PACKET 1: Gastroenteritis

- Gastroenteritis: refers to an inflammation of the lining of the stomach and intestines and is predominantly
manifested by the following symptoms: Nausea, Vomiting, Anorexia, diarrhea, abdominal discomfort.
- Travelers diarrhea: refers to gastroenteritis in travelers usually caused by bacteria endemic to the local
water.
- Travelers diarrhea may be caused by any of several bacteria, viruses, or parasites. However,
enterotoxigenic E. coli is the most common cause. E. coli organisms are commonly present in the water
supplies of areas that lack adequate water purification.
- Infection is common in persons traveling to some areas in Mexico and Latin America, the Middle East,
Asia, and Africa.
Symptoms:
- Nausea, vomiting, abdominal cramps, and diarrhea begin 12 to 72 hours after ingesting contaminated food or
water. Severity is variable. Some people develop fever and myalgias.
Prevention:
- Travelers should dine at restaurants with a reputation for safety and avoid foods and beverages from street
vendors.
- They should consume only cooked foods that are still hot, fruit that can be peeled and carbonated beverages
without ice.
- avoid eating uncooked vegetables.
- Antibiotics generally are not recommended for mild diarrhea in patients without fever or blood in the stools
as they may alter intestinal flora adversely and promote resistant organisms.
- for more severe diarrhea (three or more loose stools over 8 hours), antibiotics may be indicated, especially if
vomiting, abdominal cramps, fever, or bloody stools are present.
Note: Ciprofloxacin is contraindicated in children less than 16 years of age.
- Escherichia coli 0157:H7 Infection: This infection is a syndrome typically characterized by acute bloody
diarrhea, which may lead to the hemolytic-uremic syndrome.
- E. coli 0157: H7 and similar strains of E. coli (enterohemorrhagic E. coli) produce high levels of toxins that
are indistinguishable from the potent cytotoxin produced by Shigella dysenteriae. These Shiga toxins are
produced in the large intestine after ingestion of enterohemorrhagic E. coli.
- Although over 100 serotypes of E .coli produce Shiga toxin, E. coli serotype 0157: H7 is the most common
in North America.
- both outbreaks and sporadic cases of hemorrhagic colitis occur after ingestion of undercooked beef
(especially ground beef) or unpasteurized milk.
Symptoms
- E. coli 0157: H7 infection typically begins acutely with severe abdominal cramps and watery diarrhea that
may become grossly bloody within 24 hours.
- Some patients report diarrhea as being all blood and no stool. Fever is usually absent or when present is
usually low grade, occasionally reaching 102.2 F. In uncomplicated cases the diarrheal illness may last 1 to 8
days.
- About 5% of cases are complicated by the hemolytic-uremic syndrome (HUS)
Diagnosis
- E. coli 0157: H7 infection should be distinguished from dysentery and from other infectious diarrheas with
bloody stools by isolating the organism from stool cultures.
Treatment
- Although E. coli is sensitive to most commonly used antimicrobials, antibiotics have not been shown to
alleviate symptoms, or prevent HUS.
- Patients at risk for developing HUS should be observed for early signs. Patients who develop complications
are likely to require intensive care

- Staphylococcal Food Poisoning: an acute syndrome of vomiting and diarrhea caused by eating food
contaminated by staphylococcal enterotoxin.
- Symptoms of staphylococcal food poisoning are caused by staphylococcal enterotoxin, not by staphylococcal
itself.
Symptoms
- Onset is usually abrupt. Severe nausea and vomiting begin 2 to 8 hours after eating food containing the toxin.
Other symptoms may include abdominal cramps, diarrhea, and occasionally headache and fever.
- Because the toxin does not cause mucosal ulceration, it is usually non-bloody.
Treatment
- Diagnosis relies on recognizing the clinical syndrome. Usually several persons are similarly affected,
constituting a point source out break. Diagnostic confirmation, although rarely required, entails isolating
coagulase staphylococci from the suspected food. Gram stain of specimens of vomit may show staphylococci.
Careful food preparation is essential for prevention.
- Botulism: type on neuromuscular poisoning from Clostridium botulinum toxin
- Type A and B toxins are highly poisonous proteins resistant to digestion by our gastrointestinal enzymes.
Approximately 50% of foodborne outbreaks in the USA are caused by Type A toxin, followed by type B and
E.
- C. botulinum spores are highly heat-resistant and may survive boiling for several hours at (212 degrees F);
however, exposure to moist heat at 120 C (248 F) for 30 minutes will kill the spores.
- Toxins on the other hand, are readily destroyed by heat, and cooking food at 176 degrees F for 30 minutes
safeguards against botulism.
- Home-canned foods are the most common sources, but commercially prepared foods have been identified in
about 10% of outbreaks.
Symptoms
- The onset of foodborne botulism is abrupt; usually 18-36 hours after ingestion of the toxin, however the
incubation has been shown to vary from 4 hours to 8 days.
- This is then followed by neurological symptoms. These symptoms are characterized by bilateral descending
weakness and paralysis
- Symptoms such as Dysarthria, dysphagia, dysphonia develop. Muscles of the extremities and trunk and of
respiration progressively weaken in a descending pattern. Constipation is common after neurologic
impairment appears.
- fever is absent, weakness, trouble seeing, feeling tired, and trouble speaking
- honey should not be given to infants younger than 1
- Major complications include respiratory failure caused by diaphragmatic paralysis and pulmonary infections.
Symptoms and Signs: Wound Botulism:
- Wound botulism is manifested by neurological symptoms, as in foodborne botulism, but there are no GI
symptoms or evidence implicating food as a cause.
- A history of a traumatic injury or a deep puncture wound in the preceding 2 weeks may suggest the
diagnosis.
Symptoms and Signs: Infant Botulism:
- Infant botulism occurs most often in infants less than 6 months. It results from the ingestion of C.
botulinum spores, their colonization in the large intestine, and toxin production in vivo.
- Unlike foodborne botulism, infant botulism is not caused by ingestion of a preformed toxin.
- Constipation is present initially in 90% of cases and is followed by neuromuscular paralysis
- Most cases if infant botulism are idiopathic, although some have been traced to the ingestion of honey. C.
botulinum spores are common in the environment, and many cases may be caused by the ingestion of
microscopic dust.

