Michael Kulczycki, DO- Infectious Disease Board Review 2014- ARMC Emergency Medicine

1. BOARD REVIEW MICHAEL KULCZYCKI DECEMBER 18 2013

2. GOALS • ENDOCARDITIS • MENINGOCOCCEMIA • PERTUSSIS • PNEUMOCOCCEMIA • TETANUS • TUBERCULOSIS • THE PLAGUE • HERPESVIRIDAE • HIV

3. ENDOCARDITIS Subacute Acute • • • • RISK FACTORS • STRUCTURE • • • PROSTHETIC HEART VALVES • Normal Valves Younger Patients Sick Abnormal Valves Older patients Non-specific constitutional symptoms HEART DISEASE • RHEUMATOID HEART DISEASE • MITRAL VALVE PROLAPSE • BICUSPID AORTIC VALVE • IV DRUG ABUSE • CARDIAC PROCEDURES • INDWELLING VENOUS CATHETERS Left Heart • • • • • • More Common S. Viridans S. Aureus Enterococcus CHF, CVA, AV block Systemic infarcts from septic emboli S. Aureus = Single most common cause Right Heart • • • • • IVDA S. Aureus S. Pneumonia Respiratory Symptoms Misdiagnosed as PNA

4. Osler Nodes (painful) Roth Spots Janeway Lesions (painless) Splinter Hemorrhages

5. ENDOCARDITIS JONES CRITERIA – 2 MAJOR, 1 MAJOR + 3 MINOR, 5 MINOR Major • • 2 Positive Blood Cultures • 3 sets 1 hour apart • Cultures of typical bugs • Persistance of cultures > 12 hrs Abnormal Echo • Prosthetic valve dihiscence • New valvular regurg • Myocardial abscess • Visible vegetation Minor • • • • • Predisposition/IVDA Fever Vasular Events/Septic Emboli Immunologic Events Positive Echo or Blood cultures not meeting major criteria

6. ENDOCARDITIS Indications: • Prosthetic Valve • Congenital Defect repaired • Prior Infectious Endocarditis • Cardiac transplant with abnormal valves Manipulation of gingiva/mucosa or apical area of tooth

7. MENINGOCOCCEMIA – NEISSERIA MENINGITIDES Nuts and Bolts… • Military Recruits, College Dorms • Children < 5 • Gram (-) diplococcus • Nasopharynx = portal of entry • Septicemia without meningitis (>20% mortality)

8. MENINGOCOCCEMIA Rash • • Petechia • 50-60% Cases • Can involve mucous membranes • Trunk/Extremites Purpura Fulminans • Rapidly spreading ecchymosis • Gangrene • DIC

9. MENINGOCOCCEMIA Meningococcemia + Bilateral Adrenal Hemorrhage = Waterhouse-Friderichsen Sndrome Fulminant Meningococcemia

10. MENINGOCOCCEMIA • Lumbar Puncture • Early Antibiotics • Prophylaxis for close contacts • Ciprofloxacin • Rifampin • Ceftriaxone

11. PERTUSSIS Nuts and Bolts… • • • • • • Whooping Cough Summer and Fall months Cough > 2 weeks Respiratory Droplets Vaccination does not equal lifelong immunity Misdiagnosed as bronchitis

12. PERTUSSIS Catarrhal Phase Paroxysmal Phase URI like symptoms Cough increases, Cough, low grade fever fever subsides Highest infectivity Paroxysms of coughing (>50 times/day) Convalescent Phase Residual cough (weeks to months)

13. PERTUSSIS • High index of suspition • Lymphocytosis – correlates with severity of disease • CXR: peribronchial thickening • Nasopharyngeal culture • Macrolide (erythromycin) • Prophylactic antibiotics for close contacts • Acellular pertussis vaccination for high risk exposures

14. PNEUMOCOCCEMIA • • Lancet shaped G (+) diplococcus Most common cause of bacterial pneumonia Pneumonia • Severe rigors • Rusty colored sputum Meningitis Septicemia Endocarditis Adult vaccination for: • Adults with chronic illness • Age > 65 • Immunocomprimised / HIV • Anatomic or functional Asplenia

15. TETANUS Found in soil, dust, feces >70 % from wounds (post-operative) Bacteria produce neurotoxins – Tetanolysin/Tetanospasmin • No mental status changes • Weakness, myalgias, dysphagia, hydrophobia, drooling • Trismus – “Lock Jaw” • Risus Sardonicus - facial muscle involved • Opisthotonos – Generalized tetanus, arching of back/ neck • Laryngeal Spasm and Respiratory Failure • Autonomic Dysfunction

16. TETANUS Opisthotonos Risus Sardonicus

17. TETANUS Strychnine Poisoning Pesticide Muscle spasms, trismus, risus sardonicus, seizures

18. TETANUS Benzodiazepines/Narcotics Paralysis (non-depolarizing) Eliminate the toxin – Tetanus Immunoglobilin (TIG) Administer opposite arm of tetanus booster Eliminate the Bug – Flagyl Immunization • • • TIG if < 3 Td and dirty wound Clean wounds – Td if > 10 years Dirty wounds – Td if > 5 years

19. TUBERCULOSIS • • • • Humans sole reservoir Leading cause of infectious death worldwide Leading cause of adrenal insufficiency worldwide One third of world population infected with TB Risk Factors • Immunocompromised / HIV • Close contact / Occupational exposure • Foreign born • Low socioeconomic status • IVDA • Homeless • Prison / shelter

