Infectious Diseases for Studs

INFECTIOUS DISEASES

* Best Initial Antibiotics for different Organisms :
 Staph Aureus : Dicloxacillin, Oxacillin [Penicillins] / Cefadroxil, Cefalaxin [1st
generation Cephalosporins]
 If patient is allergic to above groups – Macrolide, newer fluoroquinolone
 If patient has MRSA – Vancomycin / Linezolid
 Streptococcus : Penicillin (if sensitive) / Ceftriaxone / levofloxacin
 Strep Pneumonia : Penicillin G / Ceftriaxone / levofloxacin
 Strep Viridans : Penicillin G / Ceftriaxone
 Strep Pyogens : Ampicillin / Ampicillin + Sulbactam
 Strep Meningitis : Ceftriaxone
 Listeria Monocytogens : Ampicillin
 Legionella Pneumonia : Erythromycin
 Rickettsia in children : Chloramphenicol, Erythromycin
 Rickettsia in adults : Doxycycline
 Lyme disease in children < 9yrs of age : Amoxicillin
 Lyme disease in children >9 yrs of age and adults : Doxycycline
 Lyme disease in Pregnant women : Amoxicillin
 Disseminated Lyme disease [Bell’s palsy, Cardiac involvement, CNS involve -
ment]: Ceftriaxone
 Syphilis : Penicillin G
 Gonococcus : Ceftriaxone
 Chlamydia, Mycoplasma : Macrolides / Doxycycline
 C.Jejunii : Erythromycin
 H Influenzae : 2nd or 3rd generation cephalosporin
 E coli : Ciprofloxacin / Ampicillin
 Pseudomonas : Piperacillin, Ticarcillin [Anti-pseudomonal penicillin]
 Klebsiella : 2nd or 3rd generation cephalosporin
 Cryptococcus : Amphotericin B (severe), Fluconazole (prophylaxis)
 Candida : Fluconazole
 Dermatophytes : Terfinabine (oral) / Meconazole (local)
 PCP : Trimethoprim + Sulfamethoxazole
 Actinomycetes : Penicillin
 Nocardia : Sulfonamides
 Anaerobes : Metronidazole / Clindamycin
 Penicillin and Aminoglycosides have synergistic effects so combination of
both (Penicillin + Aminoglycosides) is used in Enterobacteraceae and
Pseudomonas infections

 Meningitis : infection of covering of brain – fever, headache, stiff neck and focal
neurologic deficiet
· Causes :
˗ New born (< 1 month ) ®Group B Streptococci, E.coli, L. monocytogen
˗ 1 month – 18 yrs Old ® N.meningitides
˗ >18 yrs Old ® Strep Pneumoniae
˗ Staph Aureus ® recent neurosurgery
˗ L.monocytogens ® Immunocompromised (Neonates & elderly Patients)
˗ Cryptococcus ® HIV positive, CD4
+ < 100 cells
˗ RMSF ® rash on wrist, ankle ® spread towards body
˗ Neisseria ® Petechial rash
˗ Cause of viral meningitis in pediatric population in US – Arbovirus and
Enterovirus
˗ CN – 8 deficits is more common long-term neurological deficit
· Sign & Symptoms of meningitis but appear less toxic – Aseptic (Viral) meningitis
[ECHO virus – belongs to enterovirus – Picornavirus family]
· Management :
˗ Lumbar Puncture (Next Best Step / First step in management)
˗ CT scan of the Head (If Papilledema, focal motor deficit, confusion, coma)
then Lumbar puncture (LP)
˗ Culture of the CSF (most accurate test)
˗ Lyme , RMSF , Syphilis ® Serologic test
˗ Cryptococcus ® India ink test, cryptococcal antigen test

count [Neutrophils]
· CSF findings of Viral Meningitis – increase WBC (lymphocytes), normal
glucose

(Lymphocytes) , low glucose
· Treatment :
˗ Ceftriaxone (Best initial empiric therapy)
˗ Ceftriaxone + Ampicillin ( if L.monocytogens is suspected)
˗ Amphotericin B (Best initial therapy for Cryptococcus)
˗ RMSF ® Chloramphenicol, Erythromycin (children) / Doxycycline (Adults)
˗ Tx of tubercular meningitis – at least 12 months
 Encephalitis -> infection of parenchyma of brain – fever, headache, stiff neck and
altered mental status
· Causes :
˗ HSV (temporal lobe) (most common)
· Management :
˗ Lumbar Puncture (Next Best Step / First step in management)

