facebook.com/ibnkhaldon.med
Infections
facebook.com/IM.EmanAtta
Infections Disease Etiology
Scarlet Fever
Non- Typhi Salmonella
Enteric Fever ( Typhi S )
Group A ß hemolytic streptococci
G-ve Bacilli called:
- S. Choleraesuis
- S. Typhi
That elaborate erythrogenic toxin
Bordetella pertussis
- S. entriditis
-S. Paratyphi A,B,C
Feco-oral
Direct/ Indirect Contact
6-72 hours ( 3 days max. )
7-14 days
MOI
Droplet
IP
2-7 days
C/P
Whooping Cough
Prodromal Stage : ( 24 hours before rash )
7-14 days – infecve for 3 wks aer start of paroxysms :
- FAHM : ↑↑ Fever ( 41°C – acute onset ) - Sore throat : Severe
Mild cough (II) Spasmodic Stage ( 2-6 weeks) :
- Tonsils : Congested – Covered by purulent exudates
= paroxysmal stage = cough attack :
- Rash : * Diffuse erythematous eruptions , tht Blanches on pressure * fine popular rash : gooseflesh texture - Start: Axilla , groin , neck - Spread : generalized in 24 hours
:
Low grade fever - Coryza -
- Tachycardia
Eruption Stage ( 24 hours after fever )
(I) Catarrhal Stage ( 2 weeks)
(((( Spasmodic Cough )))) char. By : * Triggered By : eating – drinking –
1- Acute Gastroenteritis :
Local - Acute onset of N,V - Abdomen :
* GIT : - abd. Pain
physical Exertion – Temp. change * During Attack :
- Fever ( 38 – 39 °C )
- early Diarrhea ( pea soup consistency )
- 5 – 10 expl osive cough - rapidly in 1 expiraon
- Headache , confusion - seizers , meningismus
- late constipation * N & V : not common & usually indicate complications
General
2- Bactremia :1-5% of cases
- Eye : Bulge
RF : - i mmunodefiencies
* circum oral pallor * white strawberry tongue
- Tongue : protrude - Neck Veins : distended
3- Extra intestinal focal
* tongue → red strawberry
* Fever : incideous onset ( rise in
Lethargy – myalgia
- severe watery diarrhea
- Face : dusky red
* rash → desquamated
:
a stepwise fashion & in a week become unremittent ) * Anorexia – Headache –
- Crampy Pain - Tender , Distended
* Flushed cheeks
- End : by end of 24 hours :
Symptoms .
.
- children & neonates <3 m
Signs ( BHR
)
* Bradycardia : disproportionate to fever
- characteristic inspiratory whooping * Followed by : - vomiting of thick tinged sputum
salmonella infection :
Blood porn to many organs : - Arthritis - Brain Abscess
* HSM * Rash : 50 % - erythematous maculopapular
- child is dazed & restless * In between Attacks :
- Meningitis - Osteomeylitis - peritonitis
-in crops on lower chest and abdomen
- child is fair - chest examination : no abnormality
4- Asymptomatic carrier :
(III) Convalescence stage : (1-2 wks:)
- fecal secretion of
Episodes gradually ↓ in frequency
salmonella for weeks
- After recovery
:
Disease Complications
Investigations
Scarlet Fever
Whooping Cough
Non- Typhi Salmonella
Enteric Fever ( Typhi S ) st
1- Local Spread : O.M – Sinusitis – mastoiditis –
* Resp: - Pneumothorax
Aer 1 week
cervical adenitis - bronchopneumonia - empyema –
- Bronchopneumonia ( m/c & s )
* Intestine : Hge , perforation
Abscess ( retropharyngeal – parapharyngeal ) 2- Hematogenous Spread : Meningitis - septicemia
- TB focus - Atelectasis -Emphysema * GIT: - GE , Dehydration , PEM
* Liver : Hepatitis , cholecystitis * Pancrease : pancreatitis
– osteomyelitis – septic arthritis 3- Late immunological complications : RF, APSGN
- Prolapsed rectum , Hernias - Tongue : bitting , Ulcer of frenulum
* Chest : Pneumonia * Cardio : Toxic myocarditis
