Part 17-4. Infectious Diseases

Section 4. Viral Infection

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

  # actinomycosis 보통 opportunistic inf. 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


  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


; 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

       case 15-40%

  4. skin

     : 3rd most commonly involved organ

  5. renal nocardiosis

     : 4th most common site

       dysuria, hematuria, or pyuria


  1. direct examination of clinical material for characteristic gram-positive, acid-fast organism

  2. isolation by culture methods


  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 mortality 50%

     : 진단지연에 의한 또는 severely compromised host defense가진 환자의 debilitated state 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


  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


   : clinical grounds in conjunction with a blood smear with typical organisms or via

     blood cultures

  9. eruptive phage

   : typical verruca Dx. confirm


  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


  1. all six Afipia species

  2 .Two Rochalimaea species

     (R. quintana & R. henselae)

  3. serologic evidence

     : CSD A.felis아닌 Rochalimaea 의해 야기되는 infction 연관성을 보여줌.

  4. samples of cat scratch skin-test antigen

     : Rochalimaea antigen (not A.felis) 포함한 CSD Dx 사용

  5. Bartonella

     : new preferred nomenclature replacing the genus Rochalimaea


    ; *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%


# biopsied LN: bread spectrum of histopathology

   arteriolar proliferation with widening of arteriolar walls

   reticulum cell hyperplasia

   multiple microabscesses

   frank abscess formation

   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)


# atypical presentation

   : 10-14% of pt. with CSD

Clinical manifestation

Table 205-1

    ; usually not ill

  ; 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


    ; 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. lymphadenopathy onset 1-6주후에 발생

     mental status 갑작스런 변화와 seizure 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


  1. the most important clues for Dx

   Hx. of contact with animals

      (esp. kittens)

   identification of an inoculation skin or ocular lesion

  2. regional lymphadenopathy

    (cat contact 몇주후에 발생됨)

    : CSD suggest

      특히 primary inoculation papule혹은 pustule cat scratch 생겼다면

  3. criteria for a definitive diagnosis

   contact with a cat & the presence of a scratch or

      primary lesion of the dermis, eye, or a mucous membrane

   a positive skin test for CSD or

      positive serologic test for B. henselae antibody

   negative serologies,

       including purified protein derivative skin tests & culures of aspirated pus or LN

       performed for other causes of lymphadenopathy

   characteristic pathologic features in biopsy specimen of skin, LN or ocular granuloma

      : clinical practice

        Dx 4가지 criteria 3가지 (+) 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


  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


  1. antimicrobial therapy

    : case 대부분에서 필요없다

      adenopathy 2-4개월내 spontaneously subside

  2. involved node혹은 enlarged spleen 대한 trauma피해야

  3. antipyretics & analgesics (aspirin or acetaminophen)

     : tender adenitis

  4. I & D

    : not recommended

      suppuration 15%에서 생기지만 chronic sinus tract 발생되며, 수개월간 지속하기 때문에

  5. systemic antibiotics

   oral trimethorim (TMP)/ sulfamothoxazole

      2 or 3 times daily (10-20mg TMP/kg/24hr) for 7days

     : pt 50%이상에서 효과

   rifampin (15-20mg/kg/24hr PO 2 or3 times daily; maximum dose: 600mg/24hr)

      for 7-14 days

      : very effective

   12 이상의 children

      : ciprofloxacin in two daily doses (20-30mg/kg/24hr PO) for 7-14 days


  1. excellent

  2. lymphadenopathy

       : 2-6개월내 환자의 96%에서 spontaneously regress

  3. fatal complication & irreversible sequalae

       : 증명된 없음

Section 4. Viral Infection

Chapter 206. Meales(Rubeola)

# Three stages



; *maximal dissemination

    - catrrhal stage by droplet spray

; *isolation

    - *from the 7th day after exposure until 5 days after the rash


# *appearing in the spring in large cities at 2- to 4-yr intervals as new groups

# Immunization 15개월에 하는 이유.

    ; 9개월이후에 maternal Ab 없어지지만, some pretection 존재하여 immunization 방해


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

# 81 Rash 없는 경우

    ; patients receiving human Ab during the incubation periods

    ; HIV infection

    ; infants younger than 8mo


Differential Diagnosis


# 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)



Active Immunization

; initial immunization

    - at 12 to 15mo

# *MMR형태로 second immunization 해야 한다.

# CIx

    ; 3mo전에 immune globulin 투여 받은

           - Ab 형성이 되지 않기 때문

    ; tuberculosis

           - 치료중에는 관계 없다.

