NORMAL FLORA

Gram + or Gram - ??
o If the part of the body that is affected is EXPOSED TO O2 Gram + Aerobe
But if Hiding from O2 Gram + Anaerobe
o If part of the body that is affected is NOT EXPOSED TO O2 Gram Anaerobe
If in both locations with or without O2 Facultative
Facultative Anaerobe prefers no O2
Facultative Aerobe prefers O2
Anaerobe Clues
o Air fluid levels
o Bad breath, body odor, Farts
o Bleach works by introducing oxygen to the bacteria!!!

SKIN
Staphlococcus aureus
o MCC of skin infections
Cellulitis Flat red area; + blanching
Oomphalitis cellulitis around umbilicus of a newborn
Mastitis cellulitis around breast
Panniculitis cellulitis as a ring around abdomen
Folliculitis infection of a hair follicle
Pus at the base of the hair shaft
Carbuncle small nodular indurated area with infection
Furuncle hari follicle in the middle of carbuncle no pus
Ballintitis infection of the head of the penis
Fascitis Compartment syndrome

Compartment Syndrome
5 Ps
Pain (occurs 1st)
Palor
Poikliothermia
Parathesia
Pulselessness (occurs last)

Strep pyogenes
o S. aureus is the MCC for skin infections except for these 5 cases where it is Strep pyogenes who
is responsible
LINES
Lymphangitis infection follows lymphatic channels = red streak
Impetigo honey crusted lesions ( if bullous d/t Staph aureuss elastase
activity)
Necrotizing fascitis flesh eating strep Compartment Syndrome
Erysepelas raised edges; do not blanche (vs. cellulitis)
Scarlet Fever
How did a bacteria pick up nasty traits?
o sand paper rash
- Tranduction Phage
o Strawberry tongue
o Rash on PALMS & SOLES

Staph epidermidis
o Action is under the epidermis where it is the most abundant
o Primarily due to:
Shunt Infection
Central Lines
These both penetrate the skin underneath the epidermis

Propriobacterium Acne
o Exposed to oxygen but hiding under skin = Gram + ANAEROBE
o Affinity for Propionic Acid found in sebaceous glands
o Affinity for Progesterone
+ Females > Males
Caused by birth control pills/shots acne 2 weeks prior to menses
More common in pregnancy
o HATES O2
Therefore, acne treatment is based on exposure to O2 (Oxy 10)
o Acne Medications
Start with Oxy 5/10 Abrasive pads (open pores to O2 ) ABX treatment:
Clindymycin, Erythromycin, Minocycline (T4)
If these dont work need the BIG GUNS
Retin-A = previtamin A Stimulates skin to grow thereby pushing the bug out
for oxygen exposure
SE:
o Photosensitivity (because forming new immature skin cells that are
susceptible to damage
o Absorbed in the ileum Hyperlipidemia
o Fat soluble teratogenic

MOUTH/THROAT/ESOPHAGUS

Strep pyogenes
o Resides in the back of the throat
o Rheumatic Fever
Jones Criteria = SPECC
Subcutaneous nodules
Polyarthritis (MC)
Erythema marginatum = little red dots with margins
Chorea (Syderham)
Carditis MS >> AS/MS >> AS >> TS MC
o Strep is swallowed lungs returns via pulmonary vessels MV
o Fish mouth appearance (MS)
Pt. most likely had a prior strep infection in last 2 weeks
o Post Strep GN
Strain 12
Have IgA Protease allows bacteria to live in the mouth
without IgA killing them
Strep. Pneumonia

#1 way to paralyze cilia VIRUS

H. influenza
o Virus paralyzes cilia making the lung susceptible to
Neisseria
infection!!!
o Catarrhalis
o Cilia no longer has ability to sweep them up and out
o Meningitis
o S. pyogenes has no capsule so type I pneumocytes
o Gonorrhea
can eat them up or cause infection
MCC of Sinusitis S. pneumo, H. influ, Neisseria in that order

GUMS = Facultative anaerobes

Peptococcus
Peptostreptococcus
Fusobacterium
o Fused at the edges and tapered at the end
Vincent Angina = painful ulcers in the back of the throat
Trench mouth = pus oozing from the gums

Actinomyces
o Sulfur granules
o Fistula tracts
Strep viridans MCC of subacute bacterial endocarditis (SBE)
o Mutans responsible for dental caries ferments glucose produces lactic acid
o Sanguis
o Salivarius
Cold agglutins

STOMACH

Helicobacter pylori
o Urease +
o Duodenal gastritis is highly associated
o Dx: H2 Breath Test
o Treatment
Amoxicillin
Tetracycline/Metronidazole
Bismuth suffocates bacteria
H2 Blocker/Pump Blocker
o Infections most likely due to bad sewage systems

SMALL INTESTINE 95% are oxygenated facultative aerobes

E. coli
o Anything to do with S. int. think E. Coli
o Vitamins produced by E. Coli
Vitamin K
Cofactor for Clotting factors 2,7,9,10, protein C & S Measure PT
o This is why broad spectrum drugs can cause bleeding
Folate
Biotin
Panthotenic acid
Helps absorb Vitamin B12 in the ileum
COLON 95% of gas is CO2 also not exposed to oxygen GRAM s

Proteus
o 2nd in line for UTI
Klebsiella
o Currant jelly sputem

Big Mama Anaerobes:

Clostridium melangosepticus
Strep bovis
Bacteriodes fragilis
Rx: Clindymycin, Cefoxitin, Metronidazole

o MC in alcoholics and homeless

o 3rd in line for UTI
o Likes to hang out in the fissures of the lungs pneumoniae
Enterobacter
Citrobacter
o Multiple cerebral abcesses in the newborn 0-2 mos.
Clostridium difficile
o Pseudomembranous colitis d/t chronic antibiotic use
o Gastroenteritis after antibiotic use
Clostridium perfingens
o Gastroenteritis associated with holiday ham

