Infectious Disease

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Typhoid — Investigations

In The First Week (Invasive Stage With Bacteremia)

Diagnosis May Be Difficult Because The Symptoms Are Those Of A Generalized Infection Without Localising
Features

Typically, There Is A Leucopenia

Blood Culture
Establishes The Diagnosis

Multiple Cultures Increase The Yield

In The Second & Third Weeks

Stool Cultures Are Often Positive

Agglutination Tests (Widal & Typhidot — Detects IgM & IgG)

Detects Antibodies To O-Antigen & H-Antigen

It Is Not Specific

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Typhoid — Management

Antibiotic Therapy
Guided By In-Vitro Sensitivity Testing

In Non-Resistant Regions
Chloramphenicol (500mg 4x Daily)

Ampicillin (750mg 4x Daily)

Cotrimoxazole (900mg PO Or IV 2x Daily)

Fluoroquinolones
Previous Drug Of Choice

Ciprofloxacin (500mg - 750mg 2x Daily)

Nalidixic Acid Screening

Predicts Susceptibility, But Resistance Is Common

Extended-Spectrum Cephalosporins (Ceftriaxone & Cefotaxime)

Useful But Has An Increased Treatment Failure Rate

Macrolides
Azithromycin (500mg 1x Daily)

Alternative When Fluoroquinolone-Resistance Is Present

Treatment Is Continued For 14 Days

Extensively Drug-Resistant (XDR) Typhoid

Ongoing Outbreak In Pakistan Since 2016
 Azithromycin Is The Only Reliable Oral Therapy

Pyrexia Persists For Up To 5 Days After The Start Of Therapy

Even With Effective Therapy, There Is Still A Danger Of Complications (Recurrence, Chronic Carrier State)

Chronic Carriage
Treat For (4) Weeks With Ciprofloxacin

Requires An Alternative Agent For A Different Duration

Agent Is Guided By Antimicrobial Sensitivity Testing

Cholecystectomy May Be Necessary

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Giardiasis Intestinalis — Investigations

Clinical Diagnosis
After An Incubation Period Of 1 - 3 Weeks, There Is Diarrhoea, Abdominal Pain, Weakness, Anorexia, Nausea &
Vomiting

Upon Examination, There May Be Abdominal Distension & Tenderness

Chronic Diarrhoea & Malabsorption May Occur, Characterized By Bulky Stools That Float

Fresh Stool Sample

Stools Obtained At 2 - 3 Day Intervals Should Be Examined For Cysts

Duodenal Or Jejunal Aspiration By Endoscopy

Gives A Higher Diagnostic Yield

Stool Antigen Detection Tests

Jejunal Biopsy
May Show Giardia On The Epithelial Surface

Multiplex PCR
Increasingly Being Used In The Diagnosis Of Giardiasis, But Not In Low-Income Countries

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Giardiasis Intestinalis — Management

Tindazole
Single Dose Of 2g

Metronidazole
400mg, 3x Daily For (10) Days

Nitazoxanide
500mg Orally 2x Daily For (3) Days

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Amebiasis — Investigations

CBC
CBC
Leukocytosis

Mild ALP Elevation

Stool & Exudate Microscopic Examination

Can Reveal Motile Trophozoites Containing Red Blood Cells

Trophozoite Motility Decreases Rapidly As The Stool Preparation Cools

Several Stools May Need To Be Examined In Chronic Amoebiasis Before Cysts Are Found

Sigmoidoscopy
May Reveal Typical Flask-Shaped Ulcers

Ulcers Should Be Scraped & Examined Immediately For E. Histolytica

In Endemic Areas, 1/3 People Are Asymptomatic Passers Of Amoebic Cysts

Amoebic Abscess Of The Liver

Suspected On Clinical Grounds

Neutrophil Leucocytosis

Raised Right Hemidiaphragm On CXR

Confirmation Is By Ultrasound

Aspirated Pus From An Amoebic Liver Abscess Has The Characteristic Chocolate-Brown Appearance

It Rarely Ever Contains Free Amoebae

EIA Serum Antibodies

90% of The Time Detects Antibodies In Hepatic Amoebiasis & Intestinal Amoeboma By Immunofluorescence

Only Positive 60% Of The Time In Dysenteric Amoebiasis

DNA Detection (PCR Or LAMP Assay)

Loop-Mediated Isothermal Amplication Is Shown To Be Useful In Diagnosis But Is Not Generally Available

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Amebiasis — Management

Intestinal & Early Hepatic Amoebiasis

Responds Quickly To DOC Oral Metronidazole (700 - 800mg 3x Daily For 7 - 10 Days)

Long-Acting Nitroimidazoles Like Tinidazole Or Ornidazole (Both In Doses Of 2g Daily For 3 Days)

Nitazoxanide (500mg 2x For 3 Days)

Diloxanide Furoate Or Paromomycin (500mg Orally 3x Daily For 10 Days) Is Given To Eliminate Luminal Cysts

Indications For Aspiration

Done In A Large Liver Abscess Which Threatens To Burst

Also Done If The Response To Medical Chemotherapy Is Not Prompt

Diagnostic Uncertainty (Pyogenic Abscess, Necrotic Tumor)

Superfical Or Left Lobe Hepatic Abscess That May Rupture Into Pericardium

Rupture Of An Abscess Into The Pleural, Pericardial Or Peritoneal Cavity

Necessitates Immediate Aspiration Or Surgical Drainag

Small Serous Effusions Resolve Without Drainage

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Leptospirosis — Investigations

CBC
PMN Leucocytosis

Thrombocytopenia

Elevated CK

LFTs
Jaundice

Hepatitis

Prolonged PT

CSF Analysis
Moderately Elevated Protein Level, Normal Glucose & Variable Cell Count

RFTs & Urinanalysis

AKI & Interstitial Nephritis

Organisms Appear In Urine During The 2nd Week Of Illness

Isolation of Organism By Blood Cultures

Positive If Taken Before Day 10 Of Illness

Serological Tests
Diagnostic If Seroconversion Or 4x Increase In Titres

Microscopic Agglutination Test (MAT) IOC By The End Of The 1st Week

IgM ELISA & Immunofluorescent Techniques

Rapid Immunochromatographic Tests (Specific)

PCR
Detection Of Specific Leptospiral DNA

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Leptospirosis — Management
Most Infections Are Self-Limiting

General Care Of The Patient

For Hemorrhage Blood Transfusion

Careful Attention To Renal Function (MCC of Death)

AKI Reversible With Adequate Support & Dialysis

Oral Doxycycline Or IV Penicillin

Parenteral Ceftriaxone

Uveitis Combination Of Systemic Antibiotics & Local Glucocorticoids

L. Interrogans Prophylaxis In Military Doxycycline Weekly

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HSV — Investigations

Differentiation From Other Vesicular Eruptions

Demonstration Of Virus In Vesicular Fluid

Direct Immunofluorescence (OR) PCR

HSV Encephalitis
Diagnosed By A Positive PCR From CSF

Serology
Limited Value

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HSV — Management

Therapy Of Localised Disease

Commence Within The First 48 Hours Primary Or Recurrent Disease

After This, Therapy Is Unlikely To Influence Clinical Outcome

Oral Lesions In An Immunocompetent Individual

Topical Aciclovir

Severe Manifestations
They Should Be Treated, Regardless Of The Time Of Presentation

Suspicion Of HSV Encephalopathy

Immediate Anti-Viral Therapy

If Acyclovir Resistance
In This Case, Foscarnet Is Used

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