of 12
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Compartment Syndrom
5 P’s
Pain (occurs 1st)
Palor
Poikliothermia
Parathesia
Pulselessness (occurs l
How did a bacteria pick up nasty trait
- Tranduction Phage
NORMAL FLORA
Gram + or Gram - ??
o If the part of the body that is affected is EXPOSED TO O2 → Gram + Aerobe But if Hiding from O2 → Gram + Anaerobe
o If part of the body that is affected is NOT EXPOSED TO O2 → Gram – Anaerobe
If in both locations with or without O2 → Facultative
Facultative Anaerobe prefers no O2 Facultative Aerobe prefers O2
Anaerobe Clues
o Air fluid levels
o Bad breath, body odor, Farts
o Bleach works by introducing oxygen to the bacteria!!!
SKIN
Staphlococcus aureus o MCC of skin infections
Cellulitis → Flat red area; + blanching
Oomphalitis → cellulitis around umbilicus of a newborn Mastitis → cellulitis around breast Panniculitis → cellulitis as a ring around abdomen Folliculitis → infection of a hair follicle
Pus at the base of the hair shaft Carbuncle → small nodular indurated area with infection Furuncle → hari follicle in the middle of carbuncle – no pus Ballintitis → infection of the head of the penis Fascitis → Compartment syndrome
Strep pyogenes
o
S. aureus is the MCC for skin infections except for these 5 cases where it is Strep pyogenes whis responsible
“LINES”
Lymphangitis → infection follows lymphatic channels = “red streak”
I mpetigo → honey crusted lesions ( if bullous d/t Staph aureus’s elastaseactivity)
N ecrotizing fascitis → “flesh eating strep” → Compartment Syndrome
E rysepelas → raised edges; do not blanche (vs. cellulitis)
S carlet Fever
o “sand paper rash”
o Strawberry tongue
o
Rash on PALMS & SOLES
Staph epidermi dis
o Action is under the epidermis where it is the most abundant
o Primarily due to:
Shunt Infection
Central Lines
These both penetrate the skin underneath the epidermis
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Have IgA Protease → allows bacteria to live in the mouth
without IgA killing them
#1 way to paralyze cilia → VIRUS o Virus paralyzes cilia making the lung susceptible to
infection!!!
o Cilia no longer has ability to sweep them up and out
o S. pyogenes has no capsule so type I pneumocytescan eat them u or cause infection
MCC of Sinusitis → S. pneumo, H . inf lu , Neisseri a – in that order
Propr iobacteri um Acne
o Exposed to oxygen but hiding under skin = Gram + ANAEROBE
o Affinity for Propionic Acid found in sebaceous glands
o Affinity for Progesterone
+ Females > Males
Caused by birth control pills/shots → acne 2 weeks prior to menses
More common in pregnancy
o HATES O2
Therefore, acne treatment is based on exposure to O2 (Oxy 10)
o Acne Medications Start with Oxy 5/10 → Abrasive pads (open pores to O2 ) → ABX treatment:
Clindymycin, Erythromycin, Minocycline (T4)
If these don’t work need the BIG GUNS
Retin-A = previtamin A → Stimulates skin to grow thereby pushing the “bug” ofor oxygen exposure
SE:
o Photosensitivity (because forming new immature skin cells that are
susceptible to damage o Absorbed in the ileum → Hyperlipidemia
o Fat soluble → teratogenic
MOUTH/THROAT/ESOPHAGUS
Strep pyogenes o Resides in the back of the throat
o Rheumatic Fever
Jones Criteria = SPECC
Subcutaneous nodules
Polyarthritis (MC)
Erythema marginatum = little red dots with margins
Chorea (Syderham)
Carditis – MS >> AS/MS >> AS >> TS → MC
o Strep is swallowed → lungs → returns via pulmonary vessels → MV
o Fish mouth appearance (MS) Pt. most likely had a prior strep infection in last 2 weeks
o Post Strep GN Strain 12
Strep. Pneumonia
H. infl uenza
Neisseria
o Catarrhalis
o Meningitis
o Gonorrhea
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GUMS = Facultative anaerobes
Peptococcus
Peptostreptococcus
Fusobacterium
o Fused at the edges and tapered at the end Vincent Angina = painful ulcers in the back of the throat
Trench mouth = pus oozing from the gums
Actinomyces
o Sulfur granules
o Fistula tracts
Strep vir idans – MCC of subacute bacterial endocarditis (SBE) o Mutans → responsible for dental caries → ferments glucose → produces lactic acid
o Sanguis
o Salivarius
Cold agglutins
STOMACH
Heli cobacter pylor i
o Urease +
o Duodenal gastritis is highly associated
o Dx: H2 Breath Test
o Treatment
Amoxicillin
Tetracycline/Metronidazole
Bismuth → suffocates bacteria
H2 Blocker/Pump Blocker
o
Infections most likely due to bad sewage systems
SMALL INTESTINE – 95% are oxygenated → facultative aerobes
E. coli
o Anything to do with S. int. think E. Coli
o Vitamins produced by E. Coli
Vitamin K
Cofactor for Clotting factors 2,7,9,10, protein C & S → Measure PT
o This is why broad spectrum drugs can cause bleeding
Folate
Biotin
Panthotenic acid
Helps absorb Vitamin B12 in the ileum
COLON – 95% of gas is CO2 also not exposed to oxygen → GRAM –„s
Proteus
o 2nd
in line for UTI
Klebsiella
o Currant jelly sputem
Big Mama Anaerobes:
Clostridium melangosepticus
Strep bovis
Bacteriodes fragilis
Rx: Clindymycin, Cefoxitin, Metronidazole
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All 3 are main causes of sepsis in
the newborn
o MC in alcoholics and homeless
o 3rd
in line for UTI
o Likes to hang out in the fissures of the lungs → pneumoniae
Enterobacter
Citrobacter
o Multiple cerebral abcesses in the newborn 0-2 mos.
