Infections (2nd Edition 2019-2020) PDF

'It is more blessed to give than to receive. In Capsule Series Internal Medicine INFECTIONS Second edition...

'It is more blessed to give than to receive. In Capsule Series Internal Medicine INFECTIONS Second edition 2019-2020 By : Dr. Ahmad M.Mowafy  Freely you have received; freely give. Index Infections scheme............................... 1 Typhoid......................................... 2 Brucellosis...................................... 6 Malaria......................................... 8 Infectious mononucleosis........................ 13 Fever of unknown origin......................... 15 Fever with rash................................. 18 Fever with bradycardia........................... 18 Fever with lymphadenopathy....................... 19 Fever with jaundice.............................. 19 Fever with sore throat........................... 20 Fever with rigors................................ 20 Fever with abdominal pain........................ 21 Fever with headache.............................. 21 Fever with arthritis............................. 21 Associations of EBV.............................. 21 HIV.............................................. 22 Streptococcal infections......................... 22 Amebiasis........................................ 22 Treatment of some parasites...................... 23 Hyperpyrexia V.S. hyperthermia.................. 24 'It is more blessed to give than to receive. In Capsule Series Infections INFECTIONS SCHEME Etiology : 1. Causative organism: 2. Source of infection : 3. Mode of infection : Clinical picture : 1. Incubation period : Usually 1 – 2 weeks , but in cholera 1 – 5 days. 2. Clinical manifestations. 3. Clinical variants. 4. Complications : specific + ….itis Investigations : 2C + 2S 1. CBC : 2. Culture : 3. Serological tests. 4. Specific : Differential diagnosis : 1. Specific. 2. PUO ( Pyrexia of Unknown Origin ) Treatment : a) Prophylaxis : i. Hygienic measures. ii. Case finding. iii. Isolation & Proper treatment. iv. Chemo & immuno – prophylaxis : ………. 1  Freely you have received; freely give. In Capsule Series Infections b) Therapeutic : i. General : Rest , light nutrient diet. ii. Symptomatic : antipyretic. iii. Specific : ……… iv. Treatment of complications. TYPHOID Etiology : 1. Causative organism: Salmonella typhi & paratyphi A & B 2. Source of infection : Patient , Carrier. 3. Mode of infection : Feco – oral transmission. Clinical picture : 4 Weeks 1. Incubation period : 1 – 2 weeks. 2. Clinical manifestations : 1st week: 10 ( 3 general + 3 respiratory + 3 GIT + rash ) i. Fever : temperature rises in a step ladder manner until reaching 39 – 40o C by the end of the 1st week. ii. Headache. iii. Relative bradycardia. iv. Sore throat. v. Cough. vi. Epistaxis. vii. Coated tongue. viii. Constipation. ix. Spleen : palpable , soft & tender. 2 'It is more blessed to give than to receive. In Capsule Series Infections x. Rash ( rose spot ) : 10% o Site : Trunk. o Duration : Transient. 2nd week: ( The same as 1st but severe , no rash ) o Fever : ↑ , Continuous o Headache : ↓ with delirium. o Tachycardia. o Coated tongue. o Splenic enlargement. o Diarrhea may occur ( pea soup ). 3rd week: either o Clinical manifestations start to improve. or o Complications occur. 4th week: Convalescence begins ( but relapse may occur ) 3. Clinical variants : 6 o Afebrile. o Ambulatory. o Abortive ( mild ) o Grave : ( severe ) o Sudoral form : excessive Sweating. o Localized : Pleuro typhoid , pneumo typhoid , meningo typhoid. 