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Full text of "Diagnosis and Management of Infectious Diseases"

Diagnosis and Management of Infectious Diseases 

Phillip Petersen, B.Sc, F.A.S.M. 
Queensland Medical Laboratory and Queensland University of Technology 



Copyright Phillip Petersen 

First Published 1997 

Last Update November 2008 

Published by 

Wordnet, 

32 Bligh Street, 

Rochedale South Qld 4123 

Australia. 
Phone/Fax (0T) 3341 5795 
Email: wordnet@wordnet.com.au 
Website: www.wordnet.com.au 
© 2007 All rights reserved. 
ISBN 0-9578981-0-X 
Copying for educational purposes: The Australian Copyright Ret 1968 (the Act) allows a maximum of one chapter or 
10% of this book, whichever is the greater, to be copied by any educational institution for its educational purposes provided 
that that educational institution (or the body that administers it) has given a remuneration notice to Copyright Agency 
Limited (CAL) under the Act. For details of the CAL licence for educational institutions, contact: 
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Copying for other purposes: Except as permitted under the Act (for example, a fair dealing for the purposes of study, 
research, criticism or review) no part of this book may be reproduced, stored in a retrieval system, or transmitted in any 
form or by any means without prior written permission. All enquiries should be made to the publisher at the address above. 
Disclaimer: The information contained in this manual is the sole responsibility of the author. Neither Queensland Medical 
Laboratory nor Queensland University of Technology bear any responsibility for the inclusion of any material therein or for 
any use to which it may be put; nor do they hold any claim for remuneration for the use of the material. Though the 
information herein is given in good faith and is believed to be accurate and as current as possible, the author does not 
expect anyone to act solely on this information without consulting other appropriate documentation or authorities. Mention of 
commercial products does not constitute endorsement. 



Contents 

Preface v 

Part I: Clinical Conditions, Diseases and Syndromes 1 

1. Infections of the Respiratory Tract and Associated Structures 1 

2. Infections of the Gastrointestinal Tract and Associated Structures 35 

3. Infections of the Urinary Tract 60 

4. Infections of the Genital System 66 

5. Prenatal, Perinatal and Puerperal Infections 78 

6. Infections of the Central Nervous System 86 

7. Skin Infections 104 

8. Wound and Soft Tissue Infections, Local and Generalised Sepsis 121 

9. Infections of the Cardiovascular System 143 

10. Infections of the Reticuloendothelial System 151 

11. Infections of the Skeletal System 163 

12. Eye Infections 170 

13. Thyroiditis 178 

14. Multi-System, Generalised and Disseminated Infections 179 

15. Fever of Undetermined Origin (Pyrexia of Unknown Origin) 213 
Part II: Organisms 214 

16. Viruses 214 

17. Bacteria 233 

18. Fungi 302 

19. Animal Parasites 313 
Part III: Treatments 335 

20. Antivirals 335 

21. Antibacterials 344 



Diagnosis and Management of Infectious Disease Page iii 



22. Antifungals 390 

23. Antiparasitic Agents 397 
Part IV: Laboratory Procedures 406 

24. Collection, Handling and Processing of Specimens 406 

25. Microscopy 410 

26. Culture 412 

27. Identification of Isolates 418 

28. Antimicrobial Susceptibility Testing 426 

29. Non-cultural Methods 440 

30. Reporting Results 442 
Index 445 



Diagnosis and Management of Infectious Diseases Page iv 



PREFACE 

This book arises from numerous requests from several classes of people over many years. 

The original version was a short Beginner's Guide (subtitled Everything You Always Wanted to Know 
about Microbiology but Were Too Dumb to Ask] for branch managers and similar personnel required to assume a 
role in microbiology but with limited experience and training. 

This has been gradually expanded and modified to suit the needs also of more experienced laboratory 
practitioners; researchers; medical, medical laboratory science and science students; and medical practitioners. 

The work is in four parts. The first deals with clinical conditions, diseases and syndromes under the 
various organ systems. For each of these, causative agents, diagnosis, treatment and, where appropriate, 
prophylaxis, prevention and control are given, together with some general notes. Recommended treatments are 
current consensus opinions from a variety of authoritative sources but may not be the most suitable in all 
situations. Practitioners should always be guided by individual circumstances and local patterns and should 
always verify dosages and precautions from package inserts. 

Part II presents, by taxonomic order, descriptions of all the medically important organisms, including 
taxonomy and identification, conditions caused, some details of pathogenesis and immune response, diagnosis and 
treatment. 

Part III systematically presents descriptions of agents used in treatment, their basic characteristics, uses 
and side-effects and other relevant details. 

