Infections of the upper and lower respiratory tracts

Pneumonia
Types
1. CAP
a. Within community or first 72hrs of hospitalization
b. Can be typical or atypical
c. MCstrep pneumoniae
2. Nosocomial pneumonia
a. Occurs during hospitalization after first 72hrs
b. MCGram rods (E coli, pseudomonas) and S. aureus
Prevention
1. Influenza vaccinegive to ppl at risk; healthcare workers
2. Pneumococcal vaccinefor pts > 65yo and those at risk (heart disease, cochlear
implants, SCD, pulm disease, DM, asplenic)
Typical CAP
1. Common agents
a. S. pneumoniae (60%)
b. H. influenzae
c. Aerobic gram rods (Klebsiella, enterobacteriaceae)
d. S. aureus
2. Features
a. Sx
i. Acute onset of fever, chills
ii. Productive coughthick, purulent sputum
iii. Pleuritic chest pain (suggests pleural effusion)
iv. Dyspnea
b. Signs
i. Tachycardia, tachypnea
ii. inspiratory crackles, bronchial breath sounds, tactile/vocal fremitus,
dullness on percussion
iii. pleural friction rub
c. CXR
i. Lobar consolidation
Atypical CAP
1. Common agents
a. Mycoplasma (MC)
b. Chlamydia pneumonia or psittici
c. Coxiella burnetii (Q fever)
d. Legionella
e. Viruses: influenza (A, B) adenovirus, RSV
2. Features
a. Sxs
i. Insidious onset

ii.
iii.
b. Signs
i.
ii.
c. CXR
i.
ii.

Dry cough
Fever (usually without chills)
Pulse-temp dissociation: nl pulse but high temp
Whhezing, rhonchi, crackles
Diffuse reticulonodular infiltrates
Absent or minimal consolidation

3. Dx
a. CXR
i. After tx, CXR improvement shows after a few wks
b. Pretx sputum for Gram stain and cultureto determine Abx resistance
c. Special stains if suspect:
i. Acid-fast stainTB
ii. Silver stainfungi, P. carnii (immunosuppressed)
d. Ur Ag is suspect legionella
i. Ag persist in urine for wks (even after tx started)
Tx of CAP
1. May need to hospitalize if mod-high severity
2. Abx
a. < 60 yo
i. macrolides (azithromycin or clarithromycin)
ii. or doxy
iii. or quinolones
b. > 60 yo or if comorbidities or if tx with Abx in last 3 mo
i. quinolone
ii. or 2G or 3G cephalosporin
c. hospitalized
i. quinolone
ii. or macrolide + 3G cephalosporin
Tx of hospital acquired pneumonia
1. 3G cephalosporin
2. or carbapenam
3. piperacillin/tazobactam
4. no macrolides
complications
1. pleural effusion
2. pleural empyema (rare)
3. acute resp failure

ventilator associated pneumonia

1. nl mucociliary clearance is impaired (cannot cough); positive pressure impairs ability to
clear colonization
2. dxnew infiltrate on CXR, purulent secretions from endotracheal tube, fever, rising
WBC count
3. BAL to get cultures
4. Tx combination of each of 3 grps
a. Cephalosporin or penicillin (piperacillin/tazobactam) or carbapenam
b. Aminoglycoside or quinolone
c. Vancomycin or linezolid
Lung abscess
Causes
1. Aspiration of organisms
2. Acute necrotizing pneumonia
3. Hematogenous spread of infxn from distant site
4. Direct inoculation with contiguous spread
Features
1. Usually slow onset
2. Coughfoul smelling sputum (if anaerobic infxn)
3. SOB
4. Fever, chills
Dx
1. CXR
2. CT scanif want to differentiate between abscess and empyema
3. BAL or transtracheal aspiration for culture
Tx
1. Hospitalization
2. Abx
a. Gram + cocci: amoxillin/clavulanic acid or vanc
b. Anaerobes: clindamycin
c. Gram -: quinolone or ceftazidime
3. Continue Abc until CXR improves a lot (months)

