Classic presentations Flashcards
“lumpy jaw”, with lumps and sinus tracts after dental or jaw trauma.= ? Rx
Actinimycosis
Penicillin
Tubo-ovarian abscess, complication of intrauterine device (IUD), =
Actinomycosis
Penicillin rx
Hx : insidious onset lethargy, mild mucohemorrhagic diarrhea, non specific cramping & abdominal pain
Epi: lifelong freshwater exposure in endemic area of Africa
PE: diffuse abdominal tenderness, minimal hepatomegaly, mild malnutrition
Dx?
Rx?
Complication?
Schistosomiasis
Lab: S. mansoni ova in stool, mild eosinophilia, periportal fibrosis on U/S
Rx: Praziquantel
associated with bladder cancer
Hx: chronic cough with blood streaked sputum,
progressive chest discomfort, breathlessness on exertion
Epi: ingestion of raw freshwater crab in China, Japan, Korea, Taiwan, Philippines, India, Africa, South & Central America
Lab: CXR: patchy cystic infiltrate. Eosinophilia
Dx? Ix? Rx?
Paragonimus IgG (+).
Eggs of Paragonimus westermani in sputum or stools.
Rx: Praziquantel X 3 days
Hx: acute onset of fever, RUQ abdominal pain, anorexia, nausea, vomiting, dark urine, lasting weeks
Epi: ingestion of raw watercress, lettuce, or alfalfa
in cattle & sheep farm
PE: fever , jaundice , hepatomegaly
Dx? Ix? Rx?
Fasciola Hepatica
Fas2 ELISA (+), Fasciola
hepatica Western blot (+). ve stools
Triclabendazole for 2 days .
Hx evanescent pruritus, maculopapular rash often on trunk
Epi: West Africa, expat, back home for 1 year
PE: dermatitis, normal ocular exam, nodules rare
Lab: scanty microfilariae in skin snips
Dx? Rx?
Onchocerca volvulus
Ivermectin 12 months titrated to symptoms for up to 10 years.
Doxycycline X 6 weeks.
Hx Transient swellings, arthralgia, inconstant pruritus
Epi: expat, West or Central Africa
Eosinophilia
May migrate to?
Dx? Ix? Rx?
Loasis - ‘the eye worm’
[Calabar swellings]
antifilarial IgG (+), worm in Eye
Diethylcarbamazine X 3 wks
[So long as <2500mf/ml
Hx initial diarrhea & non specific abdominal complaints followed by fever, facial edema, painful swollen muscles including respiratory & mastication
Epi: worldwide, tropical & non tropical, ingestion of poorly cooked meat of any carnivorous animal, including pigs
PE: Temp 40 C. Tender swollen muscles, edema, chemosis, urticaria.
ESR=0, massive eosinophilia,
Dx? Ix? Rx?
Trichinella spiralis
T. spiralis IgG (+)
Deltoid muscle biopsy with larvae,
Albendazole & steroids
Hx 2 yo with fever, malaise, RUQ discomfort, anorexia, sleep disturbance
Epi: geophagia, exposure to dogs/cats,
PE: hepatomegaly, wheezing
Lab: Massive eosinophilia,
No eggs in stool.
Dx? Ix? Rx?
Visceral Lava migrans
Toxocara
T. canis IgG (+)
Albendazole. Consider steroids.
Hx severe intractable headache, nausea, mild neck stiffness, paresthesias
Epi: ingestion of raw snails/slugs alone, or green vegetables in Asia or Pacific region
Lab: Eosinophilia,
CSF: OP 50 cm, normal glucose, raised protein, Eosinophilic
=?
Rx?
Angiostrongylus cantonensis
Repeated lumbar puncture, analgesics, +/ steroids.
Hx fever, non specific abdominal symptoms, intermittent painless subcutaneous swellings
Epi: ingestion of undercooked chicken, fish, frog, reptile in Asia or Latin America
PE: Temp 38 C. Subcutaneous migratory swelling.
Lab: eosinophilia,
=?
Ix?
Rx?
Key comp?
Gnathostomiasis
ELISA for G. spinigerum
Albendazole X 3wk.
Intracerebral haemorrhage
Hx Non specific epigastric pain, intermittent diarrhea. Cough, wheezing diagnosis of allergies.
Epi: Resident or visitor to an endemic area of
Latin America USA, or SE Asia.
PE: Asymptomatic or may have non specific abdominal findings. Occasional rash pictured called?
Dx?
Ix?
Rx?
