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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

Compartment Syndrome 5 Ps Pain (occurs 1st) Palor Poikliothermia Parathesia Pulselessness (occurs last)

Strep pyogenes o S. aureus is the MCC for skin infections except for these 5 cases where it is Strep pyogenes who is responsible LINES Lymphangitis infection follows lymphatic channels = red streak Impetigo honey crusted lesions ( if bullous d/t Staph aureuss elastase activity) Necrotizing fascitis flesh eating strep Compartment Syndrome Erysepelas raised edges; do not blanche (vs. cellulitis) How did a bacteria pick up nasty traits? Scarlet Fever Tranduction Phage o sand paper rash o Strawberry tongue o Rash on PALMS & SOLES Staph epidermidis 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 Propriobacterium 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 dont work need the BIG GUNS Retin-A = previtamin A Stimulates skin to grow thereby pushing the bug out for 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 Have IgA Protease (MS) allows bacteria to live in the mouth without IgA killing them Pt. most likely had a prior strep infection in last 2 weeks #1 way to paralyze cilia VIRUS o Post Strep GN Virus paralyzes cilia making the lung susceptible to infection!!! Strain 12 Cilia no longer has ability to sweep them up and out S. pyogenes has no capsule so type I pneumocytes can eat them up Strep. Pneumonia or cause infection H. influenza Neisseria o Catarrhalis o Meningitis MCC of Sinusitis S. pneumo, H. influ, Neisseria in that order o Gonorrhea

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 viridans MCC of subacute bacterial endocarditis (SBE) o Mutans responsible for dental caries ferments glucose produces lactic acid o Sanguis o Salivarius Cold agglutins

STOMACH Helicobacter pylori 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 Big Mama Anaerobes: Proteus nd Clostridium melangosepticus o 2 in line for UTI Strep bovis Klebsiella Bacteriodes fragilis o Currant jelly sputem Rx: Clindymycin, Cefoxitin, Metronidazole 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. Clostridium difficile o Pseudomembranous colitis d/t chronic antibiotic use o Gastroenteritis after antibiotic use Clostridium perfingens o Gastroenteritis associated with holiday ham

RECTUM Group B Strep E. coli Lysteria STAPH Species:

All 3 are main causes of sepsis in the newborn

lactam ring

Staphlococcus aureus: Gram + cocci in clusters; gold pigment Enzymes: o Catalase + breaksdown hydrogen peroxide o -lactamase breaks through 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 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 its also seen with Penphiguis vulgaris) Involves the PALMS & SOLES o Erythrodermic Toxin 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 especiallyPALMS & 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 epidermidis: Enzymes: o Catalase + Resides underneath skin White pigment MCC Shunt infections and Central line infections Treatment 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 Saphrophyticus NO PIGMENT Enzymes o 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 o Groups A, B, C, D o Types of hemolysis -hemolysis partial hemolysis Green Zone -hemolysis complete hemolysis Clear Zone

-hemolysis no hemolysis Red Zone Streptokinase is responsible for -hemolysis it is used for breaking up clots and binds up fibrinogen in acute MI, but if patients had recent Strep infection, the patient has built antibodies to streptokinase and it will not work This is the reason that they doctors 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 wontt allow for anymore clots o 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 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 encapsulated organisms End Organ Failure o It is most likely that encapsulated cause that will kill DM and CF patients PSGN o Skin or throat strep can cause PSGN o Associated with Strain 12 Group A: Strep pyogenes o hemolytic

o 70 Strains o #2 for skin infections o #1 for throat infections only throat Strep causes Rheumatic Fever Group B: Strep agalactaciae o #1 Cause of Neonatal Sepsis o - hemolytic