Diagnosis
- In foodborne botulism, the pattern of neuromuscular disturbances and ingestion of a likely food source are
important diagnostic clues. The simultaneous presentation of at least two patients who ate the same food
simplifies the diagnosis which may be confirmed by demonstrating C. botulinum toxin in the serum or feces or
by isolating the organism from the feces.
- In wound botulism, finding toxin in serum or isolating the C. botulinum organism on anaerobic culture of
the wound confirms the diagnosis.
- Infant botulism may be confused with sepsis, congenital muscular dystrophy, or hypothyroidism. Finding
C. botulinum toxin in the feces establishes the diagnosis.
- The greatest threat to life is respiratory impairment and its complications. Patients should be hospitalized
and closely monitored with serial measurements of vital capacity. Progressive paralysis prevents patients from
showing signs of respiratory distress while their vital capacity decreases.
C. Perfringens: causes and acute gastroenteritis when eating foods contaminated by this organism.
- C. Perfringens is widely distributed in feces, soil, air, and water. Contaminated meat has caused many
outbreaks. When meat contaminated with C. Perfringens is left at room temperature, the organism multiplies.
Symptoms, Signs, and Diagnosis
- Mild gastroenteritis is most common, with onset of symptoms 6 to 24 hours after ingestion of contaminated
food. The most common symptoms are water diarrhea and abdominal cramps. Vomiting is unusual.
Symptoms typically resolve within 24 hours.
- Diagnosis is based on evidence of eating contaminated foods and the isolation of organism from suspected
food and stool of affected persons.
Prevention and Treatment
- To prevent disease, leftover cooked meat should be refrigerated promptly and reheated thoroughly before
serving.
- Intestinal flu is caused by infection with one of several viruses, usually characterized by the following:
vomiting, cramps, diarrhea
- Viral gastroenteritis is the most common cause of infectious diarrhea in the USA. Four categories of
viruses are known to cause gastroenteritis:
Rotavirus: is the most common cause of severe, dehydrating diarrhea in young children (peak incidence 315 months). Rotavirus is highly contagious, and most infections occur via the fecal-oral route. Adults may be
infected after close contact with an infected infant, but the illness in adults is generally mild.
- incubation (1-3 days)
Norwalk virus: commonly infects older children and adults, and infections occur year-round. Norwalk virus
is the principal cause of epidemic viral gastroenteritis; waterborne and foodborne outbreaks are well
documented. Person to person transmission also occurs because the virus is highly contagious.
- incubation (1-3 days)
Adenovirus: serotypes 40 and 41 are the second most common cause of childhood viral gastroenteritis.
Infections occur year-round with an increase during the summer. Children less than 2 years of age are
primarily affected, and transmission occurs from person to person by the fecal-oral route.
- incubation (8-10 days)
Astrovirus: infection may affect persons of all ages, but usually infect infants and young children Infection is
most common in the winter. Transmission is via fecal-oral route. Incubation 1 to 3 days.
Symptoms and Signs:
- The majority of infections caused by viral enteropathogens are asymptomatic. In symptomatic infections,
watery diarrhea is the most common symptom.
- Infants and young children with rotavirus gastroenteritis may develop severe watery diarrhea lasting 5 to 7
days. Vomiting occurs in most patients and a low grade fever occurs in about 30% of cases.

- Norwalk virus typically causes acute onset of vomiting, abdominal cramps, and diarrhea, with symptoms
lasting only 1 to 2 days. In children, vomiting is more prominent than diarrhea, whereas in adults, diarrhea
usually predominates
- adenovirus gastroenteritis is diarrhea lasting 1 to 2 weeks. Affected infants and children may have mild
vomiting that typically starts 1 to 2 days after the onset of diarrhea. Low-grade fever occurs in about 50% of
the cases.
- Astrovirus causes a syndrome similar to a mild rotavirus infection.
Daignosis
- Viral gastroenteritis is often diagnosed clinically. Rotavirus and enteric adenovirus infections can be
diagnosed rapidly using commercially available assays that detect viral antigen in the stool.
- Caregivers should wash their hands thoroughly with soap and water after changing diapers, and diaperchanging areas should be disinfected with diluted household bleach or 70% alcohol. For rotavirus outbreaks in
child care facilities, all children should be tested for excretion of the organism
Treatment:
-The mainstay of therapy is appropriate fluid resuscitation. Even if vomiting, most patients can be effectively
rehydrated with oral rehydration solutions, several of which are available OTC.
- Sports drinks and carbonated beverages are not appropriate rehydration for children less than 5 years of age.
IV rehydration is necessary only for patients with severe dehydration.
PACKET 2: Hepatitis
- Hepatitis: is an acute or chronic liver inflammation due to a variety of agents, most notably viral infection
by one of the hepatitis viruses or alcohol use.
- Hepatitis A is a single-stranded RNA picornavirus. This viral antigen is found in the serum, stool, and liver
only during acute infection. HAV is spread by fecal-oral route and can lead to epidemics.
- IgM antibody is a marker of acute infection, whereas IgG anti-HA merely indicates previous exposure to
HAV and immunity to recurrent infection.
- Hepatitis B (HBV): is a DNA hepadnavirus that can cause acute or chronic hepatitis. HBV is a major cause
of hepatocellular carcinoma worldwide. HBV is spread by blood and other body fluids, including saliva.
- The intact HBV is called the Dane particle. The Dane particle has an envelope and an icosahedral capsid
containing protein spikes. Within the envelope you will find the double-stranded DNA.
- having anti-HBsAg means that the patient is immune against HBV.
- The core of the virus is called the Hepatitis B core antigen (HBcAg). The core is also antigenic and
antibodies form against the core, however, unlike antiHBsAg, antiHBcAg are not protective.
- HBeAg is found dissolved in the serum, and is a marker for active disease.
- Hepatitis D (Delta): is caused by a small, defective RNA virus (delta agent) that is infectious only in the
presence of hepatitis B infection because it relies on hepatitis B proteins for replication. It can, therefore,
complicate acute hepatitis B infection but is seen more commonly as a super infection with an increase in
abnormal liver function tests in a patient with chronic hepatitis B
- Hepatitis E (HEV): a small RNA virus that has been described in cases of acute hepatitis in Mexico, Asia,
and Africa. It normally causes self-limited disease but can be fatal in (10%-20%) pregnant women. It is
spread via the fecal-oral route.
- HCV is an RNA virus and may cause acute or chronic hepatitis. It is major causes of cirrhosis and a major
cause of post-transfusion hepatitis. It is often associated with IV drug abuse and is spread by blood-borne
transmission

Symptoms and treatment: Acute Hepatitis:

- Acute hepatitis often starts with a viral prodrome of nonspecific symptoms (malaise, joint pain, fatigue,
nausea, vomiting, changes in bowel habits followed by jaundice.
- Chronic hepatitis usually gives rise to symptoms indicative of chronic liver disease (jaundice, cirrhosis).
- Alpha-interferon and lamivudine have proven efficacy for chronic HBV infection. For HCV you may treat
with alpha-interferon and ribavirin.
PACKET 3: Pneumonia (Typical symptoms include a cough, chest pain, fever, and difficulty breathing)
- S. pneumoniae is the most common identifiable cause of bacteria pneumonia and accounts for 2/3 of
bacteremic community-acquired pneumonias.
- Pneumococcal pneumonia generally occurs sporadically but most frequently in winter. It occurs most
commonly in persons at age extremes. There are more than 80 different serotypes.
- Pneumococci usually reach the lungs by inhalation or aspiration. They lodge in bronchioles, proliferate, and
initiate an inflammatory process that begins in the alveolar spaces with an outpouring of protein-rich fluid
- Congestion: earliest stage of lobar pneumonia and is characterized by extensive serous exudation, vascular
engorgement and bacterial proliferation.
- Red hepatization: reflects the liver-like appearance of the consolidated lung. Airspaces are filled with
polymorphonuclear cells (neutrophils), vascular congestion occurs, and extravasation of RBCs causes a
reddish discoloration on gross examination.
- Gray hepatization: is characterized by an accumulation of fibrin and inflammation. WBCs and RBCs are
seen at various stages of disintegration. The alveolar spaces are packed with inflammatory exudate.
- Resolution is characterized by resorption of the exudate.
Symptoms:
- Pneumococcal pneumonia is often preceded by an upper respiratory infection. The onset is often sudden,
with an episode of chills. The chill is ordinarily followed by fever, pain with breathing on the effected side
(pleurisy), cough, dyspnea, and sputum production
Diagnosis:
- Blood tests usually show leukocytosis. Positive blood cultures are definitive evidence of pneumococcal
infection.
- Gram stain of the sputum typically shows gram-positive lancet-shape diplococci.
- Chest x-ray shows a pulmonary infiltrate; although findings may be minimal
Treatment:
- Penicillin G or V 250 to 500mg po q 6 h is the preferred treatment for patients not severely ill.
- Vancomycin has been preferred for severely ill patients.
- morality rate 10%
Staphylococcal pneumonia:
S. aureus accounts for about 2% of community-acquired pneumonias and 10 to 15% of nosocomial
pneumonia.
- Symptoms and signs generally parallel those of pneumococcal pneumonia
- The mortality rate is generally 30 to 40 % in part due to the serious associated conditions the patients have
Treatment
- Recommended therapy is penicillinase-resistant penicillin
- The major alternative is a cephalosporin, preferably cephalothin or cefamandole
- Vancomycin is preferred when methicillin resistance is suspected.
Pneumonia caused by Gram-Negative Bacilli:
Gram negative bacilli account for less than 2 % of community acquired pneumonias. The most important
pathogen is Klebsiella pneumoniae, which causes Friedlanders pneumonia.
- Pseudomonas aeruginosa is a common pathogen in patients with cystic fibrosis, neutropenia, advanced
AIDS.
Diagnosis:
- Gram negative bacilli should be suspected in a patient with pneumonia with risks factors discussed. Positive

cultures from blood, pleural fluid, or a transtracheal aspirate obtained before treatment are considered
diagnostic.

Prognosis and Treatment:

- The mortality for gram-negative bacillary pneumonia is about 25 to 50% despite the availability of effective
antibiotics. The most preferred drug regimen includes a cephalosporin
Pneumonia caused by Haemophilus Influenzae:
- H. influenzae, is a relatively common cause of bacterial pneumonia
- Strains containing the type b (Hib) polysaccharide capsule are the most virulent and most likely to cause
serious disease, including meningitis, and epiglottitis.
Symptoms and Signs:
- Hib pneumonia usually occurs in children (average age one year).
- Gram stain of expectorated sputum shows numerous, small, gram-negative coccobacilli.
Treatment:
- Prophylaxis with H. influenzae type b (Hib) vaccine is advocated for all children to be given in three doses
at 2, 4, and 6 months of age.
Pneumonia of Legionaires Disease:
- Investigation of an outbreak of acute febrile respiratory illness among members of the American Legion in
Philadelphia in 1976 led to the discovery of the bacterium Legionella pneumophilia.
- There are more than 30 proposed species of Legionella. At least 19 species have been implicated as agents of
pneumonia in humans; of these the most common agent is L. pneumophilia
- A self-limited, flu-like illness without pneumonia sometimes called Pontiac fever
- Legionaires disease the most serious form, characterized by pneumonia
- Legionaires disease has a predilection for late summer and early fall. Person-to-person transmission has not
been shown. L. pneumonia outbreaks tend to occur in buildings, especially hospitals and hotels, or in certain
geographic areas when a water supply becomes contaminated and aerosolized organisms are spread from
evaporative condensers of air conditioner systems
Symptoms and Signs
- The usual incubation period is 2 to 10 days. Most patients have a prodromal phase, which may resemble
influenza, malaise, fever, headache, and myalgias; they develop cough that is initially nonproductive and
subsequently productive of mucoid sputum.
Prognosis and treatment
- Even with appropriate treatment, mortality is about 15% or greater in community acquired cases and is higher
among immunosuppressed or hospitalized patients.
- Erythromycin is usually the drug of choice.
- Mycoplasma pneumoniae: is a common pathogen of lung infection in persons 5 to 35 years of age. This
agent may be responsible for epidemics that spread slowly because it has an incubation period of 10-14 days.
Spread may involve close contacts or closed populations in schools, the military, and families.
- Mycoplasmal pneumonia is also called primary atypical pneumonia.
Symptoms and Signs
- Initial symptoms resemble influenza, with malaise, sore throat, and dry cough, which increase in severity as
the disease progresses. Unlike typical pneumococcal pneumonia, this disease progresses gradually. Acute
symptoms usually persist for 1 to 2 weeks followed by gradual recovery.
Prognosis and Treatment
- Nearly all patients recover with or without treatment. Because mycoplasmas do not have a cell wall, they do
not respond to antibiotics that interfere with cell wall structure.
- The preferred drugs are tetracycline or erythromycin

- Psittacosis is an infectious atypical pneumonia caused by Chlamydia psittaci and transmitted to humans by
certain birds.
- C. psittaci is found principally in psittacine birds (parrots, parakeets, lovebirds), less often in poultry,
pigeons, and canaries.