4. Complications : specific + …itis 6 o GIT :  Intestinal hemorrhage , Perforation.  Peritonitis , Cholecystitis. 3  Freely you have received; freely give. In Capsule Series Infections o CNS :  Meningitis , encephalitis , peripheral neuritis.  Typhoid state : delirium , convulsion. o CVS : myocarditis. o Chest : Epistaxis , bronchitis. o Renal : Pyelonephritis , GN. o Relapse. Investigations : 1. CBC : o ESR : ↑ o Leucopenia with relative lymphocytosis. 2. Culture : o Blood culture : +ve in 1st week o Stool culture : +ve in 2nd week. o Urine culture : +ve in 3rd week. 3. Specific : ( Widal test ) o It is +ve from 2nd week. o It is +ve when titre > 1/80 Differential diagnosis : PUO ( Pyrexia of Unknown Origin ) Treatment : a) Prophylaxis : i. Hygienic measures. ii. Case finding. iii. Isolation & Proper treatment. iv. Immuno-prophylaxis : TAB vaccine. v. Treatment of carriers : o Ampicillin : 6 gm/d for 6 weeks. o Cholecystectomy : may be indicated in resistant cases. 4 'It is more blessed to give than to receive. In Capsule Series Infections b) Therapeutic : i. General : Rest , light nutrient diet. ii. Symptomatic : antipyretic. iii. Specific : for 2 weeks 3C  Chloramphenicol : 50 mg/kg/d , orally  Ciprofloxacin : 750 mg/12h.  Co-trimoxazole ( septrin ) : 2 tab / 12h. iv. Treatment of complications.  Perforation : surgical treatment.  Hemorrhage : blood transfusion & anti-shock measures. Side effects of ciprofloxacin: 7 Hypersensitivity Photosensitivity Nephrotoxic Chondrolytic, reversible arthropathy ( CI in pregnancy ,lactation, prepubertal children) Confusion, headache Crystallurea Distension GIT , super infection 5  Freely you have received; freely give. In Capsule Series Infections BRUCELLOSIS (malta fever , undulant fever ) Etiology : 1. Causative organism: Brucella , Gm –ve coccobacilli 2. Source of infection : o Brucella melitenesis : in goats o Brucella abortus : in cows o Brucella suis : in pigs. 3. Mode of infection : o Drinking contaminated milk. o Dealing with infected animals : farmers , veterinarian. Clinical picture : 1. Incubation period : 1 – 2 weeks. 2. Clinical manifestations : mnemonic : brucellosis o Bone & muscle pain. o Relapsing fever : fever lasts for 10 days then apyrexia for 10 days , then relapse and so on. o Constipation , nausea , vomiting. o Lymph node enlargement. o Liver : enlarged , tender. o Spleen : enlarged. o Sweating. 6 'It is more blessed to give than to receive. In Capsule Series Infections 3. Clinical variants : 6 o Intermittent. o Remittent. o Continuous o Mild. o Malignant. o Localized brucellosis e.g. bone , testis. 4. Complications : 5 o Relapse. o Infective endocarditis. ‫ﯾﺑوظ اﻟﻘﻠب وﯾﻣﻧﻊ اﻟﻣﺷﺎﻋر‬ o Orchitis. ‫ﯾﻣﻧﻊ اﻟﻠﻲ ﺑﺎﻟﻲ ﺑﺎﻟك‬ o Paraplagia due to transverse myelitis....‫ﯾﺟﯾب ﻟك ﺷﻠل‬ o Abortion.... ‫وﺑﻌد ﻛل ده ﻟو ﺣﺻل ﺣﺎﺟﺔ‬ Investigations : 1. CBC : Lymphocytosis , ↑ ESR 2. Culture : blood culture +ve during fever spike. 3. Serological tests : Brucella agglutination test. Differential diagnosis : 1. Fever with lymphadenopathy. 2. PUO ( Pyrexia of Unknown Origin ) Treatment : a) Prophylaxis : Hygienic measures e.g. Pasteurization of milk. b) Therapeutic : i. General : Rest , light nutrient diet. ii. Symptomatic : antipyretic & analgesics. iii. Specific :  Tetracycline : 500 mg/6h for 6 weeks. or  Doxycyclin : 200 mg/d for 6 weeks. or  Septrin : 2 tab /12h for 6 weeks Plus  Streptomycin : 1 gm/d IM for 2 weeks or  Rifamicin : 600 mg/12h. iv. Treatment of complications. 