Infectious Disease • Bite Wounds Amy Smark, MD • Skin Infections Beaumont Health • Parasites Royal Oak, MI • Tick Born Disease • Malaria • HIV Emergencies

1/22/2019

Topics

• Pneumonia • Lung abscess • Mycobacterial disease Infectious Disease • Bite wounds Amy Smark, MD • Skin infections Beaumont Health • Parasites Royal Oak, MI • Tick born disease • Malaria • HIV emergencies

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Pneumonia Pneumonia

• For purpose of discussion will be subdivided: • Difficult to discover true etiologic agent • bacterial • Empiric treatment chosen by clinical presentation & historic • aspiration clues • atypicals • fungal • viral

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Pneumonia Bacterial Pneumonia

• Difficult to discover true etiologic agent • Streptococcus Pneumoniae • Empiric treatment chosen by clinical presentation & historic • Most common pathogen clues • Rare in older children and adults < 60 y.o. if no predisposing risk factors • Classic presentation: abrupt shaking chill & fever, productive cough • Inpt vs outpt? of rust-colored sputum, pleuritic chest pain • CAP vs HCAP? • CXR: classic is lobar consolidation • aspiration risk? • possible ICU admission? • Pseudomonas risk factors?

• Learn buzzwords for each group & each etiologic agent

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1 1/22/2019

Lobar consolidation LLL consolidation

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Bacterial Pneumonia Bacterial Pneumonia

• • H. Influenza Treatment • Second most common • Outpatient: community-acquired • Healthy: macrolides, doxycycline adult pathogen. • Significant comorbidities: • G(-) pleomorphic rod • extended spectrum fluoroquinolone vs • Often in COPD & • Augmentin + azitro/doxy debilitated pts • Inpatient CAP: • Patchy infiltrates • ceftriaxone +macrolide or • extended spectrum fluoroquinolone • HCAP • 4th gen Cephalosporin/Ext spectrum PCN + cipro/levo/tobra • PCN allergic-aztreonam • Consider vanco

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Bacterial Pneumonia Klebsiella • G- bacillus • Associated w/ alcoholism, debilitated state, & nosocomial • Acute onset high fever & chills, cough w/ currant jelly sputum (necrotizing/ hemorrhagic) • CXR: classically lobar in one upper lobe • Often complicated by abscess, empyema & bacteremia • Tx: 3rd gen cephalosporin +aminoglycoside • Often ESBL/carbapenem resis, tx guided by susceptibility

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Klebsiella: “bulging fissure” Bacterial Pneumonia

• S. Aureus • Hospitalized, debilitated, IVDA • Increased incidence during influenza season • Insidious onset following flu • Patchy, multicentric infiltrates • Often necrotizing & forms cavitation • Tx: • MSSA: oxacillin, nafcillin • MRSA: vanco, linezolid

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Bacterial Pneumonia Aspiration Pneumonia

• Pseudomonas • Anaerobic organisms & typically polymicrobial • Increased risk if recent hospitalization, neutropenia, hx of COPD, • Suspect w/ lower lobe disease (especially RLL) & clinical risk bronchiectasis or CF factors • Patchy infiltrates, may also form abscess • CNS depression • green sputum, fruity odor • Swallowing dysfunction • Treatment: 2 drug therapy • Severe periodontal disease • Antipseudomonal beta lactam (cefepime, Zosyn, imipenem) + • Fetid sputum • cipro/levo/(gent+macrolide)

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Aspiration Pneumonia Aspiration Pneumonia