Clostri dium diff icil e
o
Pseudomembranous colitis d/t chronic antibiotic use o Gastroenteritis after antibiotic use
Clostr idium perf ingens
o Gastroenteritis associated with holiday ham
RECTUM
Group B Strep
E. coli
Lysteria
STAPH Species: β lactam ring
Staphlococcus aureus:
Gram + cocci in clusters; gold pigment
Enzymes:o Catalase + → breaksdown hydrogen peroxide
o β-lactamase → breaks through β lactam containing drugs
o coagulase & staphlokinase Allows for the ability to eat through clots MCC of Acute Endocarditis → has ability to eat through the valves
MCC of death for burn unit patients in the first week β lactamase cuts
here
o Lipase → breaksdown fat Panniculitis Folliculitis Mastitis
o Elastase Bullous Emphysema/pneumatocelle
o Collagenase → affects skin and bones
MCC of Osteomyolitis (Salmonella is the 2nd
MCC of bone infection)
Type IV (basement membrane) → Scalded Skin, Kidney, Lung also affected
Type III (endothelium – arteries affected) → Vasculitis Type II (connective tissue) → MCC Fascitis and Septic Arthritis (gonorrhea #2) and
Folliculitis
Toxins:
o Exfoliatin/SSSS-T: Staph Scalded Skin Syndrome
Red rash all over the body → sloughs off = Nikolsky sign (recall it‟s also seen with
Penphiguis vulgaris) Involves the PALMS & SOLES
o Erythrodermic Toxin
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Causes Scarlet Fever
o Lecithinase Causes skin infections → Subcutaneous fat
o TSST: Toxic Shock Syndrome
Triad:
High Fever
Hypotension → shock
Bright red rash all over the body especially…PALMS & SOLES Associated with retained tampon in a female
If you see just MENSES….CLICK AND MOVE!!!
o Enterotoxin
Causes food poisoning associated with dairy products → Gastritis
Custard Pie
Staph infections usually arrive after flu-like symptoms
Treatment for Staph:
o Vancomycin – best treatment but expensive
o
Macrolides
o Chloramphenicol
o 1st Generation Cephalosporins
o Quinolones
Staph epidermidi s:
Enzymes:
o Catalase +
Resides underneath skin
White pigment
MCC Shunt infections and Central line infectionsTreatment
o Vancomycin → however, there are now vanco. Resistance
o Linezolid This is a lorefin drug and not fully tested but is an alternative to vanco. Resistentance
Staph Saphr ophyticus
NO PIGMENT
Enzymeso Catalase +
Symptoms
o
Frequent cause of UTI: Ages:
5-10 because they tend to play with themselves more at this age
18-24 → post coital UTI, especially with no circumcision
o Recall that E. Coli is the MOST COMMON CAUSE OF UTI!!!
STREPTOCOCCUS SPECIES:
General Characteristics
o Gram + cocci in CHAINS
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o Groups A, B, C, D
o Types of hemolysis α-hemolysis → partial hemolysis → Green Zone
β-hemolysis → complete hemolysis → Clear Zone
γ-hemolysis → no hemolysis → Red Zone Streptokinase is responsible for β-hemolysis → it is used for breaking up clots and
binds up fibrinogen in acute MI, but if patients had recent Strep infection, the patient ha
built antibodies to streptokinase and it will not work → This is the reason that theydoctors use tPA instead!!!
Dosing: 75,000 units IV bolus and 75,000 units drip
Works by converting plasminogen → plasmin → breaks up the clot
Binds up fibrinogen → wont’t allow for anymore clotso Allows 1-3% to bleed to death
o tPA causes < 3% to bleed to death
o APSAC can induce tPA reversal
Strep Strains:
Immunity is type specific, that is why you can get recurrent strep infections
Strep pneumoniae aka Pneumococcus
o Gram + diplococci
o α – hemolysis
o 80 Strains
o Pneumococcal vaccine (pneumovax) Covers 23 strains that account for 98% of infections by Strep pneumo. Who needs it?
Everybody > 65 y.o.
