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ID Board Review March 24, 2009.

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Presentation on theme: "ID Board Review March 24, 2009."— Presentation transcript:

1 ID Board Review March 24, 2009

2 Rickettsial Diseases

3 Rocky Mountain Spotted Fever
Peak incidence  spring & summer Mode of transmission  tick (esp. dog tick) Clinical Triad  Fever + Rash + Headache Nonspecific anorexia, myalgias, N/V, abdominal pain Rash Maculopapular rash  petechial / purpuric Begins on extremities (ankles, wrists, lower legs) Includes palms and soles Other rare findings: HSM, thrombosis, CNS Fulminant (esp w/ G6PD) : coagulopathy, thrombosis, renal failure, liver failure, respiratory failure  death < 5 days


5 Looks like RMSF but it’s not….
Differential Diagnosis Erlichiosis Meningococcemia Measles Viral exanthems Scarlet fever TSS ITP / TTP HSP Kawasaki disease

6 Diagnosis & Treatment Diagnosis Treatment Clinical + epidemiological
Lab findings: thrombocytopenia, elevated AST/ALT, bilirubin Late in dz: Skin biopsy  staining for R. rickettsii (DO not get if > 48 hrs of tx) Confirmation with serology Indirect fluorescent Ab (IFA) + Ab 7-10 d after onset Treatment Doxycycline (even in those < 8 hrs) Alternatives Tetracycline Chloramphenicol (pregnant women) Treat at least 3 days after afebrile (5-7 d)

7 Ehrlichiosis Similar to RMSF Human disease Vector Signs/Symptoms
Human monocytic ehrlichiosis Human granulocytic anaplasmosis Vector Wood tick or deer tick Signs/Symptoms Fever + Headache + Rash; N/V, myalgias, LAD, HSM **Leukopenia / neutropenia, elevated AST/ALT Treatment: Doxycycline

8 Fungal Diseases

9 Candida Predisposing factors Disease Manifestations Treatment
Recent Antibiotic use IC / Immunosuppressed (steroid use, BMT/organ transplant, malignancy), TPN, burns, DM, NICU/PICU setting, CVL Disease Manifestations Oropharyngeal, Cutaneous, Vulovaginitis/Balanitis Invasive: UTI, PNA, Peri - / Endocarditis, Osteoarticular, Meningitis, Disseminated Treatment Antifungals : Fluconazole, topical (Nystatin), Itraconazole, Ketoconazole, Voriconazole, Ampho B, Micafungin


11 Cryptococcosis Encapsulated yeast
Inhalation of spores / direct from contaminated soil, bird droppings (pigeons) Clinical Manifestations **Opportunistic Infection Immunocompetent : Pnuemonia Immunosuppressed: Disseminated disease Sepsis syndrome, Meningitis, Skin infection, Arthritis, bone involvement, chrioretinitis, LAD

12 Diagnosis & Treatment Latex agglutination – Ag India Ink Definitive:
< sensitive than cx & Ag Definitive: fungus in tissue specimen Treatment Observation Antifungals Fluconazole Ampho B +/- flucytosine

13 Coccidioidomycosis Dimorphic fungi
Found SW US (Arizona, CA, NM, west TX) Acquired via inhalation of spores Clinical manifestations Flu like symptoms, PNA Fever, night sweats, HA, cough, chest pain, myalgias/fatigue, rash Sx can persist for months Immunosuppressed  Disseminated disease Treatment Observation Antifungals: ketoconazole, fluconazole, ampho B

14 Aspergillosis Transmission soil, hay, decaying vegetation
Inhalation of spores Signs/Symptoms Allergic bronchopulmonary aspergillosis Hypersensitive reaction – asthma, CF Fever, cough, wheezing, sputum production, hemoptysis Progress to bronchietasis, fibrosis, resp. compromise Aspergilloma (fungal ball in preexisting cavity) Invasive disease – IC

15 Histoplasmosis Transmission via bird droppings (pigeons, bats, chickens) Ohio, Missouri, Mississippi river valley Signs/Symptoms Up to 95% will be asymptomatic Flu like symptoms (fever, HA, malaise, cough) PNA, HSM, rash, arthritis, pericarditis, disseminated dz Treatment Self limited Disseminated dz/IC: Ampho B, fluconazole, ketoconazole

