Disease

Pathogen

Characteristics / Virulence

Clinical 1-2 month incubation; majority of infections are probably subclinical polyclonal B cell proliferation & activation (causes CMI T cell response "Downey" cells) mono: 3-5d prodrome; sore throat & palatal enanthem on palate, symmetrical lymphadenopathy, fever, splenomegaly, increased liver enzymes adult: mono-like (heterophile negative) transplacental: major concern when mom has primary infection (often from other child!) transfusion/transplant: reactivation in suppressed host HIV pts: retinitis, GI, CNS, penumonia acute infection of salivary glands, fever, vomiting, h/a, sequelae (orchitis in adults) mild acute hepatitis w/ abrupt onset (symptomatic ~4wks); prodrome followed by jaundice, icterus, dark urine, colorless stool (viral shedding prior to prodrome symptom onset) acute: hepatic inflammation, fever, nausea, RUQ pain, jaundice, dark urine, pale stool (recovery >90%) progressive (<0.5%): rapid liver necrosis chronic (<5%): prolonged, persistent infection -> cirrhosis, carcinoma (vDNA in host genome?) acute: insidious onset (like HAV/HBV) 85% become chronic chronic: similar to HBV (20% cirrhosis, 6% liver failure)

Diagnosis atypical lymphs (Downey cells) heterophile antibodies (+monospot test) serology: IgG antivirus Ab's are permanent (best infants, children) giant cells w/ "owl eye" inclusions TORCH series (newborns) serology & culture febrile child w/ bilateral parotitis

Treatment symptomatic steroids (?) ampicillin = rash cyclosporin A = non-hodgkin's lymphoma

Notes

Infectious Mononucleosis ("Glandular Fever")

EBV

gamma-herpesvirus; enveloped; dsDNA; Bcell permanent latency (10 genes still expressed) person-to-person transmission ("kissing disease") - sexual possible

associated w/ Burkitt's lymphoma (c-MYC dysregulation) & other malignancies peak ages: 17-25yo in USA

beta-herpesvirus; replicates in vivo in epithelial cells CMV person-to-person transmission (transplant organs) paramyxovirus, -ssRNA, enveloped, H&N aerosol transmission (highly communicable)

"troll of transplantion"

Mumps

Mumps virus

prevention: MMR IVIG (within 2 wks of exposure) vaccine: children >12m or at risk adults fulminant: liver transplant chronic: many drugs available vaccine & HBIG for prevention parenteral transmission; adults most common; most common cause of need for liver transplant 1a&1b most common in US parenteral transmission; all ages affected (children more mild & chronic)

Hep A (Infectious)

HAV

picornavirus; ssRNA; capsid; replication in cytoplasm; virion release via exocytosis

serology: anti-HAV (initial IgM, then IgG) elevated AST, ALT serology: acute (anti-HBs "window"), chronic (absence of anti-HBs & late anti-HBe) clinical presentation elevated AST, ALT anti-HCV liver function tests can be erratic (often normal)

fecal-oral transmission; peak incidence teens / young adults

Hep B (Serum)

HBV

hepadnavirus; psDNA (Dane partical); HBcAg (core), HBsAg (surface), HBeAg (e core-like) angtigens; nuclear transcription w/ cytoplasmic assembly, release via exocytosis including excess HBsAg

Hep C (Transfusion Associated)

HCV

flavivirus; (+)ssRNA; glycoproteins bind CD81 on hepatocytes & other cells; cytoplasmic replication; released via exocytosis

abstain from EtOH & toxic drugs transplant

HDV infection increases severity of HBV infections; mimics Hep B presentation Hep D (Delta) HDV circlular (-) ssRNA; enveloped (HBsAg); unusual replication (not tested) coinfection = acute, recovery w/ immunity (90%); superinfection = chronic, risk of fulminant hep & cirrhosis (80%) mimics Hep A presentation

serology same as HBV + HDV antigens & Abs elevated AST, ALT serology: anti-HEV IgM; elevated AST, ALT

HBV tx HBV vaccine is protective

parenteral transmission; HBV infection necessary for infection of HDV

Hep E (Enteric)

