Infectious

 CNS:
1. Meningitis:
 Transmission:
- local invasion: otitis media, sinusitis, dental inf.
- hematogenous: endocarditis, pneumonia, surgery
 Types:
- Non-infectious (SLE, TX, sarcoidosis) // Aseptic (viral (most) (HSV, enterovirus), fungi)
- Acute bacterial: according to age group
o Neonates: group B strept. Agalacte & L. monocytogen
o Child > 3 months: N. meningitidis > S. pneumonia > H. influenza
o Adults: S. pneumonia > N. meningitides > H. influenza
o Elderly > 50: S. pneumonia > N. meningitidis > L. monocytogens
o Immunocompromised: L. monocytogens, cryptococcus
o Complication: seizure, coma, brain abscess, DIC, deafness (8th CN), hydrocephalus
 Symptoms: “* are classic triad for acute bacterial”
- fever *, headache, nausea/vomiting, stiff neck, alter mental status *, photophobia
 Signs:
- Nuchal rigidity *: stiff neck & resistance to spine flexion
- Kernig sign: inability to extend knees while pt. is supine & his hip is flexed 90o
- Brudzinski sign: passive flexion of the neck by thigh/leg flexion
- Rash: mucopapular rash & purpura (N. meningitidis), vesicular lesion (HSV/varicella)
- Increase ICP: papilledema, projectile vomiting, seizure
 Diagnosis:
- CT scan: done before LP, detect space occupying lesion
- CSF examination (LP): “CI in case if space occupying lesion”
o TB (lymphocytosis, high protein, - culture), herpes (lymphocytosis, normal glucose)
o Bacterial (leukocytosis (PMN), low glucose, high protein, cloudy CSF)
o Aseptic (WBC < 1000, lymphocytosis, normal glucose & protein)
- Blood culture
 TX:
- Bacterial:
o Dexamethasone: before Abx to ↓ deafness & mortality // Steroids: cerebral edema
o Empiric Abx: immediately after LP, vancomycin + ceftriaxone, +/- ampicillin L. mono
- Aseptic: supportive “analgesia” “self-limiting”
 Prevention:
- Vaccine:
o all > 65 yrs. Old pt. for S. pneumonia, immunocompromised for meningococcus
o asplenic pt. for S. pneumonia, N. meningitidis, H. influenza
- Prophylaxis:
o 1 dose IM ceftriaxone/rifampin for close contact of pt. with meningococcus

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2. Encephalitis:
 Causes:
- Viral (most): herpes (HSV-1 most), arbovirus, polio, EBV, measles & mumps
- Non-viral: toxoplasmosis or cerebral aspergillosis
- Non-infectious: metabolic encephalopathies & T cell lymphoma
 RF: immunosuppression (AIDS & CD4 < 100), endemic countries travel & Exposure
 S&S:
- Headache & myalgia (early), S&S of meningitis, confusion & disorientation
 Diagnosis:
- MRI & CT (TOC, frontotemporal localization > HSV), EEG (temporal discharge > HSV)
- CSF (LP): lymphocytosis, normal glucose, - culture, PCR (most specific for viral causes)
 Tx:
- HSV encephalitis: IV acyclovir/foscarnet 2-3 weeks // CMV: ganciclovir/foscarnet
- Seizure: anticonvulsant // cerebral edema: osmotic dieresis or steroids

3. Brain abscess:
 Causes:
- Immunocompromised (toxoplasmosis, aspergillosis), HIV -ve (polymicrobial)
- Spread of infection (sinusitis, mastoiditis, otitis media, pneumonia, endocarditis)
 S&S: Headache (most), fever, nausea, focal deficit
o Focal neurological findings: hemiparesis, aphasia, CN lesion & seizure
 Dx: MRI & CT (enhancement lesion + ring), LP is CI, biopsy (most accurate)
 Tx:
- HIV +: Pyrimethamine & sulfadiazine for 10-14 days
- HIV -ve: aspirate abscess + empiric (penicillin + metronidazole + ceftriaxone

 Resp:
1. influenza A&B:
 orthomyxovirus // S&S: fever, chills, malaise, non-productive cough, sore throat
 treatment: acetaminophen (for systemic S&S) + oseltamivir (antiviral)
- treat if: co-morbidity (DM, HF,..), age extremities, pregnant, immune-compromise
 prevention: influenza vaccine annually (CI in case of severe allergy to egg-anaphylaxis)