7  Freely you have received; freely give. In Capsule Series Infections MALARIA Etiology : 1. Causative organism: Four species affect mankind : Plasmodium vivax , ovale , malariae & falciparum. P. falciparum is potentially lethal , the others are usually benign. 2. Source of infection : Patients. 3. Mode of infection : Bite of female anopheles mosquito. Life cycle : 1) Sexual cycle : in female mosquito. ( exogenous phase ) ♀ mosquito picks up gametocytes from infected individual → sporzites → migrate to salivary gland to be injected into man. 2) Asexual cycle : in man ( endogenous phase ) i. Exo-erythrocytic stage : infected mosquito injects sporozytes → which migrate to liver where they formmerozites → Merozites are released to blood stream. ii. Erythrocytic stage : Merozites invade the RBCs → signet ring form→ Trophozites → rupture of RBCs releasing merozites which can infect other RBCs. Clinical picture : 1. Incubation period : 1 – 2 weeks. 2. Clinical manifestations : 3 i. Benign Tertian malaria: ( infection with P. vivax & ovale ) - The attacks occur every 48 hours. - The attack passes into 3 stages : Cold stage , Hot stage & Sweating stage. 8 'It is more blessed to give than to receive. In Capsule Series Infections a) Cold stage : ( lasts for 1 hour )  o Acute onset of sense of coldness & rigor. o Rapid rise of temperature to 39 – 40 ᵒ C o Vomiting & polyuria. b) Hot stage : ( lasts for 8 hours )  o Hotness & flushed face. o Headache. o High temperature. c) Sweating stage : ( lasts for 3 hours ) o Sweating with rapid fall of temperature with no or mild vomiting. o Spleen is enlarged after 2 weeks. ii. Quartan malaria: ( infection with P.malariae ) Similar to benign tertian malaria but the attacks occur every 72 hours. iii. Malignant malaria: ( infection with P. falciparum ) 3 a) Ordinary tertian type : Clinical manifestations are similar to benign tertian malaria but : Hot stage is prolonged. Sweating stage : ↓ Splenomegaly occurs within less than 1 week. b) Pernicious type : ( complicated – fatal ) ABCD i. Algid malaria : Abdominal pain , shock , hypothermia. ii. Bilious remittent fever : Jaundice , vomiting , gastric pain. 9  Freely you have received; freely give. In Capsule Series Infections iii. Cerebral malaria : Headache , Hyperpyrexia , Focal neurological disorders , Psychosis, RDS, retinal Hge, irritability up to coma, severe thrombocytopenia. iv. Dysenteric type : dysentery. c) Blackwater fever : o Blackwater fever is a complication of malaria characterized by intravascular hemolysis, hemoglobinuria and acute renal failure. o Quinine – anti-malarial drug – may play a role in triggering the condition. o Most probably autoimmune ? o Clinical picture :  i. Hemolysis : Fever , rigor , anemia , jaundice. ii. Hemoglobinuria : dark red or black urine ( hence the name ) , loin pain. iii. Acute renal failure : due to massive intravascular hemolysis 3. Complications of malaria : 6 Malignant malaria : ( complications of P. falciparum ) i. Pernicious malaria : ABCD ii. Blackwater fever : Hemolytic anemia , acute renal failure. Relapse : in P. ovale & vivax. ( No relapse in P falciparum ) Rupture of spleen. Tropical splenomegaly syndrome. Malarial hepatitis syndrome ( easily mistaken clinically for viral hepatitis ) Nephrotic syndrome : especially in quartan malaria ( P. malariae ) 10 'It is more blessed to give than to receive. In Capsule Series Infections Investigations : 1. Detection of the parasite : blood film , bone marrow aspirate. 