> 2 y.o. with Sickel Cell
o Functional asplenic after age 2
o
Recall that the spleen is the organ that can rid the body of encapsulatedorganisms
End Organ Failure o It is most likely that encapsulated cause that will kill DM and CF patient
PSGN o Skin or throat strep can cause PSGN
o Associated with Strain 12
Group A: Strep pyogenes
o β – hemolytic
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Likes immunocompromised patients
Nitrite Negative UTI
Treatment
o Vancomycin
Vancomycin
MOA:
o Cell wall inhibitor
o Inhibits phospholipids carrier (Nam-Nag)
o Irreversible (non-competitive inhibitor)
Treatment for all Gram +
Toxicityo Ototoxicity
o Nephrotoxicity
o Red Man Syndrome
d/t intense histamine release
This is not an allergic reaction
Causes of Meningitis
0-2 mos
o 1 - Group B Strep
o 2 – E.coli
o 3 – Lysteria
2 mos. – 10 yrs.
o 1- Strep. Pneumoniae o 2 - Neisseria
10 – 21 years
o 1 – Neiserria
> 21 years
o Strep. pneumoniae
SPORE FORMERS
Spores:
o Composed of Ca2+
- dicholinate
o Contain a poly D – glutamate membrane
The “D” gives the spore the ability to create a bad reaction in the body because we
don‟t have D-amino acids, we have L-amino acids!!!
o Spores hate HEAT!!! That is why sterilization is useful against spores
Vancomycin Treatment:
MRSA
Staph epidermidis
Enterococcus
Bugs with Preformed
toxins:
-
Bacillius anthrax- B. cerus
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Bacillis o Anthrax
2 Types:
Skin → necroses of the skin o Form a Malignant pustule
Pulmonary → Woolsorters Disease
o Induces necrosis of the lung → end up drowning in your own blood
o
Most commonly used in germ warfare Toxin has 3 Factors:
Edema Factor
Protector Factor
Lethal Factor → the one that causes death
o B. Cereus
Associated with Gastroenteritis after eating fried/reheated rice + Preformed toxin → symptoms within 8 hours of ingestion
Clostridium
o C. Perfr ingens
Causes Gas Gangrene (strict anaerobe)
Known to attack the extremities of Diabetics
Dry Gangrene
Necrotic Skin
Wet Gangrene
What we fear since blood tried to go back to necrotic area it will bring gas embo
back into the circulation which can lodge in the Right Ventricle → Gas
Embolus!!!
Treatment
o Lay person in the L side and tap on the right side
Requires immediate amputation Causes gastroenteritis associated with holiday ham/turkey → reheated
Immediate symptoms → DIARRHEA
o C. diff icil e
Pseudomembranous colitis associated with ↑ abx. Intake
Lives in the GI but when the abx. Clears E.coli it grows rampantly Pseudomembrane appears as a gray membrane Treatment
1st stop abx.
ABX:
o
Vancomycino Metronidazole
MOA: promotes production of free radical
Contraindicated in G-6PD patients SE → dysguzia, disulfiram reaction
o C. tetani
Associated with Dirty Wounds
Give anti-immunoglobulin to bind up toxin → inject it right into the wound Toxin
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Looks like eye ball is being pushed out
Neisseria
N. meningiti des
o Gram negative diplococci
o Largest encapsulated bacteria
Requires MAC complex to fight it Only encapsulated organism that can release it’s toxin without dying at the same time
o Ferments maltose
o Use a Thayer Martin Agar (chocolate agar) to plate
o Has more endotoxin than anyone else Lipid A will cause
Early vasculitis → (present with DIC)
o Purpura
o Petechiae
o Ecchymoses
If bleed into the adrenal glands = Waterhouse-Fredriechson Syndrome
o
DIC will cause adrenal hemorrhage o Look for ↓ Na/↑ K = electrolyte imbalance
o Treatment → Start Prednisone/Cortisol
o Associated with people in close quarters → college students
o Treatment Prophylaxis for close contact → Rifampin
N. gonor rhea
o MCC of STD → Chlamydia But 90% are asymptomatic
o MCC of symptomatic/purulent STD → Gonorrhea Called the drips
Men → 90% symptomatic Women → 50 % asymptomatic
+ perihepatitis → Fitz-Hugh-Curtis Syndrome
o Fallopian tube affected and pus drops next to the liver
o Disseminated gonococcal infection Can become disseminated due to it’s pili The pilli allows it to walk up the epithelium and into the bladder and into the blood
stream
o Tenosynovitis N. gononrrhea loves to attack the tendons and ligaments
Joints of the wrist and ankles
Present wi th dysur ia and painfu l wr ist 3 days later
o Gonococcal Arthritis Comon in teenagers
o Treatment
Cef triaxone – 250 mg IM x 1 Cefixeme – 400 mg IM x 1 Cefoxitin – 250 mg IM x 1
Ciprofloxacin Oflaxacin
Present like this no matter the age →
always assume Neisseria as the culprit
Must also treat for
Chlamydia:
- Azithromycin 1 g x 1
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Gatofloxicin
Recall that Neisseria is Catalase + and contains IgA protease
N. cattarrhalis → formally known as Morexella
o Normal throat flora
o “Cattar” = mucous → therefore this bug likes mucous membranes Engaging in oral sex ↑ chances for this bug
E. coli
Gram negative ROD
Vitamins produced by E. Coli
o Vitamin K
o Folate
o Biotin
o Panthotenic acid
o Helps absorb Vitamin B12 in the ileum
Illness
o MCC of UTI in all Ages
o
All small intestine infection → iliocystitis, ascending cholangitis (↑alk. Phos), appendicitis
etc…
o MCC of traveler‟s diarrhea
o #2 in neonatal sepsis
Families