* CNS : Convultion & Coma *Hemorrhages: dt ↑ VP & congestion
* -itis : peylonephritis – meningitis – orchitis – p arotitis -
Epistaxis , SubConj. , IC , Hemoptysis
endocarditis
* CBC : PMN Leukocytosis
- leukocytosis
* ↑ ESR * +ve CRP
- lymphocytosis - ( n ) ESR
* + ve ASOT > 1/333
- Culture : by cough plate technique
* Throat swab culture : ß hemolytic streptococci
On Bordet Genue medium
- Culture : * Stool culture : in GE * Aspirated specimens in focal suppuration - Serology : to detect Abs
- Bl. Culture : +ve early (40-50%) - Stool & Urine culture : st +ve aer 1 week - Monoclonal Abs : direct detection of Sal.T. Sp. Ags - PCR : Sal.T. Sp. genes in Bl. - Widal Test : +ve after 1 week ( of a little help )
TTT
ABs for at least 10 days
* Cough sedatives & avoid
- GE : correct dehydration
* Antimicrobial Therapy :
- Procaine Penicillin (400,000-800,000 u/d IM) In 4 divided doses for 10 days
precipitating factors * ABs : Erythromycin 50 mg /kg / day Or Ambicillin 100 mg/Kg/day
& electrolytes - Bacteremia & Extraintestinal focal inf :
- uncomplicated → 14 days - complicated → 3 weeks
For 10 days
Antimicrobial therapy
- Pen. G / Pen. V ( 50,000 – 100,000 u/Kg/d ) In 4 divided doses for 10 days -Erythromycin ( 40 mg/d) for 10 days if allergic to P
after C&S
Chloramphenicol – rd Ampicillin/Amoxicillin – 3 Generation cephalosporines : ceftriaxone – Trimethoprim * Dexamethazone : improve the
survival in shock Prevention
Active Immunization: DPT (2,4,6,18) Chemoprophylaxis : Erythromycin 50 mg/Kg/ day for 10 days
Several Vaccines : * Parentral heat-phenol inactivated vaccine * Oral live attenuated vaccine
Cerebrospinal Meningitis Etiology
MOI IP C/P
Poliomyelitis
* Bacterial :
PolioVirus ( enterovirus ) in 3 strains :
Up to 2 Ms 2Ms→4ys 4 ys→ Older - Group B Strept - H. influenza B - G -ve enteric bacilli - N. meningitides - N. meningitides - Lysteria Monocytog. - Strept. Pneum. - Strept. Pneum.
P1 : Brunhild
P2: Lansing
P3 : Leon
* Non-Bacterial :
- Viral : Entero>80% , HSV, Arbo-, EBV, Mumps -Neoplatic – Chemical – Post-Vaccination
* Feco-oral ( m/c)
* Droplet infection ( rare )
7 – 10 days
( Non Specific MsMs Fn Cn )
(I) Asymptomatic : Infection pass unnoticed (m/c)
* Non Specific :
(II) Abotrive
Anorexia – Poor Feeding
(III) Non Paralytic : Meningeal irritation signs (
* Mental Status Alteration :
↓ Level of coniousness * Seizers : ( Focal / Generalized ) st
1 symptom in infants & young children * Meningeal Irritation : Nuchal rigidity – Back Pain – Kernig sign – Brudziniski sign * Signs of ↑ ICT : Headache – Projectile vomiting – Blurring of vision *Focal Neurological signs :
: - last for 3-5 days
- suspected in epidemics
- influenza or GE like symptoms
) - recover completely or progress to paralysis
(IV) Paralytic :
(V) Respiratory :
paralysis may be : initial presentation or preceded by meningeal irritation Spinal
Bulbar
* ((( True Bulbar Palsy )))
Paralysis of ms of : - pharynx ( dysphagia ) - Palate ( nasal tone & fleuid Regurge )
Spinal ( Dry = peripheral Type ) Encephailitic
- Terminate fatally - Impaired consciousness - Convulsions
- Paralysis of diaphragm & IC ms
Bulbar ( wet = central type ) - RC affection & bulbar palsy
- Respiratory Distress ( rapid shallow - Accumulation of secretions Respiration & working ala nasi ) inability to cough , hoarsness - weak thoracic expansion with resp.
