Gram positive bacteria

Cocci : streptococcus ,staphylococcus ,enterococcus

Bacilli : clostridium,listeria (gram positive rods)

S-pneumonia is the most common cause of meningitis

Strep viridans (dental procedure)

Gram negative bacteria

Bacilli : E.coli,Klebsiella,pseudomonas,salmonella,shigella

E.coli is the most common cause of UTI

Diplococci : N.meningitidis,N.gonorrhea

Atypical bacteria : chlamydia,mycoplasma pneumonia ,legionella > bilateral lungs

infiltrates

The following antibiotics are excreted by the kidneys and therefore necessitate
dosage adjustments in renal failure: Aminoglycosides ,Cefazolin ,Penicillin
Vancomycin
The following antibiotics are not excreted by the kidneys and therefore do not
necessitate dosage adjustments in renal failure: Azithromycin, Flagyl ,Nafcillin
Tigecycline, Clindamycin

ESBL-extended spectrum beta lactamase

enables the degradation of the beta lactam rings of more advanced generations of
cephalosporin, such as ceftriaxone, cefotaxime. ceftazidime, as well as monobactam
and aztreonam. ESBL does not attack the beta lactam rings of carbapenems, and
therefore this is the appropriate treatment in this scenario.
Antibiotics

Aminoglycosides (gentamycin/streptomycin)

Clinical use : Gram negative bacilli

Side effects : nephrotoxic and ototoxic

Tetracycline (doxycycline)

Clinical use : lyme disease ,Rickettsia ,MRSA of skin and soft tissue (cellulitis)

Side effects : tooth discoloration

Contraindication : pregnancy ,children < 8 years

Trimethoprim/sulfamethoxazole

Clinical use : cystitis ,PCP , MRSA of skin and soft tissue (cellulitis)

Side effects : G6PD deficiency ,folic acid deficiency,aplastic anemia

Quinolones ,Aminoglycoside,Carbapenem,Cephalosporine (3rd generation)

Clinical use : grame negative bacilli

Quinolones

Side effects :Tendonitis (Achilles tendone tear) ,QT prolongation

Penicillin

Clinical use : gram + bacteria ,gram – cocci (nisseria),T.pallidum

Treatment of staphylococcus isolates

Sensitive : iv cefazolin (1st generation cephalosporine)

MERSA (resistant) : Tx with vancomycin (daptomycin/linezolid)

Side effects of linezolid : thrompocytopenia

Vancomycin side effects : Red man syndrome (connected to histamine release)

treatment administrating antihistamine or slow down the infusion rate of drug

Nisseria : tx with ceftriaxone

Pseudomonas : piperacillin-tazobactam
Pneumonia
Etiology: - Pneumonia is an infection of the lung parenchyma.
Predisposing factors: cigarette smoking, diabetes, alcoholism, malnutrition,
obstruction of the bronchi from tumors, and immunosuppression in general.
- The most common cause of community-acquired pneumonia in all groups is S.
pneumoniae (however, viruses are the most common cause in children age age <5).
- M. pneumoniae is the most common cause of atypical pneumonia.
- Hospital- acquired or ventilator-associated pneumonia shows a predominance of
Gramnegative bacilli such as E. coli, the other Enterobacteriaceae, or Pseudomonas,
as well as MRSA.
• Lobar Pneumonia : most common cause; streptococcous pneumonia. May involve
entire lobe , or the whole lung.
• Bronchopneumonia: caused by: S.pneumonia, S aureus, H influenzae, Klebsiella
• Interstitial (atypical) pneumonia: caused by: Mycoplasma, Chlamydophila
pneumoniae, Chlamydophila psittaci, Legionella, viruses (RSV, CMV, influenza,
adenovirus).
Classified as:
o Community acquired(CAP): pneumonia that occur before or within 48 hours after
hospital admission

 Typical CAP

 Atypical CAP: caused by organisms that are not detectable on gram stain and not
culturable on standard blood agar, present usually with milder symptoms with no
sputum
o Hospital acquired pneumonia (HAP) Occurs during hospitalization after first 72
hours
Presentation:
- Patients with pneumonia present with cough, fever, and often sputum production.
Severe pneumonia of any cause may present with dyspnea.
- Bacterial infections such as S. pneumoniae, Haemophilus, and Klebsiella have
significant purulent sputum production because they are infections of the alveolar
air space.
- The sputum with S. pneumoniae is described as rusty. The “rust” is simply
hemoptysis. As the blood oxidizes, it becomes brownish-red color.
- The sputum with Klebsiella pneumoniae is described as currant jelly.
- Interstitial infections such as those caused by Pneumocystis pneumonia (PCP),
viruses, Mycoplasma, and sometimes Legionella often give a nonproductive or “dry”
cough.
- Any cause of pneumonia may be associated with pleuritic chest pain. This is pain
worsened by inspiration. Commonly, pleuritic pain is associated with lobar
pneumonia, such as that caused by Pneumococcus. This is because of localized
inflammation of the pleura by the infection.
On physical examination pneumonia presents with rales, rhonchi, or signs of lung
consolidation, including dullness to percussion, bronchial breath sounds, increased
vocal fremitus, and egophony.
The respiratory rate is essential in determining the severity of a pneumonia. The
respiratory rate is often a close correlate of the level of oxygenation
-In a patient with atypical pneumonia, mycoplasma should be suspected when there
are extrapulmonary manifestations such as hematologic, neurological, cutaneous
manifestations and even glomerulonephritis, hepatitis.
treatment is Azenil (azithromycin).
-Symptoms that help distinguish an atypical pneumonia due to Legionella from other
causes of community-acquired pneumonia (CAP) include high-grade fever (>39),
gastrointestinal symptoms (diarrhea), and neurologic symptoms (confusion).
Hyponatremia (related to the inappropriate secretion of ADH) and hepatic
dysfunction are common.
- Legionella pneumophila is a gram-negative rod that stains poorly because it is
primarily intracellular; therefore, sputum Gram stain showing many neutrophils but
no organisms is also characteristic in buffered charcoal yeast extract agar.
- Urine antigen testing is rapidly available, highly specific, and the most common
method to confirm the diagnosis.
The macrolides (especially azithromycin) and the quinolones (especially levofloxacin
or ciprofloxacin) are the antibiotics of choice and are effective as monotherapy.
Initial antibiotic therapy should be given by the IV route because gastrointestinal
symptoms are common in Legionnaires’ disease.
DX.