RECTUM
Group B Strep
E. coli
Lysteria

STAPH Species:

All 3 are main causes of sepsis in

the newborn

lactam ring

Staphlococcus aureus:
Gram + cocci in clusters; gold pigment
Enzymes:
o Catalase + breaksdown hydrogen peroxide
o -lactamase breaks through lactam containing drugs
o coagulase & staphlokinase
Allows for the ability to eat through clots
MCC of Acute Endocarditis has ability to eat through the valves
MCC of death for burn unit patients in the first week
lactamase cuts
here
o Lipase breaksdown fat
Panniculitis
Folliculitis
Mastitis
o Elastase
Bullous Emphysema/pneumatocelle
o Collagenase affects skin and bones
MCC of Osteomyolitis (Salmonella is the 2nd MCC of bone infection)
Type IV (basement membrane) Scalded Skin, Kidney, Lung also affected
Type III (endothelium arteries affected) Vasculitis
Type II (connective tissue) MCC Fascitis and Septic Arthritis (gonorrhea #2) and
Folliculitis
Toxins:
o Exfoliatin/SSSS-T: Staph Scalded Skin Syndrome
Red rash all over the body sloughs off = Nikolsky sign (recall its also seen with
Penphiguis vulgaris)
Involves the PALMS & SOLES
o Erythrodermic Toxin

Causes Scarlet Fever

o Lecithinase
Causes skin infections Subcutaneous fat
o TSST: Toxic Shock Syndrome
Triad:
High Fever
Hypotension shock
Bright red rash all over the body especiallyPALMS & SOLES
Associated with retained tampon in a female
If you see just MENSES.CLICK AND MOVE!!!
o Enterotoxin
Causes food poisoning associated with dairy products Gastritis
Custard Pie
Staph infections usually arrive after flu-like symptoms

Treatment for Staph:

o Vancomycin best treatment but expensive
o Macrolides
o Chloramphenicol
o 1st Generation Cephalosporins
o Quinolones

Staph epidermidis:
Enzymes:
o Catalase +
Resides underneath skin
White pigment
MCC Shunt infections and Central line infections
Treatment
o Vancomycin however, there are now vanco. Resistance
o Linezolid
This is a lorefin drug and not fully tested but is an alternative to vanco. Resistentance
Staph Saphrophyticus
NO PIGMENT
Enzymes
o Catalase +
Symptoms
o Frequent cause of UTI:
Ages:
5-10 because they tend to play with themselves more at this age
18-24 post coital UTI, especially with no circumcision
o Recall that E. Coli is the MOST COMMON CAUSE OF UTI!!!
STREPTOCOCCUS SPECIES:

General Characteristics
o Gram + cocci in CHAINS

o Groups A, B, C, D
o Types of hemolysis
-hemolysis partial hemolysis Green Zone
-hemolysis complete hemolysis Clear Zone
-hemolysis no hemolysis Red Zone
Streptokinase is responsible for -hemolysis it is used for breaking up clots and
binds up fibrinogen in acute MI, but if patients had recent Strep infection, the patient has
built antibodies to streptokinase and it will not work This is the reason that they
doctors use tPA instead!!!
Dosing: 75,000 units IV bolus and 75,000 units drip
Works by converting plasminogen plasmin breaks up the clot
Binds up fibrinogen wontt allow for anymore clots
o Allows 1-3% to bleed to death
o tPA causes < 3% to bleed to death
o APSAC can induce tPA reversal

Strep Strains:
Immunity is type specific, that is why you can get recurrent strep infections

Strep pneumoniae aka Pneumococcus

o Gram + diplococci
o hemolysis

o 80 Strains
o Pneumococcal vaccine (pneumovax)
Covers 23 strains that account for 98% of infections by Strep pneumo.
Who needs it?
Everybody > 65 y.o.
> 2 y.o. with Sickel Cell
o Functional asplenic after age 2
o Recall that the spleen is the organ that can rid the body of encapsulated
organisms
End Organ Failure
o It is most likely that encapsulated cause that will kill DM and CF patients
PSGN
o Skin or throat strep can cause PSGN
o Associated with Strain 12
Group A: Strep pyogenes
o hemolytic

o 70 Strains
o #2 for skin infections
o #1 for throat infections only throat Strep causes Rheumatic Fever

Group B: Strep agalactaciae

o #1 Cause of Neonatal Sepsis
o - hemolytic

Group D: Strep viridians (mutans, saguis, salivarius)

o Green pigment
o - hemolytic
o #1 Cause of Subacute Bacterial Endocarditis
With Septic emboli to the brain mycotic aneurysm
Roth Spots = septic emboli to the retina
Oslers nodes = septic emboli to the fingers
Splinter hemorrhages = septic emboli to the nail bed
Janeway lesions = septic emboli to the toes
A previously traumatized heart valve will predispose to SBE
o Treatment:
Amoxicillin 3 g 2 hrs. before surgery
Amoxicillin 1.5 g 6 hrs. after surgery
Essential to protect any mucosal surface type surgery

Enterococcus (Faecalis, Faeceum)

Anaerobic
hemolytic

Likes immunocompromised patients

Nitrite Negative UTI
Treatment
Vancomycin Treatment:
o Vancomycin
MRSA
Staph epidermidis
Enterococcus
Vancomycin
MOA:
o Cell wall inhibitor
o Inhibits phospholipids carrier (Nam-Nag)
o Irreversible (non-competitive inhibitor)
Treatment for all Gram +
Toxicity
o Ototoxicity
o Nephrotoxicity
o Red Man Syndrome
d/t intense histamine release
This is not an allergic reaction