Group D: Strep viridians (mutans, saguis, salivarius) o Green pigment o - hemolytic o #1 Cause of Subacute Bacterial Endocarditis With Septic emboli to the brain mycotic aneurysm Roth Spots = septic emboli to the retina Oslers nodes = septic emboli to the fingers Splinter hemorrhages = septic emboli to the nail bed Janeway lesions = septic emboli to the toes A previously traumatized heart valve will predispose to SBE o Treatment: Amoxicillin 3 g 2 hrs. before surgery Amoxicillin 1.5 g 6 hrs. after surgery Essential to protect any mucosal surface type surgery

Enterococcus (Faecalis, Faeceum) Anaerobic hemolytic

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 + Toxicity o Ototoxicity o Nephrotoxicity o Red Man Syndrome d/t intense histamine release This is not an allergic reaction

Vancomycin Treatment: MRSA Staph epidermidis Enterococcus

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 dont have D-amino acids, we have L-amino acids!!! o Spores hate HEAT!!! That is why sterilization is useful against spores Bugs with Preformed Bacillis toxins: o Anthrax - Bacillius anthrax 2 Types: - B. cerus Skin necroses of the skin - Staph. aureus

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. Perfringens 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 emboli 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. difficile 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 Vancomycin o 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 Inhibits the release of glycine (remember that glycine has an inhibitory fxn) in the spinal cord will cause an contraction respiratory failure o Lock Jaw o Rhizorus Sardonicus Strychnine works the same way

Need to give antitoxin C. botulinum Botulism o Toxin inhibits pre-synaptic release of Ach flaccid paralysis (floppy baby) Muscles wont work Die of respiratory failure b/c diaphragm not working cant breath in Restrictive lung disease you know the profile!!! o Children Contract it from dark caramel syrups (honey/molasses) Do not give children honey until 6 mos of age because by 6 mo. They will have a normal flora that can fight against anaerobes o Adults Ingest spores via canned foods o Treatment: Antitoxin first Abx. 2nd

Lysteria monocytogenes (curved rod) recall Vibrio, Lysteria, Camp. H. pylori Produce endotoxin o Will die fast o Produce granulomas Even though it is a bacteria it attacks tissues therefore involveing Tcell and monocytes #3 cause of Neonatal sepsis Gastroenteritis in Adults o Migrant workers o Cabbage o Spoiled milk o Hot dogs Treatment o Vanomycin o Macrolides o Ampicillin GRAM NEGATIVE Hemophilus Influenza 80% are not encapsulated Non-invasive disease Type B o ENCAPSULATED = DISEASE o MCC of Epiglotitis H. ducreyi o Chancroid ulceration with central necrosis (appears as a black scar in the middle) o PAINFUL genital lesion H. aegypteus (gram negative with pleomorphic rods) 4 Causes of PAINFUL genital lesions: 1.) Chancroid o Pink Eye conjunctivae is red and swollen 2.) HSV-7 crop of vesicles coming Looks like eye ball is being pushed out together and then ulcerate Neisseria N. meningitides o Gram negative diplococci
3.) LGV (Lymphogranuloma venereum) d/t Chlamydia 4.) Granuloma Inguinale ulcerated lesion in the inguinale area d/t Calammotobacterium donovini (see Donovan bodies)

o Largest encapsulated bacteria Requires MAC complex to fight it Only encapsulated organism that can release its 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 Present like this no matter the age o Petechiae always assume Neisseria as the culprit 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. gonorrhea 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 its 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 with dysuria and painful wrist 3 days later o Gonococcal Arthritis Comon in teenagers o Treatment Must also treat for Ceftriaxone 250 mg IM x 1 Chlamydia: Cefixeme 400 mg IM x 1 - Azithromycin 1 g x 1 Cefoxitin 250 mg IM x 1 Ciprofloxacin Oflaxacin 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 travelers diarrhea o #2 in neonatal sepsis Families o EIEC = Enterinvasive E. Coli Regular travelers 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 mirabilis #2 cause of UTI Urease + (PPUNCH) o + struvite stones Treatment: o Norfloxacin

UTI infections 1. E.coli 2. Proteus 3. Klebsiella

Klebseilla 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 loves 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 2nd 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