• • Bacterial: aspirate oropharyngeal pathogens Chemical/aspiration pneumonitis: aspirate gastric contents • Community & nosocomial • Initial chemical burn followed by inflammatory rxn; • Anaerobes: Bacteroides, peptostreptococcus, fusobacterium high mortality & may lead to ARDS • +/- colonization of enteric Gram (-) and staph • Abrupt onset of symptoms within 2 hrs • Subacute or insidious onset • Wheezing, resp distress, pink/frothy sputum • CXR: infiltrate posterior lower lobes or upper lower lobes • CXR: infil in lower lobes or diffuse similar to • Tx: antibiotics are the mainstay pulmonary edema • Clindamycin if PCN allergic • Tx: • Supportive: supplemental O2, suctioning, mech vent if needed • Abx controversial unless secondary bacterial • If truly chemical aspiration, abx have not shown any long term benefit or change in outcome

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Aspiration pneumonia Atypical Pneumonia

• Term introduced in med literature early 1900s to separate from pneumococcal disease • Did not start with sudden shaking chill & fever, have period of defervescence, & no lobar appearance on X- ray • Many outbreaks in young adults w/ less severe course • 1st identified organism: Mycoplasma • Many others gradually followed: chlamydia pneumoniae, legionella, viruses, rickettsia • CXR: diffuse interstitial pattern

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Atypical pneumonia Atypical Pneumonia

• • Interstitial infiltrates Mycoplasma Pneumoniae • “walking pneumonia” • Starts w/ flu-like symptoms in young adult • Usually nonproductive cough, pharyngeal erythema, scattered rhonchi • Bullous myringitis- non specific • Serum cold aggluttins in 60% (also w/ virus) • Bilateral interstitial infiltrates • Tx: macrolides or doxy • Key feature: well appearing with significant interstitial infiltrates

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Mycoplasma pneumonia Atypical Pneumonia

• Chlamydia Pneumoniae • Obligate intracellular G- organism • Clinical picture: • Young adult- minor URI, subacute & self-limited • cough may persist for weeks • No CXR findings is common • Elderly- more likely to have unilobar infil • WBC normal • Dx by nasopharyngeal culture or serology • Tx with macrolides, doxy, fluoroquinolones

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Atypical Pneumonias Atypical Pneumonias

• Legionella • Zoonotic Causes: • Legionella pneumophilia consider as cause • Gram (-) bacilli, aerobe, obligate intracellular bacillus based on contact • Some have mild, self-limited course history • Elderly, COPD pts & immunosuppressed have more acute & severe course • Inhalation of mist from contaminated H2O source • High fever, cough, chest pain, GI symptoms (N/V/D), AMS • Hypotension, relative bradycardia • Hyponatremia, elevated LFTs & Bili • Urinary antigen test: most rapid dx (1-3d); +in 80% • Tx: macrolides, resp fluoroquinolones 1st line

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Atypical Pneumonias Atypical Pneumonias

• Psittacosis • Chlamydia psittaci • Birds • Inhalation of dust or droplets • Owners of birds/pet shop employees/poultry workers/vets • High fever, HA, HSM • Labs: ↓WBC, ↑LFTs, proteinuria • Perihilar infiltrates • Tx: tetracycline/doxy • Erythromycin in age <9 • Tx x3weeks.

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Atypical Pneumonias Atypical Pneumonias

• Tularemia • Coxiella brunetti • Francisella tularenesis • Causes Q fever • Aerobic G- pleomorphic rod • intracellular • Rabbits, ticks • Domestic animals, Sheep • Highly infectious, can live long periods of time (up to 18 • Direct contact vs inhalation months) in soil and in water or milk for 42 months • Ulceroglandular: lesion at site of contact with regional LAD • Inhalation of contaminated dust • Typhoidal: fever, chills, HSM • Slaughterhouse workers, dairy farmers • Pneumonia • ↑LFTs, high fever • Tx: streptomycin (1st line), gentamicin, doxy, cipro • Dx with serologic studies • Tx: doxycycline

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Viral Pneumonias Viral Pneumonias