2. pneumonia:
 types:
a. community acquired pneumonia: "CAP"
 aspiration of oropharyngeal secretion (most), before hospitalization or within 48 hrs.
 typical:
- organisms: S. pneumonia (most), H. influenza (with COPD), Klebsiella (alcohol & DM)
- S&S:
o fever, chills*(sign of bacteremia), pleuritic chest pain* (with respiration)
o purulent productive cough*, tachycardia & tachypnea (in severe), +/- hemoptysis
- examination:
o inspiratory crackles, + vocal/tactile fremitus, + egophony, bronchial breath sounds
o dullness on percussion, normal chest expansion, chest indrawing (child), +/- friction

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 - these * findings differentiate typical from atypical
 atypical:
- organisms: "not seen on gram stain & not cultured on standard agar"
o Mycoplasma pneumonia (most), Chlamydia (hoarseness), P. carinii & M. TB (HIV)
o Legionella (organ transplant, hotels, air condition, shower), virus (influenza A &B)
- S&S:
o fever without chills*, dry cough*, sore throat, general weakness, headache
- examination: pulse-temp difference: normal HR even with high temp, wheeze
 diagnosis:
- CXR:
o 2 views PA & lateral, sensitive (if no finding > no Abx), takes time to return normal
o mostly lobar consolidation* (multi lobar if severe or legionella* (2nd choice drug))
o diffuse reticulonodular infiltrate, absent/minimal consolidation* (atypical)
- sputum: “rust-colored sputum is classical for pneumococcal pneumonia”
o gross: current-jelly (klebsiella), foul smelling "rotten egg" (anaerobic)
o gram stain: must has >25 PMNs & <10 epithelial cells // culture: detect organisms
o special stains: Acid fast (M. TB), silver stain (HIV) / lab: hypo Na, albumin (legionella)
- urinary Ag assay or AB titer: for legionella, very sensitive, Ag remains after treatment
- blood culture, bronchoscope, PCR & serology (mycoplasma), BAL (P. jerovici)
 treatment:
- decision for hospitalization:
o depend on severity index & CURP 65 or pt. is hypoxic or hypotensive (admit)
o CURB 65: “urea > 19 mg/dL, RR > 30, SBP < 90 or DBP < 60”
 Confusion, high Urea & low Urine, high RR, low BP & high pulse, 65 or > (age)
 if score is ≤ 1: treat as outpatient, if 2-3: admit, if > 3: admit and inform ICU
- outpatient: "give Abx for 5 days & don’t stop until afebrile for 48 hrs."
o healthy pt. or <60: macrolides (Azithromycin or clarithromycin) or doxycycline
o >60 yrs. with comorbidity or treated with Abx in last 3 months:
 fluoroquinolones (levo/moxifloxacin)
- inpatients: typical: azithromycin (macrolides) + ceftriaxone or ciprofloxacin (2nd LG*)
o atypical: fluoroquinolones, macrolides (1st choice for legionella), +/- vancomycin

b. hospital acquired pneumonia: "HAP" (nosocomial)

 after admission by 48-72 hrs or after hospitalization in last 90 days
 organism: mostly gram – rods (E. coli & pseudomonas) or Gram + like MRSA
 treatment:
- cephalosporin that covers pseudomonas (ceftazidime or cefepime) or imipenem
o imipenem is a carbapenem that can cause seizure
- or piperacillin/tazobactam // +/- vancomycin (MRSA) // don’t give macrolides

c. ventilator associated pneumonia: "VAP"

 mechanical ventilation causes:
- impaired mucociliary clearance (no cough), + pressure > X colonization clearance
 diagnosis:

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 - NEW CXR infiltrates, purulent secretion, fever & high WBCs, BAL for culture, biopsy
 treatment: combination of one of each category
- anti-pseudomonal:
o cephalosporin (ceftazidime/cefepime) or penicillin (piperacillin/tazobactam) or
carbapenem (imipenem/meropenem)
- another anti-pseudomonal:
o aminoglycosides (gentamicin/amikacin) or fluoroquinolone
(ciprofloxacin/levofloxacin)
- MRSA agent: vancomycin or linezolid

d. aspiration pneumonia: anaerobic organisms, causes are listed in lung aspiration

 complications of all types:

- pleural effusion: resolve with treatment, if significant do thoracentesis
- empyema, acute respiratory failure, lung abscess
 vaccine: Influenza (high risk pt. & health care), pneumococcal (high risk pt. & > 65yrs)