HOUSE OF ella General Characteristics: o Gram negatives that like to get into the cell o The symptoms dont start until late but lasts only a few days o Granulomatous change Involves T-Cells and M Involves tissues that are invaded by M Brain, Bone, Liver, Lung, Skin, etc. Bordatella 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 cant catch breath so the suck in a whole bunch of air that creates a WHOOP sound o 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 Pasturella multocida o Dog/cat bites Bacteria is in the saliva Treatment: Amoxicillin

Shigella o Gastroenteritis associated with day care outbreaks o Shiga Toxin Neurotoxic cause seizures o Dysentary Most common in the world o Sonnei most common in America Salmonella

Gastroenteritis associated with raw chicken and raw eggs Encapsulated Likes to live around anus of chicken when egg comes out it will be wrapped in Salmonella If treated, salmonella will hide in the Gall Bladder So, do not treat or you will increase carrier state Treatment = public health risk o S. dysentery MC world wide 5 Bugs/Diseases that cause Heart Block: o S. enteritids 1. Salmonella - Typhoid Fever MC in America 2. Lyme o S. typhi = Typhoid Fever 3. Legionella 4. Diptheria Triad: 5. Chagas High fever Heart block Rose Spots Symptoms: Intestines are on FIRE Treatment: Ciprofloxacin Francisella tularensis o Tularemia o Symptoms: Fever Red Eye Swollen glands o Transmission Rabbits Treatments: Streptomycin Bartonella henselae o Swollen lymph nodes Cat Scratch Fever o Silver stains in the lymph nodes o o o o

01-29-04 Miscellaneous Gram Negatives Vibrio cholera

o Rice water diarrhea Similar to ETEC Turns the On, On ADP ribosylates Gs cAMP o Etiology = Sanitation Vibrio parahemolyticus o Raw Fish sushi o Gastroenteritis Vibrio vulnificus o Gastroenteritis associated with Oysters Yersina entercolitica o Gastroenteritis that mimics appendicitis actually acute ileitis o Mesenteric adenitis = swollen lymph nodes o Seen in daycares o Associated with Reiters Syndrome Post infectious arthritis immune complex disease (+) HLA B27 Ankylosing spondylitis (scarring/fusion of the spine) o Most commonly in a middle age male o Begins in the lumbar area Bilateral scaro-iltis (@sacro-iliac joint) HLA B27 (+) o Ankylosing of lumbar spine fusion height Ankylosing spondylitis Schoeber test spine does not move when asl to bend over o Die of aortic dilatation AR Reiters Reiters Syndrome Syndrome o Post infectious arthrititis Psoriasis 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 acid stones Yersina pestis 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 jejunii o Gastroenteritis associated with ingestion of raw eggs 4 Bugs that are comma/curved o Comma/Curved shaped shaped: o Tx: - Vibrio cholera Macrolide Erythromycin - H. pylori - Campylobacter - Lysteria ATYPICALS

General characteristics o Dont have a cell wall Therefore, cant 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 Congunctivitis in Newborn: o Most common cause for ectopic pregnancy 0-24 hrs.- chemical caused by silver Chlamydia tested with pap smear. nitrate 90% are asymptomatic 24hrs 7 days = Gonnorhea After day 7 = Chlamydia #1 cause of neonatal blindness in the world o trachoma Deep ulceration of cornea Transmitted via birth o treated with erythromycin ointment/sulfacitomide drugs Treatment: Azythromycin: 1 gm o Dont 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 o Parasite: On blood smear can see T cells and M 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: Alzheimers 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

