Clinical manifestation of

bacterial and viral infection

I K Agus Somia
Division of Tropical and Infectious Disease
Department of Internal Medicine
Sanglah Hospital/ Faculty of Medicine Udayana University
Introduction
Why important to know Clinical syndrome in infectious disease?

Diagnosis and effective treatment of

Recognised
infectious ds depends not just on isolating
an organism, but in establishing a plausible
syndromes
link between the laboratory findings, e.g.
Meningoencehalitis,
recognised syndromes and the patient's
Tonsilitis, pneumonia,
clinical condition
UTI. Hepatitis
septicaemia, endocarditis,

patient's
potential pathogen clinical
isolated syndrome
from or detected in
clinical samples
Pathologic Process
mechanism of infectious disease

AGENTS PATHOLOGIC CLINICAL

PROCESS MANIFESTTATION
In Target Cells

MICROBIAL PROLIFERATION
TOXIN
DEGRADATIVE ENZYMES
HOST RESPONSE

HOST
Skin
Respiratory tract
Genito-urinary tract
Alimentary tract
transplacental

heart

endocarditis

encephalitis
Clinical manifestation of bacterial &
Viral infections
Syndromes caused by bacterial and viral infection
can be classified into two basic types:
those defined on basis of pathogen
where a given species of bacterium or viral causes a
clearly defined syndrome
those defined on the basis of anatomical site of infection
caused by many different sorts of bacteria or viral , individually
or even in combination.

There is overlap between these types of syndrome

because some bacteria and viral can cause
characteristic infections at several sites (e.g.
Haemophilus influenzae meningitis and epiglotitis, ).
Clinical syndromes
Defined by pathogen

Typhoid fever
Legionnaires disease
Tuberculosis
Diphtheria
Leptospirosis
Rabies
Influenza
Dengue fever
etc
Clinical syndromes
defined by site

urinary tract infection

pharyngitis
pneumonia
septicaemia
endocarditis
Pericarditis
meningitis
Osteomyelitis
Synovitis
etc
Pneumonia
infection in the lung parenchyma

Clinical
Manifestation
TUBERCULOSI
S
Skin and soft tissue infection
Abscess
VIRAL INFECTIOUS DISEASES

HERPES VARIOLA
ZOSTER

HERPES MEASLE
SIMPLEKS S
Timeline for Infection

Infection
Dynamics of Latent Infectious Non-infectious
infectiousne period period
ss
Susceptible
Time
Infection

Dynamics Incubatio Symptomat Non-

of disease n period ic diseased
period
Susceptible
Time
Classification of infectious diseases
According onset and duration of
symptoms
Phases of Infectious Disease
Incubation period
time between infection and the appearance of signs and
symptoms.
Prodromal phase
mild, nonspecific symptoms that signal onset of some
diseases.
Clinical phase
a person experiences typical signs and symptoms of disease.
Decline phase
subsidence of symptoms.
Recovery phase
symptoms have disappeared, tissues heal, and the body
regains strength.
Signs & Symptoms of Infection
inflammation and fever

Redness (rubor)
Swelling (tumor)
Tenderness (dolor)
Warmth (kalor)
Loss of function (Functio laeso)
Drainage
 Sepsis:
the continuum

Increasing Inflammation
High Risk Infection SEPSIS Septic MOF
Shock
Of
Infection

Wheeler AP, NEJM 340:207-14

Progression from infection to
septic shock
Systemic
Infectio inflammato
n ry response
syndrome

Sepsis

Severe
sepsis Multiple
organ
Sepsis dysfunctio
induced n
hypotension syndrome
Septic shock Opal SM, Keusch GT: Host responses to infection.
2004
 Outcomes of Infection Process

Exposure Infection Asymptomatic Infection

Advanced
Illness, Disease Acute Symptomatic Illness:
Chronic Severity and Debilitation
Infections
and
Sequelae Sensitive Populations

Mortality Hospitalization
Fever
hallmark of infection

Fever, or pyrexia: an elevation in

body temperature that is caused by a
cytokine-induced upward
displacement of the set point of the
hypothalamic thermoregulatory
center.
Normal body temperature: 36.1 37.70 C
Fever : > 37.70 C
Hyperpireksia : > 41.20 C
Hypotermia : < 350 C
 Mechanisms of fever
Infeksi, toksin, mikroba,
mediator inflamasi, Toksin mikroba DEMAM
reaksi imunologis
Siklik Konservasi
AMP panas,
PGE2 2 produksi
Monosit, makrofag, sel panas
endotel, dll COX-2
Peningkatan
Asam
set point
arakhidonat
termostat