˗ CT scan / MRI of the Head
˗ PCR for HSV
· Treatment :
˗ IV Acyclovir for HSV
˗ Ganciclovir / Foscarnet for CMV
* Brain Abscess :
· Headache, fever, focal neurologic deficit
· CT scan with contrast (Best initial test)
· Biopsy of the lesion + gram stain + culture (most accurate test)
· Treatment : HIV positive ® Toxoplasmosis / Lymphoma (90% of cases) ®
Pyrimethamine + Sulfadiazine for 14 days followed by CT scan to check lesion
regress or not. If not regress, most probably lymphoma (Tx: radiation)
· Combination of Antibiotics (gram (+), gram(-), Anaerobes)
* Transverse Myelitis – rapidly progressing lower extremity weakness following
URI, accompanied by sensory loss and urinary retention – Dx: MRI
* Epidural abscess – patient with h/o IV drug abuse
* Otitis Media :
· Strep. Pneumoniae (35-40 %) , H. influenzae (25-30%),Moraxella(15-20%)
· Earache, fever, decrease hearing, red, bulging tympanic membrane with loss of
light reflex, immobility of the membrane on insufflations of the ear with air
· Amoxicillin (Best initial therapy) / Amoxicillin + clavulanate (if recent use of
Amoxicillin)
· Azithromycin / newer fluoroquinolone (Alternatives)
· Complications : The most common complication after an episode of otitis media
is another episode of otitis media – Acute mastoditis [pinna displaced inferior &
laterally – X-ray of skull, mastoid – IV antibiotics + surgical debridement
(mastodectomy may require)] Middle ear effusion [A normal appearing tympanic
membrane with decrease movement of pneumatic otoscopy in patient treated for
recent acute otitis media – follow up after 4-6 wks; If not resolved, tympanostomy
may require; referral to ENT]
* Malignant Otitis Externa : Diabetes Mellitus + foul smelling ear discharge &
granulation Pseudomonas Tx: IV Ciprofloxacin
* Sinusitis :
 Headache (worse on leaning forward), facial pain, nasal discharge
 Maxillary sinus x-ray (best initial test)
 Uncomplicated ® decongestant , Analgesic
 Complicated (discolored nasal discharge) ® Antibiotics
 Pharyngitis :
 Viruses, group A streptococci (15-20%)
 Exudates covering is highly suggestive of Strep.pyogen

 RM Centor at el criteria for Mx of Pharyngitis – fever, tonsillar exudates, tender
cervical lymphadenopathy and absence of cough – If 1 or 2 present, rapid antigen
test. If test is positive, give antibiotics; If 3 or 4 present, give empiric antibiotics
 Rapid Strep test (Best initial test / next step in management)
 Tx : Penicillin (1st choice), Macrolide / 2nd generation Cephalosporin orally
 Benefit of antibiotic therapy in patient with Strep. Pyogens pharyngitis – it can
prevent Rheumatic fever (not glomerulonephritis)
 Influenza :
 fever, headache, myalgias, fatigue
 Rapid antigen detection method of swab or washing of nasopharyngeal secretion
 Viral culture (most accurate test)
 Oseltamivir / Zanamivir (active against both A & B) ® within 48 hrs of onset of
Symptoms
 Vaccination (C/I in patients allergic to eggs)
 Lung Abscess :
˗ chest X-ray (Best initial test)
˗ Biopsy of lesion & culture (most accurate test)
˗ Clindamycin (Best initial Therapy)
˗ Alcoholic, Extremely bad odor ( like decomposing dead animal)
 Pneumonia :
˗ Following flu ® Stap. Aureus ( abscess )
˗ HIV positive ( CD4+ < 200 cells ) ® PCP
˗ C alifornia , desert of Arizona ® Coccidiomycosis
˗ Young ( school children ) ® Mycoplasma
˗ Alcoholics ® Klebsiella
˗ Smoker, COPD ® H. influenzae
˗ Elderly pt, CXR – lobar consolidation ® Strep. Pneumoniae
˗ Neutropenia, Steroid use, cavitatory lesion, part of the lesion moves on CXR
when patient change position ® Aspergilloma (fungus ball)
˗ Exposure to animal at the time of giving birth ® Coxiella Burnetti ( Q-fever )
˗ Birds, Triad of pneumonia, spleenomegaly and meningoencephalitis [fever, dry
cough and headache] in immunocompetent host ® Chlamydia Psittaci
Pneumonia – Tx: Doxycycline (follow-up on out patient basis)
˗ Old , smoker , Air–conditioning ® Legionella
˗ Pneumonia & diarrhea in transplant patient  CMV
˗ Immunocompromised patient, gram (+) branching rods & partially acid-fast 
Nocardia (Trimethoprim-Sulfamethoxazole)
˗ Recurrent pneumonia in chronic smoker, next step?  CT chest to rule out lung
CA which may obstruct bronchus and produce recurrent pneumonia
· Best diagnostic test for patient with recurrent pneumonia [most probable cause

will be an endobronchial obstruction] – Flexible bronchoscopy [If question is “what is the best next step in Mx of patient with recurrent pneumonia?” – order chest CT scan]
Empiric Therapy
Community – Acquired Community – Acquired Hospital – Acquired
(out-patient) (Inpatient) Pneumonia