HEV

hepevirus; ssRNA; capsid; replication in cytoplasm; release via cell lysis

HEV-specific IgG passive immunizaation

fecal-oral

Lentiviruses: HIV-1, HIV-2

envelope (gp120, gp41), nucleocapsid (enzymes, RNA - genes: gag, pol, env)life cycle: gp120 binds CD4+ lymphs (co-receptor: CXCR4/5) -> fusion -> reverse transcriptase converts RNA to DNA -> integrated into host genome -> translation into 1 polypeptide (cleaved by protease) > budding release

Retroviruses

acute HIV: asymptomatic or flu-like (cytokine release)clinical latency: asymptomatic; replication of HIV, decrease in CD4+ T cellsearly symptomatic HIV: chronic symptoms (fever, night sweats, weight loss, malaise, diarrhea) w/ decreasing T cell countAIDS (HIV+ & 1+ opportunistic infections OR CD4 <200 OR CD4<14%): immunodepression w/ infections & dementia

pt hx & clinical presentationPCR & ELISA for HIV Ab's & viral load

HAART

HIV-1: more serious, worldwideHIV-2: more mild, West Africatransmission: sexual, parenterally, perinatally

usually asymptomatic non-cytolytic Oncoviruses: HTLV infects CD4+ cells, tax gene transactivates genes for IL2 & IL2R -> T cell clonal proliferation can lead to acute T cell leukemias (ATLL) even after long latency: CD4+ malignant hyperproliferation complications: tropical spastic paraparesis, opportunistic infections ELISA: HTLVspecific Ab or antigens elevated WBC, atypical lymphs combo IFNalpha & AZT (ATLL usually fatal) most common US transmission: IVDU & blood transfusions

Dengue Fever

Dengue virus DEN1-4 (Flavivirus)

small (+) enveloped RNA; internalized via endocytosis; replication in cytoplasm of phagocytic cells Ab's enhance viral infectivity

dengue fever (DF): acute infection w/ rash followed by secondary maculopapular rash w/ desquamation; resolves in 2wks dengue hemorragic fever (DHF): upon secondary infection of different strain -> hypersensitivity reaction; thrombocytopenia, petechiae, purpura, increased Hct due to plasma loss, shock

supportive care ribavirin epidemiology & geographic distribution serology & labs control of vector population, patient isolation, vaccination (yellow fever)

worldwide no cross immunity of strains; children affected most frequently primary vector: mosquito natural reservoir: monkey

Africa, Central America, South America Yellow fever virus Dakar & 17D (Flavivirus) yellow fever: acute phase: non-specific S/S for 3-4d toxic phase (15%): jaundic, GI hemorrhage (black vomit), & widespread damage primary vector: mosquito natural host: monkey children have more mild infection Eastern & Southern Africa host: livestock vector: mosquito Asia & Europe reservoir: striped field mouse SE Europe, Asia, Africa vector & reservoir (transovarial transmission): tick Nigeria, W Africa natural host: multimammate rat transmission to humans via contaminated water or direct contact endemic to Africa natural host: fruit bats (not confirmed transmission unknown

Yellow Fever

Rift Valley Fever Korean Hemorrhagic Fever Crimean-Congo Hemorrhagic Fever

phlebovirus (bunyaviridae) hantaan virus (hantavirus, bunyaviridae) nairovirus (bunyaviridae) larger (-) RNA, enveloped, segmented genome; replication in cytoplasm; released via exocytosis or lysis

asymptomatic/mild; can progress to hemorrhage & shock, encephalitis, blindness non-specific S/S; inflammation of retina/blindness (<10%) abrupt onset non-specific S/S followed by bleeding from mucous membranes & skin, pulmonary edema & shock

Lassa Fever

Lassa fever virus (arenaviridae)

large circular enveloped ssRNA (L&S); ribosomes in envelope; replication in cytoplasm; release via budding

long incubation, slow onset non-specific S/S w/ rash; progression to necrosis of multiple organs; deafness common in survivors non-specific S/S followed by rash, then severe to fatal hemorrhagic fever, DIC, edema, shock virus replicates rapidly, causing extensive tissue necrosis; viremia persists throught acute infection benign tertian malaria: 9-15d incubation fever paroxysms every 48hrs (2-6hrs), shaking chills 10-15min, sweating, anemia, h/a, myalgia, n/v, diarrhea, cough relapsing (up to 5yrs) is linked to hypnozoite in liver

Marburg virus (filoviridae) Ebola virus (filoviridae)

filamentous pleomorphic (-) enveloped ssRNA; replication in cytoplasm; released via budding

