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Infectious Disease Lecture w/ Dr.

Lichtenberger 3 January 2012


The Topic of This Lecture Is: How to Diferentiate Organisms
The cell wall structure determines whether bacteria stain blue (Gram+) or red (Gram-).
o Gram stains also reveal shape and arrangement, along with the presence of PMs.
o !east can be seen on Gram stains. The"#re cigar-shaped, stain dar$ purple, and
larger than PMs.
To di%erentiate Gram+ bacteria, incubate a culture on bloo agar and con&rm with
chemical tests.
o Staphylococci are catalase positive, such that the" are able to brea$ down
pero'ide.
The onl" strain of Staph that is coagulase positive is S. aureus.
o (ll other Gram+ bacteria are catalase negative. The"#re di%erentiated b" their t"pe
of hemol"sis.
!"hemolysis is a mild amount of hemol"sis. )o not confuse *-hemol"tic with
Group ( Strep.
S. pneumoniae is capsule+ + optochin sensitive, S. viridans are
capsule- and resistant.
o The presence of a capsule is identi&ed b" the #uellung
reaction.
o -ensitivit" to optochin is evaluated via a disc of the antibiotic on
the agar.
o S. pneumoniae form diplococci, S. mutans and other S. viridans
ma$e chains.
(ll *-hemol"tics are bacitracin sensitive. .ecent infections "ield a
positive (-/ titer.
$"hemolysis is complete. /f these Streptococci, onl" S. pyogenes %G&'( is
bacitracin sensitive.
These bacteria are evidenced b" "ellowing of the agar around the cells.
0-hemol"tic Strep reall" li$e to infect infants. S. pyogenes is P!.+ (li$e
nterococci).
The Lance)el classi)cation system for Strep is based on 1
carboh"drate di%erences.
o S. pyogenes is G(-, S. agalactiae is G2-, S. !ovis is G)-. 3now
that for -tep 4.
ote that *"hemolysis is a stupid, awful misnomer. Enterococci do /T
hemol"5e .21s6
To di%erentiate from Strep, grow them on 7.89 a1l. ( Gram stain is
insu:cient.
;nder previous nomenclature, all nterococci were labeled as Group )
Strep.
o The two spore-forming Gram+ organisms are Clostridium and Bacillus. 2oth are
rods.
-pores are resistant to destruction and are seen with a malachite green stain.
o The Gram+ ros we care about are "oryne!acterium (diphtheria, motile) and
Listeria (non-motile).
There is onl" one Gram- coccus< Neisseria. The two strains are di%erentiated b" maltose
fermentation.
o N. meningitides is able to ferment maltose, while N. gonorrhoeae cannot. 2oth
are diplococci.
Gram" ros (G,-) are &rst grouped b" their abilit" to ferment lactose on a .ac/on0ey
agar (not blood).
o Those that ferment lactose are ntero!acteriaceae, li$e . coli, #le!siella,
"itro!acter, and Serratia.
These are evidenced b" pin$ colonies on the Mac1on$e" agar.
o Those that don#t ferment lactose are di%erentiated b" the presence of o'idase.
Pseudomonas is o'idase positive. Shigella, Salmonella, and $roteus are
o'idase negative.
Three Gram- bacteria have capsules (li$e S. pneumoniae)< H. in%uen&ae, #. pneumoniae,
and '. meningitides.
'1ecial culture re2uirements6 H. in%uen&ae chocolate agar with factors = and >.
?@(. TA@-@
o 'eisseria Tha"er-Martin media, (. tu!erculosis ?owenstein-Benser agar.
() TA@-@
Legionella charcoal "east e'tract agar, (ll fungi -abouraud#s agar.
TA@-@ T//, C;13
Inia in0 is a special stain, used primaril" to identif" Cryptococcus neoformans, whose
capsule bloc$s the in$.
&ci"fast stains wor$ for m"cobacteria (including Tb), which lac$ a cell wall.
The Giemsa stain is used to identif" intracellular organisms< $lasmodium, "hlamydia,
)orrelia, Trypanosome.
'il3er stains are used in tissue to identif" fungi (li$e 4/4 in AD= patients), which stain
blac$.
Pigmented bacteria< S. aureus is gold, $. aeruginosa is blue-green, Serratia marcescens is
rust-colored.
Cungi are &rst divided into "easts ("andida and "ryptococcus) or molds.
o C. albicans are the onl" germ tube+ organism. The" li$e to form pseudoh"phae.
o Molds are septate (*spergillus and +usarium), non-septate ((ucor and ,hi&opus), or
dimorphic.
Df it branches at E8, it#s probabl" *spergillus. Df it branches at FG, it#s
probabl" (ucor.
-usceptibilit" to antimicrobials is assessed b" the .I/. /ne method is dis$ di%usion,
another is the @-test.
o The micro-dilution techniHue is prett" cool, as a color change from pin$ to purple
indicates the MD1.
o ( number must be loo$ed up in a reference boo$ to determine if the strain is
resistant or not.
Infectious Disease Lecture w/ Dr. Lichtenberger 3 January 2012
The Topic of This Lecture Is: ,eview of *ntimicro!ials
The &rst antibiotics were $"lactams, which inhibit cell wall s"nthesis b" bloc$ing
peptidogl"can cross-lin$ing.
o Penicillin resistance is conferred b" a plasmid that carries $"lactamase.
/la3ulanic aci is a 0-lactamase inhibitor (e'. 1lavamo'). /thers are
sulbactamIta5obactam.
o 4enicillin treats Gram+ cocci + rods, and it#s still the &rst line treatment for
spirochetes li$e s"philis.
/odles of people can have h"persensitivit" reactions. -ome develop
hemol"tic anemias.
o &mo5icillin and am1icillin treat nterococci, H. in%uen&ae, . coli, Listeria, and
$roteus.
-ome Staph infections can be treated too, but most of them are resistant b"
now.
o -ome 0-lactams are penicillinase-resistant J o5acillin, methicillin, nafcillin. The"
treat most S. aureus.