Part IV constitutes an outline of important facets of laboratory practice. 

References are not included, since these would have required a book as large as the existing work. I 
freely acknowledge my debt to the thousands of colleagues who have directly or indirectly contributed. 



Diagnosis and Management of Infectious Disease Page v 



Diagnosis and Management of Infectious Diseases Page vi 



Part I: Clinical Conditions, Diseases and Syndromes 

Chapter 1 

Infections of the Respiratory Tract and Associated Strnctnres 

Antibiotics are commonly unnecessarily prescribed for respiratory infections entirely due to viral infection. 
Recent research indicates that procalcitonin levels of > 0.25 ng/L are associated with bacterial infections, while 
lower levels are unlikely to be found if bacterial infection is present. 

Cough is the presenting symptom in 6% of new episodes of illness in the UK and is responsible for 0.1% of 
ambulatory care visits in the USA. It is a common symptom of upper respiratory infections, occurring in 81% of 
patients with influenza A, in parainfluenza, rhinovirus infections and rotaviral respiratory tract infection. With 
influenza B, incidence of cough as a symptom varies with age: 99% in young adults, 86% in pre-school children, 
61% in school-age children, and 60% in older adults. Infections with adenovirus 3, 4, 7, 14 and 16 are associated 
with cough in only about 7% of patients, and echovirus 9 in 15%. Cough is, of course, a prominent and invariant 
feature of whooping cough. Productive cough is common in pneumonia, but shows variability with agent: 73% 
with Mycoplasma, 69% in pneumococcal, 47% in psittacosis, 44% in legionellosis (persisting several weeks). 
Respiratory syncytial virus infections are associated with cough in 80% of patients with pneumonia and 63% of 
bronchiolitis cases. Cough in tuberculosis is usually productive and persisting for several weeks. Paragonimiasis is 
associated with the production of tenacious brown or red sputum in 30% of cases. Cough also occurs in a number 
of intestinal infections: 39% of cases of typhoid fever, 25% of travellers' diarrhoea, 19% of cholera, 17% of 
Escherichia coli infections, 13% of salmonellosis, 12% of Shigella infections and 8% of Reromonas hydrophila 
infections. A dry cough is noted in 41% of cases of acute schistosomiasis, while ascariasis is also associated with 
cough. Systemic viral infections associated with cough include atypical measles, measles and rubella. Cough may 
also be due to chemical exposure or associated with protein energy malnutrition. 
Treatment: 

Mild Cases (Respiratory Rate < 50-70/min): honey; 'cough potion' (spearmint + amaranth 
+ammonium chloride) + paracetamol if axillary temperature > 39°C + salbutamol if > 1 y and wheezing 

Moderate Cases (Respiratory Rate 50-70/min): as above + penicillin (50,000 U/kg/d i.m.) or 
cotrimoxazole 

Severe Cases (Respiratory Rate > 70/min): single dose of antibiotic and hospital admission 
Acute Respiratory Illness: Acute respiratory disease due to a variety of viral agents is probably the 
commonest human disease. 

Agents: adenovirus, parainfluenza, influenza, echovirus, reovirus, coxsackie A21, Bl-5, respiratory syncytial virus, 
Mycoplasma pneumoniae, Coxiella burnetii, etc 

Diagnosis: EIA (sensitivity 90%) or DFA (sensitivity 80%) and viral culture (shell vial assay sensitivity 95%, 
extended culture sensitivity 54%) of nasopharyngeal aspirate or cytobrush nasopharyngeal swab (sensitivity « 
70% for nasopharyngeal aspirate); serology 
Treatment: 

Virnses: non-specific 

M.pneumoniae, C.burnetii: tetracycline 
Upper Respiratory Tract Infection, Common Cold, Feverish Cold: commonest contagious disease; 31% 
of acute illness in the USA and 5% of new episodes of illness in the UK; causes 12% of fever in returned 
travellers to Australia; transmission by airborne droplets and by touching contaminated objects; incubation period 
1-4 d 

Agents: rhinovirus (bronchitis-like cold; incubation period 2 d; duration of illness 10 d; cough in 60%, malaise in 
25%, fever in 15%), coronavirus (incubation period 3 d; duration of illness 7 d; malaise in 45%, cough in 35%, 
fever in 20%), influenza A (usually with fever; winter), B (usually with fever; winter), C, parainfluenza (in 30% of 
infections), echovirus 4, 7 (in 14% of infections), 8, 11 (in 9% of infections), 19, 20, 22, 25, 30, respiratory 
syncytial virus (bronchitis-like cold; in 80% of pneumonia and 53% of bronchiolitis cases due to this agent), 