Symptoms and Signs

After a 1 to 3 week incubation period, onset may be insidious or abrupt, with fever, chills, malaise, and
anorexia. The temperature rises gradually rises
- Mortality may reach 30% in severe untreated cases.
Diagnosis
- Psittacosis is suggested by a history of exposure to birds and is confirmed by recovery of the agent or by
serology.
Treatment
-Because other persons may become infected by inhaling cough droplets and sputum, strict patient isolation
should be instituted when the diagnosis is suspected on clinical and epidemiologic grounds.
Pneumonia caused by Pneumocystis carinii:
- P. carinii is considered a fungus and causes disease only when defenses are compromised,
- Patients with HIV infection become vulnerable to P. carinii pneumonia when the CD4 cell count is less than
200/u/L.
Symptoms, Signs, and Diagnosis:
- Most patients have fever, dyspnea, and a dry, nonproductive cough. The chest x-ray characteristically shows
diffuse bilateral perihilar infiltrates, but 20 to 30% of patients have normal X-rays.
- The drug of choice is trimethoprim-sulfamethoxazole (TMP-SMX) 20 mg/kg/day. If this treatment is not
tolerated, dapsone 100 mg/day po or aerosolized pentamidine 300 mg monthly can be used.
PACKET 4: STD's
- Syphilis: is a subacute to chronic infectious disease caused by the bacterium Treponema pallidum. It is
usually acquired by sexual contact with another infected individual. If untreated, it progresses through a
primary, secondary, and tertiary stages.
- Syphilis, with the exception of congenital syphilis, is acquired almost exclusively by intimate contact with
the infectious lesions of primary or secondary syphilis. This is usually through sexual intercourse, including
anogenital and orogenital intercourse.
- The incubation period averages approximately 21 days
Primary Syphilis: Following the incubation period, a painless papule develops and gradually breaks down to
form a clean-based ulcer with raised margins. This persists for 2 to 6 weeks and then heals spontaneously.
Secondary Syphilis: Approximately 4 to 8 weeks following the appearance of the primary chancre, patients
typically develop lesions of secondary syphilis. They may complain of malaise, fever, headache, sore throat.
- At least 80% of patients with secondary syphilis have cutaneous lesions or lesions of the mucocutaneous
junctions. The lesions are usually widespread and are symmetric in distribution. They are often pink, coppery,
of red. The face is often spared except around the mouth.
- In warm, moist areas such as the perineum, large, flat flat-topped papules may coalesce to form
condylomata lata
Latent Syphilis: is that stage in which there are no clinical signs of syphilis and the cerebrospinal fluid is
normal. Latency begins with the passing of the first attack of secondary syphilis and may last for a lifetime.
- Early latency in the United States is defined as the first year after infection.
- Late latent syphilis is ordinarily not infectious except for the case of the pregnant woman, who may transmit
infection to her fetus after many years.
Tertiary syphilis: is the destructive stage of the disease and can be crippling. Fortunately, newly recognized
cases of late syphilis have been declining steadily in the Unites States since World War II.
- On of the most complication of late syphilis is the appearance of GUMMA A gumma is a soft, rubbery, noncancerous grow with a necrotic center, and is enclosed by a fibrous capsule. They are commonly found in the

liver, brain, heart, skin, bone, testis, and other tissues

Cardiovascular Syphilis: The primary cardiovascular complications of syphilis are aortic insufficiency and
aortic aneurysm, usually of the ascending aorta. Death may eventually result from congestive heart failure.
Cardiovascular syphilis usually begins with 5 to 10 years after the initial infection but may not become
clinically apparent until 20 to 30 years after infection.
Meningovascular Syphilis: is an acute to subacute aseptic meningitis and may occur at any time after the
primary stage but usually within the first year of infection.
Tabes dorsalis: is a slowly progressive degenerative disease involving the posterior columns and posterior
roots of the spinal cord, resulting in a progressive loss of peripheral reflexes, impairment of vibration and
position sense, and progressive ataxia
Darkfield Examination: The most definitive means of making a diagnosis is finding spirochetes of typical
morphology and motility in lesions of syphilis. The darkfield examination is almost always positive in
primary syphilis and in the moist mucosal lesions of secondary syphilis.
Nonspecific Tests:
The standard test in use today for detection of anticardiolipin antibody is the Venereal Disease Research
Laboratories (VDRL) test. Many similar tests, including the rapid plasma regain (RPR) test and the
unheated serum regain (USR), are frequently used for the screen of syphilis.
Specific Treponemal Tests:
fluorescent treponemal antibody absorption (FTS-ABS) test. The FTA-ABS test is used as a confirmatory
test. It is more difficult to perform than the VDRL test. IT is sensitive and has a high degree of specificity. It
is positive in 85% of patients with primary syphilis and 99% positive in patients with secondary syphilis.
Treatment:
- T. pallidum is highly susceptible to penicillin G
Neisseria gonorrhoeae: is a common sexually transmitted organism that causes anterior urethritis in males
and endocervicitis and urethritis in females.
- Gonorrhea is the most common reportable infectious disease in the United States, with about one million
reported cases annually.
- N. gonorrhoeae is a gram negative, aerobic diplococcus. They are highly autolytic and die rapidly when
outside their normal human environment.
- The only natural hosts for N. gonorrhoeae are humans.
- Gonorrhea is very easily transmitted to women during sexual intercourse; 80-90% of women who have a
single encounter with an infected individual contract the disease, while males become infected only 20-25% of
the time after sex with an infected female.
Diagnosis: Thayer-Martin medium (80-95 sensitivity).
Treatment/Prevention: IM ceftriaxone.
- Condoms are effective prophylaxis
Chlamydia Trachomatis:C. trachomatis is a sexually transmitted disease that often coexists with or mimics N.
gonorrhoeae infection.
Herpes genitalis is caused by the herpes simplex virus, a member of the Herpesviridae family of viruses,
- Seventy to 90% of cases of herpes genitalis are caused by HSV type 2. HSV type 1 as been implicated in
about 13 %.
- Sixty-85% of women with antibodies to HSV-2 have never had a recognized genital ulcer.
- Transmission is through direct contact with someone who is actively shedding virus from skin or mucous
membrane lesions. The incubation period is 2-7 days.
- Primary infection is often associated with systemic flu-like symptoms of malaise, myalgia, and headache.
Diagnosis:
- presumptive diagnosis of herpes genitalis can be made on physical examination when typical lesions are

present. HSV-2 should be suspected

Treatment: sitz baths and topical anesthetic creams
- Catheterization may be necessary for acute urinary retention.
- Antiviral therapy: Acyclovir is an antiviral drug that is effective against herpesvirus.. It can be applied
topically or taken orally for the primary episode of HSV-2 infection
- Oral acyclovir decreases the time of viral shedding, duration of symptoms, reduces re-occurrence up 75%
HPV is a double-stranded DNA virus responsible for a variety of mucocutaneous genital lesions, affecting
both men and women. It is also known to be associated with lower genital tract cancers.
- More than 40 million sexually active adults in the US harbor HPV.
- risk of contracting warts for women whose sexual partners have obvious genital warts is 60% to 85%.
Incubation time is between 6 weeks 18 months
- Approximately 2%-4% of pap smears demonstrate the pathognomonic cellthe koilocyte (halo cell).
- Colposcopy. This involves a magnified inspection of lower genital tissues after staining with a weak acetic
acid solution. This is helpful in detecting latent or associated precancerous lesions caused by HPV
- Treatment: Treatment does not eradicate the virus.
- The treatment of latent HPV infections without dysplasia is not recommended.
HPV-related precancerous conditions, treatment modalities include
- Loop electrode excision of the transformation zone.
- Laser vaporization
- Cone biopsy of the cervix
- Surgical excision of vulvar or vaginal lesions
Gynecological Infections:
The vagina is usually resistant to infections for two major reasons:
- Its acidic environment
- A thick protective epithelium
- The vaginal flora play a critical role in vaginal defenses by maintaining the normally acidic pH (pH 3.8-4.2)
of the vagina.
- There are normally 5-15 different bacterial species (group B Streptococcus, E. coli), aerobic and anaerobic
bacteria that inhabit the vagina.
- Lactobacillus acidophilus: is the dominant bacteria in a healthy vaginal ecosystem. These organisms play a
critical role in maintaining the normal vaginal environment.
- The acidic environment of the vagina is maintained through the production of lactic acid.
- Lactic acid and hydrogen peroxide produced by lactobacilli are toxic to anaerobic bacteria in the vagina.
- Normal estrogen levels are necessary for a normal vaginal environment and resistance to infection.
- Estrogen: stimulates proliferation and maturation of the vaginal epithelium, providing a physical barrier to
infection. A mature epithelium provides glycogen, necessary for lactobacillus metabolism.
- If glycogen levels are decreased, lactobacillus counts decrease as well.
The following are several factors that alter the vaginal environment.
- Antibiotics alter the microbiology of the vagina and can increase the risk of infection.
- Hormones. As mentioned decreased levels of estrogen increases risk for infection.
- Intravaginal preparations. Douching or the use of intravaginal medications can alter the vaginal pH
affecting the vaginal flora.
- Intercourse. Semen has an alkaline pH, thus affecting the microenvironment of the vagina. New
organisms that may be introduced into the vagina also affect the microenvironment.
- Stress, poor diet, and fatigue.
- Foreign bodies.
- Common Symptoms: Burning/Itching
Bacterial vaginosis is the most common vaginal infection in the United States today.
- Bacterial vaginosis is caused by an overgrowth of a variety of bacterial species, particularly anaerobes, often