Pirogen Endotel
sitokin IL-1, IL-6, TNF, hipotalamus
IFN

Sirkulasi
Mechanisms of fever
Manifestations of fever
There are 4 successive stages
not all persons proceed through the four stages of fever development:

1. Prodrome
nonspecific complaints, such as mild headache and fatigue,
general malaise, and fleeting aches and pains;
2. Temperature rises
generalized shaking with chills and feeling of being cold;
vasoconstriction and piloerection usually precede the onset of
shivering;
skin is pale;
when the shivering has caused the body temperature to reach
the new set point of the temperature control center, the
shivering ceases, and a sensation of warmth develops.
3. Flush
cutaneous vasodilation occurs and the skin becomes warm and
flushed;
4. Defervescence
the initiation of sweating.
Types Pattern of fever
Type Description Causes

Intermitt Body temperature increase and Abscess, falciparum

then fall to normal level for a few malaria
en hours or days
(Hectic)
Remitten Body temperature could TBC, endocarditis,
decrease everyday but never typhoid fever
t reach normal level
Relapse Fever re-occur after a few days or Relapsing fever,
weeks brucellosis, tertiana or
quartana malaria

Biphasic Fever re-occur only once Leptospirosis, dengue,

clorado tic fever

continue The variation of body Encephalitis,

temperature in a day is not > 1 C salmonella.
Types Pattern of fever
Categories of Febrile
Illness

Fever with LOCALIZING symptoms

Meningoencephalitis, Pneumonia, endocarditis, osteomyelitis,
etc
Fever WITHOUT LOCALIZING symptoms
Dengue infection, malaria, leptospirosis, etc
Fever of UNKNOWN origin (FUO)
FUO
Definition
A temperature higher than 38.3C
(100.9F) that lasts for more than
three weeks with no obvious source
despite appropriate investigation
Clinical Aspects
The goal of initial evaluation is to
separate those patients who have
a serious illness from those who do
not.

History
Physical examination

Clinical diagnosis
History
Subyektif: anamnesis

A detailed history allow an appropriate differential diagnosis to

be made and useful in guiding initial investigations
Specific presenting symptom
Fever
Swollen lymph nodes
Pain
Rash, etc
The other symptoms ~ anatomic site of disease (local /
systemic)
Past medical history: Medication, Vaccination and prophylaxis
Family history: contagious ds in family
Social history: Travel history, Specific exposures (sexual
activity, etc), Occupational history
Symptoms ~ anatomic site of disease (1)

Respiratory tract infection

Sore throat, congestion and excess mucus
Coughing and sneezing
Sinus or chest pain
Shortness of breath

Infection of the mouth,ears,eyes

Localized pain or iritation
Swelling, tenderness, unusual redness

Gastrointestinal and Hepato-biliary infection

Nausea and vomiting
Icterus (yellowish eyes)
Abdominal pain
Diarrhea
Symptoms ~ anatomic site of disease (2)

CNS infection
Headache
Decrease of consciousness
Seizure, etc

Genito-Urinary tract infection

Painful, burning and frequent urination
Bloody urine
Uretral discharge
Vaginal discharge
Flank pain
Bone, Joint and muscle infection
Tenderness, pain and redness or inflammation in the
joints
Physical examination
Obyektif: sign

Temperature patterns
Vital sign
Blood Pressure, Pulse rate, Respiratory rate, body
temperature
Physical sign
Localized
Calor (heat)
Rubor (Redness)
Tumor (Swelling)
Dolor (Pain)
Functio laesa (loss of function)
Systemic
Physical examination
Obyektif: sign

Sometimes non specific and often overlap

Examine:
Skin
Maculopapular rash
Petechiae and haemorrhage
Eye
Icteric, siliar injeksi, subconjunctival bleeding
Mouth
Ulcer
Lymph nodes:
lymphadenopathy
Liver
Hepatomegaly
Spleen
splenomegaly
Kidney
Flank pain
Any other organ system associate with symptoms
DIAGNOSIS
bacterial and viral infectious ds
Clinical
Complete patient history (subjective)
Physical examination (objective)
Laboratory tests
Detect causative organism in clinical specimens
Immune response
Detect and assay antibodies
Detect and assay other specific immune responses
Detect other specific factors associated with infection
Radiologic
Detect location of infection
Case definition and surveilans syndromic
suksma