Infection Summary

Risk factors for acute invasive pulmonary aspergillosis

* neutropenic patients
* post transplat
* patients with defects in phagocytes

Presentation of acute invasive pulmonary aspergillosis

* cough
* shortness of breath
* fever
* haemoptysis
* pleuritic chest pain
* nasal congestion and pain

Management of acute invasive pulmonary aspergillosis

IV anti-fungals

Risk factors for aspergilloma

* TB
* sarcoidosis
* bronchiectasis
* after pulmonary infection
* bronchial cyst or bull

Presentation of aspergilloma

* haemoptysis
* cough
* fever
* asymptomatic

Investigations for aspergilloma

* CXR
* CT

Management of aspergilloma

* surgical resection
* long term antifungal

Presentation of aspergillosis

* cough
* shortness of breath
* wheeze
* pyrexia
* general malaise
* headache

Investigations for aspergillosis

* bloods - eosinophilia
* sputum culture
* positive skin test for aspergillosis
* positive serology for aspergillum species
* CXR / CT

Management for aspergillosis

* oral long term high dose oral prednisolone
* anti fungal treatment of itraconazole also of benefit

Presentation of chronic pulmonary aspergilliosis

* exacerbations not responding to antibiotics
* decline in lung function
* increased respiratory symptoms:
* cough
* decreased exercise tolerance
* shortness of breath

Investigations for chronic pulmonary aspergilliosis

* sputum culture
* CXR

Management of chronic pulmonary aspergilliosis

oral antifungals

Causative organisms of cellulitis

* strep pyogenes
* staph aureus

Risk factors for cellulitis

* diabetes mellitus
* tinea pedis
* lymphoedema

Presentation of cellulitis

* spreading erythematous are with no distinct borders
* fever is common

Management of cellulitis

* combination of anti-staphylococcal and anti-streptococcal antibiotics
* admission for IV antibiotics and rest in extensive disease

Presentation of clostridiodes difficile infection

* diarrhoea
* fever
* loss of appetite
* nausea

Management of clostridiodes difficile diarrhoea

* metronidazole
* oral vancomycin
* fidaxomicin (new and expensive)
* stool transplants
* surgery may be required

Presentation of dengue fever

* sudden fever
* severe headache, retro-orbital pain
* severe myalgia and arthralgia
* macular / maculopapular rash
* hemorrhagic signs
* petechiae
* purpura
* positive tourniquet test

Investigations for dengue fever

* thrombocytopenia
* leucopenia
* elevated transaminases
* positive tourniquet test
* PCR
* serology

Management of dengue fever

* no specific treatment
* rest
* fluids
* paracetamol for temperature

Complications of dengue fever

* dengue haemorrhagic fever (DHF)
* dengue shock syndrome (DSS)

Management of complications of dengue fever

* IV fluids
* fresh frozen plasma
* platelets

Causes of ebola

* transmitted through direct contact with the blood, organs, or other bodily fluids of an infected person
* People can also become infected with Ebola virus through contact with objects, such as needles or soiled clothing, that have been contaminated with infectious secretions

Presentation of ebola

* fever
* fatigue
* myalgia
* vomiting
* diarrhoea
* haemorrhage

Investigations for ebola

* PCR
* serology - IgM and IgG

Management of ebola

* Inmazeb (3 monoclonal antibodies)
* EBANGA (1 monoclonal antibody)

**Vaccination**

* Ervebo - 1 dose, used during an outbreak
* Zabdeno & Mvabea - 2 doses (1 of each)

Investigations for fever in returning traveller

* FBC
* malaria films
* liver function tests
* stool microscopy and culture
* urine microscopy and culture
* blood cultures
* CXR
* specific tests as indicated

Management of fever in returning traveller

* isolation
* supportive measures
* empirical treatment if patient unwell (antimicrobial therapy based on likely diagnosis)
* specific treatment once diagnosis is established

Management of fungal nail infection

* conservative, can do nothing
* keep nails trimmed short
* well fitting shoes
* cotton absorbent socks
* topical nail lacquer - amorolifine 5% (fingernails 6 months, toenails 9-12 months)
* oral terbinafine (fingernails 6-12 weeks, toenails 3-6 months)

Causes of gastro-enteritis

* contamination of foodstuff
* poor storage of produce
* travel-related infections e.g. salmonella
* person-to-person spread e.g. norovirus

Investigations for gastro-enteritis

* stool culture +/- molecular or Ag testing
* blood culture
* renal function
* blood count
* neutrophilia
* haemolysis
* abdominal x-ray / CT if abdomen distended, tender

Differential diagnoses of gastro-enteritis

* inflammatory bowel disease
* spurious diarrhoea - secondary to constipation
* carcinoma

Management of gastro-enteritis

rehydration

What is rehydration therapy solution?