Cor to'icit", interstitial nephritis is evidenced b" a s$in rash, elevated -1r,
fever, and K21.
o Most penicillins don#t treat $. aeruginosa, but 1i1eracillin and ticarcillin are
e%ective.
Dnterestingl", the" also wor$ against G.s and some anaerobes. D have no
idea wh".
/e1halos1orins are 0-lactams that are less susceptible to penicillinases. There are four
generations.
o 4
st
(cephale'inIcefa5olin)< Gram+ /?! LLL M
nd
(cefmeta5ole)< Gram+, some Gram-,
and anaerobes
N
rd
gen (cefpo'idime)< Mainl" Gram- LLL E
th
(cefepime)< Gram+ and resistant
Gram-
/arba1enems are awesome due to their broad spectrum. The" treat an"thing resistant to
other 0-lactams.
o ?i$e cephalosporins, the" can cross-react with P1 allergies. The" don#t wor$
against M.-(.
Monobactams li$e a6treonam treat Gram- bugs and nothing else. The" don#t cross-react
with P1.
Gl"copeptides li$e 3ancomycin inhibit cell wall formation b" preventing )-(la )-(la
binding.
o The" treat resistant Gram+, especiall" S. aureus (.-'&) and nterococci. Dt is /T
orall" active.
The" have absolutel" no e%ect on Gram- bugs or anaerobes.
o To'ic e%ects include re man synrome (Oust slow the infusion rate),
nephroto'icit", and ototo'icit".
(minogl"cosides li$e gentamicin and tobram"cin are protein s"nthesis inhibitors used for
resistant G.s.
o The" are well-renowned for their abilit" to cause ototo'icit", murdering innocent
hair cells.
7etracycline and o5ycycline cannot be used in children, as the" stunt bone growth and
ruin enamel.
o The" are used to treat ,ic-ettsiae, spirochetes, (ycoplasma, and "hlamydia.
o Their absorption is minimi5ed if ta$en with mil$. (lso, the" can induce
photosensitivit".
Macrolides (erythromycin + a6ithromycin) treat at"pical pneumonias, -T)s, and Gram+
if P1 can#t be used.
o ( lot of patients end up with GD discomfort or diarrhea. -erum levels of
anticoagulants ma" increase.
?incosamides (clinamycin) are great for dental infections< Gram+ bugs and anaerobes
(/T Gram-).
o Df a patient develops diarrhea after ta$ing clindam"cin, suspect C. difcile colitis.
-ulfonamides (sulfametho5a6ole) are great for treating ;TDs, 'ocardia, and "hlamydia.
The" inhibit )AP-.
o 7rimetho1rim inhibits )AC reductase. Dt covers pneumocystis, Shigella, and
Salmonella.
o 7.4"'.8 (9actrim) can#t be given to those with G7P) de&cienc". There#s ris$ of
nephritis or anemia.
The two drugs wor$ together to completel" inhibit bacterial folate s"nthesis.
CluoroHuinolones (ci1ro:o5acin) inhibit )( g"rase. The" mainl" treat Gram- bugs
($seudomonas6).
o The most well-$nown side e%ect is tendonitis, which can lead to tendon rupture
(esp. (chilles).
.etronia6ole creates metabolites to'ic to bacteria. Dt wor$s against anaerobes, li$e ".
di.cile.
o Dt also treats parasites. (s side e%ects, it can cause a metallic taste or nausea if
ta$en with @t/A.
Dt should onl" be given for short periods of time due to neuroto'icit".
Khen treating infections, hit earl" and hard with the appropriate antibiotic. 2roader isn#t
alwa"s better.
o Minimi5e the length of therap", since to'ic e%ects are more li$el" to appear over
time.
(n" infection that involves pus is probabl" S. aureus. Tr" o'acillin, 4
st
gen cephalosporins,
or clindam"cin.
o CluoroHuinolones are not e%ective at all. Df it#s M.-( and in the blood, use
vancom"cin.
Enterococcus infections can usuall" be treated with amo'icillin or ampicillin, not
cephalosporins.
Strep are usuall" treated b" penicillins, followed b" clindam"cin. )on#t use ciproPo'acin
or macrolides6
@'cept for $seudomonas, Gram" infections are treated b" CQs, 1lavamo',
aminogl"cosides, carbapenemsR
o .eall", Oust don#t use P1 alone, nor a 4
st
generation cephalosporin, vancom"cin, or
metronida5ole.
Cor Pseudomonas, go with ciproPo'acin, aminogl"cosides, piperacillin, a5treonam, or
cefta5idimeIcefepime.
o )rugs that don#t wor$ are macrolides, clindam"cin, TMP--M>, most cephalosporins,
and 1lavamo'.
Cor anaerobes, go with metronida5ole or clindam"cin. LLL Df it#s 4/4, the best choice is
2actrim.
Infectious Disease Lecture w/ Dr. Lichtenberger 3 January 2012
The Topic of This Lecture Is: I/ve 0ot a +ever1 and the Only $rescription Is (ore "ow!ell
( fe3er is de&ned as a core bod" temperature of S 4GG.E C, though temperature varies
with time of da", anatomic site, ph"sical or emotional activit", and gender (esp. during
ovulation).
o Dt is often, but not alwa"s, a sign of infection. (lleviation of fever signi&es
appropriate therap".
Microorganisms can release e5ogenous 1yrogens or to'ins (?P-Iendoto'in, -higa to'in,
etc).
o /yto0ines are endogenous p"rogens. @'amples are D?-4, D?-7, TC-*, and DC2-T.
o The h"pothalamus receives these signals and causes vasoconstriction, which
conserves heat.
Aeat is also retained b" pilo-erection and voluntar" activities.
The bod" produces additional heat b" increasing metabolism and shivering.
Cevers can be treated b" anti1yretics, as the" are a response to c"to$ines. The"#re not
h"perthermia6
o ;y1erthermia is unregulated, e'cessive production of heat. (ntip"retics are
useless to treat it.
o There#s feedbac$ for fevers, so temperature rarel" e'ceeds 4G8.U C.