• CXR nonspecific • Parainfluenza • Treatment is generally supportive • Pneumonia, croup, bronchitis • Influenza • Varicella • Most common cause of viral pneumonia in adults • 2-5 days after fever & rash • Risk for elderly and pregnant patients • Severe in pregnancy • Tamiflu in first 48 hrs • Admit for IV acyclovir • RSV • CMV, EBV • RSV Ag unreliable in adults and not recommended • Post-transplant patients, AIDS patients • IV gancyclovir

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Fungal Pneumonias Endemic Fungal Pneumonias • Histoplasma capsulatum • Endemic: can infect healthy persons • Mississippi & Ohio river valley • Usually self-limited • Bird, bat droppings • Can vary from asymptomatic to disseminated with • Opportunistic: infect immunocompromised multisystem organ failure in immunosuppressed • High mortality rate • Coccidioidies immitis • Diagnosis via bronchoscopy • Southwestern • Inhalation of spores, condida, or latent infection • Most self-limited reactivation • Blastomyces dermatitidis • Clue: person w/ activity near soil • Similar area to histoplasma but more extensive • Can be severe in immunosuppressed • Soil disruption

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Opportunistic Fungal Infections Opportunistic Fungal Infections

• Candida • Mucor • HIV/AIDS, cancer pts • Diabetics • Thrush/esophageal • immunocompromised candidiasis • Emergent sx • Tx: azoles • Tx: amphotericin b • Aspergillus • Soil • Cryptococcus neoformans • Pneumonia, cutaneous, • Encapsulated yeast ocular • Pigeon excrement • Voriconazole 1st line, • Immunocompromised/HIV amphotericin • Lung and CNS infection most common • Tx: fluconazole (non-CNS), amphotericin +flucytosine

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Complications of Pneumonia Lung Abscess

• Hallmark • Lung Abscess • air/fluid level • Cavity caused by necrosis of tissue filled w/ debris & fluid • Most commonly caused by aspiration & anaerobic infection • Indolent symptoms, foul smelling sputum • Bacterial causes- S. aureus, Klebsiella • More acute & treated @ same time as pneumonia • Other causes- infected bullae, carcinoma obstructing a bronchus

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Lung Abscess Complications of Pneumonia

• Lung Abscess • Treatment: • Continue to treat empirically till organism isolated • Clindamycin if aspiration suspected • Duration of antibiotics: 4-6 weeks • Rarely surgical: percutaneous drainage or resection

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Complications of Pneumonia Empyema

• Empyema • Pus in the pleural space • CXR: fluid in the fissure • Treatment: • Usually antibiotics & pleural drainage • If loculated- may require surgical intervention

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Tuberculosis Tuberculosis

• Mycobacterium tuberculosis • Ghon complex • obligate aerobic rod w/ acid-fast staining properties • 1/3 world population is infected • Primary TB • 90% asymptomatic • Lower lobes • + skin test +/- Ghon complex on CXR • Reactivation TB • Most common clinical form • Fever, night sweats, malaise, productive cough • Upper lobes, areas of high oxygen tension

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Tuberculosis Tuberculosis

• Extrapulmonary TB • TB & HIV • Meningitis • AIDS-defining illness • CSF: decreased glu; increased prot & WBCs (similar to aseptic • More often atypical symptoms/ CXR findings & often meningitis) multidrug resistant • Genitourinary • Diagnosis: • Dysuria, hematuria, pyuria w/o bacteria • • Miliary (disseminated) Skin test • Bloodstream seeding • >5mm if HIV, abnl CXR, exposure • Symptoms depend upon site • >10mm if IVDA, healthcare workers, immigrants • Osteomyelitis (Potts) • >15mm all others • LAD • CXR • And many more! • AFB Studies • Sputum via Ziehl-Neelsen or fluorescent stain • Culture of sputum for AFB

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Tuberculosis Tuberculosis

• Primary TB • Reactivation • Small infiltrates in any • Upper lobe apices or area & unilateral hilar posterior adenopathy • +/- cavitation • Ghon complex: calcified complex

