BOARD REVIEW

MICHAEL KULCZYCKI

DECEMBER 18 2013

GOALS

• ENDOCARDITIS

• MENINGOCOCCEMIA

• PERTUSSIS

• PNEUMOCOCCEMIA

• TETANUS

• TUBERCULOSIS

• THE PLAGUE

• HERPESVIRIDAE

• HIV

ENDOCARDITIS

• RISK FACTORS

• PROSTHETIC HEART VALVES

• STRUCTURE HEART DISEASE

• RHEUMATOID HEART DISEASE

• MITRAL VALVE PROLAPSE

• BICUSPID AORTIC VALVE

• IV DRUG ABUSE

• CARDIAC PROCEDURES

• INDWELLING VENOUS CATHETERS

Acute

• Normal Valves• Younger Patients• Sick

Subacute

• Abnormal Valves• Older patients• Non-specific

constitutional symptoms

Left Heart

• More Common• S. Viridans• S. Aureus• Enterococcus• CHF, CVA, AV block• Systemic infarcts

from septic emboli

Right Heart

• IVDA• S. Aureus• S. Pneumonia• Respiratory

Symptoms• Misdiagnosed as PNA

S. Aureus = Single most common cause

Roth Spots

Osler Nodes(painful)

Janeway Lesions(painless)

Splinter Hemorrhages

ENDOCARDITIS

JONES CRITERIA – 2 MAJOR, 1 MAJOR + 3 MINOR, 5 MINOR

Major

• 2 Positive Blood Cultures• 3 sets 1 hour apart• Cultures of typical bugs• Persistance of cultures > 12

hrs• Abnormal Echo

• Prosthetic valve dihiscence• New valvular regurg• Myocardial abscess• Visible vegetation

Minor

• Predisposition/IVDA• Fever• Vasular Events/Septic

Emboli• Immunologic Events• Positive Echo or Blood

cultures not meeting major criteria

ENDOCARDITIS

Indications:• Prosthetic Valve• Congenital Defect repaired• Prior Infectious Endocarditis• Cardiac transplant with abnormal

valves

Manipulation of gingiva/mucosa or apical area of tooth

MENINGOCOCCEMIA – NEISSERIA MENINGITIDES

Nuts and Bolts…• Military Recruits, College Dorms• Children < 5• Gram (-) diplococcus• Nasopharynx = portal of entry• Septicemia without meningitis (>20% mortality)

MENINGOCOCCEMIA

Rash• Petechia

• 50-60% Cases• Can involve mucous membranes• Trunk/Extremites

• Purpura Fulminans• Rapidly spreading ecchymosis• Gangrene• DIC

MENINGOCOCCEMIA

Meningococcemia + Bilateral Adrenal Hemorrhage =

Waterhouse-Friderichsen Sndrome

Fulminant Meningococcemia

MENINGOCOCCEMIA

• Lumbar Puncture • Early Antibiotics

• Prophylaxis for close contacts• Ciprofloxacin• Rifampin• Ceftriaxone

PERTUSSIS

Nuts and Bolts…

• Whooping Cough• Summer and Fall months• Cough > 2 weeks• Respiratory Droplets• Vaccination does not equal lifelong immunity• Misdiagnosed as bronchitis

PERTUSSIS

Catarrhal Phase

URI like symptoms

Cough, low grade fever

Highest infectivity

Paroxysmal Phase

Cough increases,

fever subsides

Paroxysms of coughing

(>50 times/day)

Convalescent Phase

Residual cough

(weeks to months)

PERTUSSIS

• High index of suspition

• Lymphocytosis – correlates with severity of disease

• CXR: peribronchial thickening

• Nasopharyngeal culture

• Macrolide (erythromycin)

• Prophylactic antibiotics for close contacts

• Acellular pertussis vaccination for high risk

exposures

PNEUMOCOCCEMIA

• Lancet shaped G (+) diplococcus• Most common cause of bacterial pneumonia

Pneumonia• Severe rigors• Rusty colored sputumMeningitisSepticemiaEndocarditis

Adult vaccination for:• Adults with chronic illness• Age > 65• Immunocomprimised / HIV• Anatomic or functional Asplenia

TETANUS

Found in soil, dust, feces>70 % from wounds (post-operative)Bacteria produce neurotoxins – Tetanolysin/Tetanospasmin

• No mental status changes

• Weakness, myalgias, dysphagia, hydrophobia, drooling

• Trismus – “Lock Jaw”

• Risus Sardonicus - facial muscle involved

• Opisthotonos – Generalized tetanus, arching of back/

neck

• Laryngeal Spasm and Respiratory Failure

• Autonomic Dysfunction

TETANUS

Opisthotonos Risus Sardonicus

TETANUS

Strychnine Poisoning

PesticideMuscle spasms, trismus, risus sardonicus, seizures

TETANUS

Benzodiazepines/Narcotics

Paralysis (non-depolarizing)Eliminate the toxin –

Tetanus Immunoglobilin (TIG)Administer opposite arm of tetanus booster

Eliminate the Bug – Flagyl

Immunization

• TIG if < 3 Td and dirty wound• Clean wounds – Td if > 10 years• Dirty wounds – Td if > 5 years

TUBERCULOSIS

• Humans sole reservoir• Leading cause of infectious death worldwide• Leading cause of adrenal insufficiency worldwide• One third of world population infected with TB

Risk Factors • Immunocompromised / HIV• Close contact / Occupational exposure• Foreign born• Low socioeconomic status• IVDA• Homeless• Prison / shelter