Larva currens
Simple Intestinal Strongyloidiasis stercoralis
stool strongy visualised.
Baermann or agar plate culture or sampling of upper GI secretions
Ivermectin.
Hx Corticosteroid or other immunosuppressive treatment. Non specific epigastric pain, intermittent diarrhea.
Epi: resident of an endemic area of Latin America, USA, or SE Asia
PE: Non specific abdominal findings. Ileus . : pneumonia, bacterial septicaemia , shock, no eosinophilia
Dx?
Key causes?
Rx?
Strongyloides hyperinfection
Steroids, HTLV-1, Cancer Rx
Ivermectin + antibiotics for bacterial infection
Hx: subacute febrile illness, right upper quadrant abdominal pain, weight loss
Epi: immigrants or residents in endemic areas of Asia, Africa & Latin America
PE: fever, pallor, exquisite point tenderness over the liver, dullness & rales at the right lung base
Lab/Xray: anemia, raised neutrophil WBC , Raised Alk. P.
Dx?
Ix? Seen on CXR?
Rx?
Amebiasis
E. histolytica IgG
US - Abscess right lobe liver .
CXR: elevated R diaphragm / effusion
Tinidazole + paromomycin
[Colitis on endoscopy - mimics IBD]
Hx: Fever, chills, muscle aches For 2 days. Fever constant.
Epi: One week volunteer work in rural area of Amazonian Brazil.
Blood film … no schizonts
Rx?
P. falciparum
Atovaquone proguanil 4 tabs qd X 3 or
ACT ( eg . Artemether lumefantrine bid X 3 days ),
Hx Travel to India 6 months earlier, took appropriate prophylaxis with atovaquone/proguanil. Acute onset of fever, chills/rigors, myalgias & headache
Epi: Traveler & endemic populations, worldwide distribution in tropics & subtropics, especially in India, the Americas, & SE Asia
PE: acutely ill & febrile, otherwise unremarkable Splenomegaly after a few days of illness
Lab: Anemia, leucopenia, thrombocytopenia.
Blood film….
Rx? When would you use alternative?
P Vivax relapse
Chloroquine
+ primaquine X 14d or Tafenoquine 300 mg
[ Vivax in Papua New Guinea, Indonesia requires ACT + primaquine]
Or ACT
Hx 21 yo with syncope , fatigue
Epi: childhood in rural Brazil , thatched roof dwelling
PE: Afebrile
Dx?
Seen on XR? Most common arrhythmia?
Ix?
Rx?
Trypanosoma cruzi
CXR: massive cardiomegaly
Complete RBBB
T. cruzi IgG (+). Xenodiagnosis
Rx Benznidazole , nifurtimox
[no benefit in late disease]
Acute systemic febrile illness in travelers; remembers painful tsetse bite in Tanzania
PE: high fever, inoculation chancre, rash, generalized lymphadenopathy
thrombocytopenia, anemia
Blood film shows:
Dx?
Essential Ix?
rx?
Trypanosoma brucei rhodesiense
CSF
Early disease -> Suramin
CNS infection -> Melarsoprol
Slow progressing neurological disease
PE: intermittent fever, posterior cervical lymph node, neurological signs
Dx?
Ix?
Rx?
Trypanosoma brucei gambiense
serological screening (CATT/RDT
LP - ALWAYS NEEDS AN LP
Early disease -> Pentamidine
CNS -> Eflornithine/nifurtimox
Fexinidazole for both early and CNS now
Hx: sudden unilateral loss of visual acuity without ocular pain
Epi: Ingestion of undercooked meat
PE: unilateral chorioretinitis, peri macular cotton wool spots
and no vascular involvement
Dx?
Key ix?
Rx?
Ocular toxoplasmosis - toxoplasma gondii
Toxoplasma IgG (+); IgM (+) in travelers
Pyrimethamine plus sulfadiazine and folinic acid 6 weeks
OR Co-trimoxazole
Hx: single painless chronic cutaneous ulcer progressing over weeks to months. Subsequent mucosal dissemination.
Epi: exposure in rainforested areas of S. America
PE: ulcer with raised indurated border with clean granulated base & with no surrounding inflammation
Which leish?
Leishmania V braziliensis
Pentavalent antimonals Eg SB5, AmphoB
Topical drug for limited cutnaeous leish?
topical paromomycin.
Imiquinoid
Hx febrile illness acute, subacute, or chronic course
Epi: Exposure to sandflies, zoonosis or anthroponosis rare in travelers, common in endemic populations. India, Sudan, Brazil, Southern Europe.