- weak irregular respiration
- Larynx ( Horseness, stridor, repeated chocking ,
→ wet polio ) aspiration *Affection of : RC→ irr breathing , VC→ Arrhythmia
* Cranial Neuropathies :
Characterized By: (LAMS)
Distribution :
( m/c Abducent nerve )
-LMNL ( flaccid paralysis )
- LL : (m/c) Adductors of : Hip & Ant. Tipial
-Acute onset -Asymetrical
- UL : Ms of Shoulder Girdle ( specially : Del toid )
-Maximal from start -Motor purely ( no sensory l oss )
- Abdomen : Localized Bulge , on : crying or straining
-Spotty distribution
- Neck Muscles : Inability to support the Head
- Trunk : Skoliosis – Kyphosis – Kyphoscoliosis , Tripod sign - Diaphragm & IC muscles : Respiratory Distress st
Paralyc Polio pass through 3 stages : a) Acute : 1 3 weeks b) Subacute : ll 6 months c)Old : aer 6 months"deformity"
Cerebrospinal Meningitis Complication
Poliomyelitis
Systemic : sepsis , purpera fuminans
* Chest : Respiratory Failure
Neurologic :
* Cardio : HTN , HF
- Herniation : cerebral / cerebellar
* GIT : Acute Gastric Dilatation , Melena ( dt intestinal erosions )
- Hydrocephalus /+ ↑ ICT - Motor deficits
* Renal : Acute Retension , UTI , stones
- Thrombosis of dural venous sinuses - Seizers - Stroke - Subdural effusions : resistant H. influenza &
* Psychiatry : Pstpilio $ ( PPS ) : Psychological Trauma
*Bone : Bone deformties & Joint contractures
* Due to prolonged recumbency : Osteoporosis , DVT , Constipation , Bed Sores
pneumoncoccal infecons in infant <18 ys → prolonged fever , bulging Ant. Fontanelle , ↑ OFC Investigations
Lubar Puncture :
- Viral isolation :
(Pressure – Leukocytes – PMN – Protein – Glucose) - Viral : Normal or ↑
- from stool → up to 6-8 weeks from the onset of the disease - from nasopharynx → up to 2 weeks
- Bacterial : ↑↑↑ except Glucose ↓
- CSF : ↑ proteins & Pleocytosis ( 20-300 / cmm ) = picture of asepc meningis
Blood Culture : reveal organisms in 80-90% of
meningitis in childhood CBC : Leukocytoisis , PNL leucopenia = bad prong. TTT
rd
1- ABs : 3 Generation Cephalosporines : for ic pts
( ACUTE STAGE )
( Ceftriaxone , Cefotaxime ) 2- ttt of ↑ ICT : Dehydration measurements 3- Steroids : in Bacterial Meningitis , Prevent :
- Bed rest in best position of function - Hot moist packs - Analgesics & Antipyretics - Care of Bladder (A) Spinal polio : -ve pressure respirator - Management of Respiratory polio :
- Cytokines Mediated Infl. Response - Edema - Neutrophil infiltration - neurologic injury
(B) Bulbar polio : - Clear airway by postural drainage
- NasoGastric tube Feeding - Monitoring of Blood pressure - Mechanical ventilation in severe cases ( Subacute , Chronic & Old Cases )
(a) Physiotherapy : for 1.5 – 2 years ( b) Plastic Splints & Supporting braces : ( Old Cases – Physio therapy – Orthopedic operations ) Prevention
- H. Infleunza B : - Rifambicin : for household contact 10 mg/kg/d for 4 days
- TPOV
- Vaccine : Conjugate polysaccharide vaccine - N. Meningitidis : - Rifambicin : for close contact 10 mg/kg/d for 4 days
- Sabine Vaccine / IPV
- Vaccine : used with Rifambicin & during epid emics - Strept Pneumonia : Vaccine for high risk patient & Sickel Cell Anemia : daily Chemoprophylaxis + Oral Penicillin
- Salk Vaccine
Dis.
Measles ( Rubeola )
Rubella ( German measles )
Mumps ( Epidemic parotidis )
Chicken Box (Varicella )
EBV
Etiol.
Measles Virus
Rubella virus
Mumps virus
Varicella – Zoster virus
MOI
Droplet infection( Direct / InD.)