Causes of Meningitis
0-2 mos
o 1 - Group B Strep
o 2 E.coli
o 3 Lysteria
2 mos. 10 yrs.
o 1- Strep. Pneumoniae
o 2 - Neisseria
10 21 years
o 1 Neiserria
> 21 years
o Strep. pneumoniae
SPORE FORMERS
Spores:
o Composed of Ca2+- dicholinate
o Contain a poly D glutamate membrane
The D gives the spore the ability to create a bad reaction in the body because we
dont have D-amino acids, we have L-amino acids!!!
o Spores hate HEAT!!!
That is why sterilization is useful against spores
Bugs with Preformed
toxins:
- Bacillius anthrax
- B. cerus

Bacillis
o Anthrax
2 Types:
Skin necroses of the skin
o Form a Malignant pustule
Pulmonary Woolsorters Disease
o Induces necrosis of the lung end up drowning in your own blood
o Most commonly used in germ warfare
Toxin has 3 Factors:
Edema Factor
Protector Factor
Lethal Factor the one that causes death
o B. Cereus
Associated with Gastroenteritis after eating fried/reheated rice
+ Preformed toxin symptoms within 8 hours of ingestion

Clostridium
o C. Perfringens
Causes Gas Gangrene (strict anaerobe)
Known to attack the extremities of Diabetics
Dry Gangrene
Necrotic Skin
Wet Gangrene
What we fear since blood tried to go back to necrotic area it will bring gas emboli
back into the circulation which can lodge in the Right Ventricle Gas
Embolus!!!
Treatment
o Lay person in the L side and tap on the right side
Requires immediate amputation
Causes gastroenteritis associated with holiday ham/turkey reheated
Immediate symptoms DIARRHEA
o C. difficile
Pseudomembranous colitis associated with abx. Intake
Lives in the GI but when the abx. Clears E.coli it grows rampantly
Pseudomembrane appears as a gray membrane
Treatment
1st stop abx.
ABX:
o Vancomycin
o Metronidazole
MOA: promotes production of free radical
Contraindicated in G-6PD patients
SE dysguzia, disulfiram reaction
o C. tetani
Associated with Dirty Wounds
Give anti-immunoglobulin to bind up toxin inject it right into the wound
Toxin

Inhibits the release of glycine (remember that glycine has an inhibitory fxn) in the
spinal cord will cause an contraction respiratory failure
o Lock Jaw
o Rhizorus Sardonicus
Strychnine works the same way
Need to give antitoxin
C. botulinum Botulism
o Toxin inhibits pre-synaptic release of Ach flaccid paralysis (floppy baby)
Muscles wont work Die of respiratory failure b/c diaphragm not working cant
breath in Restrictive lung disease you know the profile!!!
o Children
Contract it from dark caramel syrups (honey/molasses)
Do not give children honey until 6 mos of age because by 6 mo. They will have a normal
flora that can fight against anaerobes
o Adults
Ingest spores via canned foods
o Treatment:
Antitoxin first
Abx. 2nd

Lysteria monocytogenes (curved rod) recall Vibrio, Lysteria, Camp. H. pylori

Produce endotoxin
o Will die fast
o Produce granulomas
Even though it is a bacteria it attacks tissues therefore involveing Tcell and monocytes
#3 cause of Neonatal sepsis
Gastroenteritis in Adults
o Migrant workers
o Cabbage
o Spoiled milk
o Hot dogs
Treatment
o Vanomycin
o Macrolides
o Ampicillin

GRAM NEGATIVE
Hemophilus Influenza
80% are not encapsulated Non-invasive disease
Type B
o ENCAPSULATED = DISEASE
o MCC of Epiglotitis
H. ducreyi
o Chancroid ulceration with central necrosis (appears as a black scar in the middle)
o PAINFUL genital lesion
H. aegypteus (gram negative with pleomorphic rods)
4 Causes of PAINFUL genital lesions:
1.) Chancroid
o Pink Eye conjunctivae is red and swollen

2.) HSV-7 crop of vesicles coming

together and then ulcerate
3.) LGV (Lymphogranuloma
venereum) d/t Chlamydia
4.) Granuloma Inguinale ulcerated

Looks like eye ball is being pushed out

Neisseria
N. meningitides
o Gram negative diplococci
o Largest encapsulated bacteria
Requires MAC complex to fight it
Only encapsulated organism that can release its toxin without dying at the same time
o Ferments maltose
o Use a Thayer Martin Agar (chocolate agar) to plate
o Has more endotoxin than anyone else
Lipid A will cause
Early vasculitis (present with DIC)
o Purpura
Present like this no matter the age
o Petechiae
always assume Neisseria as the culprit
o Ecchymoses
If bleed into the adrenal glands = Waterhouse-Fredriechson Syndrome
o DIC will cause adrenal hemorrhage
o Look for Na/ K = electrolyte imbalance
o Treatment Start Prednisone/Cortisol
o Associated with people in close quarters college students
o Treatment
Prophylaxis for close contact Rifampin
N. gonorrhea
o MCC of STD Chlamydia
But 90% are asymptomatic
o MCC of symptomatic/purulent STD Gonorrhea
Called the drips
Men 90% symptomatic
Women 50 % asymptomatic
+ perihepatitis Fitz-Hugh-Curtis Syndrome
o Fallopian tube affected and pus drops next to the liver
o Disseminated gonococcal infection
Can become disseminated due to its pili
The pilli allows it to walk up the epithelium and into the bladder and into the blood
stream
o Tenosynovitis
N. gononrrhea loves to attack the tendons and ligaments
Joints of the wrist and ankles
Present with dysuria and painful wrist 3 days later
o Gonococcal Arthritis
Comon in teenagers
o Treatment
Must also treat for
Ceftriaxone 250 mg IM x 1
Chlamydia:
Cefixeme 400 mg IM x 1
- Azithromycin 1 g x 1
Cefoxitin 250 mg IM x 1
Ciprofloxacin
Oflaxacin

Gatofloxicin

Recall that Neisseria is Catalase + and contains IgA protease

N. cattarrhalis formally known as Morexella
o Normal throat flora
o Cattar = mucous therefore this bug likes mucous membranes
Engaging in oral sex chances for this bug