Exam: fever, cachexia, hepatosplenomegaly generalized lymphadenopathy
Pancytopenia with relative lymphocytosis, hypergammaglobulinemia, hypoalbuminemia.
Which type of leish?
Seen on labs?
Ix?
Rx?
L. donovani or
L.chagasi (=L. infantum)
Amastigotes in bone marrow or splenic aspirates.
Serology(+): DAT or rK39
Liposomal Amphotericin
[Miltefosine if oral]
Hx: abrupt onset fever, vomiting, diarrhea evolving to severe fatigue, anorexia, nausea, weight loss with intermittent diarrhea
Epi: Warm months in Nepal, Peru, Guatemala.
Dx?
Ix?
Rx?
Cyclospora cayetanensis.
Stool with AFB (+). 10um
Co-trimoxazole
Hx HIV infected, CD4 < 100, chronic diarrhea, abdominal pain, no mucus, no tenesmus.
Epi: tropical developing country or developed country
PE: malnourished, lymphadenopathy, oral thrush, increased bowel sounds, abdominal tenderness
Dx?
Ix?
rx?
Bar HIV who might commonly get this?
Cryptosporidium hominis
Stool: AFB(+) oocysts of C. parvum or C. hominis
4-6um
Nitazoxanide
ART therapy
Normal host: 1 yr old with persistent diarrhea
Hx: chronic RUQ abdominal pain, sensation of RUQ fullness. Early satiety.
Epi: Resident of sheep raising areas worldwide including temperate zones. Exposure to dogs.
PE: hepatomegaly
Dx?
Ix?
Rx?
Echinococcus
U/S: hypoechoic cystic lesion in the liver
CT: septate cystic lesion.
Echinococcus Western Blot (+)
PAIR / Albendazole / surgery depending on stage
Hx: previously healthy 20 yo with new onset seizures
Epi: lifelong exposure in a rural area with poor sanitation & extensive contact with pigs
PE: unremarkable
Dx?
Ix?
Rx?
Neurocysticercosis
CT B
T. solium Western Blot (+).
Rx: Albendazole + PZQ X 10d.
Dexamethasone starting 2 days before
+/-Antiepileptic
Hx: flat white worm segment noted by patient in stool. Motile segments felt during defecation.
Asymptomatic or nonspecific abdominal complaints.
Epi: worldwide distribution, tropical & temperate
Cows nearby
PE: unremarkable
dx?
ix?
rx?
Stool examination: eggs or segments of Taenia saginata
(>15)
Praziquantel
Hx: child with nonspecific abdominal complaints of varying duration. Mild diarrhea. Headache, sleep disturbances
Epi: Resident of Egypt, Sudan, Thailand, India, South America, South Europe.
PE: unremarkable
Stool shows…
Dx?
Ix?
Rx?
Remember?
Hymenolepis nana
Stool sample for eggs
Praziquantel + repeat after 10 days
Person-to-person spread; other family members with positive stools.
Hx: constant fever, headache, diarrhea followed by constipation, insomnia
Epi: ingested food from street vendors in India
PE: Temp 40.1 o C; pulse = 84. Borborygmi.
leukopenia with left shift, no eosinophilia.
Dx?
Ix?
Rx?
When do complications happen?
Typhoid fever
Blood or bone marrow culture Salmonella. typhi.
Cipro / azithro
Cef if severe or in Asia / quinolone resistance likely
Complications usually around 3 week mark Eg GI bleed/perf
Hx: abrupt onset fever, chills, myalgia, headache, sore
throat, nausea, vomiting.
-Second (immune) phase with meningeal symptoms.
Epi: swimming, hiking, biking or exposure of wounds to stagnant water contaminated by rodent urine
PE: Temp 40 C, conjunctival suffusion, muscle tenderness, hepatomegaly, meningeal signs in immune phase
Lab/X Ray: Raised CK, thrombocytopenia,
Very high bilirubin with almost normal transaminases.
CSF: mononuclear pleocytosis.
Dx?
ix?
rx?
leptospira interrogans
Serology - [Urine best]
Rx: Ceftriaxone
Hx: fever, severe headache, malaise, arthralgia, lesion pictured with local swelling, lymphangitis,
Epi: exposure in rural area of Africa or Mediterranean basin, almost always South Africa in travelers.
PE: Temp 40 C, single tache noire, petechial rash local
adenopathy.
Dx?
Ix?
Vector?
rx?