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Tuberculosis Tuberculosis

• Miliary • Treatment: • Scattered, multiple • 4 drugs currently 1st-line small nodules • 1) Isoniazid (INH) bilaterally • Give w/ Vit B6 to prevent peripheral neuropathies • CYP 450 inducer • 2) Rifampin • Orange-colored body secretions • 3) Pyrazinamide • Increased uric acid, hepatitis • 4) Ethambutol • Optic neuritis (ethambutol)

• 4 drug Tx for 8 weeks • Followed by INH/RIF for 18 wks • Close ID care

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Bite Wounds Bite Wounds

• Human: • 3 to know: human, dog, cat • Management: hand • Human: • Xray, full neurovascular assessment, • Polymicrobial; both anaerobes & aerobes • Irrigate & debride • Staph, Strep, Eikenella • Leave open for delayed closure and splint in • Tdap needed & discuss hepatitis/HIV risk position of function • Hand has high rate of infection whereas other locations similar rate • <24 hrs & no concomitant tendon, joint or bone as other lacerations injury– D/C on Augmentin w/ F/U 1-2d • Closed fist and full thickness of the hand considered high risk • >24hrs, already w/ signs of infection, or debilitated state—IV abx • Unasyn/Zosyn • Ceftriaxone + flagyl • Clinda + Bactrim vs cipro

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Bite Wounds Bite Wounds

• Human • Dog • Management: Body • Polymicrobial: staph, strep, +/- Pasteurella • If low risk --Generally treat similar to other lacerations • Overall infection risk: 5-10%; greatest on hand & least on face • If high risk (deep puncture, crush wound, presenting >24 hrs, or • Capnocytophaga canimorsus debilitated) place on Augmentin and delayed closure • Rare infection 2-3d following bite • Localized infection can generally be treated w/ oral antibiotics • Causes overwhelming sepsis, DIC, & gangrene @ bite site • Always consider rabies • Pet? Stray? Shots?

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Bite Wounds Bite Wounds

• Dog • Cat • : Management • Typical bite is puncture • Prophylactic antibiotics for hand, high-risk • Higher risk of infection than dog bite wound, immunocompromised • Staph, strep as in other bites • Augmentin (1st line) • PCN or Bactrim or fluoroquinolone + clinda or • Pasteurella incidence much higher than dogs flagyl • Earlier onset of infection: usually within 6-24 hrs • If infection occurs <24 hrs– Pasteurella • Can occur with scratch • If infection occurs >24 hrs– staph/strep/cc • Augmentin, dicloxacillin • Suturing- • Hand: delayed • <12 hrs: close, esp facial • >12 hrs: delayed

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Bite Wounds Bite Wounds

• Cat • Management: • Prophylactic antibiotics for all wounds • Augmentin 1st line • Infected bites usually require IV abx • Same choices of antibiotics • Tetanus/rabies • Suture: face only • General rule—puncture wounds should not be sutured

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Bite Wounds Skin Infections

• 5 types to be discussed: Subcutaneous • 1) Abscess emphysema • 2) Necrotizing fasciitis • 3) Cellulitis • 4) Erysipelas • 5) Impetigo

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Abscess Abscess

• Localized collection of purulent material forming a fluctuant mass • Anaerobic: surrounded by erythema • more common in mucous membrane involvement • Extremity: usually follows break in skin integrity • Aerobic: • Head/Neck & perineal: apocrine or sebaceous duct obstruction • more common in cutaneous • Perirectal: anal crypt bacteria spread • Staph Aureus #1 • Vulvovaginal: Bartholin’s duct obstruction • Ultrasound useful to delineate & R/O radiopaque foreign • Pilonidal: embedded hair bodies