o EIEC = Enterinvasive E. Coli Regular traveler’s diarrhea Loose stools
o ETEC =enterotoxigenic E. Coli
ADP-ribosylates Gs → Turns the On, On → ↑ cAMP Looks like rice water stool
Same toxin as Vibrio cholera Most often due to poor sanitation
o EHEC – Enterohemorrhageic E. Coli Endemic HUS
0157:H7 → Epidemic HUS
HUS
o Occurs 2 weeks after E. coli infection
o Likes medium sized arteries (GI/Renal) MCC of renal failure in children
Most commonly associated with RAW HAMBURGER Lives in the anus of cows
Proteus mir abili s
#2 cause of UTI
Urease + (PPUNCH ) o + struvite stones
UTI infections
1. E.coli
2. Proteus3. Klebsiella
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Treatment:o Norfloxacin
Klebseil la pneumonia
#3 cause of UTI
Encapsulated
Associated with pneumonia in alcoholics and homeless
“currant jelly sputem” → suputem + blood
Loves fissures of lungs
GRAM NEGATIVES THAT ATTACK IMMUNOCOMPROMISED PATIENTS
Serratia mascecents
o Red pigment
Acenetobacter
Citrobacter o Encapsulated
o + Multiple Cerebral Abcess
Pseudomonas aeruginosa o Contains the same enzymes as Staph → green pigment
Can cause same sickness Same populations affeceted
CF
Diabetic
Burn patients
Neutropenic
o Treatment: If Staph → 1 abx
If Pseudo → 2 abx Next treat for fungus
o Can become “normal flora” after 48 hrs. in the hospital (need to cover for it!!!), because it love
plastic Catheters Intubation
o Infections Malignant otitis externa
Red, swollen →Very tender when ear is lifted
Can kill patient quickly
Tx: Hospitalize → ICU → IV abx
NOT SWIMMERS EAR Most commonly associated with Burn patients in the 2
nd week
Whirlpool folliculitis
Loves to live in the water
Butt crack and soles of feet meet water first → INFECTION
o Treatment:
Quinolones (ciprofloxacin) can cover pseudo and staph together
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HOUSE OF “ella”
General Characteristics:
o Gram negatives that like to get into the cell
o The symptoms don’t start until late but lasts only a few days
o Granulomatous change Involves T-Cells and MФ
Involves tissues that are invaded by MФ
Brain, Bone, Liver, Lung, Skin, etc…. Bordatell a pertussis = Whooping cough
o Gram –
o NO ENDOTOXIN
o Exotoxin
ADP riboslyate Gi → Turns the Off, Off → Gs remains on o 3 stages of Whooping cough
Prodromal – little fever/rhinorrhea → not a big deal
Catarrhal – production of mucous in lungs Paroxysmal – staccato coughing
Cough so much that can’t catch breath so the suck in a whole bunch of air that
creates a WHOOP soundo DTaP vaccine available
o ELISA Test and nasal pharyngeal washing used to test for antigens in the back of the throat o Treatments:
Erythromycin (macrolides)
Also, give this to those in close contact
o CBC ↑↑↑ WBC → lymphocytosis
Brucella o Undulating fever (fever spikes 7x/day)
o
Risk Veterinarian Can be found in the placenta of an aborted aninmal
o B. abortus → cows
o B. suis → pig
o B. militensis → goats
Pastur ell a multocida
o Dog/cat bites
Bacteria is in the saliva Treatment: Amoxicillin
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01-29-04
Miscellaneous Gram Negatives
Vibr io cholera
o “Rice water diarrhea” Similar to ETEC → Turns the On, On ADP ribosylates Gs → ↑ cAMP
o Etiology = Sanitation
Vibr io parahemolyticus o Raw Fish – sushi
o
GastroenteritisVibrio vulnif icus
o Gastroenteritis associated with Oysters
Yersina entercoli tica o Gastroenteritis that mimics appendicitis → actually acute ileitis
o Mesenteric adenitis = swollen lymph nodes
o Seen in daycares
o Associated with Reiter’s Syndrome Post infectious arthritis → immune complex disease (+) HLA B27
Ankylosing spondylitis (scarring/fusion of the spine)
o
Most commonly in a middle age maleo Begins in the lumbar area → Bilateral scaro-iltis (@sacro-iliac joint)
o Ankylosing of lumbar spine → fusion ↓ height Schoeber test – spine does not move when asl to bend over
o Die of aortic dilatation → AR
Reiter’s Syndrome
o Post infectious arthrititis
o MC infectious associations Chlamydia Shigella
Yersina IBD
o Most treat unrderlying problem 1st
Psoriasis
o Oval, silvery plaques on extensor surfaces → usually the back of the
forearm
o Recall that this relates to rapidly dividing cells (skin) possible uric acidstones
Yersina pestis
HLA B27 (+)
Ankylosing
spondylitis
Reiter’s
Syndrome
Psoriasis
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o Bubonic plague/Pneumonic Plague
o Rat carries it, rat bitten by fly → used as a VECTOR
o Bubbo = infected crop of lymph nodes → fluctuant mass
o Used in germ warfare
o Presentation: A guy still alive walking in Mexico or Arizona → Likes dry heat
Camoylobacter j ejuni i o Gastroenteritis associated with ingestion of raw eggs
o
Comma/Curved shapedo Tx:
Macrolide → Erythromycin
ATYPICALS
General characteristics
o Don’t have a cell wall Therefore, can’t use PCN Rx:
Tetracycline
Macrolide Quinolone
o They are not real bacteria therefore, a cell mediated reaction will take place
o organs that are invaded by macrophages will be affected
Chlamydia
Chlamydia Trachomatis
o Most common cause of STD (cervicitis, PID)
o Most common cause of infertility in women
o Most common cause for ectopic pregnancy Chlamydia tested with pap smear.