16 Sporotrichosis Fungus Sporothrix schenckii
Found in soil, decaying vegetation Acquired via trauma to skin or inhalation Signs/Symptoms Skin: Local pustule/ulcer , nodules developing along draining lymphatics Systemic: Pulmonary-- granulomatous pneumonitis IC: Disseminated Considered one of the AIDS related conditions Treatment: KI, Antifungals (Ampho B, fluconazole)


18 Parasites

19 Giardiasis Mode of transmission: fecal-oral, contaminated water
Risk factors: poor hygiene, poor handwashing Common cause of diarrhea in daycares Carrier rates up to 60% Clinical presentation Watery foul smelling diarrhea, NON-BLOODY Other sx: low grade fever, bloating/flatus, abdominal cramps, nausea, generalized malaise, weight loss, anorexia Subacute / Chronic – FTT Duration 3-10 wks (untreated)

20 Diagnosis & Treatment Diagnosis Treatment
Stool x 3 for ova and parasites Stool Ag detection (IFA, ELISA) CBC  NO EOSINOPHILA Treatment Metronidazole (Flagyl) Alternatives: Tinidazole,

21 Toxoplasmosis Mode of transmission: undercooked / raw meat, cat feces
Congenital Early infection  less chance of fetal infection but more severe consequences Late infection  more chance of fetal infection but less severe Clinical Asymptomatic Microcephaly, hydrocephalus, chorioretinitis, diffuse cerebral calcifications (ring enhancing), jaundice, HSM 50% rule 50% of infected pregnant women pass to fetus 50% will be asymptomatic at birth Late findings Hearing loss, vision impairment, seizures, MR, LD Diagnosis PCR of amniotic fluid Infant IgG and IgM

22 Toxoplasmosis Acquired Treatment Most will be asymptomatic
Fever, myalgias, HA, fatigue, LAD Treatment Pregnant mom : Spiramycin Pyrimethamine or sulfadiazine + folinic acid


24 Enterobiasis Pinworm Enterobius vermicularis
Common in children ages 5-10 yrs Transmission: direct contact Signs / Symptoms Perianal itching (pruritus ani) – esp. nocturnal Restlessness, insomnia, abdominal pain, N/V Vulvovaginitis, UTI, Eosinophile entrocolitis Diagnosis “Scotch tape” test x 3 (early AM) Treatment Mebendazole or albendazole x 1 dose Repeat in 2 weeks Other considerations Treat household members, wash bedding and clothes Can attend daycare

25 Trichinosis Nematode Trichinella
Ingestion of undercooked or raw meat (esp. pork) Reportable disease Signs/ Symptoms Diarrhea, severe myalgias, fever, facial edema, HA, rash Rhabdomyolysis like (elevated CPK, myoglobinuria) Cardioneurologic Syndrome Dx : Eosinophilia , ELISA after 2 wks, Western blot for confirmation; muscle biopsy Treatment: Mebendazole + Steroids

26 Ascaris Intestinal roundworm Ascaris lumricoides
Fecal – oral transmission, eating soil Increased incidence poor sanitation, travelers, immigrants, refugees, adoption Signs/ Symptoms Early: fever, cough, dyspnea, wheezing Late (GI) : passage of worms, N/V, abdominal pain ***Intestinal obstruction, common bile duct obstruction, cholangitis Eosinophilia, eggs in stool Treatment Albendazole, mebendazole Alternatives: pyrantel pamoate

27 Visceral Larva Migrans
Due to roundworm Toxocara species (dogs, cats) Seen in preschool age children History of eating dirt (ingest eggs) Signs / Symptoms Nonspecific fever, anorexia, pruritic /urticarial rash GI: abdominal pain, HSM Pulmonary: wheezing More serious: Ocular involvement, seizures, Myocarditis, HSM, Encephalitis Dx: Leukocytosis, eosinophilia, elevated isohemagglutinins A, B, ELISA Treatment: supportive, +/- Mebendazole

28 Amebiasis Entamoebal histolytica Fecal – oral transmission
Signs/ Symptoms Most cases asymptomatic Gradual onset bloody diarrhea colicky abdominal pain, tenesmus, anorexia, weight loss, fever Most common extraintestinal manifestation : Liver abscess Other: brain abscess, toxic megacolon, pleuropulmonary Labs: Stool + WBC & RBC, Stool culture + cyst & trophozoites, eosinophilia, mild elevation transminases Treatment Metronidazole

29 Coming soon..… ID part deux Bacterial and Congenital Infections
Whew, that’s all for now!! Coming soon..… ID part deux Bacterial and Congenital Infections

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