Chapter 202. Actinomycosis
* Actinomycosis species
1. slow-growing, gram-negative bacteria
2. part of the normal oral flora in humans
3. filamentous structure
* actinomycosis
1. chronic, granulomatous, suppurative disease
2. characterized by peripheral spread with extension to contiguous tissue
in the formation of multiple draining sinus tracts
3. involve the cervicofacial, thoracic, abdominal, or pelvic regions
1) Etiology
1. Actinomycosis israelii
: the predominant organism causing disease in human
2. 그외 중요한 순서로 Arachinia propionica, A. odontolyticus, A. meyeri, A. naeslundii,
A. viscosus & Bifidobacterium eriksonii
2) Epidemiology
# actinomycosis는 보통 opportunistic inf.은 아니지만 steroid사용하는 환자에서 (+)
: leukemia, renal failure, congenital immunodeficiency disease &
human immunodeficiency virus (HIV)/acquired immuno deficiency synd (AIDS)
Clinical manifestation
# Dx. of actinomycosis in children
: suspicion for an underlying immunodeficiency disease state, esp. chronic granulomatous ds.
Cervicofacial Actinomycosis
; enter the tissue through mucous membraine of mouth or pharynx by way of caries or through tonsillar tissue
;
*pain, trismus, firm swelling
& fistula with drainage containing the characteristic sulfur granule
;
*painless, slow growing, with a
hard mass called “lumpy jaw”
; later involvement of bone
- periostitis, mandibular OM, perimandibular abscess
; DDx from actinomycosis
- burrow through tissue planes even bone
Abdominal & Pelvic Actinomycosis
; result of acute, perforative GI disease or after trauma to abdomen
; delayed diagnosis
; 25% appendicitis
-
*after appendectomy hard,
irregular mass in ileocecal area
Pulmonary Actinomycosis
: specific diagnosis
→ examining purulent sinus tract drainage for sulfur granules & appropriate cultures
Diagnosis
1. microscopic exam with appropriate strains
2. culture of purulent drainage from fistula, abscess or draining sinus tracts,
along with bronchoalveolar lavage & sputum
→ one of the three major agents Actinomyces, Arachnia & Bifidobacterium
5) Treatment
1. prolonged antibiotics
& an appropriate surgical approach to sinus tracts & abscess
2. PC (250,000 u/kg/24hr IV, divided every 4hr)
3. appropriate therapy
: parenteral antibiotics for 2-6 wk
followed by oral antiobiotics for 3-12mo.
4. the oral antibiotic of choice
: PC (100mg/kg/24hr, divided every 6hr)
5. hepatic abscess or other deep tissue infections
: treated for 6-12mo
large abscesses
: srugical excision필요
6. removal of chronically infected tonsils & treatment of pyorrhea or caries
: eliminate possible sources of inf.
7. prognosis
: excellent, with adequate therapy & early diagnosis
Chapter 203. Nocardiasis
; acute, subacute, or chornic suppurative infection with tendency to remission and exacerbations
; uncommon in children
; *primarily
lung disease in immunocompromised hosts
Etiology
; N. asteroides complex
Clinical manifestations
1. primarily a pulmonary ds in 75% of all cases
2. almost all cases
: in immunocompromised patients or
patients with underlying pulmonary ds. esp. alveolar proteinosis
3. brain
: the most common secondary site
case의 15-40%
4. skin
: 3rd most commonly involved organ
5. renal nocardiosis
: 4th most common site
→ dysuria, hematuria, or pyuria
Diagnosis
1. direct examination of clinical material for characteristic gram-positive, acid-fast organism
2. isolation by culture methods
Treatment
1. sulfonamide
: the treatment of choice in human nocardiosis
2. standard
: Trisulfapyrimidines or sulfasoxazole
(120-150mg/kg/24hr divided every 6hr)
therapy for 3-6mo
3. surgical drainage of abscess
: important
4. 적절한 치료에도 불구하고 overall mortality는 50%
: 진단지연에 의한 또는 severely compromised host defense가진 환자의 debilitated state에 의한
2차적인 원인으로
Chapter 204. Bartonellosis
# two predominant forms
1) Oroya fever
; *severe, febrile hemolytic anemia
2) verruca peruana
; eruption of hemangioma-like lesion
; found in only in mountain valleys of the Andes Mountains in Peru, Ecuador, Colombia, Chile & Bolivia
Etiology
1. B. bacilliformis
2. vector: sandfly, Phlebotomus noguchi
Clinical manifestation
; totally asymptomatic or nonspecific symptoms
(such as headache & malaise without anemia)
; oroya fever
- febrile with rapid development of anemia
- clouding of the sensorium & delirium
--> progress to psychosis
- anemia
/
*macrocytic & hypochromic with
reticulocyte counts as high as 50%
- B. bacilliformis
/
*seen on Giemsa stain as
red-violet rods in the erythrocytes
; verruca peruana
- pre-eruptive stage
/ arthralgia, myalgia & paresthesis
- appearance of the eruptive phase
Diagnosis
: clinical grounds in conjunction with a blood smear with typical organisms or via
blood cultures
9. eruptive phage
: typical verruca → Dx. confirm
Treatment
1. sensitive to many antiobiotics
: PC, TC, CM
2. very effective in rapidly lowering fever & eradicating with organism from the blood
3. CM
: drug of choice
4. oral TC
: aid in healing of lesion
Chapter 205. Cat Scratch Disease
* most common cause of chronic (3주이상) lymphadenopathy
: usually develops following cat contact &/or a cat scratch in children & young adults
Etiology
1. all six Afipia species
2 .Two Rochalimaea species
(R. quintana & R. henselae)
3. serologic evidence
: CSD는 A.felis아닌 Rochalimaea에 의해 야기되는 infction의 연관성을 보여줌.