Dn h"perthermia, the temperature freHuentl" e'ceeds 4GV.7 C, so the patient
fries to death.
( single temperature measurement is not clinicall" useful. The acuit" and pattern are wa"
more helpful.
o 1haracteristic patterns on a tem1erature cur3e can suggest particular diagnoses.
Cevers can be managed with ice pac$s or sponges with cool water. Dce baths are not
recommended.
o /r, use drugs li$e (P(P, aspirin, -(D)s, or corticosteroids.
o Dt#s probabl" a good idea to let the fever go for a bit to establish a pattern and &ght
infection.
<e3er of un0nown origin (<=>) de&es diagnosis is 8-489 of cases. Dt#s a diagnosis of
e'clusion.
o Ph"sical e'ams loo$ at the temperature curve, s$in, mucous membranes, l"mph
nodes, organ si5eR
Dnitial labs loo$ at 121, ?CTs, @-., ;(, blood cultures, and 1>..
o Df still nothing is found, do 1Ts, ultrasounds, M.Ds, and hell, ma"be even a nuclear
medicine scan.
o The de&nition of a classical <=> is a temp of S NU 1 for at least N wee$s with S M
hospital visits.
(s$ about travel, contacts, animals, medications, and immuni5ations.
Dt could be cancer, infection, inPammation, etc. Bust observe6 )on#t waste
antibiotics.
o ( hospitali5ed patient who gets a fever after admission li$el" has a nosocomial
infection or drug fever.
o Patients who are immune-de&cient probabl" have an infection. 'tart
antimicrobials &'&4.
o Df a de&nitive diagnosis can#t be reached and the condition is chronic, mortalit"
rates are low.
The longer the presence of fever, the less li$el" it#s an infection (higher
chance of cancer).
-urvival rates are Huite poor if the onl" sign of a neoplasm is a C;/.
Infectious Disease Lecture w/ Dr. Lichtenberger ? January 2012
The Topic of This Lecture Is: Infections "haracteri&ed !y +ever and Lymphadenopathy
.ononucleosis"li0e synrome involves fever, fatigue, l"mphadenopath" (esp. in the
nec$), and phar"ngitis.
o This usuall" a%ects "oung patients. The di%erential includes infections, l"mphoma,
and leu$emia.
Infectious mononucleosis is caused b" @2=, but most people infected b" @2= do not
develop s"mptoms.
o 3ids in da"cares and college-aged fol$s (48-ME) are the most li$el" to get the
s"mptomatic disease.
Dt is probabl" spread b" saliva e'change, not b" fomites. That isn#t hard data.
o The virus doesn#t have to spread from s"mptomatic patients. Aealth" people shed
the virus.
o /ne of the biggest ris$s is s1lenomegaly, as an enlarged spleen can rupture with
ph"sical activit".
o 121s will hopefull" show S 8G9 mononuclear cells and S 4G9 at"pical
l"mphoc"tes.
@arl" on, there are transient =1(-Ig.s (heterophile). ?ater, permanent DgGs
are developed.
The test used most commonl" is a rapid agglutination test called
.onos1ot.
?CTs ma" be mildl" elevated, while in cases of 1M=, the" ma" be severel"
elevated.
o (ntivirals don#t wor$, so Oust treat the s"mptoms and ensure the patient doesn#t
rupture a spleen.
/ytomegalo3irus (/.@) is the largest virus that can infect humans. Dnfection rates are
prett" high.
o ?i$e mono, $ids that go to da"care tend to get it. -heltered $ids will get it as
adolescents.
Dt can be passed verticall". (nd, in D1 patients, proph"la'is is needed to avoid
encephalitis.
o -erolog" does not reveal heterophiles. The C;/ lasts longer, and a sore throat is
less common.
There#s also less splenomegal", and at"pical l"mphoc"tosis is not e'pected.
o ?i$e mono, we don#t $now how it#s transmitted. Dt can be b" saliva and b" blood
(transfusions).
( 1rimary ;I@ infection presents however it wants. The most common are those in this
lecture#s topic.
o Dn the &rst few wee$s, ;I@ -,& 4/- is far, far superior to the @?D-( serolog" (onl"
positive in 8G9).
o Dn acute retroviral s"ndrome, antiretrovirals is a good idea, but the s"mptoms are
self-limited.
Dt is possible to notice abnormalities in l"mph tissue on a colonoscop".
7o5o1lasmosis is caused b" a proto5oon. Aumans are an intermediate host for a parasite
that li$es cats.
o The disease is caused b" touching cat feces (or soil that# s been soiled A(. A(.)
and then eating.
o /nl" 4G-MG9 of cases are s"mptomatic, producing mono-li$e s"ndrome, at times
with chorioretinitis.
o During 1regnancyA acute to5o1lasmosis is ba. Dt#s totall" &ne to have it before
pregnanc" (DgG+).
Cetuses get intracerebral calci&cations, h"drocephalus, and chorioretinitis.
o )iagnosis is b" serolog" in health" patients. Dn D1 patients, to'oplasmosis can
reactivate in the brain.
(D)- patients that get sei5ures will have ring-enhancing lesions on M.D
(biops" con&rms).
o /nl" D1 patients (K21 W MGG) reHuire treatment. ;se sulfaia6ine and
1yrimethamine.
/at"scratch fe3er is caused b" )artonella henselae. The vector is a Pea, but a cat#s
scratch is reHuired.
o Dn this disease, there#s a primar" cutaneous papule N-4G da"s after the scratch that
lasts 4-N wee$s.
(5ithrom"cin decreases the duration of the l"mphadenopath". .arel",
resection is needed.
o (t"picall", there#s 4arinauBs oculoglanular synrome. Thin$ Xe"e problem +
l"mphadenopath"Y.
o (ntibiotics don#t reall" help, especiall" in at"pical disease. Prevent it b" $eeping
cats Pea-free.