TB
1. Ppl with primary TB are noncontagious
MOA
1. Primary TBinhale bacilli, Mo ingest them, granuloma formation
2. Secondary TB (reactivation)hosts immunity is weakened
a. Apical/posterior lungs
3. Extrapulm TB
Features
1. Primary TB

a. Asymptomatic
b. If incomplete immune response, then pulm and constitutional sxs may develop
progressive primary TB
2. Secondary TB
a. Constitutional sxs (night sweats)
b. Dry cough purulent hemoptysis (if really adv)
c. Apical rales
Dx
1. CXR
a. Upper lobe infiltrates with cavitations
b. Possible
i. pleural effusion
ii. Ghon complex, Ranke complex: shows healed primary TB
2. Sputum studies
a. Culturetakes 4-8wks
b. PCR rapid
c. Acid fast bacillishows mycobacteria
3. PPD test
a. Test for primary TB
Tx
1. Active TB
a. Maintain in isolation until sputum is negative for AFB
b. 2 mo of RIPE, then 4 mo of RI
2. ptx for latent TB
a. INH for 9 mo
Influenza
1. Fever, chills, malaise, headache, nonproductive cough, sore throat
2. Supportive tx mainly
3. NA inhibitor (zanamivir or oseltamavir) given if severe disease/high risk of
complications and within first 48hr

Infxns of the CNS

Meningitis
1. Infectious or non-infectious causes (SLE, sarcoidosis, carcinomatosis)
MOA
1. Infectious agent colonizes the nasopharynx, resp tract
2. Agent enters CNS via
a. Invasion of bloodstream
b. Retrograde transport along cranial (olfactory) n or peripheral n
c. Contiguous spread from sinusitis, otitis media, surgery, trauma
Timeline

1. Acuteonset within hr to days

2. Chroniconset within wks to mo; mycobacteria, fungi, Lyme disease, parasites
Types
1. Acute bacterial
a. Causes
i. NeonatesGrp B strep, E. coli, Listeria
ii. Child > 3moNeiserria meningitidis, S. pneumoniae, H. influenzae
iii. Adults (18-50 yo)S. pneumoniae, N. meningitidis, H. influenzae
iv. Elderly (> 50yo)S. pneumoniae, N. meningitidis, L. monocytogenes
v. ImmunocompromisedListeria, gram bacilli, S. pneumoniae
2. Aseptic
a. Viruses (enterovirus, HSV)
b. Cannot be easily distinguished clinically from bacterial meningitis
i. If uncertain, tx for acute bacterial meningitis
Features
1. Headache (possible more severe when laying down)
2. Fevers
3. N/V
4. Stiff, painful neck
5. Malaise
6. Photophobia
7. AMS
Signs
1. Nuchal rigidity (may be absent)
2. Rashes
a. Maculopapular rash with petechiaeN. meningitidis
b. Vesicular lesionsvaricella or HSV
3. Increased ICPpapilledema, seizures
4. CN palsies
5. Kernig sign?inability to extend knee when pt is supine with hips flexed (90 degrees)
6. Brudzinski sign?
Dx
1. CSF inspection (LP)
2. CT of head recommended before performing LP if there are focal neurological signs or if
there are signs of elevated ICP
3. Obtain blood cultures before Abx given

Tx
1. Bacterial meningitis
a. Empiric Abxstart immediately after LP is performed (if CT scan must be
performed/ there are delays in performing LP, then can give Abx firstagent can
still be identified from CSF)
b. IV Abx
c. Steroidsif cerebral edema
d. Vaccination
i. Adults > 65 yo for S. pneumoniae
ii. Asplenic pts for S. pneumoniae, N. meningitidis, H. influenzae
iii. Immunocompromised pts for meningococcus
e. Ptx (rifampin or ceftriaxone) for close contact of pts with meningococcus
2. Aseptic meningitis
a. Supportive
b. Analgesics for fever reduction

Encephalitis
1. Inflammation of brain parenchyma; may be seen simultaneously with meningitis
Cause
1. Virus

a. HSV-1 (-2 maybe)

b. ArbovirusWest Nile virus, equine encephalitis
c. Enteroviruspolio
d. Othermeasles, mumps, EBV, CMV, VZV, rabies, Creutzfeldt-Jakob disease
2. Nonvirus
a. Toxoplasmosis
b. Cerebral aspergillosis
3. Noninfectious
a. Metabolic Encephalopathies
b. T-cell lymphoma
Risk factors
1. AIDS pthigh risk for Toxo when CD4 count < 200
2. Immunosuppression
3. Travel
4. Mosquitos, wild animals
Features
1. Prodrome of headache, malaise, myalgias
2. Within days, pts become more acutely ill
3. Signs/sxs of meningitis
4. AMS
5. Focal neuro deficits
Dx
1. r/o nonviral causesCXR, urine and blood cultures, urine tox screen
2. perform LP (unless high ICP)
a. CSF cultures usually negative
b. CSF PCT most sensitive/specific for viruses
3. MRI of brain
a. r/o abscess
b. increased T2 signal in frontotemporal localizationHSV encephalitis
4. EEG in HSV encephalitisunilateral or bilateral temporal lobe discharges
Tx
1. Supportive care, may need mechanical ventilation
2. Antiviral tx
a. HSVacyclovir
b. CMVganciclovir
3. Complications
a. Seizuresanticonvulsants
b. Cerebral edemahyperventilation, diuresis, steroids