Diagnosis and Management of Infectious Disease Page 1 



Infections of the Respiratory Tract and Associated Structures 



Rotavirus (in 33% of infections in patients < 6 mo and 19% > 6 mo), adenovirus (bronchitis-like cold), 
coxsackievirus A10, 21, 24, B3-5, human metapneumovirus (15% of cases in children; mild to severe); also 
Mycoplasma pneumoniae (atypical pneumonia-like disease) 

Diagnosis: mild to moderate dry cough and chest discomfort, mild malaise, stuffy nose, sneezing, sore throat; 
viral culture of nasal swab, throat swab, sputum, faeces; immunofluorescence of pharyngeal aspirate; ELISA 
(antigen) on nasopharyngeal secretions; complement fixation, haemagglutination inhibition, neutralisation; PCR 

Respiratory Syncytial Virns: acute wheezing common; lymphocytosis with neutropenia, becoming 
neutrophilia if secondary bacterial infection 

Treatment: paracetamol, hydration, oral (not < 12 y, diabetes, heart disease, hypertension, prostatic 
hypertrophy, hyperthyroidism) or topical decongestant (not < 6 mo) for not more than 5 d, antihistamines, steam 
inhalations, nasal saline irrigation, ipratropium bromide 21 pg/spray 4 sprays into each nostril or 42 pg/spray 2 
sprays into each nostril to 3-4 times daily reducing as rhinorrhoea improves for up to 4 d 
Prophylaxis: arinterferon spray 5 MU daily for 7 d; experimental vaccines and antiviral drugs 
Upper Respiratory Tract Infection Symptoms also occur in 62% of cases of travellers' diarrhoea, in 
Norovirus infections and poliomyelitis and in < 10% of Haemophilus influenzae conjunctivitis. 
Coryza: watery discharge from nose, becoming purulent; no systemic symptoms; course 7-10 d; RSV infection in 
30% of cases; common with influenza A, influenza B (in 91% of infected young adults, 72% of infected pre-school 
children and 66% of infected school-age children), influenza C, parainfluenza, measles, rubella and infections with 
adenovirus 3, 4, 7, 14, Mycoplasma hominis, occurs also in a few patients with intestinal infections: 10% of 
Shigella infections, 8% of Salmonella, 6% of Aeromonas hydrophila and 4% of cholera and enterotoxigenic 
Escherichia coli infections 
Rhinitis 

Agents: coronavirus, rhinovirus, influenza, parainfluenza, respiratory syncytial virus, enteroviruses, adenovirus, 
reovirus; also 10-25% of cases of infectious mononucleosis and in primary amoebic meningoencephalitis 
Diagnosis: viral culture of nasal swab, washings; serology; exclude CSF leak 
Treatment: paracetamol, hydration, oral (not < 12 y, diabetes, heart disease, hypertension, prostatic 
hypertrophy, hyperthyroidism) or topical decongestant (not < 6 mo) for not more than 5 d, antihistamines, steam 
inhalations, nasal saline irrigation, ipratropium bromide 21 pg/spray 4 sprays into each nostril or 42 pg/spray 2 
sprays into each nostril to 3-4 times daily reducing as rhinorrhoea improves for up to 4 d 
Rhinosporidiosis 
Agent: Rhinosporidum seberi 

Diagnosis: microscopy of infected material from nose, pharynx, larynx, eye, lacrimal sac, skin; histology of 
polyps 

Treatment: natamycin 

Nasopharyngitis: 4% of new episodes of illness in the UK 

Agents: parainfluenza 1, 2, Haemophilus influenzae, Streptococcus pyogenes, Streptococcus pneumoniae 
Diagnosis: culture of nasopharyngeal swab, nasal swab, throat swab 
Treatment: amoxycillin, cefuroxime axetil, cefpodoxime, erythromycin 

Resistant Streptococcus pneumoniae: clindamycin, grepafloxacin, levofloxacin, sparfloxacin, 
trovafloxacin 

Rhinoscleroma (Scleroma Nasi): a granulomatous disease of the nasopharynx characterised by the formation 
of hard, crusted, patchy or nodular lesions; endemic in northern and central Africa, S E Asia, Central America 
Agent: believed to be caused by Klebsiella pneumonia subsp rhinoscleromatis 
Diagnosis: clinical; culture of pus from sinus 
Treatment: cotrimoxazole for 1 mo to several mo; surgery where indicated 
Oronasopharyngeal Histoplasmosis 
Agent: Histoplasma capsulatum 

Diagnosis: intracellular, oval yeast cells in mononuclears on biopsy; fungal culture of biopsy or swab at 25°C 
and 35°C; hypochromic anemia and leucopenia; in children, lymphocytosis with atypical mononuclears 
Treatment: amphotericin B, ketoconazole 