- The most important initial test for any type of pneumonia is the chest x-ray.
- Besides being able to simply show the presence of disease, the chest x-ray gives
the initial clue to determining the diagnosis.
- S. pneumoniae (and other causes of “typical” pneumonia) usually appear as a lobar
pneumonia with parapneumonic pleural effusion.
- Interstitial infiltrates are associated with PCP, viral, Mycoplasma, Chlamydia,
Coxiella, and sometimes Legionella pneumoniae.
Chest X-Ray : bilateral interstitial infiltrate
- Sputum should be obtained for both Gram stain as well as culture. Sputum culture
is the most specific diagnostic test for lobar pneumonia, such as with S. pneumoniae,
Staphylococcus, Klebsiella, and Haemophilus.
- The other organisms (viral, Mycoplasma, Chlamydia, Coxiella, etc.), the so-called
“atypical” organisms, will not show up on a Gram stain or regular bacterial culture
for various reasons.
- Organism-specific diagnostic methods are as follows: o Mycoplasma: Specific
serologic antibody titers. o Chlamydia pneumoniae, Coxiella, Coccidioidomycoses,
and Chlamydia psittaci: All of these are diagnosed with specific serologic antibody
titers. o Legionella: Specialized culture media with charcoal yeast extract and urine
antigen tests. o PCP: Bronchoalveolar lavage, increased LDH.
Sputum Gram Stain And Culture : adequate if there are >25 wbcs and <10
epithelial cells.
TX
Indication for hospitalization
Hypotension (systolic <90 mm Hg)

Respiratory Rate >30/ min , or pO2< 60 mmHg, pH <7.35

BUN >30 mg/dL

Na <130 mmol\L

Glucose >250 mg/dL

Pulse (Heart Rate) > 125 per minute.

Confusion.

Temperature >104 F.

Age >65

Comorbidities : cancer , CODP, CHF, renal failure, liver disease.

Since the patient in question has community acquired pneumonia with additional
comorbidity in the form of COPD, the empirical treatment of choice is a respiratory
quinolone, such as ciprofloxacin, or a combination of a beta lactam drug such as
ceftriaxone with a macrolide, such as azithromycin. Doxycycline can be used as an
alternative to the macrolide.

The patient has severe community-acquired pneumonia (CAP). Since the patient
experienced respiratory failure and was ventilated in the emergency department, he
should receive treatment in the intensive care unit (ICU). The antibiotic treatment of
choice for this patient is a combination of a 3rd generation cephalosporin and either
azithromycin or a respiratory quinolone.

Mycoplasma is a bacteria that can cause many of these symptoms and the treatment is
Azenil (azithromycin).
Blood cultures are positive for pneumococcus in a minority of patients, less than 30%
of cases.

The clinical picture describes a young patient with the flu that is not getting better as
expected and even worsens, therefore a secondary infection is suspected. The typical
organism in this case is Staph Aureus.

The influenza virus can cause pneumonia in several different ways. The first is primary viral
pneumonia which may be severe and classically present as an interstitial pattern on imaging.
Secondly, a bacterial infection may arise that can cause pneumonia by itself or with a
combination with the influenza virus.

The influenza virus causes de-epithelization of the airways and damages cilia function
therefore raises the risk of secondary bacterial infections. A common causal organism is the
Staphylococcus which is a known cause of cavitary pneumonias.

Legionella’s disease is suspected in cases of pneumonia with a typical exposure history,

hyponatremia and diarrhea. Diagnosis is made by a urine antigen test.
❖ N.B

: 1. Alveolar consolidation in pneumonia causes hypoxemia due to right -to-left

intrapulmonary shunting. ▪ Positional changes that make the consolidation more
gravity dependent worsen ventilation/perfusion mismatch, increase intrapulmonary
shunting, and lead to worsened hypoxemia.
2. Aspiration pneumonia is due to inhalation of oropharyngeal secretions colonized
by pathogenic bacteria. Aspiration risk factors include the following:
- Altered consciousness due to seizures, alcoholism, drug overdose, or sedation.
- Neurologic dysphagia (dementia, parkinsonism, cerebrovascular accident,
myasthenia).
- Disruption of the gastroesophageal junction (esophageal disease, gastric reflux).
- Mechanical disruption of glottic closure (endotracheal intubation, bronchoscopy,
endoscopy). ▪ Heavy alcohol users are at risk of aspiration if they have impaired
consciousness.
▪ Patients usually present with indolent symptoms (days to weeks), foul-smelling
sputum, and concurrent periodontal disease. ▪ Imaging reveals infiltrate in the lower
lobes or right middle lobe (aspiration while upright) or the posterior segment of the
upper lobes (aspiration while recumbent).
▪ The infectious organisms are frequently oral flora (mixed aerobic and anaerobic).
▪ Broad-spectrum antibiotics with good anaerobic coverage (clindamycin,
amoxicillinclavulanate) are the mainstay of treatment.
▪ Tuberculosis (TB)
is an infection with Mycobacterium tuberculosis.
▪ TB is spread exclusively by person-to-person transmission by means of respiratory
droplet infection.
▪ Impairment of T-cell-mediated cellular immunity is the most significant defect
associated with re-activation. This is why steroid use, organ transplantation,
leukemia, lymphoma, and HIV are such important risk factors.
▪ Presentation:
- Patients present with cough, sputum, fever, and an abnormal lung exam.
- Weight loss is common because of the chronicity of the infection.
- Night sweats may occur.
- TB can occur outside the lungs (15-20% of cases).
Miliary TB is caused by the hematogenous spread of Mycobacterium tuberculosis. It
may arise during primary infection or with reactivation.
- Presentation depends on site involved. Any part of the body can be involved. - In
extrapulmonary TB, the lymph node (adenitis), meningeal, GI, and GU are most
commonly seen.
Diagnosis:
- Chest x-ray is the best initial test
- Sputum examination with specific staining for acid-fast bacilli (AFB) allows specific
diagnosis. AFB stain has limited sensitivity, and you need 3 negative smears to reach
>90% sensitivity. AFB-positive sputum staining is usually the trigger to start therapy
for TB.
• Tuberculin (Mantoux ) Test ( Used for Screening ): • Is intradermal injection of
Mycobacterium tuberculosis proteins. • when test is negative it should be repeated.
• 2 Mantoux tests are needed to exclude disease.

• When 1st test is (+) -- perform chest X-ray, if CxR is normal, this is called latent
disease ( patient should be tx with isoniazid for 9 months or with rifampicin for 4
months).

• If chest –X-ray is ( +) --- Tx with RIPE (rifampicin , isoniazid. Pyrazinamide,

ethambutol) for 6-12 months.
• All anti – TB drugs increases the ALT and AST (liver enzymes).
Infective Endocarditis
Endocarditis is an inflammation of Endocardium or heart valves usually due to
bacterial infection.
Risk factors:
Rheumatic heart disease- mainly in developing countries
Intravenous drug use
Degenerative valvular disease
Prosthetic valve- mainly at the first 6-12 months after replacement
Intracardiac devices
Old age (higher incidence)
Most common bacteria's:
- Staph. aureus (most common cause)
- Staph. epidermidis (Most common in first 2 months after Prosthetic valve)
- Streptococcus bovis (most common with colorectal cancer)
- Streptococcus viridians (most in poor dental hygiene)

- Non-infective endocarditis: o Libman-Sacks due to SLE o Marantic endocarditis

due to malignancy
Mitral valve is most frequently involved.
Tricuspid valve endocarditis is associated with IV drug abuse
Signs and symptoms:
• New Murmur + Fever = Endocarditis.
- Non-specific symptoms: (fever, rigors, general weakness)
- Cardiac: (dyspnea, chest pain, clubbing, new murmur, CHF)
- Embolic phenomena: (petechiae, splinter hemorrhage, Janeway lesion- at sole and
palm, CNS or Renal emboli)
- Immune complex phenomena (Osler's nodes at digits, Glomerulonephritis, Roth's
spots at retina)
- Haemolytic anemia can be caused if infective Endocarditis in prosthetic valve
Dx.
• Best initial : blood culture ( 95-99% sensitive).
• TTE (transthoracic echocardiogram) :
• TEE ( transesophageal echocardiogram) is more better than TTE
• EKG : may show heart block • Perform TEE after blood culture to see vegetations.