E. coli
Gram negative ROD
Vitamins produced by E. Coli
o Vitamin K
o Folate
o Biotin
o Panthotenic acid
o Helps absorb Vitamin B12 in the ileum
Illness
o MCC of UTI in all Ages
o All small intestine infection iliocystitis, ascending cholangitis (alk. Phos), appendicitis
etc
o MCC of travelers diarrhea
o #2 in neonatal sepsis
Families
o EIEC = Enterinvasive E. Coli
Regular travelers diarrhea
Loose stools
o ETEC =enterotoxigenic E. Coli
ADP-ribosylates Gs Turns the On, On cAMP
Looks like rice water stool
Same toxin as Vibrio cholera
Most often due to poor sanitation
o EHEC Enterohemorrhageic E. Coli
Endemic HUS
0157:H7 Epidemic HUS
HUS
o Occurs 2 weeks after E. coli infection
o Likes medium sized arteries (GI/Renal)
MCC of renal failure in children
Most commonly associated with RAW HAMBURGER
Lives in the anus of cows

Proteus mirabilis
#2 cause of UTI
Urease + (PPUNCH)
o + struvite stones

UTI infections
1. E.coli
2. Proteus
3. Klebsiella

Treatment:
o Norfloxacin

Klebseilla pneumonia
#3 cause of UTI
Encapsulated
Associated with pneumonia in alcoholics and homeless
currant jelly sputem suputem + blood
Loves fissures of lungs
GRAM NEGATIVES THAT ATTACK IMMUNOCOMPROMISED PATIENTS

Serratia mascecents
o Red pigment
Acenetobacter
Citrobacter
o Encapsulated
o + Multiple Cerebral Abcess
Pseudomonas aeruginosa
o Contains the same enzymes as Staph green pigment
Can cause same sickness
Same populations affeceted
CF
Diabetic
Burn patients
Neutropenic
o Treatment:
If Staph 1 abx
If Pseudo 2 abx
Next treat for fungus
o Can become normal flora after 48 hrs. in the hospital (need to cover for it!!!), because it loves
plastic
Catheters
Intubation
o Infections
Malignant otitis externa
Red, swollen Very tender when ear is lifted
Can kill patient quickly
Tx: Hospitalize ICU IV abx
NOT SWIMMERS EAR
Most commonly associated with Burn patients in the 2nd week
Whirlpool folliculitis
Loves to live in the water
Butt crack and soles of feet meet water first INFECTION
o Treatment:
Quinolones (ciprofloxacin) can cover pseudo and staph together

HOUSE OF ella
General Characteristics:
o Gram negatives that like to get into the cell
o The symptoms dont start until late but lasts only a few days
o Granulomatous change
Involves T-Cells and M
Involves tissues that are invaded by M
Brain, Bone, Liver, Lung, Skin, etc.
Bordatella pertussis = Whooping cough
o Gram
o NO ENDOTOXIN
o Exotoxin
ADP riboslyate Gi Turns the Off, Off Gs remains on
o 3 stages of Whooping cough
Prodromal little fever/rhinorrhea not a big deal
Catarrhal production of mucous in lungs
Paroxysmal staccato coughing
Cough so much that cant catch breath so the suck in a whole bunch of air that
creates a WHOOP sound
o DTaP vaccine available
o ELISA Test and nasal pharyngeal washing used to test for antigens in the back of the throat
o Treatments:
Erythromycin (macrolides)
Also, give this to those in close contact
o CBC
WBC lymphocytosis

Brucella
o Undulating fever (fever spikes 7x/day)
o Risk
Veterinarian
Can be found in the placenta of an aborted aninmal
o B. abortus cows
o B. suis pig
o B. militensis goats
Pasturella multocida
o Dog/cat bites
Bacteria is in the saliva
Treatment: Amoxicillin

Shigella
o Gastroenteritis associated with day care outbreaks
o Shiga Toxin
Neurotoxic cause seizures
o Dysentary Most common in the world
o Sonnei most common in America
Salmonella
o Gastroenteritis associated with raw chicken and raw eggs
o Encapsulated
o Likes to live around anus of chicken when egg comes out it will be wrapped in Salmonella
o If treated, salmonella will hide in the Gall Bladder
So, do not treat or you will increase carrier state
Treatment = public health risk
o S. dysentery
MC world wide
5 Bugs/Diseases that cause Heart Block:
o S. enteritids
1. Salmonella - Typhoid Fever
MC in America
2. Lyme
o S. typhi = Typhoid Fever
3. Legionella
Triad:
4. Diptheria
High fever
5. Chagas
Heart block
Rose Spots
Symptoms:
Intestines are on FIRE
Treatment:
Ciprofloxacin
Francisella tularensis
o Tularemia
o Symptoms:
Fever
Red Eye
Swollen glands
o Transmission
Rabbits
Treatments:
Streptomycin
Bartonella henselae
o Swollen lymph nodes Cat Scratch Fever
o Silver stains in the lymph nodes

01-29-04
Miscellaneous Gram Negatives
Vibrio cholera
o Rice water diarrhea
Similar to ETEC Turns the On, On
ADP ribosylates Gs cAMP
o Etiology = Sanitation
Vibrio parahemolyticus
o Raw Fish sushi
o Gastroenteritis
Vibrio vulnificus
o Gastroenteritis associated with Oysters
Yersina entercolitica
o Gastroenteritis that mimics appendicitis actually acute ileitis
o Mesenteric adenitis = swollen lymph nodes
o Seen in daycares
o Associated with Reiters Syndrome
Post infectious arthritis immune complex disease
(+) HLA B27
Ankylosing spondylitis (scarring/fusion of the spine)
o Most commonly in a middle age male
o Begins in the lumbar area Bilateral scaro-iltis (@sacro-iliac joint)
HLA B27 (+)
o Ankylosing of lumbar spine fusion
height
Ankylosing
Schoeber test spine does not move when asl to bend over
spondylitis
o Die of aortic dilatation AR
Reiters
Reiters Syndrome
Syndrome
o Post infectious arthrititis
o MC infectious associations
Psoriasis
Chlamydia
Shigella
Yersina
IBD
o Most treat unrderlying problem 1st
Psoriasis
o Oval, silvery plaques on extensor surfaces usually the back of the
forearm
o Recall that this relates to rapidly dividing cells (skin) possible uric acid
stones
Yersina pestis

