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Generic Clinical Skills > Examination of Infectious Diseases Patient > Flashcards

Examination of Infectious Diseases Patient Flashcards

1
Q

What does examination aim to do?

A
  • To assess a patient that presents with unexplained fever
  • Identification of oral lesions with infective causes
  • Identifying patients that require additional work up for surgery due to immunosuppression or bleeding risk
  • Prevention of cross infection to clinician and staff
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2
Q

Where to look for assessment of the infectious patient? (6)

A
  1. General
  2. Hands
  3. Arms
  4. Face
  5. Eyes
  6. Ears
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3
Q

What are the most common causes of fever?

A

1.Bacterial Infection (Odontogenic abscess, Tuberculosis, Osteomyelitis)
2,Viral Infection (EBV, HIV, HSV)
3.Fungal (Histoplasmosis, Cryptococcosis)
4.Autoimmune Conditions (Giant Cell Arteritis, Rheumatoid Arthritis)
5.Malignancy(Leukemias/ Lymphomas)

The longer the duration of fever > less likely to be infective

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4
Q

When a patient has an unexpected fever what do we ask?

A
  1. Fever history? Onset, duration, Severity, Precipitating & relieving factors, swelling, changes. pain
  2. Recent infection? Types, symptoms, what resolved it
  3. Exposure? sick, food, injuries, sex
  4. Other? recent surgical history
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5
Q

General assessment?

A

Temperature >38 C

Weight loss (chronic illness/malignancy)

Skin rash Viral: Infectious mononucleosis, Rubella, dengue fever, Bacterial: Syphilis, Non – Infective: Drugs, SLE, Erythema Multiforme (possible other underlying condition)

Cervical Lymphadenopathy

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6
Q

Hands and Arms assessment?

A 
Purpura & Petechiae
Finger clubbing (IE)

Drug injection sites, recent cannula sites

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7
Q

Face assessment?

A

Seborrheic dermatitis (HIV)
Ulcerative/ vesicular lesions (Location- HSV/ VZV)
Swellings/ Fistulae
Jaundice

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8
Q

Eyes and Ears assessment?

A

Eyes:

  • Conjunctivitis, pain, double vision, photophobia
  • Retinal haemorrhages (Leukemia)
  • Jaundice (Hepatitis, Malaria)

Ears: Drainage from ear canal (Middle Ear Infection)

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9
Q

Localised signs of infection Upper Respiratory Tract?

A

Cough, Stridor, sinus, tooth pain

Pharyngeal erythema, enlarged tonsils, regional lymphadenopathy

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10
Q

Localised signs of Lower Respiratory Tract?

A

Chest pain, cyanosis, sputum

Tachypnoea, crackles, wheezing

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11
Q

Localised signs of infection Genito-Urinary ?

A

Dysuria, vaginal discharge

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12
Q

Localised signs of infections Cardiovascular?

A

Chest pain, tachycardia, hypotension, cardiomegaly

Janeway lesions, Osler’s Nodes (IE signs/ symptoms

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13
Q

Localised signs of infection Hepatic?

A

Jaundice, nausea, Right upper quadrant pain

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14
Q

Localised signs of infection CNS Changes

?

A

Headache, photophobia, seizures, confusion

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15
Q

What tests should we order?

A

WBC, Acute phase reactants, blood and urine cultrures

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16
Q

What does WBC test show?

A

Bacterial: Increased neutrophil count
Viral: Initial transient neutrophil increase, then increase in monocytes
EBV: Atypical lymphocytes, large T lymphocytes – IM
Eosinophilia : Allergic/ Parasitic infections

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17
Q

What does Acute reactant tests show?

A 
C Reactive Protein (CRP) 
Erythrocyte Sedimentation Rate (ESR) 
Elevated in infection
Non specific 
Tool to assess recovery
18
Q

What special tests would we do?

A

Blood Cultures
Urine Cultures
Specific Cultures: Bacterial, Viral, Fungal, Mycobacterial > identify pathogens
Serological Tests:
Western Blotting (Acute/ latent infection)
LFTs
Lumber punch

19
Q

What infectious disease have oral manifestations?