Opthalmia Neonatorum (gonnorhea) Treated with silver nitrate

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 5 infections that cause Cryoglobulinemia Walking pneumonia I AM HE o In the interstitium of the lungs 1. Influenza o CXR findings: 2. Adenovirus Interstitial pattern 3. Mycoplasma Ground glass appearance 4. Hep B Reticulonodular pattern 5. EBV 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 myringitis o Located on tympanic membrane Cold Agglutinins Warm Agglutinins IgM IgG Acute Inflammation Chronic Inflammation Mycoplasma Hominis Cause vaginitis RARE Legionella 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 Legionnairs disease = full blown pneumonia Will silver stain in the lung (along with pneumocyctis corinii) Charcoal yeast agar extract (CYAE) will grow it. (+) Heart Block Atypical pneumonia 0-2 months - chlamydia 10-30 years - Mycoplasma >40 years - Legionella

Mycobacterium: 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 TB Contact Bacteris inhaled tubercule sticks to respiratory epithelium and develops into Ghon focus. Wont even know got it = Asymptommatic o Ghon focus o Ghon complex - M ingest bacteria and bring them to the lymph node M tries to fuses with a lysosome but cant 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: 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 pops 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 Upper lobe cavitary lesion o Bacteria Explodes out of its cavitary lesion again hoping to get back to GI tract. Cough and swallow Causing obstruction in ileum (bacteria gets absorbed because its fat soluble) where all lymphoid tissue exists and tries to stop infection But it cannot Ileum swells up = Obstruction rd 3 Contact Milliary TB: 1.

o When gets into blood stream and goes all over body o Arrives everywhere M go Meningitis: MC affected nerve = CN III posterior fossa (+) hydrocephalus CN 9, 10, 11 12 Potts disease = TB of spinal cord (+) compression fracture Sterile Pyuria (in Kidney) White cells in urine that wont go away Skin rash = eythema nodosum Hepatosplenomegaly Bone Adrenal failure = Na/K Pericarditis Diffuse ST elevation

PPD Test Most people dont 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 3rd world countries (Africa, Asia, South America, Philippines, inner city projects, nursing 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) +PPD o AIDS patients= 10%/year risk of getting TB Tend to get multiple drug resistant TB Tend to get infected with new strains Sx No Sx MANAGEMENT Positive ppd o Symptomatic Treat o Asymptomatic CXR Treatment: Everyone must be given 4 drugs for 4 mos. INH Rifampin o (-) subunit of RNA Poly Pyrizinamide o Unknown

Treatment

CXR

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

Negativ e CXR

<35yo

>35yo Yearly CXR

INH, Vit. B

o SE Liver Failure Ethambutal o Unknown o SE Impairs Red-Green discrimination Streptomycin o Aminoglycoside D Cycloserine

Mycobacterium Leprae Leprosy Hansens Disease Neuropathy o d/t granuloma formation around nerves Lion Like Facies Treatment: o Dapsone o SE inhibits p450, Autoimmune hemolytic anemia Mycobacterium Kansasii swollen lymph nodes Mycobacterium Avium Intracellulare CD4< 100 Experience gastroenteritis before it hits the lung Drug of choice = Clarithromycin & Azithromycin Mycobacterium Scrofulaceum Granuloma Formation Supraclavicular adenopathy in children Granulomas secrete Remove lymph nodes o INF- Made by M Mycobacterium ulcerans (+) Protein Syn. Show up as ulcers o INF- Made by T-cells (+) Caseating granulomas Mediate M Mycobacterium marinum transformation into Cleaning fish tanks Giant cells, Caseating granulomas histiocytes etc Spirochetes spiral shaped, flipping motility, (+) cell mediated response Treponema Pallidum Rule of 6s 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 Hutchinsons 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 TORCH Neonatal Infections Toxoplasmosis multiple ring enhanced lesions in the parietal lobe Cat exposure Other Rubella cataracts, hearing loss, autism, blueberry muffin rash, PDA CMV Central calcifications, #1 Cause of congenital blindness Herpes temporal lobe encephalitis 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)

Specific blood test

Screening VDRL (CNS for tertiary syphilis) sensitive but not specific can remain postive for 1 yr after treatment 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 Syphilic aortitis = obliterative endarteritis (tree bark appearance of blood vessels) proximal aorta only.

