:Meningitis

:Cp

Neck stiffness…..key word

Fever, headache

Maculopapular rash

Photophobia, papiloedema

:INV

First step………CT NOT LP …..VVVVVVVV IMP

Second step……..LP

……Labs
terpretation of abnormal results
  White cell count Biochemistry

Neutrophils Lymphocytes Protein Glucose

(x 10  /L)
6
(x 10 /L)
6
(g/L) (CSF:blood
ratio)

Normal 0 ≤5 < 0.4 ≥ 0.6 (or ≥ 2.5

(>1 month of mmol/L)
age)

Normal term 0*   < 20 < 1.0 ≥ 0.6 (or ≥ 2.5

neonate mmol/L)

Bacterial 100-10,000 Usually < 100 > 1.0 < 0.4

meningitis (but may be (but may be (but may be
normal) normal) normal)

Viral Usually <100 10-1000 0.4-1 Usually normal

meningitis (but may be (but may be
normal) normal)

TB Usually <100 50-1000 1-5 < 0.3

meningitis
TTT: Best initial ttt…..cefotriaxone, vancomycin and steroid
Very imp tips vvvvvvvvvvvvvvvvvvvvvvvvvvvv imp

:Most common cause of meningitis in these age groups

Newly born up to 1 month…….Group B streptococcus

Children……strep. Pneumonia

Adult………….. Nisseria meningitides

Eldery……….. strep. Pneumonia

First step in kid with signs of meningitis….Iv cefotriaxone or iv

penicillin

If you have to choose one of them……Iv cefotriaxone

If you suspect meningitis:….vvvvvvvvvvv imp

First step……….blood culture
Second step………empirical antibiotics
Third step……….brain CT
Fourth step……..lumbar puncture
Bacterial meningitis…..marked increased neutrophils

Viral meningitis……..lymphocytosis

Herpes encephalitis……RBC's

TB meningitis……..increased protein

Petechial rash over the body = meningococcus

Most common neurological sequale after meningitis….deafness

Marked drop of blood pressure after meningitis…..acute

adrenal crisis( water house friedreichson's syndrome)

:Main ttt of
Viral meningitis…….supportive

Herpes………iv acyclovie

TB meningitis……steroid and antituberculous drugs

Acute adrenal crisis……steroid

:Prophylaxis of the contact

Who requires prophlylaxis?

 All intimate, household or daycare contacts who have been

exposed to Index Case within 10 days of onset.

1st line……………rifampicin

2nd line………….ciprofloxacin

:Encephalitis

Most common cause……herpes simplex

Second most common …… Enteroviruses ( coxackie)

Most common symptom of encephalitis…..confusion

LP of herpes encephalitis…..RBC's in the CSF…vvvvvvvvvvv imp

Main ttt of herpes encephalitis…..iv acyclovir

:Sinusitis

Fever

Headache

Pain and tenderness over the sinus….key word

Post nasal discharge

Diagnosis….CT is the best

TTT……amoxicillin clavulanate for 10 days …the best

Most common affected sinus…..maxillary….vvvvv imp

:Pharyngitis and tonsillitis

:Main key words of bacterial pharyngitis

Bad general condition

High grade fever

Whitish spots (pus)

Marked lymphadenopathy
At the clinic…..rapid strep test

Best confirmatory……culture

:TTT

AMOX- CLAV……the best

:Complications

rheumatic fever-1

post strep. Glomerulonephritis-2

peritonsillar abscess-3

How to diagnose??......deviation on the uvula

to opposite side

If causes severe respiratory stress…….intubation

TTT…..aspiration then removal of the tonsil after 4 weeks

?????Indication for tonsillectomy

??? Key word for viral pharyngitis

Low grade fever

Good general condition

Redness of pharynx

TTT…..supportive……….NO antibiotics

:Influenza

Cp: Fever, myalgia, chills, cough, coryza

Investigations: imp

Nasopharyngeal aspiration……..very fast

Viral culture……..confirmatory

:Anitiviral

Oseltamivir, neuraminidase or zanamivir

When??......only first 48th hours

Value……decrease the duration of the symptoms

What if after 48th hours??......only symptomatic ttt

Vaccination:………….. Type…..inactivated virus

Frequency………every year vvvv imp

Route………IM

?For who

Old age vvv imp

Children and Chronic diseases e:g: DM, HIV

 HIV

:Risk factors

Drug abuse

Unprotected sex (vaginal, oral or anal)