90% are asymptomatic
#1 cause of neonatal blindness in the worldo “trachoma”
Deep ulceration of cornea Transmitted via birth
o treated with erythromycin ointment/sulfacitomide drugs
Treatment: Azythromycin: 1 gm
o Don’t confuse with CMV which causes congenital blindness (not of the newborn)
Chlamydia Pneumonia
o Symptoms:
stacatto coughing Due to irritation of the interstituim
o 0-2 months- atypical pneumonia MCC of Interstitial pneumonia Present severely short of breath
Non-productive cough
o On X-ray
Reticulonodular Ground glass appearance
4 Bugs that are comma/curved
shaped:- Vibrio cholera
- H. pylori
- Campylobacter
- Lysteria
Congunctivitis in Newborn:0-24 hrs.- chemical caused by silver
nitrate24hrs – 7 days = Gonnorhea
After day 7 = Chlamydia
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o Parasite: On blood smear can see T –cells and MФ
Cause eosinophilia
This can help separate it from the other atypicals
o Only one with DNA and RNA Inranuclear and enteronuclear cyto inclusion bodies
o 2 phases:
Elementary – infectious phase Reticulate – resting phase
Dormant activity because it is invading your cell for ATP
o Associated with:
Alzheimer‟s – Ag in neurofibrillary tangles in the hippocampus
Coronary artery disease – find in atherosclerotic plaque
Chlamydia Psittacii
o Associated with parquets and parrots.
o
Cause pneumonia in the lungs Intersitial Pneumonia
Ureaplasma
Urease positive (pseudomonas, cryptoccocus, proteus, ureaplasma, H. pylori)
No cell wall = plasma only → no epithelial lining at all
Non gonnococal urethritis
Mycoplasma Pneumonia
Most common cause of atypical pneumonia age 10-30
“Walking pneumonia”
o
In the interstitium of the lungs
o CXR findings: Interstitial pattern Ground glass appearance Reticulonodular pattern
Has Mycolic acid in membrane (not true bacteria)
Has no cell wall
Spends too much time in blood, so body forced to make antibodies to them
o Cryoglobulinemia = cold agglutinins IgM
Acute infection only Detect by using an antigen from Strep Salivarius
o Ex. Patient positive for Strep salivarius antigen which is the same as cold agglutinins.
Bullous myringitiso Located on tympanic membrane
Mycoplasma Hominis
Cause vaginitis
RARE
Opthalmia Neonatorum (gonnorhea)
Treated with silver nitrate
5 infections that cause
Cryoglobulinemia“I AM HE”
1. Influenza2. Adenovirus
3. Mycoplasma
4. Hep B
5. EBV
Cold Agglutinins Warm Agglutinins
IgM IgG
Acute Inflammation Chronic Inflammation
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Legionell a pneumophila
Most common atypical pneumonia after age 40
Loves standing water found in heating and air-conditioning ducts
“High rise building syndrome”
Pontiac fever = get just fever due to IL-1 + non-specific symptoms
Legionnair‟s disease = full blown pneumonia
Will silver stain in the lung (along with pneumocyctis corinii)
Charcoal yeast agar extract (CYAE) will grow it.
(+) Heart Block
Mycobacteri um:
Mycolic acid with peptidoglycan wall
o But not typical bacteria T-cells and macrophages affecting tissues that macs invade
Rx:
o INH
o MOA: Inhibit peptidoglycan wall
o SE: Pull Vitamin B6 out of system (used by transaminases) Myositis Hepatitis (fat soluble)
Inhibits p450 (macrolides, inh, quinilones) Drug induced lupus
TUBERCULOSIS
TB1st. Contact Bacteris inhaled → tubercule sticks to respiratory epithelium and develops into Ghon focu
Wont even know got it = Asymptommatic
o Ghon focus
o Ghon complex - MФ ingest bacteria and bring them to the lymph node → MФ tries to fuses
with a lysosome but can’t
Cord factor inhibits lysosomal fusion
o IL-1 – fever, recruit T - helper celss = Granuloma formation
o IL-2 to release more response
o IL-12 promote cell mediated immunity
o Macs and T-cells start secreting interferons Interefere with protein synthesis and cells start dying around it granuloma in he right
lower lobe As cells die they calcify =dystrophic calcification
o Macs and T-cells start secreting TNF:
Atypical pneumonia
0-2 months - chlamydia
10-30 years - Mycoplasma
>40 years - Legionella
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Wt. Loss
o When T lymphocytes are knocked out by prednisone or decreased immunity, the tubercule will
come out and cause a cavitary lesion. TB po ps out into the airway and begins to rip up the vasculature → Cough up blood Can stay dormant → waits for opportune time
2nd
Contact
Lesion symptomatic causing cavitary lesions in the upper lobe
o
Cough b/c the bacteria needs to get up the the upper lobe because it has the most O2 = 20 Upperlobe cavitary lesion
o Bacteria Explodes out of it’s cavitary lesion again hoping to get back to GI tract. Cough and swallow Causing obstruction in ileum (bacteria gets absorbed because it’s fat soluble) where all
