NMLE step I: Infectious Diseases

NL: Infectious disease II Bacterial

infection

.. (MED26)

Encoded and proof by 32 MED34

Term
Bacteremia
clinical
syndrome sepsis
Sepsis bacteremia sepsis

Melioidosis Burkholderia pseudomallei

BP drop Clinical signs and symptoms

bacteremia
Sepsis BP < 90/60 mmHg
Septic shock pathophysiology vascular
leakage
SIRS (Systemic Inflammatory Response Syndrome)

inflammatory cytokine

Sepsis Sepsis = Infection + SIRS
SIRS tachycardia,
tachypnea, hyperthermia (Body temperature > 38 C)

NMLE step I: Infectious Diseases

inflammatory cytokine acute
pancreatitis leakage lipase fat
necrosis inflammation cytokine
target organs
cytokine
SIRS
non-infectious SIRS
Infection 3

host factors? host defense

predisposing conditions
(Immunocompromised)

Atypical
infection 20
pneumonia
infectious pneumonia

Streptococcus pneumoniae

immunocompromised patient
opportunistic infections PCP (Pneumocystis carinii

jiroveci)

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20

Streptococcus pneumoniae Mycoplasma pneumoniae

60 Gram negative
Klebsiella pneumoniae

identify organism
prognosis

Drug resistance

identify organism

Timing
7
virulence Virus Gram positive Gram
negative bacteria Timing Slow
growing Mycobacteria TB, fungus,
Actinomyces
Pattern

Plasmodium

NMLE step I: Infectious Diseases

falciparum pattern
Plasmodium vivax

Past medical history

(P. falciparum)

melioidosis

Endemic area

Travellers diarrhea E.

coli

Tetanus
, Chronic renal disease,

Thalassemia B.

Pseudomallei Melioidosis
Alcoholic cirrhosis Klebsiella pneumoniae

steroid, glucocorticoid,

NMLE step I: Infectious Diseases

incidence Nocardia sp.

Review

Staphylococcus aureus

Gram +ve cocci incluster

Clinical manifestations
Most common chief complaint: Skin and Soft tissue
infection ( Anatomy skin soft tissue )
Hair
follicle Folliculitis ( )
Carbuncle

NMLE step I: Infectious Diseases

impetigo
Soft tissue cellulitis

Folliculitis

Carbuncle

Cellulitis
Impetigo

dermis subcutaneous
layer deep fascia necrotizing fasciitis
Treatment: Cloxacillin (Dicloxacillin: absorption ), 1

st

gen cephalosporin ( Gram +ve)

warm
and tender lesion
cellulitis
cellulitis Staphylococci
Streptococci Skin lesion
Staph.

NMLE step I: Infectious Diseases

Strep.
Lymphangitis ( distribution
) Streptococcal cellulitis

Staphylococcal cellulitis

Streptococcal cellulitis

Staphylococci
Osteomyelitits

Septic arthritis Staphylococcus aureus

Synovial fluid
Double dose Cloxacillin Dicloxacillin

NMLE step I: Infectious Diseases

Bones Joints
Dose

Site of infection duration

Joint infection
Synovial fluid

Pathogenesis of septic arthritis

1.

(Haematogenous spread)

2.

Staphylococcal Pneumonia
Liquefactive necrosis

NMLE step I: Infectious Diseases

neutrophil
empyema
Lobar pneumonia

Staphylococcus aureus

Hospital-acquired: Catheter (
)

Staphylococci Normal Flora

attach
Acute infective endocarditis
antibiotic double dose
Staphylococcal toxic shock syndrome
exotoxin (TSST-1)
SIRS superantigen
cytokine
o : (Erythroderma),
hypotention, multiple organ failure (Acute renal failure,
ARDS) Desquamation plaque syndrome