Gays

Transfusion

perinatal

:Cp
History of travel to Thailand vvvvvvvvvv imp

:Flu like syndrome

Fever

Fatigue, sore throat, lymphadenopathy

Headache

Recurrent infections

CNS……lymphoma and toxoplasma

:Tests

ELISA……highly sensitive but not specific

Western blot……confirmatory

:TTT

Combination from two transcriptase inhibitors and one

protease inhibitior

:Route of transmission
Most common route of HIV in Australia…..homosexual

Most common type of sex liable to HIV…..anal followed by oral

Hardest type of sex to transmit HIV…….vaginal

Does kissing transmit HIV……noooooo

:Most common cause of the following with HIV

Pneumonia……..pneumicystitis carnii

Diarrhea……….cryptosporidium

Esophagitis……..CMV

Blindness………CMV

Meningitis…..cryptococcus

TTT of pneumicystitis carnii……..trimethoprim sulpha

:HIV and pregnancy

During pregnancy…….mom takes antiretroviral therapy

During labor……..CS

After labor……give baby zidovudine for 6 weeks

Breast feeding …….nooooooo

:Imp tips for HIV

Most imp history…….travel to Thailand

ELISA (+) and western blot (-)…..false positive

Contact with prostitutes now maculopapular rash,
lymphadenopathy, sore throat and atypical lymphocytosis……….HIV
Recurrent oral and vaginal candidiasis….exclude HIV

Post exposure prophylaxis to HIV…..start therapy till the results

are back

Any patient coming from Thailand any symptom…..HIV until

proved otherwise

:HIV associated lesions #

:PRIMARY CNS LYMPHOMA .1.

Solitary

TOXOPLASMOSIS .2.

Multiple

:PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY .3.

 :Syphilis

Organism…….treponema pallidum

:Stages

:Primary synphilis-1

Chancre……..painless ulcer with indurated edge

Best inv……..biopsy

Do you need blood tests …..noooo

Examination under….dark field microscopy….visualization of

the organism

TTT…….iv single dose of penicillin

Prognosis……heal spontaneously even without ttt

:Secondary-2

Maculopapular rash

Generalizaed lymphadenopathy

Mucous patches

Condyloma lata

VDRL or RPR……sensitive

FTA-ABS………..Specific

:TTT

Single dose iv penicillin

:Tertiary stage-3

Tabes dorsalis

Argyl Robertson pubil

Aortitis

TTT…..iv penicillin

What if patient is allergic to the penicillin?...doxycyclin

:Imp tips

Painless ulcer on genitalia…..syphilis until proved other wise

Inv of chancre……biopsy not blood tests

Painful ulcer on genitalia…………Herpes simplex

Inv of choice for herpes simplex…….PCR

Key word for primary syphilis……chancre

Key word for secondary syphilis….generalized

lymphadenopathy and maculopapular patches

Patient with rash and alopecia with history of sexual contact……

syphilis
Main ttt of syphilis……iv single dose penicillin

Condyloma lata……syphilis

Condyloma accuminata……HPV

Organism causing syphilis…….treponema pallidum

???What is jarish-Herxheimer reaction

Fever and headache after giving penicillin

TTT…..aspirin and antipyretic

:UTI

:Cystitis

:Cp

Suprapubic pain…….key word

Urgency, frequency and dysuria

Mild or absent fever…..DD

pyelonephritis

:Investigation

Best initial…..urine analysis

Best confirmatory…..urine culture
Nitites or leucocytes in urine = infection ..if NO symptoms = NO TTT

TTT: BEST…….trimethoprim sulpha

:Very important tips

Most common organism of UTI……E-COLI

Key word of cystitis……suprapubic pain with no fever

Key word of pyelonephritis….very high fever, chills, flank pain

What you will see in urine analysis….WBC'S more than 10

What you will see in urine culture….E-COLI more than 100.000

Why female is at higher risk of UTI….short urethra

Why pregnancy at high risk…..progesterone relax ligaments

:Collection of sample

Adult…..mid stream collection

???How to collect urine samples in pediatrics

If more than 4 years……mid stream collection

If younger esp, less than 1 year…..suprapubic aspiration

If failed….catheterization

N:B: Most accurate way to collect urine sample….suprapubic

aspiration….imp

:When to say (+) sample

Wbc's ( pus cells)…..more than 10

E-coli……..more than 100.000

Further investigation to children…..US is a must

If recurrent UTI…..micturiting cystourethrography

:UTI antibiotics
:Normal people -1
:Cystitis
1st line……….TMP-sulpha
2nd line……….amoxycillin or cephalosporin
:Pyelonephritis
Cefotriaxone….1st line OR
amox+gentamicin OR
pipracilin + tazopactam(tazocin)

