viruses that produce rashes continued: Shingles ? Fifth disease ? Roseola ? Echovirus and adenovirus infxn often produce a rash Epstein Barr virus:? Primary HIV infection?

Shingles (varicella zoster): pain, tingling, then blisters on the dermatome. Fever, headache, chills, upset stomach Fifth disease (erythema infectiosum, parvovirus): rash, fever, headache, slapped cheek appearance on face, then a “lacy” rash on extremities. Severe congenital infection Roseola (erythema subitem, human herpes virus 6): 6th dz. High fever followed by a rash that appears on trunk, limbs, neck and face. Pink or rose colored, has fairly small sores that are slightly raised Echovirus and adenovirus infxn often produce a rash Epstein Barr virus: fever, sore throat, swollen lymph glands; swollen spleen or liver involvement. Can look like strep throat Primary HIV infection (often associated w/ a rash): body-wide S/Sx: fever, sore throat, headache, muscle/joint pain lasting approximately 2 weeks

viruses that produce rashes continued: Shingles ? Fifth disease ? Roseola ? Echovirus and adenovirus infxn often produce a rash Epstein Barr virus:? Primary HIV infection?

Shingles (varicella zoster): pain, tingling, then blisters on the dermatome. Fever, headache, chills, upset stomach Fifth disease (erythema infectiosum, parvovirus): rash, fever, headache, slapped cheek appearance on face, then a “lacy” rash on extremities. Severe congenital infection Roseola (erythema subitem, human herpes virus 6): 6th dz. High fever followed by a rash that appears on trunk, limbs, neck and face. Pink or rose colored, has fairly small sores that are slightly raised Echovirus and adenovirus infxn often produce a rash Epstein Barr virus: fever, sore throat, swollen lymph glands; swollen spleen or liver involvement. Can look like strep throat Primary HIV infection (often associated w/ a rash): body-wide S/Sx: fever, sore throat, headache, muscle/joint pain lasting approximately 2 weeks

Pages 12 - 21 Flashcards by Cal Schiller

 Varicella vs Variola
• Severity and location of lesions
o VZV – ?S P - ?

• Types of lesions
o VZV – ? SP – ?

• Timing of transmission
o VZV – contagious___ pox appear, SP – contagious ___ pox appear

• Severity and location of lesions
o VZV – trunk, SP - extremities
• Types of lesions
o VZV – combination scabs, vesicles, pustules, SP – synchronous lesions
• Timing of transmission
o VZV – contagious before pox appear, SP – contagious after pox appear

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 Varicella vs Variola
• Severity and location of lesions
o VZV – ?S P - ?

• Types of lesions
o VZV – ? SP – ?

• Timing of transmission
o VZV – contagious___ pox appear, SP – contagious ___ pox appear

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Rubeola vs Rubella

RubeOla - last Over 3 days, fever Over 101, cOugh, cOryza, or cOnjunctivitis, kOplik spOts

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viruses that produce rashes continued:

Shingles ?
Fifth disease ?
Roseola ?
Echovirus and adenovirus infxn often produce a rash
Epstein Barr virus:?
Primary HIV infection?

Shingles (varicella zoster): pain, tingling, then blisters on the dermatome. Fever, headache, chills, upset stomach
Fifth disease (erythema infectiosum, parvovirus): rash, fever, headache, slapped cheek appearance on face, then a “lacy” rash on extremities. Severe congenital infection
Roseola (erythema subitem, human herpes virus 6): 6th dz. High fever followed by a rash that appears on trunk, limbs, neck and face. Pink or rose colored, has fairly small sores that are slightly raised
Echovirus and adenovirus infxn often produce a rash
Epstein Barr virus: fever, sore throat, swollen lymph glands; swollen spleen or liver involvement. Can look like strep throat
Primary HIV infection (often associated w/ a rash): body-wide S/Sx: fever, sore throat, headache, muscle/joint pain lasting approximately 2 weeks

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viruses that produce rashes continued:

Shingles ?
Fifth disease ?
Roseola ?
Echovirus and adenovirus infxn often produce a rash
Epstein Barr virus:?
Primary HIV infection?