A 
HIV/ AIDS 
Syphilis 
Actinomyces 
Tuberculosis
Hepatitis B & C
Herpes Simplex 1& 2
Herpes Zoster Virus
20
Q

What is HIV?

A

Retrovirus – invades T helper lymphocytes > self replicates
Increased susceptibility to opportunistic infections, drug interactions and adverse effects
Routine HIV Testing for patient with unexplained infectious disease
Progressive: Acute > seroconversion > latency > symptoms > AIDS> advances HIV
Transmission: Bloodborne

21
Q

What are the symptoms of HIV?

A

Primary Infection

  • Fever
  • Lymphadenopathy
  • Maculopapular rash
  • Arthralgia
  • Pharyngitis
  • Nausea
  • Vomiting
  • Headache
  • Weight loss
22
Q

What are the oral manifestations of HIV?

A 
Oral Hairy Leukoplakia 
Ulcerations 
Kaposi's Sarcoma
Candidiasis (Erythematous and Pseudomembranous) 
Necrotizing Periodontitis
Linear Gingival Erythema 
Recurrent Aphthous Ulcerations 
Salivary Gland Disease 
Other : TB, Toxoplasmosis
* 1992 EC Clearinghouse Classification
23
Q

What else should we check in HIV patients?

A

Points to check in a HIV + patient:
Initial and current viral load and CD4 counts
TB, Hep B, C status
STI Screen
Current management?– HAART & possible side effects
Incidence of opportunistic infections – Candidiasis, HZV
Lifestyle & social circumstances
Signs of cognitive impairment

24
Q

What diagnostic tests are used for HIV patients?

A

Diagnostic Tools:

  • Rapid Antibody Tests (Oral fluids/bloods)
  • Antigen/ Antibody Tests
  • Nucleic Acid Tests – blood test
  • possible HIV nephrology

Viral Load – Elevated VL > more progressive disease
CD4 T cell Counts

Other: FBC, LFTs, STI’s, Hepatitis, TB, BGL (antivirals interact with glucose metabolism)
CDC Guidelines- CD4 T cell Count
- 200 and 350 cells/mm3 Intra- oral lesions
< 200 cells/mm3 –
AIDS
< 50 cells/mm3 – Advanced HIV

25
Q

What is Syphilis?

A

Sexually transmitted infection – Treponema Pallidum (5-20um Spirochete)
Three Subtypes: Primary, Secondary, Tertiary, Congenital
Male Predilection
Mode of Transmission: Bloodborne, mucous membranes
Look for oral lesions, may imitate neoplastic process

26
Q

What is primary syphilis?

A

Solitary painful papule > Infectious ulceration with yellow slough
Regional lymphadenopathy
Last 3-7 weeks and spontaneously heal
Primary Lesions: Skin, lip, tongue, oropharynx

27
Q

What is secondary syphilis?

A

Fever, malaise, headaches, arthralgia
> 30% oral lesions
Macula-popular lesions (Condyloma lata), snail track lesions, leucoplakia
Pharyngitis, Tonsillitis, Lymphadenopathy

28
Q

What is tertiary syphilis?

A

Gammas’- rare with bony resorption, atrophic glossitis
Neurosyphilis, Cardio syphilis

Gammas are painless ulcerations, non-infectious- inflammatory granulomatous lesions with central zone of necrosis
Palate is most common intra-oral site

29
Q

What is congential syphilis?

A

Hutchinson’s incisors, Mulberry Molars, high palate, skin fissures

30
Q

What are 3 ways for testing for syphilis?

A

Traditional Methods:

1) 2 Testing Groups (Nontreponemal (VDRL, RPR) & Treponemal)
2) Treponemal Enzyme Assay (EIA) + additional nontreponemal tests

Novel Method: Rapid Syphilis Safety Health Check – 2014
Finger prick blood sample
Rapid Results (10 mins)

Histopathology
Granulomatous with Langerhans's multinucleated giant cells &amp; epithelioid histiocytes 
 Lymphoplasmacytic infiltrate
Necrosis (Gummas)
Immunohistochemistry – high sensitivity
31
Q

What is TB?

