michael kulczycki, do- infectious disease board review 2014- armc emergency medicine
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BOARD REVIEW
MICHAEL KULCZYCKI
DECEMBER 18 2013
GOALS
• ENDOCARDITIS
• MENINGOCOCCEMIA
• PERTUSSIS
• PNEUMOCOCCEMIA
• TETANUS
• TUBERCULOSIS
• THE PLAGUE
• HERPESVIRIDAE
• HIV
ENDOCARDITIS
• RISK FACTORS
• PROSTHETIC HEART VALVES
• STRUCTURE HEART DISEASE
• RHEUMATOID HEART DISEASE
• MITRAL VALVE PROLAPSE
• BICUSPID AORTIC VALVE
• IV DRUG ABUSE
• CARDIAC PROCEDURES
• INDWELLING VENOUS CATHETERS
Acute
• Normal Valves• Younger Patients• Sick
Subacute
• Abnormal Valves• Older patients• Non-specific
constitutional symptoms
Left Heart
• More Common• S. Viridans• S. Aureus• Enterococcus• CHF, CVA, AV block• Systemic infarcts
from septic emboli
Right Heart
• IVDA• S. Aureus• S. Pneumonia• Respiratory
Symptoms• Misdiagnosed as PNA
S. Aureus = Single most common cause
Roth Spots
Osler Nodes(painful)
Janeway Lesions(painless)
Splinter Hemorrhages
ENDOCARDITIS
JONES CRITERIA – 2 MAJOR, 1 MAJOR + 3 MINOR, 5 MINOR
Major
• 2 Positive Blood Cultures• 3 sets 1 hour apart• Cultures of typical bugs• Persistance of cultures > 12
hrs• Abnormal Echo
• Prosthetic valve dihiscence• New valvular regurg• Myocardial abscess• Visible vegetation
Minor
• Predisposition/IVDA• Fever• Vasular Events/Septic
Emboli• Immunologic Events• Positive Echo or Blood
cultures not meeting major criteria
ENDOCARDITIS
Indications:• Prosthetic Valve• Congenital Defect repaired• Prior Infectious Endocarditis• Cardiac transplant with abnormal
valves
Manipulation of gingiva/mucosa or apical area of tooth
MENINGOCOCCEMIA – NEISSERIA MENINGITIDES
Nuts and Bolts…• Military Recruits, College Dorms• Children < 5• Gram (-) diplococcus• Nasopharynx = portal of entry• Septicemia without meningitis (>20% mortality)
MENINGOCOCCEMIA
Rash• Petechia
• 50-60% Cases• Can involve mucous membranes• Trunk/Extremites
• Purpura Fulminans• Rapidly spreading ecchymosis• Gangrene• DIC
MENINGOCOCCEMIA
Meningococcemia + Bilateral Adrenal Hemorrhage =
Waterhouse-Friderichsen Sndrome
Fulminant Meningococcemia
MENINGOCOCCEMIA
• Lumbar Puncture • Early Antibiotics
• Prophylaxis for close contacts• Ciprofloxacin• Rifampin• Ceftriaxone
PERTUSSIS
Nuts and Bolts…
• Whooping Cough• Summer and Fall months• Cough > 2 weeks• Respiratory Droplets• Vaccination does not equal lifelong immunity• Misdiagnosed as bronchitis
PERTUSSIS
Catarrhal Phase
URI like symptoms
Cough, low grade fever
Highest infectivity
Paroxysmal Phase
Cough increases,
fever subsides
Paroxysms of coughing
(>50 times/day)
Convalescent Phase
Residual cough
(weeks to months)
PERTUSSIS
• High index of suspition
• Lymphocytosis – correlates with severity of disease
• CXR: peribronchial thickening
• Nasopharyngeal culture
• Macrolide (erythromycin)
• Prophylactic antibiotics for close contacts
• Acellular pertussis vaccination for high risk
exposures
PNEUMOCOCCEMIA
• Lancet shaped G (+) diplococcus• Most common cause of bacterial pneumonia
Pneumonia• Severe rigors• Rusty colored sputumMeningitisSepticemiaEndocarditis
Adult vaccination for:• Adults with chronic illness• Age > 65• Immunocomprimised / HIV• Anatomic or functional Asplenia
TETANUS
Found in soil, dust, feces>70 % from wounds (post-operative)Bacteria produce neurotoxins – Tetanolysin/Tetanospasmin
• No mental status changes
• Weakness, myalgias, dysphagia, hydrophobia, drooling
• Trismus – “Lock Jaw”
• Risus Sardonicus - facial muscle involved
• Opisthotonos – Generalized tetanus, arching of back/
neck
• Laryngeal Spasm and Respiratory Failure
• Autonomic Dysfunction
TETANUS
Opisthotonos Risus Sardonicus
TETANUS
Strychnine Poisoning
PesticideMuscle spasms, trismus, risus sardonicus, seizures
TETANUS
Benzodiazepines/Narcotics
Paralysis (non-depolarizing)Eliminate the toxin –
Tetanus Immunoglobilin (TIG)Administer opposite arm of tetanus booster
Eliminate the Bug – Flagyl
Immunization
• TIG if < 3 Td and dirty wound• Clean wounds – Td if > 10 years• Dirty wounds – Td if > 5 years
TUBERCULOSIS
• Humans sole reservoir• Leading cause of infectious death worldwide• Leading cause of adrenal insufficiency worldwide• One third of world population infected with TB
Risk Factors • Immunocompromised / HIV• Close contact / Occupational exposure• Foreign born• Low socioeconomic status• IVDA• Homeless• Prison / shelter
TUBERCULOSIS
Pulmonary Tuberculosis