lymphoid tissue exists and tries to stop infection
But it cannot → Ileum swells up = Obstruction 3
rd Contact
Milliary TB:
o When gets into blood stream and goes all over body
o Arrives everywhere MФ go
Meningitis: MC affected nerve = CN III – posterior fossa → (+) hydrocephalus
CN 9, 10, 11 12
Pott’s disease = TB of spinal cord → (+) compression fracture
Sterile Pyuria (in Kidney)
White cells in urine that won’t go away
Skin – rash = eythema nodosum
Hepatosplenomegaly
Bone Adrenal failure = ↓ Na/↑K
Pericarditis
Diffuse ST elevation
PPD Test
Most people don’t know they have TB until PPD test
o Intadermal injection 1 (strength) – used when just want to prove a symptomtic case of TB 5 – used for screening 250 – used only in AIDS patients b/c have no CD4 cells → Hypersensitive skin
o watch a granuloma create
Positive test:
o 15mm induration with no risk factors
o
10 mm induration with 1+ risk factors: all health care workers 3
rd world countries (Africa, Asia, South America, Philippines, inner city projects, nursin
homes, jail) → Overcrowding
o 5mm for Aids patients
o 10% risk of getting TB if come in contact with someone who had it ( + 1 risk factor)
o After one year treatment with INH the risk will go down to 1% (general population)
o AIDS patients= 10%/year risk of getting TB Tend to get multiple drug resistant TB
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+PPD
Sx No Sx
4 drugs for 4 months for
everybody, if Tb is
sensitive to INH and
Rifampin can finish the
year with just Rifampin
and INH otherwise cont.
with all four.
Treatment CXR
treatment NegativeCXR
35yo
INH, Vit. B6 Yearly
CXR
Tend to get infected with new strains
MANAGEMENT
Positive ppd
o Symptomatic
Treat
o
Asymptomatic CXR
Treatment:
Everyone must be given 4 drugs for 4 mos.
INH
Rifampin
o (-) β subunit of RNA Poly
Pyrizinamide
o Unknown
o SE – Liver Failure
Ethambutal
o
Unknown
o SE – Impairs Red-Green discrimination
Streptomycino Aminoglycoside
D Cycloserine
Mycobacteri um L eprae
Leprosy
Hansen’s Disease
Neuropathy
o d/t granuloma formation around nerves
Lion – Like Facies
Treatment:o Dapsone
o SE → inhibits p450, Autoimmune hemolytic anemia
Mycobacteri um Kansasii
swollen lymph nodes
Mycobacteri um Avium Intracell ulare CD4< 100
Experience gastroenteritis before it hits the lung
Drug of choice = Clarithromycin & Azithromycin
Mycobacteri um Scrofulaceum
Supraclavicular adenopathy in children
Remove lymph nodes
Mycobacteri um ulcerans
Show up as ulcers
Granuloma Formation
Granulomas secrete
o INF-α → Made by MФ (+) Protein Syn.
o INF-γ → Made by T-cells
Mediate MФ
transformation intoGiant cells,
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(+) Caseating granulomas
Mycobacteri um mar inum
Cleaning fish tanks
Caseating granulomas
Spirochetes → spiral shaped, flipping motility, (+) cell mediated response
Treponema Pall idum
Rule of 6’s
o Classic painless chancre (disappear in 6 wks)
o 6 wks later a rash will develop involving the palms and soles (scarlet fever, TSS)
o Will appear 6 yrs. Later with neuropathy neurosyhpyllis
Lancinating shooting stabbing
“like a pin” cutting the skin
Will attack dorsal columns tabes dorsalis = wide gait
Attack Edinger – Westphal nucleus part of reactive vision (coordination between CN III-VI) syphilic eye accommodates but not reacts = Argyll-Robertson Pupil
Loves bone – that is how to differentiate neonatal syphilis
o
Flat forehead
o Snuffles- nasal bone gone
o Hutchinson’s teeth – teeth look razor sharp Saber tooth shins with anterior bowing of the legs → Tibia eaten away Long fissure along corner of the mouth = Rhagades
Testing for Syphilis:
Dark field microscopy (most specific test)
Blood Test :
o FTA – ABS (IgM antibody test)
IgM will bind if it is present
o TPI (Trep. Pallidum Immobilize)
Screening
VDRL (CNS for tertiary syphilis) sensitive but not specific can remain postive for 1 yr aftertreatment
RPR – blood sensitive but not specific, used for screening can be positive for life
Treatment:
1° syphilis: Penicillin (procaine) 1.2 million unit x1
2° syphilis: Penicillin 2.4 million units x1 → each buttock
3° syphilis: Penicillin 2.4 million units 1/wk for 3 wks.
Neonatal: 50,000 units/kg/day for 10 days
TORCH → Neonatal Infections
Toxoplasmosis → multiple ring enhanced lesions in the parietal lobe – Catexposure
Other
R ubella → cataracts, hearing loss, autism, “blueberry muffin” rash, PDA CMV → Central calcifications, #1 Cause of congenital blindness
Herpes → temporal lobe encephalitis
Specific blood test
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Syphilic aortitis = obliterative endarteritis (tree bark appearance of blood vessels) proximal aort
only.