According to the modified Duke’s criteria a Definite IE is defined by fulfillment of 2

major criteria, 1 major + 3 minor criteria or 5 minor criteria.
Major criteria: o Positive culture "2 cultures, 48 hrs apart, and typical organisms" o
Positive Echo.
- Minor criteria: o Predisposing factors o Fever>38.5 o Embolic phenomena o
Immune complex phenomena o Positive culture but not meeting major criteria
Best initial empiric therapy : vancomycin + gentamycin.

The indications for prophylactic treatment for endocarditis have changed and
decreased in recent years and include the following conditions: Amoxicillin
A. Artificial valve
B. Prior endocarditis
C. Unrepaired cyanotic cardiac defect
D. Cardiac defect repaired in the last six months
E. Incompletely repaired cardiac defect
F. Valvular disease in implanted heart
The procedures that require prophylaxis are:
Dental treatments with gingival involvement / Periapical tooth treatment / Mucosa
perforation
Respiratory surgery
Invasive procedures in a contaminated urinary system or contaminated skin.
Indications for emergent surgery (within 24 hours) - Cardiogenic shock or
pulmonary edema due to valvular dysfunction, Acute onset of aortic regurgitation
causing premature mitral valve closure, sinus of valsalva abscess ruptured into right
heart, and rupture into pericardial sac.
Indications for urgent surgery (within 48 hours) - Vegetation or blood clot blocking
the valve, unstable prosthetic valve, acute AR or MR with severe heart failure (NYHA
3-4), perforated septum, ineffective antibiotic therapy, and perivalvular spread of
infection with or without evidence of conduction abnormalities on EKG.

NB
-One of the complications of endocarditis is glomerulonephritis, which manifests as
kidney failure, hypertension, proteinuria and red cell casts on urinalysis. This occurs
due to immune complex deposition on the glomerular basement membrane, causing
hypocomplementemic glomerulonephritis. Initiation of antibiotic therapy generally
improves kidney function.
-The most common organism of endocarditis in patients without structural cardiac
defects or injured endothelium is Staphylococcus aureus.
-the major risk factors for embolization can be divided according to the siize and to the location:
size -more than 10 mm- location -mitral valve.
Bacterial meningitis
is an infection of the subarachnoid space, causing an inflammatory response in the
CNS which presents as decreased consciousness, seizures, increased ICP, and stroke.
Infection could be acute and fulminant (over hours) or subacute (over days).
Clinically, some patients may present with the ‘classic triad’ of fever, headache and
nuchal rigidity (“stiff neck”). Most patients (75%) also experience altered mental
status, 20-40% will have seizures, and some will complain of nausea, vomiting and
photophobia. It is also important to examine the patient and look for the typical
meningococcal rash- starting as a diffuse erythematous maculopapular rash, with a
rapid transformation to petechiae.
• After neurosurgical procedures (especially shunting procedures ) for
hydrocephalus; staphylococcus aurues , coagulase –negative stapylococci.
• Viral meningitis (atypical ): most common cause : enterovirus (coxsackie).
Diagnosis is made with CSF analysis by lumbar puncture. The typical findings in
bacterial meningitis are high opening pressure > 180 mm H2O, 10-10,000 WBC
(mostly neutrophils), low glucose (<40), high protein (>45), positive gram stain (in
60% of cases) and culture (in 80%), and bacterial DNA on PCR.
• Fundoscopic examination : papilledema
CT scan before LP include:
history of recent head trauma
papilledema on fundus exam
changes in the level of consciousness
focal neurologic deficits
TX
In community acquired bacterial meningitis, the empiric antibiotic therapy for adults
includes Ceftriaxone and Vancomycin + dexamethasone in case of proven or
suspected pneumococcal meningitis (given 10-15 minutes before the antibiotic
therapy)
Patients above the age of 55, infants, pregnant women or immunocompromised
should receive ampicillin (covers listeria) in addition to ceftriaxone and steroids.
The presence of gram-positive rods in CSF indicates that the bacterium is Listeria and
therefore treatment should include Ampicillin.
Meningits + skin rash = neisseria meningitidis
Most patients with meningococcemia do need an addition of dexamethasone
especially those who have refractory shock in association with impaired adrenal
gland responsiveness.
When bacterial meningitis is suspected, blood cultures should be immediately obtained and
empirical antimicrobial and adjunctive dexamethasone therapy initiated without delay.
UTI (urinary tract infections)
Urinary tract infection is a common infectious syndrome. Generators are usually
gram-negative bacilli bacteria. It is common to divide the infections into complicated
and uncomplicated. Urinary tract infection, which is not complicated, is an
inflammation of a healthy, non-pregnant woman, without suspicion of resistant
bacteria. All other infections are considered to be complicated UTI.
The most common pathogen is E. coli, which accounts for 75-90% of cases of acute
uncomplicated cystitis in the United States. Another common pathogen, mainly in
younger women, is Staphylococcus Saprophyticus which accounts for 5-15% of case
Many antibiotics are used for the treatment of UTI including beta-lactams,
fluroquinolones, trimethoprim-sulfamethoxazole.
Before initiating antibiotic treatment in patients with catheter associated UTI, the
catheter must be replaced and urine cultures should be obtained.
-DRUG INDICATIONS for Specific Infections, Associated Pathogens, and Sample
Susceptibility Rates:
Antimicrobial(s) Infections
Ampicillin, AMOXICILLIN ENTEROCOCCUS FAECALIS UTI
-Delirium and urinary tract infections (UTI) are two very common conditions in the
elderly. While delirium has multiple etiologies, it is widely viewed as one of the
atypical symptoms of UTI in the elderly!
there is an association between UTI and delirium!
-Staphylococcus saprophyticus is the cause of 5-15% of acute uncomplicated UTI
pyelonephritis
Signs and symptoms of pyelonephritis include an acute onset of fever, shivering,
vomiting, nausea and flank or lower back pain.
The pathogens causing uncomplicated pyelonephritis and cystitis are similar and are
dominated by E.coli.
Dx: • Urinalysis show WBCs and urine culture.
• CT or Ultrasonography :to see complications ( abscess) or anatomic defects.
Tx • Ceftriaxone (Rocephin)
• Ertapenem • Ampicillin + gentamycin • Ciprofloxacin (oral for outpatient).
• When patients don’t response in 48 hours ---- CT scan or ultrasound looking for
abscess or anatomic defects.
Acute simple cystitis
is a UTI in a healthy woman, who is not pregnant and who has no anatomical
abnormalities or instrumentation of the urinary tract. Moreover, there are no signs
of more invasive disease such as fever or flank pain.
The most common symptoms are: A burning sensation while urinating, frequent and
urgent urination.
There are a number of treatment options including: Fosfomycin, Resperim,
Nitrofurantoin, a Beta lactam drug, etc. Fosfomycin is unique in that, in contrast to
other drugs, it is given as a single dose treatment.