Droplet inf. / Transplacenta l
Droplet infection ( Direct / Indirect)
Droplet inf. / Direct contact è vesicles
Oral – Saliva – Contaminated food
IP
10-14 days
14-21 days
14-21 days
14-21 days
5-15 days
Infec.
7days
(Rash)
5 days
.
7days
(Rash)
7 days
1 d (Symptoms , ↓ swelling)
.
3 d.
Human Herpovirus type 4
1 d (rash) till all lesions are crusted.
Pharyngeal excretion persist for ms
period
C/P
Prodromal Stage (3 days ) .
♦ ↑ Fever ♦ Malaise ♦ Nasal Catarrhal ♦ Associated :
♦ mild Catarrhal symptoms
2 Eyes : - Conjunctivitis - Photophobia 2Mouth : - Dry Cough - Hoarseness of voice Skin : Koplik Spot LNs : Generalized Lymhadenopathy Eruptive Stage
Prodromal Stage (24 hours ).
(7-10 d )
* Rash : Pink maculopapular * Start : Along Hairline & behind ears * Spread : Face → Neck → rd Trunk → UL → LL ( 3 Day ) *Associations : ↑ Temperature ( up to 40 ° C ) for 2 – 3 days + mild itching & may be Hemorrhagic ( Black measles )
before rash ( pass unnoticed ) ♦ Enlarged Tender LNs : - retro auricular - post cervical -sub occipital LN enlargement & persist for a weak Eruptive Stage
(3 d )
* Rash : Pink maculopapular * Start : face * Spread : so quickly , cover enre body within 24 hours rd * End : by the 3 day with minimal desquamation if any
.
(1) Start By : FAHM , aer 24 hours → Salivary Glands ++ (2) Paros : (m/c) = Painful swelling of one/ both parotids ( one parotid may proceed the other ) Pain is ↑ by : - mastication - sour liquids ( lemon juice ) - Palpation of gland Swelling - reach maximum size within 1 -3 days - Obliteration of angle between mandible & mastoid process -Push ear lobule outward & upward - +ve erythema around : orifice of nd Stenson's duct ( opposite upper 2 molar ) - subside within 4 – 7 days (2) Submandibular Swelling : (3) Sublingual swelling :
Prodromal Stage (24 hours ).
♦ Fever : very mild ♦ AHM ( pass unnoticed ) ♦ Short for 24hours before rash Eruptive Stage
.
* Rash : Pleomorphic ; many forms of lesion at the same time Centripetal more profuse in trunk -present also in : m.m - conj. - cornea * Form : macule → papule → vesicle → ulcerate & crust *liquid : Clear –then→ Cloudy *Associations : Pruritis + generalized Lymphadenopathy - New Lesions appear up to 3-4 days - Whole Duraon : 10-14 days * End : disappear with no residual scarring
Pharyngitis * Sorethroat * Enlarged Tonsils * covered by white membrane
Triad
Lymphadenopathy
- Cervical (m/c) - may be generalized - Discrete , firm , tender HSM . Splenomegaly .
Hepatomegaly . - (1/3 of cases ) - Anicteric Hepatitis - Jaundice : rare
- ( 50 % of cases) - Lt. upper quadrant discomfort - Tenderness
+ Fever : - high fever ( 39.5°C ) - Gradually ↓ along 7 days
- May be low grade prolonged + Rash : ( 5 – 15 % )
Convalescence Stage (7-10 d ) - Symptoms improve with disappearance of rash - Desquamation isn’t infectious - Takes 7 – 10 days
- Maculopapular - related to Ampicillin
Dis. Comp.
Measles ( Rubeola ) Neurological manifestation . * Encephaliti s : - Early viral - Late Post viral * SSPE : Subacute Sclerosing Pan Encephalitis ( rare ) ( 4-8 years aer infecon ) -WHY ? slow viral infection & reactivation → Brain Cell degeneration & dementia -WHAT ? personality changes – convulsions - ∆ & extra ∆ manifest. * Others : GB$ - TM – ON - HP
Rubella ( German measles ) ( CP TEN )
( MOOD PEM itis )
1- Congenital Rubella $ : 2- Polyarthritis : ( more in ♀) - affect small joints of hands - appear as the rash i s fading - clear spontaneously after 5-10 days 3- Trombocytopenia, Purpera 4- Encephalitis 5- Neuritis , GB $
Respiratory manifestation . * Pneumonia : ( m/c cause of death ) - Early interstitial Viral - Late 2ry Bacterial * Obstructive Laryngitis & Tracheobronchitis : marked Hoarseness & Stridor * Dormant TB Focus Activation * Otitis Media : infective & secretory ( dt obstruction )
TTT
Prev.