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Abscess Abscess • Simple Cutaneous Management: • incision & drainage • Bartholin Cyst: • Antibiotics in immunocompromised or significant • Post-lat vaginal opening surrounding cellulitis • Mixed flora • MRSA- chronic, recurrent infection • 10% Gonorrhea/ Chlamydia • Hidradenitis Suppuritiva • I & D followed by placement of Word • Chronic, reoccurring abscesses of apocrine glands catheter • Sinus tracts & fistulas often form • Catheter for 4-6 wks so • Frequently require surgical drainage that a sinus tract may form

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Abscess Abscess

• Perirectal • Perirectal • Originate in anal crypts & extend to ischiorectal space • May have underlying fistulas • Perianal - I& D in radial direction from anal opening - Abx only if systemic signs • Intersphincteric • Ischiorectal

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Abscess Pilonidal cyst/abscess

• Pilonidal • Location: gluteal fold over coccyx • Process: small pit forms from epithelial disruption, plugs with hair & epithelium, becomes tender fluctuant nodule • Treatment: I & D with removal of plug; refer for more definitive care if sinus tract present or if deep

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Necrotizing Fasciitis Necrotizing fasciitis

• Bullae • Fournier’s • Usually mixed flora infection of anaerobes & aerobes • Clostridium, Grp A Strep • Early signs similar to infected wound but rapid progression, deep pain out of proportion to outward signs • Necrotic patches & bullae ensue • X-ray: gas in tissues • Fever

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Necrotizing Fasciitis Cellulitis

• Local inflammation of skin presenting w/ warmth, localized • Fournier’s pain, induration & erythema • Perineum usually males, affecting penis & scrotum • Preceding trauma, hematogenous or lymphatic spread st • Pain 1 then swelling, fever, crepitance, erythema, • Clinical diagnosis inflammation • R/O bacteremia if diabetic/immunosuppressed • Treatment: • Staph/strep & also H. Inf in kids • Always early surgical consult for aggressive debridement • Treatment: • • IV abx against Staph/Strep, gram neg & anaerobes Outpatient: previously healthy & non-toxic • Vanco + • Keflex (low risk MRSA) • Zosyn + clinda • Clinda • Carbapenem + clinda • Bactrim +keflex • Consider adding fluoroquinolone if freshwater • Doxycycline exp • Inpatient: • IV abx if diabetic, immunosuppressed, febrile, asplenic or if involving head/neck or >50% extremity

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Cellulitis Cellulitis

• Periorbital (pre-septal) • trauma (insect bite/infect) • CT • Reach periorbital area by either hematogenous • CT is performed when orbital involvement is likely spread or direct extension from ethmoid sinus • CT with contrast needed for periosteal abscess • Highest incidence < 3 • More likely to be bacteremic • Fever more common • Periorbital edema more prominent • Orbital • Can occur at any age • Contiguous spread most common • Proptosis or limitation/painful extraocular muscle function

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Cellulitis Cellulitis

• periorbital • orbital Periorbital Orbital • Infection confined to tissue • Tissues within the orbit post ant to orbital septum to the septum • Periorbital edema • Edema, proptosis, pain on • Erythema EOM, limitation of EOM, pupillary abn • Staph, strep, h.flu • Admit, IV Abx, ophtho • EOM, visual acuity, pupils normal • Tx: blood cultures, oral abx if good outpt f/u. • IV Abx (unasyn, rocephin)

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Orbital cellulitis

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Erysipelas Impetigo

• Cellulitis involving dermis, lymphatics & subcutaneous tissue • Skin infection confined to epidermis • Most commonly on lower extremities; also face • Staph/strep • **raised plaque, deeply demarcated border, painful & • Usually less than 6 yrs old erythematous • Highly contagious/autoinoculation • Grp A strep main cause • 2 varieties: • Very young or age > 50 • impetigo contagiosa– papule then vesicles then honey-colored crusted • Often appear toxic & are febrile lesions • Treatment: • bullous impetigo– superficial bullae w/ purulent material • Toxic appearing, IV abx • Penicillinase-resistant PCN or 2nd/3rd gen cephalosporin • If non-toxic: amox, keflex, clinda po

