Diagnostic Workup

• Assessing px’s general appearance before taking the history or • Blood can be obtained at time of IV insertion and before
performing PE can yield valuable info antibiotics are administered
• Physician’s subjective sense of whether px is septic or toxic o For cultures, CBC w/ differential, serum electrolytes, BUN,
often proves accurate serum creatinine, serum glucose, LFTs, lactate
• Visible agitation or anxiety in a febrile patient can be a harbinger • Acute endocarditis → get 3 sets of blood cultures
of critical illness • Blood smears helps diagnose
• The most important task of the physician is to distinguish these o Severe parasitic diseases (e.g. malaria, babesiosis)
syndromes from other infected febrile whose illness will not o Ehrlichiosis
progress to fulminant disease o Anaplasmosis
• CSF is drawn before starting antibiotics in px w/ possible
meningitis
Clinical Course • Focal findings, depressed mental status, or papilledema should
• Presenting symptoms are frequently nonspecific be evaluated by brain imaging prior to lumbar puncture, which,
• Onset and duration of symptoms? in this setting, could initiate herniation
• Changes in severity or rate of progression over time? o Antibiotics should be administered before imaging but after
• Predispose to specific infections and to increased severity blood for cultures has been drawn
o Lack of splenic function • If CSF culture (-) → blood culture is diagnostic in 50-70% of cases
o Alcoholism with significant liver disease • Molecular diagnostic techniques (e.g., broad-range 16S rRNA
o IV drug use (IVDU) gene PCR testing for bacterial meningitis pathogens)
o HIV infection increasingly important in rapid diagnosis
o Diabetes • Focal abscess → immediate CT or MRI for surgery
o Malignancy • Other diagnostic procedures should not delay the initiation of
o Organ transplantation treatment for more than minutes
o Chemotherapy Treatment
• Is there a nidus for invasive infection? • Require close observation, aggressive supportive measures,
o Recent URTI, influenza, or varicella and—in most cases—admission to ICUs
o Prior trauma
o Disruption of cutaneous barriers (lacerations, burns, surgery,
body piercing, or decubiti)
o Foreign bodies (nasal packing, tampons, prosthetic joint)
• May lead to diagnoses that would not otherwise be
considered:
o History of travel
o Contact with pets or other animals
o Activities resulting in tick or mosquito exposure
• Pregnancy might increase the risk and severity of some
illnesses, such as influenza, or increase the risk of significant
morbidity for the fetus, as in Listeria or Zika virus infection
Physical Exam
• General appearance, vital signs, skin and soft tissue exam,
neurological exam are of particular importance
• Px may appear anxious and agitated or lethargic and apathetic
Skin Findings Etiology
Petechial rashes Meningococcemia or Rocky
Mountain spotted fever
Erythroderma TSS or drug fever
Areas of erythema or Necrotizing fasciitis, myositis,
duskiness, edema, tenderness or myonecrosis
Macupapular rashes Usually nonemergent
infections; may be early
meningococcal or rickettsial
Disease
Exanthems Viral
• Fever usually present; elderly px or compromised hosts (uremic,
cirrhotic, taking glucocorticoids or NSAIDs) may be afebrile
• Critically ill patients may be hypothermic, w/ a high risk of organ
failure and mortality
• Airway must be evaluated to rule out the risk of obstruction
from an invasive oropharyngeal infection

Page 1 of 6 Internal Medicine | dz.insignis

 • Empirical antibiotic therapy should be administered without
delay in addition to fluid resuscitation and vasopressor support
as needed
• Surgical attention as needed
• Neurosurgical evaluation for subdural empyema
• Otolaryngologic surgery for possible mucormycosis
• Cardiothoracic surgery for critically ill patients w/ acute
endocarditis
• Necrotizing fasciitis and clostridial myonecrosis → rapid surgical
intervention trumps other diagnostic or therapeutic measures
• Adjunctive treatment may reduce morbidity and mortality rates
o Usually initiated within the first hours of treatment
o Dexamethasone for bacterial meningitis
▪ Given before or at the time of the first dose of antibiotic
o IV immunoglobulin for TSS and necrotizing fasciitis caused by