Hepatitis
Hepatitis B virus types :
1- Acute HBV infection
2- Subacute HBV infection from 3-6 months
3- chronic HBV infection HBV for >6 month
Epidemiology : the incubation period of HBV is from 60-180 days
Mode of transmission : 1- 99% sexual transmission mostly usually in patient from
20-29 years
2- IV like by injection of drugs (by stomatology )
3- perinatal from mother to child (mother with HBV positive )
- Serological markers for the hepatitis B virus include the following :

A. HBsAg: The first virologic marker to be elevated in HBV is HBsAg. It appears in the
serum within 1-12 weeks. It appears before elevation in ALT and AST and clinical
symptoms. It usually decline 1-2 months after jaundice appears and become
undetectable.
B. Anti-HBs: Appearing in the serum after either successful HBV vaccination or the
clearance of HBsAg, this marker remains detectable for life.
Anti- HBs is seen in immunization and in recovery phase.
C. HBcAg: This marker is not detectable in serum as it is normally sequestrated
within the HBsAg coat
D. Anti-HBc: Appearing in the serum shortly after the emergence of HBsAg, this
marker remains detectable long after the patient recovers.
The lgM fraction signals the acute/Recent phase infection, whereas the lgG fraction
signal prior exposure or chronic infection.
Because lgM anti-HBc is present in the "window period," it is an important tool for
diagnosis when HBsAg has been cleared and anti-HBs is not yet detectable.
Thus, lgM anti-HBc is the most specific marker for diagnosis of acute hepatitis B
E. HBeAg: This antigen is detectable shortly after the appearance of HBsAg and
indicates active viral replication and high infectivity.
F. Anti-HBe: This marker suggests the cessation of active viral replication and low
infectivity.
Treatment:
- There is no effective therapy for acute hepatitis B. Treatment options of chronic
hepatitis B include interferon alpha (pegylated or standard), lamivudine, entecavir,
ortenofovir.
In HBV patients with decompensated cirrhosis, treatment is indicated regardless of
ALT or HBV DNA levels.
In compensated cirrhosis, patients with HBV DNA levels above 2000 should be
treated. Treatment for patients with chronic HBV and compensated cirrhosis is with
tenofovir or entecavir.
NB
-acute HBV infection. Positive markers for HBsAg and HBeAg indicate acute HBV
infection together with IgM anti HBc
-During "window" phase of HBV infection, IgM anti-HBc is usually the only marker
that indicates HBV infection.
-Risk factors for chronic hepatitis:
asymptomatic acute hepatitis, hepatomegaly that persists, high aminotransferases
that don't decline, presence of HBeAg 3 months following acute disease
presentation, etc.
Coinfection with HDV doesn't increase the risk of chronicity but in patients with
chronic HBV, infection with HDV will worsen the hepatitis.

This patient presents with low HBV DNA and positive HBeAg. This shows that HBV is
not very active. The risk of developing HCC and cirrhosis in chronic patients depends
on the viral load and this leads to guidelines regarding therapy.
In the case of HBeAg positive patients:
Chronic hepatitis - an elevation of ALT levels twice above normal limits and viral load
of more 20,000 IU/mL indicate therapy.
Compensated cirrhosis - any ALT levels and a viral load of more than 2,000 IU/mL
indicate therapy.
Decompensated cirrhosis - any ALT levels and a detectable viral load indicate
therapy.
This patient has no indication for initiation of HBV therapy.
HAV infection is transmitted via the fecal oral way. Its incubation time is 15 -45 days.
Endemic area where sanitary is poor requires HAV vaccination.
HAV vaccine can be both active and passive vaccine forms. The active vaccine is
effective for 20 years. 4 weeks are required between the vaccination and travelling.
The prognosis of HAV is excellent and complete recovery is expected.
usually asymptomatic , Only 30% of infected children < 6 year are symptomatic
Diagnosis : Positive Ab HAV IgM positive(IgG antibody indicate immunity that has
been obtained by previous infection or by vaccination )
Management :
1- (No therapy ) its resolve spontaneously and will result in life long immunity
2- Specific Vaccination is present : inactivated vaccine has decrease the incidence of
the disease
Hepatitis C virus Types :
1- Acute HCV : acute process is asymptomatic < 3 month
2- Subacute 3-6 month
3- Chronic HCV – if the infection with HCV will be for > 6 months
Epidemiology : the incubation period of HCV is 14-110 days , one of the most
common causes of chronic liver diseases worldwide . 7 genotype of HCV 1a and 1b –
most common predominate in America and Europa , 2 and 3 – north/south American
and Europe and Asia , 4- Africa /Egypt , 6-was identified in patient from Canada
Mode of transmission mostly by parenteral (IV drug use ) and in the history of
patient we can find inability to donate blood which mean chronic HCV Structure of
HCV is a single stranded RNA virus
Symptoms 1- Clinical syndromes 2- Extrahepatic manifestation –
hematological(cryoglobinemia) dermatological (like planus) renal (glomeronephritis ,
nephrotic syndrome) autoimmune CREST syndrome
Diagnosis 1- Laboratory findings : little increase AST /ALT /bilirubin /PT
2- Serological marker (antibodies ) Ab HCV IgM and Ab HCV IgG (and Anti-LKM1 in
10% of patient )
3- HCV RNA testing is the most sensitive on PCR
4- Liver Biopsy for assessment of liver fibrosis (fibro sure /fibro test/prai index are
noninvasive test to determine fibrosis in HCV patient ) Vaccination no vaccination
against HCV is present
Prognosis : 1- 95% patient affected with HCV will have risk of chronization ,from
them about 60% will have evidence of chronic liver disease
2- Patient with ongoing alcohol abuse , genotype 3 , co infection with HIV or HBV or
more likely to develop rapidly fibrosis
-All patients with chronic HCV should be treated with antiviral therapy, It is
important to remember that antiviral therapy has been shown to improve survival
and slow the progression of the disease. sofosbuvir/ledipasvir or
simeprevir/sofosbuvir.
-Nowadays IV drug injection is the most common cause of HCV infection.
Hepatitis D virus Epidemiology :
1- high prevalence in Italy /Moldova / all meditariean zone
2- more common in adult than in children
Mode of transmission : mostly parenteral drug use Form of HDV
1- Co-infection
2- Super-infection
Diagnosis : 1- Has only 2 antibodies Ab HDV IgM (acute infection)and Ab HDV IgG
(chronic infection) (Anti LKM3 against P450 in some patient )
2- Serum HDV RNA
3- All patient with Ag HBs positive need to be check for both hepatitis at the same
time HBV and HDV
4- Liver biopsy like patient with HBV will show only ground glass and eosinophilic
cytoplasm
HEV is transmitted via the fecal oral route and its incubation time is 14-60 days. It
poses an increased risk for pregnant women and mortality can go up to 10-20%
Prognosis :the rate of fulminant HEV infection is only 1% , but in pregnancy women
increase till 20% .
Complication of HEV in pregnancy : 1- Acute hepatic failure 2- Acute renal failure 3-
Hemorrhage (because of decrease prothrombin like in all viral hepatitis due to
hepatodepressive biochemical syndrome )
Acute HIV syndrome usually appears as a nonspecific fever disease accompanied by
sore throat and sometimes a rash.
of people who are infected with HIV virus develop a clinical syndrome %70-50
within 3-6 weeks after infection. Typical manifestations are fever, myalgia, sore
throat and lymphadenopathy and sometimes nonspecific maculopapular rash. The
clinical picture is similar to infectious mononucleosis.
These symptoms may be more common in those who have been infected by sexual
contact than those who have been infected by using a contaminated needle.
HIV diagnosis is based on identification of antibodies against HIV and\or direct
identification of viral components. Anti-HIV antibodies are detected in blood 3-12
weeks following infection. These antibodies are detected by an ELISA test which has
over 99.5% sensitivity. The new generation test combines both the anti-HIV
antibodies and the viral antigen p24.
When an acute HIV infection is suspected (less than 3 months), it is important to obtain a
PCR test.