:KIDS-2
1st line……….trimeothoprim
2nd line………cephalaxin = amoxycillin
3rd line……….nitrofurantoin
: Renal failure-3
1st line…………ciprofloxacin
2nd line…………cephalosporin
3rd line…………Trimethoprim sulpha
: In pregnant -4
Cystitis
nitrofurantoin
cephalexin
amoxclav
:Urosepsis

Most common cause of fever after urology procedure…bacteremia

Empirical antibiotics……….amoxycillin and gentamycin

:Pyelonephritis NOT responding to ttt

1st inv……US

Inc of choice………CT

Infectious mononucleosis…vvvvvvvvvvvvvvvvvvvvvvv imp

Organism……..EBV

flu like + hepatosplenomegaly

Triad of the disease….young patient with fever, sore throat and

lymphadenopathy
Tonsil…….very enlarged( kissing disease)
Most common lymph node affected….posteroir cervical
:Complications

Cancer……lymphoma and nasopharyngeal carcinoma

Liver…..hepatitis…..jaundice

Spleen…….rupture….vvvvvvvv imp

Blood……….auto immune Hemolytic anemia

Airway…..obstruction with enlarged tonsil

:Investigations

EBV antigen…….the most specific

Monospot test ….heterophil antibody….vvvvvvv imp

Lymphocytosis…..atypical lymphocytes…vvvvvv imp

What if monospot test is (-) and atypical lymphocytes are (+)……

CMV

:Management

Only supportive

If very enlarged tonsil…..cortisone

Infectious mononucleosis and ampicillin????.. imp

Cp…..maculopapular rash

When...after 24 hours

TTT...stop the ampicillin

chronic fatigue syndrome??........vvvvvvvvvvvvvvvv imp

history…….flu like illness

Duration…..minimum 6 months

Cause…..EBV

Fatigue:

New onset severe 

 Unrelated to exertion

not relieved by rest….. imp

Not a result of other medical conditions.

The fatigue causes a significant reduction of previous

activity levels.

 impaired memory or concentration
 post-exertional malaise
 un refreshing sleep
 muscle pain (myalgia)
 pain in multiple joints (arthralgia)
 headaches 
 sore throat
 tender lymph nodes (cervical or axillary)

 depression 

Cognitive behavioural therapy….TTT of choice 

graded exercise therapy

N:B: pain in her joints. feeling tired all the time and poor memory,
lost appetite nauseate sensation………chronic fatigue syndrome
Most imp advise to the patient…vvvvvvvvvvvv imp

Avoid sport contact

Till when………….till recovery




???? CAT BITE VS CAT SCRATCH DISEASE 
:Cat scratch 
Organism…….bartonella hernesale 
Cp……just skin scratches 
Lymphadenopathy……key word 
TTT: Azithromycin in severe cases 
:Cat bite 
Organism…….pasterulla multocoida 
Cp………cellulitis like ( marked swelling, redness and pain) 
No lympadenopathy ….vvvvvvv imp 
 TTT………..penicillin
:Human bites 
 Much worse than animal bites
clean and debride the wound-1 
give prophylactic penicillin and -2 
tetanus toxoid
hepatitis B and HIV infection -3 
prophylaxis
NO suturing………. imp-4-3 

:Jelly fish stinges

:Types

:Blue bottle-1
 Most common

 Common to most southeastern Australian beaches

Very painful but very begnin

:First aid

 Wash sting site and remove tentacles

 Hot water immersion (45°C for 20
minutes*)
 Avoid vinegar as it may worsen the pain

Need of hospital transfer…..noooo

:major box-2

:First aid

 Apply vinegar and remove tentacles

Transport to hospital for: Consider antivenom in patients with

cardiovascular collapse

Snake bite:

Majority of snakes are…..non poisonous

Do not:
 Cut a bite wound
 Attempt to suck out venom
 Apply tourniquet, No ice, no water
 Give the person alcohol or caffeinated drinks

Cp: Just minor pain and redness in over 90% of cases

  nausea and vomiting, diarrhea
 anaphylaxis 
  ,necrosis, severe internal bleeding, kidney failure,
and respiratory failure
 coagulopathy …..
 neurotoxicity……… vision blurriness and parathesia
investigation:
Best……..biopsy from the bite… imp
Second …..Urine
First aid in snake bites……….bandage