group A Streptococcus
• Glucocorticoids can be harmful, sometimes resulting in worse
outcomes e.g. setting of cerebral malaria or viral hepatitis
• Brief prodrome of nonspecific symptoms and signs that
progresses quickly to hemodynamic instability w/ hypotension,
tachycardia, tachypnea, respiratory distress, and altered mental
status
• DIC w/ clinical evidence of a hemorrhagic diathesis is a poor
prognostic sign
Septic Shock
• Bacteremia leading to septic shock may have a primary site of
infection (pneumonia, pyelonephritis, cholangitis)
• Elderly px w/ comorbids, hosts compromised by malignancy and
neutropenia, and recent surgery or hospitalization are at
increased risk for an adverse outcome
• Can present as intractable hypertension and multiorgan failure:
o Gram-negative bacteremia (P. aeruginosa or E. coli)
o Gram-positive infection w/ S. aureus (including MRSA) or
group A streptococci
• Treatment can be initiated empirically based on the
presentation, host factors, and local patterns of bacterial
resistance
• Outcomes are worse when antimicrobial treatment is delayed or
pathogen becomes resistant
• Active empirical antimicrobial coverage administered before
admission to the ICU → strong asso. w/ improved survival
o Broad-spectrum antimicrobial agents are therefore
recommended and should be instituted rapidly, preferably
within the first hours after presentation
• Risk factors for fungal infection should be assessed
• Biomarkers (CRP and procalcitonin) not proven reliable
diagnostically but serial measurements can facilitate
appropriate de-escalation of therapy and predict outcome
• Glucocorticoids for severe sepsis who do not respond to fluid
resuscitation and vasopressor therapy
Overwhelming Infection in Asplenic Patients
• Asplenic adult patients succumb to sepsis 58x the rate of the
general population
• Most infections occur within the first 1-2 years, but the
increased risk persists throughout life
• Median interval between splenectomy and sepsis is 5.75 years
(1–19 years)
• Encapsulated bacteria cause majority of infections
• MCC isolate: S. pneumoniae (40-70%)
• Adults are at lower risk vs children
Page 2 of 6
• Risk of infection with H. influenzae or N. meningitidis is also
greater in patients without splenic function
• Other organisms involved E. coli, S. aureus, group B streptococci,
P. aeruginosa, Bordetella holmesii, and Capnocytophaga,
Babesia, and Plasmodium
Babesiosis
• If (+) history of recent travel to endemic areas, infection w/
Babesia is considered
• 1-4 weeks after a tick bite → chills, fatigue, anorexia, myalgia,
arthralgia, shortness of breath, nausea, and headache
o Ecchymosis and/or petechiae are occasionally seen
• Ixodes scapularis—MC tick transmitting Babesia, but also
transmits Borrelia burgdorferi and Anaplasma
o Co-infection → more severe disease
• European species Babesia divergens is more frequently
fulminant than U.S. species Babesia microti
• B. divergens → febrile syndrome with hemolysis, jaundice,
hemoglobinemia, and renal failure; mortality rate of >40%
• Severe babesiosis is especially common in asplenic hosts but
can occur in normal splenic function (>60 yo and
immunosuppressive conditions)
• Complications: renal failure, acute respiratory failure, and DIC
Other Sepsis Syndromes
• Tularemia (Francisella tularensis)—associated w/ wild rabbit,
tick, and tabanid fly contact
• Can be transmitted by arthropod bite, handling of infected
animal carcasses, consumption of contaminated food and
water, or inhalation
• Typhoidal form—gram-negative septic shock and a mortality
rate of >30% esp. among w/ comorbids and immunosuppression
• 90% of plague (Yersinia pestis) cases occur in Africa
• Septic form—shock, multiorgan failure, 30% mortality rate
• CDC considers F. tularensis, Y. pestis, and B. anthracis as
potential bioweapons
Sepsis w/ Skin Manifestations
• Primary HIV infection—rash typically maculopapular involving
upper part of body but can spread to palms and soles
o Usually febrile, can have lymphadenopathy, severe headache,
dysphagia, diarrhea, myalgias, and arthralgias
• Petechial rashes caused by viruses
o Seldom asso. w/ hypotension or toxic appearance, except for
severe measles or arboviral infection
• Petechial rashes limited to distribution of the SVC rarely asso.