• Cough – most common symptom• Fever• Night sweats• Weight loss• Pleuritic Chest pain• Hemoptysis – mild to severe• Erosion into pulmonary artery = Rasmussen aneurysm
Chest x-ray• Primary TB – difficult to differentiate from PNA• Hilar / Midiastinal LAD common in primary TB• Miliary (disseminated) TB – multiple nodules bilaterally• Reactivation TB – Cavitation without lymphadenopathy
TUBERCULOSIS
Extrapulmonary TB
Lymphadenitis – Scrofula• Enlarged / painful mass near cervical nodes• Most common extrapulmonary manifestation• Do Not I&D
Bone and Joints – Pott’s Disease (spine)
Acute Dissemination• Typically elderly and AIDS• Associated with SIADH
CNS – Tuberculous Meningitis• Subependymal tubercle ruptures into subarachnoid space• Lowest CSF glucose of any meningitis
TUBERCULOSIS
AFB sputum smear – hours, many false negatives/positives
AFB culture – weeks, Gold standard, 87% sensitive
Latent TB • Isoniazid - 9 months
Active TB• 4 drug regimen – 6 months
Extrapulmonary TB• 4 drug regimen – 6 months
Isoniazid – seizures (pyridoxine)
Rifampin – orange urine. OCP failure
Pyrazinamide - hepatotoxic
Ethambutal – red-green color blindness
Pregnancy – INH, RIF, ETH cross placenta and are safe
THE PLAGUE – YERSENIA PESTIS
Nuts and bolts…
• Vector – rat flea – xenopsylla cheopis
• Traditionally from rats, now squirrels and cats
• Potential biologic weapon
• Transmission – bites, close contact, direct inhalation
• Veterinarians, animal handlers
• Non-specific symptoms – Fever and myalgias
THE PLAGUE
Three Clinical Syndromes
Bubonic Plague• Bubos on the skin, invasion of
lymphatics and vasculature• Generalized painful LAD
Septicemic Plague• Direct invation of vasculature
without bubos
Pneumonic Plague• Most aggressive• Severe pneumonas, sepsis,
death
Black Plague – deep cyanosis and gangrene with disseminated disease
“Ring around the rosy”“Ashes, ashes we all fall down”
THE PLAGUE
• Gram stain of bubo aspirate
• CXR – infiltrate or hilar lymphadenopathy
• Respiratory Isolation
• Streptomycin or Doxycycline
• Supportive care
HERPESVIRIDAE
Herpes Simplex Virus
HSV-1 - oropharyngealHSV-2 – genital
Multiple, painful shallow ulcers which may coalesceShedding lasts up to 3 weeks
Herpetic Whitlow• Herpetic finger infection• Do not I&D
Neonatal Herpes• Transmission at deliver• High mortality if untreated
Herpes Encephilitis• Most common cause of encephalitis in U.S.• Fever and bizarre behavior
HERPESVIRIDAE
Varicella-Zoster Virus
Chickenpox• Acute generalized viral illness• Lesions everywhere on skin and mucous membranes
(palms/soles spared)• Maculopapular then vesiculated
Herpes Zoster• Reactivation in DRG – dermatomal• Multiple vesicles on erythematous base
Zoster Opthalmacus• Lesions on cornea / tip of nose (Hutchinson sign)• Nasociliary branch of V1 - opthalamic branch of trigeminal
nerve
Ramsy Hunt Sydrome• Bells palsy with herpetic blisters in the auditory canal or
pinna
HERPESVIRIDAE
Epstein Barr Virus
Fever Exudative tonsillitis Posterior cervical LADHepatomegally in 50%
Lymphocytosis with atypical lymphocytes
Splenic Rupture – no contact sports Characteristic rash with antibiotics (ampicillin)
Supportive treatmentSteroids for severe tonsilar edeam
HIV
Nuts and bolts…
RetrovirusHIV-1 (most common), HIV-2 (western Africa)Semen, vaginal secretions, blood, breastmilkAttacks CD4 Helper T cells
Acute HIV infection • Follows exposure by 2-6 weeks• Usually missed
HIV
AIDS - CD4 < 200
CD4 < 500• TB, Zoster, HSV
CD4 < 200• Pneumocysti Jiroveci
Pneumonia, Candidiasis, AIDS Dementia, Non-Hodgekin B-cell lymphoma
CD4 < 100• Toxoplasmosis, isospora,
microsporidia, histoplasmosis, cryptococcus
CD4 < 50• CMV, progressive multifocal
leukocencephalopathy (PML), MAC
HIV
Pneumonia
Most common reason for ER visitCD4 > 500 – encapsulated bacteria, TB, malignancyCD4 < 500 – Think PJP, Fungal, CMV
Pneumocystis Jiroveci Pneumonia• Diffuse interstitial infiltrate – “bat wing”• Bactrim DS• Steroids of PaO2 < 70 or Aa gradient > 35• Prophylaxis with Bactrim if CD4 <200• Pentamidine 2nd line agent if sulfa allergy
HIV
Buzz words
Diarrhea - cryptosporidium, isospora
Esophagitis – CMV, candidiasis, HSV
Retinitis – CMV
Ring enhancing lesions – Toxoplasmosis, CNS lymphoma
Fever and headache – Cryptococcus
Plaques on Tongue – oral candidiasis vs hairy leukoplakia
Purple papules/plaques – Kaposi’s sarcoma
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