Hospitalization)
Newer Fluoroquinolones O2 Saturation ( < 94 % at
room )
3rd generation
Cephalosporin
PR > 24 Carbapenem
Macrolide / Doxycycline +
New fluoroquinolone / 2nd
generation cephalosporin/
B-lactam + B – lactamase
inhibitor combination
B-lactam / B- lactamase
inhibitor combination
 PPD : PPD is Positive if induration after 48 hrs is
- > 5 mm ® HIV Positive , recent exposure to TB , Immunocompromised
- > 10 mm ® High risk group ( Health workers , recent immigrant , Homeless)
- > 15 mm ® Low risk group
- PPD is Best screening Test (not diagnostic test) to check TB exposure
- PPD positive, CXR negative – INH + Vit-B6 for 9 months; PPD become
positive again on routine test and CXR negative – reassurance and no Tx require
- Prophylaxis for only INH resistant TB – Rifampin for 4-months
- Prophylaxis for both INH and Rifampin resistant TB – Pyrazinamide and
Ethambutol or levofloxacin
 Diarrhea :
˗ Traveler’s diarrhea – E.coli
˗ Undercooked hamburger meat – E.coli 0157 : H7 ( associated with HUS )
˗ Giardia lamblia – camping, contaminated water source
˗ HIV Positive, CD4 < 50 cells, Acid fast oocyst – Cryptosporidium
˗ Ingestion of unrefrigerated meat – Cl. Difficile
˗ Fired rice – Bacillus Cerius
˗ Contaminate Shellfish – V. parahaemolyticus
˗ Severe liver disease patient – V.vulnificus
˗ Diagnosis : Presence of blood in stool by methylene blue test (1st step)
˗ Stool culture (most accurate)
˗ Patient with chronic diarrhea – stool microscopic examination (first step) [not
stool culture]

˗ Treatment : Ciprofloxacin (Best initial empiric therapy)
˗ Cryptosporidiosis ® raise CD4+ count
˗ Scombroid ® Histamines ® Symptoms in few mins ® Tx – Anti-Histamines
˗ Salmonella enteritidis diarrhea – supportive care (rarely use antibiotics)
˗ Giardia & Cl. difficile ® Metronidazole
˗ For Giardiasis, only symptomatic carries are treated – Asymptomatic carriers are
not treated except for few circumstances like pregnant woman in house,
immunocompromised individual, cystic fibrosis - Tx of Giardiasis in pregnant
women – Paromomycin
 Hepatitis B :
˗ Acute ® HBsAg, IgM to HBV
˗ HBsAg ® Active disease + Persistent disease
˗ Anti – HBcAb ® 1st Ab to appear in Hepatitis B
˗ HBeAg ® Active viral production + Infectivity
˗ Anti - HBeAb ® Appear after viral no longer detectable
˗ Anti – HBsAg ® Protective Ab, Immunization
˗ Window Period ( equivalence zone of Ab production ) ® Anti – HBcAb, Anti-
HBeAb
· Treatment : Interferon / Lamivudin (chronic Hep B)
˗ Needle stick injury with HBsAg positive ® HB immunoglobulin + HB vaccine
˗ Tx of HBV post-exposure in a patient who already had Hep B vaccine but did
NOT seroconvert after Hep B vaccination – Hep B immunoglobulin
˗ Diagnosis of Acute HAV, HDV, HEV ® Presence of IgM antibody
 Hepatitis C :
˗ Blood transfusion
˗ Dx: PCR HCV RNA
· Treatment ® Interferon + Ribavirin
˗ Advance stage (cirrhosis) ® Liver Transplant
 Pelvic Inflammatory Disease :
˗ Lower Abdominal and pelvic pain, fever, leucocytosis, discharge (vagina)
Cervical motion tenderness
˗ Gram stain & culture of discharge
˗ USG (to exclude ovarian cyst / Tubo-ovarian abscess)
˗ Tx : Single dose Ceftriaxone + Doxycycline for two weeks (out patient)
˗ Inpatient (high grade fever / ↑↑ WBCs) ® Doxycycline + IV Cefoxitin
˗ Goal of Tx of severe PID is to obtain high blood concentration of antibiotics as
soon as possible so all therapy should be intravenous. use IV Cefoxitin + Oral
Doxycycline or IV ceftriaxone + oral Doxycycline