o Bubonic plague/Pneumonic Plague

o Rat carries it, rat bitten by fly used as a VECTOR
o Bubbo = infected crop of lymph nodes fluctuant mass
o Used in germ warfare
o Presentation: A guy still alive walking in Mexico or Arizona Likes dry heat
Camoylobacter jejunii
o Gastroenteritis associated with ingestion of raw eggs
4 Bugs that are comma/curved
o Comma/Curved shaped
shaped:
o Tx:
- Vibrio cholera
Macrolide Erythromycin
- H. pylori
- Campylobacter
- Lysteria

ATYPICALS
General characteristics
o Dont have a cell wall
Therefore, cant use PCN
Rx:
Tetracycline
Macrolide
Quinolone
o They are not real bacteria therefore, a cell mediated reaction will take place
o organs that are invaded by macrophages will be affected
Chlamydia
Chlamydia Trachomatis
o Most common cause of STD (cervicitis, PID)
o Most common cause of infertility in women
Congunctivitis in Newborn:
o Most common cause for ectopic pregnancy
0-24 hrs.- chemical caused by silver
Chlamydia tested with pap smear.
nitrate
90% are asymptomatic
24hrs 7 days = Gonnorhea
#1 cause of neonatal blindness in the world
After day 7 = Chlamydia
o trachoma
Deep ulceration of cornea
Transmitted via birth
o treated with erythromycin ointment/sulfacitomide drugs
Treatment: Azythromycin: 1 gm
o Dont confuse with CMV which causes congenital blindness (not of the newborn)

Chlamydia Pneumonia
o Symptoms:
stacatto coughing
Due to irritation of the interstituim
o 0-2 months- atypical pneumonia
MCC of Interstitial pneumonia
Present severely short of breath
Non-productive cough
o On X-ray
Reticulonodular
Ground glass appearance

o Parasite:
On blood smear can see T cells and M
Cause eosinophilia
This can help separate it from the other atypicals
o Only one with DNA and RNA
Inranuclear and enteronuclear cyto inclusion bodies
o 2 phases:
Elementary infectious phase
Reticulate resting phase
Dormant activity because it is invading your cell for ATP
o Associated with:
Alzheimers Ag in neurofibrillary tangles in the hippocampus
Coronary artery disease find in atherosclerotic plaque

Chlamydia Psittacii
o Associated with parquets and parrots.
o Cause pneumonia in the lungs
Intersitial Pneumonia

Opthalmia Neonatorum (gonnorhea)

Treated with silver nitrate

Ureaplasma
Urease positive (pseudomonas, cryptoccocus, proteus, ureaplasma, H. pylori)
No cell wall = plasma only no epithelial lining at all
Non gonnococal urethritis
Mycoplasma Pneumonia
Most common cause of atypical pneumonia age 10-30
5 infections that cause
Walking pneumonia
Cryoglobulinemia
o In the interstitium of the lungs
I AM HE
o CXR findings:
1. Influenza
Interstitial pattern
2. Adenovirus
Ground glass appearance
3. Mycoplasma
Reticulonodular pattern
4. Hep B
Has Mycolic acid in membrane (not true bacteria)
5. EBV
Has no cell wall
Spends too much time in blood, so body forced to make antibodies to them
o Cryoglobulinemia = cold agglutinins
IgM
Acute infection only
Detect by using an antigen from Strep Salivarius
o Ex. Patient positive for Strep salivarius antigen which is the same as cold agglutinins.
Bullous myringitis
o Located on tympanic membrane
Cold Agglutinins
Warm Agglutinins
Mycoplasma Hominis
Cause vaginitis
RARE

IgM
Acute Inflammation

IgG
Chronic Inflammation

Legionella pneumophila
Most common atypical pneumonia after age 40
Loves standing water found in heating and air-conditioning ducts
High rise building syndrome
Pontiac fever = get just fever due to IL-1 + non-specific symptoms
Legionnairs disease = full blown pneumonia
Will silver stain in the lung (along with pneumocyctis corinii)
Charcoal yeast agar extract (CYAE) will grow it.
(+) Heart Block

Atypical pneumonia
0-2 months - chlamydia
10-30 years - Mycoplasma
>40 years - Legionella

Mycobacterium:
Mycolic acid with peptidoglycan wall
o But not typical bacteria T-cells and macrophages affecting tissues that macs invade
Rx:
o INH
o MOA: Inhibit peptidoglycan wall
o SE:
Pull Vitamin B6 out of system (used by transaminases)
Myositis
Hepatitis (fat soluble)
Inhibits p450 (macrolides, inh, quinilones)
Drug induced lupus
TUBERCULOSIS
TB
1st. Contact Bacteris inhaled tubercule sticks to respiratory epithelium and develops into Ghon focus.
Wont even know got it = Asymptommatic
o Ghon focus
o Ghon complex - M ingest bacteria and bring them to the lymph node M tries to fuses
with a lysosome but cant
Cord factor inhibits lysosomal fusion
o IL-1 fever, recruit T - helper celss = Granuloma formation
o IL-2 to release more response
o IL-12 promote cell mediated immunity
o Macs and T-cells start secreting interferons
Interefere with protein synthesis and cells start dying around it granuloma in he right
lower lobe
As cells die they calcify =dystrophic calcification
o Macs and T-cells start secreting TNF:

 Wt. Loss
o When T lymphocytes are knocked out by prednisone or decreased immunity, the tubercule will
come out and cause a cavitary lesion.
TB pops out into the airway and begins to rip up the vasculature Cough up blood
Can stay dormant waits for opportune time
nd
2 Contact
Lesion symptomatic causing cavitary lesions in the upper lobe
o Cough b/c the bacteria needs to get up the the upper lobe because it has the most O2 = 20 Upper
lobe cavitary lesion
o Bacteria Explodes out of its cavitary lesion again hoping to get back to GI tract.
Cough and swallow
Causing obstruction in ileum (bacteria gets absorbed because its fat soluble) where all
lymphoid tissue exists and tries to stop infection
But it cannot Ileum swells up = Obstruction
3rd Contact
Milliary TB:
o When gets into blood stream and goes all over body
o Arrives everywhere M go
Meningitis:
MC affected nerve = CN III posterior fossa (+) hydrocephalus
CN 9, 10, 11 12
Potts disease = TB of spinal cord (+) compression fracture

Sterile Pyuria (in Kidney)

White cells in urine that wont go away
Skin rash = eythema nodosum
Hepatosplenomegaly
Bone
Adrenal failure = Na/K
Pericarditis
Diffuse ST elevation

PPD Test
Most people dont know they have TB until PPD test
o Intadermal injection
1 (strength) used when just want to prove a symptomtic case of TB
5 used for screening
250 used only in AIDS patients b/c have no CD4 cells Hypersensitive skin
o watch a granuloma create
Positive test:
o 15mm induration with no risk factors
o 10 mm induration with 1+ risk factors:
all health care workers
3rd world countries (Africa, Asia, South America, Philippines, inner city projects, nursing
homes, jail) Overcrowding
o 5mm for Aids patients
o 10% risk of getting TB if come in contact with someone who had it ( + 1 risk factor)
o After one year treatment with INH the risk will go down to 1% (general population)
o AIDS patients= 10%/year risk of getting TB
Tend to get multiple drug resistant TB

Tend to get infected with new strains

+PPD

MANAGEMENT
Positive ppd
Sx
o Symptomatic
Treat
o Asymptomatic
CXR
Treatment
Treatment:
Everyone must be given 4 drugs for 4 mos.
INH
4 drugs for 4 months for
Rifampin
everybody, if Tb is
o (-) subunit of RNA Poly
sensitive to INH and
Pyrizinamide
Rifampin can finish the
o Unknown
year with just Rifampin
and INH otherwise cont.
o SE Liver Failure
with all four.
Ethambutal
o Unknown
o SE Impairs Red-Green discrimination
Streptomycin
o Aminoglycoside
D Cycloserine

No Sx

CXR

Negative
CXR

treatment

<35yo

INH, Vit. B6

>35yo
Yearly
CXR

Mycobacterium Leprae
Leprosy
Hansens Disease
Neuropathy
o d/t granuloma formation around nerves
Lion Like Facies
Treatment:
o Dapsone
o SE inhibits p450, Autoimmune hemolytic anemia
Mycobacterium Kansasii
swollen lymph nodes
Mycobacterium Avium Intracellulare
CD4< 100
Experience gastroenteritis before it hits the lung
Drug of choice = Clarithromycin & Azithromycin
Mycobacterium Scrofulaceum
Granuloma Formation
Supraclavicular adenopathy in children
Granulomas secrete
Remove lymph nodes
o INF- Made by M
Mycobacterium ulcerans
(+) Protein Syn.
Show up as ulcers
o INF- Made by T-cells
Mediate M
transformation into
Giant cells,

 (+) Caseating granulomas

Mycobacterium marinum
Cleaning fish tanks
Caseating granulomas
Spirochetes spiral shaped, flipping motility, (+) cell mediated response
Treponema Pallidum
Rule of 6s
o Classic painless chancre (disappear in 6 wks)
o 6 wks later a rash will develop involving the palms and soles (scarlet fever, TSS)
o Will appear 6 yrs. Later with neuropathy neurosyhpyllis
Lancinating shooting stabbing
like a pin cutting the skin
Will attack dorsal columns tabes dorsalis = wide gait
Attack Edinger Westphal nucleus part of reactive vision (coordination between CN III-VI)
syphilic eye accommodates but not reacts = Argyll-Robertson Pupil
Loves bone that is how to differentiate neonatal syphilis
o Flat forehead
o Snuffles- nasal bone gone
o Hutchinsons teeth teeth look razor sharp
Saber tooth shins with anterior bowing of the legs Tibia eaten away
Long fissure along corner of the mouth = Rhagades
TORCH Neonatal Infections
Toxoplasmosis multiple ring enhanced lesions in the parietal lobe Cat
exposure
Other
Rubella cataracts, hearing loss, autism, blueberry muffin rash, PDA
CMV Central calcifications, #1 Cause of congenital blindness
Herpes temporal lobe encephalitis
Testing for Syphilis:
Dark field microscopy (most specific test)
Blood Test :
o FTA ABS (IgM antibody test)
IgM will bind if it is present
o TPI (Trep. Pallidum Immobilize)

Specific blood test

Screening
VDRL (CNS for tertiary syphilis) sensitive but not specific can remain postive for 1 yr after
treatment
RPR blood sensitive but not specific, used for screening can be positive for life
Treatment:
1 syphilis: Penicillin (procaine) 1.2 million unit x1
2 syphilis: Penicillin 2.4 million units x1 each buttock
3 syphilis: Penicillin 2.4 million units 1/wk for 3 wks.
Neonatal: 50,000 units/kg/day for 10 days

Syphilic aortitis = obliterative endarteritis (tree bark appearance of blood vessels) proximal aorta
only.