4. samples of cat scratch skin-test antigen
: Rochalimaea antigen (not A.felis) 포함한 CSD Dx에 사용
5. Bartonella
: new preferred nomenclature replacing the genus Rochalimaea
Epidemiology
;
*worldwide & all races
; in temperate climate, 62-88% from september through februray
; in warmer climates, frequently in july and august
;
*more than 80% are less than 21yr
Transmission & communicability
# *cat
contact 95%, dog contact 4%
;
*cat scratch 76%, dog scratch 2%
Pathology
# biopsied LN: bread spectrum of histopathology
① arteriolar proliferation with widening of arteriolar walls
② reticulum cell hyperplasia
③ multiple microabscesses
④ frank abscess formation
⑤ round or stellate granulomas
# cat scratch bacilli
;
*demonstrated best by the
Warthin-Starry silver impregnation stain of LN (removed during the first 4 wk
of illness)
Pathogenesis
# atypical presentation
: 10-14% of pt. with CSD
Clinical manifestation
★Table
205-1
; usually not ill
; ⅓ fever
- greater than 101℉ (38.3℃)
; malaise, fever, fatigue, headache & anorexia
- 50%
; less often
- splenomegaly, sore throat, conjunctivitis, blindness, various rashes & raely arthralgia &/or parotid swelling
Inocular Lesion
1. 60-93% of pt
: 3-5mm inoculation lesion (vesicle or pustule, papule)
3-10 days after introduction of the organism into the skin
Lymphadenopathy
;
★regional lymphadenopathy with single or multiple nodes
- *hallmark of CSD
- within 2wk of the scratch (*range, 7-60days)
;
*proximal LN of inoculation site
; involved LN
-
★axillary, epitrochlear, cervical and/or supraclavicular
/
*80%
- submandibular, preauricular
; 1-5cm size
- estend 10-12cm due to edema, swelling
;
*usually tender
;
*regression over 2-4mo
Atypical CSD
; 9-14%
Oculoglandular Synd.
; *▲frequently
; = parinaud oculoglandular syndrome
;
*conjunctival granuloma at the
inoculation site & preauricular lymphadenopathy
Neurologic Synd
1. 환자의 2%에서 발생
: encephalopathy, coma &/or seizures, myelitis, radiculitis, polyneuritis, paraplegia,
neuroretinitis, cerebral arteritis
2. neurologic Sx.은 lymphadenopathy onset후 1-6주후에 발생
mental status의 갑작스런 변화와 seizure가 특징
Systemic Cat Scratch Disease
1. longer duration of fever, malaise, fatigue, skin rashes, myalgia & arthralgia
2 .generalized lymphadenopathy, larger LN, wt loss (5lb이상)
3. granulomatous hepatitis
4. hematologic manifestation
: hemorrhagic anemia, hepatosplenomegaly, thrombocytopenic purpura,
nonthrombocytopenic purpura & eosinophilia
Diagnosis
1. the most important clues for Dx
① Hx. of contact with animals
(esp. kittens)
② identification of an inoculation skin or ocular lesion
2. regional lymphadenopathy
(cat contact후 몇주후에 발생됨)
: CSD suggest
→ 특히 primary inoculation papule혹은 pustule이 cat scratch후 생겼다면
3. criteria for a definitive diagnosis
① contact with a cat & the presence of a scratch or
primary lesion of the dermis, eye, or a mucous membrane
② a positive skin test for CSD or
positive serologic test for B. henselae antibody
③ negative serologies,
including purified protein derivative skin tests & culures of aspirated pus or LN
performed for other causes of lymphadenopathy
④ characteristic pathologic features in biopsy specimen of skin, LN or ocular granuloma
: clinical practice
→ Dx은 4가지 criteria중 3가지 (+)인 경우
4. confirm in atypical cases
: fourfold rise in titer for B. henselae or by demonstrating small, pleomorphic bacilli
in Warthin-Starry stained sections of LN, skin or conjunctiva
# cat scratch skin test
1. the skin-test antigen (0.1ml)
: injected intradermally on the flexor (volar) surface of the arm
2. exact extent of induration
: 72-96시간후
3. positive reaction
: induration 5mm이상
Laboratory
1. mild to moderate leukocytosis
2 .ESR: elevated during the first few weeks of adenopathy
3. indirect immunofluorescent antibody (IFA) test for genus specific antibodies to
Bartonella antigens
4. PCR analysis of cat scratch skin test antigen
Treatment
1. antimicrobial therapy
: case의 대부분에서 필요없다
→ adenopathy는 2-4개월내 spontaneously subside
2. involved node혹은 enlarged spleen에 대한 trauma피해야 됨
3. antipyretics & analgesics (aspirin or acetaminophen)
: tender adenitis
4. I & D
: not recommended
→ suppuration이 15%에서 생기지만 chronic sinus tract가 발생되며, 수개월간 지속하기 때문에
5. systemic antibiotics
① oral trimethorim (TMP)/ sulfamothoxazole
2 or 3 times daily (10-20mg TMP/kg/24hr) for 7days
: pt의 50%이상에서 효과
② rifampin (15-20mg/kg/24hr PO 2 or3 times daily; maximum dose: 600mg/24hr)
for 7-14 days
: very effective
③ 12세 이상의 children
: ciprofloxacin in two daily doses (20-30mg/kg/24hr PO) for 7-14 days
Prognosis
1. excellent
2. lymphadenopathy
: 2-6개월내 환자의 96%에서 spontaneously regress
3. fatal complication & irreversible sequalae
: 증명된 바 없음
Section 4. Viral Infection
Chapter 206. Meales(Rubeola)
# Three stages
Etiology
Infectivity
; *maximal
dissemination
- catrrhal stage by droplet spray
; *isolation
-
*from the 7th day after exposure
until 5 days after the rash
Epidermiology
# *appearing
in the spring in large cities at 2- to 4-yr intervals as new groups
#
♥Immunization을 15개월에
하는 이유.