normally found in the vagina.

- Organisms most often included Bacteroides, Gardnerella vaginalis (most common!!)
- Fifty percent of women with bacterial Vaginitis are asymptomatic. The most common presentation is a
malodorous, gray discharge.

Diagnosis:
The diagnosis is based on finding three of the following four criteria.
- A vaginal pH greater than 4.5.
- Wet mount preparation showing minimal or no leukocytes, an abundance of bacteria, and the
characteristic clue cell. The clue cell is a squamous cell in which coccobacillary bacteria have adhered
to the cell surface.
- Application of 10% KOH to the wet mount specimen produces a fishy odor, indicating a positive
whiff test.
- The presence of gray, homogenous, malodorous discharge.
Treatment
Treatment is based on the use of agents with anaerobic activity and uses both topical and systemic agents.
Both appear to be quite effective.
- Treatment during pregnancy is critical because data suggest an associated of adverse and maternal and fetal
outcomes with bacterial Vaginitis. Clindamycin can be used throughout pregnancy. Metronidazole can be
used after the first trimester.
Candida Vaginitis is the second most common vaginal infection in the United States, accounting for 1-3
million cases a year.
- The etiologic agent for this infection is a yeast (fungi) organism, usually Candida albicans
- Several factors have been identified that can lead to symptomatic infection. These include the following:
- Contraceptive practices (e.g., birth control pills and vaginal spermicides, which influence the vaginal
pH).
- Use of systemic steroids, which influence the immune system.
- Use of antibiotics, which alters the microbiology of the vagina; 25-70% of women report yeast
infections after antibiotic use.
- Tight clothing, panty hose, and bathing suits, because yeast thrive in a dark, warm moist environment.
- Undiagnosed or uncontrolled diabetes.
Trichomoniasis is the third most common vaginitis, accounting for 25% of cases.
- The trichomonad can be recovered from 70% to 80% of the male partners of the infected patient;
Trichomonas vaginitis is therefore an STD.
Classic evidence of trichomoniasis includes the following:
- Copious, green, frothy discharge.
- The vaginal pH is usually greater than 4.5
- Saline wet mount of the vaginal discharge reveals numerous leukocytes and the highly mobile,
flagellated trichomonads in up to 75% of cases.
Treatment:
- Because of the multiple sites of infection, vaginal therapy alone is ineffective, and systemic agents are
necessary.
- Because the causative agent is sexually transmitted, both partners require therapy.
- Cure rates of 90% are achieved with treatment with metronidazole.
- Patients should be warned of a disulfiram-like reaction and told to abstain from alcohol with
treatment.

PACKET 5: Staph Infections

- Staphylococci are members of the family Micrococcaceae, of which there are two genera of clinical
importance, the micrococci and the staphylococci.
- These two genera are both catalase positive, only staphylococci can anaerobically to ferment glucose to
produce acid.
- Staphylococci may colonize almost all animal species, and S. epidermidis is universally present on the human
skin
- Humans carry S. aureus predominantly in the nasopharynx, although some individuals can be heavily
colonized in the axillae, groin, and perineal region.
- Patients who regularly use needles have an increased rate of carriage of S. aureus. Drug addicts, diabetics
injecting insulin, patients on hemodialysis, and even patients receiving brief courses of allergy shots all have
increased rate of nasal carriage of S. aureus
- The most effective technique for stopping transmission of staphylococci from person to person, especially in
the hospital setting, is to wash ones hands meticulously immediately before and after examining each patient.
Microbial Virulence:
- Normally, a healthy immune system wards off Staphylococcus aureus, so it lives harmlessly as part of the
normal flora. But given the chance, it can cause a variety of disease.
- Protein A is a surface protein found in the cell wall of Staphylococcus aureus. This protein has the ability to
bind immunoglobulins through interaction with the heavy chain.
- Coagulase:This enzyme leads to fibrin formation around the bacteria, protecting it from phagocytosis.
- Hemolysins: There are four types of hemolysins (alpha, beta, gamma, and delta). They destroy red blood
cells, neutrophils, macrophages, and platelets.
- Leukocidins: As the name implies, Leukocidins destroy leukocytes (white blood cells).
- Penicillinase: This is a secreted form of beta-lactamase. By disrupting the beta-lactum portion of penicillin
it inactivates it
Proteins that tunnel through tissue may include the following:
- Hyaluronidase: is a protein that breaks down proteoglycan in connective tissue, while lipase is capable of
degrading fats and oils, which often accumulates on the surface of our body.
Exotoxins released from Staphylococci include the following:
- Exfoliatin is a diffusible exotoxin that causes the skin to slough off (scalded skin syndrome)
- Enterotoxins are associated with food poisoning, resulting in vomiting and diarrhea.
- TSST-1 has been associated with Toxic shock syndrome
Staphylococcal Gastroenteritis: Most cases of gastroenteritis caused by S. aureus follow ingestion of foods
containing a preformed toxin. The toxin itself is not produced within the gastrointestinal tract.
- Custards, cream-filled pastry, milk, processed meat, and fish provide media where coagulase-positive
staphylococcal grow and provide enterotoxin.
- Onset is usually abrupt. Severe nausea and vomiting begin 2 to 8 hours after eating food containing the toxin.
Other symptoms may include abdominal cramps, diarrhea, and occasionally headache and fever.
- Diagnosis relies on recognizing the clinical syndrome. Usually several persons are similarly affected,
constituting a point source outbreak. Diagnostic confirmation, although rarely required,
Toxic shock syndrome caused by staphylococcal exotoxin, is characterized by the following: high fever,
diarrhea, skin rash, vomit.
- Toxic shock syndrome occurred predominantly in menstruating women who used tampons. After widespread
publicity of the role played by tampons and diaphragms,
- Onset is sudden, with fever (102-105 degrees F.), headache, sore throat, nonpurulent conjunctivitis, profound
lethargy, intermittent confusion, vomiting,
- Patients suspected of having toxic shock syndrome should be hospitalized immediately and treated
intensively: tampons, diaphragms, and other foreign bodies should be removed at once. Fluid and electrolyte
replacement must be given to prevent hypovolemia, hypotension, or shock.

