Michael Kulczycki, DO- Infectious Disease Board Review 2014- ARMC Emergency Medicine
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Michael Kulczycki, DO- Infectious Disease Board Review 2014- ARMC Emergency Medicine
- 1. BOARD REVIEW MICHAEL KULCZYCKI DECEMBER 18 2013
- 3. ENDOCARDITIS Subacute Acute • • • • RISK FACTORS • STRUCTURE • • • PROSTHETIC HEART VALVES • Normal Valves Younger Patients Sick Abnormal Valves Older patients Non-specific constitutional symptoms HEART DISEASE • RHEUMATOID HEART DISEASE • MITRAL VALVE PROLAPSE • BICUSPID AORTIC VALVE • IV DRUG ABUSE • CARDIAC PROCEDURES • INDWELLING VENOUS CATHETERS Left Heart • • • • • • More Common S. Viridans S. Aureus Enterococcus CHF, CVA, AV block Systemic infarcts from septic emboli S. Aureus = Single most common cause Right Heart • • • • • IVDA S. Aureus S. Pneumonia Respiratory Symptoms Misdiagnosed as PNA
- 6. 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
- 7. ENDOCARDITIS Indications: • Prosthetic Valve • Congenital Defect repaired • Prior Infectious Endocarditis • Cardiac transplant with abnormal valves Manipulation of gingiva/mucosa or apical area of tooth
- 8. MENINGOCOCCEMIA – NEISSERIA MENINGITIDES Nuts and Bolts… • Military Recruits, College Dorms • Children < 5 • Gram (-) diplococcus • Nasopharynx = portal of entry • Septicemia without meningitis (>20% mortality)
- 9. MENINGOCOCCEMIA Rash • • Petechia • 50-60% Cases • Can involve mucous membranes • Trunk/Extremites Purpura Fulminans • Rapidly spreading ecchymosis • Gangrene • DIC
- 10. MENINGOCOCCEMIA Meningococcemia + Bilateral Adrenal Hemorrhage = Waterhouse-Friderichsen Sndrome Fulminant Meningococcemia
- 11. MENINGOCOCCEMIA • Lumbar Puncture • Early Antibiotics • Prophylaxis for close contacts • Ciprofloxacin • Rifampin • Ceftriaxone
- 12. PERTUSSIS Nuts and Bolts… • • • • • • Whooping Cough Summer and Fall months Cough > 2 weeks Respiratory Droplets Vaccination does not equal lifelong immunity Misdiagnosed as bronchitis
- 13. PERTUSSIS Catarrhal Phase Paroxysmal Phase URI like symptoms Cough increases, Cough, low grade fever fever subsides Highest infectivity Paroxysms of coughing (>50 times/day) Convalescent Phase Residual cough (weeks to months)
- 14. 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
- 16. PNEUMOCOCCEMIA • • Lancet shaped G (+) diplococcus Most common cause of bacterial pneumonia Pneumonia • Severe rigors • Rusty colored sputum Meningitis Septicemia Endocarditis Adult vaccination for: • Adults with chronic illness • Age > 65 • Immunocomprimised / HIV • Anatomic or functional Asplenia
- 17. 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
- 19. TETANUS Strychnine Poisoning Pesticide Muscle spasms, trismus, risus sardonicus, seizures
- 20. 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
- 21. 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
- 22. 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
- 23. 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
- 24. TUBERCULOSIS AFB sputum smear – hours, many false negatives/positives AFB culture – weeks, Gold standard, 87% sensitive Isoniazid – seizures (pyridoxine) Latent TB • Isoniazid - 9 months Active TB • 4 drug regimen – 6 months Extrapulmonary TB • 4 drug regimen – 6 months Rifampin – orange urine. OCP failure Pyrazinamide - hepatotoxic Ethambutal – red-green color blindness Pregnancy – INH, RIF, ETH cross placenta and are safe
- 25. 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
- 26. 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”
- 27. THE PLAGUE • Gram stain of bubo aspirate • CXR – infiltrate or hilar lymphadenopathy • Respiratory Isolation • Streptomycin or Doxycycline • Supportive care
- 28. HERPESVIRIDAE Herpes Simplex Virus HSV-1 - oropharyngeal HSV-2 – genital Multiple, painful shallow ulcers which may coalesce Shedding 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
- 29. 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
- 30. HERPESVIRIDAE Epstein Barr Virus Fever Exudative tonsillitis Posterior cervical LAD Hepatomegally in 50% Lymphocytosis with atypical lymphocytes Splenic Rupture – no contact sports Characteristic rash with antibiotics (ampicillin) Supportive treatment Steroids for severe tonsilar edeam
- 31. HIV Nuts and bolts… Retrovirus HIV-1 (most common), HIV-2 (western Africa) Semen, vaginal secretions, blood, breastmilk Attacks CD4 Helper T cells Acute HIV infection • Follows exposure by 2-6 weeks • Usually missed
- 32. HIV AIDS - CD4 < 200 CD4 < 500 • TB, Zoster, HSV CD4 < 200 • Pneumocysti Jiroveci Pneumonia, Candidiasis, AIDS Dementia, NonHodgekin B-cell lymphoma CD4 < 100 • Toxoplasmosis, isospora, microsporidia, histoplasmosis, cryptococcus CD4 < 50 • CMV, progressive multifocal leukocencephalopathy (PML), MAC
- 33. HIV Pneumonia Most common reason for ER visit CD4 > 500 – encapsulated bacteria, TB, malignancy CD4 < 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
- 34. 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