Infectious Disease Lecture w/ Dr. Lichtenberger ?"C January 2012
The Topic of This Lecture Is: Infections "haracteri&ed !y +ever and ,ash
.acules are Pat, non-palpable lesions in the plane of the s$in. Thin$ earl" chic$en po'.
o 4a1ules are palpable and raised. Df the" are large enough, the"#re called noules.
o 4ustules are papules that are full of pus. @esicles are small blisters and bullae
are large blisters.
=esiculo-bullous lesions include A-=, varicella &oster, and vi!rio vulni2cus (this one is
more bullous).
Aumans are the onl" reservoir for ;'@. A-=-4 presents in the oral cavit", A-=-M hangs out
in "our pants.
o D1 patients can have disseminated disease. ( fever blister might be a precursor to a
fatal disease.
o Dn additional to fever and l"mphadenopath", the rash for A-= is grouped vesicles
that are painful.
o )iagnosis is made b" the 76anc0 test (smear the opened vesicle), a cultureIP1., or
Oust a histor".
Treatment is an"thing in the famil" of acyclo3ir. Df it#s severe (li$e, in the
e"es), go D=.
These drugs wor$ b" competing with d-GTP on the viral )( pol"merase.
Varicella zoster (@D@) onl" a%ects humans. Dt#s spread b" airborne droplets, so it
replicates in the nose.
o The &rst infection causes chic$en po', but reactivation for whatever reason causes
singles.
o The disease starts out maculopapular. -oon after, vesicles form in a dermatomal
distribution.
;nli$e smallpo', these lesions will be in di%erent stages of healing (mi'ed
presentations).
o Df shingles presents in on 1 =4, e"esight can be destro"ed. This necessitates D=
antivirals.
-amsay";unt 'ynrome refers to involvement of 1 =DD, causing 2ell#s
pals".
Vibrio vulnicus is acHuired b" eating raw shell&sh or o"sters, or warm ocean water with
these critters.
o Dt prett" much onl" hits patients with underl"ing liver disease (e'cess iron).
o -"mptoms have abrupt onset of fever accompanied b" h"potension and severe
cellulitis.
There is no diarrhea6 Treat immediatel" with debridement, ci1ro:o5acin,
and cefta6iime.
,ecroti6ing fasciitis is an immediate emergenc", as both fascia and fat are
progressivel" destro"ed.
o T"pe D is a mi' of aerobic and anaerobic bacteria. Dt happens in D1 patients or after
surger".
o T"pe DD is from S. pyogenes. This can a%ect otherwise health" patients and $ill within
hours.
o Dn necroti5ing fasciitis, the lesion is painful (out of proportion), as is the surrounding
area.
( bulla is Oust the tip of the iceberg. Debriement is absolutely
necessary.
Neisseria meningitides can cause bacteremia, causing disseminated intravascular
coagulation ()D1).
o The &brin thrombi can then occlude arterioles, leading to infarcts. This is 1ur1ura
fulminans.
This disease is e'tremel" contagious. 1lose contacts need proph"lactic
antibiotics.
o 1ultures reveal Gram- diplococci that ferment maltose and glucose
(meningococcemia).
( few hemorrhagic pustules at small Ooints can be from isseminate N. gonorrheae.
Treat with ceftria'one.
o .ather than getting a culture at the pustule, get it from the source of entr" (mouth
or genitals).
Infecti3e enocaritis from S. viridans or Staph ma" be evidenced b" painless
hemorrhagic macules on the palms or soles (Janeway lesions) or painful purpuric nodules
on the pulp of the digits (>slerBs noes).
Capnocytophaga canimorusus is found in the mouths of dogs. Dt causes severe disease
in asplenic patients.
o There is a disseminated purpuric rash. Treat these patients with 1lavamo'.
S. aureus can cause soft tissue infections, li$e cellulitis. Dt reall" li$es to form pus-&lled
abscesses.
o Treat with 2actrim, clindam"cin, or do'"c"cline. Df it#s M.-(, use vancom"cin.
'econary sy1hilis involves fever, headache, m"algia, l"mphadenopath", and a
characteristic rash.
o The rash is maculopapular and er"thematous or brown. Dt#s on the palms, soles, and
trun$.
o Get a CT( on these patients to con&rm the diagnosis. Treat with ben5athine or
penicillin G.
Eschars are necrotic lesions that grow. Dn $seudomonas, there bacteria invades arteries
and veins.
o There is ischemic necrosis termed ecthyma gangrenosum. 1ulture and treat
accordingl".
/utaneous anthra5 is from )acillus anthracis, a Gram+ spore-forming aerobic rod.
o Patients contact spores from animals that feed on grass. The ulcer is painful and
edematous.
o Treat this with ciproPo'acin or do'"c"cline, unless it#s susceptible to amo'icillin.
D1 patients or diabetics can get mucormycosis in their nasal cavities. Dt ma$es broad
h"phae at FG.
Infectious Disease Lecture w/ Dr. Lichtenberger C January 2012
The Topic of This Lecture Is: Travelers/ Diseases
The most common food-related illnesses are travelers# diarrhea, Aepatitis (, t"phoid fever,
and giardiasis.
o Travelers should bring alcohol-based hand saniti5er and use it damn near constantl".
/nl" eat freshl" coo$ed food that#s still hot (not a bu%et), or commerciall"
wrapped food.
The" should boil water for S 4G minutes, and the" should avoid ice made
from tap water.
o The ris$ of food-borne illness is increased simpl" because meals aren#t home-
coo$ed.
Most cases of tra3elersB iarrhea are caused b" Enteroto5igenic E. coli (E7E/),
"ielding water" diarrhea.
o The disease is self-limited to N-E da"s, although in rare cases, there#s post-infectious
irritable bowel.
2lood" stool and more severe diarrhea are associated with E&E/ and C.
!e!uni.