((((
Investigaions
))))
( usually not needed except when there is contact with pregnant )
1- Isolation of the virus : From nasopharynx during rash & 7 days aer 2- Serological Tests : As : Hemagglutination – inhibition test to detect anti-Rubella Abs
- Vit. A supplementation - Sedatives & antipyretics - Care of the eye : Eye drops + Avoid Direct Light
1- Isolation at home for 7 days after onset of rash 2- Symptomatic ttt : Antipyretics 3- Complication ttt
Active Imm. : Measles Vaccine :
Active Imm. : MMR
either Sparate or MMR
Passive Imm. :
Passive Imm. :
Immune serum Igs
SerAttenuation - 0.05 dose IM - √ acquired imm
Seropervention - 0.25 dose IM - first 5 days - no acquired imm
Mumps ( Epidemic parotidis ) * Meningeo-Encephalitis : - most dangerous - either viral / post infectious * Orchitis & Epidedynitis : ( 30% of adolescence & adult ♂ ) - Tender swollen testis - red edematous scrotum - OR Testicular Atrophy dt tough tunica albugina - No infertility *Oopheritis:(7% of postpupertal ♀) - Pelvic Pain & Tenderness - No infertility * Deafness: ( usually unilateral ) *Pancreatitis : - F,V,Shock - Epigastric Pain & Tenderness - ↑ Serum Lipase - DM : late * mumps Emryopathy : Endocrinal *it is : Nephritis – Myocarditis – Thyroididtis – Mastoiditis – arthritis
1- Symptomatic : - Analg & AntiPyr. - Bed rest till swelling subside - Diet : Soft / Semisolid , avoid sour liquid & spices 2-ttt of complication : - Orchitis : Bed res + Local Support + CorticoSteroids + Analgesics - Pancreatitis : Antiemetics + adequate fluid intake + Analgesics
Chicken Box (Varicella )
EBV
( Noha CT Skin )
1- Neurological : - Cerebellitis ( viral / post viral ) - GB$ - TM – transient ON – FP 2- Ocular : Keratitis – Vesicular Conjunctivitis 3- Hepatitis & Reye $ 4- Arthritis & acute myoscitis 5- Cardiac : Pancarditis 6- Congenital Varicella : charac. By : - LBW - Cortical Atrophy – seizures – MR – cataract – microcephaly – chorioretinitis 7- Thrompocytopenia , Purpera 8- Skin Lesions : ( m/c) 2ry Bacterial infecon → Scarring TTT 1- General Measures :
Local antiseptics - daily change of clothes & bed linens 2- Antipyretics : paracetamol 10-15 mg/Kg/dose 3- systemic ABs : for 2ry bacterial infections 4- AntiViral Agents : Acyclovir 10 mg / Kg 8 hours , for : - immunocompromised patients - < 2 ys - Viral encephalitis - Occular affection
Active Imm. : Mumps Vaccine :
Active Imm. : Live attenuated
either Sparate or MMR
Vaccine for 1 year
st
Passive Imm. :
( Neuro FORCH )
1- Neurological : - aseptic meningitis – GB $ - TM 2-Fulminent EBV : in IC patients 3- Oncogenic : - Burkitt's lymphoma - Nasopharyngeal Carcinoma 4-Rupture Spleen 5- Cardiorespiratory : myocarditis - atypical pneumonia 6- Hematology : ITP – Hemolytic Anemia – Aplastic Anemia
((((
Investigaions
))))
-CBC :Leukocytosis – l ymphocytosis - Paul – Bunnel Test : agglutination test detecting heterophil Abs ( with sheeps RBCs ) - EBV specific serology test - (1) Anviral Capsid Ag :
IgM → early Ig G → late - (2) EBNA " EB Nuclear Ag " anbodies , late to appear
1- Antipyretic 2- Steroids indicated in : - Pharyngeal Edema - Autoimmune phenomena : ITP , hemolytic Anemia , GB $ , TM