DIC

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Staphylococcal Scald Skin Syndrome (SSSS):

exfoliative toxin
foci
of infection
Treatment: Cloxacillin + Clindamycin (

50S ribosomal subunit

exotoxin exotoxin )
immunoglobulin
neutralize exotoxin

Streptococcus pyogenes (-hemolytic streptococcus

Group A)
exudative
Gram +ve cocci in chain

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Clinical manifestations
Pharyngitis, pyoderma, erysipelas, cellulitis,
necrotizing fasciitis
exudative

Acute rheumatic fever
Autoimmune reaction cell epitope M
protein Basal ganglia glomerulus

subcutaneous nodule (
Acute rheumatic heart fever)
Poststreptocoocal glomerulonephritis
Acute glomerulonephritis ( Strain Acute
rheumatic fever strain
Poststreptococcal glomerulonephritis)
10

Viral pharyngitis Streptococcal
pharyngitis exudates ulcer Viral pharyngitis

Corynebacterium diphtheria
White patch

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Viral pharyngitis

12

Diphtheria

Necrotizing fasciitis
gangrene
S. pyogenes Flesh-eating bacteria
Bleb

Deep fascia

o Treatment: PGS high dose + Clindamycin + surgical

removal of dead tissue

Clindamycin : exotoxin
Necrotizing fasciitis

Stationary phase -lactams
Protein systhesis inhibitor

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Erysipelas Skin
poor lymphatic drainage

Erysipelas

Scarlet fever

[Scarlet fever Erythrogenic toxin

glossitis ] <<

Streptococci Group B
vaginal canal

Streptococci
Group B
Group B streptococcal sepsis
meningitis encephalitis
Soft tissue infection
minute injury
osteomyelitis,
septic arthritis, meningitis

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Treatment: PGS Ampicillin ( Gram

ve )

Enterococci group D

Urinary tract infection, intra-abdominal

infection, Gram +ve cocci in chain

Treatment: PGS, Ampicillin **
Cephalosporins**

Subacute bacterial endocarditis

[ Vancomycin
(Vancomycin resistance enterococci - VRE)]

Streptococci Viridans group

Normal flora (

S. mutans ) underlying disease

vulvular heart disease Artificial heart valve

Turbulent flow vegetation media

colonize
Subacute bacterial endocarditis

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Streptococcus mutans

vegetation

15

3-4 (
staphylococcal endocarditis 2-3
) Heart failure
Treatment: PGS + Gentamicin
Aminoglycoside?: Synergistic effect
cell wall systhesis inhibitor PGS PGS
cell wall Aminoglycoside
( Aminoglycosides
Gram +ve
cell wall )

Streptococcus pneumoniae

40 3

( Pneumonia) Gram +ve

diplococci lancet-shape

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Community-acquired pneumonia
Clinical manifestations

S. pneumoniae

Bronchitis, Lobar
pneumonia ( ), Bronchopneumonia (
)

meningitis
subarachnoid space
CSF
Treatment: Pneumonia Penicillins meningitis
Ceftriaxone, vancomycin, rifampin
pennicillins mutation
PBPs Target
Penicillins

Bacillus anthracis

Skin lesion

ulcer gangrene
Gram +ve bacilli

DDx: B. anthracis Clostridium sp.

setting

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Clinical manifestations
Cutaneous anthrax: Skin lesion
eschar ( eschar
Scrub Typhus )
Inhalation anthrax:
pneumonia mediastinitis septicemia

Treatment: PGS high dose antibiotic of choice

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Listeria monocytogenes

Gram +ve bacilli

Meningitis CSF
immunocompromised
patients

Treatment: Antibiotic of choice Ampicillin (

meningitis ceftriaxone resistant
cephalosporins )

Clostridium perfringens
Clinical manifestations

Food poisoning:

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Gas gangrene:
Crepitation gas

Treatment: PGS + Clindamycin

Gram stain of C. perfringens

Clostridium difficile

Antibiotic-associated colitis

Gas gangrene

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Normal flora colon Antibiotic

C. difficile

cytotoxic colon
Pseudomembranous colitis
Treatment: Metronidazole Anaerobe
Diaphragm
Oral vancomycin Gram positive