-Antiretroviral therapy should be administered to all HIV patients, regardless of their CD4
counts, as it can slow disease progression at all stages./slows down disease progression at all
stages of HIV infection and significantly reduces the transmission of the infection.
1- Antiretroviral triple therapy (NA like zidovudine , lamivudine . Protease inhibitor
like Nelfinavir , ritonavir ) (should be continue to all positive pregnant women )
which lead to decrease transmission .
2- Cesarean section in women with low CD4 and high RNA viral loads (>1000) at time
of delivery
3- Infants born to mothers who are HIV positive require therapy as close to birth as
possible within 6 to 12 hours:4-week course of zidovudine to exposed neonate
Infectious mononucleosis The virus spreads through contact with saliva by infecting
the lymphocytes in the tonsils, continuing into the bloodstream, and then to the rest
of the lymphatic system.
is a clinical manifestation of EBV virus infection. Symptoms include sore throat,
prolonged fever, and lymphadenopathy. A rash can be seen with IM, but it is far
more likely to occur after administration of ampicillin or amoxicillin. The post-
antibiotic rash is typically polymorphous and maculopapular.
Blood tests reveal lymphocytosis and atypical lymphocytes Thrombocytopenia,
autoimmune hemolytic anemia, and abnormal liver enzymes may be seen..
In patients with a classic presentation and characteristic lab results, heterophile
antibody tests are diagnostic. The test is positive in 40% of patients during the first
week of illness, and in 80-90% during the second week.
-EBV-specific antibodies: indicated if infectious mononucleosis is suspected but the .
monospot test is negative.

Anti-viral capsid antigen antibodies (anti-VCA): IgM antibodies appear early, thus are -
useful for diagnosing acute infection as they disappear 3 months after infection.

- Anti-EBV nuclear antigen antibody (EBNA): usually detected late (3-6 weeks after
infection) and persists for life, thus indicating a previous exposure to EBV.

Complication : 1- airway obstruction

2- sever thrombocytopenia /hemolytic anemia /CNS involvement /Myocarditis/
3- splenic rupture
Q fever
is a zoonotic disease, caused by Coxiella burnetii. Main sources of transmission are
cattle, sheep and goats. Individuals in risk are farmers, veterinarians, ranchers and in
fact anyone who comes in contact with animals and especially with newborns or
placenta.
Q fever encompasses two clinical syndromes: acute and chronic infection. Acute Q
fever presents with hepatitis (40%), pneumonia (20%), isolated fever or CNS
involvement. Chronic Q fever is manifested as endocarditis, usually in predisposed
patients.
Diagnosis is usually based on serological tests, which are sensitive and specific.
Positive phase II serology in high titers, and especially a 4-fold increase in re-
examination, strongly supports the diagnosis of acute Q fever. Cultures are an
option, but are not routinely available and require laboratory precautions. PCR
testing can be performed from tissues.
The treatment for acute Q fever is doxycycline at 100 mg twice daily for two weeks.
A 50-year-old man presents with dry mouth, pupil dilation, dyspnea, dysarthria. He
says that he ate a vegetarian meal with canned vegetables and home-made
cheese. What will prevent paralysis later? anti toxin
clostridium botulinum,
which causes a disease called botulism. Most commonly it occurs after eating home-
canned food.
Clinical manifestation includes paralysis of cranial nerves that may cause diplopia,
dysarthria, ptosis, ophthalmoplegia, depressed pupil reflex, dilated pupils,
respiratory depression, dizziness, dry mouth and sore throat, flaccid paralysis of
voluntary muscles and even death. Patients are usually fully conscious, but
dysarthria, ptosis and paralysis may mislead that there is a change in their state of
consciousness.
The incubation period from consumes infected food until the onset of symptoms is
8-36 hours and can take up to 10 days.
The cornerstone of botulism treatment is ICU and the botulinum anti toxin. Anti-
toxin prevents disease progression.
Brucellosis
is a bacterial zoonosis transmitted directly or indirectly to humans from infected
animals.
Diagnostic clues in the patient’s history may include consumption of unpasteurized
milk products (including soft cheeses), contact with animals, or accidental
inoculation with veterinary Brucella vaccines.
SX- Brucellosis usually causes fever, which may be associated with profuse night
sweats. In addition to experiencing fever and sweats, patients with brucellosis may
complain of fatigue, myalgia, headache,weight loss and chills.
The fever of brucellosis is associated with musculoskeletal signs 50% in about one-
half of all patients. One-quarter of patients have hepatosplenomegaly, and 10–20%
have significant lymphadenopathy. Furthermore, Neurologic involvement is
common, especially depression and lethargy.
Brucellosis osteomyelitis more commonly involves the lumbar and low thoracic
vertebrae than the cervical and high thoracic spine.
DX- Isolation of brucellae from blood, CSF, bone marrow, or joint fluid is the
definitive diagnostic test. When doing laboratory tests in brucellosis patients;
hepatic enzymes and bilirubin may be elevated. CBC may show normal WBC count or
even peripheral leukopenia, with relative lymphocytosis.
TX- The most effective treatment for brucellosis is the dual therapy of streptomycin
and tetracyclines.
For adults with acute nonfocal brucellosis (less than one-month duration) a 6-week
course of therapy incorporating at least two antimicrobial agents is required.
Complex or focal disease may necessitate ≥3 months of therapy.