Fever, urinary frequency, urgency, burning
Purulent Discharge No Discharge
Urethritis (Tx: Ceftriaxone + Azithromycin) Cystitis
Gonococcus Chlamydia - E.coli (>80%)
gram stain Serology Urinary stasis / Foreign
body Predisposes
Culture Ligase chain reaction Suprapubic tenderness
Tx : Ceftriaxone IM Tx Doxycycline(7 days ) Urine Analysis looking for
WBCs ( Best Initial )
Azithromycin Azithromycin(single) Nitrates ® Nitrites
(gram(-) organism)
Ciprofloxacin Mucopurulent discharge Urine culture (> 100000
colonies)
Cefixime
Purulent discharge
Dx of Chlamydia is
costlier than Tx so all
patient with gonorrhea
receive Azithromycin (1g
single dose)
Tx: If uncomplicated,
Trimethoprim /
Sulfamethoxazole or
Quinolones X 3 days
In DM ® 7 days
· Tx Chlamydia infection in pregnancy – Erythromycin 500mg PO four times a day
for 7 days
· Asymptomatic bacteruria is common in elderly, and doesn’t require treatment if
WBC count is less than 20 / HPF. [reassure and repeat urine culture again after 1-
2 months]
· Treatment of UTI /Asymptomatic bacteriuria in pregnancy  Nitrofurantoin
or Ampicillin for 7-10 days
· Uncomplicated UTI can be treated by prescribing TMP-SMX over the phone
¨ Chancre ¨
Painless Painful
1 0 Syphilis (Treponema Pallidum)
- Dark field exam (best initial for
primary)
- VDRL & RPR (Best initial for 20 &
tertiary)
- FTA-ABS, MHA-TP (most specific test)
Chancroid ( H . ducreyi )
- Genital ulcer, enlarged tender inguinal
lymphnode
- Gram stain, culture, PCR
- Tx : Azithromycin (single dose)
Ceftriaxone 250 mg 1M(single)

2 0 Syphilis
® Cutaneous rash (symmetrical)
® Condylomata lata (infectious)
˗ Condylomata Acuminata (HPV): verrucous, papilliform, skin color lesion
˗ Condylomata late (Secondary Syphilis): flat or velvety lesion
* Tertiary Syphilis ® gumma, Tabes dorsalis , Argil-Robertson pupils
* Treatment : Penicillin (Benzathin) – 2.4 million units / Week IM for 10 (1 week)
& 20 (3 weeks)
* Tertiary – 10-20 million units / day IV for 10 days
* If Allergic to Penicillin – Doxycycline for 10 & 20
* If Allergic to Penicillin - Desensitization in tertiary & pregnancy.
· No effective prevention is available for Jarisch-Herxheimer reaction occur within
24-hrs after starting therapy to syphilis
 Lymphogranuloma Venerum :
- Chlamydia trachomatis (L1,L2,L3)
- Small, transient , non indurated lesion that ulcerates & heals quickly; unilateral
enlargement of inguinal lymphnodes, multiple draining sinuses, buboes
- Diagnosis ® serological tests. Isolation of Chlamydia from pus in buboes
- Tx ® Doxycycline
■ Granuloma Inguinale :
˗ Donovania granulomatis, calymmatobacterium granulomatis
˗ Painless red nodule that develops into an elevated granulomatous mass
˗ Slow healing & scar formation occur
˗ Giemsa / wright stain , Punch biopsy
˗ Tx ® Doxycycline.
 Genital warts :
˗ caused by HPV
˗ Condylomata acuminate
˗ warm , moist surface in the genital areas
˗ Cauliflower appearance
˗ Tx : Imiquimod ( immune stimulant ) , Cryotherapy, Podophyllin ,Laser removal
 Acute Bacterial Pyelonephritis :
- E.coli (MCC) , Proteus , Klebsiella, Enterococcus
- Costovertebral angle tenderness
- Diagnosis : Dysuria, flank pain, urine culture (> 100000 Colonies)
- USG ( to rule out obstruction )
- Tx : Ciprofloxacin for 10-14 days (Any gram (-) Coverage antibiotics)