2. CBC: Features of hemolytic anemia. Leucocytosis during the attack. 3. Serological tests: to detect antibodies. 4. Therapeutic test: fever responds to anti-malarial drugs. 5. Investigations for complications: e.g. Acute renal failure. Differential diagnosis : 1. Fever with rigor. 2. PUO ( Pyrexia of Unknown Origin ) Treatment : a) Prophylaxis : i. Hygienic measures ( Anti-mosquto measures ) : Insecticides , bed nets , repellants. ii. Chemo prophylaxis : when travelling to endemic areas.  Chloroquine : 500 mg/week, one week before arriving and 4 weeks after leaving  Others : primaquine , mefloquine , proguanil. b) Therapeutic : Active malaria infection withP. falciparumis a medical emergency requiring hospitalization. Infection with P. vivax, P. ovale or P. malariae can often be treated on an outpatient basis. i. General : Rest , light nutrient diet. ii. Symptomatic : antipyretic. iii. Specific : ( Anti-malarial drugs ) a) Tissue schizonticides ( against exoerythrocytic form) : for preventing relapse e.g.  Primaquine.  Pyrimethamine. 11  Freely you have received; freely give. In Capsule Series Infections b) Blood schizonticides : (ttt of Acute malaria) These drugs act on the erythrocytic forms of the parasite and terminate clinical attacks of malaria. These are the most important drugs in anti malarial chemotherapy e.g.  Chloroquine : - Dose : 4 tab at first ( tab = 250 mg ) , then 2 tab after 12 h then 2 tab/d for 2 successive days. - Side effects : Corneal opacity , GIT irritation , Itching. - Contra indications: Chloroquine should be used with caution in patients with hepatic disease.  Quinine : Dose : 650 mg t.d.s. for 1 week Side effects : Cinconism ( nausea , vomiting , tinnitus ) , Hemolytic anemia.  Mefloquine.  Fansidar ( compination of pyrimethamine & sulphadoxine ) 3 tab as a single dose.  Doxycycline.  clindamycin iv. Treatment of complications: e.g. blackwater fever o Acute renal failure : dialysis. o Blood transfusion. o Cortisone Throughout nature, infection without disease is the rule rather than the exception. Rene Dubos 12 'It is more blessed to give than to receive. In Capsule Series Infections INFECTIOUS MONONUCLEOSIS ( Glandular fever ) Etiology : 1. Causative organism: Epstein – Barr virus. 2. Source of infection : Carriers , Patients. 3. Mode of infection : Kissing , droplets infections. Clinical picture : 1. Incubation period : 1 – 2 weeks. 2. Clinical manifestations : 7 o Asymptomatic. o Fatigue. o Sore throat , tonsillitis. pharyngitis. o Fever : is usually present and is low grade. o Enlarged LN , spleen & liver. o Transient rash on ampicillin therapy. o Periorbital edema. 3. Clinical variants : 5 o Glandular type. o Aglandular type : especially in elderly patients. o Febrile type : with high fever. o Ictric type : with jaundice , especially in elderly patient. o Encephalitic type. 13  Freely you have received; freely give. In Capsule Series Infections 4. Complications : 4 o Liver : hepatitis. o Spleen : Rupture. o Blood : Autoimmune hemolytic anemia , thrombocytopenia. o CNS : Meningitis, encephalitis, transverse myelitis , Guillain-Barré syndrome. EBV infection has also been proposed as a risk factor for the development of multiple sclerosis but this has not been confirmed. Investigations : 1. CBC :lymphocytosis & monocytosis. 