Food poisoning
is caused by consumption of toxin generated outside the body and consumed with
food. The common bacteria that cause food poisoning are Staph aureus, Bacillus
cereus and Clostridium perfringens.
The onset of gastrointestinal symptoms begins shortly after eating - about one to six
hours and most symptoms go away within 12 hours.
Symptoms usually include abdominal pain, vomiting, and sometimes diarrhea. Fever
is not common. Treatment is supportive and symptomatic.
Starting of symptoms from time of eating depend on the generator, when infections
with staph and bacillus develop 1-6 hours from eating.
1- Bacillus aureus + S aureus / staphylocccocal food poisoning + heavy metal like
copper , when nausea and vomiting will begin within 1- 6 hours after eating
2- Campylobacter jejuni + E coli + Salmonella + Shigella + vibrio parahaemolyticus
when Abdominal pain and diahrrea will begin> 8 hours after earing
3- Enterotoxigenic coli + Vibrio cholera + salmonella + Norovirus leading to Watery
diarrhea 12-24 hours after eating
4- Yersinia enterocolitica can cause fever + abdominal pain without diarrhea
5- Campylobacter . 2-7 days after eating
6- Parasite : Cryptosporidiosis + cyclosporiasis + Giardiasis , they can cause diarrhea
that persist for 1-3 weeks (without fever )
Leptospirosis
is a zoonotic infection caused by a spirochete. This disease can infect nearly all
mammal species including mice, rats, other rodents and farm animals. Humans are
infected upon direct contact with animal secretions or tissue. It seems that human-
to-human transmission is possible as well. An additional option for transferring this
disease is via polluted water.
Possible risk factors for this infection include:
Working in close proximity with animals.
Exposure to water ( sailing, swimming in freshwater).
Travelers
The incubation period ranges between 1-30 days, and is usually between 1-2 weeks.
In most cases the infection is asymptomatic, and when symptoms do develop the
disease is usually mild, characterized most oftenly by a sudden fever. Only 1% of
those who are infected develop a severe disease.
Leptospirosis is biphasic by nature. The first, leptospiremic phase, lasts
approximately 3-10 days, and is characterized by fever and flu like symptoms. During
this phase, spirochetes can be isolated from the blood and PCR can be performed in
order to locate these bacteria. In the second, immune phase, resolution of the
symptoms occurs, and antibodies can be detected. This stage is further characterized
by the ability to detect the spirochete in a urine sample. A common lab result in
leptospirosis is thrombocytopenia.
Weil syndrome is a severe manifestation of leptospirosis, and its manifestations are:
jaundice, thrombophilias, and kidney failure. This disease can be life threatening,
and can deteriorate to full blown sepsis with multi organ failure. Meningitis with
impaired consciousness can also occur.
Definitive diagnosis of leptospirosis is achieved via PCR or seroconversion.
In mild cases, patients can be treated with either amoxicillin or doxycycline PO. Once
severe disease is suspected, patients should be treated with penicillin IV. Other
possible antibiotic treatments include: Ceftriaxone, Cefuroxine or Doxycycline IV. It is
important to treat other complications when severe disease occurs, such as airway
support when necessary, and the performance of dialysis in the case of renal failure.
Malaria
is caused by parasites that can spread to humans through mosquito bites. Malaria is
prevalent in tropical regions, with P.Falciparum mostly seen in Africa, New Guinea,
Dominican Republic, and Haiti. P.Vivax is seen mainly in Central America but is also
found in India, South America, and East Asia.
The parasite is spread by Anopheles mosquito bites, which inject the parasite to the
infected person’s bloodstream. The parasite then moves to the host’s liver, where it
reproduces in cells and later breaks out and moves into RBC to further reproduce
until the erythrocyte is ruptured, releasing parasites back to the bloodstream.
The first symptoms of the disease are non-specific and include fever, malaise,
orthostatic hypotension, headaches, fatigue, abdominal discomfort, and nausea.
Cough, arthralgia, diarrhea, and myalgia may also occur.
The main symptoms of malaria are paroxysmal fever and chills.
Severe Falciparum Malaria is characterized by:
Cerebral malaria: includes comma, delirium, and seizures, seen in 10% of adults and
up to 50% of children with malaria.
Hypoglycemia: a common complication of severe malaria. Hypoglycemic malaria is
associated with poor prognosis since it appears when liver involvement is so severe
it can no longer produce glucose through gluconeogenesis.
Acidosis: appears as a result of organic-acid formation and is aggravated by AKI.
AKI: often due to ATN, is a common symptom of Falciparum Malaria.
Anemia: caused by parasite invasion and reproduction within red blood cells, which
leads to cell rupture.
Liver insufficiency: characterized by jaundice, hypoglycemia and lactic acidosis.
Diagnosis :
1- thick and thin blood Giemsa smear preparation of peripheral blood and CBC 2-
malaria antigen
Treatment :
1- antimalarial drugs (chloroquine ) 2- Clindamycin (an adjunct to treatment
regimens for malaria)
Prophylaxis depends on resistance (should begin 2 days – 2weeks before traveling )
- 1- Drug of choice : mefloquine 2- Primaquine for resistant malaria parasite
3- Doxycycline used for malaria prophylaxis in children over the age of 8.
All travelers returning from a malaria-endemic region such as Africa who develop fever
should be tested for malaria via thick and thin blood smears to directly visualize the malaria
parasite.

The combination of fever, orthostatic hypotension, hypoglycemia, anemia, and renal

involvement in a patient who recently traveled to Africa is indicative of severe malaria
caused by Plasmodium Falciparum.
Mucormycosis
is an invasive and destructive fungal disease with a relative high mortality rate. The
fungus is commonly found in normal surrounding environments yet afflicts disease
mainly in immunosuppressive patients- patients with uncontrolled diabetes,
neutropenia, chronically treated with steroids, solid organ or hematopoietic stem
cell transplantation.
The common clinical presentation of Mucormycosis is rhinocerebral Mucormycosis.
The first symptoms are usually nasal or conjunctival secretions and eye or facial
paraesthesia and pain. In advanced disease, damage to the muscles of the eyes may
occur, manifested by proptosis and even ophthalmoplegia. Rarely, the disease will
present with lung, skin or GI involvement.
The diagnosis can be done with a tissue culture taken from a suspicious area, yet it is
positive only in 50% of cases. Imaging can aid in the diagnosis and the most common
finding on CT or MRI of the head or sinuses is sinusitis that is hard to differentiate
from bacterial sinusitis. A biopsy remains the most sensitive and specific test to
diagnose the fungus. The classical finding on biopsy are wide, thick-walled, ribbon-
like hyphal elements that branch at right angles.
Treatment should not be delayed and if there is clinical suspicion of Mucormycosis,
treatment should be initiated also before a histological diagnosis is made. The agent
of choice is the antifungal drug amphotericin B in its various forms.