* sodium bicarbonate
* glucose
* sodium chloride
* water

Risk factors for genital candidiasis (vaginal thrush)

* just before and during menstruation
* obesity
* diabetes
* iron deficiency anaemia
* immunodeficiency
* recent course of broad spectrum antibiotic
* high dose combined OCP . oestogen based HRT
* pregnancy

Presentation of genital candidiasis (vaginal thrush)

* itch
* soreness and burning discomfort
* dysuria
* vulval oedema, fissures and excoriations
* cottage cheese / white curd discharge
* bright red rash

Investigations for genital candidiasis (vaginal thrush)

* clinical
* vaginal swab

Management of genital candidiasis (vaginal thrush)

* clotrimazole - topical antifungal pessary or cream
* oral treatment - fluconazole
* supportive measures - loose clothing, avoiding soap or bubble baths to wash

Presentation of seroconversion HIV

* flu-like illness
* fever
* malaise and lethargy
* pharyngitis
* lymphadenopathy
* toxic exanthema

Causes of HIV and AIDS

* anal or vaginal sex without a condom
* sharing needles, syringes or other injecting equipment
* transmission from mother to baby during pregnancy, birth breastfeeding

Prevention of HIV and AIDS

* using a condom for sex
* post-exposure prophylaxis (PEP)
* pre-exposure prophylaxis (PrEP)

Presentation of HIV and AIDS

* fever
* sore throat
* body rash
* tiredness
* joint pain
* muscle pain
* swollen glands

Investigations for HIV and AIDS

HIV test (blood or saliva sample)

Management of HIV and AIDS

* antiretroviral medicine
* take regular exercise
* eat healthy diet
* stop smoking
* have yearly flu jabs

Antiretroviral medication for HIV and AIDS

* bictegravir / tenofovir alafenamide / emtricitabine (Biktarvy)
* dolutegravir (tivicay) plus tenofovir / emtricitabine (Truvada)
* dolutegravir, plus emtrictabine or lamivudine, plus tenofovir alafenamide or tenofir disproxil fumarate
* dolutegravir / lamivudine

Presentation of pneumocystis jiroveci pneumonia

classic history of dry cough and increasing breathlessness over several weeks

Investigations for pneumocystis jiroveci pneumonia

* chest x-ray
* induced sputum or broncoscopy for PCR

Management of pneumocystis jiroveci pneumonia

* cotrimoxazole
* pentamidine
* prophylaxis until CD4 > 200

Causes of impetigo

* staph aureus (most commonly)
* strep pyogenes

Risk factors for impetigo

* skin abrasions
* minor trauma
* burns
* poor hygiene
* insect bites
* chickenpox
* eczema
* atopic dermatitis

Presentation of impetigo

* sores and blisters (multiple vesicular lesions on an erythematous base)
* golden crust is highly suggestive of this diagnosis

Management of impetigo

* topical antibiotics alone for small areas
* topical treatment and oral antibiotics for larger areas - flucloxacillin

Risk factors for influenza

**For complicated influenza (high risk groups)**

* Neurological, hepatic, renal, pulmonary and chronic cardiac disease
* Diabetes mellitus
* Severe immunosuppression
* Age over 65 years
* Pregnancy (including up to two weeks post partum)
* Children under 6 months of age
* Morbid obesity (BMI ≥40)

Presentation of influenza

* incubation period 2-4 days
* abrupt fever up to 21ºC which lasts 3 days
* 2 or more of: cough, \[sore throat, rhinorrhoea\], myalgia, headache, malaise
* less common: nausea, vomiting, diarrhoea

Investigations for influenza

* viral nose and throat swabs
* chest x-ray - pneumonitis / pneumonia / ARDS
* blood culture
* pulse oximetry (SpO₂

Complications of influenza

**Common**

* acute bronchitis
* secondary bacterial pneumonia

**Less Common**

* primary viral pneumonia
* myocarditis / pericarditis
* transverse myelitis / Guillain-Barre
* myositis and myoglobinuria

Cause of Lyme disease

the bacterium Borrelia burgdorferi via bite of infected blacklegged tick

Presentation of Lyme disease

* fever
* chills
* headache
* fatigue
* facial palsy
* irregular heartbeat
* dizziness
* erythema migrans

Investigations for Lyme disease

* ELISA test (Enzyme-linked immunosorbent assay)
* immunoblot test

Management of Lyme disease

* antibiotics
* doxycyline
* amoxicillin
* ceftriaxone

Causes of malaria

bite by infected mosquito

Presentation of malaria

* fever
* rigors
* aching bones
* abdo pain
* headache
* dysuria
* frequency
* sore throat
* cough
* splenomegaly
* hepatomegaly
* mild jaundice

Investigations for malaria

* thick and thin blood films
* quantitative puffy coar (QBC) - centrifugation, UV microscopy
* rapid antigen tests
* OptiMal
* ParaSight-F

Management of uncomplicated P. falciparum malaria

* riamet (artemether-lumefantrine) - 3 days
* eurartesim (dihydroartemisinin-piperaquine) - 3 days
* malarone (atovaquone-proguanil) - 3 days
* quinine - 7 days plus oral doxycycline

