|
|
Systemic manifestations of SBE
|
Emboli
Stroke Monocular blindness Acute abdominal pain Coronary syndrome Splenic infarct/abscess Renal Microscopic hematuria Renal insufficiency |
|
|
Viridans strep species
|
S. mutans
S. sanguis S. salivarius S. mitis |
|
|
Amaurosis fugax
|
Monocular blindess from thrombus to retinal artery
|
|
|
Incidence of UTIs in childbearing women
|
10-20%
|
|
|
Clinical manifestation of acute bacterial endocarditis
|
Abrupt onset
High fever Rigors common Prominent cutaneous manifestations Emboli common Rapidly changing murmur Rapid development of CHF |
|
|
Viridans strep
Where? |
Predominant organism in normal oral cavity
Most common cause of SBE on previously damaged valves |
|
|
Endocarditis associated w/ IDU
|
Usually normal valves
Staph aureus, polymicrobial, fungi High frequency of tricuspid involvement High fever, cough, chills, malaise Pleuritic chest pain from septic pulmonary emboli is hallmark of right sided IE |
|
|
Causes of uncomplicated bacterial UTIs
|
E. coli (95%)
Staph saprophyticus signficant in young women |
|
|
Additional complications with prosthetic valve endocarditis
|
Often associated with perivalvular invasion
Valve-ring abscesses Valvular dysfnc Valve dehisence Can get obstruction/abnormal fnc |
|
|
Peptostreptococcus
|
Obligate anaerobes
Gram positive cocci in clumps or chains Normal oral/fecal flora Common cause of anaerobic infections (brain abscesses, liver abscess) Quite sensitive to penG |
|
|
Blood cultures in infective endocarditis
|
Hallmark is sustained bacteremia
Take a different sites over hours in SBE Take multiple sites right away in ABE Each into aerobic and anaerobic |
|
|
Diagnosing UTI
|
Urinalysis
>5-10 WBC is HBF = infection Bacteria in spun sediment Positive leukocyte esterase rxn 75-95% sensitive 95% specific for signif Nitrite test - based on bacterial reduction of nitrate by bacteria in urine -less useful 2/2 false negs |
|
|
Transthoracic US in endocarditis
|
Rapid, noninvasive
98% specific for vegetations 60-70% sensitive Body habitus may limit |
|
|
Enterococcus fecalis
Appearance |
Gram positive cocci in pairs or chains
Grows in bile-esculin broth |
|
|
Transesophagic US in endocarditis
|
75-95% sensitive for vegetions
Highly specific Can also see myocardial abscesses Invasive, expensive |
|
|
Urine gram stain
|
One organism/oil immersion field = 10^5 bacteria/cc of urine
G+/G- for treatment guidance |
|
|
Duke's criteria for diagnosing infective endocarditis
|
3 major or 1 + 3 or 5 minor
Major: Organism on 2+ blood cultures New murmur/+ECHO Minor Risk factors Fever Vascular phenomenon Immunologic phenomenon Not persistent, but positive BC |
|
|
Enterococcus fecalis
Where? |
Normal fecal flora
5-10% of UTIs Second most common cause of SBE |
|
|
Immunologic phenomena of IE
|
glomerulonephritis
RF Osler's nodes Roth spots |
|
|
Sources used for urine culture
|
Clean catch midstream specimen
Catheter specimen |
|
|
How good is Duke's criteria?
|
Specificity said to be 99%
NPV - 92% |
|
|
Staphylococcus aureus
Appearance |
Gram positive cocci in singly, pairs, or in clusters
Coagulase positive |
|
|
Does this staph aureus bacteremia include an endocarditis?
|
25-35% do
Increased risk w/ Community acquired Absence of primary focus Presence of metastatic sequelae Fever/bacteria lasting >3 days after removing cat |
|
|
Urine culture in UTI and treatmetn
|
Symptoms + >10^2 bacteria/cc
Asymptomatic + >10^6 bacteria/cc x2 |
|
|
Bad prognostic signs in endocarditis
|
(Increased risk for needing valve replacement)
Persistent bacteremia/fever Recurrent emboli Heart block - abscess hindering conduction CHF New heart murmur |
|
|
Staphylococcus epidermidis
Appearance |
Gram positive cocci in singly, pairs, or in clusters
Coagulase negative |
|
|
Cardiac complications of infective endocarditis
|
Valve damage causing CHF
Myocardial abscess Extension into septum causing heart block Purulent pericarditis |
|
|
When and how to image in UTI
|
Looking for causes of complication
Or poorly understood reinfection Indirect imaging: Intravenous pyelogram, US, CT/MRI Direct: cystoscopic |
|
|
Neurologic complications of infective endocarditis
|
20-40% frequency
Mostly emboli -- stroke Also mycotic aneurysm can rupture and hemorrhage Risk during anticoag for valve replacement Treatment rapidly decreases risk |
|
|
Staphyloccus sapryophyticus
Appearance |
Gram positive cocci in singly, pairs, or in clusters
Coagulase negative |
|
|
Treatment of infective endocarditis
|
Cultures first
High doses of parenteral agents 4+ weeks for native valve 6 weeks for prosthetic Inpatient until clear response (afebrile, repeat negative blood cultures) |
|
|
W/U of UTI
|
History: previous UTIs, sexual history, underlying disease, meds
Physical: pelvic/rectal UA Urine culture for complicated and recurrent |
|
|
What to treat with in infective endocarditis?
