Infectious Diseases USMLE Notes

Infectious diseases
Tick-Borne Diseases
Disease
Description
- Is a protozoal disease caused by the genus plasmodium,
(which is a RBC parasite) .
- Transmitted by tick bite of infected: anopheles mosquitoes.
Malaria
- You have 4 species:

Falciparum: Most deaths are due to falciparum
vivax, ovale: are responsible for several relapse.
malariae.
Clinical Features
- Hallmark is cyclical fever (which it coincides with RBC lyses by parasites)
Fever patter :
Fever occurs every 48 hours with vivax & ovale.
every 72 hours with malarieae,
Periodicity is NOT seen with falciparum (constant fever)
- The typical episode consists of 3 stages :
1- Cold stage: chills & shivering followed by
2- Hot stage: high grade fever 2-6 hours later
3- Sweating stage: diaphoresis & resolution of the fever.
Contraindicated in Seizures & Psych.
Add a 2-week regimen of : Primaquine
Contraindicated in patients with G6PD deficiency
Diagnosis & Treatment

Dx is made from :
Giemsa-stained peripheral blood smear
TTT:
A) Treatment:
- Chloroquine (safe in pregnancy) If chloroquine resistance :
a- Quinine & Tetracycline or
(P. falciparum IV Quinidine & Doxycycline)
b- & Mefloquine & Atovaquoneproguanil # in Pregnancy & CRD
B) Prophylaxis : to all travels to malarious regions
1- Mefloquine :is the DOC for chemoprophylaxis against
chloroquine-resistant malaria.
- Started 1 week before travel continued until 4 weeks after
departure from an endemic area.
2- Primaquine (both for prophylaxis & ttt ) is indicated against:
p. vivax or p. ovale, (which can cause persistence in the liver).
Babesiosis
Clinically significant illness
usually occurs in people:
1- Over age 40, pts
2- Without a spleen, or
3- Immunocompromised.
Lyme disease
Rocky
mountain
spotted fever
- The most serious tickborne disease in the US
Ehrlichiosis
Is a protozoal disease caused by the genus babesia .
Transmitted by tick bite of infected: ixodes tick , in

endemic area:
Etiology: B. microti in the northern & midwestern of US.
Is a tick-borne illness caused by the spirochete Borrelia

Burgdorferi .
Transmitted by tick bite of infected: ixodes scapularis
History of: Outdoor activities (e.g., hiking, camping).
Is a tick-borne illness caused by the intracellular bacteria

Rickettsia Rickettsii
Transmitted by tick bite of ticks feeding on animals
History of: Outdoor activities
Organisms enter the host cells via tick bites multiply in the
vascular endotheliumDamage to the vascular endothelium
results in : microhemorrhages, and microinfarcts.
-
Is a tick-borne illness caused by one of 3 different

intracellular gram -ve bacteria , genus Ehrlichia
Transmitted by tick bite.
It infects and kills WBCs show

intracellular inclusions (morulae)
Parasite enters the patients RBC and causes hemolysis.

Clinical manifestations vary from :
Asymptomatic infection to
Hemolytic anemia associated with:
jaundice, hemoglobinuria, renal failure, and death.
Unlike other tick-borne illnesses, rash is NOT a feature of babesiosis,
except in severe infection where thrombocytopenia may cause a
secondary petechial or purpuric rash.
1- Early localized stage:
- Skin: erythema chronicum migrans (Bull's eye) at site of tick
2- Early disseminated stage: (days to weeks to months after skin rash)
- Fever + Chills, fatigue, arthralgias, headache
- Neuro : -- Bell palsy (Cranial neuritis)
-- sensory-motor neuropathies
-- Aseptic meningitis (Brudzinski & Kernig signs negative).
-- Encephalitis
- Cardiac: AV block / Myocarditis / Pericarditis
3- Late disseminated stage: (few months to years later) :
- Joint: Monoarthritis(Large especially knee) / chronic synovitis
- Neuro: Encephalitis / Transverse myelitis
Typically 1 week after the tick bite.