; 9개월이후에 maternal Ab는 없어지지만, some pretection이 존재하여 immunization을 방해
Pathology
Clinical manifestation
# Incubation periods ; 10-12days
# prodromal phase
; lasts 3-5days
; low-grade to moderate fever, hacking cough, coryza, conjunctivitis
;
*always precede koplik spots by
2-3days
# ★Koplik
spots
; pathognomonic sign
; grayish white dots as small as grains of sand
; opposite the lower molars
; rarely midportion of the lower lip, on the palate, on the lacrimal caruncle
# Rash
#
*Severity Of Disease
; *directly related to extent & confluent of rash
# ※81주 Rash가 없는
경우
; patients receiving human Ab during the incubation periods
; HIV infection
; infants younger than 8mo
Diagnosis
Differential Diagnosis
Complication
#
♥Chief Complication
; OM
; pneumonia
; encephalitis
# Pneumonia
; by virus itself
- interstitial lesion
- companied by rash
; by secondary infection
-
*bronchopneumonia
-
*more frequent
- pneumococcus, streptococcus, stphylococcus, Haemophilus influenzae
# Other Complication
; gangrene, noma of cheeks
; purpura fulminans, DIC
; myocarditis
;
neurologic complication
#
※95 Neurologic Complication
; encephalomyelitis
; G-B syndrome
; hemiplegia
; cerebral thrombophlebitis
; retrobulbar neuritis
; SSPE(subacute sclerosing panencephalitis)
Prognosis
Prophylaxis
Active Immunization
; initial immunization
- at 12 to 15mo
#
*MMR형태로 second immunization을 해야
한다.
#
♥CIx
; 3mo전에
immune globulin을 투여 받은 자
-
Ab 형성이 되지 않기 때문
; tuberculosis
-
치료중에는 관계 없다.
; pregnancy
; those receiving
immunosuppressive drugs
#
★HIV infected children은
immunization해야 한다.
Passive Immunization
; effective for prevention and attenuation of measles
; *gamma
globulin in a dose of 0.25ml/kg im within 5days after exposures
Treatment
; oral vitamine A(400,000IU)
Chapter 207. Rubella
# older children & adult
; occasionally joint involvement & purpura
Etiology
Epitermiology
; most cases
-
*susceptible teenagers & young
adults
; usually during *the spring
Clinical Manifestation
# *▲characteristic sign
; retroauticular, post.
cervical, postoccipital adenopathy
-
*24hr before rash and remain for 1wk
or more
#
Skin rash
; *begins on the face and spreads quickly
; 2nd day - pinpoint
appearance
; 3rd day - clear
#
WBC counts ; normal or slightly reduced
#
*thrombocytopenia with or without
purpura
#
★Polyarthritis
; *esp. in older girl and women
; arthralgia, swelling, tenderness,
effusion
; *any joint but ▲frequently small joint
of hands
Differential Diagnosis
♥DDx from measles
; no photophobia
; fever - slight during rash
; rash - no more 3 days
; not common anorexia, headache, malaise
#
Diagnositic tests
; latex agglutination, enzyme
immunoassay, passive hemagglutination, fluorescent immunoassay
; rubella-specific IgM
Complication & Prognosis
; neuritis, arthritis
Prevention
# Passive
; ISG within the first 7-8days after exposure
; 0.25-0.5ml/kg
# Active
; live-virus vaccine RA 27/3
★CIx
; Pregnancy
- no cases of congenital rubella syndrome
; immune-deficiency state
; severe febrile illness
; hypersensitivity to vaccine components
; therapy with antimetabolites, corticosteroids, steroid-like substances
★Side Effects of
Immunization
; fever, typical
lymphadenopathy, rash, arthritis, arthralgia
; paresthesia of the hands or
arm
-
at night lasts for up to 1hr
-
recurrent
; pain behind the knee & limitation of motion
※81,84,87 Management Of Pregnant Women
Exposed To Or Acquiring Rubella
; preg. 14wks이후부터 risk of damage 감소
㉿Unknown immune state preg. women이
노출되었을때
--> Ab test immediately as an emergency measure
--> immune state이면, 임신을 계속
--> susceptible state이면, abortion가능 여부에 따라 치료
- abortion을 할 수 없는 경우
/ ISG 20-30ml im immediately
- abortion이 가능하면
/ 반복하여 Ab test
--> rubella develop하거나 subclinical infection on Ab test가 증명되면 abortion
Reinfection
Treatment
; admantanamine hydrochloride(amantadine)
; interferon
; isoprinosine
Chapter 208. Mumps
Etiology
Epitermiology
Pathogenesis
Clinical Manifestation
# incubation period
; 14-24 days
# *accompanies
swelling of submandibular glands
; 10-15% only submandibular glands
Complication
Meningoencephalomyelitis
;
*▲frequent
;
★Pathogenesis
- primary infection of neurons
/ parotitis appears at the same time or following the onset of encephallitis
- postinfectious encephalitis with demyelination
/ encephallitis follows parotitis by 10days
Orchitis, Epididymitis
; impairment of fertility
- 13%
-
*but absolute infertility is rare
Oophoritis
Pancreatitis
Nephritis
Tyroiditis
Myocarditis
Mastitis
Deafness
Ocular Complication
Arthritis
Thrombocytopenic Purpura
Mumps Embryopathy
Diagnosis