Symptoms include dull sinus pain, fever, cellulitis, proptosis, nasal congestion and purulent
or bloody nasal discharge, and gangrenous destruction of the nasal septum, orbits, or palate.
In many cases, a black eschar is formed in the nasal area
Rhino-orbital mucormycosis is a life threatening fungal infection that mainly affects
diabetic patients with poor glycemic control.
A 19.5-year-old field soldier complains of high fever, headaches, and a rash on his trunk
and limbs. He has recently been in contact with dogs. Which of the following antibiotics
should be initiated at this stage, even before confirming the diagnosis?doxy

This presentation of rash, fever, arthralgia, leukopenia, thrombocytopenia and

hyponatremia, suggests Rocky Mountain Spotted Fever, caused by a Rickettsia
infection.
R.rickettsii is transmitted through tick bites and is common in North and South
America.
The incubation period is around a week. After 3 days from exposure, non-specific
symptoms start to appear, such as fever, headaches, muscle pains and vomiting.
Afterwards, begins a progressive maculopapular rash, which starts on the soles of
hands and feet and progresses to the rest of the body.
Dangerous complications of the disease include hypovolemia, lung congestion and
CNS involvement.
Typical lab results are anemia (in 30% of patients), thrombocytopenia (in 50%), high
CRP/ESR, hypoalbuminemia and hyponatremia.
Without treatment, the disease can be fatal, within 5-18 days from the beginning of
the disease.
RMSF is hard to diagnose, and an important factor in the diagnosis is information
about traveling to endemic areas and a rash that involves the hands and feet.
Serology is positive only 7-10 days from exposure, therefore when suspected,
empiric treatment with doxycycline should be given.
Cellulitis
is an acute infectious disease characterised by pain, erythema, swelling, and local
hyperthermia. Common pathogens are skin microbiome bacteria- staph aureus and
GAS, but may also include exogenous pathogens. Strep groups B, C,and G infections
may also cause cellulitis, more often seen in geriatric patients and diabetics.
In patients with cellulitis there is often pre-existing damage to the skin such as an
ulcer, fungal infection, a sting or bug bite, furunculosis, an IV, and others.
Recurring episodes of cellulitis are associated with venous insufficiency and
lymphedema.
Laboratory findings include leukocytosis with neutrophilic predominance, elevated
inflammatory markers.
Diagnosis is usually made on clinical grounds, gram staining and culture are not
usually used. Imaging studies (e.g. MRI) may be indicated to assess the depth and
extent of infection.
Cellulitis is treated with intravenous antibiotics that cover streptococcal and
staphylococcal infections such as Nafcillin, Oxacillin, or alternatively Cefazolin,
Erythromycin or Clindamycin.
Erysipelas
a common skin infection, is characterized by an acute appearance of an
inflammatory area with warm, red and raised-clear borders. The typical pathogen is
Streptococcus Pyogenes (group A strep).
Blisters may sometimes develop. Propagation into deeper tissues is rare.
A common source of penetration is damaged skin due to mycosis, injuries, stings and
more.
Penicillin or Cefazolin treatments are effective.
necrotizing fasciitis.
This is a medical emergency where the infection and necrosis are located in the
fascia and the hypodermis. Possible causes include trauma or post-surgical infection,
but it may also be caused by less traumatic events such as varicella infection or a
muscle strain.
The most common pathogen is group A streptococcus. Other pathogens include
mixed aerobic and anaerobic pathogens or Clostridium perfringens. Diabetes, IV drug
use, and liver or kidney disease are risk factors.
Patients classically present with pain out of proportion relative to skin appearance
on physical exam, and elevated inflammatory markers.
Necrotizing fasciitis is a medical emergency. Treatment includes IV antibiotics, such
as Penicillin and Clindamycin, and emergent wound debridement.
A 70-year-old male is admitted to the ER following a right lower limb buns from an
oven several days ago. He states that his pain is severe. Past medical history -
diabetes and hypertension. On examination- pulse regular 100/min, blood
pressure 80/50 mmHg, T 39°C, room air saturation 99%. On examination of the
foot - purple vesicles and severe tenderness. Right lower limb CT- soft tissue gas.
Which of the following is correct?
Penicillin and clindamycin are the treatment of choice
A 50 year old female with a history of diabetes and hypertension presents with
what she describes as severe pain in her left calf. Vital signs: temperature 39
degrees, BP 80/60, tachycardia and tachypnea. Physical examination reveals no
erythema or swelling, intense pain upon palpation, and no visible infected wound.
Labs- leukocytosis 20K with neutrophilia and elevated CRP. What must be done
immediately?Emergent surgery
In patients presenting with septic shock and limb pain with no visibly apparent
cause, necrotizing fasciitis should be suspected. Treatment includes emergent
fasciotomy together with antibiotic therapy.
The patient in question is in septic shock, and she must be treated with IV fluids with
hemodynamic monitoring and broad spectrum IV antibiotics. However, the most
important step that must be taken immediately is emergent transferral to the OR and
surgical treatment.
A 30-year-old man arrived with a pain in his right chest. In examination a bite
appeared and around her redness and sensitivity. He complained of pain in the
wound area. After a while, he deteriorated, vital signs - fever 40oC, blood pressure
60/30 mmHg and tachycardia. He developed an extensive erythroderma. What is
the treatment?

A patient with toxic shock syndrome that probably developed from dermal
infection is described in the question. According to the description hypotension, high
fever and erythroderma are very suspicious of TSS as a result of Staph aureus.
Treatment first and foremost must include fluids and vasopressors to increase blood
pressure.
In terms of antibiotic therapy, the recommendation today is a combination of
clindamycin with penicillin. The use of clindamycin is recommended because it is a
protein synthesis inhibitor which lowers the toxin synthesis. Clindamycin and
vancomycin can be combined for penicillin resistant bacteria.
Guillain-Barre Syndrome (GBS)
is an autoimmune damage of multiple peripheral nerves. - By definition, there is no
CNS involvement. A circulating antibody attacks the myelin sheaths of the peripheral
nerves, removing their insulation.
- GBS is associated with Campylobacter jejuni or Mycoplasma pneumoniae infection.
▪ “What Is the Most Likely Diagnosis?”
- Look for weakness in the legs that ascends from the feet and moves toward the
chest, associated with a loss of DTRs. Gradually over days to even weeks
- A few patients have a mild sensory disturbance. - The main problem is that when
GBS hits the diaphragm, it is associated with respiratory muscle weakness.
- Autonomic dysfunction with hypotension, hypertension, or tachycardia can occur.
- Ascending weakness + loss of reflexes = GBS.
▪ Diagnostic Tests: - The most specific diagnostic test is nerve conduction
studies/electromyography. These will show a decrease in the propagation of
electrical impulses along the nerves, but it takes 1-2 weeks to become abnormal.
- CSF shows increased protein concentration with a normal cell count
(albuminocytologic dissociation).
▪ Tests of Respiratory Muscle Involvement: - When the diaphragm is involved, there
is a decrease in forced vital capacity and peak inspiratory pressure. Inspiration is the
“active” part of breathing and the patient loses the strength to inhale. PFTs tell who
might die from GBS.
- Death from GBS, although rare, is from dysautonomia and respiratory failure.
▪ Treatment: - Intravenous immunoglobulin (IVIG) or plasmapheresis are equal in
efficacy. Combining IVIG and plasmapheresis is a wrong answer.
Lyme disease