20. TUBERCULOSIS Pulmonary Tuberculosis • • • • • • • Cough – most common symptom Fever Night sweats Weight loss Pleuritic Chest pain Hemoptysis – mild to severe Erosion into pulmonary artery = Rasmussen aneurysm Chest x-ray • Primary TB – difficult to differentiate from PNA • Hilar / Midiastinal LAD common in primary TB • Miliary (disseminated) TB – multiple nodules bilaterally • Reactivation TB – Cavitation without lymphadenopathy

21. TUBERCULOSIS Extrapulmonary TB Lymphadenitis – Scrofula • Enlarged / painful mass near cervical nodes • Most common extrapulmonary manifestation • Do Not I&D Bone and Joints – Pott’s Disease (spine) Acute Dissemination • Typically elderly and AIDS • Associated with SIADH CNS – Tuberculous Meningitis • Subependymal tubercle ruptures into subarachnoid space • Lowest CSF glucose of any meningitis

22. TUBERCULOSIS AFB sputum smear – hours, many false negatives/positives AFB culture – weeks, Gold standard, 87% sensitive Isoniazid – seizures (pyridoxine) Latent TB • Isoniazid - 9 months Active TB • 4 drug regimen – 6 months Extrapulmonary TB • 4 drug regimen – 6 months Rifampin – orange urine. OCP failure Pyrazinamide - hepatotoxic Ethambutal – red-green color blindness Pregnancy – INH, RIF, ETH cross placenta and are safe

23. THE PLAGUE – YERSENIA PESTIS Nuts and bolts… • Vector – rat flea – xenopsylla cheopis • Traditionally from rats, now squirrels and cats • Potential biologic weapon • Transmission – bites, close contact, direct inhalation • Veterinarians, animal handlers • Non-specific symptoms – Fever and myalgias

24. THE PLAGUE Three Clinical Syndromes Bubonic Plague • Bubos on the skin, invasion of lymphatics and vasculature • Generalized painful LAD Septicemic Plague • Direct invation of vasculature without bubos Pneumonic Plague • Most aggressive • Severe pneumonas, sepsis, death Black Plague – deep cyanosis and gangrene with disseminated disease “Ring around the rosy” “Ashes, ashes we all fall down”

25. THE PLAGUE • Gram stain of bubo aspirate • CXR – infiltrate or hilar lymphadenopathy • Respiratory Isolation • Streptomycin or Doxycycline • Supportive care

26. HERPESVIRIDAE Herpes Simplex Virus HSV-1 - oropharyngeal HSV-2 – genital Multiple, painful shallow ulcers which may coalesce Shedding lasts up to 3 weeks Herpetic Whitlow • Herpetic finger infection • Do not I&D Neonatal Herpes • Transmission at deliver • High mortality if untreated Herpes Encephilitis • Most common cause of encephalitis in U.S. • Fever and bizarre behavior

27. HERPESVIRIDAE Varicella-Zoster Virus Chickenpox • Acute generalized viral illness • Lesions everywhere on skin and mucous membranes (palms/soles spared) • Maculopapular then vesiculated Herpes Zoster • Reactivation in DRG – dermatomal • Multiple vesicles on erythematous base Zoster Opthalmacus • Lesions on cornea / tip of nose (Hutchinson sign) • Nasociliary branch of V1 - opthalamic branch of trigeminal nerve Ramsy Hunt Sydrome • Bells palsy with herpetic blisters in the auditory canal or pinna

28. HERPESVIRIDAE Epstein Barr Virus Fever Exudative tonsillitis Posterior cervical LAD Hepatomegally in 50% Lymphocytosis with atypical lymphocytes Splenic Rupture – no contact sports Characteristic rash with antibiotics (ampicillin) Supportive treatment Steroids for severe tonsilar edeam

29. HIV Nuts and bolts… Retrovirus HIV-1 (most common), HIV-2 (western Africa) Semen, vaginal secretions, blood, breastmilk Attacks CD4 Helper T cells Acute HIV infection • Follows exposure by 2-6 weeks • Usually missed

30. HIV AIDS - CD4 < 200 CD4 < 500 • TB, Zoster, HSV CD4 < 200 • Pneumocysti Jiroveci Pneumonia, Candidiasis, AIDS Dementia, NonHodgekin B-cell lymphoma CD4 < 100 • Toxoplasmosis, isospora, microsporidia, histoplasmosis, cryptococcus CD4 < 50 • CMV, progressive multifocal leukocencephalopathy (PML), MAC

31. HIV Pneumonia Most common reason for ER visit CD4 > 500 – encapsulated bacteria, TB, malignancy CD4 < 500 – Think PJP, Fungal, CMV Pneumocystis Jiroveci Pneumonia • Diffuse interstitial infiltrate – “bat wing” • Bactrim DS • Steroids of PaO2 < 70 or Aa gradient > 35 • Prophylaxis with Bactrim if CD4 <200 • Pentamidine 2nd line agent if sulfa allergy

32. HIV Buzz words Diarrhea - cryptosporidium, isospora Esophagitis – CMV, candidiasis, HSV Retinitis – CMV Ring enhancing lesions – Toxoplasmosis, CNS lymphoma Fever and headache – Cryptococcus Plaques on Tongue – oral candidiasis vs hairy leukoplakia Purple papules/plaques – Kaposi’s sarcoma

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