The Staphylococcal Scalded Skin Syndrome (SSSS):

- SSSS is another toxin-mediated disease produced by certain strains of S. aureus.
- The skin is often tender and very erythematous, producing a sunburn-like rash during the initial phase.
Infants are most commonly involved, and outbreaks of this syndrome have occurred in nurseries after
introduction of a toxin producing strain.
- The rash proceeds rapidly to desquamation, but healing is rapid and is related to how promptly the peripheral
site has been treated.
Diseases Related To Direct Invasion and Systemic Spread of Staphylococci:
- Impetigo is a superficial vesiculopustular infection.
- Impetigo may occur on normal skin, especially on the legs of children. Lesions vary from a pea-sized
vesicopustule to large, ringworm like lesions.
- Ecthyma is an ulcerative form of impetigo.
- Ecthyma is characterized by small, purulent, shallow, punched-out ulcers with thick, brown-black crusts and
surrounding erythema. Itching is common and scratching may cause spread.
-The arms, legs and face are more susceptible to impetigo and ecthyma than unexposed areas
Treatment: Application of mupirocin ointment 3 times daily has been effective in treating impetigo caused by
S. aureus and group A Beta hemolytic streptococci.
Furuncles: are acute, perifollicular inflammatory nodules resulting from infection by staphylococci.
- Furuncles occur most frequently on the neck, breasts, face, and buttocks but are most painful when on skin
closely attached to underlying structures (e.g., on the nose, ear or fingers)
- A single furuncle is treated with intermittent hot compresses to allow the lesion to point and drain
spontaneously.
- A patient with a furuncle in the nose or central facial area and patients with multiple furuncles should be
treated with systemic antibiotics
Carbuncles: are a cluster of furuncles with subcutaneous spread of staphylococcal infection, resulting in deep
suppuration, often extensive local sloughing, slow healing, and a large scar.
- Carbuncles occur most frequently in males and most commonly occur in healthy persons. Diabetes mellitus,
debilitating diseases and old age are predisposing factors.
Folliculitis is a superficial or deep bacterial infection and inflammation of the hair follicles, usually caused by
S. aureus but occasionally caused by other organisms such as P. aeruginosa
- In this condition, infected hairs may be easily removed, but new papules tend to develop. Folliculitis may
become chronic where the hair follicles are numerous or deep in the skin, as in the bearded area
- Treatment of acute folliculitis is similar to that of impetigo. Topical antibiotics and antiseptics
- Cellulitis is a spreading, acute inflammation within solid tissues characterized by hyperemia, WBC
infiltration, and edema without cellular necrosis and suppuration (formation of pus)
-Streptococcus pyogenes (group A Beta-hemolytic streptococcus) is the most common cause of superficial
cellulitis; diffuse infection occurs because streptokinase, DNASE, and hyaluronidaseenzymes produced
by the organism
- The skin is hot, red, and edematous, often with an infiltrated surface resembling the skin of an orange
Treatment: For streptococcal cellulitis, penicillin is the drug of choice
- For severe cases which require hospitalization, aqueous penicillin is indicated.
Osteomyelitis is an inflammation and destruction of bone caused by aerobic and anaerobic bacteria,
mycobacteria, and fungi.
- Osteomyelitis occurs in vertebrae and in bones of the feet in patients with diabetes or at sites of bone
penetrated by trauma or surgery.
Symptoms
- Patients with acute osteomyelitis of peripheral bones are usually febrile, have had weight loss and fatigue,
and have localized warmth, swelling, erythema, and tenderness
- Vertebral osteomyelitis produces localized back pain with paravertebral muscle spasm that is unresponsive to
conservative treatment.

Diagnosis: X-rays become abnormal after 3-4 weeks, showing bone destruction, soft tissue swelling, and loss
of vertebral height. CT scan can define the abnormality
- In a patient with localized bone pain, fever and malaise suggests osteomyelitis.
- Antibiotics should be selected to cover gram-positive and gram negative organisms until culture results are
available.
- In children and adults, initial antibiotic treatment should include penicillinase-resistant penicillin (nafcillin or
oxacillin)
Staphylococcal Endocarditis: This condition follows staphylococcal bacteremia during which a nidus of
infection becomes established on one or more heart valves. Endocarditis consists of two clinical syndromes.
- subacute bacterial endocarditis the patients present with a history of days to weeks of low-grade fever with
or without chills, myalgias, night sweats, and weight loss. The word subacute refers to the clinical
manifestations.
- S. epidermidis is the most common cause, however, of endocarditis occurring in association with
prosthetic heart valves
Acute Bacterial Endocarditis: The word acute refers to the clinical presentation of the patient who
experiences the rapid onset of fever, chills, and myalgias, often with back pain or some gastrointestinal
symptoms. The fever is often quite high (103 to 105 Fahrenheit), and the individual at first has the feeling of
developing a very bad flu.
Exanthems are rashes that arise as cutaneous manifestations of infectious diseases. They include the
following:
Measles (rubeola): is an acute, highly contagious viral disease that occurs chiefly in young children living in
densely populated areas. This disease is characterized by fever, cough, and conjunctivitis.
- Measles is caused by an RNA paramyxovirus. Its single antigenic serotype has been remarkably stable
throughout the world for many years with no variations noted.
- An incubation period extends for 8-12 days after initial exposure to the virus
- Within 2 or 3 days after the onset of symptoms, Koplik spots (small, irregular red spots with central gray or
bluish white specks)
- An erythematous maculopapular rash erupts about 5 days after the onset of symptoms.
Diagnosis: Warthin Finkeldy giant cells, which often contain 100 plus nuclei, are a characteristic find in
rubeola.
-Therapy is mainly supportive.
Prevention: Measles is part of the MMR (measles, mumps, and rubella) vaccine, which is a live attenuated
vaccine.
- Complications are rare, but may occur, especially in malnourished of immunocompromised children
- Secondary bacterial otitis media (most common complication)
Rubella (German measles): is an acute, usually benign infectious disease characterized by a 3-day rash,
generalized lymphadenopathy, and minimal or no prodromal symptoms.
- Rubella is caused by rubella virus, an RNA virus that is classifieds as a togavirus.
Postnatal rubella. Clinical manifestations are absent in many cases of rubella.
- Incubation 12-19
Congenital rubella: most commonly results in deafness, cataracts, glaucoma, congenital heart disease, and
mental retardation.
- Disease at 1-3 months gestation is associated is associated with a 30%-60% risk of multiple congenital
defects
- Disease at 4 months gestation is associated with a 10% risk of a single defect.
- Disease at 5-9 months gestation occasionally is associated with a single defect.
Definitive diagnosis of rubella requires either virus isolation or serologic confirmation.
Postnatal rubella usually is mild and self-limited, requiring no treatment. Treatment of congenital rubella is
supportive.
Prevention of rubella is effected by a live attenuated vaccine, which is usually given at age 15 months