w/ severe disease
Meningococcemia
• ~75% of patients w/ N. meningitides bacteremia have a rash
• Most often affects young children i.e. 6 mos-5 years old
• Sub-Saharan Africa is known as the “meningitis belt” due to
thousands of deaths annually
o Epidemic waves occur every 8–12 years
o W135 and X serogroups—important emerging pathogens
• USA: cases mostly from day-care centers, schools, army
barracks
• Household contacts of index cases are at 400–800x greater
risk of disease than the general population
• Fever, headache, nausea, vomiting, myalgias, changes in mental
status, and meningismus
• Rapidly progressive form of disease (10-20% of cases) is not
usually asso. w/ meningitis
• Rash: initially pink, blanching, and maculopapular, appearing on
the trunk and extremities, but then becomes hemorrhagic,
becoming petechiae
• Petechiae—first seen at the ankles, wrists, axillae, mucosal
surfaces, and palpebral and bulbar conjunctiva, w/ subsequent
spread on the lower extremities and to the trunk
Internal Medicine | dz.insignis
 o Becomes purpuric in rapidly progressive meninggococcemia
→ DIC, multiorgan failure, shock → 50-60% mortality rate, w/
survivors requiring extensive debridement or amputation of
gangrenous extremities
• Associated w/ fatal outcomes:
o Hypotension w/ petechiae for <12 h
o Cyanosis
o Coma
o Oliguria
o Metabolic acidosis
o Elevated partial thromboplastin time
• Early initiation of treatment (antibiotics) before hospital
admission may improve diagnosis and be life-saving
• Meningococcal conjugated vaccines
o Protective against serogroups A, B, C, Y and W135
o A, C, Y and W135 — recommended for children 11–18 years of
age and for other
o B — recommended for high-risk individuals >10 years of age
Rickettsial Diseases
Rocky Mountain Spotted Fever (RMSF) is a tickborne disease
caused by Rickettsia rickettsia
• 40% have no history of tick bite → history of travel or outdoor
activity can be determined
• First 3 days: headache, fever, malaise, myalgias, nausea,
vomiting, and anorexia
• Day 3: 50% have skin findings:
o Blanching macules initially on the wrists and ankles and then
spread over the legs and trunk
o Lesions become hemorrhagic and are frequently petechial
o The rash spreads to palms and soles later in the course
o 10-15% never develop a rash
• The centripetal spread is a classic feature of RMSF but occurs
in a minority of patients
• Px can be hypotensive and develop noncardiogenic pulmonary
edema, confusion, lethargy, and encephalitis progressing to
coma
• CSF findings include 10-100 cell/µL, glucose often normal,
protein slightly elevated
• At a 3-5x risk of death are Native Americans, children 5–9 yo,
adults >70 yo, and persons with underlying immunosuppression
Mediterranean spotted fever caused by Rickettsia conorii is found
in Africa, southwestern and southcentral Asia, and southern Europe
• Fever, flu-like symptoms, and an inoculation eschar at the site
of the tick bite
• Maculopapular rash develops within 1–7 days, involving the
palms and soles but sparing the face
• Elderly patients or those with diabetes, alcoholism, uremia, or
CHF are at risk for severe disease
o Neurologic involvement, respiratory distress, and gangrene of
the digits or purpura fulminans
o Mortality rate 50%
Epidemic typhus, caused by Rickettsia prowazekii, is transmitted in
louse-infested environments and emerges in conditions of extreme
poverty, war, and natural disaster
• Sudden onset of high fevers, severe headache, cough, myalgias,
and abdominal pain.