Treat with oral reh"dration and a dose or two of PuoroHuinolones or
a5ithrom"cin (". 3e3uni).
o The onset ma" be more insidious and associated with gas if it#s a parasite, li$e
giardia or . histolytica.
o .arel", the cause is rota3irus or noro3irus (cruise ships6). There will be more
nausea and vomiting.
These viruses are e'tremel" contagious, and outbrea$s are hard to contain.
o -"mptomatic treatments are antidiarrheals (bismuth) and antimotilit" agents
(loperamide).
People who are at high ris$ for infection (D1) can ta$e proph"lactic rifa5imin.
?ater, she said that rifa'imin is a good alternative to bismuth. Dt#s Oust
more costl".
;e1atitis & is caused b" an ss.( virus. Dt#s preventable b" vaccine. Dt#s transmitted b"
the oral-fecal route.
o The incubation period is about a month. -"mptoms are fever, malaise, anore'ia,
and nausea.
The disease is more severe with increased age, leading to hepatitis (Oaundice
and dar$ pee).
o Df travel will begin shortl" after vaccination, hepatitis ( immunoglobulins are given
instead.
7y1hoi fe3er is caused b" S. typhi. Dt#s seen ever"where but &rst-world countries, e'cept
for travelers.
o The bug can remain in a gallbladder, shedding bacteria chronicall" and a%ecting
close contacts.
o -"mptoms are high fever (S 4GN C), headache, malaise, anore'ia, splenomegal",
and a faint rash.
o The vaccine is not 4GG9 e%ective, but it#s recommended to be given M wee$s before
travel.
Df e'posed, diagnosis is made b" culturing the stool, due to bacterial
shedding.
Cor Entamoeba histolytica, mature c"sts are ingested, but tropho5oites are what cause
disease.
o The parasites can travel to the lungs or form abscesses in the liver with chocolate-
colored pus.
o This is a large bowel diarrhea (colitis) J man" small amounts of painful, blood"
diarrhea.
1ontrast this to small bowel diarrhea, which is e'plosive, large amounts of
water" diarrhea.
o ?i$e most parasites, onset is insidious. 1"sts in stool or positive serolog" appear
before s"mptoms.
Df a biops" is done, Pas$-shaped ulcers will be seen due to in3asi3e
amoebiasis.
o Df there#s no invasion, treat the diarrhea with paramom"cin. Df it#s invasive, use
metronida5ole.
4aramomycin is an aminogl"coside that is not absorbed from the GD tract
(lumenal).
"iardia is a proto5oon that is not invasive. The tropho5oites Oust attach to the duodenum.
o (s a small bowel issue, there are foul-smelling, greas" stools with a lot of Patulence
and cramps.
o )iagnosis is made b" an @?D-( test on the stool. Treat this parasite with
metronida5ole.
&rthro1o"relate infections include those from mosHuitoes, sandPies (?eishmaniasis),
tic$s, and Peas.
o Minimi5e ris$ b" wearing proper attire, inspecting for tic$s, and avoiding activit"
from dus$ to dawn.
.epellants li$e )@@T help, as do bed nets or clothes that have been treated
with permethrin.
Dn an" patient that has come from an endemic area and has a C@=@., suspect malaria as
a cause.
o /nl" a few areas in the world have malaria that can be treated b" chloro2uine
(Aaiti is one of them).
o )isease is caused b" sporo5oites that mature in the liver and leave as mero5oites.
The" mature in .21s, which eventuall" l"se (anemia6) and release
gametocytes.
o The mosHuitoes that carr" the disease are #nopheles, which are nocturnal (that#s
important).
The &rst s"mptoms are C@=@., headache, and malaise. ?ater, there#s
hemol"tic anemia.
o The $lasmodium species that $ills people is P. falciparum. /thers are $. viva4 and
$. ovale.
The latter patients reHuire 1rima2uine to treat the liver h"pno5oites.
o 1hemoproph"la'is is onl" given to travelers whose itinerar" puts them at ris$.
Df chloroHuine can be given, it#s a wee$l" drug given 4-M wee$s before to E
wee$s after.
Df not, tr" me:o2uine, but it has some prett" awful ps"chiatric side e%ects.
)rugs that must be ta$en dail" include ato3a2uone (Malarone) and
o5ycycline.
Dengue fe3er is transmitted b" *edes aegypti, which is a diurnal mosHuito that loves
stagnant water.
o There are four serot"pes. (n initial infection "ields immunit" for one but not the
others.
2ut, a second infection b" another serot"pe increases ris$ for hemorrhagic
fe3er (D;<).
o Dnitial s"mptoms are fever, retro-orbital headache, m"algia, and a rash on da"s N-8.
o Dn cases of )AC, there are lea$" capillaries and thromboc"topenia, necessitating
medical care.
(n"one with a diagnosis of dengue fever should avoid aspirin for this reason.
The same mosHuito for dengue caries yellow fe3er, transmitted b" a Pavivirus for which
we have a vaccine.
o @arl" s"mptoms are Pu-li$e, but a to'ic phase follows with liver failure and
hematemesis.
o The vaccine for "ellow fever has a chance of inducing neurotropic disease. That
suc$s.
$ic%ettsiae africae is carried b" tic$s. Dt#s an intracellular pathogen that hangs out in
sub--aharan (frica.
o Most patients will develop a fever, rash, and ma"be other benign s"mptoms. Treat
with do'"c"cline.
&eptospirosis is caused b" a spirochete that hangs out in water that infected animals
piss in.
o Cirst, there are Pu-li$e s"mptoms, followed b" liver damage.
?CTs are ver" high, but total bilirubin onl" mildl" elevated.
o The spirochetes can be identi&ed b" serolog" or DG Puoroscop". Treat with
do'"c"cline.
'y1hilis is caused b" Treponema pallidum. Dt can imitate man" diseases due in its later
stages.
o The initial presentation chancre is a painless chancre, seen on whatever touched a
vagina.
The secondar" stage is conylomata lata (rash), along with s"stemic signs.