Management of complicated or severe P. falciparum malaria

* IV artesunate
* IV quinine plus oral doxycycline

Management of P. vivax, P. ovale, P. malariae and P. knowlesi malaria

* chloroquine - 3 days
* riamet - 3 days
* add primaquine in vivax and ovale to eradicate liver hypnozoites - 14 days (check for G6PD deficiency)

Complications of malaria

* cerebral malaria
* blackwater fever
* pulmonary oedema
* jaundice
* severe anaemia
* algid malaria

Causes of type 1 necrotising fasciitis

* streptococci
* staphylococci
* enterococci
* gram negative bacilli
* clostridium

Causes of type 2 necrotising fasciitis

strep pyogenes

Risk factors for necrotising fasciitis

* diabetes mellitus
* surgery
* trauma
* peripheral vascular disease
* skin popping

Presentation of necrotising fasciitis

* rapid onset
* haemorrhagic bullae
* skin necrosis
* crepitus may develop
* fever
* hypotension
* tachycardia
* delirium
* multi-organ failure

Investigations for necrotising fasciitis

imaging may help but could delay diagnosis

Management of necrotising fasciitis

* surgical review
* antibiotics (flucloxacillin, gentamicin, clindamycin)

Presentation of oral candidiasis (oral thrush)

* white or yellow plaques in mouth
* mild burning
* erythema
* altered taste
* ‘furry tongue’
* if chronic can cause dysphagia

Management of oral candidiasis (oral thrush)

* topical anti-fungal - nystatin, miconazole gel
* if extensive oral fluconazole
* smoking cessation
* good oral hygiene

Presentation of pyrexia of unknown origin (PUO)

temperature > 38.3ºC with no diagnosis after:

* 3 outpatient visits OR
* 3 days in hospital OR
* one week of outpatient investigation

Investigations for pyrexia of unknown origin (PUO)

* History
* Examination
* chest x-ray
* urinalysis and urine microscopy
* full blood count and differential white cell count
* C-reactive protein and erythrocyte sedimentation rate (acute phase reactants)
* blood cultures taken at times of fevers
* urea, creatinine, electrolytes, liver function tests

Management of pyrexia of unknown origin (PUO)

* Therapeutic trial
* rarely used
* suspected mycobacterial infection (anti-tuberculous therapy)
* suspected vasculitis or connective tissue disorder (steroids)
* diagnosis of Mtb unlikely if no response to chemotherapy within two weeks
* response of temporal arteritis to steroids is dramatic

Causes of rabies

viral infection (lyssavirus) transmitted from the bite of an infected animal

animal transmitters:

* dogs
* bats
* monkeys
* foxes
* racoons
* skunks
* wolves
* cats

Presentation of furious rabies

* hydrophobia
* insomnia
* confusion
* agitation
* coma

Presentation of paralytic rabies

* ascending flaccid paralysis
* fever
* confusion
* coma

Investigations for rabies

* PCR of skin biopsy, saliva
* brain biopsy (post mortem)

Management of rabies

Milwaukee protocol:

It involves chemically inducing the patient into a coma, followed by the administration of antiviral drugs combined with ketamine and amantadine

Presentation of rickettsiosis infection

abrupt onset of:

* fever
* headache
* confusion
* endovasculitis
* rash (macular, petechial)
* bleeding

Investigations for rickettsiosis infection

* clinical features
* serology

Management of rickettsiosis infection

tetracycline

Presentation of sepsis

* fever >38ºC - presenting as chills, rigours, flushes, cold sweats, night sweats
* hypothermia

Investigations for sepsis

* blood culture
* measure urine output
* take lactate

Management of sepsis

* give IV antibiotics
* give oxygen
* give IV fluids

Causes of septic bursitis

infection from either direct inoculation (usually superficial bursa) or haematogenous or direct spread from other sites (deep bursa involvement) causes inflammatory bursitis

Causative organisms of septic bursitis

* staph aureus (most common)
* gram negatives
* myobacteria
* brucella

Risk factors for septic bursitis

* rheumatoid arthritis
* alcoholism
* diabetes mellitus
* intravenous drug abuse
* immunosuppression
* renal insufficiency

Presentation of septic bursitis

* peribursal cellulitis
* swelling
* warmth
* fever
* pain on movement
* joint stiffness

Investigations for septic bursitis

aspiration of fluid

Management for septic bursitis

oral antibiotics

Causes of toxic shock syndrome

* high-absorbency tampons
* skin infections due to staph aureus secreting TSST1

Presentation of toxic shock syndrome

* fever
* hypotension
* diffuse macular rash
* three of the following organs involved:
* liver
* blood
* renal
* gastrointestinal
* CNS
* muscular

Management of toxic shock syndrome

* urgent surgical debridement of the infected tissues
* remove offending agent (ex tampon)
* intravenous fluids
* inotropes
* antibiotics
* intravenous immunoglobulins