• Maculopapular rash develops (primarily on the trunk) in >50%
and can progress to petechiae and purpura
• Serious signs include delirium, coma, seizures, noncardiogenic
pulmonary edema, skin necrosis, and peripheral gangrene
• Mortality rates 60% (preantibiotic era), >10–15% (contemporary
outbreaks)
Scrub typhus, caused by Orientia tsutsugamushi (a separate genus
in the family Rickettsiaceae)
• Transmitted by larval mites or chiggers
• One of the MC infections in SEA and the western Pacific
Page 3 of 6
• Organism is found in areas of heavy scrub vegetation
• Hx & PE: inoculation eschar, maculopapular rash,
lymphadenopathy, dyspnea may be found
• Severe cases progress to pneumonia, meningoencephalitis,
myocarditis, DIC, and renal failure
• Mortality rate 1-70% and vary by location, increasing age,
myocarditis, delirium, pneumonitis, or signs of hemorrhage.
If recognized early, rickettsial disease is very responsive to
treatment
• Doxycycline (100 mg twice daily for 3–14 days) is the
treatment of choice for both adults and children
• Newer macrolides may be used, but mortality rates are higher
when tetracycline-based treatment is not given
Purpura Fulminans
• The cutaneous manifestation of DIC, presenting as large
ecchymotic areas and hemorrhagic bullae
• Mainly asso. w/ N. meningitides but in splenectomized px can be
caused by S. pneumoniae, H. influenza, and S. aureus
• Progression of petechiae to purpura, ecchymoses, and
gangrene is asso. w/ CHF, septic shock, acute renal failure,
acidosis, hypoxia, hypotension, and death
Ecthyma Gangrenosum
• Seen in septic shock d/t P. aeruginosa or Aeromonas hydrophila
• Hemorrhagic vesicles surrounded by a rim of erythema with
central necrosis and ulceration
• Gram-negative bacteremia are MC among px w/ neutropenia,
extensive burns, and hypogammaglobulinemia
Other Infections Asso. w/ Rash
Noncholera Vibrio bacteremia (e.g. Vibrio vulnificus)
• Focal skin lesions and overwhelming sepsis in hosts with chronic
liver disease, heavy alcohol consumption, iron storage disorders,
diabetes, renal insufficiency, hematologic disease, or
malignancy or other immunocompromising conditions
• After ingestion of contaminated raw shellfish → sudden onset
of malaise, chills, fever, and hypotension
• Bullous or hemorrhagic skin lesions, usually on the lower
extremities, and 75% of patients have leg pain
• Mortality rate as high as 50–60%, particularly when (+)
hypotension
• Treatment: fluoroquinolones with or without cephalosporins or
with tetracycline-containing regimens
Aeromonas, Klebsiella, and E. coli → hemorrhagic bullae and death
due to overwhelming sepsis in cirrhotic patients
Capnocytophaga canimorsus → septic shock in asplenic patients
• Infection usually follows a dog bite
• Fever, chills, myalgia, vomiting, diarrhea, dyspnea, confusion, and
headache
• Exanthem or erythema multiforme, cyanotic mottling or
peripheral cyanosis, petechiae, and ecchymosis
• 30% w/ the fulminant form die of sepsis and DIC
• Survivors may require amputation because of gangrene
Erythroderma
• TSS is usually associated w/ erythroderma, which is more
common in cases caused by Staphylococcus
• Fever, malaise, myalgias, nausea, vomiting, diarrhea, and
confusion
• Sunburn-type rash that is usually diffuse and found on the face,
trunk and extremities
• Desquamates after 1–2 weeks
Staphylococcal TSS
• Hypotension develops rapidly (within hrs) after the onset of
symptoms but may preceded by early renal failure, which
distinguishes this from other septic shock syndromes
• Cutaneous or mucosal entry for organism
Internal Medicine | dz.insignis
 • Colonization rather than overt infection of the vagina or a
postoperative wound, is typical w/ staphylococcal TSS, and the
mucosal areas appear hyperemic but not infected
Streptococcal TSS
• More often associated w/ skin or soft tissue infection (including
necrotizing fasciitis); px more likely to be bacteremic
TSS caused by Clostridium sordellii is asso. w/ childbirth or with