3. lung abscess: (in examination: localized consolidation & bronchial breath sounds)
 necrosis of infected lung tissue & formation of cavities (>2cm)
 causes: aspiration of pharyngeal content or food, acute necrotizing pneumonia
 RF: seizures, alcohol, anesthesia, endotracheal intubation, loss of gag reflex (stroke)
 organism: aerobics: S. aureus, S. pneumonia, E. coli // anaerobic (Rt. Lower lobe most)
 S&S: fever, SOB, weight loss, cough (foul smelling sputum), night sweats, clubbing
 diagnosis: CXR (cavities formation + air-fluid level), CT (diagnostic, rule out empyema)
 treatment:
- ampicillin or vancomycin to cover gram positive
- clindamycin or metronidazole to cover anaerobes
- fluroquinolones to cover gram negative

4. Tuberculosis:
 Mycobacterium TB (acid fast bacilli), transmit via inhalation of droplets of active TB pt.
 pathophysiology:
- 1ry TB: inhalation of bacilli > alveolar macrophage ingestion > granuloma formation
- 2ry: reactivation of dormant infection in case of decrease immunity
 RF:
- recent immigration (<5 yrs.), close contact of pt. with active TB, prisoner
- HIV + pt., health care, steroid use, alcohol, DM
 S&S:
- no S&S (1ry), fever, weight loss, nigh sweat, cough (dry > sputum > hemoptysis)
- extra-pulmonary: can affect any organ (LN, spleen, urinary tract, hematogenous)
 diagnosis:
- CXR:
o best initial, mostly upper lobe, cavity formation, +/- pleural effusion
o Ghon focus (calcified granuloma), Ghon complex (Ghon focus + LN involvement)
o Ranke complex (calcification & fibrosis of Ghon complex)

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  LN involvement DDx: TB, sarcoidosis, pneumonia
- sputum: should take 3 morning samples, diagnosis by culture or PCR
- tuberculin skin test (PPD) or interferon gamma release assay (IGRA):
o used as screening test for mainly 1ry TB (if + check CXR for active TB)
o if patient never had PPD test & 1st result was negative > repeat it (risk of false neg.)
o positive if:
 >15 mm in patient with no risk factors
 > 10 mm in patient with RF above
 >5 in patient with: organ transplant, HIV +, contact with active TB p.t, steroid use
- HIV pt.: difficult because – PPD, - sputum culture, atypical CXR findings
 treatment:
- + PPD test (prophylaxis): 9 months INH (after excluding active TB) + B6
- active TB: (1st 3 drugs + 4th or 5th) (isolate pt. until -ve sputum culture for AFB)
o isoniazid: S/E: peripheral neuropathy > give pyridoxine B6
o rifampin: S/E: harmless organ body secretion (will decrease sulfonylurea)
o pyrazinamide: S/E: hyperuricemia & CI in pregnancy & in chronic liver failure
o ethambutol: S/E: red-green eye blindness (decrease dose in renal failure)
o or streptomycin: S/E: ototoxicity & nephrotoxicity, CI in pregnancy
o initial phase (4 drugs for 2 months), 2nd phase (INH & rifampicin for 4 months)
o give treatment > 6 months if: osteomyelitis, military TB, meningitis, pregnancy
o all drugs are hepatotoxic so stop when liver enzymes are 3-5 times > normal
 TB preemployment guideline:
- Non-Bahraini:
o IF PPD < 10 & normal CXR: FIT & no Tx
o PPD > 10 & normal CXR: FIT + INH & B6 prophylaxis for 6 months
o PPD > 10 & minor CXR changes: FIT + INH & B6 prophylaxis for 6 months
o PPD > 10 & minor CXR changes but symptomatic or + sputum: UNFIT
 Minor CXR changes: fibrocystic changes/granuloma < 1 cm, LN, pleural effusion
o PPD > 10 & significant CXR changes: UNFIT
 Sig. CXR: cavitation, fibrocystic changes ≥ 1 cm, hilar LN, military, 1ry complex
o if patient was UNFIT send him/her directly to A/E
- Bahraini: replace the 10 mm with 15 mm

5. Acute bronchitis:
 Cause: viral (most) // Dx: no need except if pneumonia suspected
 S&S: cough +/- sputum, chest discomfort, +/- fever (low grade)
 TX: cough suppressor +/- bronchodilators

6. Common cold:
 MC URTI, hand-hand transmission, children > adults
 Causes: viral (rhinovirus (most), coronavirus, parainfluenza, adenovirus)
 S&S: rhinorrhea, nonproductive cough, sore throat, nasal congestion, +/- fever
 Complication: secondary bacterial infection
 Tx: hydration, rest, analgesia, cough depressant, nasal decongestant, antihistamine

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 7. Sore throat:
 Causes: viral (most) (adenovirus, parainfluenza), bacterial (GABH, chlamydia)
 Dx: if suspect bacterial > throat culture, rapid strep test
 Tx: step throat > 10 days penicillin/erythromycin, viral (acetaminophen, warm fluids)