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Impetigo Parasitic Infections

• Treatment: • To decrease risk of • 6 types to be discussed: cellulitis • 1) Pediculosis • Keflex or Mupirocin • 2) Scabies • Won’t decrease • 3) GI- Ascaris incidence of post-strep • 4) GI- Pinworms glomerulonephritis • 5) GI- Schistosomiasis • Rheumatic fever is NOT • 6) Malaria a complication

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Pediculosis Pediculosis

• Pediculus humanus • Pediculus humanus corporis (body) capitis (head lice) • Pithirus pubis (pubic) • Itching • Treatment: • • Permethrin (nix) Often occiput, st postauricular scalp • 1 line • Apply to scalp when hair is dry for 10 min then rinse • Repeat dose in 1 week

• Ivermectin po • Treatment failures • Age >10, not pregnant/bf

• Lindane (kwell) • Reserved for treatment failures • CNS toxicity & seizures (esp children)

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Scabies Scabies

• Mite infestation • Presentation: papules surrounded by erythema & scratch marks • Kids—more generalized • Areas: interdigital web spaces, wrists, axilla, genitals • Highly contagious • Tx for infected and close personal/household members • Permethrin, tx x2 • Po Ivermectin (caution pregnancy, children) • Clothing, bedding

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Ascaris Pinworms

• Large nematode & is most common roundworm • Enterobius vermicularis • Most common parasite worldwide • Most common • Eggs are ingested, larvae roundworm in the U.S. hatch, migrate through body & re-enter GI tract • Ingested thru transfer of • Children & those w/ heavy worm burden: worms may eggs from anus to tangle & cause SBO mouth via fingers • Also causes appendicitis • Dx: via increased eosinophils • Clinical: causes intense & eggs in stool perianal itching worse at • Tx: • Albendazole, mebendazole night • Pyrantel pamoate in pregnancy

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Pinworms Schistosomiasis

• Diagnosis: tape test • Not endemic to US • Treatment: Albendazole/Mebendazole • Parasites infect snails that release larvae & enter • All family members get treated into humans thru intact skin, then migrate thru • Wash all towels, blankets, sheets in hot water vasculature, become worms & release eggs • Eggs cause intense immunologic response • Symptoms depend on where the eggs migrate • Bowel—bloody diarrhea • Bladder—hematuria, bladder ulcers • Portal circulation—hepatic disease & portal HTN • CNS—seizures, transverse myelitis, AMS

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Schistosomiasis Malaria

• Acute Illness • Present several wks after contact w infested water • Serum sickness type illness: fever, HA, RUQ pain, • Predominantly in tropics bloody diarrhea, malaise • 4 species: • Chronic Illness • Presents months to years after initial infection • P. falciparum (most deadly), P. • Again depends on location of migration & worm Ovale, P. Vivax, P. malariae burden • Via infected mosquito • Treatment • Life cycle thru hepatocytes • po Steroids if significant inflammation then replicate in erythrocytes • Praziquantel, may need repeat dose • Symptoms start a few weeks after infection but may be up to several months

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Malaria Malaria

• Symptoms • Treatment • Irregular fevers is hallmark • Must speciate to treat • Only chronic infection • Review CDC updates have periodicity to • Doxycycline plus quinine fevers • Review Chloroquine • Nonspecific signs: lethargy, resistance HA, abd pain • Artemisinin combination • Severe infection: anemia, therapy (ACTs) HSM, coma, resp failure • Diagnosis • Blood smear

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Tick-Borne Infections Lyme

• 2 to be discussed: • Caused by spirochete: Borrelia burgdorferi • 1) Lyme • Ixodes tick is the vector • 2) RMSF • New England and Mid Atlantic states • May to August is highest incidence • Incubates several days to weeks then migrates to any site in the body