Clostridium tetani

Tetanospasmin neurotoxin Motor nerve

Spinal cord brainstem

GABA presynaptic neuron excitatory neuron

spastic tone
Clinical manifestations
hyperreflexia Tetanus lesion Spinal
cord UMN lesion excitatory neuron

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Lock-jaw
Tachycardia hyperreflexia
antibiotic

Deep space infection Tetanus
expired
Treatment: PGS + Antitoxin +
muscle
relaxant
*** Gram positive ***

Neisseria meningitidis
24 purpura
CSF Gram ve diplococci kidney-shape

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Clinical manifestations

meningococcemia meningitis
Sepsis

Neisseria sp.

terminal complement deficiency ( C6-C9)

Complement system HIV

Meningoencephalitis petechial rash

Waterhouse-Friderichsen syndrome:
meningococcemia Sepsis DIC
Acute renal insufficiency
Treatment: Ceftriaxone

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close contact:: Rifampin,

Petechiae

Meningococcal septicemia

meningococcemia

Neisseria gonorrhoeae

Discharge Intracellular
Gram ve diplococci kidney-shape

Clinical manifestations

<< Urethritis

urethritis

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Pelvic inflammatory
disease
Septic arthritis


Disseminated gonococcal infection (DGI)

Treatment: Ceftriaxone Doxycycline

Chlamydia

Gonococcal cervicitis

Disseminated gonococcal
infection (DGI)

Gram ve diplococci kidney-shaped
Respiratory infection
COPD Moraxella catarrhalis
Gram ve diplococci 3 N.

meningitides ( meningitis), N. gonorhoeae (

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ectocervicitis 5 Arthritis
)

Moraxella catarrhalis

Neisseria sp.
morphology

Setting Respiratory infection
COPD

Clinical manifestation
Respiratory infection, otitis media, sinusitis, bronchitis,
pneumonia COPD
-lactamase Penicillins
-lactamase inhibitor
component Amoxycillin + clavulanate
Augmentin cephalosporins

Gram ve dipolococci
Gram ve diplococci kidney-shaped CSF

Neisseria meningitides

discharge penis

Neisseria gonorrhoeae

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sputum
sinus

Moraxella catarrhalis

** setting

Gram ve diplococci kidney-shaped

Gonorrhoea **
Gram ve cocci
bacilli Gram ve coccobacilli
background staining
COPD
respiratory infection

Haemophilus influenzae

Moraxella catarrhalis

meningitis
respiratory infection complication
Sensory hearing loss

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COPD Bronchitis
pneumonia

-lactamase Moraxella

catarrhalis
Augmentin

Legionella pneumophila

Legionnaires disease

intracellular organism gram

intracellular infection CMIR
Legionella sp.
CMIR defect HIV, on steroid, transplantation

Clinical manifestation
Atypical pneumonia: pathology Alveolar septum
interstitial infiltration
diarrhea
nausea vomiting Hyponatremia

Legionella sp. setting

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electrolyte hyponatremia 1 3
mental confusion
Coronary manifestration: myocarditis

Gram -ve

bacilli
Ag Ab ELISA, IFA
Treatment: intracellular bacteria
antibiotic cellular
concentration macrolides (Azithromycin)
Quinolone (Ciprofloxacin)

Mycoplasma sp.

Legionella

sp. Mycoplasma sp.

pneumonia
Mycoplasma pneumoniae
Clinical manifestation

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Respiratory infection:
pharynx migrate
Anatomy Alveolar septum
Pneumonia
( Typical viral pneumonia PCP
Strep Staph Bronchopneumonia
)
Systemic manifestation: encephalitis

conscious level convulsive
activity Seizure
meninges Aseptic meningitis
spinal cord transverse myelitis
5 : involve RS
CNS involve
Hemolytic anemia (RBC )
Myopericarditis Myocarditis pericarditis
Heart failure Rare
manifestation
Skin manifestation:

Mycoplasma

pneumoniae Maculopapular
rash vesicle Erythema multiforme (

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Erythema marginatum Acute rheumatic fever )

skin Targeted lesion ( )
Typical M.