 GI:
1. Infectious diarrhea:
 Blood & WBC in stool:
- Campylobacter (MCC, GBS association), shigella (2nd MCC, associated with HUS)
- E. coli (traveler’s diarrhea, undercooked meat, HUS association), C. difficle (H/O Abx)
- salmonella (contaminated poultry & egg, mostly watery), vibrio (shellfish, skin lesion)
 No blood or WBCs:
- Giardia (contaminated water, foul smelling), viral (rotavirus & Norwalk)
- Cryptosporidiosis (AIDS pt. with CD4 < 100)
 Food poisoning: Associated with vomiting, reheated rice (bacillus), meat (S. aureus)
 Dx: initial (fecal leukocytosis +/- blood), stool lactoferrin, stool culture (most specific)
 Tx: fluid replacement, ciprofloxacin (if severe), giardia/C. difficle (metronidazole)

2. Viral hepatitis:
 types:
- Hepatitis D: co-infection or superinfection with HBV, anti-HDV > superinfection
- Hepatitis A:
o feco-oral transmission, RNA, only acute, IgM + > active infection/ IgG + > resolve
o anti-HAV is found in acute inf. & persist for long life
- Hepatitis E:
o feco-oral, RNA, only acute, India/Pakistan/Asia, fulminant hepatitis in pregnancy
o IgG + > resolve/IgM + > active infection
- Hepatitis B:
o Parenteral/sexual/perinatal, DNA, 90% acute & 10% chronic (need 10-30 yrs.)
o Association: polyarteritis nodosa, Africa & Asia // has 30% risk in contagious needle
o HBsAg: 1st Ag ↑, chronic if present > 6 months // HBeAg: if + > active infection
o Anit-HBs: + in vaccination (only one) or past inf., indicates immunity
o Anti-HBc: 1st Ab to ↑, IgM (acute), IgG (chronic), only marker in window period
- Hepatitis C:
o Parenteral (IV abusers), RNA, 90% chronic/10% acute, cryoglobulinemia association
o viral load by PCR, pt. should take HBV & HAV vaccination (fulminant hep. Failure)
 S&S:
- Jaundice (1st in sclera), dark urine, RUQ pain, nausea & vomiting
- Severe: hepatic encephalopathy (asterixis), hepatorenal syndrome, aplastic anemia
 Diagnosis: serum serology mentioned, PCR, bilirubin, ALT > AST (ALT > 1000)
 Tx:
- acute: only Tx acute HCV > interferon (S/E: arthralgia, leukopenia, thrombocytopenia)

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 - chronic: HVC or HBV: ribavirin, lamivudine > IFN-a

3. Autoimmune hepatitis:
 Types: AIH1: MC, P-ANCA, +/- SMA & ANA // AIH2: anti-LKM1, child// AIH3: SLA, LP Ab
 S&S: fatigue, hepatomegaly, jaundice, ABD discomfort
 Dx: AST > ALT, hyperbilirubinemia, hypergammaglobulinemia
 Prognosis: 40% will develop cirrhosis, ascites or hepatic encephalopathy ↓ prognosis
 Tx:
- Mostly prednisolone + azathioprine // stop Tx if: no S&S, normal lab, Tx toxicity
- Prednisolone only if: severe cytopenia, pregnancy, + malignancy

4. Other Non-infectious hepatitis: alcoholic hepatitis, drug-induced hepatitis

5. Botulism:
 preformed toxins of C. botulinum spore’s, canned food or contaminated wound
 S&S:
- ABD pain, nausea & vomiting, symmetrical descending flaccid paralysis (hallmark):
o start with dry mouth, diplopia, dysarthria, limb paralysis (last)
 Dx: toxins in stools/serum/gastric content
 Tx: admit pt., gastric lavage, antitoxins (toxoid), penicillin & wound cleaning

 Renal:
1. Prostitis:
 acute bacterial: young, more serious, urgent, causes: ascending inf., catheter
 chronic bacterial: more common, elderly, causes: recurrent acute inf., ascending inf.
 S&S:
- Acute: fever & chills, perineal pain, urinary retention, dysuria
- Chronic: asymptomatic (most), recurrent UTI
 organism: E. coli (most), klebsiella, protues, Enterobacter
 Dx:
- PR: boggy tender prostate (acute), enlarge non-tender (chronic)
- Urinalysis: ↑WBCs in acute cases // urine culture: always positive
- Prostate secretion: WBCs + > chronic // avoid prostatic massage > bacteremia risk
 Tx: Acute: admit pt., TMP/SMX PO or IV for 4-6 weeks // chronic: fluoroquinolones