Differential Diagnosis
Treatment
Prophylaxia
Chapter 209. Enteroviruses
Etiology
; *RNA
virus belonging to the Picornavididae family
; *retain
activity for several days at room temperature & stored indefinitely at
ordinary freezer temperatures(-20℃)
Epidermiology
; reservoir for human enterovirus
- only human
; transmission
- person-to-person by fecal-oral and oral-oral routes
★Table
209-1
Pathology And Pathophysiology
# ★PM
neuronal lesion
1) spinal cord ; ant. horn cell chiefly and dorsal horn & dorsal root ganglia
2) medulla ; vestibular nuclei, cranial nerve nuclei, reticular formation
3) cerebellum ; nuclei in ther roof and vermis only
4) midbrain ; chiefly graymatter but also substantia nigra and occasionally red nucleus
5) thalamus and hypothalamus
6) pallidum
7) cerebral cortex ; motor cortex
Clinical Manifestation
Poliovirus Infections
1)
*inapparent infection in 90-95%
2) abortive PM
3) nonparalytic PM
4) paralytic PM
Abortive PM
Nonparalytic PM
Paralytic PM
# flaccid paralysis
;
*▲obvious clinical expression
Nonpolio Enterovirus Infections
Asymptomatic Infection
Nonspecific Febrile Illness
Respiratory Manifestation
# Herpangina
; vesicular, ulcerative lesion
- surrounded by erythematous ring in size up to 10mm in diameter
- sites
/ ant. tonsillar pillars : major sites
/ soft palate, uvula, tonsils, pharyngeal wall
Skin Manifestation
# Hand-Foot-Mouth Syndrome
;
*coxsackievirus A16
Differential Diagnosis
Paralytic PM
; infectious neuronitis
; peripheral neuritis
; arthropid-borne encephalitis, rabies, tetanus
; botulism
; demyelinizing types of encephalomyelitis
; tick-bite paralysis
; neoplasma
; familial periodic paralysis, MG, acute porphyria
; hysteria, malingering
Chapter 211. Herpes Simplex Virus
Clinical Manifestation
Acute Herpetic Gingivostomatitis (Acute Infectious
Gingivostomatitis, Catarrhal Stomatitis, Ulcerative Stomatitis, Vincent
Stomatitis)
;
*▲common cause of stomatitis in 1-3yr
; fever : 40-40.6℃
; vesicle
- initial lesion
- later covered with yellow-gray membrane
Recurrent Stomatitis And Herpes Labialis
; one or a few vesicles at mucocutaneous junction
Genital Herpes
; mostly caused by HSV-2
- 10-25% HSV-1
;
★primary site of infection
-
*cervix
; risk factor for HIV infection
Systemic Infection
In The Newborn Infants
In The Immunocomprimized Hosts
;
★▲common syndrome
-
*local & chronic mucocutaneous
disease
/
*typical vesicle & ulcers
progressing to large necrotic painful erosions or atypical exophytic wartlike
lesions
; ▲severe manifestations
- widespread disseminated disease
CNS Infections
Treatment
# primary genital infection
;
*oral acylovir 200mg five times
daily for 5days
- less pain, itching, time to crusting, shorter duration
;
*not prevent recurrence
# recurrent genital infection
; oral acyclovir
;
*prophylactic oral acyclovir
-
*diminish recurrence
#
★IV acyclovir
; 10mg/kg/dose over 1hr every
8hr for 14-21days
-
Tx of choice of herpes encephalitis
; 5-10mg/kg/dose over 1hr
every 8hr for duraton depending clinical response
-
*in comprimised hosts
-
localized mucocutaneous diseases로서 반응이 좋으면, switched to oral
therapy
; *10-20mg/kg/dose every 8hr for 14-21days
-
*all form in neonate
#
chronic suppressive oral therapy
; immunocomprimized patients
with frequently recurring HSV infection
Chapter 212. Human Herpesvirus 6
Clinical Manifestation
Roseola Infantum(Exanthem Subitum)
; sudden onset fever
-
39.4-41.2℃
-
crisis on 3rd-4th day
; bulging ant. fontanelle,
convulsions(5-35%)
; ★Outstanding
Features
-
*absence of physical finding sufficient
to explain fever
; macular or maculopapular
eruption
-
as fever return to normal
-
*start on trunk, spreading arm, neck
; cervical lymphadenopathy
-
not to extent
Infection In The Immunocompromised
; unexplained fever, BM
suppression
; idiopathic pneumonitis
Diagnosis
#
virus isolation
; PB leukocytes in 1st
3-4days by cocultivation with mitogen-treated human umbilical cord blood
mononuclear cells or established T-cell lines
#
detection of Ab
; immunofluorescence,
neutralization, immunoblot, enzyme immunoassay
; *sereocoversion & fourfold rise
#
★Definite Diagnosis
; *exclusion of primary CMV infection
#
HHV-6 antigen or high level of DNA by immunohistochemical or PCR methods
Prophylaxis And Treatment
; no methods for shortening
course of roseola
; in vitro
-
*susceptible to ganciclovir and
foscarnet and much less to acyclovir
Chapter 213. Varicella-Zoster Virus
;
causes chickenpox, shingles
Epidermiology
#
infectivity
; ★24-48hr
before rash & when uncrusted vesicles are present
; 3-7days
Treatment
㉿Table 213-1