skin injection of black-tar heroin
Diagnosis and treatment of TSS
• Clinical criteria of fever, rash, hypotension, and multiorgan
involvement
• Fever is typically absent if d/t C. sordellii
• Mortality rate
o 5% menstruation-associated TSS
o 10–15% for nonmenstrual TSS
o 30–70% for streptococcal TSS
o 90% for obstetric C. sordellii TSS
• Clindamycin, IVIG improves outcomes
Viral Hemorrhagic Fevers
• Zoonotic illnesses caused by viruses that reside in either animal
reservoirs or arthropod vectors
• Worldwide incidence, restricted to areas where host species live
• Caused by four major groups:
Arenaviridae Lassa fever
Bunyaviridae Rift Valley fever, hantavirus
hemorrhagic fever with renal
syndrome, Crimean-Congo
hemorrhagic fever
Filoviridae Ebola and Marburg virus
Flaviviridae Yellow fever, dengue
• Lassa fever, dengue, yellow fever → also transmitted person to
person
• The vectors for most viral fevers are found in rural areas, except
for dengue and yellow fever
• Prodrome of fever, myalgias, and malaise
• Px then develop evidence of vascular damage, petechiae, and
local hemorrhage
• Shock, multifocal hemorrhaging, and neurologic signs (e.g.,
seizures or coma) → poor prognosis
• Dengue is the MC arboviral disease worldwide
o >500,000 DHF cases annually, w/ at least 12,000 deaths
o Triad of hemorrhagic manifestations, evidence of plasma
leakage, and platelet counts of <100,000/μL
o Mortality rate 10-20%; 40% if (+) dengue shock syndrome
• Ebola infection
o 2014 outbreak in West Africa had a mortality rate of >50%
o Most patients become ill within 9 days (2–21 days)
o First presents w/ fatigue, fever, headache, and muscle pains,
and the illness can progress to multiorgan failure and
hemorrhaging
o Careful volume-replacement is key to survival
o Ribavirin also may be useful against Arenaviridae and
Bunyaviridae
• Viral illness w/ rash e.g. measles can have high mortality rates
• Steroids sometimes useful in severe disease in malnourished
populations, especially if (+) neurologic complications
Necrotizing Fasciitis
• Infection characterized by extensive necrosis of the
subcutaneous tissue and fascia
• May arise from:
o Minimal trauma or surgical incision
o Recent varicella
o Childbirth
o Muscle strain
• MCC: group A streptococci alone and a mixed facultative and
anaerobic flora
• DM, IVDU, chronic liver or renal disease are asso. risk factors
• PE: soft tissue edema and erythema
• Infected area is red, hot, shiny, swollen, and exquisitely tender
• Untreated infection → blue-gray patches develop after 36h →
cutaneous bullae and necrosis after 3-5 days
• Necrotizing fasciitis d/t mixed flora can be asso. w/ gas
production
• Decreased pain, d/t thrombosis of the small blood vessels and
destruction of the peripheral nerves, is an ominous sign
• Mortality rates
o 15–34% overall
o >70% in association w/ TSS
o ~100% without surgical intervention
• Clostridium perfringens may also cause NF
o Px is extremely toxic; mortality rate is high
o Within 48h, rapid tissue invasion and systemic toxicity
associated w/ hemolysis and death ensue
o Muscle biopsy to distinguish this and clostridial myonecrosis.
• Necrotizing fasciitis caused by CA-MRSA also has been reported
Clostridial Myonecrosis
• Myonecrosis often associated with trauma or surgery but can
develop spontaneously
• Incubation period usually 12–24h, w/ massive necrotizing
gangrene develops within hours of onset
• Systemic toxicity, shock, and death can occur within 12 h
• Px’s pain and toxic appearance are out of proportion to PE
• PE: febrile, apathetic, tachycardic, and tachypneic and may
express a feeling of impending doom
• Hypotension and renal failure develop later, and hyperalertness
is evident preterminally
• Skin over the affected area is bronze-brown, mottled, and
edematous
• Bullous lesions with serosanguineous drainage and a mousy or
sweet odor can develop
• Crepitus can occur secondary to gas production in muscle tissue
• Mortality rates
o >65% for spontaneous myonecrosis (often associated w/ C.