2. Cystitis: “lower UTI”

 Organism: E. coli (80%), S. saprophyticus, klebsiella, protues
 Non-infectious: cytotoxic agent (cyclophosphamide), interstitial cystitis, radiation
 RF:
- Female: short urethra, pregnancy, catheter, sexual intercourse “honeymoon cystitis”
- Male: uncircumcision, anal intercourse, infected vaginal intercourse
- Host dependent: DM, immunosuppression, structural abnormalities
 S&S: no fever, suprapubic pain, dysuria (burning), ↑frequency, oliguria
 Dx:
- Dipstick: + urine leukocytes esterase, + nitrate // urine gram stain: >105 organism

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 -Urinalysis: ↑WBCs (pyuria), if epithelial squamous cell > contaminated > catheter
-Urine culture:
o confirm Dx, ≥ 105 CFU/mL, indication: pt. ≥ 65 yrs., DM, S&S > 7 days, recurrent inf.
 Complication:
- Complicated UTI: pyelonephritis, RF: DM, pregnancy, obstruction, anatomical
- UTI in pregnancy: risk of preterm labor or low birth weight // recurrent infection

 Tx:
- Uncomplicated: TMP/SMX for 3 days (1st choice), fluoroquinolones for 3 days (2nd)
- Pregnant: Nitrofurantoin/ amoxicillin/cephalosporin for 7 days (fluoroquinolones CI)
- Male UTI: same as uncomplicated but for 7 days
- Recurrent infection:
o if relapse within 2 wks.: continue Tx for 2 wks.
o > 2 UTI/year: single dose TMP/SMX after 1st S&S or after intercourse

3. Pyelonephritis: “upper UTI”

 Organism: E. coli (most), klebsiella, gram + (S. aureus)
 Complication: sepsis, empysematous pyelonephritis, chronic pyelonephritis, scarring
 Symptoms: fever & chills, flank pain, nausea & vomiting
 Signs: fever, tachycardia, costovertebral angle & ABD tenderness
 Dx:
- Urinalysis: pyuria, bacteremia, nitrites, esterase, leukocyte casts // CBC: leukocytosis
urine culture: ≥ 105 CFU/mL
- US & CT: in case of failed Tx or complication // blood culture: for hospitalized pt.
 TX:
- Uncomplicated:
o 1 dose of ceftriaxone (1st), TMP/SMX or ciprofloxacin for 10-14 days (2nd)
- Very ill, elderly, pregnant: admit pt., IV ampicillin + gentamicin
- + blood culture: IV Abx for 2-3 weeks // Relapse with same organism: Tx for 6 weeks
- Relapse with different organism: another Abx for 2 weeks

 STD:
1. Chlamydia trachomatis “urethritis”:
 MC bacterial STDs, often coinfected with gonorrhea, incubation period 1-3 weeks
 S&S: asymptomatic (most)
- Men: dysuria, scrotal pain, swelling, fever, purulent urethral discharge
- Female: intermenstrual or postcoital bleeding, dysuria, purulent urethral discharge
 Dx: urethral swab for culture, PCR (screening & Dx), no serology (not helpful)
 Complications:
- Men: epididymitis, prostitis // female: PID, salpingitis, ↑cervix cancer risk, infertility
 Tx: azithromycin (1 dose) or doxycycline (for 7 days), treat all sexual partners

2. Gonorrhea “urethritis”:
 N. gonorrhea, gram -, intracellular diplococci, coinfected with chlamydia, sexual trans.
 S&S:

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 - Men: dysuria, ↑frequency, purulent urethral discharge
- Female: asymptomatic (most), purulent discharge, intermenstrual bleeding, dysuria
- Disseminated inf.: fever, arthralgia, skin rash, hand/feet tenosynovitis, endocarditis

 Dx:
- Urethral discharge gram stain (organism within WBCs), blood culture (disseminated)
- Urethral discharge culture (men), endocervical discharge culture (female)
 Complication:
- Disseminated inf., pharynx/conjunctiva/rectum inf., same complication of chlamydia
 Tx:
- Ceftriaxone (1 dose IM)/ciprofloxacin + azithromycin/doxycycline (chlamydia cover)
- If disseminated: admit pt., ceftriaxone IV/IM for 7 days

3. Cervicitis:
 Causes: gonorrhea, chlamydia, trichomoniasis, genital herpes
 S&S: cervical discharge, strawberry cervix on physical examination
 Dx: cervical swab for NAAT (nucleic acid amplification test)
 Tx: ceftriaxone & azithromycin/doxycycline in single dose