Prvevention
#
VZIG
; ♥Indications
-
immunocompromised children, pregnant women, newborn infants exposed to maternal
varicella
- herpos zoster와 close contact시에도 실시한다.
; 1 vial per 10kg im within
96hr, if possible, within 48hr after exposure
; *no effective when given after onset of symptom
#
Acyclovir
; no prophylaxis
#
live, attenuated varicella vaccine(Oka-Merk strain)
; seroconversion *more than 95%
; can be given to children
with leukemia in remission
Chapter 214. Cytomegalovirus
;
mostly inapprent
;
*▲common
congenital viral infection
--> hepatosplenomegaly,
jaundice, petechia, purpura, microcephaly
;
normal immunocompetent adults
- mononcleosis-like syndrome
Etiology
; largest of herpesvirsues
Epidermiology
#
sources
; saliva, milk, cervial &
vaginal secretions, urine, semen, stools, blood
#
transmission
; person-to-person or via
contaminated formites
Clinical Manifestation
#
young children
; *pneumonitis, hepatitis, hepatomegaly, petechial rashes
#
older children
; *mononucleosis-like syndrome
-
fatigue, malaise, myalgia, headache, fever, hepatosplenomegaly, abnormal liver
function tests, atypical lymphocytosis
#
immunocompromised patients
; *pneumonitis(▲common), hepatitis,
chorioretinitis, GI disease, fever with leukopenia
; often fatal
Prevention
Passive Immunoprophylaxis
Active Immunoprophylaxis
; indication
-
seronegative women of childbearing age, seronegative transplant recipients
; live attenuated vaccines
-
*immunogenic but wanes quickly
Chapter 215. Epstein-Barr Virus
Epidermiology
; transmitted in oral
secretion by close contact or exchange of saliva
; environmental source or
formites not contribute to spread
#
developing conturies & socioeconomically disadvantage populations
; occurs during infancy and
early childhood
#
affluent populations
; *occurs during childhood(▲common),
1/3 during adolescence & adults
#
primary infection in adolescents & adults
; *manifest more than 50%
; ★classic
triad
-
fatigue, pharyngitis, generalized lymphadenopathy
#
*rarely apparent in children younger
than 4yr
; aymptomatic
Pathogenesis
#
*infection of B lymphocytes in blood
& entire lymphoreticular system
#
★Atypical Lymphocytes
; CD8+ T lymphocytes
-
suppressor and cytotoxic functions
; resulting in transient
reversal of normal 2:1 CD4+/CD8+ T-lymphocytes ratio
#
*lifelong latent infection after
primary illness
; carried in oropharyngeal
epithelial cell and B lymphocytes
Clinical Manifestation
#
RES involvements
; generalized lymphadenopathy
- 90%
; splenomegaly - 50%
; hepatomegaly - 10%
#
skin rash
; maculopapular
; 3-15%
; *if treated with ampicillin or amoxacillin, 80% rash onset
-
unknown
Diagnosis
#
confirmed by serologic testing
Treatment
#
short course of corticosteroids
; less than 2wks
; not evaluated critically
; ♥Indication
-
incipient airway obstruction, thrombocytopenia with hemorrhage, autoimmune
hemolytic anemia, seizures, meningitis
; prs 1mg/kg/24hr(maximum
60mg/24hr) for 7days and tapered over another 7days
Chapter 216. Influenza Viral Infections
Complication
#
*OM, pneumonia
; common
#
myocarditis, toxic shock syndrome
Chapter 217. Parainfluenza Virus
Etiology
Chapter 218. Respiratory Syncytial Virus
Epidermiology
# placentally transmitted Ab
;
*partial protection
- uncommon severe infection in 1st 4-6wks
# ★Bronchiolitis
(45-75%), childhood pneumonia(15-25%), croup(6-8%)
Clinical Manifestation
# first sign
; rhinorrhea, pharyngitis
# young infants
;
*periodic breathing, apneic spells
Prognosis
# worse in young, premature infants or those with underlying disease of neuromuscular, pulomonary, cardiovscular, or immunologic system
Chapter 219. Adenoviruses
; pharyngoconjunctival fever, follicular conjunctivitis, epidemic keratoconjunctivitis, hemorrhagic cystitis, acute diarrhea, intussusception, encephalomyelitis
Etiology
Epidermiology
Pathology And Pathogenesis
Clinical Manifestation
Acute Respiratory Disease
Conjunctivitis And Keratoconjunctivitis
Gastrointestinal Infection
; *1/2 enteric types 40 or 41
Hemorrhagic Cystitis
; sterile hematuria, dysuria,
frequency, urgency
; last 1-2wks
; *type 11, 21
Reye Syndrome Nd Reye-Like Syndromes
Infection In Immunocompromised Hosts
Diagnosis and Differential Diagnosis
Chapter 221. Hepatitis A Through E
Hepatitis A
Etiology
; 27nm diameter, RNA-containing virus, Picornavirus family
Epidermiology
# prevalence
;
*100% in children by the age of
5yr
# *only
cause acute hepatitis
# more symptomatic in adults
;
*most childfhood infection are
asymptomatic or mild, nonspecific manifestations
# transmission
;