pneumoniae (
Herpes virus
)

tympanic membrane
bullous tympanitis
Treatment: intracellular concentration
erythromycin, azithromycin, Fluoroquinolone

Chlamydia pneumoniae

Atypical pneumonia Mycoplasma

skin
manifestation

20 upper and lower respiratory

symptoms ( upper

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lower ) CXR
( )
interstitium alveolar septum
interstitial pneumonia

CXR infiltration

Erythema multiforme

septum
Skin lesion Erythema
multiforme
Mycoplasma pneumoniae

Treatment: Quinolones Ciprofloxacin Macrolides

Azithromycin
Gram negative bacilli
Enterobacteriaceae morphology
Gram ve
Community-acquired infection Communityacquired pneumonia E. coli

Klebsiella sp.

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Pneumonia in alcoholism - Klebsiella sp.

40 Alcoholic hepatitis

Gram stain Gram ve bacilli

with thick capsule
Morphology Klebsiella sp. capsule
capsule

currant jelly sputum

Pneumonia in immunocompromised hosts

E. coli

immunosuppressive drugs

Nosocomial infections

Enterobacters
Pseudomonas aeruginosa
UTIs, sepsis, GI, pneumonia

E. coli

Klebsiella pneumoniae

NMLE step I: Infectious Diseases

Capsule Klebsiella

pneumoniae

33

CXR
Lobar pneumonia

GI system Chief complaint

3
1. Food poisoning
Food poisoning Clostridium botulinum

Staphylococcus aureus

onset
6
4



Toxin
2. Watery diarrhea
lesion Small bowel infection

prototype small bowel infection

Vibrio cholera Cholera toxin

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cAMP secretion
Hypovolemic
shock Stool exam blood cell

mucosa
3. Tenesmus Large bowel infection
2
(Tenesmus

lesion Sigmoid colon Rectosigmoid




)
Large bowel infection
tenesmus
mucus-bloody stool stool exam pus cell

cytotoxin mucosa
EHEC, EIEC, Shigella
Scenario

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Shigella sp.

stool exam

Clinical manifestation
Shigellosis: Mucous-bloody diarrhea, dysentery, tenesmus
complication Toxin
Colon Toxic
megacolon perforation
Serious condition: Hemolytic uremic syndrome (HUS)
Shigella dysenteriae type I

mucus-bloody diarrhea ( uricemia)

flushing hemolytic anemia Shigellosis
Shiga toxin
neurotoxin

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Treatment: efficacy Gram ve 3

rd

generation cephalosporins Ceftriaxone

Quinolone group Ciprofloxacin

Campylobacter jejuni

mucus-bloody diarrhea
invasive organism
blood cells

Treatment: Ciprofloxacin

Vibrio cholera

Serotype classic O1
profound watery diarrhea

Clinical manifestation

Vibrio sp.

Watery diarrhea hypovolemic shock stool

exam Blood cell Small bowel
infection culture TCBS agar
Vibrio cholera

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Treatment:
antibiotic
Tetracycline doxycycline [ ORS ]

Vibrio parahemolyticus

pus cell
2-3

Vibrio vulnificus

alcoholism
septic shock

Clinical manifestation

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skin lesion bullae

Hemorrhagic bullous necrotizing bullous
cellulitis clinical
Treatment: Tetracycline
()

Hemorrhagic bullous Vibrio vulnificus

Soft tissue

Salmonella sp.

Salmonella Typhi Typhoid (Enteric)

fever

Clinical manifestation

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Gram stain: Salmonella

Typhi

Nocardia sp.

SLE steroid

Gram +ve filamentous branching

modified acid-fast
(bead-like appearance)
Clinical manifestation

Nocardia asteroides
immunocompromised hosts

CMIR defect intracellular
pathogen Nocardia sp.

pneumonia effusion
CNS Brain abscess

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Treatment: Co-trimoxazole

Modified acid-fast stain

CXR Nocardia

asteroides

Actinomyces sp.