 Perinephric Abscess :
- Persistent of pyelonephritis – like symptoms after treatment of pyelonephritis
- Urinanalysis & Urine culture ( best initial test )
- USG (best initial scan)
- Biopsy & culture ( most accurate test for etiology of organism )
- Tx : gram (-) coverage + Drainage
 Molluscum Contagiosum :
˗ Caused by Poxvirus
˗ Papules with central umbilication, Giemsa stain ® inclusion body
˗ D/D : Cutaneous Cryptococcosis – red colored papules with central
umbilication (resembles Molluscum Contagiosum) – Dx: biopsy of lesions
˗ Tx : Freezing, electrocautery, curettage
 Osteomyelitis :
˗ Pain erythema, swelling, tenderness over the infected bone, draining sinus tract
˗ Hematogenously Spread
˗ Steph Aureus (MCC)
˗ Salmonella in pt with Sickle cell disease. [Order Hb electrophoresis to confirm
diagnosis of sickle cell disease]
˗ Best initial test ® X ray ® Periosteal elevation
˗ Earliest test ® MRI / Bone Scan
˗ Most accurate test ® Bone biopsy & culture
˗ Best empiric Treatment ® Oxacillin / Neficillin + Aminoglycosides
˗ Chronic osteomyelitis ® 12 weeks followed by 8-12 weeks orally
˗ ESR ® useful to follow during treatment
˗ MRI – diagnosis of osteomyelitis in vertebrae and diabetic foot (most accurate
test) [C/I in patient with implanted pacemaker, defibrillators – Bone scan is
useful in those patient]
· Low-grade fever, elevated ESR, low backache, tenderness to gentle percussion
over the spinous process, diagnosis? Osteomyelitis of vertebrae; best test? MRI
 Gas Gangrene :
· Caused by Cl. Perfringens
· Deep , necrotic wound , without exit to the surface
· Crepitation over the site
· X – ray ® gas bubbles
· Tx ® High does penicillin / clindamycin
® Surgical debridement / Amputation
 Tetanus :
˗ caused by Cl. Tetani

˗ Lockjaw , Respiratory arrest , dysphagia , flexion of arms & extension of lower
extremities
* Tetanus Prophylaxis : (TIG – Tetanus Immunoglobulin)
˗ Two Important factors – Vaccination history & Wound (clean or dirty)
˗ Last TT dose (< 10 yrs) & clean wound – No need to give tetanus prophylaxis
˗ Last TT dose (> 5 yrs) & dirty wound – Give TT prophylaxis
˗ No previous vaccination & clean wound – Give TT prophylaxis
˗ No previous vaccination & dirty wound – Give TT + tetanus immunoglobulins
 B lastomycosis ® Broad base bud , rooting woods, skin lesions (crusted, heaped
up, warty lesion with violaceous hue) – Tx: Amphotericin B
 Histoplasmosis ® Soil enriched with bird / bat feces, No skin lesions, found in
RES cells
 Coccidioides – California, spherules, skin lesions (Erythema multiforme and
Erythema nodosum)
 Aspergillosis ® Neutropenia / steroid use / Cytotoxic drug, cavitatory lesion,
CXR – Abnormal, Sputum – Aspergillus, Acute 45 0 branching
 Babesiosis – hemolytic anemia with jaundice, no rash, tick-bite – Tx: quinine +
clindamycin / atovaquone + azithromycin
 Ehrlichiosis – tick-bite, “spotless – Rocky Mountain spotted fever”, fever,
malaise, headache, nausea and vomiting – Tx: Doxycycline
 Trichinellosis – Swelling around eye, severe muscle pain, splinter hemorrhage,
eosinophilia, no murmur
 Acquired Immuno Deficiency Syndrome (AIDS) :
· Prophylaxis in AIDS ® CD4+ < 200 cells ® Trimethoprim / Sulfamethoxazole
(Pneumocystis Carinii - PCP)
CD4+ < 50 cells ® Azithromycin once a week for MAC
(Mycobacterium Avium Complex - MAC)
· Indication corticosteroid in PCP – alveolar-arterial O2 ratio >35 mmHg on room

· Start Antiretroviral therapy when CD4 + <> 55000
· Post exposure prophylaxis – AZT + Lamivudin + PI (4-wks)
· Tx of HIV-associated thrombocytopenia – Zidovudine

can be reevaluated every 3 months
· CD4 count & HIV viral load monitoring for patient not on HAART – once
every 3-4 months