Treponema Palli dum Variant Bi jel
Tr eponema Pertenve Yaws
Treponema Carateum Pinta
Borrellia Borgdorfori:
Lyme disease: EAST COAST
o 1° stage: Bitten by tick (Ixodes tick ) (only 60% report bite)
tick also carries babesiosis
stage: rash
Erythema chronicum migrans
o 2° stage: arthritis, heart block,
o 3° stage: neuropathy (non-specific)
o Dx: Lyme titers
Check antibodies to Lyme (IgM < 2 mos. and IgG > 2 mos.)o Treatment:
Penicillin
Tetracyclin
Borr ell ia Recur rentis
Relapsing fever – get fever once a wk for 5-6 wks → Check the history
o Brill Zinsser disease = pathogen hides in lymph nodes and comes out once a wk slightly
mutated
Leptospir osis I nterogens
Sewege worker, because it is in rat urine Likes to attack liver and kidney
o Weils disease = infectious nephritis and hepatitis
o “Fort Brag fever”
Treatment: Penicillin
SULFA Drugs
MOA
o Replaces PABA → competitive inhibition
o Inhibits Folate
SE: Megaloblastic anemia
Coverageo Gram (+)
No S. aureus
o Simple Gram (-)
E. coli
H. influenza
SE:o Photosensitivity
All come in with rash → disappear with no
consequence
Bulls eye lesion
that enlarges
over time
Ixodes Tick VectorLyme Disease
Babesiosis
Erlichiosis
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o Allergic reaction
o G6 – PD
o Hemolytic anemia
o Intersitial nephritis
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Fungi:
Like warmth and moisture
o B/w skin folds, groin, axilla, vagina
o Prevention = Keep Cool and Dry
Loves sugar → think about Diabete
Contains Ergosterol- target for drugs
Topical → do not get absorbed = NO SE
o
Nystatino Tinactin
o Micatin
o Myconazole
MOA: Bind to ergesterol, make hole in membrane and cells swell up and die
Amphoteracin B (IM/IV) – also binds to ergesterol, but gets confused with cholesterol and pokes holes incells of body:
o SE: Hyperkalemia – systemic toxicity
Hypokalemia – renal toxicity → K will leak out in urine Renal failure
Inhibit synthesis of ergosterol – can’t use with amphoteracin B because it will have nothing to bind to = ↑SE
o Hraconazole
o Ketoconazole – inhibits p450, inhibits 5α-reductase
o Fluconazole – has best CNS penatration, x bbb, 1 dose PO treatment against candidisis (diflucan)
o Griseofulvin Fat soluble drug that inhibits microtubles = (-) Mitosis
Superficial fungi:
Piedre
o Little black balls on the hair shaft → like dead cells on hair
o Tx. Cut hair off.
Cutaneous Fungi:
Give Tinea name
Location will give last name:
o Tinea Capitus – thick flaky crusty lesions of the scalp MC in children
Kerion = complication caused by bacterial infection (S. aureus) of flaky lesion,swollen lesion underneath
o Need to treat fungi, bacteria, and inflammation
o Tinea Babae – on chin
o Tinea Intertrigo – skin touches skin (armpits, underneath breasts)
Red macerated area
o
Tinea Corporis – on body, most commonly on the face Ring worm
o Tinea Manis – on hand (webs between fingers)
o Tinea Nigra – flaking on the palms causing darkening of the life lines
o Tinea Cruris – on the groin (jock itch)
o Tinea Pedis – between toes (athlete foot)
o Tinea Versicolor – on the back, in the shape of a upside down x-mass tree Likes pigment Common in blacks and Hispanics see pigment changes.
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Treatment: Gresiofulvan (best for capitus and versicolor) or Selsin blue (5% selenium)
Deep fungi:
Tinea Unguum (underneath nail)
o Need to remove the nail → the nail turns black
o
Seen in a Diabetic foot
Systemic fingi:
Candidiasis
o Most common cause of vaginitis (#2 Gardenella – fishy odor, #3 Trichomonas – frothy
green discharge) in females and thrush in neonates (Beware of DiGeorge) – white curdy
discharge
Mucocutaneous Candidiasis
o T-cell defect involving only candidiasis
Histo → Midwest
o Pigeons, bats
o
Lives within macrophages Blasto → Northeast
o Pigeons
o Big Broad Based Budding hyphae → cavitary lesions
Coccidio → Southwest
o Broad based cavity
o Thin wall cavity
Paracoccidio → South America
o Looks like a ship wheel
Aspergillus → Moldy hay/basement
o Fungus ball
o
Bad vasculitis (invades blood vessels)
o Severe allergic reaction in the lungs due to fibers. (mimics asthma) PIE syndrome
PIE = Pulmonary infiltrate with eosinophilia
Most common cause is ABPA (allergic bronchopulmonary aspergillosis)
Loeffler (worms) → invades the lung
Churg-Strauss – necrotizing vasculitis, idiopathic
o Treatment: Steroids
Cryptococcus AIDS pt. With headache/meningitis
o Encapsulated
o Stains with Indian Ink
o
Urease positive Rhizo/Mucor
o Diabetic with something growing out of nostrils
Sporothrix – rose busho Treat with Potasium Iodide on skin and treat like any other fungus if it is systemic.