Treponema Pallidum Variant Bijel Treponema Pertenve Yaws Treponema Carateum Pinta

All come in with rash disappear with no consequence

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:

Bulls eye lesion that enlarges over time

Ixodes Tick Vector Lyme Disease Babesiosis Erlichiosis

Penicillin Tetracyclin

Borrellia Recurrentis 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 Leptospirosis Interogens 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 Coverage o Gram (+) No S. aureus o Simple Gram (-) E. coli H. influenza SE: o Photosensitivity o Allergic reaction o G6 PD o Hemolytic anemia o Intersitial nephritis

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 Nystatin o 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 in cells of body: o SE: Hyperkalemia systemic toxicity Hypokalemia renal toxicity K will leak out in urine Renal failure Inhibit synthesis of ergosterol cant use with amphoteracin B because it will have nothing to bind to = SE o Hraconazole o Ketoconazole inhibits p450, inhibits 5-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. 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 bush o Treat with Potasium Iodide on skin and treat like any other fungus if it is systemic. Enterococcus will cause nitrite negative UTI

Parasites GASTRITIS T cells, macrophages and eosinophils How did you get it Liver flukes: 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 lumbricoides o Strongyloides Treatment: o Mobendazole (vermox) give 1 tablet and then repeat in a week = DOC Paralyzes microtubules cant hook on o Pyrantel Pamaoate specific treatment for pin worm o Thiobendazole treatment for Strongyloides 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 Cystericerosis o 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) Heart: o Trypanasoma Cruzi Chagas disease Eats ganglia and causes heart block Get it from South America

Lung:

Reduuvid bug

GI:

o Pneumocystis Corinii Silver stains (along with Legionella) CD4 count below 200 Treatment: Bactrim (SMX-TMP) 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 o Trichimonas # 3 cause of Vaginitis Treatment: Metronidazole 2g x 1 Also treat partner

GU:

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

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 Just like malaria but acts in the East coast Looks different only on smear Treatment with anti malarial Carried by Ixodes tick (lyme disease) o Plasmodium:

Malaria most common strain world wide Fever every 3rd day Quartian (fortnight) Falciparum most fatal (can hemolize all mature RBCs most rapidly) Black water fever (urine turned black with bilirubin) Vivax go to liver (chronic malaria) Prophylactic Meds: Likes reticulocyes (young RBCs) 1 pill/2wk before you leave Ovale - go to liver (chronic malaria) 1/wk while gone Likes mature RBC 4 wks after coming back Symptoms: total tx wks = 6 wks + wks away Malaria = quartian o Gives you fever every third day Falciparum, vivax, ovale = tertian o Gives you fever every other day Usually associated with travel

Oxidize RBC membrane causing Treatment: hemolytic anemia and killing Quinine bacteria with it not good for G6PD Chloraquine mostly RBCs b/c it will lyse these cells Mefloquine good liver penetration. Primaquine best liver penetration o Always start for vivax and ovale o Important reasons for treatment: Malaria is the most common parasite Most common infectious disease related cause of death in the world Most common cause of hemolytic anemia in the world. Rickettsia (+) Eosinophilia Likes to invade blood vessels causing vasculitis bleed or clot. Symptoms: Purpura Ecchymoses Petechia Cerebral hemorrhage Nephritic syndrome Hemoptysis Melena/ melachesia Microcytic hypochromic anemia Blood Test will show: o High platelets, eosinophilia, hypochromic anemia Rickettsia Rickettsia o Rocky mountain spotted fever o RMSF Tick (deer, dermacanter andersoni) 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 Prowzekii o Epidemic typhus o Louse born Rickettsia Akari o Rickettsial pox fleshy papules/ vesicles o Mites Rickettsia Tsutsugamushi o Scrub typhus o Caused by mite (mighty mite) Coxiella Burnetti (long lost relative) o Q fever o Find in dusty barn o Doesnt behave like rest of rickettsia family NO vasculitis Just get lung disease