The tertiar" stage is (rg"ll-.obertson pupil, neuros"philis (ata'ia), and
whatever else.
o @D-L is a non-speci&c test. 1on&rm the diagnosis with <7& (both positive means an
active infection).
Df the =).? is + but CT( is -, it#s a false positive. Df onl" CT( is +, it#s been
treated.
o (gain, the &rst-line treatment for s"philis is an inOection of penicillin G.
These are spirochetes, so don#t get these mi'ed up with the arthropod-mediated diseases.
Infectious Disease Lecture w/ Dr. Lichtenberger C January 2012
The Topic of This Lecture Is: 0eographic Diseases of the 5.S. of *
-oc0y .ountain s1otte fe3er is caused b" ,ic-ettsia ric-ettsii. Dt is /T found in
states near the .oc$ies.
o ( special stain is needed to identif" this intracellular pathogen indigenous to the
&tlantic coast (1).
The tic$ has to be attached for several hours before ,. ric-ettsii is
transmitted.
o Dnitial s"mptoms are Pu-li$e, but later there#s abdominal pain with arthralgia.
.ash starts after fever. Dt#s petechial, with small, Pat, pin$, non-itch" macules
on distal Ooints.
-evere s"mptoms of .M-C are pneumonitis and vasculitis.
)iagnosis is b" s"mptoms and the epidemiological clues (near tall grass,
woods, etc).
o /n serolog", DgM titers appear &rst, then DgG antibodies after M wee$s (li$e
ever"thing else).
The antibod" assa" is for Feil"<eli5. ?earn that name. Treat this with
do'"c"cline.
Ehrlichia cha'eensis is a small Gram- bacteria that clusters inside of macrophages.
o Dt#s carried b" the Lone"star tic0 or dog tic$, which hang out in Te'as and the
-outheast ;.-.
o (s opposed to .M-C, the rash is maculopapular, and it#s also less li$el" to be seen.
=asculitis is rare.
)iagnosis is made b" elevated DgG and a blood smear for the pathogen (or
P1.).
o 1ontrast this bug with #naplasma phagocytophilim, which is from I4odes in the
ortheast ;.-.
(lso, *. phagocytophilim invades granuloc"tes li$e PMs rather than
macrophages.
Lyme isease is caused b" the spirochete )orrelia !urgdorferi, via the tic$ ()odes
scapularis.
o The most prominent epidemiological sites are Minnesota, Kisconsin, and the
ortheast ;.-.
The disease is transmitted b" n"mph-stage tic$s that feed for ME-N7 hours.
o The pathognomonic sign is the bullBs"eye rash, which has the fanc" name
erythema migrans.
@arl" ?"me titers are probabl" negative, so Oust diagnose via the clinical
picture.
o ?ater signs are fever, (= nodal bloc$, mononeuritis, hepatitis, ophthalmitis, and
arthritis.
The arthritis is seen in stage N (persistent), along with encephalopath" or
pol"neuropath".
o The cornerstone of treatment is do'"c"cline. ?ater-staged disease reHuires
ceftria'one too.
(nother disease carried b" I4odes is Babesia microtii, which forms a Maltese cross within
cells.
o Dt#s not a huge deal e'cept in patients without spleens. Dt presents a lot li$e malaria.
There#s fever, chills, headache, m"algia, anemia, etc. 2ut, there#s no histor"
of travel.
Patients without spleens will die from cardiorespirator" failure or renal failure.
o This is the onl" tic$-related disease not treated with do'"c"cline6 Dnstead, treat it
li$e malaria.
Go with ato3a2uone and a6ithromycin. Give blood transfusions for severe
anemia.
The three enemic mycoses are dimorphic, in that the" are molds in nature but "east in
tissue.
o The clues for diagnosis are the geographic distribution and the smear.
o The" all cause progressive fever, d"spnea, and cough with oral ulcers and
organomegal".
*istoplasma capsulatum is found in the Mississippi .iver =alle". Thin$ bats, cave
e'ploration, and Tennessee.
o -putum cultures are rarel" positive. The" loo$ li$e little suns or li$e &sh eggs.
Df in the lungs, antigens are obtained on lavage. Df disseminated, antigens are
in the urine.
o Df the disease is progressive or chronic, use itracona6ole. Dn D1 patients, use
amphotericin 2.
Blastomyces dermatitidis also li$es the M.=. Dt prefers the lungs, but has the potential
to infect bones.
o 1ultures of s$in lesions and biops" are much better than serolog".
o (s opposed to histoplasmosis and coccidiom"cosis, treat E@E-G>,E, not Oust
complicated cases.
Cor Coccidiodies immitis, it#s found in the soil of the -outhwestern deserts and -an
BoaHuin .iver =alle".
o )issemination is rare in an immunocompetent host. Pulmonar" s"mptoms are Oust
Pu-li$e.
o The mainsta" of diagnosis is serolog" (or biops"), not blood culture. There is
eosino1hilia6
o Dn most cases, Oust observe. 2ut, pregnant or D1 patients reHuire Pucona5ole.
4aracocciiomycosis presents the same wa", but it#s found in 2ra5il and -outh (merica.
o Dt can cause chronic pulmonar" s"mptoms. )iagnose b" biops" of a bug that loo$s
li$e a ship#s wheel.
Infectious Disease Lecture w/ Dr. Lichtenberger C January 2012
The Topic of This Lecture Is: 6oonoses
(gain, /at"scratch fe3er is caused b" )artonella henselae. 1ats are bacteremic but
as"mptomatic.
4lague is caused b" 7ersinia pestis, transmitted b" a Pea bite from those that live on
prairie dogs, rats, etc.
o ( bubonic lym1h noe is painful and e'tremel" swollen, locali5ed near the bite.
o 4ulmonic 1lague is a rapid pneumonia that can spread through blood or an
aerosol (dear God).
Dt can cause septicemia and necrosis of distal e'tremities. Treat with
aminogl"cosides.