septicum or C. tertium and malignancy
o 63% trunk infection
o 12% limb infection
Bacterial Meningitis
• One of the MC infectious disease emergencies of the CNS
• Most cases in adults are d/t S. pneumoniae (30–60%) and N.
meningitidis (10–35%)
• Listeria monocytogenes meningitis is a risk for hosts w/ cell-
mediated immune deficiency
• Classic presentation of fever, meningismus, and altered
mental status is seen in only one-half to two-thirds of patients
• Elderly can present without fever or meningeal signs
• Cerebral dysfunction → confusion, delirium, and lethargy that
can progress to coma
• Fulminant presentation w/ sepsis and brain edema
• Papilledema unusual and suggests another dx
• Focal signs, including CN palsies (IV, VI, VII) in 10-20% of cases

Page 4 of 6 Internal Medicine | dz.insignis

 • 50-70% have bacteremia
• Poor outcome is asso. w/:
o Coma, seizures
o Hypotension
o Pneumococcal etiology
o Respiratory distress
o CSF glucose <0.6 mmol/L (<10 mg/dL)
o CSF protein level of >2.5 g/L
o Peripheral WBC count of <5000/μL
o Serum sodium <135 mmol/L
• Odds of an unfavorable outcome may increase by 30% for each
hour that treatment is delayed
• Dexamethasone is an adjunctive treatment of meningitis in
adults, esp. if caused by S. pneumoniae
o Must be given before or w/ the first dose of antibiotic
Suppurative Intracranial Infections
• Rare intracranial lesions present along with sepsis and
hemodynamic instability
• Rapid recognition of the toxic px and central neurologic signs
improves the dismal prognosis
• Px w/ DM or hematologic disease at ↑risk for these infections
Subdural empyema arises from the paranasal sinus in 60–70% of
cases
• Microaerophilic streptococci and staphylococci are the
predominant etiologic organisms
• Toxic, with fever, headache, and nuchal rigidity
• 75% have focal signs and 6–20% die
• 15–44% of patients are left with permanent neurologic deficits
Septic cavernous sinus thrombosis follows a facial or sphenoid
sinus infection
• 70% of cases d/t staphylococci (including MRSA), and the rest d/t
aerobic or anaerobic streptococci
Fungi have been common in some series
• Unilateral or retro-orbital headache progresses to a toxic
appearance and fever within days
• 75% patients have unilateral periorbital edema that becomes
bilateral and then progresses to ptosis, proptosis,
ophthalmoplegia, and papilledema
• Mortality rate as high as 30%
Septic thrombosis of the superior sagittal sinus
• Spreads from the ethmoid or maxillary sinuses
• Caused by S. pneumoniae, other streptococci, and staphylococci
• Fulminant course → headache, nausea, vomiting, rapid
progression to confusion and coma, nuchal rigidity, and
brainstem signs
• If sinus totally thrombosed → mortality rate >80%
• Broad-spectrum antibiotics and early surgical intervention at
the primary site of infection may improve outcomes
• Anticoagulation or steroids are of uncertain benefit
Brain Abscess
• Often occurs without systemic signs.: ~50% of px are afebrile,
and presentations are more consistent with a space-occupying
lesion in the brain
• 70% of patients have headache and/or altered mental status
• 50% have focal neurologic signs, 25% have papilledema
• Abscesses can be single or multiple lesions resulting from
contiguous foci or hematogenous infection (endocarditis, or
after surgery or trauma)
• The infection progresses over several days from cerebritis to an
abscess with a mature capsule
• ~50% of infections are polymicrobial, with an etiology
consisting of aerobic bacteria (primarily strep) and anaerobes
• Abscesses arising hematogenously tend to rupture into the
ventricular space → sudden and severe deterioration in clinical
status and a high mortality rate
• Otherwise, mortality is low (<20%) but morbidity is high (30-55%)
Page 5 of 6
• Presenting with stroke and a parameningeal infectious focus,
such as sinusitis or otitis → may have a brain abscess →
physicians must maintain a high level of suspicion
• Prognosis worsens in patients with a fulminant course, delayed
diagnosis, abscess rupture into the ventricles, multiple