Malaria

Plasmodium vivax

1) sporozoite: infective stage, migrates to liver, 2) merozoites erupt from hepatoctyes & infect RBCs ("ring stage"), 3) trophozoite develops, lyses RBC upon exit vector: anopheline mosquito (night feeder) host resistance: sickle cell anemia

infected RBCs are enlarged w/ Schuffner's dots, Giemsa stain +

oral chloroquine, IV quinidine primaquine targets hepatic stages

young RBCs are most susceptible rarely fatal

(heterozygotes), duffy antigen (reduction of IL8R - blocks invasion) Plasmodium falciparum

malignant tertian malaria: fever paroxysms (longer febrile period, shorter intervals), chills, anemia blackwater fever (free Hgb in urine), capillary obstruction (cerebral malaria), algid malaria (cold skin c high visceral temp) quartan malaira: fever paroxysms (every 72hr, last 6hrs) fever paroxysms (every 48hrs) fever paroxysms (every 24hrs) intraerythrocytic, malaria-like parasite: fever, chills, h/a, myalgia asymptomatic or flu-like in immunocompetent hosts congenital infections: worst in 1st trimester, chorioretinitis, hydrocephaly, microcephaly, spontaneous abortion chronic ASS: trypanosomal chancre/sore, parasitemia, lymphadenitis, fever, somnolence, CNS invasion = death acute ASS: trypanosomal sore, parasitemia, lymphadenitis, encephalomyelitis, no somnolence (death before CNS invasion) acute: children <5yo, mild S/S w/ Romana's sign (swelling of eyelid) chronic: adults (silent for decades), cardiac (cardiomyopathy) & GI (megacolon) complications, nerve cell necrosis

often double or multiple small ring stages, no schuffner's dots

all RBCs are invaded this is the deadly form!

Plasmodium malariae Plasmodium ovale Plasmodium knowlesi Nantucket Island Fever (Babesiosis) Babesia microti vector: deer tick

basket & band form trophozoites

infect older RBCs West coast Africa

basket & band form trophozoitse "maltese cross" is diagnositic (but not always seen) clindamycin + quinine only tx symptomatic pts pyrimethamine + sulfadiazine New England region

Toxoplasmosis

Toxoplasma gondii

infective stage: eat zoitocyst (bradyzoite) in meat, or oocyst (cat feces) tachyzoites target parenchymal cells & RES system

trophozoites in tissue bx & serology

pregnant women & immunodeficient pts

Trypanosoma brucei gambiense African Sleeping Sickness Trypanosoma brucei rhodesiense

amastigote (no flagella), promastigote & trypomastigote (flagella)glycoprotein switching allows for evasionvector: tsetse files (day feeder)

West & Central Africa trypomastigote in blood East & Central Africa

Chagas Disease

Trypanosoma cruzi

infective stage: metacyclic trypomastigote vector: reduviid (triatmoid, kissing) bug droppings (not bite)

trypomastigote in blood, amastigote (pseudocyst) in tissues xenodiagnosis

nifurtimox or benznidazole (not tested!)

Central & South America

Leishmaniasis

Leishmania tropica, mexicana, braziliensis Leishmania donovani Schistosoma mansoni

infective stage: promastigote vector: sand flies

dermotropic form: cutaneous ulcer at bite site (secondary infections common), spontaneously heals (2m-1yr) w/ scar viscerotropic form: high fever (RES involvement), hepatosplenomegaly

clinical presentation

stibogluconate sodium

L.braziliensis: mucocutaneous form cartilage destruction / necrosis

trematodes (blood flukes) Schistosoma japonicum Schistosomiase s Schistosoma haematobium Schistosoma mekongi Schistosoma intercalatum Cercarial Dermatitis ("Swimmer's Itch") definitive host: waterfowl Schistosoma spp. cercariae seldom go futher than the epidermis intermediate host: snail cercariae penetrate skin -> liver -> mesenteric vv. & bladder vv. -> eggs pass -> larvae penetrate snail -> cercariae release from snail

migratory phase: parasite entry & development/migration; allergic rxn at skin entry site; can develop Katayama syndrome acute phase: worm migration & egg release chronic phase: host response to eggs in tissues (fibrosis of liver, intestine, bladder), granuloma formation