Brucella is found in man" animals, but we care about livestoc$, since it#s transmitted in
unpasteuri5ed dair".
o Dt#s a widespread 5oonosis mediated b" a Gram- intracellular bacteria. )on#t eat
fanc" Crench cheese.
o There#s an insidious onset of fatigue, weight loss, anore'ia. Patients Oust feel unwell
for months.
There ma" be sacroiliitis, epidid"mitis, orchitis, and so on. Dt involves man"
organs.
o )iagnosis reHuires a histor" of consuming unpasteuri5ed dair". -erologic testing
con&rms.
Monotherap" doesn#t wor$ often, so we go with a tag-team of do'"c"cline
and gentamicin.
+rancisella tularensis is a Gram- intracellular bug that causes tularemia. Dt#s carried b"
bunnies and sHuirrels.
o The animals get it from tic$s. Ke get it being near infected rabbits or eating poorl"
coo$ed bunn".
The epidemiological areas for the boards are Missouri, (r$ansas, and
Martha#s =ine"ard.
o -i' forms< ulceroglandular, glandular, oculoglandular, orophar"ngeal, t"phoidal,
pulmonar".
o Tularemia can be obtained b" aerosol, so be careful when culturing it for diagnosis
(P1. wor$s too).
Df the lungs are a%ected, mortalit" rates are high. Treatment is alwa"s b"
aminogl"cosides.
,. ric-etsii causes .M-C (tic$s), $. typhi is from Peas, $. pro+aze%ii is from lice. (ll are
Feil"<eli5 1ositi3e.
o Khile .M-C has a petechial rash that a%ects palms and soles (Ooints6), the other two
do not.
(lso note that enemic ty1hus causes a more maculopapular rash (esp. on
the bac$).
o (ll of these are treated b" do'"c"cline. ote that onl" ,. prowa&e-ii is not endemic
(it#s epidemic).
Co)iella burnetii is transmitted b" aerosol. Dt does not cause a rash, rather, it causes #
fe3er.
o )iagnosis is b" serolog" and a histor" of being near pregnant livestoc$ or pets.
o Dt#s part of the wor$up for C;/, although there ma" also be headache and
pneumonia.
*antavirus is transmitted b" aerosols from dried rat feces from a chronicall" infected rat.
o Dt presents with severe pneumonia along with fever, m"algia, and cough.
o )iagnose it b" DgM serolog" or P1.. -ince it#s a virus, there#s no treatment but
support.
Lym1hocytic choriomeningitis (L/.) is an ss.( virus transmitted b" rats. 1lose
contact is reHuired.
o D1 patients (transplant recipients) are at ris$ too. Dt#s from inhaling e'creta or being
scratched.
o The Pu-li$e s"mptoms subside after M-E da"s, then come bac$ (hopefull" not as
encephalitis).
Fest ,ile @irus is a J.( virus transmitted b" mosHuitoes. Df it gets into birds, the birds
die rapidl".
o Aumans and other animals are incidental hosts. (lmost ever"one is &ne within a
wee$.
o 2ut, W 49 of fol$s get meningoence1halitis, fever, ata'ia, and muscle wea$ness
(Paccid paral"sis).
o )iagnosis is b" DgM in the serum or 1-C. ote that P1. is not helpful.
Infectious Disease Lecture w/ Dr. Lichtenberger C January 2012
The Topic of This Lecture Is: Infectious Diarrheal Illnesses
The incubation period for norovirus is about EU hours. =omiting and diarrhea persist for
about M da"s as well.
o $otavirus also causes viral enteritis. Prett" much ever" $id will get it b" the time
the"#re 8 "ears old.
Cor food-borne diseases, incubation periods provide clues to diagnosis. Df it#s W M hours, it#s
a chemical agent.
o Df it#s M-V hours, it#s a preformed to'in (li$e S. aureus). Df it#s U-4E hours, it#s
Clostridium pernges.
(n"thing more than 4E hours is a viral or bacterial pathogen doing its thing.
o )o not give antibiotics for S. aureus foo 1oisoning6 (lso, the $e"word is
Xma"onnaiseY.
o Cor ". per2nges, there#s water" diarrhea and no vomiting. The $e"word is Xreheated
meatY.
o Cor Bacillus cereus, there#s an emetic form with a short incubation and an enteric
form that#s longer.
The $e"word for ). cereus mediated food poisoning is Xfried riceY.
on-invasive diarrhea is caused b" @T@1 or @(@1. This is tra3elersB iarrhea or
persistent diarrhea in $ids.
o Treat this with 2actrim or PuoroHuinolones, and it#ll resolve without seHuelae.
Dnvasive diarrhea is ysentery. There#s fever, abdominal pain, and blood" diarrhea with
mucus.
Enterohemorrhagic E. coli (E;E/) secretes a to'in li$e -higella. Dt contaminates leaf"
green veggies.
o Dt also a%ects undercoo$ed meats. ( tin" amount of bacteria can cause s"mptoms.
There#s no fever.
o There is hemorrhagic colitis without fever, but there#s a ris$ for hemolytic uremic
synrome.
A;- is evidenced b" hemol"tic anemia, renal failure (high -1r), and
thromboc"topenia.
o )o /T give antibiotics or antimotilit" agents because this is mediated onl" b" a
to'in6
Shigella is similar, but it also causes a fever. Dt 1( be cured b" antibiotics< CQ, 2actrim,
and ceftria'one.
,on"ty1hoi Salmonella infects poultr" (eggs6). Dt induces blood" diarrhea and can
cause bacteremia.
o (s opposed to Shigella, it has a high inoculum, and it is motile. 2oth of them are
lactose fermenters.
Campylobacter !e!uni causes the same s"mptoms. Dt can be cultured at higher
temperatures (EM 1).
o -o, s"mptoms are usuall" not enough to di%erentiate causes of invasive diarrhea.
Get a culture.
o Treat ". 3e3uni with a5ithrom"cin. 1omplications include G2- or reactive arthritis.