· Best indicator of immune status of HIV(+) patient – CD4 count
· Mx of Esophagitis in HIV positive – empiric Fluconazole; If doesn’t get better,
endoscopy
· Fluctuation of CD4 count and viral load in patient on HAART is common and is
self-limited
· CT scan of AIDS patient shows multiple hypodense, non-enhancing lesion with
no mass effect in the cerebral white matter, diagnosis? Progressive multifocal
leukoencephalopathy (PML) (JC virus) – without treatment, majority of patient
die within 3-6 months after onset of symptoms – Tx: HAART
· Dx of HIV during window period – measuring viral load by HIV RNA PCR
assay or by confirming presence of p24 antigen
· Pregnant Patient ® AZT start at 14 wks. If serious disease ( very low CD4 /
very high viral load ) ® start 3 drugs
· Only efavirenz is teratogenic
· AZT ® Severe Anemia
· Didanosine (DDI ) & Zalcitabine (DDC) ® Pancreatitis
· Stavudine ® Peripheral neuropathy
· Indinavir ® Nephrolithiasis
· All Protease Inhibitors ® Central obesity, hyperlipidemia (Tx: Gemfibrozil),
hyperglycemia
· Nucleoside reverse transcriptase inhibitors can cause lactic acidosis by reduced
O2 utilization by tissue
· Disseminated Histoplasmosis in HIV  IV amphoterecin B, followed by lifelong
itraconazole
· Contact of saliva of patient with HIV has never shown to transmit infection so If
patient present with human bites from HIV-infected person, give standard wound
care and prescribe Ampicillin + Sulbactam

and thoroughly evaluated (blood, urine & CSF culture) and start antibiotics
■ TORCH Infection :
 Toxoplasmosis – more serious in first trimester → intracranial calcifications,
IUGR, microcephaly, blindness – First trimester  Spiramycin / elective
abortion; In second & third trimester  pyrimethamine + sulfadiazine – Newborn
– Pyrimethamine and Sulfonamide & leucovorin.
 Other (Syphilis) – can be transmitted to fetus at any stage of pregnancy → fever,

Hutchinson teeth, saber skin, saddle nose, clutton joints (late manifestation)
 Rubella – IUGR, Cataract, PDA (Patent Ductus Arteriosus), Deafness,
blueberry muffin lesions.
 CMV – IUGR, Chorioretinitis, Periventricular calcification.
 Herpes – infection occur due to passage through an infected birth canal → first
time infection in mother has high rate of transmission → local (5-14days),
disseminated (5-7 days), CNS (3-4 wks). – Tx: Acyclovir, delivery by c-section.

 Varicella – neonatal (Perinatal) disease is treated with VZIG if mother develop
varicella 5 days before to 2 days after delivery, Acyclovir in all perinatal
disease.
■ Pertussis :
- Whooping cough ® forceful inspiratory gasp (whoop) after a paroxysmal cough.
- Children < 5 yrs of age.
- Catarrhal stage (infectious stage), paroxysmal stage, convalescent stage.
- Leukocytosis caused by absolute lymphocytosis.
- Direct fluorescent antibody testing of nasopharyngeal secretion (Rapid test).
- Tx : Supportive/Erythromycin.
- ALL contacts should receive prophylaxis with Erythromycin regardless of
their age & immunization status.
■ Cat Scratch Disease :
- Bartonella Hensalae.
- Chronic regional lymphadenitis, fever, headache, malaise.
- Resolve spontaneously in 2-4 months or Azithromycin for 5 days
- Bacillary Angiomatosis in AIDS patient.
■ Erythema Infectiosum :
- Fifth disease, Parvovirus B19
- “Slapped cheek” appearance (due to erythematous rash)
- Aplastic crisis in sickle cell anemia patient
- Infectious before the appearance of rash
■ Roseola (Exanthema Subitum) :
- HHV (Human herpes Virus-6)
- High grade fever ® resolve by 3-4 day ® maculopapular rash appear.
- Supportive therapy.
■ Measles ( Rubeola ) :
- Cough, coryza, conjunctivitis, koplik spots (grayish white dots on the buccal
mucosa), rash appear on face and spread towards trunk (rash pattern is same in
Rubella but patient looks more ill in Measles compare to Rubella)
- Supportive therapy, Vit-A supplementation.
■ Mumps :
- Contagious 1 day before and 3 days after the swelling.
- Swelling of the parotid gland, orchitis.
- Elevation of serum amylase – Tx : Supportive treatment
■ Rubella (German Measles) :
- Contagious 2 days before the rash begin and 5 days after the rash
- Retroauricular, Posterior cervical & Postoccipital lymphadenopathy
- Supportive treatment.