- In the first 3 days:
Indistinguishable from a self-limiting viral illness
FAHM: Fever, Anorexia, Headache, Myalgias / Nausea, vomiting
- After 3 days of fever Rash :
1- Maculopapular rash:
Starts peripherally (palms & soles) Spread centrally (limbs/trunk/face)
2- then petechiae:
Micro vascular damage as disease progress :
- Petechiate + Hypotension & Non-cardiogenic pulmonary edema
Incubation period varies from 1 to 3 weeks.

- FAHM
- No Rash its description as : spotless rocky mountain spotted fever.
- Complications: Renal Failure / GIT bleeding
LABS:
leucopenia / thrombocytopenia aminotransferases.
Definitive dx is made from :

Giemsa-stained thick & thin blood smear.
TTT:
1- Quinine-Clindamycin
or
2- Atovaquone-Azithromycin.
Dignosis clinical / +ve (ELISA) & Western Blot tests for antibodies.
TTT:
- Early Lyme Disease (Rash / Joint / Bell's palsy) :
1- Doxycycline (Oral) for 21 days
Contraindicated in: Pregnant / Child <8 y Amoxicillin
Allergy: Erythromycin
2- Amoxicillin / Cefuroxime
- For Cardiac & CNS (other than Bell's palsy) :
Ceftriaxone (IV)
Dx requires a high index of clinical suspicion
TTT:
ABCs should always come first when treating any pt. check vitals
to make sure that the pt is stable.
- If signs of shock (hypotensive) :
The best NEXT best step is: IV fluids to replete intravascular volume.
- After he is stable: DOC :
Doxycycline (Oral/IV) for both adults & children.
- In pregnant:
Chloramphenicol
Dx : Confirm by serology
TTT:
- Doxycyline (for 1 week)
Cestode
-
Cysticercosis
NCC is the most common
parasitic infection of brain
Echinococcosis
Hydatid cyst is a fluid filled
cyst with an inner germinal
layer and an outer acellular
laminated membrane
Is a parasitic disease caused by larval stage of the pork

tapeworm: Taenia solium
If a person (rather than a pig"intermediate host") consumes the T. solium

eggs excreted in human feces Cysticercosis results.
- After ingestion, the embryos are released in the intestine larvae

Normal Life cycle of Taenia Solium:
invade the intestinal wall disseminate hematogenously to encyst in:
* Definitive Host: Humans (only)
1- Brain: Neurocysticercosis
* Intermediate host: pig
-- multiple, small (usually <1cm ) , fluid-filled cysts in the brain
* Infective stage: larva
parenchyma and have a membranous wall
* Mode of infection: humans eat larvae in meat such as
-- On neuroimaging: invaginated scolex
infected, undercooked pork.
2- Skeletal muscle
* Habitat: adult in upper jejunumexcretes its eggs into feces
3- Subcutaneous tissue
If a pig consumes these eggs, it becomes an
4- Eye
intermediate host, with larvae encysting in its tissues.
- Echinococcus tape worm has two main species:
- If a human (rather than sheep) consumes infectious eggs excreted by
dogs in the feces Echinococcosis results.
1- E.Granulosus causes: cystic echinococcosis (CE)
2- E. multilocularis causes: alveolar echinococcosis (AE)
- After ingestion, the oncospheres are hatched in the intestine
Normal Life cycle of E.Granlosus:
penetrate the bowel wall disseminate hematogenously to various
visceral organs Formation Hydatid Cyst, mostly in :
* Definitive Host: Dogs (& other canines)
1- Liver : RUQ pain, rupture to peritoneal cavity anaphylaxis
* Intermediate host: Cattle / Sheep
2- Lung: cough / chest pain / dyspnea / hemoptosis
* Infective stage: Embryonated Eggs in feces.
* Mode of infection: Eating food contaminated with egg.
Germinal layer gives rise to numerous secondary daughter cysts.
* Habitat: Small intestine
TTT:
Treatment of Neurocysticercosis :
Albendazole
Both be diagnosed with a combination of imaging and serology