2. Culture and BM examination. 3. Serological tests: anti EBV antibodies. 4. Specific : monospot test( antibodies in human serum  agglutinate horse RBCS) Differential diagnosis : 1. Specific. 2. PUO ( Pyrexia of Unknown Origin ) Treatment : a) Prophylaxis : i. Hygienic measures. ii. Case finding. iii. Isolation & Proper treatment. iv. Chemo & immuno – prophylaxis : b) Therapeutic : i. General : Rest , light nutrient diet. ii. Symptomatic : antipyretic. iii. Specific : no specific ttt. iv. Treatment of complications. 14 'It is more blessed to give than to receive. In Capsule Series Infections FEVER OF UNKNOWN ORIGEN (FUO) FUO) Definition : Persisting elevation of body temperature over 38.5 for at least 2 weeks without diagnosis after proper history taking ,physical examination & routine investigations. Causes :  Infections (30% ) Types of Fever Bacterial: Sustained fever: daily fluctuations less than 1 c°  TB Remittent fever: daily fluctuations  IE more than 1 c°  Typhoid fever Hectic fever: temp. falls to normal level once or more during the day.  Brucellosis  Lung abscess Relapsing fever: short days of fever intercepted by short days of  Pyelonephritis normal temp.  Septic focus ( prostatitis ) Normal body temp. is 36.5 – 37.3 c° Viral :  EBV – CMV – HIV – Hepatitis Protozoa :  Malaria  Amoebiasis 15  Freely you have received; freely give. In Capsule Series Infections Malignancy (20%) hematologic :  Lymphoma  Leukemia Non hematologic :  Hypernephroma  Hepatoma  Bronchogenic carcinoma Collagen disease (10%)  Rheumatic fever , PAN , SLE , RA Others (20% )  Sarcoidosis.  Pulmonary embolism.  Hemolysis.  Crohn’s disease.  Cerebral hemorrhage.  Atropine. Undiagnosed (20%) Most will resolve spontaneously 16 'It is more blessed to give than to receive. In Capsule Series Infections Investigations : 1. Lab :  ESR ↑: TB , collagen, malignancy.  CBC: leukemia , anemia.  Blood culture.  Urine & stool culture.  Liver , kidney function test.  Serology → widal test , ANA &Anti DNA. 2. Imaging :  x-ray: chest , bone.  U/S :Heart , Abdomen , Pelvis. 3. Endoscopy :  upper GIT & lower GIT. 4. Biopsy :  LN , Bone marrow , liver. 5. Skin test :  tuberculin test. 6. Therapeutic tests :  Mitronidazole ( amoeba )  Chloroquine ( malaria )  Aspirin ( RF) 17  Freely you have received; freely give. In Capsule Series Infections FEVER WITH RASH 4 Viral Infection: - Exanthemata: ( Measles, rubella, Chickenpox ) - Infectious mononucleosis (EBV) Bacterial Infection: - Exanthemata: Scarlet fever - Infective endocarditis - Lyme disease - Typhoid - Secondary syphilis - Meningococcal Meningitis - Septicemia (toxic shock syndrome) Autoimmune: - Rheumatic fever - SLE - RA Others: - Leukemia - Skin disease - Drug allergy (steven johnson's rash) FEVER WITH RELATIVE BRADYCARDIA A. Specific fevers: Viral infection eg , influenza , viral hepatitis , mumps. Typhoid fever Mycoplasmal pneumonia B. CNS lesions with increased ICT: Meningitis Encephalitis Brain abscess Intracranial hemorrhage eg , subarachnoid & pontine hemorrhage. 