    ; pregnancy

    ; those receiving immunosuppressive drugs

# HIV infected children 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


; oral vitamine A(400,000IU)

Chapter 207. Rubella

# older children & adult

    ; occasionally joint involvement & purpura



; 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


# Passive

    ; ISG within the first 7-8days after exposure

    ; 0.25-0.5ml/kg

# Active

    ; live-virus vaccine RA 27/3


    ; 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. women 노출되었을때

    --> Ab test immediately as an emergency measure

    --> immune state이면, 임신을 계속

    --> susceptible state이면, abortion가능 여부에 따라 치료

           - abortion 없는 경우

                   / ISG 20-30ml im immediately

           - abortion 가능하면

                   / 반복하여 Ab test

                           --> rubella develop하거나 subclinical infection on Ab test 증명되면 abortion



; admantanamine hydrochloride(amantadine)

; interferon

; isoprinosine

Chapter 208. Mumps




Clinical Manifestation

# incubation period

    ; 14-24 days

# *accompanies swelling of submandibular glands

    ; 10-15% only submandibular glands



    ; *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








Ocular Complication


Thrombocytopenic Purpura

Mumps Embryopathy


Differential Diagnosis



Chapter 209. Enteroviruses


; *RNA virus belonging to the Picornavididae family

; *retain activity for several days at room temperature & stored indefinitely at ordinary freezer temperatures(-20)


; 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


# 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


# 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


# infectivity

    ; 24-48hr before rash & when uncrusted vesicles are present

    ; 3-7days


Table 213-1



    ; Indications

           - immunocompromised children, pregnant women, newborn infants exposed to maternal varicella

           - herpos zoster 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


    ; largest of herpesvirsues


# 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


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


    ; 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


# *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


# confirmed by serologic testing


# 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


# *OM, pneumonia

    ; common

# myocarditis, toxic shock syndrome

Chapter 217. Parainfluenza Virus


Chapter 218. Respiratory Syncytial Virus


# 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


# 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



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


    ; 27nm diameter, RNA-containing virus, Picornavirus family


# 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



; 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



; *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



Chapter 224. Human Papillomavirus


Clinical Manifestation


    ; 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


# no treatment

    ; aymptomatic or mild symptomatic pulmonary histoplasmosis

# mediastinal complication

    ; surgical treatment

Chapter 233. Coccidioidomycosis


    ; 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)


# oral azole

    ; 과거에는 primary coccidioidal infection spontaneously recovery 되므로 antifungal agents 사용하지 않았으나 *최근에는 oral azole 등장으로 사용을 많이 한다.

# Antifungal chemotherapy

    ; indication

           - high risk for severe coccidioidomycosis

           - metapulmonary dissemination

    ; Amphotericin B

           97 Side Effect

                   Thrombophlebitis ; common


                   Renal toxicity


                   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


    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


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


# 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


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


# transmission

    ; bite of infected Anopheline mosquitoes

           - natural method

    ; congenital malaria

    ; neonatal malaria

Clinical Manifestation

# cerebral complication

# splenomegaly


# *identification of parasites in the blood


# 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


# 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


    ; *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


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


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


245.6 Eosinophilic Meningitis


; *Angiostrongylus cantonensis

    - *common

; Gnathostoma species

245.8 Flukes: Liver, Lung, and Intestine




    ; *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


    ; 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


    ; 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


# Ancylostoma Braziliense

    ; *common

# *Necator americanus, Ancylostoma duodenale, Stronglyoides stercoralis

    ; human parasites