abscesses, or abnormal neurologic status at presentation
• In one study, mortality at 1 year was 19%
Cerebral Malaria
• Urgently considered in px w/ recent travel to areas endemic for
malaria presenting w/ a febrile illness and lethargy or other
neurologic signs
• Fulminant malaria is caused by Plasmodium falciparum and is
associated with temp. of >40°C, hypotension, jaundice, acute
respiratory distress syndrome, and bleeding
• Any patient with a change in mental status or repeated
seizure in the setting of fulminant malaria has cerebral malaria
• In adults, this nonspecific febrile illness progresses to coma
over several days; occasionally, coma occurs within hours and
death within 24 h
• Nuchal rigidity and photophobia are rare
• PE: encephalopathy is typical; UMN dysfunction w/ decorticate
and decerebrate posturing seen in advanced disease
• Unrecognized infection results in a 20–30% mortality rate
Intracranial and Spinal Epidural Abscesses
• Spinal and intracranial epidural abscesses (SEAs and ICEAs) can
result in permanent neurologic deficits, sepsis, and death
• At-risk include those with DM; IV drug use; chronic alcohol
abuse; recent spinal trauma, surgery, or epidural anesthesia; HIV
infection
• Fungal epidural abscess and meningitis can follow epidural or
paraspinal glucocorticoid injections
• In areas of limited access to health care, SEAs and ICEAs cause
significant morbidity and mortality
ICEAs SEAs
Fever, mental status changes, Fever, localized spinal
and neck pain tenderness, and back pain
Polymicrobial Due to hematogenous seeding
(Staph MC agent)
• Early diagnosis and treatment, which may include surgical
drainage
• Outcomes are worse for:
o SEA due to MRSA
o Infection at a higher vertebral-body level
o Impaired neurologic status on presentation
o Dorsal rather than ventral location of the abscess
o Elderly patients and persons with renal failure, malignancy,
and other comorbidities
• Infection at any 1° focus can result in bacteremia and sepsis
• Lemierre’s syndrome, jugular septic thrombophlebitis caused
by Fusobacterium necrophorum, is associated with metastatic
infectious emboli (primarily to the lung but sometimes to the
liver or other organs) and sepsis, with mortality rates of >15%
• TSS → septic arthritis, peritonitis, sinusitis, and wound infection
• Destruction of the primary site of infection as in endocarditis
and oropharyngeal infections can lead to rapid clinical
deterioration and death
Invasive Rhinocerebral Mucormycosis
• Those w/ DM, immunocompromising conditions are at risk
• Low-grade fever, dull sinus pain, diplopia, decreased mental
status, decreased ocular motion, chemosis, proptosis, dusky or
Internal Medicine | dz.insignis
 necrotic nasal turbinates, and necrotic hard-palate lesions that
do not cross the midline
• >50-85% mortality rate if not detected and treated early
• Uncontrolled DM and increasing age are negative prognostic
factors
Acute Bacterial Endocarditis
• More aggressive course than subacute endocarditis
• S. aureus, S. pneumoniae, L. monocytogenes, Haemophilus
species, and streptococci of groups A, B, and G attack native
valves
• Native-valve endocarditis caused by nosocomial S. aureus
(including MRSA) is increasing
• Mortality rate 10-40%
• Fever, fatigue, and malaise <2 weeks after onset of infection
• PE: changing murmur and CHF, Janeway lesions (hemorrhagic
macules on palms or soles
• Older patients with S. aureus endocarditis likely present with
nonspecific symptoms
• Petechiae, Roth’s spots, splinter hemorrhages, and
splenomegaly are unusual
• Destruction of the aortic valve → pulmonary edema and
hypotension
• Myocardial abscesses can form, eroding through the septum or
into the conduction system and causing life-threatening
arrhythmias or high-degree conduction block
• Large friable vegetations can result in major arterial emboli,
metastatic infection, or tissue infarction
• Rapid intervention is crucial for a successful outcome
Inhalational Anthrax
• The most severe form of disease caused by B. anthracis, which