Africa, Middle East, tropical America; mesenteric venules; humans are only reservoir eggs in stool (mansoni & japonicum) eggs in urine (haematobium) Far East; mesenteric venules praziquantel Middle East, Africa; bladder venules; humans are only reservoir Thailand, Laos, Cambodia Central Africa antihistamines for pruritis steroid creams to reduce swelling remove worm a little bit at a time around stick

itching, erythema & maculopapular eruptions at cercariae entry sites; most common on LE

clinical presentation & epidemiology

global distribution associated w/ swimming near shore

Dracunculiasis

Dracunculus medinensis

infective stage: larva (ovoviviparous) in copepod

ingest copepods, larvae emerge in stomach & penetrate GI wall, migrate to skin & exit causing blisters & ulcers filarial fever -> lymphangitis -> lymph stagnation -> elephantiasis lymphedema occurs when lymphatic channels are occluded gross elephantoid tissue is not reversible similar to wuchereriasis

infective stage: filariform larvae Wuchereriasis (Elephantitis) Wuchereria bancrofti vector: night feeding mosquito enters via bite & migrates to peripheral lymphatics Malayan Filariasis Brugia malayi vector: mosquito

diagnostic stage: microfilaria in blood serology & PCR

DOC: diethylecarbamazine mosquito prevention

endemic in Africa, Asia, Brasil

Asia & South Pacific

Onchocerciasis (River Blindness)

infective stage: filariform larvae Onchocerca volvulus intermediate host: black fly Breed in river/streams infective stage: filariform larve

subcutaneous nodules & elephantoid symptoms; invasion of optic n. & retina causes visual impairment & sclerosing keratitis local adult worm migrates through subcutaneous tissues (eye)

Remove nodule, microscope ID

Ivermectin Protect from fly Diethylcarbamazine Surgery

Africa & Ecuador

Loa loa intermediate host: deer fly Dirofilaria immitis (dog heartworm) infective stage: filariform larvae vector: mosquito in dogs- R/pulmonary a.

Africa

Dirofilariasis

in humans the adult worms cause coin lesions (lungs) & nodules in subcutaneous tissue

CXR- COIN LESION like tumor

surgery

Southeast US

SIRS (Systemic Inflammatory Response Syndrome) Sepsis MODS (Multiple Organ Dysfunction Syndrome)

dysregulated host inflammatory responsefever > 100.5F, HR >90, RR >20, high or low WBCs or bands Sepsis: SIRS due to culture-proven or visually identified infection Severe Sepsis: sepsis + hypoperfusion/dysfunction S/S Septic Shock: severe sepsis + systemic BP<60 or maintaining BP requiring drugs altered organ function & homeostasis can't be maintained w/o intervention primary vs. secondary S. aureus Step mutans Group D Strep Group B Strep most common cause subacute disease; common mostly subacute acute in pregnant pts & older pts w/ underlying disease subacute disease most common gram neg isolates from subacute acute; homeless males IVDA subacute 1) Identify agent 2) IV antibiotics (high serum conc.) Duke Criteria 3) Surgical removal of vegetation 4) prophylactic antibiotics

1) resuscitate 2) ID infection & treat 3) maintain organ functions

triggered by a variety of conditions

Acute: invasive bacterial infection; febrile, toxic, days-weeks, normal valves Subacute: less virulent pathogen, only abnormal valves Pathogenesis: 1) nonbacterial thrombotic vegetation, platelet & fibfrin aggregation 2) bacteremia: organism can adhere to damaged area, vegetation breaks off causing emboli & microemboli Clinical: janeway lesions (flat, painless macules), splinter petechiae, glomerulonephritis, Osler's nodes (small red painful nodules), Roth's spots (retina)

Infective Endocarditis

Staph epidermidis HACEK Bartonella Polymicrobial Fungi

Tularemia (Rabbit Fever)

Francisella tularensis tularensis (type A)

small gram neg coccobacillus; intracellular (macrophages) aerobe transmission: 1) tick or deer fly bite, 2) direct contact (rabbit), 3) aerosols, 4) ingestion, 5) animal bite (cat), 6) lab exposure