Roseola infantum (exanthema subitum): is a common, acute disease and young children, which is caused by
human herpesvirus 6.
- The illness usually begins with an abrupt fever characterized by temperatures of 103-104 F. The fever
persists for 1-5 days
- Complications are uncommon, although febrile convulsions may occur. The prognosis is generally good.
Varicella or chickenpox: is an acute communicable disease characterized by a generalized vesicular rash.
Because it is highly contagious, most individuals contract it in childhood.
- Herpes zoster is due to reactivation of varicella-zoster virus (VZV).
- Varicella is caused by VZV, a member of the herpes virus family. It is a double stranded DNA virus. The
human is the only known natural host of this virus.
- The incubation period is usually about 14 days
- disease is known to be spread by direct contact. Airborne spread also has been demonstrated, most notably in
hospitals.
- occurring primarily in children younger than 10 years of ag
- Infectious period: Patients are infectious beginning approximately 24 hours before the appearance of the
rash until all lesions are crusted, which usually occurs 1 week after the onset of the rash.
- Bacterial infections of the skin are the most common complication of chickenpox in childhood.
- The major complications of varicella in adults are encephalitis and pneumonia.
- Varicella in pregnant women is believed to be more serious than in nongravid females; fatalities have been
reported.
- varicella embryopathy: These infants are born with cerebral damage and a variety of ocular findings and
characteristically have a scarred, atrophic limb.
Attacks of zoster may begin with pain along the affected sensory nerve, accompanied by fever and malaise,
although these symptoms are more common in adults than in children.
Diagnosis: of both varicella and zoster usually is obvious from the clinical presentation. If the diagnosis is
unclear, a Tzanck test should be performed on scrapings take from the base of a vesicle, early in the course of
the illness
Therapy:
- Uncomplicated cases of varicella are treated with antipruritic medication and daily bathing to reduce
secondary bacterial infections.
- Immunocompromised children, for example those with AIDS or leukemia who have not had varicella and
who are exposed to someone with the disease should received prophylaxis with varicella-zoster immune
globulin within 96 hours of exposure
- Immunocompromised children with varicella or disseminated zoster should be treated with intravenous
acyclovir.
- Oral acyclovir is given to adolescents and adults with increased risk of serious disease
Erythema infectiosum: is a mild, self-limited systemic illness accompanied by a distinctive rash. It occurs
primarily in epidemics involving children, although adults may also be affected.
- Parvovirus B-19 is the cause of the illness
the rash progresses through three stages:
- It begins as a marked erythema of the cheeks, which gives a slapped cheek apperance
- This is following by an erythematous maculopapular rash that involves the arms and spreads to the trunk and
legs.
- This stage usually last 2-3 weeks, but may persist for several months, with low grade fever.
- Parvovirus B-19 infection during pregnancy can cause fetal hydrops and death.
- therapy is supporive

Scarlet fever: is an acute illness characterized by fever, pharyngitis, and an erythematous rash. It is rare in
infancy and may occur more than once in a single patient.
- A strawberry tongue and pharyngeal erythema with exudate may be present.
-The face is flushed, and there is increased erythema in the skin folds (Pastia lines). The skin may feel rough,
similar to sand paper.
- 10 days of orally administered penicillin
Rocky Mountain spotted fever: is an acute febrile illness characterized by the sudden onset of fever,
headache, myalgia, mental confusion, and rash. The disease may be severe, leading to shock and death in 57% of patients
- Rocky Mountain spotted fever is a tick-borne illness caused by Rickettsia rickettsii
- The principle vectors of Rocky Mountain spotted fever are Dermacentor andersoni, which is the wood tick
that is found in the West and is most active in the spring,
- Almost two-thirds of the cases of Rocky Mountain spotted fever occur in patients who are younger than 15
years of age.
- fever, headache, chills, confusion
- incubation period that averages about 5-10 days
Diagnosis is made primarily on the basis of clinical appearance and history
Antibiotic therapy includes either chloramphenicol or tetracycline given 5-7 days
LYME DESIASE
- Lyme disease: is a multisystem infection caused by the spirochete, Borrelia burgdorferi, which is
transmitted by a tick bite.
*Lyme disease is the most common tickborne illness in the United States.
- Vector born illness: usually Ixodes ticks
- Phase I: is characterized by an enlarging erythematous rash (erythema migrans) at the site of the original
tick bite.
*The rash resembles a bulls-eye. Aside from the rash the patient may also experience malaise, headache,
and a mild fever.
- Phase II: involves the heart (conduction abnormalities, arrhythmias) or the nervous system (cranial or
peripheral neuropathies or aseptic meningitis).
*A new onset of Bells palsy (paralysis of cranial nerve VII) should suggest the possibility of Lyme disease.
- Phase III: consists of monoarticular (oligoarticular) arthritis which develops in 605 of patients. Intermittent
swelling and pain occur in a few large joints, particularly, the knees.
- Lyme disease is a clinical diagnosis, based on suggestive history and the characteristic rash on physical
examination.
- Children older than 8 years of age should receive oral doxycycline for 14 days
- Younger children are treated with amoxicillin.
- Severe or persistent arthritis, cardiac, or CNS disease warrant parenteral therapy with high-dose penicillin G
or ceftriazone.
MALARIA
- Malaria results from infection with any of the four different species of Plasmodia, causing periodic periods
of chills, fever, diaphoresis, anemia, and splenomegaly.
*The four important Plasmodium species are: P falciparum, P. vivax, P. ovale, P. malariae
*Plasmodium falciparum: most severe, life threatening.
- Most blacks in West Africa are resistant to P. vivax because their RBCs lack the Duffy blood group, which is
required for the invasion of RBCs.