*person-to-person by fecal-oral
route
Chapter 222 Rotavirus And Other Agnets Of Viral Gastroenteritis
# Rotaviral Infection
;
*▲important cause of severe dehydrating diarrhea in early
childhood
Etiology
Rotaviruses
; wheel-like, double-shelled icosahedron containing 11 segments of double-strand RNA
; *Classification
- group A, B, C, D, E
- subgroup I or II
; Group A
- no antigenic relationship
- common human antigen
; Group B
- cause of severe disease in infants and adults in china but not elsewhere
; Group C
- occasional human outbreaks
# Subgrouping is determined by *inner capsid protein, vp6
# ★G type
; *serotyping by outer capsid glycoprotein, vp7
# ★P type
; *serotyping by outer capsid glycoprotein, vp4
Epidermiology
Rotaviruses
; *▲common in winter in temperate climates
; *incidence
is not due to single prevalent strain or serotype
--> several serotypes for one or two seasons
; *most
clinical cases in younger than 2yr(but older than 3mo)
; subclinical infection & outbreaks in newborn nurseries
Pathology And Pathogenesis
; *selectively
infect & destroy villus tip cells in small intestine
--> 1) imbalance of ratio of intestinal fluid absorptio
2) malabsorption of complex carbohydrates, particularly lactose
; biopsy finding
- villus blunting, roud cell infiltration in lamina propria
; *pathologic
changes not correlate with severity of clinical symptoms
Clinical Manifestation
Laboratory Finding
Diagnosis And Differential Diagnosis
Treatment
Prevention
Chapter 224. Human Papillomavirus
Epidermiology
Clinical Manifestation
Diagnosis
; no routine laboratory tests
;
*biopy or cytology of specimens
- koilocytes, dysplastic changes
Chapter 225. Arboviruses
225.1 Dengue Fever And Dengue-Like Disease
225.2 Dengue Hemorrhageic Fever And Dengue Shock Syndrome
225.3 Other Viral Hemorrhagic Fevers
★Table 225-2
225.4 Yellow Fever
225.5 Japnes Encephalitis
Chapter 226. Hantavirus Pulmonary Syndrome
Chapter 227. Rabies
Prevention Of Rabies
Pre-Exposure Prophylaxis
Post-Exposure Pophylaxis
★Table 227-1
Local Treatment
Passive Antibody
; human rabies immune globulin
- 20IU/kg
-
*half of dose sc at the site of
bite or scratch
Active Immunization
Chapter 228. Slow Viral Infection Of The Human Nervous System
Slow Infections With Convential Viruses
Subacute Sclerosing Panencephalitis
Progressive Rubella Panencephalitis
Other Chronic Conventional Viral Infections Of The Nervous System
Slow Infections With Unconventional Viruses : The Subacute
Spongiform Encephalopathies
# ★2
Diseases
1) kuru
2) CJD
3) its variants, gerstmann-sträussler-scheinder syndrome
Clinical Manifestation
# kuru
; progressive degenerative disease of the cerebellum and brain stem
;
*cerebella ataxia
-
*1st sign
Other Degerative Diseases Of The Cental Nervous System Possibly
Caused By Unconventional Viruses
section 5. mycotic infections
Chapter 229. Candida
Chapter 230. Aspergillosis
Hypersensitivity Syndromes
Allergic Bronchopulomonary Aspergillosis
# ♥Criteria
1) reversible paroxysmal bronchodilator obstruction
2) immediate cutaneous reactivity to A. fumigatus antigens or specific serum IgE to A. fumigatus (RAST)
3) elevated total serum IgE
4) peripheral blood eosinophilia
5) precipitating serum antibodies against A. fumigatus
6) proximal bronchiectasis
Chapter 231. Histoplasmosis
Clinical Manifestation
# ★3
Forms
1) acute pulmonary infection
2) chronic pulmonary histoplasmosis
3) progressive disseminated histoplasmosis
Acute Pulmonary Infection
;
*mostly asymptomatic
; prodromic flulike symptoms
- headache, fever, chest pain, cough
; hepatosplenomegaly
- more often in infants, young children
; maybe significant respiratory distress, hypoxia, requiring intubation, ventilation, steroid therapy
; prolonged illness
-
*10days to 3wks
- weight loss, dyspnea, high fever, asthenia, fatigue
;
patchy bronchopneumonia, *hilar adenopathy
; histoplasmonas
; mediastinal granulomas
Treatment
# no treatment
; aymptomatic or mild symptomatic pulmonary histoplasmosis
# mediastinal complication
; surgical treatment
Chapter 233. Coccidioidomycosis
Etiology
; fungus Coccidioides immitis
# no person-to-person transmission
Clinical Manifestation
# ★3
Forms
1) benign, self-limites, primary infection (60%)
2) residual pulmonary lesion
3) rare, disseminating sometimes fatal disease
Primary Coccidioidomycosis
Residual Pulmonary Coccidioidomycosis
Desseminated Or Progressive Coccidioidomycosis
(Coccidioidal Granuloma)
Treatment
# oral azole
;
과거에는 primary
coccidioidal infection이 spontaneously recovery 되므로 antifungal agents을 사용하지 않았으나 *최근에는 oral azole의
등장으로 사용을
많이 한다.
