Copyright Elsevier

Infectious diseases


Contents
Whats it all about?
Conditions you will be asked about in your first week
Dos
Donts
History and Examination
Whats it all about?

Infectious disease occurs when the hosts defense systems are compromised by one (or
several) of a wide range of disease-causing microorganisms (pathogens).
Pathogens include bacteria, viruses, protozoa, fungi, and helminths.
Since vaccinations have become a routine part of childrens preventative healthcare, the
incidence of many infectious diseases has been greatly reduced. Indeed, smallpox has been
eradicated worldwide.
New infectious diseases are appearing (e.g. severe acute respiratory syndrome [SARS]) and
other infectious diseases are becoming more prevalent due to several factors, including
population overcrowding and other environmental changes and the emergence of antibiotic-
resistant strains.
Infectious diseases is a specialty of its own, but the conditions are also encountered in the
specialties of pediatrics, family medicine, neurology, internal medicine, and even surgery.
Infectious diseases can occur in any system of the body and at any age.

Conditions you will be asked about in your first week

Because infectious disease occurs in every body system, its helpful to be aware of the most
common diseases those that you are most likely to see in the clinic in your first week and be
asked about in examinations. Ive summarized these by body system below, but make sure that
you learn and understand the characteristics of each disease, their main causative agents, the
differential diagnosis (DDx), and appropriate treatment (Tx).

Ears
Acute otitis media
Signs and symptoms
Earache, cough, congestion, rhinorrhea, fever.
Bulging, red tympanic membrane with fluid behind it that does not move well with pneumatic
otoscopy.

Dx
Acute otitis media (peak incidence 618 months) caused by Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis.

DDx
External otitis (swimmers ear) caused by Pseudomonas aeruginosa. This will cause pain when
the physician moves the pinna, but otitis media will not.

Tx
High-dose amoxicillin.

Notes
Rare but serious complications of otitis media include mastoiditis, osteomyelitis of the temporal
bone, and facial nerve paralysis.

Throat children aged 3 months3 years
Croup
Signs and symptoms
Upper respiratory infection (URI) followed by barking cough, nasal flaring,
suprasternal/infrasternal retractions, low-grade fever, inspiratory stridor.

Investigation
Chest radiograph (CXR) steeple sign on anteroposterior (AP) film.

Dx
Croup caused by parainfluenza virus.

DDx
Acute epiglottitis.

Tx
Humidified oxygen.

Throat children aged 6 years and up
Bacterial pharyngitis
Signs and symptoms
High fever, tonsillar exudates, tender anterior cervical lymphadenopathy, no cough or rhinitis,
headache, difficulty swallowing.

Investigation
Positive rapid streptococcal test if negative, you must follow up with culture of throat swab.

Dx
Group A beta-hemolytic streptococcal pharyngitis.

DDx
Infectious mononucleosis.
Viruses that can mimic a streptococcal pharyngitis include EpsteinBarr virus, adenovirus,
herpes simplex virus, enterovirus, and influenza virus.

Tx
Penicillin.
If allergic to penicillin treat with erythromycin.
If not treated can lead to acute rheumatic fever.
Infection can lead to poststreptococcal glomerulonephritis in a subgroup of population.

Viral pharyngitis
Signs and symptoms
Rhinorrhea, cough, sneezing, sore throat, no significant fever, cervical lymphadenopathy.

Investigation
No labs necessary.

Dx
Viral pharyngitis causative agent rhinovirus.

DDx
See other viral agents listed above in DDx of bacterial pharyngitis.

Tx
Only treat symptoms steam, decongestants, and antihistamines.



Pulmonary system
Pneumonia
Signs and symptoms of bacterial pneumonia
Fever, chills, cough with purulent sputum, dyspnea, tachypnea.

Viral pneumonia
Signs and symptoms of viral pneumonia
Gradual onset, dry, nonproductive cough, fever and chills may or may not be present, rales,
rhonchi, and wheezing.

Investigation
Complete blood count (CBC), sputum Gram stain and culture, blood culture, CXR.

DDx
Cystic fibrosis, other causative agents such as fungi, parasites, and rickettsiae.