Treponema Pallidum Variant Bijel

Treponema Pertenve Yaws
Treponema Carateum Pinta

All come in with rash disappear with no

consequence

Borrellia Borgdorfori:
Lyme disease: EAST COAST
o 1 stage: Bitten by tick (Ixodes tick) (only 60% report bite)
tick also carries babesiosis
stage: rash
Erythema chronicum migrans
o 2 stage: arthritis, heart block,
o 3 stage: neuropathy (non-specific)
o Dx: Lyme titers
Check antibodies to Lyme (IgM < 2 mos. and IgG > 2 mos.)
o Treatment:
Penicillin
Tetracyclin

Bulls eye lesion

that enlarges
over time

Ixodes Tick Vector

Lyme Disease
Babesiosis
Erlichiosis

Borrellia Recurrentis
Relapsing fever get fever once a wk for 5-6 wks Check the history
o Brill Zinsser disease = pathogen hides in lymph nodes and comes out once a wk slightly
mutated
Leptospirosis Interogens
Sewege worker, because it is in rat urine
Likes to attack liver and kidney
o Weils disease = infectious nephritis and hepatitis
o Fort Brag fever
Treatment: Penicillin
SULFA Drugs

MOA
o Replaces PABA competitive inhibition
o Inhibits Folate
SE: Megaloblastic anemia
Coverage
o Gram (+)
No S. aureus
o Simple Gram (-)
E. coli
H. influenza
SE:
o Photosensitivity

o
o
o
o

Allergic reaction
G6 PD
Hemolytic anemia
Intersitial nephritis

Fungi:
Like warmth and moisture
o B/w skin folds, groin, axilla, vagina
o Prevention = Keep Cool and Dry
Loves sugar think about Diabete
Contains Ergosterol- target for drugs
Topical do not get absorbed = NO SE
o Nystatin
o Tinactin
o Micatin
o Myconazole
MOA: Bind to ergesterol, make hole in membrane and cells swell up and die
Amphoteracin B (IM/IV) also binds to ergesterol, but gets confused with cholesterol and pokes holes in
cells of body:
o SE:
Hyperkalemia systemic toxicity
Hypokalemia renal toxicity K will leak out in urine
Renal failure
Inhibit synthesis of ergosterol cant use with amphoteracin B because it will have nothing to bind to =
SE
o Hraconazole
o Ketoconazole inhibits p450, inhibits 5-reductase
o Fluconazole has best CNS penatration, x bbb, 1 dose PO treatment against candidisis (diflucan)
o Griseofulvin
Fat soluble drug that inhibits microtubles = (-) Mitosis
Superficial fungi:
Piedre
o Little black balls on the hair shaft like dead cells on hair
o Tx. Cut hair off.
Cutaneous Fungi:
Give Tinea name
Location will give last name:
o Tinea Capitus thick flaky crusty lesions of the scalp
MC in children
Kerion = complication caused by bacterial infection (S. aureus) of flaky lesion,
swollen lesion underneath
o Need to treat fungi, bacteria, and inflammation
o Tinea Babae on chin
o Tinea Intertrigo skin touches skin (armpits, underneath breasts)
Red macerated area
o Tinea Corporis on body, most commonly on the face
Ring worm
o Tinea Manis on hand (webs between fingers)
o Tinea Nigra flaking on the palms causing darkening of the life lines
o Tinea Cruris on the groin (jock itch)
o Tinea Pedis between toes (athlete foot)
o Tinea Versicolor on the back, in the shape of a upside down x-mass tree
Likes pigment
Common in blacks and Hispanics see pigment changes.

Treatment: Gresiofulvan (best for capitus and versicolor) or Selsin blue (5% selenium)

Deep fungi:
Tinea Unguum (underneath nail)
o Need to remove the nail the nail turns black
o Seen in a Diabetic foot
Systemic fingi:
Candidiasis
o Most common cause of vaginitis (#2 Gardenella fishy odor, #3 Trichomonas frothy
green discharge) in females and thrush in neonates (Beware of DiGeorge) white curdy
discharge
Mucocutaneous Candidiasis
o T-cell defect involving only candidiasis
Histo Midwest
o Pigeons, bats
o Lives within macrophages
Blasto Northeast
o Pigeons
o Big Broad Based Budding hyphae cavitary lesions
Coccidio Southwest
o Broad based cavity
o Thin wall cavity
Paracoccidio South America
o Looks like a ship wheel
Aspergillus Moldy hay/basement
o Fungus ball
o Bad vasculitis (invades blood vessels)
o Severe allergic reaction in the lungs due to fibers. (mimics asthma) PIE syndrome
PIE = Pulmonary infiltrate with eosinophilia
Most common cause is ABPA (allergic bronchopulmonary aspergillosis)
Loeffler (worms) invades the lung
Churg-Strauss necrotizing vasculitis, idiopathic
o Treatment: Steroids
Cryptococcus AIDS pt. With headache/meningitis
o Encapsulated
o Stains with Indian Ink
o Urease positive
Rhizo/Mucor
o Diabetic with something growing out of nostrils
Sporothrix rose bush
o Treat with Potasium Iodide on skin and treat like any other fungus if it is systemic.
Enterococcus will cause nitrite negative UTI

Parasites GASTRITIS
T cells, macrophages and eosinophils
How did you get it
Liver flukes:
o Schistosomiasis walking bear foot in a swamp snails carry it
Mansoni affect the liver Risk for CA
Hematobium- squamous cell bladder cancer (chonic irritation)
o Toxacara :
Carti cat larvae
Cani- dog larvae
Cutaneous larva migrans can see larva burrowing under the skin Itchy
Visceral larva migrates to organs (liver)
o Echnococcus from eating raw lamb/sheep/dogs
o Clinorchis Sinensis/Opthorchis likes biliary tract
Clue for biliary involvement is Alkaline Phosphatase
Causes gastroenteritis
Treatment of Liver flukes with Praziquantel
Hook worms
Hook into the intestinal/bowel wall
Cause sever cramps and diarrhea
Pneumonic = NEAT ASs:
o Necator americanus
o Enterobius Vermiculris- pin worm
Symptoms: pruritis ani (ass itching) (caused by eggs)
Scotch tape test: only female comes out at night to anus to lay eggs
Worm lives in the cecum
o Anclystoma Duodenale
Duodenal obstruction
o Trichuris Trichurium Whip worm
Anchors into rectum causing tenesmus (feel the nee to poop!!!)
And rectal prolapse b/c the worm will get bigger and push it back farther
o Ascaris lumbricoides
o Strongyloides
Treatment:
o Mobendazole (vermox) give 1 tablet and then repeat in a week = DOC
Paralyzes microtubules cant hook on
o Pyrantel Pamaoate specific treatment for pin worm
o Thiobendazole treatment for Strongyloides