Setting Nocardia Skin

lesion abscess sinus tract ( Cutaneous

fistula) Gram +ve branching rod
Actinomycosis
Clinical manifestation
non-sporeforming anaerobic Gram-ve rod common
Actinomyces israeli Mycetoma (
)
Nocardia braziliensis

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Mycetoma Abscess
cervicofacial, abdominal, pelvic mycetoma
(cervicofacial mycetoma)

( abscess)
steroid
Actinomycosis Gram stain
Gram +ve rod filamentous branching

Treatment: PGS high dose, metronidazole (

anaerobe )

Mycobacterium tuberculosis

CXR

reticular infiltration right upper lobe

hilar lymph node

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(Gram neutral
Gram ghost ) AFB nonbranching bead-like organism Mycobacterium

tuberculosis

Clinical manifestation
TB
Aerobe
upper lobe
Pathology TB interstitium
lymphocyte plasma cell
Granulomatous inflammation
TB
Sputum AFB positive
CMIR defect ( HIV, on steroid, etc.)
Pulmonary TB:

secondary infection reactivation

CXR reticular infiltration upper lobe lymph node

TB
( pleural effusion ), ,

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genitourinary infection TB orchitis

hematogenous spread
meningitis
Timing
bacterial meningitis 1
Calcification
Scar CXR hilar lymph node
Calcification
Ghon complex
Treatment: Anti-TB drug 2 isoniazid +
rifampin + PZA + Etambutol 4
isoniazid + rifampin 6
o ADR: Isoniazid peripheral neuropathy (
) pyridoxine
metabolism, hepatotoxicity
o ADR: Rifampin
Flu-like symptom
o ADR: PZA
hyperuricemia

o ADR: Etambutol optic neuritis

NMLE step I: Infectious Diseases

CXR

44

Granuloma with caseous necrosis

TB

AFB

Anti-TB drug

Non-tuberculous mycobacteria (NTM)

HIV
infection skin and soft tissue
NTB TB

Clinical manifestation

Mycobacterium fortuitum
sternum [

Thoracotomy Transternal approach

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Bone marrow biopsy and transplantation ]

AFB positive

Mycobacterium abscessus disseminated infection

Mycobacterium marinum

AFB positive
Treatment: intracellular organism

intracellular concentration

Clarithromycin, Aminoglycosides amikin

Mycobacteria

Mycobacterium marinum

Swimming pool granuloma

Mycobacterium leprae

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general appearance ulnar nerve

AFB positive

Clinical manifestation
Chief complaint
sensory loss (anesthesia) skin lesion
(hypopigmentation)

Treatment: Dapsone

Hypopigmentation of
skin
sensory loss

Leonine facies

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Practice

1. Echocardiogram vegetation at anterior mitral valve leaflet

2 hemoculture reported Streptococcus viridans
Treatment
PGS + Gentamicin
2. 40 1 skin signs
probable diagnosis

skin sign splinter hemorrhage, Osler node,

subconjuctival petechiae Janeway lesion
infective endocarditis
3. diagnosis treatment

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Necrotizing fasciitis S.

pyogenes
deep fascia

PGS high dose + Clindamycin

4. Pus gram stain diagnosis treatment

Streptococcal pharyngitis amoxicillin 400 mg 2x2 bid. 20

tablets
5. 70 3 ; CXR patchy infiltration right lower
lung Sputum Gram stain most likely organism
Treatment

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Staphylococcus aureus Cloxacillin 2 gm iv q 6 hr

cefazolin 2 gm iv q 8 hr 2-4 weeks

6. 30 3 Pus Gram stain as shown

most likely organism, Treatment

Ceftriaxone 125 mg im. Single dose Cefixime 400 mg

oral Doxycycline 100 mg oral bid x 7 days
Azithromycin 1.0 g oral single dose non-GC
urethritis couple

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7. 60 admit COPD exacerbation; on respirator

1 Sputum Gram stain as shown
most likely organism Treatment

COPD H. influenzae

Moraxella catarrhalis antibiotics

ceftriaxone