4. Pelvic inflammatory disease “PID”:

 Inflammation of uterus, ovaries, & fallopian tubes
 Causes: N. gonorrhea or chlamydia
 S&S:
- Lower ABD tenderness/pain, cervical motion tenderness, fever // exclude pregnancy
 Dx:
- Cervical swab for culture or NAAT, CBC (leukocytosis), clinical
- Laparoscopy: most accurate,indication: persistent S&S after Tx, recurrent, unclear Dx
 Tx: (inpatient if high grade fever)
- In patient: cefotetan + doxycycline // outpatient: IM ceftriaxone + doxycycline
- Penicillin allergy: levofloxacin (outpatient), gentamicin (inpatient)

5. Syphilis:
 Caused by treponema Pallidum spirochete through sexual contact
 1ry stage:
- painless chancre on genitalia, inguinal lymphadenopathy, highly infectious
- appears after 3-4 weeks of infection & heals in 14 weeks
 2ry stage:
- mucopapular rash on palms & soles, condylomata lata (hypertrophic wart like lesion)
- 4-8 weeks after chancre healing, infectious stage, +/- alopecia
 Latent stage: + serology but no S&S, not infectious, 1/3 of pt. will move to 3rd stage
 3ry stage:
- Neurosyphilis:
o Dementia, personality changes, Argyll Robertson pupil (no light reflex)
o Tabes dorsalis: post. Column degeneration, loss of position & vibration
- CVS: AR & aneurysm // Gammas (subcutaneous granuloma): affect bone & skin

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  Congenital: early (<2yrs.) & late (Hutchinson teeth, saber shin, interstitial keratitis)
 Dx:
- Dark field microscopy: definitive, sample form chancre, visualize spirochete

- Serology:
o non-treponemal test “RPR & VDRL”:
 Sensitive, for screening, if + > do treponemal test, false + > SLE, endocarditis, APL
o Treponemal test “FTA-ABS & MHA-TP”: specific, only to confirm + non-treponemal
- HIV: all patient should be tested for HIV infection
 Tx:
- 1ry or 2ry: benzathine penicillin G IM 1 dose/ doxycycline PO 2 wks (penicillin allergy)
- 3ry or latent: IV/IM penicillin for 3 weeks, desensitize to penicillin (penicillin allergy)
 Follow up: repeat non-treponemal test every 3 months

6. Chancroid:
 Caused by Hemophilus ducreyi (gram negative rod), incubation 2-10 days
 S&S: painful genital ulcer with ragger border, unilateral tender lymphadenopathy
 Dx: clinical, rule out syphilis & HSV, PCR
 Tx: IM ceftriaxone one dose or PO azithromycin one dose

7. Pediculosis pubis: “crabs”: ( ‫) قمل‬

 Caused by phthirus pubis, transmitted by sexual contact/clothing/towels
 S&S: sever pruritis in hairy area // Dx: examine hair area by naked eyes/microscope
 Tx: permethrin then wash off, treat sexual partner

8. Genital herpes:
 Caused by HSV-2 (HSV-1 more related to flue, sores, & blisters)
 S&S: painful genital pustules or vesicles, tender lymphadenopathy, +/- discharge
 Dx: Tzank smear (multinucleated giant cells), culture of HSV (gold standard), Elisa
 Tx: acyclovir or foscarent (for resistance cases)

9. Genital warts “condylomata acuminate”:

 Caused by HPV 6, 11, MC STD, soft pink/red growth over genitalia
 Dx: clinical // Tx: cryotherapy, podyphyllin immersion, laser therapy

10. HIV & AIDS:

 Retrovirus, affect CD4 count (normally 600-1000)
 Transmission:
- Mother to baby: highest risk, if viral load > 1000 do C-section
- Anal (2nd higher risk, homosexual), needle, sexual, IV
 S&S:
- primary infection: fever, malaise, sweating, lymphadenopathy
- asymptomatic: seropositive, no S&S, normal CD4, longest phase (4-7 years)
- pre-AIDS:
o generalized lymphadenopathy, dermatitis, localized fungal infection

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 o oral hairy leukoplakia, night sweats, weight loss, diarrhea
- AIDS: CD4 < 200, S&S according to opportunistic infection or malignancy