African tick bite fever - Rickettsia africae
Serology for IgG/IgM
Amblyomma tick
Doxy
Hx painless pa pule with surrounding erythema and edema that evolves into an hemorrhagic vesicle, ulcerates and develops a black central eschar. Painful regional adenopathy.
PE: necrotic ulcer with raised indurated borders and
painful regional lymphadenopathy. Pleural effusion,
widened mediastinum, hemorrhagic meningitis.
Dx?
Modes of transmission?
Ix?
Rx?limited cutaneous? GI/systemic? Meningitis?
Prevention?
Anthrax - Bacillus anthracis
-contact with infected animals or animal products.
-Inhalation of spores (inhalational anthrax)
- ingestion of contaminated meat (gastrointestinal).
Cutaneous - Amox (kids) or cipro
Inhaled/systemic - Antitoxin (Raxibacumab) or IVIg +Cipro + linezolid
Add meropenem + dexamethasone for meningitis
Vaccine - bioThrax in selected populations
Hx lesion beginning as single painless non tender nodule with subsequent ulceration with wide undermined edge
PE: Afebrile. Undermined highly invasive ulcer.
Non systemic. No adenopathy.
Dx?
ix?
Rx?
Buruli ulcer
Mycobacterum ulcerans
Direct smear from ulcer border with clumped AFB+
Rifampin + clarithromycin
Hx two or more) well defined chronic non pruritic hypopigmented macules or erythematous plaques
PE: impaired sensation on the skin lesions
One or more thickened nerves
Dx?
Ix?
Rx?
Leprosy - Paucibacillary
-Slit skin smears from the lesions AFB ( (–)
- Biopsy with granulomas in skin & nerves
- Lepromin skin test +ve
Dapsone + rifampin + clofazimine for 6 months
Hx : multiple , chronic , non pruritic , non anesthetic mildly erythematous infiltrative lesions on skin, papules and nodules
PE: Normal or impaired sensation on the lesion (s). One or more thickened nerves in longstanding disease
dx?
ix?
rx?
Leprosy Multibacillary
-Slit skin smears from a lesion AFB (5+).
-Biopsy with foamy histiocytes , perineural bacilli .
-Lepromin ((–).
Rifampicin , clofazimine and dapsone for 12 months
Hx: abrupt onset fever, rigors, severe headache, myalgias arthralgias; cyclical episodes
Epi: person to person in settings of cold, crowding & poverty. Horn of Africa
PE: Temp 39 C, lethargy, truncal rash (petechial), conjunctival suffusion, hepatosplenomegaly, hemorrhage.
Dx?
Ix?
Rx? comp?
Louse borne relapsing fever
-Borrelia recurrentis,
typical spirochetes in peripheral blood, thrombocytopenia, increased LFTs/Bili.
Doxy single dose - Jarisch/Herxheimer reaction.
Hx: fever, septic picture in a 46 yo diabetic
Epi: rainy season in farming areas of East Asia or Northern Australia
PE: Temp 40ºC, obtunded, shock
Lab/X Ray:
CXR: extensive pneumonia.
U/S: hepatic & splenic abscesses. + muscle a abscesses
dx?
Ix?
Rx?
Burkholderia pseudomallei Melioidosis
Gram-negative rods in pus from abscesses
Cef OR mero 2 weeks
followed by co-trimoxazole for 20 weeks
Hx Abrupt onset fever, chills, arthralgia, headache,
eye & lumbosacral pain.
Epi: Travel or residence in urban areas of tropics
PE: Fever, generalized erythematous macular rash, relative bradycardia & generalized lymphadenopathy.
Petechial haemorrhages & epistaxis
DX?
Bloods?
Ix?
Rx?
Dengue
Marked leukopenia, thrombocytopenia.
-Viral isolation or PCR from acute serum
- Dengue IgM (+) after day 5 of illness
-NS1 protein
Symptomatic Rx
Dengue vs Chikungunya vs Zika
Which has the worst arthralgia? which has none?
Which commonly has peripheral oedema?
Retro-orbital pain?
conjunctivitis?
Hepatomegally?
Leukopenia?
Haemorrhage?
Hx: Gradual onset, sore throat, cough, GI symptoms, deafness (20%) in convalescence.
Epi: Sierra Leone, Liberia, Guinea, Nigeria.
rats as well as stored rain
PE: pharyngitis, hypotension with generalized edema, non-icteric, sometimes facial + neck swelling.
Dx?
Transmission?
ix?
rx?
Lassa fever
Rodents/contaminated urine / human-human
Lab IgM, viral isolation, PCR.