Enterococcus will cause nitrite negative UTI
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Parasites → GASTRITIS T cells, macrophages and eosinophils
How did you get it
L iver fl ukes:
o Schistosomiasis –walking bear foot in a swamp → snails carry it
Mansoni → affect the liver → Risk for CA Hematobium- squamous cell bladder cancer (chonic irritation)
o Toxacara : Carti – cat larvae
Cani- dog larvae
Cutaneous larva migrans – can see larva burrowing under the skin → Itchy Visceral – larva migrates to organs (liver)
o Echnococcus – from eating raw lamb/sheep/dogs
o Clinorchis Sinensis/Opthorchis – likes biliary tract Clue for biliary involvement is Alkaline Phosphatase Causes gastroenteritis
Treatment of Liver flukes with Praziquantel
Hook worms
Hook into the intestinal/bowel wall
Cause sever cramps and diarrhea
Pneumonic = NEAT ASs:
o Necator americanus
o Enterobius Vermiculris- pin worm Symptoms: pruritis ani (ass itching) (caused by eggs) Scotch tape test: only female comes out at night to anus to lay eggs
Worm lives in the cecum
o Anclystoma Duodenale Duodenal obstruction
o Trichuris Trichurium – Whip worm Anchors into rectum causing tenesmus (feel the nee to poop!!!) And rectal prolapse b/c the worm will get bigger and push it back farther
o
Ascaris lumbricoideso Strongyloides
Treatment:
o Mobendazole – (vermox) give 1 tablet and then repeat in a week = DOC
Paralyzes microtubules → can‟t hook on
o Pyrantel Pamaoate – specific treatment for pin worm
o Thiobendazole – treatment for Strongyloides
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NASA = parasites associated with loffler syndrome = endocarditis & pneumonitis
Part of their life cycles occur in the heart and lungs Necator americanus Anclystoma duodenale Schistosomiasis Strongyloides Ascaris lumbricoides
(Pulmonary infiltrate and severe eosinophilia)
Flat Worms:
Will curl around the intestine D. Latum
o Likes to eat B12 (homocystiene methyl transferase, methyl malonyl mutase)
Tanea Saginatum
o Associated with raw beef
Tanea Solium → larvae from Cystericerosiso Raw pork
o Likes to swim in the aqueous humor of the eye
Trichinella Spiralis
o Raw bear meat
o Tunnels under muscles causing myoisitis Treatment:
o Hyclosamine
o Niclosamide These inhibit oxidative phosphorylation = ↓ ATP
Protozoa: Brain:
o Naeglaria Fowleri
“swimming through swamp” → penetrates through cribiform plate fulminant meningo encephalitis – eat through meninges and brain
o Toxoplasmosis Associated with cat litter
Parietal lobe ring enhanced lesion Treatment = Pyremethamine/ Sulfadiazine
o Trypanosomaa Rhodienses Carried by Tsetse fly → GABA connection
African sleeping disease Cornea:
o Acanthomoeba Associated with contact lenses Will eat through cornea
o Erlichiosis Dog licking face Picked up via saliva
Penetrates side of the eye (puncture wound next to eye)
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Heart:
o Trypanasoma Cruzi
Chagas disease
Eats ganglia and causes heart block Get it from South America
Reduuvid bug
Lung: o
Pneumocystis Corinii Silver stains (along with Legionella)
CD4 count below 200 Treatment: Bactrim (SMX-TMP)
GI: o Giardia → gastroenteritis
Loves fresh water/ well water → hiking in the moutains Treatment- IV metronidazole
o E. histolyticum
Multiple liver abscesses
Never do surgery Treatment: metronidazole (8wks)
o Microsporidium Most common cause of diarrhea in AIDS patients
o Cryptosporidium Most common cause of VERY WATERY diarrhea → dehydration Partially acid fast Treatment → Cipro
o Isospora Belli
GU:
o Trichimonas
# 3 cause of Vaginitis Treatment:
Metronidazole 2g x 1
Also treat partner
Skin: o Leschmaniasis
“Gulf war syndrome” Transmitted by sand flies
o Leschmania Donivini Attacks skin and nostrils
o Leschmania Rhodiensis
Likes to be systemic (in the blood) → Attacks organs Caled Kala-Azar if systemic Treatment → Stibogluconate
Lymphatics:
o Wucheria Bacrofti Elephantitis No treatment
Blood:
o Babesiosis
Common causes of vaginitis in order of
incidence:
1.
Candida- white cheesy curdy
discharge
2.
Gardnerella – fishy odor, clue
cells
3. Trich- frothy green discharge
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o Petichial rash involving “palms and soles”
o Centripital rash = From periphery to torso
Rickettsia Typhi
o Endemic typhs
o Flea born
o Rash starts in axilla and going outward
Rickettsia Prowzeki i
o
Epidemic typhuso Louse born
Rickettsia Akar i
o Rickettsial pox – fleshy papules/ vesicles
o Mites
Rickettsia Tsutsugamushi
o Scrub typhus
o Caused by mite (mighty mite)
Coxiell a Burnetti (long lost relative)
o Q fever
o Find in dusty barn
o
Doesn’t behave like rest of rickettsia family → NO vasculitis Just get lung disease