1) ulceroglandular: via bite; painful papule at entry site, ulcerates after 96hrs, lymphadenopathy 2) pneumonic: via inhalation; necrotizing granulomas, patchy infiltrates on CXR 3) oropharyngeal: via ingestion; GI S/S 4) oculoglandular: autoinoculation of eye 5) typhoidal: systemic illness w/ no anatomic location mild, few complications

reportable disease culture, agglutination test antibiotics

category A biodefense agent; low infectious dose

Brucella abortus Brucella meitensis Brucella suis Brucella canis Bartonella bacilliformis small gram neg coccobacillus, intracellular aerobe transmission: zoonotic (no vector) - ingestion (milk products), direct contact, or inhalation

reportable disease cultures anemia, thromobocytopenia, low to normal WBC antibiotic combos

cattle sheep, goats most common in US swine & rodents dogs, foxes, coyotes host: various animals vector: sandfly host: humans only vector: human body louse

Brucellosis

acute: fever & non-specific S/S chronic: abscesses & granulomas -> GI, arthritis, respiratory chronic, destructive lesions mild, few complications acute: Oroya fever - anemia, nonspecific S/S chronic: Verruga - cutaneous nodules Trench Fever: 5-7d fever, recurs every 4-5d; + non-specific S/S Bacilliary Angiomatosis (also caused by B. henselae) Cat Scratch Disease: via cat bite (or cat flea bite) papule/pustule -> chronic regional lymphadenopathy

Bartonellosis

Bartonella quintana

small gram neg bacillus, intracellular aerobe

clinical presentation & pt history

antibiotic combos

Bartonella henselae

host: cats vector: cat flea children 59yo;reservoir/vector: dog tick (SE & West), wood tick (Rocky Mtns & SW Canada) reservoir: house mouse; vector: mouse mite

Rocky Mtn Spotted Fever

Rickettsia rickettsii

Rickettsiaceae: gram neg, aerobic bacilli, glycocalyx, weak lipid A, phospholipase A, obligate intracellularinfect vascular endothelium

persistent fever >102, intractable frontal H/A, rash begins on wrist/ankles spreading centripetally red papular rash at bite site -> eschar formation -> fever, H/A -> generalized rash (pox-like)

cultureserology: titer >64 for RMSF, >128 for all othersPCR

doxycycline (begin early upon suspicion)

Ricketsial Pox

Rickettsia akari

doxycycline

Epidemic Typhus

Rickettsia prowazekii

Rickettsiaceae: gram neg, aerobic bacilli, glycocalyx, weak lipid A, phospholipase A, obligate intracellularinfect vascular endothelium

fever, intractable H/A, followed by rash beginning on trunk spreading centrifugal (sparing face, palms/soles) Brill-Zinsser disease: recrudescent epidemic typhus

cultureserology: titer >64 for RMSF, >128 for all othersPCR

formalininactivate vaccine

crowding / poor sanitation; reservoir: humans; vector: human body louse (feces in bite wound - lack transovarial transmission) warm & humid areas (urban); reservoir: rat; vector: rat flea (via bite or feces) majority in Asia; reservoir: rodents & mites; vector: chigger mites (via bite) SE & Midwest reservoir: deer, dogs, foxes, coyotes, wolves; vector: Lone Star tick

Murine Endemic Typhus

Rickettsia typhi

mild epidemic typhus S/S

doxycycline

Scrub Typhus

Orientia tsutsugamushi

papular rash that ulcerates at bite site > fever>104F -> severe H/A -> rash on trunk spreading centrifugally

doxycycline

Human Monocytic Ehrlichiosis Canine Granuloctic Ehrlichiosis

Ehrlichia chaffeensis Anaplasmataceae: gram neg, aerobic coccobicilli, slime layer, lack endotoxin & peptidoglycan, obligate intracellular (in vesicles = morulae) infect WBCs

Ehrlichia ewingii

infects monocytes/macrophages; maculopapular rash after prodrome (20%)

detection of morulae PCR, serology

doxycycline

Anaplasmosis

Anaplasma phagocytophilum

infects neutrophils; rash after prodrome (10%) CXR serology: IgM to phase I&II, IgG to phase II (acute) liver granulomas

mostly in dogs; serology crossreactivity w/ E.chaffeensis NE & Midwest reservoir: various small mammals; vector: black-legged tick Worldwide reservoir: animals, ticks, birds transmission: inhalation (most common), ingestion (milk), tick bite (rare)