Shingles (varicella zoster): pain, tingling, then blisters on the dermatome. Fever, headache, chills, upset stomach
Fifth disease (erythema infectiosum, parvovirus): rash, fever, headache, slapped cheek appearance on face, then a “lacy” rash on extremities. Severe congenital infection
Roseola (erythema subitem, human herpes virus 6): 6th dz. High fever followed by a rash that appears on trunk, limbs, neck and face. Pink or rose colored, has fairly small sores that are slightly raised
Echovirus and adenovirus infxn often produce a rash
Epstein Barr virus: fever, sore throat, swollen lymph glands; swollen spleen or liver involvement. Can look like strep throat
Primary HIV infection (often associated w/ a rash): body-wide S/Sx: fever, sore throat, headache, muscle/joint pain lasting approximately 2 weeks

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there is a TB question

GO LOOK AT TB STUFF NERD!

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invasion of the synovial membrane enveloping the joint space by microorganisms. Infection occurs by direct penetration, extension from an existing infection, or hematogenous spread from a focus elsewhere in the body. Three main types: gonococcal, non-gonoccocal, artificial joint.

o Infectious arthritis:

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o Infectious arthritis:

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young adults, asymptomatic infection, typically in the wrist, fingers, ankles, and toes. More than one joint may be affected

 Gonococcal (purulent) arthritis BENIGN:

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classical presentation includes recent onset of fever, malaise, and local findings of pain, warmth, swelling, and decreased range of motion in the involved joint (knee, hip, shoulder, or ankle). Acute: children/young adults. Chronic: underlying diseases – rheumatoid arthritis, prosthetic joints or immunosuppression (slow onset, gradual swelling, warmth. Typical agents: mycobacterium, fungi, B burgdorferi-Lyme)

 Non-gonoccocal (septic) arthritis DESTRUCTIVE:

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acute or chronic. Surgical site infection. Common organisms: Staph epidermidis, S aureus. Fever, chills, severe pain in affect joint, especially w/ movement, welling, warmth, erythematous, fatigue, generalized weakness

 Prosthetic infectious (septic) arthritis:

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o Osteomyelitis

Acute or chronic purulent bone infection…. causative agents of each?

Acute: S aureus or strep spp.

Chronic: (diabetic ulcers) Enterobacteriaceae. Prosthetics: S epidermidis

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o Osteomyelitis

Acute or chronic purulent bone infection…. causative agents of each?

Acute: S aureus or strep spp.

Chronic: (diabetic ulcers) Enterobacteriaceae. Prosthetics: S epidermidis

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o Osteomyelitis

 Sx: ?
 Labs: ?

 Sx: bone pain, fever, general discomfort, uneasiness, or ill-feeling (malaise), local swelling, redness, warmth, reduction in extremity use. Other sx: chills, excessive sweating, low back pain, swelling of the ankles/feet/legs

 Labs: blood cultures, bone biopsy, CBC, CRP, ESR, needle aspiration

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o Osteomyelitis

 Sx: ?
 Labs: ?

 Labs: blood cultures, bone biopsy, CBC, CRP, ESR, needle aspiration

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Intraerythrocytic asexual stages in all species of malaria?

 P falciparum- infect RBCs any age
 P malariae- usually infects older RBCs
 P vivax/ovale - infect only young RBCs, which expand with the growth of the organism

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o TWO IMPORTANT ITEMS when dx malaria?

o TWO IMPORTANT ITEMS – travel history and periodicity of fever spikes

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o Three distinct stages of malaria (time and name of stage)?

o Three distinct stages: lasts 4-8 hours

 Cold stage: feeling of intense cold, despite a fever. Vigorous shivering. Lasts 15-60 minutes

 Hot stage: intense heat, dry burning skin, throbbing headache, lasts 2-6 hours

 Sweating stage: profuse sweating, declining temperature, exhausted and weak –> sleep. Lasts 2-4 hours

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A type of malaria:

 Clinical manifestation: continual fevers, irregular spikes, often misdiagnosed

 Cerebral malaria – CNS changes, respiratory distress, bleeding, circulatory collapse, fatigue, malaise

 Hepatic malaria – hyperbilirubinemia, jaundice. Blackwater fever.

 Medical emergency, high mortality, low parasitemia. Fatality, microvascular obstruction, hemolysis, multiorgan system failure

falciparum malaria

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A type of malaria:

 Clinical manifestation: continual fevers, irregular spikes, often misdiagnosed

 Cerebral malaria – CNS changes, respiratory distress, bleeding, circulatory collapse, fatigue, malaise

 Hepatic malaria – hyperbilirubinemia, jaundice. Blackwater fever.

