12. PERTUSSIS
Nuts and Bolts…
•
•
•
•
•
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Whooping Cough
Summer and Fall months
Cough > 2 weeks
Respiratory Droplets
Vaccination does not equal lifelong immunity
Misdiagnosed as bronchitis
13. 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)
14. 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
15.
16. 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
17. 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
21. TUBERCULOSIS
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•
•
•
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
22. 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
23. 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
24. 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
25. 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
26. 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”
27. THE PLAGUE
•
Gram stain of bubo aspirate
•
CXR – infiltrate or hilar lymphadenopathy
•
Respiratory Isolation
•
Streptomycin or Doxycycline
•
Supportive care
28. 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
29. 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
30. 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
31. 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