# Antifungal chemotherapy
; indication
- high risk for severe coccidioidomycosis
- metapulmonary dissemination
; Amphotericin B
※97
Side Effect
① Thrombophlebitis ; common
② Anemia
③ Renal toxicity
④ Agranulocytosis
⑤ hepatic insufficiency⑥⑦⑧⑨
; fluconazole po or iv
; ketoconazole or itraconazole
; miconazole
- intrathecal or intraventricular
Chapter 234. Cryptococcosis
Etiology & Epidermiology
# cryptococcus neoformans
;
*▲common
;
*predominant in HIV infection
individual
Chapter 237. Pneumocystis Carinii Peumonitis(Interstitial Plsma Cell Pneumonitis)
※97 life-threatening infection in
ther lungs of an immunosuppressed host
Etiology and Epidemiology
; host-specific nature
; *no
defined human-to-human transmission
; most humans - before 4yr
; healthy host - asymptomatic
; infants and children - 40%
adults with AIDS - 70%
children with leukemia - 12%
patients with organ transplants - 10%
Pathogenesis and Pathology
; found in alveolar space: cyst form 5-8um
; *attach
to Type I alveolar epithelial cells by adhesive proteins such as fibronectin
and mannose-dependent ligand
; cell-mediated immunity is major role
♥ Histopathology
1. infantile form(=infantile interstitial plasma cell pneumonitis)
; in epidemic outbreaks
; around 3-6mo age
; extensive infilatration with thickening of the alveolar septum - plasma cell prominent
2. sporodic form(=diffuse desquamativbe alveolar disease)
; immunocompromized patients
; large numbers of P. carinii in a foamy exudate with alveolar macrophage in alveoli
; alveolar setpum - no infiltration
Clinical Manifestation
1. infantile form
; subtle onset
;
*no fever
; progressing to intercostal, suprasternal, infrasternal retractions
; nasal flaring, cyanosis
2. sporodic form
; more common
; abrupt onset
; fever, tachypnea, dyspnea, cough
; progressing to nasal flaring, cyanosis
;
*rale usually absent
; extrapulmonary site infection - retina, spleen, bone marrow
Chest X-ray
; bilateral diffuse alveolar disese with granular pattern
;
*sparing the apical areas until
last
Diagnosis
1)
*bronchoalveolar lavage ; more
practical
2) tracheal aspirates
3) transbronchial lung biopsy
4) bronchial brushings
5) percutaneous transthoracic needle aspiration
6)
*open lung biopsy ; most reliable
※97 Treatment
; fatal within 3-4wks without treatment
1)
*Trimethoprim(15-20mg/kg/24hr) +
sulfamethoxazole(75-100mg/kg/24hr)
; *first choice
; *2wks for non-AIDS, 3wks for AIDS
2)
*Pentamidine isethionate
; *4mg/kg/24hr
; *frequent adverse effect
3) Atovaquone
4) Trimetrexate glucuronate
5) Trimethoprim-dapsone
6) Clindamycin + primaquine
7) Corticosteroids
; increase survivals
Prevention
# ♥Indication
; HIV infection
; severe combined immunodeficiency syndrome
; organ transplantation
; those receiving intensive immunosuppressive therapy for cancer or other diseases
# Chemoprophylaxis
1) Trimethoprim(5 mg/kg/24hr) + Sulfamethoxazole(25 mg/kg/24hr)
; daily or 3 days per wk
2) Dapsone
3) Dapsone + pyrimethmamine
4) Pentamidine by aerosol
section 6. rickettsial infections
Chapter 238. Rickettsiae
Clinical Manifestation
★Table
238-1
Pathogenesis
section 7. parasitic infections
Chapter 244. Protozoan Diseases
244.5 Giardiasis And Other Protozoal Disease
Giardia Lamblia
; ubiquitous GI protozoa resulting clincial picture from asymptomatic to acute or chronic diarrheal illness
Clinical Manifestation
; mostly asymptomatic
244.7 Malaria
Epidermiology
# transmission
; bite of infected Anopheline mosquitoes
- natural method
; congenital malaria
; neonatal malaria
Clinical Manifestation
# cerebral complication
# splenomegaly
Diagnosis
# *identification
of parasites in the blood
Treatment
# 4 categories
1) specific chemotherapy for the attack, whether fresh infection, recrudescence, or relapse
2) supportive treatment and management of complication
3) specific chemotherapy to prevent late relapse of vivax or ovale infections