Ribavirin
Hx 43 yo with non tender swelling beginning in toe, progressive over 30 years now with sinus tracts and drainage of black granular material. Otherwise well.
Epi: Farmer from Chiclayo on the coast.
PE: Afebrile. Normal except foot.
Lab: Hyphal forms in KOH prep of black granules. Culture (slow-growing)
Dx?
Rx?
Madurella mycetomatis
Itraconazole
Hx: undifferentiated fever, cough, dyspnea, weight loss
Epi: typically HIV high risk group, living in Eastern U.S., Central & South America
PE: fever, diffuse rash, organomegaly
Lab: pancytopenia, raised LDH
CXR military
dx?
rx?
Histoplasma capsulatum
Amphotericin B followed by itraconazole
Progressive worsening headache in HIV with poor adherence to ARVs
umbilicated skin lesions
dx?
ix?
rx?
Cryptococcus neoformans
-India ink
-CrAg in CSF/serum
Amphotericin B + flucytosine + fluconazole 2 weeks
Then 800mg fluconazole 8 weeks
then 200mg fluconazole until CD4 >200 minimum 1 year
Hx: Single papular lesion on hand after local trauma progressing over weeks to multiple nodular lesions in a lymphatic distribution up the arm. No systemic
symptoms.
Epi: farmer in a rural area of Peru
PE: afebrile, ulcerated violaceous hand lesion with lymphatic spread
dx?
ix?
rx? if no money?
sporothrix schenckii
Biopsy & direct smear from ulcer negative.
S. schenckii on culture.
Itraconazole for >3 months or
potassium iodide if economic constraints
Hx cough, proliferative skin lesions, bone pain, constitutional symptoms
Epi: Asian, Filipino, or Black with exposure to U.S. Southwest, Mexico, parts of S. America
PE: fever, verrucous skin lesions (focal or diffuse), bone pain
Dx?
Ix
rx
coccidioides immitis
Lab: serum or CSF complement fixation (+)
Amphotericin B for severe disease,
itraconazole or fluconazole for stable
Hx:>4 months of chronic disease with oral and/or skin lesions, exertional dyspnea
Epi: exposure in forested areas of S. America. Farmer with history of smoking & alcohol abuse
PE: cachetic adult male painful oral exophytic ulcers affecting gums which bleed, & ulcerative polymorphic skin lesions
Dx?
Ix?
Rx
Paracoccidioides brasiliensis
Direct exam & culture of lesions or bronchial secretions for P. brasiliensis
Complement fixation or immunodiffusion
Rx Itraconazole at least 1 year
Hx child with fever , lymphadenopathy & anorexia
Epi resident of forested region of S. America
PE: fever , generalized adenopathy (may suppurate ) including abdominal, hepatosplenomegaly
Dx?
Ix?
Rx?
Paracoccidioidomycosis - Sub acute juvenile infection
P. brasiliensis in the direct aspirate of lymph node .
Ampho B / itra
Hx: diffuse itchy hyperkeratotic skin lesions
Epi: Worldwide in compromised hosts.
PE: Afebrile. No adenopathy. Diffuse skin lesions.
Dx?
Ix
Rx?
Link to?
Norwegian Scabies
direct scrapings crawling with mites
Rx: oral ivermectin
HTLV 1 positive
Hx Snakebite, intense pain & swelling at site with headache, abdominal pain.
Epi in rural or jungle area of South America
PE: Wound: edema, erythema, ecchymosis, bullae, cyanosis, necrosis and inflammation, oozing of blood through fang marks. Local lymphadenopathy. Extensive swelling of whole limb.
Which snake?
Systemic sx?
Key Ix?
Rx?
Viper - (e.g. Bothrops sp . or Lachesis sp .)
Systemic: hypotension, spontaneous systemic bleeding.
Lab: incoagulable blood (20WBCT). DIC profile, hemoconcentration , increased CK, myoglobinuria , increased BUN/Cr.
Rx: Supportive. Appropriate specific antivenom Crotalidae. Pre treat with epinephrine. Debridement and skin grafting
(not fasciotomy ) as required
Who am I
DR. EDUARDO GOTUZZO HERENCIA
Fever. Sore throat. Feeling sick.
Painful, blister-like lesions on the tongue, gums and inside of the cheeks.
A rash on the palms, soles and sometimes the buttocks. The rash is not itchy, but sometimes it has blisters.
EPI : kid in child care centre
Dx?
coxsackievirus 16 - Hand foot and mouth disease