Infections of the GI tract

Viral hepatitis
Transmission
1. A, Efecal-oral route

2. Bparenterally or sexually
3. Drequires the outer envelope of hepB sAg for replication
a. Co-infection with HBV
b. Or superinfection in chronic HBV carrier
4. Cparenterally
5. B,C,Dcan progress to chronic
Features
1. Classification
a. Acute (<6mo)
b. Chronic (>6mo)
2. Jaundice
3. Dark-colored urineconjugated hyperbilirubinemia
4. RUQ pain
5. N/V
6. HM
Complications
1. Hepatic encephalopathyasterixis, palmar erythema
2. Hepatorenal syndrome
3. Bleeding diathesis
Dx
1. PCR
2. LFTs
3. Ags, Abs
a. Aanti-HAV Ab
b. B
i. HBsAg
ii. HBeAg
iii. Anti-HBs Ab
iv. Anti-HBc Abimportant during window period (sAg is disappearing and
sAb not yet seen)
v. Viral PCR
c. Canti-HCV Ab, viral PCR
d. Danti-HDV Ab
Tx
1. A, E: supportive
2. Chr BIFN-alpha or lamivudine
3. Chr CIFN-alpha or ribavirin
Botulism
1. Ingestion of preformed toxins by spores of C. botulinum. (inactivated toxins by cooking
at high T), wound contamination
Features
1. N/V, diarrhea
2. Symmetric, descending flaccid paralysis; starts w/ dry mouth, diplopia, dysarthria
Dx

1. Toxin in serum, stool

Tx
1.
2.
3.
4.

Admit, monitor resp status

Gastric lavage if early
Antitoxin (toxoid) as soon as labs specimens obtained (do not wait for results)
Contaminated woundsdo above + penicillin

Intra-abd abscess
1. CausesSBP, pelvic infxn, pancreatitis, perforation of GI tract, osteomyelitis of vertebral
bodies with secondary extension
2. DxCT or US
3. Txdrainage, broad spectrum Abx

Infections of the GU tract

Lower UTIs
1. MC UTI is uncomplicated acute cystitis
Risk factors
1. Female
2. Sexual intercourse
a. Diaphragms, spermicides increase risk (alter vaginal colonization)
3. Pregnancy
4. Indwelling Ur catheter
5. Host-dependent factors
a. DMrisk for upper UTI
b. Spinal cord injury
c. Immunocompromised state
d. Any impedence of urinary flow (neurogenic bladder, BPH, vesicoureteral reflex,
calculi)
e. Malesuncircumcised
Features
1. Dysuriaburning on urination
2. Frequency
3. Urgency
4. Suprapubic tenderness
5. Lower UTIs, fever is absent
Dx
1. Dipstick UA
a. + leukocyte esterasepyuria
b. + nitrite testpresence of gram bacteria (enterobacteraceiae)
2. UA (clean-catch midstream)
a. Adequacy of collection
i. Presence of epithelial (sq) cells suggests vulvar or urethral contamination