 Medical emergency, high mortality, low parasitemia. Fatality, microvascular obstruction, hemolysis, multiorgan system failure

. falciparum malaria

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• Blood film exam (gold standard)

o Thick smear – gold standard fror ___ detection
o Thin smear – gold standard for _____
o Single set of negatives does not exclude ____
o Additional specimens at __ hour intervals for __ hours

• Blood film exam (gold standard)
o Thick smear – gold standard fror parasite detection
o Thin smear – gold standard for speciation
o Single set of negatives does not exclude malaria
o Additional specimens at 12 hour intervals for 36 hours

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Diagnosing malaria is considered an emergency and is thus ordered as a STAT test. The GOLD standard for identification of malaria cases as well as speciation is done by blood films. Rapid antigen tests are also available and can be used in addition to the blood films for diagnosis. We stain with Giemsa stain and look at both thick and thin smears. The thick smear is basically a drop of blood on the slide that has dried, so if parasites are present, it will be easiest to see anything on this smear, because of the concentrated area. The thin smear is basically spreading out that droplet and looking at the “feathered edge” of the blood in order to see individual RBCs and identify the species of parasite by the structures.

THANKS for the knowledge homie

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THANKS for the knowledge homie

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Malaria blood films

• If there is a positive result, we’ll note the level of parasitemia (i.e. how severe is the infection), and then you will want to submit additional specimens following treatment to determine if it is effective. Theoretically, a patient responding to therapy will have a

reduced level of parasitemia over time.

DUH

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Signs of malaria?

 Signs: during PE, enlarged liver/spleen. Malaria blood smears taken at 6-12 hour intervals confirm the diagnosis. Best if taken after fever spike. Differentiation based on morphology and timing of fevers.

Signs of malaria?

Meningitis question: by age groups

write it out on your white board elderly vs adults vs children vs neonates

Meningitis question: by age groups

write it out on your white board elderly vs adults vs children vs neonates

o Normal oropharyngeal flora?

 Viridans streptococci, B-hemolytic streptococci, Staph aureus, H. influenzae, Strep pneumoniae, Moraxella catarrhalis, anaerobic bacteria, yeast

 External nares: cultured to identify carriers of

Staph aureus (MRSA)

 External nares: cultured to identify carriers of

Staph aureus (MRSA)

o The common cold: rhinovirus, coronavirus, adenovirus s/s?

• Sneezing, watery eyes, nasal congestion, discharge, sore throat, cough, low grade fever, HA, malaise. Clinical diagnosis.

• Fever, headache, fatigue, dry cough, sore throat, runny or stuffy nose, muscle aches. Influenza A/B most common. Mortality attributed to flu (bacterial pneumonia, viral superinfection)

o Influenza: orthomyxovirus

o Influenza: orthomyxovirus testing?

• Testing: Pts at high risk for complications, immunocompromised. Test to confirm a diagnosis (seasonal begin/end), infection control, community surveillance. Gold standard: viral culture b/c cheap and confirms screening test. Recommended test: PCR

o Bacterial vs Viral Pharyngitis examples of bacterial? ages effected?

* Group A strep: M/C Pneumoniae, N gonorrhea, C diptheriae, A haemolyticum. Sx: swollen uvula, whitish spots, red swollen tonsils, throat redness, gray furry tongue * Age: younger kids. Sudden onset, headache, vomiting, high fever

o Bacterial vs Viral Pharyngitis examples of viral?

• MORE COMMON: Adenovirus, EBV, Herpes simplex, cytomegalovirus. Sx: red swollen tonsils, throat redness, white exudates, cervical lymphadenopathy. Coxsackievirus, pharyngitis w/ vesicles (herpetic) in the posterior pharynx

Viral Pharyngitis conjunctivitis + pharyngitis (pharyngoconjunctival fever)

Adenovirus:

Viral Pharyngitis vesicular lesions (herpangina). In older patients, pharyngitis may be indistinguishable from GABHS infection

o Herpes simplex:

Viral Pharyngitis like herpes, whitish and nodular vesicles in oropharynx

o Coxsackieviruses:

Viral Pharyngitis infectious mononucleosis, looks like GAS infection. Exudative pharyngitis is prominent. Retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear

o EBV:

Viral Pharyngitis like mono. Patients are older, sexually active, have higher fever and more malaise. Pharyngitis may not be a prominent complaint

o CMV:

Viral Pharyngitis like mono, pharyngeal edema and erythema, common aphthous ulcers. Fever, myalgia, and lymphadenopathy are also found, initial infection noticed

o HIG-1:

Viral Pharyngitis o TWO VIRAL AGENTS THAT GIVE APPEARANCE OF STREP:

EBV and HIV

Viral Pharyngitis common ages?