was used as a bioweapon in the 2001 Anthrax attacks
• Malaise, fever, cough, nausea, drenching sweats, shortness of
breath, and headache; rhinorrhea was unusual
• All patients had abnormal chest roentgenograms at
presentation, w/ the MC findings: pulmonary infiltrates,
mediastinal widening, pleural effusions
• Hemorrhagic meningitis in 38%
• Survival more likely when antibiotics given during the
prodromal period and when multidrug regimens were used
• Delayed intervention → hypotension, cyanosis, and death
Viral Respiratory Tract Illness
• For px who present w/ a respiratory illness + exposure and travel
history, these viral illnesses must be considered
Avian and Swine Influenza
Avian influenza has occurred primarily in SEA; Vietnam (H5N1) and
China (H7N9)
• Should be considered in px w/ severe RTI + exposed to poultry
• High fever, an influenza-like illness, and LRT symptoms
• Can progress rapidly to bilateral pneumonia, ARDS, multiorgan
failure, and death
• Younger age → lower risk of complications
• Mgmt: early tx w/ neuraminidase inhibitors along with
aggressive supportive measures
Swine influenza has more established human-to-human
transmission
• A/H1N1 virus has spread rapidly; by 2012, 214 countries have
cases, w/ 18,449 deaths
• Most at risk for severe disease are children <5 years of age,
elderly persons, patients with underlying chronic conditions,
and pregnant women, and obesity
• Immunosuppression and co-infection with S. aureus at
presentation are independent risk factors for increased
mortality
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SARS and MERS
SARS, caused by a coronavirus, was identified in 2002 in China but
has been diagnosed elsewhere, mainly Asia
• Possible animal reservoirs include bats and civets
• Characterized by efficient human transmission but relatively
low mortality
• MOT: person to person via droplets; “super-spreader” airborne
events
• The 2002 pandemic was controlled through identification and
isolation of infected patients
• A 3- to 7-day prodrome characterized by fever, malaise,
headache, and myalgia can progress to nonproductive cough,
dyspnea, and respiratory failure
o Risk of contagion is low during the prodrome
• Older patients and those w/ DM, chronic hepatitis B, and other
comorbidities can have less favorable outcomes
Middle East respiratory syndrome is caused by novel ß-
coronavirus, first recognized in 2012 in Saudi Arabia
• Human cases asso. w/ direct and indirect contact w/ dromedary
camels
• Inefficient human transmission but carries a high mortality rate
• As of 2015: 1180 cases, 40% mortality
• Ranges from asymptomatic infection to ARDS, multiorgan
failure, and death
• At highest risk for poor outcomes: elderly men w/ comorbidities
• Nosocomial infection must be prevented by adherence to strict
infection control practices
• Currently a low-level public health threat, unless the virus
mutates and its transmissibility increases
Hantavirus Pulmonary Syndrome
• High mortality
• Hantaviruses are single-stranded RNA viruses
• Most cases occur in rural areas and are associated with
exposure to rodents
• Nonspecific viral prodrome of fever, malaise, myalgias, nausea,
vomiting, and dizziness that may progress to pulmonary edema,
respiratory failure, and death
• Causes myocardial depression and increased pulmonary
vascular permeability, thus the need for careful fluid
resuscitation and use of pressor agents
• Early onset of thrombocytopenia may help distinguish this
syndrome from other febrile illnesses
Clostridium difficile Infection (CDI)
• Toxin-mediated diarrheal syndrome strongly associated w/
prior antibiotic use; PPIs are a potential risk factor
• One of the top 3 health threats asso. w/ antibiotic use (CDC)
• Almost all cases of CDI occurred in the health care setting, but
community-onset CDI is increasing
• Community-onset CDI less likely to have hx of antibiotic/PPI use
• Community-onset cases occur in younger patients than
nosocomial cases
• Associated w/ significant morbidity and mortality, particularly
among older patients
Internal Medicine | dz.insignis