Q Fever

Coxiella burnetii

Coxiellaceae: pleomorphic gram neg bacillus, weak lipid A, aerobic; SCV vs. LCV; phase variation

acute: not tested chronic: >6 months; subacute endocarditis

doxycycline + antibiotics

week 1: stepwise fever, h/a, rose spots week2: progression; abdominal distension; hepatosplenomegaly; bradycardia & dicrotic pulse week 3: more toxic; typhoid stage (apathy & confusion); risk of intestinal hemorrhage or perforation, toxemia, & myocarditis week 4: slow improvement w/ neuro complications 1) Bubonic Plague: flea bite; sudden onset non-specific S/S -> buboe formation (unilateral) -> if untreated can lead to pneumonia, meningitis, bacteremia 2) Pneumonic Plague: often secondary to bubonic / bacteremia (primary = aerosol droplets); sudden onset dyspnea, cough, sputum; rapidly fatal if untreated 3)Septicemic Plague: NO buboes; febrile & extremely ill -> hypotension, DIC, multiorgan failure Stage 1: Early Infection:erythema migrans rash (bull's eye)Stage 2: Disseminated:lymphohematogenous spread (spirochetemia) -> non-specific S/S w/ secondary erythema migransStage 3: Late Infection:CNS (meningitis, bell's palsy), cardiac (irregular heart beats), & musculoskeletal involvement (arthritis) notify WHO wayson stain bipolar, safety pin antibody titer or immunofluorescence stain to F1 antigen CXR DOC: tetracyclines & sulfonamides respiratory isolation (4872hr) no commercial vax vector: flea; host: rodents infectious dose: 1 native americans at 10x risk cats- aresol!! culture (black on HE agar) most snesitive from bone marrow aspirate serology: typhidot histologic sections begin empirical antibiotic tx followed by susceptibility tests vaccine prior to travel oral-

Typhoid Fever

Salmonella typhii

motile, facultative intracellular anaerobic, gram neg bacilli; nonlactose fermenter; produce H2S; O, Vi, & H antigen; tropism for M cells of terminal ileum

fecal-oral transmission (poor sanitation); large inoculum required (overcome gastric acid)

Plague

Yersinia pestis

non-spore-forming, non-motile, gram neg coccobicillus, intracellular (monocytes); wide temp tolerance; Ca & temp regulated virulence (Yops, V&W antigens, F1 envelope antigen, coagulase), LPS endotoxin

oral doxycycline serology: initial ELISA for antiBorrelia Ab's; then western blot for B.burgdorferi JarischHerxheimer possible vax taken off market

Lyme Disease

Borrelia burgdorferi

motile gram neg spirochete; no LPS; microaerophile; linear chromosome; virulence: OSP, no toxins, peptidoglycan, not cleared readily

New England & Minn/Wisc regionsvector: Ixodes scapularis & pacificus (hard body tick) -bite only once, 48hr feedingreservoir: mouse, chipmunks

SE & S Central US Southern TickAssociated Rash Illness (STARI) Borrelia lonestari similar to Lyme disease vector: Amblyomma americanum (Lone Star tick) - aggressively bite!

much larger (microscopy ID is much easier); cold seasons (crowding) Epidemic Relapsing Fever (LBRF) Borrelia recurrentis 1) Incubation: 6-7d 2) Primary Spirochetemia: acute onset high fever, chills, h/a, arthralgia, hepatosplenomegaly (3-6d) 3) Latent Phase: afebrile, bacteria enter organs (not in blood) to replicate (710d) 4) Secondary Spirochetemia: antigenic shift variation, decrease in duration & severity with each relapse hx, blood ID (not latent phase), culture (BSK) vector: Pediculus humanus (body louse) infection occurs when bite is felt & bug is smashed reservoir: humans vector (&reservoir): Ornithodoros hermsii (soft-bodied tick) reservoir host: rodents (blood & tissues are infectious) west of Miss Riv, MaySept, feed fast & at night 1) Septicemic Stage: 4-7d flu-like, then 1-3d afebrile asymptomatic, then fever recurs 2) Immune Stage: aspetic meningitis, subconjuntival hemorrhage, renal S/S 3) Icteric Stage (Weil Syndrome): jaundic, MODS hx culture (definitive) serology: MAT, IgM ELISA supportive, antibiotics JarischHerxheimer response possible host: renal tubes of mammals (rodents) transmission: contaminated water & vertical tropics, temperate regions (warm & wet)

doxycycline & tetracycline JarischHerxheimer response possible

Endemic Relapsing Fever (TBRF)

Borrelia hermsii (& turicatae)

Leptospirosis

Leptospira interrogans

long & thin, 18+ coils, intracellular, no virulence, hardy/persists outside of host