 Dx:
- CD4 count: best indicator for:
o immune system status, disease progression, therapy response
- Viral load (RNA PCR): indicate therapy response, for neonate’s HIV Dx
- Elisa: (not reliable in infants as maternal ab present for 6 months after delivery)
o Best initial & screening method to detect HIV Ab, done 3-7 wks. After inf.
o If +: do confirmatory test // if -: 99% no HIV (very sensitive)
- Western blot: confirmatory test for + Elisa (very specific)
- Viral resistance testing “genotyping”: done before initiating Tx & in case of Tx failure
 Tx: “HAART”
- Indication: HIV +ve regardless CD4 count, CD4 < 500 with no S&S
- Triple therapy: 2 NRTI & 1 non NRTI/PI/II
- NRTI:
o E.g. abacavir, lamivudine, tenofovir, zidovudine (ZDV) (pregnant, intrapartum inj.)
o S/E: Steven-Johnson syndrome (abacavir), BM suppression, peripheral neuropathy
- Non NTRI:
o E.g. nevirapine, delavirdine, efavirenz // S/E: CI in pregnancy, rash, hepatotoxicity
- Protease inhibitor “PI”: E.g. indinavir, darunavir // S/E: DM, hyperlipidemia
- Integrase inhibitor “II”: e.g. rultegravir, elvitegravir // S/E: hypercholesterolemia
- Fusion inhibitor: 2nd line, e.g. enfuviritide
- Response rate: monitored with viral load that should be undetectable
- Tx is during pregnancy (but not breast feeding) even if viral load is undetectable
- Tx is adequate if ≥ 50% ↓ in viral load in 1st month
- Pre-exposure prophylaxis: emtricitabine & tenofovir before & 1 month after
 Opportunistic infection “OI”: depending on CD4 count
- < 500 Kaposi sarcoma: HHV-8, painless raised papule, face/chest/genitalia/oral cavity
- < 200: pneumocystis Jerovici:
o S&S: fever, dry cough, SOB, chest pain //Tx: cotrimoxazole (TMP/SMX) & steroids
o Dx: CXR (initial, bilateral interstitial infiltrates), BAL (accurate), serum (↑LDL)
- <100:
o toxoplasmosis:
 brain mass & encephalitis effect // S&S: headache, seizure, focal deficit, confusion
 Dx: head CT (enhanced lesion, +/- edema) // Tx: pyrimethamine & sulfadiazine
 Prophylaxis TX: TMP/SMX
o Cryptococcosis:
 Meningitis S&S // Tx: amphotericin B for 10-14 days, fluconazole life-long
 Dx: lumbar puncture, Indian ink of CSF (↑lymphocytes & protein, ↓sugar), Ag
- <50:
o CMV infection:
 Retinitis, esophagitis, encephalitis, colitis // Dx: fundoscopy, colonoscopy, biopsy
 Tx: ganciclovir or foascarent

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 o Mycobacterium avium complex (MAC):
 MC OI // S&S: fever, diarrhea, sweating, anemia, lymphadenopathy, wasting
 Dx: blood/BM/liver culture // Tx: clarithromycin & ethambutol
 Vaccination: pneumococcal, influenza, hepatitis B (no live vaccine)

11. Herpes simplex:

 HSV-1 (oral lesion), HSV-2 (genital), resides in dorsal root ganglia
 Transmission: contact with ulcerative lesion, kissing, sexual contact
 S&S:
- HSV-1:
o oral lesion of vesicles over erythematous patch, fever, headache, +/- bells palsy
o herpes labialis: painful cold sores of the lips
- disseminated HSV: in immunocompromised Pt.
o encephalitis, meningitis, keratitis, pneumonitis, esophagitis
- neonatal HSV: congenital malformation, IUGR, neonatal death
 DX: clinical, Tzank smear, culture (gold standard) // Tx: acyclovir or foscarent

 zoonoses and arthropod-borne disease

1. rocky mountain spotted fever:
 Rickettsia bacteria, ticks are the vectors, endemic in US, summer & spring
 S&S: "after 1 week of tick bite"
- sudden onset of: fever, headache, vomiting, malaise, photophobia
- popular rash that starts peripherally (wrist, hands, ankle) then moves centrally
 diagnosis: ELISA, western blot, PCR, & clinically
 treatment: doxycycline (IV if pt. is vomiting), if CNS S&S/pregnant > chloramphenicol

2. Rabies:
 deadly viral encephalitis, from infected animal`s bites
 S&S:
- pain @ bite site, sore throat, nausea, CNS (confusion, hyperactivity, fever, seizure)
- hydrophobia: inability to drink, hyper-salivation
 diagnosis: viral Ag, Ab titer, PCR, Negri bodies on histology
 treatment: passive immunization (rabies IG), & active immunization (3 IM vaccine inj.)
3. Lyme disease:
 most common (endemic) in US, summer months, outdoor hiking or camping
 transmission cycle:
- caused by = spirochete Borrelia Burgdorferi // hosted via= mice or deer
- transmitted via = ticks (mostly deer tick ixodide scapularis) // 3-32 days incubation
 S&S:
- stage 1: localized skin lesion "erythema migrans" (thigh, axilla, groin)
- stage 2: early disseminated // spread by LN & blood, within days-moths of skin rash
o S&S:
 General: flu-like S&S, headache, nick stiffness, chills, musculoskeletal pain
 CNS: bilateral facial palsy (most), meningitis