- complication of Rubella – Arthritis, thrombocytopenia and encephalitis
■ Herpes Simplex :
- Burning rash followed by generalized eruption after 2-3 weeks, Vesicles on red
erythematous base – Tx: Acyclovir
■ Varicella (Chickenpox) :
- Contagious 2 days before the rash begin and until all the lesions are crusted.
- Pruritic rash consisting of papules, vesicles, pustules and crusted lesions in
crops in various stages
- Varicella Zoster Immunoglobulin (VZIG), Acyclovir
- Varicella Post exposure prophylaxis  VZLG / Acyclovir (within 72 hrs only)
- Transmission of varicella from vaccinated individual to the organ transplant
household member is not typical. It can occur if rash appear after vaccination. If
rash appear, isolate the vaccinated person.
■ Scarlet Fever :
- Group A β-hemolytic Streptococci.
- “Strawberry” tongue, circumoral pallor, maculopapular/sandpaper rash,
pastia lines, military sudamina (small, vesicular lesions over the hands, abdomen
and feet), bilateral cervical lymphadenopathy
- Tx : Penicillins (DOC), Erythromycin, 1st generation cephalosporin.
■ Kawasaki Disease :
- Child with unilateral cervical lymphadenopathy, fever, desquamating rash on
palm, sole & mouth, Strawberry tongue, fissured lips
- Echocardiography (Best screening test – Coronary artery aneurism)
- Tx : IV Immunoglobulin (first step in treatment), High dose Aspirin [If need
arise to give continuous Aspirin, patient should receive influenza vaccine to
prevent Reye’s syndrome]
■ Hand, foot and mouth disease :
- Coxsackie A 16 virus
- Vesicular rash involve hand, foot & mouth.
- Supportive treatment
■ Scabies :
- Permethrin 5% cream / 1% lindane (>2 months of age).

- All family member & care taker should be treated.
■ Laryngotracheobronchitis (Croup) :
● Parainfluenza virus
● Cold symptoms followed by brassy, barking cough & intermittent inspiratory
stridor
● X-ray: “steeple” signs indicate a narrow subglottic space.

● Tx : steam from a vaporizer, continuous humidification (mild cases).
● Stridor at rest ® epinephrine and corticosteroids systemically.
● give trial of epinephrine before intubation
■ Acute Epiglottitis :
- H.influenzae type B
- Acute onset of symptoms – high grade fever, stridor, drawling.
- Younger child sit in tripod position with neck hyperextended.
- X-ray: “thumb print” sign
- Tx : Intubation ( 1 s t step ) (regardless of degree of respiratory distress), Antibiotic
■ Bronchiolitis: infection of lower respiratory tract
- Respiratory syncytial virus (RSV)
- around 6 months of age
- H/O URTI, rhinorhea, sneezing
- RSV infection increase the risk of asthma in later life
- CXR: hyperinflation of the lungs
- Antigen detection in nasopharyngeal secretion/culture.
- Criteria for hospitalization: premature, younger than 3 months old, RR>60/min,

- Tx: respiratory isolation and supportive therapy (like IV fluids Antipyretics,
Humidified air and bronchodilators), Aerosolized epinephrine (no
corticosteroids), Ribavirin (aerosolized) (reserved for serious cases), Intubation.
 Rocky-Mountain Spotted Fever : headache, fever, rose-red maculopapular
rash (rosettes) on palms & soles ® Tx: Doxycycline (benefits out weigh the
risk) (In Lyme, course of treatment is long that’s why we use Amoxicillin in
children less than 9 yrs of age)
 Lyme Disease : erythema chronicum migrans – The risk of acquiring Lyme disease after tick bite is less than 1.5%. The most common complication of tick
bite is local inflammation and infection – Tx of classic early-localize Lyme disease – oral Doxycycline for 28-days [It is clinical diagnosis, doesn’t require
serological test] – Dx of Lyme arthritis – ELISA antibodies in synovial fluid –
Prognosis of Lyme arthritis is good and more than 90% of patients are diseasefree
one year after treatment – Early-disseminated-Lyme – do CSF examination
– If positive Lyme serology on CSF, give IV antibiotics – When pregnant patient
exposed to tick bite, prophylaxis of Lyme is necessary – give Amoxicillin orally
[All other patient doesn’t require any prophylaxis; Tick must be attached for more
than 24-hrs to transmit Lyme disease]
 Tx of UTI in newborn – fever, increase WBC, >20 hpf – Ampicillin +
Gentamicin (both IV)