18 'It is more blessed to give than to receive. In Capsule Series Infections FEVER WITH lymphadenopathy Infectious disease:  Bacterial: TB, Brucellosis  Viral: EBV, CMV  Protozoal: toxoplasmosis Autoimmune:  Collagen disease as: SLE, RA Malignancy:  Leukemia as: CLL  Lymphoma Granulomatous disease:  Sarcoidosis FEVER WITH jaundice  Hepatocellular Jaundice: o Viral hepatitis o Drug hepatitis o EBV o Yellow fever o Septicemia o Cirrhosis  Obstructive Jaundice: o Calcular cholecystitis o Charcot's fever o Cancer head of pancreas o Liver secondaries  Hemolytic jaundice: o Malaria (Black water fever) o Hemolytic anemia (congenital And acquired) 19  Freely you have received; freely give. In Capsule Series Infections FEVER WITH SORE THROAT 1. Local throat diseases: Tonsillitis Pharyngitis Vincent’s angina Pharyngeal abscess Pharyngeal ulcers 2. Specific fevers: Diphtheria Infectious mononucleosis Scarlet fever 3. Hematological diseases: Leukemia Neutropenia eg. in aplastic anemia FEVER WITH RIGORS Malaria. Liver abscess. Hemolytic crisis. Subpheneric abscess. Blood transfusion ( hemolytic Pyelonephritis. or pyogenic reaction ) Perinephric abscess. Military TB Appendicitis. Septicemia. Osteomyelitis. IE. Prostatitis. Cholecystitis. Puerperal sepsis. Cholangitis. Salpengitis. 20 'It is more blessed to give than to receive. In Capsule Series Infections FEVER WITH abdominal pain Diffuse abdominal pain:  Spontaneous Bacterial peritonitis  Secondary peritonitis localized abdominal pain:  Hepatitis  Pyelonephritis  Cholecystitis  Splenic abscess  Cholangitis  Diverticulitis  Appendicitis FEVER WITH headache Allergies Heat stroke Cold and flu Sinusitis Meningitis Brain abscess FEVER WITH Arthritis Septic arthritis Collagen and autoimmune disease o SLE o Rh. Arthritis o Rh. Fever Reactive arthritis o Reiter's arthritis Associations of EBV Chronic fatigue syndrome Arthralgia Lymphoma Nasopharyngeal carcinoma (NPC) 21  Freely you have received; freely give. In Capsule Series Infections HIV Mode of transmission:  Sexual (hetero>homo)  Perinatal  Parenteral stages: 1. Acute viral infection 3. Symptomatic 2. Asymptomatic 4. AIDS Streptococcal infections Diseases caused by it: o Pharyngitis o Erysipelas o Necrotizing fasciitis o Pneumonia o Pyoderma o Bacillary dysentery o Cellulitis (shigellosis) Symptoms of bacillary dysentery: o Abdominal discomfort ----> dysentery o Vomiting, dehydration, fever Inv. Stool analysis (and culture) TTT replacing fluids and salts ciprofloxacin Amebiasis Inv. Stool analysis (3 separate samples) Sigmoidoscopy Serology (by immune flurescence) TTT 1. Luminal amoebicidal (quinoline, quinines, diloxanide) 2. systemic amoebicidal (emetine, dehydro-emetine, chloroquine) 3. Luminal amoebicidal Metronidazole (750mg, tds, for 10 days) Or Tinidazole (2gm daily, for 5 days) 22 'It is more blessed to give than to receive. In Capsule Series Infections TREATMENT OF ANCYLOSTOMA – ASCARIS – ENTOROBIUS VERM. 1. Flubendazole or Mebendazole: Drug of choice ( 100 mg. 1x2x3) 2. Thiabendazole: 25 mg/kg/day for 2 days 3. Pyrantel Pamoate: 11 mg/ kg single dose 4. Levamisole: 150 mg single dose NB in case of Entorobius verm. ttt. of all family members at the same time. TREATMENT OF BILHARZIASIS 1. Praziquantel: Drug of choice of all types. Mechanism of action: Ca influx into the worm  marked contraction & spastic paralysis of the worm. Dose: 40mg / kg oral single dose. S/E: headache, abdominal pain , nausea, vomiting, pruritis, fever, elevation of liver enzymes. 2. Oxamniquine. 3. Metrifonate. 4. Niridazole. TREATMENT OF GIARDIA 1. Metronidazole: 2gm single dose for 2 successive days. 2. Tinidazole: 2gm single dose. This is only the Drug treatment take care there are other treatment items like general care, symptomatic ttt., and ttt. of complications. 23  Freely you have received; freely give. In Capsule Series Infections Hyperpyrexia V.S. Hyperthermia 24