March 24, 2009
Rocky Mountain Spotted Fever
 Peak incidence  spring & summer
 Mode of transmission  tick (esp. dog tick)
 Clinical
 Triad  Fever + Rash + Headache
 Nonspecific anorexia, myalgias, N/V, abdominal pain
 Rash
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Maculopapular rash  petechial / purpuric
Begins on extremities (ankles, wrists, lower legs)
Includes palms and soles
 Other rare findings: HSM, thrombosis, CNS
 Fulminant (esp w/ G6PD) : coagulopathy, thrombosis, renal
failure, liver failure, respiratory failure  death < 5 days
Looks like RMSF but it’s not….
 Differential Diagnosis
 Erlichiosis
 Meningococcemia
 Measles
 Viral exanthems
 Scarlet fever
 TSS
 ITP / TTP
 HSP
 Kawasaki disease
Diagnosis & Treatment
 Diagnosis
 Clinical + epidemiological
 Lab findings: thrombocytopenia, elevated AST/ALT, bilirubin
 Late in dz:
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Skin biopsy  staining for R. rickettsii (DO not get if > 48 hrs of tx)
Confirmation with serology
 Indirect fluorescent Ab (IFA) + Ab 7-10 d after onset
 Treatment
 Doxycycline (even in those < 8 hrs)
 Alternatives
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Tetracycline
Chloramphenicol (pregnant women)
 Treat at least 3 days after afebrile (5-7 d)
Ehrlichiosis
 Similar to RMSF
 Human disease
 Human monocytic ehrlichiosis
 Human granulocytic anaplasmosis
 Vector
 Wood tick or deer tick
 Signs/Symptoms
 Fever + Headache + Rash; N/V, myalgias, LAD, HSM
 **Leukopenia / neutropenia, elevated AST/ALT
 Treatment: Doxycycline
Candida
 Predisposing factors
 Recent Antibiotic use
 IC / Immunosuppressed (steroid use, BMT/organ transplant,
malignancy), TPN, burns, DM, NICU/PICU setting, CVL
 Disease Manifestations
 Oropharyngeal, Cutaneous, Vulovaginitis/Balanitis
 Invasive: UTI, PNA, Peri - / Endocarditis, Osteoarticular,
Meningitis, Disseminated
 Treatment
 Antifungals : Fluconazole, topical (Nystatin), Itraconazole,
Ketoconazole, Voriconazole, Ampho B, Micafungin
Cryptococcosis
 Encapsulated yeast
 Inhalation of spores / direct from contaminated soil,
bird droppings (pigeons)
 Clinical Manifestations
 **Opportunistic Infection
 Immunocompetent : Pnuemonia
 Immunosuppressed: Disseminated disease
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Sepsis syndrome, Meningitis, Skin infection,
Arthritis, bone involvement, chrioretinitis, LAD
Diagnosis & Treatment
 Latex agglutination – Ag
 India Ink
 < sensitive than cx & Ag
 Definitive:
 fungus in tissue specimen
 Treatment
 Observation
 Antifungals
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Fluconazole
Ampho B +/- flucytosine
Coccidioidomycosis
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Dimorphic fungi
Found SW US (Arizona, CA, NM, west TX)
Acquired via inhalation of spores
Clinical manifestations
 Flu like symptoms, PNA
 Fever, night sweats, HA, cough, chest pain, myalgias/fatigue, rash
 Sx can persist for months
 Immunosuppressed  Disseminated disease
 Treatment
 Observation
 Antifungals: ketoconazole, fluconazole, ampho B
Aspergillosis
 Transmission soil, hay, decaying vegetation
 Inhalation of spores
 Signs/Symptoms
 Allergic bronchopulmonary aspergillosis
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Hypersensitive reaction – asthma, CF
Fever, cough, wheezing, sputum production, hemoptysis
Progress to bronchietasis, fibrosis, resp. compromise
 Aspergilloma (fungal ball in preexisting cavity)
 Invasive disease – IC
Histoplasmosis
 Transmission via bird droppings (pigeons, bats, chickens)
 Ohio, Missouri, Mississippi river valley
 Signs/Symptoms
 Up to 95% will be asymptomatic
 Flu like symptoms (fever, HA, malaise, cough)
 PNA, HSM, rash, arthritis, pericarditis, disseminated dz
 Treatment
 Self limited
 Disseminated dz/IC: Ampho B, fluconazole, ketoconazole
Sporotrichosis
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Fungus Sporothrix schenckii
Found in soil, decaying vegetation
Acquired via trauma to skin or inhalation
Signs/Symptoms
 Skin: Local pustule/ulcer , nodules developing along
draining lymphatics
 Systemic:
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Pulmonary-- granulomatous pneumonitis
IC: Disseminated
 Considered one of the AIDS related conditions
 Treatment: KI, Antifungals (Ampho B, fluconazole)
Giardiasis
 Mode of transmission: fecal-oral, contaminated water
 Risk factors: poor hygiene, poor handwashing
 Common cause of diarrhea in daycares
 Carrier rates up to 60%
 Clinical presentation
 Watery foul smelling diarrhea, NON-BLOODY
 Other sx: low grade fever, bloating/flatus, abdominal cramps,
nausea, generalized malaise, weight loss, anorexia
 Subacute / Chronic – FTT
 Duration 3-10 wks (untreated)
Diagnosis & Treatment
 Diagnosis
 Stool x 3 for ova and parasites
 Stool Ag detection (IFA, ELISA)
 CBC  NO EOSINOPHILA
 Treatment
 Metronidazole (Flagyl)
 Alternatives: Tinidazole,
Toxoplasmosis
 Mode of transmission: undercooked / raw meat, cat feces
 Congenital
 Early infection  less chance of fetal infection but more severe
consequences
 Late infection  more chance of fetal infection but less severe
 Clinical
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Asymptomatic
Microcephaly, hydrocephalus, chorioretinitis, diffuse cerebral
calcifications (ring enhancing), jaundice, HSM
 50% rule
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50% of infected pregnant women pass to fetus
50% will be asymptomatic at birth
Late findings
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Hearing loss, vision impairment, seizures, MR, LD
 Diagnosis
 PCR of amniotic fluid
 Infant IgG and IgM
Toxoplasmosis
 Acquired
 Most will be asymptomatic
 Fever, myalgias, HA, fatigue, LAD
 Treatment
 Pregnant mom : Spiramycin
 Pyrimethamine or sulfadiazine + folinic acid
Enterobiasis
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Pinworm Enterobius vermicularis
Common in children ages 5-10 yrs
Transmission: direct contact
Signs / Symptoms
 Perianal itching (pruritus ani) – esp. nocturnal
 Restlessness, insomnia, abdominal pain, N/V
 Vulvovaginitis, UTI, Eosinophile entrocolitis
 Diagnosis
 “Scotch tape” test x 3 (early AM)
 Treatment
 Mebendazole or albendazole x 1 dose
 Repeat in 2 weeks
 Other considerations
 Treat household members, wash bedding and clothes
 Can attend daycare
Trichinosis
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Nematode Trichinella
Ingestion of undercooked or raw meat (esp. pork)
Reportable disease
Signs/ Symptoms
 Diarrhea, severe myalgias, fever, facial edema, HA, rash
 Rhabdomyolysis like (elevated CPK, myoglobinuria)
 Cardioneurologic Syndrome
 Dx : Eosinophilia , ELISA after 2 wks, Western blot for
confirmation; muscle biopsy
 Treatment: Mebendazole + Steroids
Ascaris
 Intestinal roundworm Ascaris lumricoides
 Fecal – oral transmission, eating soil
 Increased incidence poor sanitation, travelers, immigrants,
refugees, adoption
 Signs/ Symptoms
 Early: fever, cough, dyspnea, wheezing
 Late (GI) : passage of worms, N/V, abdominal pain
 ***Intestinal obstruction, common bile duct obstruction,
cholangitis
 Eosinophilia, eggs in stool
 Treatment
 Albendazole, mebendazole
 Alternatives: pyrantel pamoate
Visceral Larva Migrans
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Due to roundworm Toxocara species (dogs, cats)
Seen in preschool age children
History of eating dirt (ingest eggs)
Signs / Symptoms
 Nonspecific fever, anorexia, pruritic /urticarial rash
 GI: abdominal pain, HSM
 Pulmonary: wheezing
 More serious: Ocular involvement, seizures, Myocarditis,
HSM, Encephalitis
 Dx: Leukocytosis, eosinophilia, elevated isohemagglutinins
A, B, ELISA
 Treatment: supportive, +/- Mebendazole
Amebiasis
 Entamoebal histolytica
 Fecal – oral transmission
 Signs/ Symptoms
 Most cases asymptomatic
 Gradual onset bloody diarrhea colicky abdominal pain,
tenesmus, anorexia, weight loss, fever
 Most common extraintestinal manifestation : Liver
abscess
 Other: brain abscess, toxic megacolon, pleuropulmonary
 Labs: Stool + WBC & RBC, Stool culture + cyst &
trophozoites, eosinophilia, mild elevation transminases
 Treatment
 Metronidazole
Coming soon..…
ID part deux
Bacterial and Congenital Infections