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  CVS: transient AV block (most), palpitation
- stage 3: late if left untreated
o arthritis: in 60% of pt. oligoarticular/mono-arthritis, mostly knee joint
o CNS: neuralgia, cognitive impairment // CVS: myocarditis, ventricular arrhythmia
 diagnosis: clinical for erythema migrans + ELISA, western blot, or PCR all for IgM or IgG

 treatment:
- stage I give PO antibiotics for 10 days, stage2 or stage III (joint & facial) for > 20 days
o give doxycycline, if CI (pregnant women or child < 8 yrs.) > amoxicillin/cefuroxime
o if the patient was pregnant & has penicillin allergy > erythromycin
- if stage III complicated (CNS other than facial & cardiac) IV ceftriaxone for 4 weeks

4. malaria:
 protozoal inf. cause by (Plasmodium falciparum, ovale, vivax, malaria), mosquito bites
 S&S: fever, chills, nausea & vomiting, diarrhea, CNS (confusion, seizure), anemia
- fever pattern: constant or irregular (flaci.), Q48hr (vivax & ovale), q72 hrs. (malaria)
 diagnosis: thick smear (geimsa stain) for detection then thin smear for species
 treatment:
- P. falciparum: mefloquine or proguanil (chloroquine in preg.), IV quinidine in severe
- others: chloroquine & primaquine (to avoid relapse) (CI in G6PD deficiency)
- prophylaxis: for travels to endemic area give mefloquine (2 days – 2 weeks before)

 common fungal infections:

1. candidiasis:
 mostly by candida albican // RF: Abx, DM, immunosuppressant therapy, IC pt
 S&S: mucocutaneous
- vagina: thick, white, "cottage cheese" discharge
- mouth: thick white plaques in oral mucosa, painless
- coetaneous: erythemates patches "satellite lesion", more in DM, in skin folds
- GI: esophagitis // systemic: invasive dissemination in IC pt
 diagnosis: clinical, KOH preparation (yeasts), blood or tissue culture for invasive
 treatment:
- mouth & GI: clotrimazole & nystatin mouthwash (mouth) & PO ketoconazole (GI)
- vagina: miconazole or clotrimazole cream // skin: oral nystatin powder
- systemic/invasive: amphotericin B or flucanazole

 fever & sepsis:

1. fever on unknown origin:
 criteria: fever > 38.3c, continues for @ east 3 wks, no diagnosis despite 1 wk admit
 causes:
- inf.: most, TB, occult abscess, UTI, endocarditis, HIV, malaria
- neoplasm: 2nd cause, lymphoma, leukemia
- CT: SLE. temporal arteritis, polymyalgia rheumatic
 S&S: chills, rigors, night sweats, alter mental status, weight loss
 diagnosis: history, all lab test, all imaging, biopsy // all done to rule out any cause

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  treatment: observation except in severe fever or with respiratory S&S

2. toxic shock syndrome:

 caused by enterotoxins of S. aureus mostly & in some case exotoxins of group A strept.
 RF: menstruating women & tampon use (most), surgical wounds, burns, insect bite
 S&S: high grade fever, myalgia, diffuse macular rash, strawberry tongue, low BP
 diagnosis: clinical suspicion, negative blood culture (toxins not bacteria)
 treatment: aggressive fluid & vasopressors, deal with the cause if found, oxacillin

3. neutropenic fever:
 causes: BM failure/invasion, peripheral (hypersplenism, AIDs), drug (PTU)
 complication: infection like septicemia, cellulitis, pneumonia
 diagnosis: CXR, blood, urine, sputum, CBC
 treatment: isolation, broad spectrum ABx and if fever persist give anti fungal

 miscellaneous:
1. infectious mononucleosis:
 caused by EBV (rarely CMV), mainly in adults, infected saliva "kissing disease"
 symptoms: high grade fever, sore throat, malaise & weakness
 signs: lymphadenopathy (90%), splenomegaly, maculpapular rash
 diagnosis: “lymphocytosis”
- serology: monospot test (heterphile Ab) // peripheral smear: atypical lymphocytes
 complication: hepatitis, neurological (encephalitis, GBS, Bell palsy), hemolytic anemia
 treatment: (no specific treatment)
- rest, fluids, avoid severe activity (to avoid splenic rapture), analgesia, steroids

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