- The basic elements of the life cycle are the same for all four species.
1. Transmission begins when a female Anopheles mosquito feeds on a person with malaria and ingests blood
containing gametocytes.
2. During the following 1 to 2 weeks, gametocytes inside the mosquito reproduce sexually and develop into
infective sporozoites.
3. When the mosquito feeds on a human, it inoculates sporozoites, which quickly infect hepatocytes.
4. Schizogony occurs within infected hepatocytes. Schizogony is a form of asexual reproduction, in which the
nucleus divides many times before the cytoplasm divides to form the daughter cells (merozoites).
5. The merozoites invade RBCs and there transform into trophozoites. The trophozoite stage represents the
activated feeding stage in the cycle. They appear as rings in stained RBCs.
6. The trophozoites grow and develop into schizonts, which rupture the RBC. Simultaneously, a separate cycle
of development results in the formation of gametocytes in the RBCs.
- Anopheles mosquito acts as malaria vector
- trophozoite stage: is a feeding stage
- P. falciparum: causes the most severe disease and can be fatal if untreated. RBCs containing P. falciparum
schizonts adhere to vascular endothelium
*Patients with cerebral malaria may develop symptoms ranging from irritability to coma; respiratory
syndrome, diarrhea, epigastric tenderness, retinal hemorrhages, and severe thrombocytopenia may also occur.
*Renal disease may result from volume depletion, the plugging of blood vessels, immune complex deposition,
or blackwater fever (hemoglobinemia and hemoglobinuria resulting from intravascular hemolysis).
*Finding Plasmodium in the blood is diagnostic.
- P. vivax and P. ovale: rarely compromise the function of vital organs. Mortality is rare and is mostly due to
splenic rupture or uncontrolled hyperparasitemia in asplenic persons.
- P. malariae: infections often cause no acute symptoms, but low-grade parasitemia may persist for decades
and lead to immune-complex mediated nephritis. P. malariae is the most common cause of transfusion malaria.
Prevention & Treatment
- Mefloquine is recommended for travel to areas where chloroquine-resistant P. falciparum exists.
- Doxycycline should not be given during pregnancy.
- Chloroquine is the drug of choice against P. malariae, P. ovale, and chloroquine sensitive P. falciparum and
P. vivax.
- Chloroquine-resistant P. falciparum and P. vivax is treated with oral quinine sulfate.
MENINGITIS
- Meningitis: refers to an inflammation of the meninges of the brain or spinal cord.
- A large variety of bacteria can cause meningitis, however, the two most common are the following:
1. Neisseria meningitides (meningococcus)
2.Streptococcus pneumoniae (pneumococcus)
- Factors such as age, history of head trauma with CSF leaks, and immune status are helpful in determining
the causative agent.
- Meningococci exist in the nasopharynx of approximately 5% of the population and spread by respiratory
droplets and close contact.
- Pneumococcus is the most common cause of meningitis in adults. Those at risk include the following:
alcoholics, individuals with chronic otitis, sinusitis, and mastoiditis, those with closed head injuries with CSF
leaks.
- H. influenzae type b is an uncommon cause unless there is a predisposing factor (eg, head trauma,
compromised immunity).
- Gram-negative meningitis (most often due to E. coli, Klebsiella, or Enterobacter) can occur in
immunocompromised persons or after CNS surgery or trauma, bacteremia

- Staphylococcal meningitis can occur after penetrating head wounds, bacteremia (eg, from endocarditis), or
neurosurgical procedures.
- Listerial meningitis can occur at all ages, particularly in patients with chronic renal failure, liver disease, or
an organ transplant
- Bacteria reach the meninges by hematogenous spread, by extension from nearby infections (eg, sinusitis,
epidural abscess).
Symptoms and Signs:
- A prodromal respiratory illness or sore throat often precedes the fever, headache, stiff neck (nuchal
rigidity), and vomiting that characterize acute meningitis.
- Dehydration is common, and vascular collapse may lead to shock and the Waterhouse-Friderichsen
syndrome, especially in meningococcal septicemia.
Waterhouse-Friderichsen syndrome is a massive usually bilateral hemorrhage into the adrenal glands. It is
characterized by the following: hypotension, shock, widespread purpura,
- In infants between 3 months and 2 years of age, symptoms and signs are less predictable. Fever, vomiting,
irritability, convulsions, a high-pitched cry, and bulging or tight fontanelles are common; stiff neck may be
absent.
Diagnosis:
- If bacterial meningitis is suspected, antibiotics should be given immediately, without waiting for diagnostic
test results.
- The head, ear, and skin should be inspected for sources of infection. Abrupt neck flexion in a supine patient
results in involuntary flexion of the hips and knees (Brudzinskis sign).
- Attempts to extend the knee from the flexed-thigh position are met with strong passive resistance (Kernigs
sign).
- Lumbar puncture should be performed promptly, but only after a CT scan has excluded a mass lesion;
- Spinal tap
- In bacterial meningitis, the CSF is characterized as follows:
*Elevated WBC, Elevated protein, Normal or lowered glucose level
- In aseptic meningitis, the CSF is characterized as follows:
*Mildly elevated WBC, Normal or mildly elevated protein level, Normal glucose
- A low peripheral WBC count is a bad prognostic sign. Persistent leucopenia, delayed therapy, and the
development of the Waterhouse-Friderichsen syndrome reduces the chances of survival.
Treatment:
- A third generation cephalosporin ( ceftriazone or cefotaxime) should be included
- However, because pneumococcal strains resistant to ceftriaxone and cefotaxime are becoming increasingly
prevalent, vancomycin, with or without rifampin, is usually added.
EBOLA
- The Ebola virus belongs to the viral family Filoviridae. Scientists also call it Filovirus. These virus types
cause hemorrhagic fever or profuse bleeding inside and outside the body accompanied by a very high fever.
- The virus is known as a zoonotic virus because its transmitted to humans from animals: fruit-bats, chimps,
porcupines, gorillas, monkeys, Forrest antelopes.
-Since people may handle these infected animals, the virus can be transmitted via the animals blood and body
fluids: sweat, urine, vomit, feces, blood, saliva, breast milk, semen
- People can get Ebola when they come in contact with these fluids via the eyes, nose, mouth, or broken skin
- Blood tests can identify antibodies or the Ebola virus when people show the first symptoms of what could be
Ebola. Blood tests may also reveal low white blood cell counts, low platelet counts, and high liver enzymes.

- Ebola case fatality rate is 50 percent.

- Zaire and Sudan viral strains have a 90 percent fatality rate.

TREATMENT:
- Pneumococcal pneumonia: Penicillin G or V 250
- Staphylococcal pneumonia: penicillinase-resistant penicillin (oxacillin of nafcillin)
- H. influenzae: trimethoprim-sulfamethoxazole (TMX-SMX).
- Legionella pneumophilia: Erythromycin is usually the drug of choice. Others prefer ciprofloxacin or
azithromycin.
- Mycoplasma pneumoniae: tetracycline or erythromycin for adults or erythromycin for children.
- Psittacosis: Tetracycline
- P. carinii: trimethoprim-sulfamethoxazole (TMP-SMX)
- T. pallidum: is highly susceptible to penicillin G
- C. trachomatis: Doxycycline or azithromycin,In pregnant patients, erythromycin
- Herpes genitalis: Acyclovir is an antiviral drug that is effective against herpesvirus
- Trichomoniasis: metronidazole