• Age: young adults. Slow progression, coughing, rhinorrhea, low grade fever, conjunctivitis (adenovirus)

* Abrupt onset of sore throat, increase fever, malaise, and headache * Pharynx and tonsils can appear erythematous with exudate and swollen tender lymphadenopathy * Sequelae: scarlet fever, rheumatic fever (cardiac complications, arthritis, rash), glomerulonephritis (kidney fxn)

Streptococcal pharyngitis | • Strep pyogenes (GAS)

o Scarlet fever: incubation period 1-2 days. Begins with fever and sore throat; might also exhibit chills, vomiting, abdominal pain. “Strawberry tongue” due to exotoxins. Abx treatment o Acute glomerulonephritis: 10-14 days after strep infxn; associated w/ fluid retention, hypertension and edema, usually remits spontaneously Common Sx: blood in the urine, foamy urine, swelling of the face, eyes, ankles, feet, legs, or abdomen o Rheumatic fever: inflammatory dz that can affect the heart, joints, skin, and brain. Affects children ages 6-15, occurring about 20 days after strep throat or scarlet fever. Common Sx: polyarthritis, carditis, nodules under skin, rapid/jerky movements, skin rash

Streptococcal pharyngitis | • Strep pyogenes (GAS)

• Centor criteria (UK guideline)?

strep pharyngitis tonsillar exudates, tender anterior cervical adenopathy, fever by history, absent of cough. 2 or less symptoms, do NOT treat or test. 3 or more symptoms, treat

 Pharyngitis by other that GAS bacteria: in young adults, presents with headache, pharyngitis, and lower respiratory symptoms. Approximately 75% of patients have a cough, which is distinctive from GAS infection

• Mycoplasma pneumonia:

 Pharyngitis by other that GAS bacteria: clinical picture similar to M pneumoniae. Pharyngitis usually precedes the pulmonary infection by about 1-3 weeks

• Chlamydia pneumoniae:

 Pharyngitis by other that GAS bacteria: think genitals in the mouth, but not clams

• N gonorrhoeae: rare cause

 Pharyngitis by other that GAS bacteria: foul-smelling gray-white pharyngeal membrane, may result in airway obstruction

• Corynebacterium diphtheriae:

 Pharyngitis by other that GAS bacteria: presents similarly to GAS and appears identical on culture plate, gram stain resembles Corynebacterium

• Arcanobacterium haemolyticum:

 Diagnostic testing • Streptococcal pharyngitis o ___ __ test (70-90%). Screening – 30 min • ______ (gold standard). Confirmatory – 24 hrs, follow up a negative rapid Ag test result * ___ – > 24 hrs. Antistreptolysin O (ASO) and anti-deoxyribonuclease B (Dnase B) to diagnose acute rheumatic fever (ARF) * ___ pharyngitis – typically more symptoms than GAS. Monospot. Heterophile antibody

 Diagnostic testing • Streptococcal pharyngitis o Rapid antigen test (70-90%). Screening – 30 min * Throat culture (gold standard). Confirmatory – 24 hrs, follow up a negative rapid Ag test result * Serology – > 24 hrs. Antistreptolysin O (ASO) and anti-deoxyribonuclease B (Dnase B) to diagnose acute rheumatic fever (ARF) * EBV pharyngitis – typically more symptoms than GAS. Monospot. Heterophile antibody

 Parainfluenza virus. Common illness in young children (3 months – 5 years, usually < 2)  Sx: variable fever, inspiratory stridor. Barking, non-productive cough. Sx worse at night (5-6 nights). Increasing or persistent breathing difficulty, fatigue, bluish coloration of the skin, or dehydration indicates the need for medical attention  Clinical diagnosis. ????