Causes : boriela burgdorferi , which is transmitted by the ixodid tick , usually begin a
few weeks after camping trip Prevalence : more common in USA
Stages : 1- Early stage from 1day – 1 month after tick bite , Erythema migrans/bulls
eye with central cleaning , the rash is asymptomatic or it may itch/burn , EM will be
located at the site of tick , will growth over the next days and its not rapidly
disappearance .
2- Early disseminated disease usually develop 1-3 months after inoculation 25% of
patient will have sign of disseminated disease at presentation .(multiple EM 1-5 cm
which appear not at the site of tick bite and they are evanescent (quickly
disappearing ) and do not show the typical expansion over days , fever , headache,
malaise , myalgia , arthralgia , aseptic meningitis(with headache and neck stiffness ) ,
cranioneuropathy like cranial nerve 7 paralysis ( bell palsy ), Cardiac involvement
mostly AV block , borrelial lymphocytoma is a red nodular swelling that is almost on
the lobe of the ear or areola of nipple , it may itch . depression
3- Late disseminated disease appear after 3 months after inoculation : Arthritis is the
main sign of late disease (involve large joints like knee , warmth , swelling from
effusion , limited range of motion help to distinguish arthritis from simple arthralgia )

Treatment : 1- Early disease EM : Oral-Doxycycline , amoxicillin (if age < 8 years ,

pregnancy or lactating women ) 2- Arthritis , Cardiac or Neurological involvement:
Sever, IV parenteral (ceftriaxone , penicillin G ) mild Oral (doxycycline , amoxicillin )
and cardiac monitoring
Fever of unknown origin (FUO)
Prolonged fever with no apparent cause

FUO is defined as a fever > 38.3 degree on at least 2 separate measurement that last
for 3 weeks in a patient with no known cause of immunosuppression

therefore workup needs to be directed using good anamnesis and physical exam.
Initial workup must include CXR, abdominal US, and laboratory tests: CBC, ESR, CRP,
electrolytes, IG levels, protein electrophoresis, liver enzymes, ANA, LDH, RF, blood
cultures (3 sets), ferritin, urine test, and PPD.

Nocardia
is an aerobic bacterium found in soil that sporadically infects patients with cellular-
type immunosuppression (steroidal therapy, lymphoma, AIDS, anti-TNF drugs).
Pneumonia is the most common presentation.
Chest X-RAY shows multiple pulmonary nodules.
The most common involved organ is the brain therefore a head CT must be done in
cases of pulmonary or disseminated diseases.
Sputum will reveal gram-positive branching filaments that stain positive in acid-
fast and silver staining.
Treatment : Resprim (TMP/SMX)
Rabies
NB
1-Extended spectrum beta-lactamase (ESBL) producing bacteria are resistant to all
beta-lactam antibiotics except carbapenems.
2-Septic arthritis is a medical emergency that must always come to mind when a
patient presents with mono-arthritis, even if the patient has a history of other
arthritic conditions. Patients with Rheumatoid Arthritis are at increased risk of
developing septic arthritis due to chronic inflammation and anti-inflammatory
treatments.The treatment of septic arthritis is based on antibiotics with special
attention to Staph and Strep coverage.
3-In patients undergoing lung transplants: In the early stage that includes the
perioperatively period and up to 2 weeks following the transplant the usual
pathogens include Gram-negative bacteria (such as Enterobacteriaceae and
Pseudomonas species). CMV pneumonia usually manifests between 2 weeks and up
to 4 months following the transplant. Preventative treatment for CMV is very
effective except for cases of resistance.
4-Infectious peritonitis is an important complication of peritoneal dialysis, which
presents with abdominal pain, cloudy peritoneal fluid, and fever. More than 100
leukocytes in aspirated fluid with >50% PMNs is diagnostic for peritoneal
infection.Treatment includes intraperitoneal antibiotics with appropriate coverage of
common skin pathogens and gram negative bacteria. Severe cases may require IV
antibiotics as well.
5-endoscopic procedures that require prophylactic antibiotic administration:
Pancreatic cysts drainage (pseudocysts, necrosis, etc.).
Gastrostomy tube placement (PEG).
Colonoscopy in peritoneal dialysis patients.
ERCP in patients with biliary drainage blockage (without an active infection) when
there is a doubt that the procedure will relieve the obstruction fully. Examples
include patients with sclerosing cholangitis or with constrictions of the biliary tracts.
If complete drainage is expected, there is no need for antibiotics administration.
Situations that DO NOT require prophylactic antibiotic treatment:
Patients with prosthetic joints (in any kind of endoscopic procedures
Patients with coronary bypass (stents or grafts)
FNA biopsies though gastroscopies
6-The development of colorectal cancer is associated with a number of risk factors,
including: diet, some hereditary syndromes, inflammatory bowel disease, tobacco
use and Streptococcus Bovis bacteremia (also known as Sterptococcus Gallolyticus)
7-For which of the following patients is the Influenza vaccine most recommended ?
Influenza vaccine is especially important in high-risk populations such as adults over
the age of 50, children under the age of 5, people with depressed immune systems,
pregnant women, nursing home residents and morbidly obese people (BMI greater
than 40).
8-Red man syndrome is considered a side effect of vancomycin and is connected to
histamine release. In very rare cases, especially when given intravenously and in high
infusion this reaction is life-threatening. Treatment involves administering
antihistamines or slowing down the infusion rate of the drug
9-After initiating successful antiretroviral therapy in patients with HIV, especially in
patients with CD4 under 50, up to 30% of patients develop a chain reaction called
IRIS due to a sharp decrease in HIV RNA. The response is particularly common in
patients starting concomitant anti-tuberculosis and antiretroviral therapy, so the
recommendation is to treat tuberculosis first, and wait up to 4 weeks before starting
antiretroviral therapy if CD4 is above 50.
10-The most commonly occurring side effects of TMP-SMX are associated with the GI
tract and include nausea, vomiting and diarrhea. If the drug is used for a long period
of time, leukopenia, thrombocytopenia and granulocytopenia may develop.Aplastic
anemia
11-Quinolones like Ciprofloxacin are synthetic antibiotics that inhibit bacterial DNA
synthesis by inhibiting the enzymes gyrase and topoisomerases. They are considered
well-tolerated and safe, but side effects have been reported including achilles
tendon tendinitis and tear, QT prolongation, myasthenia gravis exacerbation,
convulsions, hyperglycemia.
12-The most common cause of early infections after kidney transplant is UTI due to
anatomical changes made during surgery.
Middle period infections (1-4 months after surgery) – often related to T-cell
suppression. Two-thirds of middle-period infections are caused by CMV
Late infections (6 or more months after surgery) – Bacterial infections, including late
UTIs and BK-virus (may lead to nephropathy or transplant failure).
Late infections may also involve the CNS and lead to CMV-retinitis, Cryptococcus
Neoformans meningitis, listeria, fungi, mycobacterium, etc.
13-MCC travelers diarrhea is – eneterotoxigenic E.coli TX- ciprofloxacin