b. UTI criteria
i. Bacteriuria: >1 organism per oil-immersion field. Bacteruria without
WBCs may reflect contamination.
ii. Pyuria: > 10 leukocytes/uL is abnl
3. Urine gram stain
4. Urine cultureneeded if sxs are not typical of UTI, if complicated infxn suspected,
persistent sxs despite tx
5. Blood cultures
Complications
1. Complicated UTI
a. Any UTI that spreads beyond the bladder
b. Any UTI caused by structural abnl, metabolic disorder, neurologic dysfxn
2. UTI during pregnancyrisk for preterm labor, low birth weight
3. Recurrent infxns
Tx
1. Acute uncomplicated cystitis
a. Oral TMP/SMX (3d)
b. Nitrofurantoin (7d)CI if pyelonephritis suspected
c. Fosfomycin (one dose)CI if pyelonephritis suspected
d. quinolones, Cipro (3d)
e. phenazopyridineurinary analgesic
2. pregnant women with UTI
a. ampicillin, amoxicillin, oral cephalosporin for 10d
b. avoid quinolones (can cause fetal arthropathy)
3. UTIs is men
a. Tx as uncomplicated UTI but for 7d
4. Recurrent infxns
a. If relapse occurs within 2wks of cessation of tx, continue tx for 2 more wks +
obtain urine culture
b. If pt has 2+ UTIs/yr, then ptx
i. Single dose of TMP/SMX after sex or at first sign of sxs
ii. Low dose TMP/SMX for 6 mo
Pyelonephritis
1. Infxn of upper tract
Features
1. Fevers, chills, flank pain
2. Possible sxs of cystitis
3. Possible sxs of N/V/diarrhea
4. CVA tenderness
5. Possible abd tenderness
Dx
1. UA
a. Pyuria, bacteriuria, leukocyte casts
b. Possible hematuria, proteinuria (cystitis also shows this)

2.
3.
4.
5.
6.

Urine culturealways obtain is suspected pyelonephritis

Blood culturesin ill-appearing or hospitalized pts
CBCleukocytosis
Renal fxnusually preserved
Imaging studiesif tx fails

Tx
1. Uncomplicated pyelonephritis
a. Oral Abx if pt can take oral rx
i. Gram - : TMP/SMX or quinolone for 14d
ii. Gram + cocci : amoxicillin
iii. Single dose of ceftriaxone or gentamicin is given initially before starting
oral tx
b. Repeat urine cultures 2-4d after cessation of rx
2. If pt is ill, elderly, pregnant, unable to take oral rx
a. Hospitalize and give IV fluids
b. Abx
i. Broad spectrum (initially): IV ampicillin + gentamicin/Cipro
ii. If blood cultures are -, tx with IV Abx untile afebrile for 24hrs; then give
oral Abx for 14d
iii. If blood cultures are +, tx with IV Abx for 2-3 wks
Prostatitis
MOA
1. Ascending infxn from urethra
2. May occur after urinary cath
3. Otherdirect or lymphatic spread from rectum
4. Hematogenous spread (rare)
Features
1. Acute prostatitis
a. Fever, chillspts may appear toxic
b. Irritative voiding sxsdysuria, frequency, urgency
c. Perineal pain, low back pain, Ur retention
2. Chronic prostatitis
a. Aymptomatic. Do not appear ill. Fever uncommon
b. Recurrent UTIs with irritative voiding/obs urinary sxs
c. Dull, poorly localized pain in lower back, perineal, scrotal, suprapubic region
Dx
1. DRE
a. Acute: boggy, tender prostate
b. Chronic: enlarged, nontender prostate
2. UAnumerous WBCs present in acute bacterial prostatitis
3. Urine culturesalways positive in acute prostatitis
4. Chronic prostatitispresence of WBCs in expressed prostatic secretions suggests dx;
Urine cultures + in chr bacterial prostatitis vs in nonbacterial prostatitis.
5. Obtain CBC, blood cultures if pt appears toxic or suspected sepsis

Tx
1. Acute prostatitis
a. If severe and pt appears toxic, then hospitalize + IV Abx
b. If mild, then oral Abx for 4-6 wks
i. TMP/SMX or quinolone + doxy
2. Chr prostatitis
a. Quinolone
STIs
Genital warts
1. Caused by HPV
2. MC STD
Chlamydia
1. MC bacterial STD; Chlamydia trochomatis
2. Intracellular organism
3. Likely co-infected with gonorrhea
Features
1. Asymptomatic
2. Symptomatic
a. Mendysuria, purulent urethral d/c, scrotal pain/swelling, fever
b. Womenpurulent urethral d/c, intermenstrual/postcoital bleeding, dysuria
Dx
1. No serologic tests
2. Culture, PCR
Tx
1. Azithromycin (oral 1 dose) or doxy (oral for 7d)
2. Tx sexual partners
Gonorrhea
1. N. gonorrheae (gram -, intracellular diplococci)
2. Likely co-infxn with chlamydia
Features
1. Men
a. Asymptomatic
b. dysuria, purulent urethral d/c, scrotal pain/swelling, fever
2. Women
a. Mostly asymptomatic
b. purulent urethral d/c, intermenstrual/postcoital bleeding, dysuria
3. disseminated gonococcal infxn
a. fever, arthralgias, tenosynovitis (of hands/feet)
b. migratory polyarthritis/septic arthritis, endocarditis, meningitis

c. skin rash
Dx
1.
2.
3.
4.