NASA = parasites associated with loffler syndrome = endocarditis & pneumonitis

Part of their life cycles occur in the heart and lungs
Necator americanus
Anclystoma duodenale
Schistosomiasis
Strongyloides
Ascaris lumbricoides
(Pulmonary infiltrate and severe eosinophilia)

Flat Worms:
Will curl around the intestine
D. Latum
o Likes to eat B12 (homocystiene methyl transferase, methyl malonyl mutase)
Tanea Saginatum
o Associated with raw beef
Tanea Solium larvae from Cystericerosis
o Raw pork
o Likes to swim in the aqueous humor of the eye

Trichinella Spiralis
o Raw bear meat
o Tunnels under muscles causing myoisitis
Treatment:
o Hyclosamine
o Niclosamide
These inhibit oxidative phosphorylation = ATP

Protozoa:
Brain:
o Naeglaria Fowleri
swimming through swamp penetrates through cribiform plate
fulminant meningo encephalitis eat through meninges and brain
o Toxoplasmosis
Associated with cat litter
Parietal lobe ring enhanced lesion
Treatment = Pyremethamine/ Sulfadiazine
o Trypanosomaa Rhodienses
Carried by Tsetse fly GABA connection
African sleeping disease
Cornea:
o Acanthomoeba
Associated with contact lenses
Will eat through cornea
o Erlichiosis
Dog licking face
Picked up via saliva
Penetrates side of the eye (puncture wound next to eye)

 Heart:

Lung:

o Trypanasoma Cruzi
Chagas disease
Eats ganglia and causes heart block
Get it from South America
Reduuvid bug
o Pneumocystis Corinii
Silver stains (along with Legionella)
CD4 count below 200
Treatment: Bactrim (SMX-TMP)

GI:
o Giardia gastroenteritis
Loves fresh water/ well water hiking in the moutains
Treatment- IV metronidazole
o E. histolyticum
Multiple liver abscesses
Never do surgery
Treatment: metronidazole (8wks)
o Microsporidium
Most common cause of diarrhea in AIDS patients
o Cryptosporidium
Most common cause of VERY WATERY diarrhea dehydration
Partially acid fast
Treatment Cipro
o Isospora Belli
GU:

Skin:

o Trichimonas
# 3 cause of Vaginitis
Treatment:
Metronidazole 2g x 1
Also treat partner

Common causes of vaginitis in order of

incidence:
1. Candida- white cheesy curdy
discharge
2. Gardnerella fishy odor, clue
cells
3. Trich- frothy green discharge

o Leschmaniasis
Gulf war syndrome
Transmitted by sand flies
o Leschmania Donivini
Attacks skin and nostrils
o Leschmania Rhodiensis
Likes to be systemic (in the blood) Attacks organs
Caled Kala-Azar if systemic
Treatment Stibogluconate
Lymphatics:
o Wucheria Bacrofti
Elephantitis
No treatment
Blood:
o Babesiosis

 Just like malaria but acts in the East coast

Looks different only on smear
Treatment with anti malarial
Carried by Ixodes tick (lyme disease)
o Plasmodium:
Malaria most common strain world wide
Fever every 3rd day Quartian (fortnight)
Falciparum most fatal (can hemolize all mature RBCs most rapidly)
Black water fever (urine turned black with bilirubin)
Vivax go to liver (chronic malaria)
Prophylactic Meds:
Likes reticulocyes (young RBCs)
1 pill/2wk before you leave
Ovale - go to liver (chronic malaria)
1/wk while gone
Likes mature RBC
4 wks after coming back
Symptoms:
total tx wks = 6 wks + wks away
Malaria = quartian
o Gives you fever every third day
Falciparum, vivax, ovale = tertian
o Gives you fever every other day
Usually associated with travel
Oxidize RBC membrane causing
Treatment:
hemolytic anemia and killing
Quinine
bacteria with it not good for G6PD
Chloraquine mostly RBCs
b/c it will lyse these cells
Mefloquine good liver penetration.
toopatients.
Primaquine best liver penetration
o Always start for vivax and ovale
o Important reasons for treatment:
Malaria is the most common parasite
Most common infectious disease related cause of death in the world
Most common cause of hemolytic anemia in the world.

Rickettsia
(+) Eosinophilia
Likes to invade blood vessels causing vasculitis bleed or clot.
Symptoms:
Purpura
Ecchymoses
Petechia
Cerebral hemorrhage
Nephritic syndrome
Hemoptysis
Melena/ melachesia
Microcytic hypochromic anemia
Blood Test will show:
o High platelets, eosinophilia, hypochromic anemia
Rickettsia Rickettsia
o Rocky mountain spotted fever
o RMSF Tick (deer, dermacanter andersoni)

o Petichial rash involving palms and soles

o Centripital rash = From periphery to torso
Rickettsia Typhi
o Endemic typhs
o Flea born
o Rash starts in axilla and going outward
Rickettsia Prowzekii
o Epidemic typhus
o Louse born
Rickettsia Akari
o Rickettsial pox fleshy papules/ vesicles
o Mites
Rickettsia Tsutsugamushi
o Scrub typhus
o Caused by mite (mighty mite)
Coxiella Burnetti (long lost relative)
o Q fever
o Find in dusty barn
o Doesnt behave like rest of rickettsia family NO vasculitis
Just get lung disease