o Croup – laryngotracheobronchitis Nasal wash submitted for viral culture or PCR

Nasal wash submitted for viral culture or PCR

o Croup – laryngotracheobronchitis

 “Thumb” sign. Infxn of the epiglottis and soft tissues above the vocal cords. Cartilage inflammation that covers the trachea  Sx: high fever, sore throat. The 3 “D’s” – dysphagia, drooling, distress. Notable choking sensation, distressed during inspiration, anxiousness, restlessness, and irritability. Muffled speech “hot potato” voice. Tripod posture. pathogen and what is causes?

o Epiglotitis  Haemophilus influenzae type B

o Epiglotitis  Haemophilus influenzae type B lab instructions?

 Potentially life-threatening dz (respiratory distress). CBC, blood culture, and epiglottal culture after airway restoration. Alert the lab – requires specialized media for growth

 Corynebacterium diphtheriae – toxin producing strain  Hallmark feature: thick pseudo-membrane (gray to black, tough, fiber-like) that can cover the tonsils, uvula, and palate  Sx: sudden onset with malaise, sore throat, exudative pharyngitis, and a low-grade fever, swollen cervical lymph nodes – bull neck appearance. May also produce skin lesions  Complications from severe diseases include breathing obstruction, cardiac arrhythmia, and coma (paroxysmal stage). Treat w/ antitoxin before confirmation  Spreads through respiratory droplets or contaminated objects or food (milk)  Preventable: DPT vaccine  how do we test?

o Diphtheria Positive culture + toxin assay. Alert the lab – requires specialized media for growth

 Sx: develop after 7-10 day incubation. Starts out like a cold, developing severe coughing bouts (paroxysms), cough ends with a “whoop” noise: whooping cough. May occur 40-50 times daily and are frequently terminated w/ vomiting and exhaustion  Most infectious during catarrhal stage. Adults are main carriers – chronic cough pathogen and lab process?

o Pertussis  Bordetella pertussis, B. parapertussis  Alert the lab – requires specialized media for growth

stages of pertussis?

catarrhal stage: common cold s/s and low grade fever paroxysmal stage: whooping cough and mucous production convalescent stage: paroxysms less, but can have complications

o Otitis media bacterial and viral causes?

 Bacterial: S pneumoniae, M catarrhalis, H influenza, P. auruginosa  Viral: RSV, picornavirus  Viral can lead to bacterial in very short time  Infection or inflammation of the middle ear causing “earache”. Almost always accompanied by a viral upper respiratory infection  Acute infections are mostly caused by respiratory viruses as well as certain bacteria  Some children may average 5-6 incfections/year  There are 3 different forms of otitis media, but just understand that this is an ear infection that is commonly caused by bacteria and almost always follows an initial cold-like illness (runny nose).  Place drainage tubes (myringotomy)

 S aureus, GAS can cause furunculosis. Swimmer’s ear: P aeruginosa, Aspergillus. Malignant OE severe necrotizing P aeruginosa infection. Trauma by Q-tip  Infection or inflammation of the external auditory canal  Sx: localized pain and itching

o Otitis externa

o Sinusitis  Infection or inflammation of the sinus ostia, typically follows a ___  Viral or bacterial origins – difficult to distinguish clinically • Yellow/green snot does NOT always indicate bacterial cause

URI

sinusitis bacterial vs viral vs fungal?

 Viral – rapid onset, self limiting  Bacterial – may follow viral infection, gradual onset, last longer (> 7 days), worsen with time, and may become chronic • Sx – nasal congestion, sore throat, post-nasal drip, headache, cough, fever, bad breath, purulent nasal secretions, and maxillary facial or tooth pain  Fungal – notable in chronic sinusitis, invasive in immune suppressed individuals (Rhinocerebral mucormycosis)

 Inflammation of the main air passages to the lungs. AKA “chest cold”. Generally preceded by URI (flu, cold, respiratory viruse).  Acute form: rapid onset, recovery within 7-10 days.  Chronic form: lasts at least 3 months

o Bronchitis  Inflammation of the main air passages to the lungs. AKA “chest cold”. Generally preceded by URI (flu, cold, respiratory viruse).  Acute form: rapid onset, recovery within 7-10 days.  Chronic form: lasts at least 3 months