Tx
Age less than 2 weeks ampicillin and gentamicin.
Age 2 weeks5 years amoxicillin.
Age 515 years azithromycin.
Elderly cephalosporin and macrolide.

Notes
Although adult patients rarely present with pneumonia, if an adult patient presents with
progressive pneumonia, you should suspect an immunocompromised host such as someone with
AIDS or immunosuppression caused by cancer.

Gastrointestinal system
Diarrhea
Signs and symptoms
Low-grade fever, nausea, vomiting, diarrhea, abdominal cramps. Dehydration is a complication
Investigation
For bloody diarrhea, high fever, prolonged symptoms, and foreign travel:
complete urine analysis (UA) with urine specific gravity (specific gravity <1.015 =adequate
hydration).
stool analysis for blood and leukocytes.
stool culture for ova and parasites including Entamoeba histolytica and Giardia lamblia.

Dx
Most common cause is rotavirus infection.

DDx
Other common pathogens causing diarrhea are:
Campylobacter jejuni most common bacterial gastroenteritis in children and adults and
caused by ingestion of contaminated food or water. Illness is self limited and lasts less than 1
week. May contain blood. Tx: erythromycin.
Staphylococcus aureus toxin fastest onset (<5 h). Ends quickly.
Enterotoxigenic Escherichia coli travelerss diarrhea. Watery diarrhea.

Tx
Oral rehydration therapy. Remember no fruit juices or carbonated drinks.


Renal and urinary system
Urinary tract infection (UTI)
Signs and symptoms
Chief complaints are dysuria and abdominal pain.
Risk factors history of previous UTI, diabetes mellitus, pregnancy.

Investigation
Urine dipstick increased leukocytic esterase, increased nitrites.
Microscopic analysis over five leukocytes per high-power field (hpf).

Dx
Most common causative agent is E. coli.

Tx
Trimethoprimsulfamethoxazole or ciprofloxacin.

Notes
UTI can progress to acute pyelonephritis the patient will present with flank pain and fever
and should be hospitalized and treated with intravenous antibiotics (ciprofloxacin or ampicillin and
gentamicin.)

Womens health
Vulvovaginitis candidiasis
Signs and symptoms
Thick, white, vaginal discharge, no odor, and severe, vaginal itching.
Risk factors chronic alcoholic use, diabetes mellitus, oral contraceptive pill (OCP) usage.

Investigation
Vaginal pH normal.
Potassium hydroxide (KOH) preparation positive for pseudohyphae, mycelial tangles,
budding yeast cells.

Tx
Fluconazole. If pregnant, only use it topically.

Sexually transmitted diseases (STDs)
Male urethritis
Signs and symptoms
Dysuria and mucopurulent urethral discharge.

Investigation
Gram-negative diplococci on Gram stain if caused by Neisseria gonorrhoeae

Dx
Causative agents N. gonorrhoeae and/or Chlamydia trachomatis.

Tx
Doxycycline for C. trachomatis coverage and oral cefixime for N. gonorrhoeae

Pelvic inflammatory disease (PID)
Signs and symptoms
Acute lower abdominal pain, fever, malaise.
Risk factors multiple sex partners, lack of barrier contraception.

Investigation
White blood cells (WBCs) on wet preparation, elevated erythrocyte sedimentation rate (ESR),
elevated C-reactive protein (CRP).

Dx
Causative agents N. gonorrhoeae, C. trachomatis.

Tx
Intravenous cefoxitin or intravenous cefotetan plus doxycycline
Important to treat to prevent tubal scarring.

Viral exanthems
Exanthem subitum (aka roseola infantum)
Signs and symptoms
Acute onset of high fever, then fever breaks, maculopapular rash.
Lasts less than 24 h

Dx
Causative agent human herpesvirus (HHV-6)

Erythema infectiosum (aka fifth disease)
Signs and symptoms
Low-grade fever, then slapped cheek rash; also headache, pharyngitis, myalgias, arthritis.

Dx
Causative agent parvovirus B12.

Notes
Can cause hemolytic anemia so be aware in patients with sickle cell disease because it can
lead to sickle cell crisis.