TTT….antivenom…..only if symptoms appear…

vvv imp
Risk of antivenom…..severe anaphylaxis and death

When to consider transfer to tertiary centre

Envenomed children should be considered for transfer to a
tertiary

: Otitis externa
Cause…..pseudomonas aeuroginosa

Risk factor……swimming in a pool

Pain the ear movement

TTT…..antibiotic and steroid

:Malignant otitis externa

Occurs in DM

Infiltration of facial nerve……….facial nerve palsy……VVVVV IMP

TTT………..debridement

:RAMSAY HUNT SYNDROME

Cause…….herpes zoster

Painful Vesicular rash in and around ear

Risk,….facial nerve palsy

TTT…..acyclovir
:Take care plz

Ear discharge + facial nerve palsy = malignant otitis

Vesicles + facial nerve palsy = ramsay hunt syndrome

Q-fever:
Organism…… Coxiella burnetii
Source.......cattle, sheep, goats
Upper respiratory problems…… dry cough,pleuritic pain
Gastrointestinal symptoms… nausea, vomiting, and diarrhea.
Hepatic symptoms:…..hepatitis, liver enlargement, and pain in
the right upper quadrant of the abdomen.
Diagnosis :
serology
Treatment :
doxycycline, tetracycline, chloramphenicol, ciprofloxacin.
:Dengue fever

Cause…..dengue virus ( flavi virus)

:Cp

headache

Rash

Joint pain

Muscle pain

Low platelets………..vvvvvvvvvvv imp

TTT….support

?????Dengue fever vs malaria

Malaria needs at least 7-10 days to cause symptoms

Dengue fever………..marked thrombocytopenia

Jaundice ……excludes dengue fever

Scrub typhus

Transmission: tick bite

Key work……..black scar after tick bite

fever, headache, muscle pain, cough, and

gastrointestinal symptoms.

Treatment: doxycycline or tetracycline

 Retro-pharyngeal abscess:

Fever & sore throat.

Dysphagia & Odynophagia.

Trismus

Pain on neck EXTENSION

Inv …CT

TTT…drainage

:Ross river fever

Spread only by mosquitoes.

The main reservoir hosts are kangaroos 
Symptoms:
arthralgia, arthritis, fever, Maculopapular rash
Diagnosis:
A blood test is the only way to confirm
Treatment and prevention:
Simple analgesics, anti-inflammatories, anti-pyretics 
WESTERN AUSTRALIA = ROSS RIVER FEVER …
Western australia with arthralgia ...... ross
If no arthalgia ......western encephalitis
Brucellosis (undulant fever) NOT IMP

Source……cattle…..zoonotic disease

Symptoms
 Abdominal pain, Back pain
 Chills
 Excessive sweating, Fever
 Headache
 Blood culture
 Serology for brucellosis antigen

Anthrax:…..NOT imp 
Biological weapon 
:Skin 
Purpuric papules 
Regional lymphadenopathy 
Black eschars 
:Inhalational 
Dyspnea, hypoxia and pneumonia 
GIT…..bloody diarrhea 
Inv….culture 
TTT….Ciprofloxacin for 10 days 
Prophylaxis….. Ciprofloxacin 

Yellow fever: NOT IMP

:Prophylxis

 Use insect repellent. . 

 Wear proper clothing to reduce bites. .
Get Vaccinated :….single dose gives protection for 10
years

:Lyme disease
S
o
u
r
c
e

o
f

i
n
f
e
c
tions………..ticks

Key word ……rash

Most common organ affected….knee joint

Most common CNS manifestation…..bilateral facial nerve palsy

Most common CVS manifestation…..heart block

TTT……doxycyclin

:N:B
Most common infections in elderly:
1st……….UTI
2nd ……….strep.pneumoniae
3rd…………influenza
Most common infection causing:
Surgical wound infection………staph
Chest tube infection…………staph
Central venous line infection………staph
Omphalitis……….staph
Impetigo……….staph
Septic arthritis,………staph
Cellulitis……..strep pyogenes
Pneumonia, otitis media, sinusitis…….strep.pneumonaie

Patient with varicella.now has headche and ataxia…..post infectious

cerebellitis

Patient with otitis media presented now with neck stiffness……

streptococcal pneumonia meningitis