 Destruction and widening of the large airways. Recurrent inflammation or infection of the airways. Usually begins in childhood after infection or inhaling a foreign object  Congenital. Cystic fibrosis: Burkholderia cepacian, S aureus, P aeuginosa (mucoid)  Acquired: COPD/smoking  Specimen: sputum for culture

o Bronchiectasis

how do we test for bronchiectasis?

sputum for culture

how do we test for bronchiolitis?

nasal wash - rapid Ag, culture, PCR

 Swelling and mucus buildup in the bronchioles  Sx: bluish skin (cyanosis). Cough, wheezing, SOB, or difficulty breathing. Fever, intercostal retractions, nasal flaring in infants, rapid breathing (tachypnea)  Respiratory syncytial virus (RSV): adenovirus, influenza, PIV. Transmitted by direct contact w/ nasal fluids or airbone droplets  Seasonal disease: fall and winter months  Mainly affects children < 2 years. 3-6 months peak  Also seen in elderly populations (long term care)  Nasal wash – rapid Ag, culture, PCR

o Bronchiolitis

 Sx: high fever, chills, clamminess, blueness, headache, loss of appetite, mood swings, low BP, tachycardia, N/V, pain, fatigue, aches, cough w/ sputum or phlegm, shortness of breath, pleuritic chest pain, hemoptysis

o Pneumonia

CAP children and young adults?

 Community acquired • Children. Mainly viral 80%, difficult to determine cause. RSV, metapneumovirus, parainfluenza, influenza, adenovirus, H influenzae, S pneumoniae, S aureus • Young aduls: influenza, M pneumoniae, C pneumoniae

CAP in adults when do we do a bacterial or viral culture?

* Adults: mainly bacterial but also viral and fungal. S pneumonia, S aureus (follows flu virus), K pneumoniae (alcoholics – aspiration), A baumanii (wounded SM), L pneumophila, Mycobacterium tuberculosis, mixed anaerobes (poor dentition), influenza, Histoplasma capsulatum, C immitis, and C neoformans * Bacterial or viral culture is warranted IF the patient requires hospitalization

3 types of pneumonia ?

Community acquired (CAP) Nosocomial Immunocompromised

* Bacteria: E coli, multidrug resistant Acinetobacter baumanii and Pseudomonas aeruginosa, methicillin resistant S aureus (MRSA), legionella pneumophila, and Mycobacterium tuberculosis * Fungi: candida and Aspergillus species * Viruses: influenza and RSV * CBC – leukocytosis * Acquired ruing hospital or care facility stay or treatment. Chest radiography shows segmental or lobar infiltrates. Blood cultures should be done in all patients with acute pneumonia. Sputum should be cultured as well. Potentially rapid Ag testing

 Nosocomial

 Nosocomial pneumonia... what are we doing diagnositlcally?

* CBC – leukocytosis * Acquired ruing hospital or care facility stay or treatment. Chest radiography shows segmental or lobar infiltrates. Blood cultures should be done in all patients with acute pneumonia. Sputum should be cultured as well. Potentially rapid Ag testing

• Can be infected by true and opportunistic pathogens. • HIV patients o Pneumocystis carinii, S pneumoniae, MDR mycobacterium tuberculosis, aspergillus, cryptococcus, capnocytophaga • Solid organ transplant recipients o CMV, HSV, L pneumophila, P carinii, and nocardia spp

 Immunocompromised pneumonia

• Diagnosed based on known patient features + manifestations • Typical (bacterial) o Abrupt onset. High fever and shaking chills. Production of yellow/brown sputum when coughing. Chest pain, which is usually worse with breathing or coughing. SOB, especially w/ chronic lung conditions such as asthma or emphysema

 Immunocompromised pneumonia

Gradual onset, usually follows another illness in the days to weeks before the pneumonia. Fever is usually lower and shaking chills are less likely. HA, body aches, and joint pain. Coughing may be dry or produce only a little sputum. Slight/no chest pain, abdominal pain may be present. Malaise and myalgia. Mycoplasma pneumoniae