In the absence of a positive serologic test: percutaneous aspiration
or biopsy (may be required to confirm the diagnosis).
TTT:
1- Surgical resection as in liver cycts.
2- Percutaneous management
3- Medical:
Albendazole: 1 week prior to surgery/ 4 weeks postoperatively
Nematode
- It is caused by the roundworm trichinella spiralis
Trichinosis
(trichinellosis)
Ascariasis
- It is acquired by eating undercooked pork that contains

encysted trichenella larva
Triad :
1- Muscle pain (myositis)
2- Periorbital edema
3- Eosinophilia
after eating raw meat = Trichinella spiralis (trichinosis)
- It is caused by the roundworm Ascaris Lumbricoides
- It is acquired by eating food that contains Embryonated egg
(containing 2nd stage rhabditiform larva)
Notes :
Ascariasis can also present with GIT symptoms + eosinophilia
Enterobiasis
Cutaneous
larva migrans
(creeping eruption)
- It is caused by the pinworm Enterobius Vermicularais.

- Adult parasite thrives in the Cecum / appendix.
- It is caused by dog & cat hookworm ancylostoma braziliense.
- It's acquired after skin contact with soil/sand contaminated
with dog or cat feces containing the infective larvae
Notes :
Most common seen in the LE / but the UE can also be involved.
3 phases + Eosinophilia.
Initial phase: in 1st week larvae invade the intestinal wall.
GIT symptoms: abdominal pain, nausea, vomiting, diarrhea.
2nd phase: in 2nd week of infection larval migration :
Local & Systemic hypersensitivity reaction
Nail : splinter hemorrhages,
Eye: conjunctival & retinal hemorrhages/per orbital edema/chemosis.
3rd phase: larvae enter the pts skeletal muscle:
Muscle symptoms: muscle pain, tenderness, swelling, weakness.
Ascariasis often presents as :
1- Lung phase with non productive cough followed by :
2- Asymptomatic intestinal phase
Symptoms result from obstruction caused by the organisms, as:
small bowel or biliary obstruction.

At night, females migrate out through the rectum onto the perianal skin
to deposit eggs Nocturnal Perianal Pruritis.
- Initially :
multiple pruritic, erythematous papules at the site of larval entry
- Followed by: Migration
Severely pruritic, elevated, serpiginous, reddish brown lesions on
the skin, which elongate at the rate of several millimeters per day as
the larvae migrate in the epidermis.
Dx: Triad clinical symptoms confirmed by serology.

TTT:
1- mild infection : No Antiparasitics
Symptomatic treatment with analgesia & Antipyretics
2- In Systemic Symptoms :
- Albendazole / Mebendazole
- together with corticosteroids
Dx : Egg seen in stool examination.
TTT:
1- First line: Albendazole / Mebendazole
Contraindicated in: Pregnant Pyrantel Pamoate
2- Alternative: Ivermectin / Nitazoxanide
Dx is by the scotch tape test demonstrates presence of eggs.
TTT: Albendazole or Mebendazole
Dx is clinical in cutaneous disease/ & pulmonary disease : dry cough
TTT:
1- Preferred : Ivermectin
2- Alternative: Albendazole
No Antiparasites in Pulmonary disease since illness is mild & self-limited
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Infectious diseases

- You have 4 species:

Add a 2-week regimen of : Primaquine

Contraindicated in patients with G6PD deficiency

Diagnosis & Treatment

Is a protozoal disease caused by the genus babesia .

Transmitted by tick bite of infected: ixodes tick , in

Is a tick-borne illness caused by the spirochete Borrelia

Transmitted by tick bite of infected: ixodes scapularis

History of: Outdoor activities (e.g., hiking, camping).

Is a tick-borne illness caused by the intracellular bacteria

Transmitted by tick bite of ticks feeding on animals

History of: Outdoor activities

Is a tick-borne illness caused by one of 3 different

It infects and kills WBCs show

Parasite enters the patients RBC and causes hemolysis.

Typically 1 week after the tick bite.

Incubation period varies from 1 to 3 weeks.

Definitive dx is made from :

Is a parasitic disease caused by larval stage of the pork

If a person (rather than a pig"intermediate host") consumes the T. solium

- After ingestion, the embryos are released in the intestine larvae

Both be diagnosed with a combination of imaging and serology

- It is acquired by eating undercooked pork that contains

- It is caused by the pinworm Enterobius Vermicularais.

small bowel or biliary obstruction.

Dx: Triad clinical symptoms confirmed by serology.

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