■ Eye discharge in Neonate :
- 1-3 day of life – Physiological
- 3-5 day of life (Mucopurulent discharge) – Gonococcal Conjunctivitis (Tx :
topical antibiotics)
- Few days after birth – Mucoid discharge – Chlamydia Conjunctivitis (Tx : Oral
(systemic) antibiotics to prevent pneumonia)
■ Eye discharge in child :
- Purulent discharge, crusting in the morning – Bacterial conjunctivitis
- Clear watery discharge (usually bilateral, h/o URTI) – Viral Conjunctivitis
 Otitis Media (infant is irritable) in patient with h/o conjunctivitis (red eye) is
caused by non-typable H. Influenzae so use Amoxicillin + Clavulanate acid (not
Amoxicillin alone)
■ IMMUNIZATION :
· Live Attenuated Vaccine :
- Viral : MMR, Yellow fever, Varicella
- Bacterial : BCG, oral typhoid
· Inactivated Vaccine :
- Viral : Polio, Rabies, Hepatitis A ( whole)
- Fractional
Protein based – Subunit ® Hep B, Influenza, acellular Pertussis
Toxoid ® Diphtheria, Tetanus
Polysaccharide based – Pure ® Pneumococcal, Hib, meningococcal
Conjugate ® Hib, Pneumococcal
· Influenza & Yellow fever vaccines are contraindicated in persons with
hypersensitivity to egg.
· IPV & MMR are contraindicated in persons with hypersensitivity to neomycin/
streptomycin.
· Contraindications to vaccines :
- severe allergic reaction to prior doses of vaccine ( or) to a component
- Encephalopathy following Pertussis vaccine
- Immunocompromised state & pregnancy
- Only MMR is contraindicated in HIV infected patient with severe
immunocompression & Symptomatic. All other vaccine can be given in HIV
positive symptomatic person.
- Previous febrile illness is not a contraindication (C/I) for giving MMR
- C/I to MMR are: pregnancy, severe immunodeficiency (asymptomatic HIV is
not a C/I), recent immunoglobulin administration, allergy to neomycin

· Immunization : Usually vaccines [DTaP, Hib, PCV, IPV] and Hep B (if not
given at birth) are given at 2, 4, 6 months and then boosters if appropriate.
· All pre-term infants should receive vaccines according to their chronological
age, not their gestational age. Hep B vaccine should be administer at birth (Wt
should be >2 kg)
- Hep-B vaccine ® at birth.
- DTaP, Hib, PCV, IPV ® Started at 2 months of age.
- MMR, Varicella ® started at 12 months of age.
- Influenza ® started at 6 months of age.
- DTaP ® 2nd & 3rd dose 4-6 weeks apart, 4th dose 6 months after 3rd dose.
- Hib ® All doses 4-6 weeks apart, if first dose is given after 15 months of age
then no need for other doses, booster b/w 12-15 months of age
- PCV ® All doses 4-6 weeks apart, no doses for healthy child of ³ 24 months of
age, booster b/w 12-15 months of age
- MMR ® 2nd doses® 4-6 weeks after 1st dose/at 4-6 yrs f age.
- Meningococcal Vaccine (serotypes A, C, Y, W - 135) ® not protective for those
< 2 yrs of age. That means give vaccine after 2 yrs of age
- If mother is HBsAg positive ® HBIG + HB Vaccine at birth.
- OPV (oral polio vaccine) is not used in USA
- Immunization in internationally adopted child without written
documentation – Give all necessary immunization according to recommendation
for unimmunized child + screen for Hep B, Hep C, HIV, Syphilis and TB

Fifth Disease

'I asked him what the rash of fifth disease looked like. He sat on the red velvet sofa and instructed me to lay, face down, on his lap and pull down my pants. "I'll show you", he said, as he proceeded to slap my cheeks real hard, making me wail and convulse.

After he was done, the print on his massive fingers was on my cheeks. "That", he said, "is what the rash in fifth disease looks like; and that's where it gets its' name - slapped cheek appearance - from. Rather convenient, don't you think? Five fingers - fifth disease".

I thanked him profusely for taking the time to instruct me in the intricacies of fifth disease.'

Sporotrichosis

After thorn prick to gardener

'My baby, my prince, Prince Anthony as I used to call him, offered me a long-stemmed Rosa rugosa rose from his flower bed with his muscular arm. "I will love you long time", he whispered to me (his command of English was less than perfect...), as he offered me the rose. I thought I was in heaven. A gush of love rushed through my body. Unfortunately though, a rose thorn pricked me and I contracted Sporothrix schenkii'

Rose gardener, thorn injury --> Sporothrix shenkii

Infectious Diseases for Studs

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