|
Based on cultures
Pen if you can Nafcillin/Vanco add rifampin |
|
|
Neisseria meningitis
Appearance |
Gram negative
Coffee-bean shaped diplococci Oxidase positive Grows best with CO2 |
|
|
Response to therapy in infective endocarditis
|
Fever should be gone in a week
CRP fall in 1-2 weeks |
|
|
UTI in infants and young children
|
Presents as FTS, fever, vomitting
Check for congenital abnormalities At risk for long term renal damage from persistent UTI May need careful FOL or prophy antibiotics to maintain urine sterility |
|
|
Valve replacement in infective endocarditis
|
Indicated in 25-40% of native and 45% of prosthetic
Best to do before development of CHF or spread to perivascular tissue Low risk of infecting new valve |
|
|
N. meningitis serotypes
|
Capsule based
Vaccines are made against the capsule Capsule can be detected in CSF |
|
|
Indications for surgery in infective endocarditis
|
Persistent bacteremia
Perivalvular invasive disease Mod/severe CHF Recurrent emboli Large vegetations Pseudomonas, fungi, resistant enterobacter |
|
|
Urethral syndrome
|
Dysuria
(no suprapubic pain) Caused by uti, sti |
|
|
Mortality in infective endocarditis
|
4-16% - viridans strep
15-25% with enterococci 25-50% with staph >50% for gram negs, fungi |
|
|
Gonococcus
|
Neisseria gonorrhea
Gram negative diplocci Cause urethritis, pid Require enriched media and CO2 to grow in culture Can be diagnosed off swab for DNA |
|
|
Prophylaxis in endocarditis
|
Theory is to give high risk pts antiobiotics prior to events likely to cause bacteremia
Unproven Highest risk: previous endocarditis, prosthetic valves, cyonotic heart malformations Times: dental work, surgery |
|
|
Vaginitis symptoms
|
Discharge
Vulvar discomfort |
|
|
Non-pathogenic Neisseria
|
Gram neg diploccis
Do not require special growth media |
|
|
How long to treat a UTI
|
Short course for lower tract infections (3 days)
Long course for upper tract (1-2 weeks) |
|
|
Morexalla catarrhalis
|
Gram negative diplocci
Infrequent cause of pneumonia in elderly, COPD pts Also suppurative otitis media |
|
|
Distinguishing between reinfection and relapse
|
Urine culture 2 weeks out from treatment
If positive, relapse is likely source of recurrent UTIs |
|
|
Hemophilus influenza
Appearance |
Gram negative small rod
Some pleiomorphism Requires chocolate culture with X (hemin) and V (NAD) factors to grow Capsular antigen is important to virulence/vaccine |
|
|
Treating recurrent UTIs
|
If reinfection is the problem, prophylaxis if more than 3/year
If relapse is the problem, treat with longer course of antibiotics |
|
|
What does H. flu cause
|
Meningitis in unvaccinated kids
Epiglottitis (bronchitis) Otitis Pneumonia |
|
|
Pregnancy and UTI
|
Dilation and altered peristalsis of ureter predisposing to ascending pyelo
Screen all for bacteruria Treat all bacteruria |
|
|
Enterobacteriacea family
|
E. coli
Klebsiella Enterobacter Salmonella Shigella Proteus Serratia |
|
|
UTI in young man
|
Evaluate for STIs
Rare congenital abnormality found |
|
|
E. coli
Appearance/culture |
Gram negative rod
Facultative anaerobe Glucose and Lactose fermenter |
|
|
UTI treatment in the elderly
|
Only treat symptomatic infections
Not asymptomatic bacteriuria Prophy for recurrent, symptomatic infections |
|
|
E. coli
Where? |
Major large intestinal flora
Bacteremia, UTI in neonates Most common cause of UTI Gram neg sepsis in hospitals Hospital acquired pneumonia |
|
|
Chronic foley catheter patients and UTIs
|
High incidence of infection
(1% for one catheterizaiton outpatient, 10% inpatient) Only treat if symptomatic Ignore bacteriuria, candida in urine |
|
|
Klebsiella
|
Gram negative rode
Facultative anaerobe Glucose and lactose fermenter |
|
|
Prostatitis diagnosis and treatment
|
Difficult to diagnosis
Suspect in male with multiple UTIs Treat symptomatically with agents that reach high blood/tissue levels ? actually infectious/curable |
|
|
Klebsiella causes?