Clostridium difcile is an anaerobic Gram+ bug that forms spores and produces a to'in.
o Dt is the usual cause of antibiotic"associate iarrhea. Dt#s diagnosed b" seeing
to'in in the stool.
2ecause it ma$es spores, it#s hard to $ill. This is wh" it spreads in hospitals.
o 4seuomembrane colitis can worsen into 7>8I/ .EG&/>L>, with certain
strains of ". di.cile.
ot ever"one with 1)() presents with diarrhea. Most don#t have fever, Oust
leu$oc"tosis.
Dmaging ma" show dilation of the colon. Df it gets to S 4G cm, hol" shit cut out
the colon.
o Treatment is metronida5ole is if it#s mild or /.(? vancom"cin if it#s severe (ma"be
with D=DG).
(n odd treatment that actuall" wor$s ver" well is a fecal transplant.
Infectious Disease Lecture w/ Dr. Lichtenberger H January 2012
The Topic of This Lecture Is: ,espiratory 8iral Infections: In%uen&a
In:uen6a & infects oodles of animals and humans, so it causes epidemics and
pandemics.
o DnPuen5a 2 onl" infects people and parrots. DnPuen5a 1 onl" infects humans and
swine.
o The antigen gl"coproteins in inPuen5a are hemagglutinin and neuraminiase
(AZZ).
Kithin the viral capsid, there are multiple .( segments. The" are able to
mutate.
o The viruses that can infect humans are A4-AN and 4-M, but dramatic drifts are
possible and deadl".
Dt#s na[ve viruses that cause maOor issues, as people develop antigens if
the"#re e'posed.
DnPuen5a ( tends to start in wild aHuatic birds, then gets to poultr", then pigs
or people.
o Pandemics tend to occur when an avian virus undergoes genetic reassortment with
a human virus.
The most important s"mptom of inPuen5a is a 3ery high fe3er, plus chills, bone pain,
m"algia, and nausea.
o Dnfants, old people, and pregnant chic$s can end up with pneumonia, m"ocarditis,
or encephalitis.
o Khen a patient with inPuen5a is in the hospital, an F8 mas$ is not needed, Oust a
regular one.
Dt is spread b" droplets that do not remain as an aerosol. The virus hangs out
on surfaces.
o ( ra1i antigen test is obtained b" Oamming a swab into the nasophar"n' (not the
mouth).
Khile the test is prett" speci&c, it is not sensitive. Preferabl", Oust use the
clinical picture.
/ne should test hospitali5ed patients, pregnant women, and cases outside of
outbrea$s.
7ami:u is onl" given if the Pu is caught within the &rst EU hours. /therwise, Oust provide
supportive Puids.
o The e'ception to this rule is pregnant women. Dn clinical practice, the" get meds no
matter what.
/thers include $ids under 8, people over 78, and those with chronic medical
conditions.
o >seltami3ir (TamiPu) and 6anami3ir are neuraminidase inhibitors that prevent
release of virions.
o Df there are pulmonar" s"mptoms, treat the patients for 1(P, which ma" be from
secondar" bacteria.
DnPuen5a can be prevented b" vaccination and freHuent hand-washing. (lso, snee5e into
"our damn elbow.
o )on#t touch "our mucous membranes after touching other stu%. -ta" home if "ou#re
sic$.
Infectious Disease Lecture w/ Dr. Lichtenberger H January 2012
The Topic of This Lecture Is: HI8 and $rimary "are
(ntigenicit" to AD= is mediated b" the surface gl"coprotein g1120, along with gpE4.
o AD= li$es to infect 1)E T-cells, macrophages, and dendritic cells. Dt binds to the host
at //-C.
People who are homo5"gous for a 11.8 variant are immune to AD=.
o (fter binding, .( is inOected into the cell. Dt#s reverse transcribed to )(, then
integrated.
/nce integrase does its thing, new viral .( and AD= proteins can be
transcribed.
o The turnover of the virus is unbelievabl" fast. /ver 4G
4G
virions are produced and
destro"ed dail".
o .everse transcriptase is a prett" awful en5"me, but its mista$es provide
heterogeneit" for the virus.
Dn dudes, the incidence of AD= from heterose'ual contact is increasing toward that of ga"
men.
o Cor women, the second most li$el" cause of AD= other than se' is D= drug abuse.
o 2ut, on a case b" case basis, the highest ris$ is from needle-sharing or receiving
buttse'.
Dmmediatel" after e'posure, there#s an e'tremel" high viral load. Dt then drops to a
relativel" stable set point.
o -imilarl", the T-cell count drops acutel", then returns to baseline. Dt then steadil"
declines.
o &ID' is de&ned as a 1)E count below MGG. (t that point, viral load starts increasing
sharpl".
(t a 1)E count below 8GG, there#s increased ris$ of infections and neoplastic
events.
Df 1)E drops below 8G, then patients can get stu% li$e 1M=, M(D, or
l"mphoma.
The other de&nition of (D)- is the presence of an opportunistic infection.
o The most common pneumonia in (D)- patients is still S. pneumoniae, even though
the" can get P1P.
The normal test for AD= is ELI'&, con&rmed b" Festern blot, since there#s a ris$ of false
positives.
o 2ecause of false positives, never report @?D-( as positive6 Dt is termed Xreacti3eY or
Xnon-reactiveY.
Df there is a reactive @?D-(, the &rst step is to repeat it. Then, do a Kestern
blot.
Calse negatives can be due to a winow 1erio (\M wee$s), recent
transfusion, or transplant.
o ( positive Kestern blot is an" M of pME, gpE4, or gp47GI4MG. egative ] no bands,
else indeterminate.
Dndeterminate tests can be interpreted with regard to 3iral loa (positive if S
4GGG).
Kestern blots will be negative at later evaluation if antiretrovirals are started
earl".
o The other test is for the AD= .( viral load, which is the nucleic antigen test (,&7
;@"1).
(lwa"s get informed consent before an AD= test and onl" disclose results in person.
o Go over the last three slides, since it#s stu% that needs to be regurgitated on the
e'am.

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