Immunocompromised • Atypical (bacterial, viral, fungal, parasitic)1`

```  Fungal pneumonia • Endemic fungal pathogens: ? • Opportunistic fungal organism: ? • Sx: ? • CBC count w/ differential. ? ``` Culture: blood and sputum. Antigen detection assays, PCR, serology

 Fungal pneumonia • Endemic fungal pathogens: Histoplasma capsulatum, coccidioides immitis, Blastomyces dermatitidis, cause infection inboth healthy and immunocompromised hosts (dimorphic fungi) • Opportunistic fungal organism: candida species, aspergillus species, mucor species, cryptococcus neoformans tend to cause pneumonia in patients with congenital or acquired defects in their host defenses • Sx: fever, dry cough, pleuritic chest pain, dyspnea, obstructive sx, hemoptysis, hx of travel to or exposure • CBC count w/ differential. Elevated WBC count w/ endemic mycoses. Eosinophilia may denote Coccidioides. Neutropenic or leukopenic patients may be infected with candida or aspergillus. Direct examination KOH prep (look for fungal hyphae or yeasts). Culture: blood and sputum. Antigen detection assays, PCR, serology

fungal pneumonia... how do we test?

Culture: blood and sputum. Antigen detection assays, PCR, serology

• Influenza virus, RSV, adenovirus, and parainfluenza virus (PIV). Less common: human metapneumovirus, coronavirus (SARS). Pneumonia + rash: measles, varicella zoster (chicken pox). Immunocompromised: CMV, herpes simplex. Zoonotic: hantavirus, avian influenza, swine flu • Sx: fever, chills, nonproductive cough, rhinitis, myalgias, headaches, and fatigue

 Viral pneumonia

* Sx: fever, night sweats, weight loss, hemoptysis * Transmitted through air: infected person coughs, sneezes, or talks. Infected person coughs, sneezes, or talks. Usually infects the lungs – increasing drug resistance.

 Tuberculosis | • Mycobacterium tuberculosis

* Person-to-person transmission by respiratory droplets. Can be life threatening * High fever, headache, body aches, dry cough, followed by pneumonia

 Severe acute respiratory syndrome: SARS coronavirus

• Deadly. Lungs fill with fluid. Carried by rodents. Contact w/ infected animal droppings. Adult respiratory stress syndrome. Fatalities in 30-40%

 Hantavirus pulmonary syndrome

 Rare opportunistic infections

Klebsiella pneumoniae, staph A pneumonia, Q fever, legionellosis,, inhalation anthrax

 Rare opportunistic infections • Klebsiella pneumoniae: hospital-acquired – aspirated. At risk: infants, older persons, alcoholics, persons with chronic disease x

• Klebsiella pneumoniae: hospital-acquired – aspirated. At risk: infants, older persons, alcoholics, persons with chronic disease

 Rare opportunistic infections • • follows influenza infection – high mortality rates. Common in immunocompromised individuals. Usually hospitalized and institutional acquired

Staph aureus pneumonia:

 Rare opportunistic infections – gram-positive spore forming coccobacillus. Globally, affects sheep, goats, cattle, dogs, cats, birds, rodents, and ticks. Organism can be excreted in milk, urine, feces

•• Q fever: zoonotic Coxiella burnettii

 Rare opportunistic infections L pneumophilia. Found in water sources. Inhalation of water mist. Watery secretions – not viscous like other bacterial agents. Affects immunocompromised (smokers, COPD)

•• Legionellosis:

 Rare opportunistic infections – gram-positive, spor forming, facultative anaerobe. Widened mediastinum. Infection: through skin, inhalation, ingestion. Once spores germinate – release of toxin. Causes internal bleeding, swelling, tissue necrosis.

•• Inhalation anthrax: bacillus anthracis

 Necrosis of pulmonary tissues creating cavities > 2 cm caused by infection. Often caused by aspiration (alcoholics). Mainly anaerobes, Klebsiella pneumoniae, S aureus, S pneumoniae.  Sx: cough, fever, night sweats, foul smelling purulent sputum, hemoptysis, chest pain, SOB, lethargy

o Lung abscess

Meningitis onset? preceded by? Adult/kid presentation? newborn/infant presentation?

o Symptoms  Fulminant onset (<24 hrs)  Respiratory illness precede onset  Adults and Children • Classic triad – fever, headache, stiff neck • Other – vomiting, seizures, impaired consciousness  Newborns and Infants • Temperature instability, listlessness, lethargy, irritability, high pitched crying, anorexia, vomiting, diarrhea, respiratory distress, bulging fontanelles, seizures

o Characteristics  S/Sx: Headache, high fever, stiff painful neck, photophobia, nausea and vomiting and deteriorating level of consciousness  Diagnosis: how done and rule out what?  Types: ?

Meningitis  Diagnosis: History and physical, brain imaging to rule out space occupying lesion, lumbar puncture, CSF studies and culture  Types: Bacterial, viral, fungal, parasitic, chronic

 S/Sx: Headache, high fever, stiff painful neck, photophobia, nausea and vomiting and deteriorating level of consciousness Main agents?

o Bacterial meningitis  Bacteria (Big 3) • Streptococcus pneumoniae, Neisseria meningitidis • Haemophilus influenzae type B,  Medical emergency – life threatening

 S/Sx: mild, self limiting. Headache, fever, viral syndrome – malaise, myalgia, upper respiratory symptoms, sore throat, rash – gastroenteritis (enterovirus) AGENTS?

o Viral meningitis Enterovirus, Arbovirus (West Nile Virus, St Louis encephalitis virus), HSV, Adenovirus, HIV, Measles

• Aseptic meningitis o Short history of a flu-like upper respiratory tract infection (cold or runny nose, diarrhea, vomiting) prior to meningitis symptoms, o Occasionally a nondescript, non-blanching maculo-papulo-vesicular rash o Self limiting, symptoms last from 7 to 10 days and the patient recovers completely o Seasonal – summer and fall months. Usually affects infants and children

 Enterovirus meningitis

• S/Sx: Gradual onset headache, fever, stiff painful neck, drowsiness, seizures • Fungi: Cryptococcus, Candida, Aspergillus, dimorphics (Histoplasma, Blastomyces, Coccidioides) • Usually found in an immunocompromised patient o Consider geography and travel history to areas of endemicity o Recreational activities (eg raise pigeons)

 Fungal meningitis

 Parasitic meningitis o S/Sx: ? • Parasites: ?

 Parasitic meningitis o S/Sx: headache, high fever, stiff painful neck, photophobia, nausea and vomiting and deteriorating level of consciousness • Parasites: NAEGLERIA, Acanthamoeba, Taenia, Toxoplasma • Exposure risks o Naegleria – swimming in warm fresh standing water o Taenia – ate parasite eggs o Toxoplasma – ate improperly cooked food, or cleaned litter box

• S/Sx: Headache, fever, meningismus, confusion, hydrocephalus • Diagnosis: S/Sx are often non-specific. Suspected in chronic encephalopathy, or hydrocephalus. o MRI or CT of head may show hydrocephalus or contrast enhancement of the basal meninges. o Lumbar puncture • Organisms ?

 Chronic meningitis slow growing organisms o Cryptococcus neoformans (common!) , HIV, M. tuberculosis, M. avium, T. pallidum, Nocardia sp., Candida sp., Aspergillus sp. ,Taenia solium (cysticercosis), Brucellosis, Toxoplasma gondii