A

Mycobacterium Tuberculosis (acid fast obligate aerobe)
Droplet Transmission- mucous and saliva secretions
Pulmonary TB: Persistent cough, mucoid/ purulent sputum, SOB

32
Q

What are TB manifestations?

A

Painful ulcerations- rotten apple appearance
Lateral tongue> palate
Osteomyelitis
Can appear in any intra-oral site, variable presentation
Non tender lymphadenopathy with matting, ulcerations, ‘cold’ abscess

33
Q

What investigations are done for TB?

A

Histopathological Features

  • FNA, Core Biopsy, Soft tissue biopsy
  • Acid Fast Bacilli
  • Epithelioid granuloma
  • Langerhans’s Multinucleated Giant Cells

Chest X-ray

  • Ghon Lesions, Lymphadenopathy
  • Patchy consolidations (Secondary TB)
  • Serology Testing: Culture Tests and NAAT’s

Latent Infection:
QuantiFERON – TB Gold Test (Gold Standard)
Mantoux Test

34
Q

What is Actinomycoses ?

A

Rare chronic infection affecting the cervicofacial region
Actinomyces Israelii- G +, non contagious commensal (Oral Cavity, tonsillar crypts, dental plaque)
Predisposing Factors:
- Periapical infection
- Immuno-suppression, DM, Malignancy

35
Q

What are the clinical features of actinomycoses?

A

Firm, slow growing, painless swelling
Progresses to multiple fistulae > drains ‘yellow sulphur granules’
Cellulitis or multi-focal abscess
Abdominal, pulmonary fistulae
Appearance mimics neoplasia
Site: Perimandibular > submandibular > TMJ

36
Q

What investigations are done for actinomycoses?

A 
Challenging diagnosis 
DDX: Granulomatous diseases, malignancy
Microbiological cultures- high false negative, low culture yield 
FNA and Core Biopsy- inconclusive
Histopathology with Open Biopsy: 
Gram + branching bacilli  (BB Stain)
Club shaped/ beaded bacilli  
Blue clumped colonies on H &amp; E stain
Not acid fast +
Savoca E, et al, 2018
37
Q

What is HSV & HZV?

A

Herpes Simplex Virus and Herpes Zoster Virus

HSV 1, HSV 2
Transmission through secretions/ close contact
High rates of subclinical, asymptomatic shedding
Latent Stages: HSV 1(Trigeminal Ganglion), HSV 2 (Sacral G)

38
Q

What are the primary features of HSV and HZV?

A

Primary: Fever, malaise, gingivostomatitis
Recurrent: Herpes Labialis, intra-oral herpes, Bell’s Palsy
Stages: Prodrome, Macule, Papule, Vesicle, Ulcer, Scab
Vesicle and Ulcer stages are infective

39
Q

What investigations can be done for HSV/HZV?

A

Direct Immuno-fluorescence (DIF)
Rapid, requires fresh samples

Real Time PCR Assays
High sensitivity and specificity
Detects asymptomatic shedding

Serology – HSV 1, HSV 2
IgG – past infection
IgM- recent infection (not reliable)

Histopathology
Hallmark: Intra-epithelial vesical formation
Enlarged nuclei, multinuclear syncytial cells

40
Q

HZV specific primary, latent and investigations?

A

VZV:
Primary: Varicella / Chicken Pox
- Low grade fever, pruritis, malaise, skin rash

Latent infection:
- Orofacial & thoracic region
Unilateral, dermatome involvement
10-15% post-herpetic neuralgia

Investigations
PCR – rapid, high sensitivity
Biopsy of the lesion for histopathology: 
Acantholysis of epithelial cells 
Free-floating Tzank cells
Multinuclear cells

Check for underlying immuno-suppression

41
Q

What is SIRS?

A

Systemic inflammatory response

>/ 2 of following: Fever > 38.3, Tachycardia, Tachypnoea, Elevated WBC

Generic Clinical Skills (10 decks)

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