|
Pneumonia, UTI
Others less commonly |
|
|
Antibiotics commonly used in outpatient lower UTI
|
TMP/SMX
Ciprofloxacin Amoxicillin clavulanate |
|
|
Enterobacter
Appearance/culture |
Gram neg rod
Facultative anaerobe Fairly resistant to antibiotics |
|
|
Antibiotics use in outpatient upper UTI
|
Ciprofloxacin
|
|
|
What do Kelbsiella and enterobacter produce a lot of?
|
Gas during fermentation
|
|
|
Antibiotics used for prophylaxis of UTI
|
TMP/SMX
trimethoprim nitrofurantoin cephalexin cirpofloxacin |
|
|
Salmonella typhi
|
also S. paratyphi A, B
Tyhoid fever - an enteric fever Human to human, fecal oral disease with significant m and m |
|
|
Upper UTI treatment inpatient
|
Aminoglycoside + ampicillin
piperacillin/tazobactam ciprofloxacin |
|
|
Salmonella characteristics
|
Gram neg rod
Facultative anaerobe Non-lactose fermenting H - flagellar - antigen O - cell wall antigen |
|
|
Other UTI pathogens
|
Pseudomonas
Klebsiella Enterobacter Seratia If you see this bugs, consider a complicated infection |
|
|
Salmonella not typhi
|
S. enteritidis, newport, typhimurium, hiedleburg
Many serotypes Cause gastroenteritis Tramission to humans from carriage in domestic animals Self-limiting enteric disease |
|
|
Shigella
|
Gram neg rod
Facultative anaerobe Non-lactose fermenting Non-motile Shigellosis - dysentery - blood and pus in stool Usually transmitted through contact with human feces |
|
|
Pseudomonas aeruginosa
|
Gram neg rod
Obligate aerobe Green pigment producing |
|
|
Pseudomonas aeruginosa causes
|
Bacteriemia
UTI Burn infections Pneumonia in CF, hospital |
|
|
Causes of pneumonia in CF patients
|
Pseudomonas
Burkholderia cepacia Stenotrophomonas maltophilia |
|
|
Campylobacter
|
Gram neg rod
Curved shape Microaerophilic (5% O2 is best) Causes gastroenteritis |
|
|
Vibrio
|
Gram neg rod
Comma shaped Requires special media to culture stool |
|
|
Vibrio parahemolyticus
|
Watery diarrhea
Associated with eating raw seafood |
|
|
Yersinia enterocolitica
|
Gram neg rod
Infrequent cause of gastroenteritis Transmitted to humans from domestic animal feces |
|
|
Bacteriodies
general |
Gram neg
Anaerobe |
|
|
Bacterioides
where? |
Common in normal intestine and mouth
Extraintestinal disease |
|
|
Penicillin for a lower GI tract infection?
|
No
B fragilis is resistant |
|
|
Legionella pneumophilia
|
Gram neg rod
Difficult to culture Facultative intracelluar Causes pneumonia Azithromycin May see antigen in urine |
|
|
Bordetella pertusis
|
Small gram neg rod
Not easily cultured (PCR) Causes whopping cough Acellular vaccine |
|
|
Mycoplasma
|
Bacteria without cell walls!
Don't use cell wall agents |
|
|
Chlamydia
|
Obligate intracellular bacteria
Non gonococcal urethritis, eye infections, pneumonia |
|
|
Mycobacterium marinum
|
Forms pigment if grown in light
Skin disease |
|
|
Mycobacterium kansaii
|
Causes pulmonary disease
Forms pigment if grown in light |
|
|
Clostridium difficile
appearance toxins |
Gram positive rod
Obligate anerobe Toxin A - enterotoxin Toxin B - cytotoxin |
|
|
Bacillus anthracis
|
Aerobic gram positive rod
Form resistant spores B cereus- food poisoning in reheated food |
|
|
Listeria monocytogenes
|
Gram positive rod
Aerobic Transmitted by dairy/meat to cause food poisoning, occasional meningitis Can be transmitted to fetus and cause death |