Congenital infections
Congenital cytomegalovirus (CMV) infection
Signs and symptoms
Characteristic features are microcephaly, purpuric rash, hepatosplenomegaly, chorioretinitis,
progressive hearing loss, and intracranial calcifications.

Investigation
Urine culture is test of choice to detect virus when detection within the first 3 weeks of life is
considered proof.

Notes
CMV is the most common congenital infectious agent.

Nervous system
Acute bacterial meningitis
Signs and symptoms
Can progress over a few hours to several days.
Typical symptoms include fever, meningismus (stiff neck, positive Kernig sign and Brudzinski
sign), and headache.
Additional signs include altered mental status, nausea and vomiting, seizures, photophobia.
Petechial or purpuric skin lesions are important clues for a diagnosis of meningococcal
meningitis.

Investigation
Cerebrospinal fluid (CSF) findings CSF leukocytosis with neutrophil predominance, elevated
protein, decreased glucose (<40 mg/dL), and an elevated opening pressure.

Dx
Common causative agents are:
Streptococcus pneumoniae and Neisseria meningitidis are the most common etiologic agents
of community-acquired bacterial meningitis.
Pseudomonas aeruginosa and staphylococci are the most common causative agents of
hospital-acquired meningitis, particularly following neurosurgical procedures.

Tx
Bacterial meningitis is a medical emergency so begin treatment with a third-generation
cephalosporin (ceftriaxone) and vancomycin even before the CSF Gram stain and culture results
are obtained.
Specific treatment for meningococcal meningitis:
o Penicillin G is the antibiotic of choice.
o Ampicillin is added when there is a suspicion of listeriosis or in a neonate or in the elderly (>65
years of age).

Viral (aseptic) meningitis
Signs and symptoms
Fever, headache (may be severe), but without impairment of consciousness or focal
neurological findings.

Investigation
CSF findings CSF leukocytosis with lymphocytic predominance, normal protein, normal
glucose, and normal opening pressure.
In herpes simplex meningitis a high CSF red blood cell count (unlike in meningitis caused by
bacteria and other viral agents in the absence of a traumatic tap).

Dx
Causative agents enteroviruses, herpes simplex virus 1 and/or 2.

Tx
Supportive or symptomatic therapy.

Dos

Learn to write prescriptions.
Give pneumococcal vaccines to patients who are immunocompromised or over 65 years of
age.
Ensure that children have up-to-date immunization records.
Formulate an assessment and plan for the patient before presenting to the attending physician.
Tell patients that good handwashing is the most effective way to prevent transmission of
infectious agents.
Realize a total WBC over 15 000 cells/mm
3
combined with a left shift (i.e. an elevation in the
number of neutrophils, especially band forms) strongly suggests a serious bacterial infection.
Most viral infections are associated with normal WBC and differential.
Realize that a negative HIV polymerase chain reaction (PCR) test ensures that an individual is
not infected with HIV.
Realize that a positive nitrite test from a urine analysis is highly specific for bacteriuria and a
negative nitrite test has poor sensitivity (i.e. lots of false negatives for bacteriuria).

Donts

Dont take a throat swab from other sites in the mouth apart from the tonsils and posterior
pharyngeal wall.

History and examination

Start with the chief complaint
Ask patients:
How long they have had symptoms.
Whether the symptoms are getting worse or better.
Whether they have taken any medications for the illness already and other chronic medications
that they are taking.
If there is pain associated with symptoms, to grade its intensity on a scale from 1 to 10 (10
being the worst).

Physical examination(PE)
Start with the patients general appearance. Does the patient look well nourished, lethargic,
jaundiced, or pale?
Vital signs are always an essential component.

Investigation
After completing the PE, there are certain laboratory tests that can either support or eliminate a
diagnosis.These include:
Complete blood cell count (CBC).
Erythrocyte sedimentation rate (ESR).
Radiologic studies.
Tissue histology.
To investigate the causative agent, the following orders can be issued:
Culture grown on solid or liquid media to identify causative bacteria or fungi.
Microscopic examination using Grams stain, acid-fast stain, silver staining.
Polymerase chain reaction (PCR) testing to identify microorganism DNA.
Immunologic methods to identify microbial antigens or antibodies.

Author

Arti Muralidhara, Mercer University School of Medicine