4) specific chemotherapy to destroy or sterilize gametocytes and to protect the community if mosquitoes are present
# specific chemotherapy for the attack, whether fresh infection, recrudescence, or relapse
; chloroquine phosphate or hydroxychloroquine sulfate
- 10mg base/kg po then 5mg base/kg 6hr later, then 5mg base/kg daily for 2days
; quinine sulfate
- 25mg/kg/24hr #3 po for 10-14days
; parenteral adminstration of chloroquine or quinine
-
*persistent vomiting, coma, no
swallowing
-
*as possible as po due to shock
244.8 Toxoplasmosis
Epidermiology
# transmission
; oral route via undercooked or raw meat containing cysts or by ingestion of oocytes
;
*no person-to-person transmission
-
*except) transplacental infection,
organ transplantation or transfusion infection
Clinical Manifestation
Congenital Toxoplasmosis
Transmission
; *50% of untreated women
-
transmit parasite to their fetus
; *incidence
-
*least early in gestation &
greatest later in gestation
; *more severe clinical symptoms in transmission early in gestation
Genetics
Spectrum And Frequency Of Signs And Symptoms
# range from mild signs, such as SGA, prematurity, peripheral retinal scars, persistent jaundice, mild thrombocytopenia, CSF pleocytosis
to classic triads
#
★Classic Triads
; chorioretinitis,
hydrocephalus, cerebral calcifications
#
normal newborn in perinatal periods
; more than half
; *almost ocular involvement later of life
Acquired Toxoplasmosis In Immunologically Normal
Individuals
#
*enlargement of one or a few LN in
cervical regions
; *▲common symptom
Ocular Involvement In The Older Child
Toxoplasmosis In The Immunocompromized Patients
Laboratory Diagnosis
Laboratory Diagnosis Of Congenital Toxoplasmosis
Laboratory Diagnosis Of Acute Acquired Toxoplasmosis
Infection In The Immunocompetent Individuals
Laboratory Diagnosis Of Ocular Toxoplasmosis
Treatment
Therapeutic Agents
Treatment Of Congenital Toxoplasmosis
;
*treated for 1yr
#
1st 6mo
; pyrimethamine 1-2mg/kg/24hr
po for 2days
then
1mg/kg/24hr for 2mo
then
1mg/kg/24hr Monday, Wednesday, Friday
+ sulfadiazine or tiple
sulfonamides 100mg/kg loading dose then 100mg/kg/24hr #2
+ calcium leukovorin
5-10mg/24hr Monday, Wednesday, Friday
#
2nd 6mo
; alternate months with
spiramycin 50mg/kg bid a day
Chapter 245. Helminthic Diseases
245.1 Ascariasis
Clinical Manifestation
# pulmonary ascariasis
; cough, blood stained sputum, eosinophilia
;
*loeffler-like syndrome
# intestinal ascariasis
;
*obstrution th gut or biliary
tracts
245.3 Echinococcosis
;
*▲prevalent,
serious human cestodes infection
Etiology
245.6 Eosinophilic Meningitis
Etiology
;
*Angiostrongylus cantonensis
- *▲common
;
Gnathostoma species
245.8 Flukes: Liver, Lung, and Intestine
Clonochiasis
Fascioliasis
Etiology
;
*Fasciola hepatica
Lung Flukes(Paragonimiasis)
; Paragonimus westermani
; older children, adolescents 11-15yr
; asso. /c eating raw freshwater crayfish or crabs
Clinical Manifestation
; most asymptomatic
; hemoptysis in 98%
;
cough, production of *rust-colored sputum
; marked eosinophilia
; extrapulmonary infiltration
- brain, peritoneum intestines
Chest X-ray
;
*small patchy infiltrates
;
*radiolucencies in the mid-lung
fields
; rare case
- lung abscess, pleural effusion, bronchiectasis
Treatment
; prziquantel 25mg/kg po tid in 1 day
245.9 Hookworms
; three species
- Ancylostoma duodenale
- Necator americanus
- Ancylostoma ceylanium
Pathology And Pathogenesis
# anemia
;
*major pathologic manifestation
245.13 Toxocariasis
Visceral Larva Migrans
Etiology
; larva of toxocara sp.
Clinical Manifestation
;
*fever(80%), cough with
wheezing(60-80%), seizures(20-30%)
; abdominal pain
; hepatomegaly(65-87%), rale or rhonchi(40-50%), urticarial skin lesion(20%), LN enlargements(8%)
Cutaneous Larva Migrans
Etiology
# ★Ancylostoma
Braziliense
;
*▲common
# *Necator
americanus, Ancylostoma duodenale, Stronglyoides stercoralis
; human parasites