gram stain of urethral d/cshows organisms w/in leukocytes

obtain urethral/endocervical cultures
test for syphilis, HIV
blood cx, if disseminated

tx
1. ceftriazone (IM); also effective against syphilis
2. if disseminated, hospitalize + ceftriazone (IV or IM for 7d)
HIV/AIDS
Features
1. primary infxn
a. mono-like syndrome 2-4 wks after HIV exposure
2. asymptomatic infxn (seropositive but no clinical sxs)
a. CD4 count nl (>500)
b. Longest phase
3. Symptomatic HIV infxn (pre-AIDS)
a. Persistent generalized LAN
b. Localized fungal infxns
c. Recalcitrant vaginal yeast and trichomonal infxns in women
d. Oral hairy leukoplakia
e. Skinseborrheic dermatitis, psoriasis exacerbations, molluscum, warts
f. Constitutional sxs
4. AIDS
a. CD4 < 200 cells/mm3
b. Or AIDS-defining illness
Dx
1. PCR RNA viral load test
2. P24 Ag
3. Seroconversion (3-7wks after infxn)
a. ELISAhigh sensitivity
b. WB, if positive ELISA
Tx
1. HAART: 2 NRTIs + 1 other (NNRTI or protease inhibitor)
a. Continue HAART during pregnancy
b. Monitor HIV viral load
2. OIs
a. PCP
i. CD4 < 200
ii. Sxsdyspnea, dry cough, fever
iii. Tests: CXR (bilateral infiltrates), LDL (high), ABG (hypoxia or increased
A-a gradient), sputum stain, BAL
iv. TxTMP/SMX (or dapsone/pentamidine/atovaquone)
b. Toxoplasmosis

i. CD4<100
ii. TxTMP/SMX (dapsone + pyrimethamine + leucovorin)
c. Mycobacterium avian complex
i. CD4<50? Or 100?
ii. Txazithromycin or clarithromycin (or rifabutin, which promotes Cyp
metabolism of ARTs)
d. TB
i. TxINH + pyridoxine (9mo)
3. Vaccines
a. No live vaccines
b. Influenzaq1yr
c. Pneumococcal polysaccharide vaccine (pneumovax)q5yr
d. HepB (if not Ab positive)

Herpes simplex
MOA
1. HSV replicates in dermis/epidermis travels via sensory nerves to DRG latent infxn
of DRG
Features
1. HSV-1
a. Primary infxn usually asymptomatic
b. If symptomaticsystemic sxs (fever, malaise), oral lesions
c. a/w Bells palsy
2. HSV-2
a. Primary infxn causes severe, prolonged sxs; recurrent episodes are milder, shorter
b. Painful genital vesicles or pustules, tender inguinal LAN, vaginal/urethral d/c
3. Disseminated HSV

a. Seen in immunocompromised pts

4. Neonatal HSV
a. Congenital malformations, IUGR, death
5. Ocular disease
a. HSV-1/2
b. Keratitis (cornea), blepharitis (eyelid), keraroconjuctivitis
Dx
1. Clinical lesion
2. Tzanck smear
a. Swab base of ulcer, stain with Wright stain
b. Multinucleated giant cells (seen in HSV and VZV)
3. Culture ulcer
4. Fluorescent assay, ELISA
Tx
1. No cure; anti-virals for sx relief
2. Mucocutaneous disease
a. Oral and/or topical acyclovir for 10d
i. Oral acyclovir for ptx
b. Foscarnet if resistant or immunocompromised pt
3. Disseminated HSVhospitalize + IV acyclovir
Syphilis
1. Treponema pallidum
2. 4 stages
features
1. primary stage
a. chancrepainless, crater-like lesion that appears on genitals 3-4wks after
exposure
b. heals in 14wks, even without tx
c. highly infectious, even to touch
2. secondary stage
a. develops 4-8wks after chancre has healed
b. maculopapular diffuse rash on body
c. contagious
3. latent stage
a. positive serologic tests despite no clinical sxs
4. tertiary
a. neurosyphilis (dementia, personality changes, tabes dorsalisposterior column
degeneration), gummas (subQ granulomas), cardiovascular syphilis
dx
1. dark-field microscopyvisualize spirochetes from chancre
2. serology
a. nontreponemal testsRPR, VDRL
i. high sensitivity