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Erythema Migrans Lyme

• Circular lesion with bright red • Stages of Illness border, pale interior; warmth; non-tender • Stage I: within 1 month; localized • Fever, malaise • Erythema migrans- **hallmark • Stage II: weeks to months later; disseminated • Neurologic signs predominate: fluctuating meningoencephalitis, cranial neuropathies (Bell’s most common), peripheral neuropathies • Cardiac: myocarditis & AV Block

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Lyme RMSF

• Stage III: months to yrs later; chronic • Rickettsia ricketsii carried by female Dermacentor tick • Migratory oligoarthritis • Name is misnomer as cases from Canada to Brazil • Vast neurologic complaints • • Diagnosis: serologic IgM & IgG Peak in spring & summer • EM in an endemic area is diagnostic • Symptoms caused by rickettsia infecting vascular endothelial & smooth mm cells leading to a vasculitis • CSF may mimic viral meningitis • Treatment: depends on stage & symptoms • Stage I adult, non-preg & >8yo: doxycycline X 10-21d • Stage I pregnant or < 8yo: amoxicillin X 21d • Stage II Bell’s: treat as Stage I • Stage II serious CNS disease & carditis: ceftriaxone • Stage III: ceftriaxone or PCN X 30d

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RMSF RMSF

• Clinical features: • Rash: • Fever, severe HA, myalgias, GI • Spreads to palms/ soles then complaints usually around 7d moves centrally to cover body after tick in 6-12 hrs • Rash: 2-6 days after fever; • Becomes deeper red & starts as erythematous maculopapular in 2-3d then blanching macules on flexor fixed & petechial surface of wrists, ankles

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RMSF HIV I.D. Emergencies

• Other Clinical Features: • • **gastrocnemius TTP 3 diseases to discuss: • Myocarditis, interstitial pneumonitis, vast neurologic • 1) PCP manifestations • 2) Cryptococcus neoformans • Diagnosis: • 3) Toxoplasma gondii • Presumptive diagnosis • Serology testing or skin biopsy to confirm, do not wait for results to treat • Treatment: • Doxycycline, best outcomes starting in 5 days of onset • Only mildest cases treated as outpt

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PCP PCP

• Pneumocystis jirovecii • Clinical Features • PneumoCystis Pneumonia (PCP) • Hypoxia • most common opportunistic infection in AIDS • Can be significant • • A fungus but responds to antiparasitic agents Tachypnea, tachycardia, mild fever • Increased LDH is marker of severity • Occurs in adults with CD4 count < 200 • CXR • Symptoms often develop slowly over 1-2 weeks • May be normal early • Classically: bilateral diffuse interstitial infiltrates from perihilar area (batwing) • Pt may not know HIV status-high index of suspicion

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Pneumocystis pneumonia PCP

• Diagnosis: • Examination of sputum using immunofluorescent staining • BAL • Treatment: • Initiate when suspected • Bactrim po or IV X 14-21d • IV Pentamidine • TMP +dapsone

• Steroids for mod-sev infection (low O2) • initiate before abx • RA PaO2<70 mmHg

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Cryptococcus Neoformans Cryptococcus

• Most common meningitis in HIV pts • May cause focal cerebral lesions or diffuse meningoencephalitis • Symptoms: • fever, HA, vertigo, photophobia, seizures, CN palsies • Diagnosis: • Head CT to R/O lesion then LP • India ink prep & fungal cx • Serum antigen titer is most sensitive • Treatment: • Mild Pulmonary dz: fluconazole, itraconazole • Severe Infections/meningitis: Amphotericin + flucytosine

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Toxoplasma Gondii Toxoplasmosis

• Most common focal encephalitis & mass lesion in AIDS patients • Symptoms: fever, HA, AMS, focal neurologic signs • Diagnosis: • Head CT showing ring-enhancing lesions (“signet ring sign”) w/ contrast • IgG, IgM, IgA Ab’s • May be unreliable in immunosuppressed pts • Treatment: • Pyrimethamine + Sulfadiazine + leucovorin

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