``` o CSF profile. Collect 4 tubes of CSF, 1 or 2 ml each of fluid  Standard tests include: • Tube #1: ? • Tube #2: ? • Tube #3: ? • Tube #4: ? ```

* Tube #1: glucose and protein * Tube #2: cryptococcal antigen, Gram stain, cultures (Micro) * Tube #3: hematology, cell count and differential * Tube #4: immunology, serology * Color/Clarity

explain the difference between bacterial meningitis, sub hemorrhage, and traumatic tap for CSF tube draws?

o Turbidity - bloody or cloudy.  Bacterial meningitis thick cloudy fluid, usually implying a high cell count  Subarachnoid hemorrhage the fluid is frankly bloody  Traumatic tap – each successive tube becomes clearer

 ___________ is a yellowish or reddish discoloration of the spinal fluid caused by pigments resulting from breakdown of red blood cells.  Fluid centrifuged to sediment out cells. In severe cases, the spun fluid may look like cherry "Kool-Aid".

Xanthochromia

tell me about glucose in CSF conditions ex viral vs bacterial meningitis

o Glucose: CSF glucose is normally 2/3 that of the serum.  Glucose is normal in viral meningitis, and may be normal in chronic meningitis, but is often very low in acute bacterial meningitis.

protein in CSF conditions?

o Protein: Very high in bacterial meningitis, moderately elevated in viral meningitis