b. treponemal testFTA-ABS (fluorescent treponemal Ab absorption), MHA-TP

(microhemagglutination treponema pallidum)
3. test for HIV
tx
1. penicillin (one dose IM) or oral doxy (2wks)
2. repeat nontreponemal tests q3mo to ensure response to tx
chancroid
1. Haemophilus ducreyi (gram rod)
2. No systemic findings (no dissemination)
Features
1. Painful genital ulcers with deep borders and purulent base
2. Unilateral tender inguinal LAN (buboes)appears 1-2wks after ulcer
Dx
1. Clinical
2. r/o syphilis, HSV
tx
1. azithromycin or ceftriaxone
lymphogranuloma venereum
1. Chlamydia trachomatis (L1-L3)
Features
1. Painless ulcer
2. Unilateral tender inguinal LAN
3. Constitutional sxs
Complications
1. Proctocolitis (rectum, colon) perianal fissures, rectal strictures
2. Obs of lymphatics elephantiasis of genitals
Tx
1. Doxy (21d)
Pediculosis pubis (pubic lice or crabs)
1. Phthirus pubis
2. Sexual contact, clothing, towels
Features
1. Severe pruritus in genital region
Dx
1. Exam hair under microscopeadult lice or nits
Tx
1. Permethrin 1% shampoo
2. Wash clothes, linen

Wound and soft tissue infections

Cellulitis
1. MCGrp A strep (strep pyogenes) or S. aureus

Dx
1. Obtain tissue cx if wound, ulcer, or site of infxn
2. Obtain plain film, MRI if suspicion for deeper infxn
Tx
1. IV Penicillin or cephalosporin until signs improve. Then, oral Abx for 2wks
Erysipelas
1. Cellulitis confined to dermis and lympahtics
2. Well-demarcated, red, painful lesion
Tx
1. If uncomplicatedIM/oral penicillin or erythromycin
2. If complicated (sepsis, subQ spread, necrotizing fasciitis)tx as like cellulitis
Necrotizing fasciitis
1. MCstrep pyogenes, C perfringes
Features
1. Fever/pain out of proportion to appearance of skin
2. Thrombosis of microcirculation tissue necrosis, discoloration, crepitus, cutaneous
anesthesia
a. Different from DVTrestricted to posterior calf, Doppler US confirmatory
Tx
1. Surgical exploration, excision of tissue
2. Broad-spectrum Abx
Lymphadenitis
1. Inflammation of LN(s) caused by local skin or soft tissue bacterial infxn
Features

1. Fever, tender LAN

2. Red streaking of skin from area of cellulitis
Tx
1. Penicillin G (IV), cephalosporin
2. Warm compress
3. Wound drainage possibly
Tetanus
1. Caused by neurotoxins produced by spores of C. tetani (gram + anaerobic rod)
2. Exotoxin blocks inhibitory transmitters at NMJ
Features
1. Trismus (lockjaw)
2. General muscle contractions
a. Risus sardonicusgrin
b. Opisthotonosarched back
3. Sympathetic hyperactivity
Dxclinical
Tx
1. Hospitalize, resp support
2. Diazepam for tetany
3. Neutralize unbound toxin with passive immunizationtetanus Ig
4. Active immunization with Td (tetanus/diphtheria toixoid)
5. Debride necrotic wounds

Infxns of bones and joints

Osteomyelitis
1. Hematogenous osteomyelitis (mostly in kids)secondary to sepsis
2. Direct spread of bacteria from
a. Adjacent infxn (diabetic foot ulcer, decubitus ulcer)
b. Trauma (open fx)
c. Vascular insufficiency (PVDperipheral vascular disease)
3. MC agentsS. aureus, coagulase-negative staph
Features
1. Pain over involved area of bone
2. Localized erythema, warmth, or swelling
3. Draining sinus tractif chr osteomyelitis
Dx
1. WBC countmay or may not be elevated
2. ESR, CRP
a. Nonspecific, nonsensitive
b. Useful to monitor tx
3. Needle aspiration of infected bone or bone biopsy