TUBERCULOSIS

Pulmonary Tuberculosis

• Cough – most common symptom• Fever• Night sweats• Weight loss• Pleuritic Chest pain• Hemoptysis – mild to severe• Erosion into pulmonary artery = Rasmussen aneurysm

Chest x-ray• Primary TB – difficult to differentiate from PNA• Hilar / Midiastinal LAD common in primary TB• Miliary (disseminated) TB – multiple nodules bilaterally• Reactivation TB – Cavitation without lymphadenopathy

TUBERCULOSIS

Extrapulmonary TB

Lymphadenitis – Scrofula• Enlarged / painful mass near cervical nodes• Most common extrapulmonary manifestation• Do Not I&D

Bone and Joints – Pott’s Disease (spine)

Acute Dissemination• Typically elderly and AIDS• Associated with SIADH

CNS – Tuberculous Meningitis• Subependymal tubercle ruptures into subarachnoid space• Lowest CSF glucose of any meningitis

TUBERCULOSIS

AFB sputum smear – hours, many false negatives/positives

AFB culture – weeks, Gold standard, 87% sensitive

Latent TB • Isoniazid - 9 months

Active TB• 4 drug regimen – 6 months

Extrapulmonary TB• 4 drug regimen – 6 months

Isoniazid – seizures (pyridoxine)

Rifampin – orange urine. OCP failure

Pyrazinamide - hepatotoxic

Ethambutal – red-green color blindness

Pregnancy – INH, RIF, ETH cross placenta and are safe

THE PLAGUE – YERSENIA PESTIS

Nuts and bolts…

• Vector – rat flea – xenopsylla cheopis

• Traditionally from rats, now squirrels and cats

• Potential biologic weapon

• Transmission – bites, close contact, direct inhalation

• Veterinarians, animal handlers

• Non-specific symptoms – Fever and myalgias

THE PLAGUE

Three Clinical Syndromes

Bubonic Plague• Bubos on the skin, invasion of

lymphatics and vasculature• Generalized painful LAD

Septicemic Plague• Direct invation of vasculature

without bubos

Pneumonic Plague• Most aggressive• Severe pneumonas, sepsis,

death

Black Plague – deep cyanosis and gangrene with disseminated disease

“Ring around the rosy”“Ashes, ashes we all fall down”

THE PLAGUE

• Gram stain of bubo aspirate

• CXR – infiltrate or hilar lymphadenopathy

• Respiratory Isolation

• Streptomycin or Doxycycline

• Supportive care

HERPESVIRIDAE

Herpes Simplex Virus

HSV-1 - oropharyngealHSV-2 – genital

Multiple, painful shallow ulcers which may coalesceShedding lasts up to 3 weeks

Herpetic Whitlow• Herpetic finger infection• Do not I&D

Neonatal Herpes• Transmission at deliver• High mortality if untreated

Herpes Encephilitis• Most common cause of encephalitis in U.S.• Fever and bizarre behavior

HERPESVIRIDAE

Varicella-Zoster Virus

Chickenpox• Acute generalized viral illness• Lesions everywhere on skin and mucous membranes

(palms/soles spared)• Maculopapular then vesiculated

Herpes Zoster• Reactivation in DRG – dermatomal• Multiple vesicles on erythematous base

Zoster Opthalmacus• Lesions on cornea / tip of nose (Hutchinson sign)• Nasociliary branch of V1 - opthalamic branch of trigeminal

nerve

Ramsy Hunt Sydrome• Bells palsy with herpetic blisters in the auditory canal or

pinna

HERPESVIRIDAE

Epstein Barr Virus

Fever Exudative tonsillitis Posterior cervical LADHepatomegally in 50%

Lymphocytosis with atypical lymphocytes

Splenic Rupture – no contact sports Characteristic rash with antibiotics (ampicillin)

Supportive treatmentSteroids for severe tonsilar edeam

HIV

Nuts and bolts…

RetrovirusHIV-1 (most common), HIV-2 (western Africa)Semen, vaginal secretions, blood, breastmilkAttacks CD4 Helper T cells

Acute HIV infection • Follows exposure by 2-6 weeks• Usually missed

HIV

AIDS - CD4 < 200

CD4 < 500• TB, Zoster, HSV

CD4 < 200• Pneumocysti Jiroveci

Pneumonia, Candidiasis, AIDS Dementia, Non-Hodgekin B-cell lymphoma

CD4 < 100• Toxoplasmosis, isospora,

microsporidia, histoplasmosis, cryptococcus

CD4 < 50• CMV, progressive multifocal

leukocencephalopathy (PML), MAC

HIV

Pneumonia

Most common reason for ER visitCD4 > 500 – encapsulated bacteria, TB, malignancyCD4 < 500 – Think PJP, Fungal, CMV

Pneumocystis Jiroveci Pneumonia• Diffuse interstitial infiltrate – “bat wing”• Bactrim DS• Steroids of PaO2 < 70 or Aa gradient > 35• Prophylaxis with Bactrim if CD4 <200• Pentamidine 2nd line agent if sulfa allergy

HIV

Buzz words

Diarrhea - cryptosporidium, isospora

Esophagitis – CMV, candidiasis, HSV

Retinitis – CMV

Ring enhancing lesions – Toxoplasmosis, CNS lymphoma

Fever and headache – Cryptococcus

Plaques on Tongue – oral candidiasis vs hairy leukoplakia

Purple papules/plaques – Kaposi’s sarcoma