4. Plain films
a. By first 10 dperiosteal thickening or elevation
b. Lytic lesionsif advanced
5. Radionucleotide bone scansnonspecific (metastatic disease, trauma, overlying soft
tissue inflammation)
6. MRImost effective to dx, determine extent of disease
Tx
1. Blood cx
2. IV Abx for 4-6wks; Abx is agent dependent
Acute infectious arthritis
MOAagents enter joint via
1. Hematogenous spreadMC
2. Contiguous spread from another locus
3. Traumatic injury to joint
4. Iatrogenic
Acute bacterial
1. S. aureus
2. N. gonhorreae
3. Pseudomonas or Salmonellaif hx of SCD, immunodeficiency, IV drugs
Features
1. Joint swollen, warm, painful
2. Limited ROM
3. Constitutional sxs
Dx
1. Joint aspiration
a. WBC count with differential
b. Gram stain
c. Cultureaerobic, anaerobic
d. Crystal analysis
e. PCRif gonococcal suspected but negative stain/cx
2. Blood cx (usually negative in gonococcal)
3. High ESR, CRP
Tx
1. Abx STAT (start even when cx, other labs are pending)
2. Drainage of joint as long as effusion persists
Zoonoses and arthropod-borne diseases
Lyme disease
1. Caused by the spirochete Borrelia burgdorferi
2. Transmitted by ticksIxodidae scapularis
Features
1. Stage 1localized infxn

a. Erythema migransskin lesion at site of tick bite; large, painless, welldemarcated targetoid lesion
b. If multiple lesionshematogenous spread
2. Stage 2disseminated infxn
a. Spreads via blood, lymphatics
b. Intermittent flu-like sxs, headaches, neck stiffness, fever/chills, malaise, MSK
pain
c. may also develop
i. meningitis (Brudzinski, Kernig sign negative), encephalitis
ii. cranial neuritis (bilateral facial n. palsy)
iii. peripheral radiculoneuropathy (motor or sensory)
iv. cardiac sxs (AV block, pericarditis, carditis)
3. stage 3persistent infections
a. arthritisusually affects the large joints (knee)
b. chr CNS disease
c. acrodermatitis chronica atrophicans (rare)red/purple plaques/nodules on
extensor surfaces of legs
dx
1. clinical dx.
2. Labsconfirmatory
a. ELISA to detect serum IgM and IgG
b. WB to conform +/0 ELISA
Tx
1. Early, localized
a. If confined to the skin, 10d of Abx
b. If evidence of spread, 30d of Abx
i. doxy (CI in pregnant women, kids <8yo) or amoxicillin/cefuroxime (or
erythromycin)
2. if facial n palsy, arthritis, cardiac disease tx for 30-60d
a. if meningitis or CNS complications IV Abx for 30d
RMSF
1. caused by intracellular Rickettsia rickettsii
2. transmitted via tick bites
features
1. onset of sxs 1wk after tick bite
2. sudden onset of fever, chills, malaise, N/V, myalgias, photophobia, headache
3. papular rash appears 5d after fever; rash starts PERIPHERALLY CENTRALLY
a. papular maculopapular petechial
dx
1. clinical
2. labshigh LFTs, thrombocytopenia
tx
1. doxy; give IV if pt is vomiting
2. CNS manifestations or pregnant ptgive chloramphenicol

Malaria
Features
1. Fevers, chills, myalgias, headache, N/V, diarrhea
2. Fever pattern
a. P. falciparumfever constant
b. P. ovale, P. vivaxfever spikes q48 hr
c. P. malariaefever spikes q72 hr
Dx
1. Peripheral blood smear with Giemsa stain
Tx
1. Quinine + tetracycline (or atovaquone-proguanil + doxy)
2. Additionally, in P. vivax and P. ovale, relapses occur due to dormant hypnozoites in liver.
Add primaquine
3. Ptxmefloquine (has replaced chloroquine)
Rabies
Features
1. Incubation period of months
2. Sxs
a. Pain at site of bite
b. Prodromal sxssore throat, fatigue, headache, N/V
c. Encephalitisconfusion, combativeness, hyperactivity, fever, seizures
d. Hydrophobiainability to drink, laryngeal spasm with drinking, hypersalivation
e. Possible ascending paralysis
Dx
1. Virus or viral Ag in infected tissue or salive
2. Negri bodies (eosinophilic inclusion bodies found in cytoplasm of nerve cells containing
rabies virus)
3. PCR for virus
Tx
1. Clean wound
2. If known rabies exposure, do both:
a. Passive immunizationgive human rabies Ig in the wound + gluteal region
b. Active immunizationgive antirabies vaccine

419