Diagnosis and Management of Infectious Diseases Page 2 



Infections of the Respiratory Tract and Associated Structures 



Nasopharyngeal and Oronasal Leishmaniasis 

Agents: Leishmania braziliensis (espundia; severe form of leishmaniasis that may occur months or years after the 

cutaneous form of the disease, characterised by erosive lesions that may cause extensive destruction of 

nasopharyngeal tissues; usually fatal if untreated), Leishmania mexicana (rare; lesions on mucous membranes) 

Diagnosis: examination of smears of tissue or aspirate from lesion; culture of tissue or exudate; IFA, ELISA 

Treatment: sodium stibogluconate 

Nasopharyngeal Myiasis: infestation of nares and/or pharynx by larvae of certain flies 

Agents: Chrysomya bezziana, Ckysomya megacephala, Cochliomyia hominivorax, Cochliomyia macellaria, Oestrus 

ovis, Luciiia sericata, Rhinoestrus purpureus, Wohlfaktia vigil 

Diagnosis: pain, purulent nasal discharge, nasal obstruction; may be extensive tissue destruction; sometimes 

fatal 

Treatment: removal 

Halzoun (NIarrara): acute oedematous condition of upper respiratory tract 

Agents: usually Linguatula serrata (nasopharyngeal); also Fasciola hepatica (pharynx) and Limnatis nilotica 

(larynx or trachea) 

Diagnosis: direct visualisation 

Treatment: levamisole 

Lagochilascariasis: infestation of tonsils and nose; occasional metastatic abscesses; Brazil, Colombia, Costa 

Rica, Mexico, Tobago, Trinidad, Venezuela 

Agent: Lagochilascaris minor 

Diagnosis: usually detected by migration of worms through mouth or nose or by visualisation during 

tonsillectomy 

Treatment: levamisole 150 mg orally 8 hourly for 8 d, then 150 mg orally 12 hourly for 3 days of the week for 

12 w (child: 150 mg orally 8 hourly for 15 d) 

Catarrh 

Agents: measles, rubella, other viruses, Bordetella pertussis 

Diagnosis: viral culture of throat swab, bacterial culture of nasopharyngeal swab plated directly to charcoal 

agar; serology 

Treatment: hydration, steam 

Bordetella pertussis, erythromycin 
Acute Sinusitis: symptoms < 4 w; mainly maxillary; 0.5% of new episodes of illness in UK; 0.2% of 
ambulatory care visits in USA; viral sinusitis in 39%, and bacterial sinusitis in 0.5-2.5%, of patients (5-15% of 
children) with common cold 

Agents: 20-36% Streptococcus pneumoniae, 15-30% Haemophilus influenzae (nontypeable strains; 13% of 
sphenoid), 9-15% rhinovirus, 9% a-streptococci, 7-19% Moraxella catarrhalis, 5-10% anaerobes, 3% Streptococcus 
viridans, 3% p-haemolytic streptococci not group A (including Streptococcus millerr, group C also frontal), 2-9% 
Gram negative enteric bacteria, 2-5% influenza virus, 2-3% Streptococcus pyogenes, 1-6% Staphylococcus aureus 
(56% of sphenoid), 1% Pseudomonas aeruginosa (increased in AIDS), 1% parainfluenza 2, 1% parainfluenza 3; 
adenovirus (2% in children), Legionella pneumophila (in AIDS), measles (in 2% of cases), Capnocytophaga, 
Salmonella (in renal transplant recipients), Chlamydophila pneumoniae, Moraxella lacunata, Pasteurella multocida, 
Haemophilus aprophilus, Haemophilus paraprophilus, no growth in 20-25% of cases; may be initial manifestation of 
Rcanthamoeba infection in AIDS 

Diagnosis (Bacterial): persistent mucopurulent nasal discharge (> 7 d), postnasal drainaage, anosmia, nasal 
congestion, prolonged fever, facial pain, headache, cough, tenderness over sinuses (especially unilateral maxillary 
tenderness), tenderness on percussion of maxillary molar or premolar teeth that cannot be attributed to a single 
tooth, headache, daark circles under eyes, periorbital edema, lymphoid hyperplasia, purulent material in pharynx, 
poor response to decongestants; in children, also irritability, vomiting, gagging on mucus, prolonged cough; culture 
of maxillary sinus aspirate; serology; microimmunofluorescent antibody to Chlamydophila pneumoniae (IgG and IgM 
in paired sera 6-8 w apart) 

Differential Diagnosis: dental neuralgia (careful dental examination), temperomandibular neuralgia (location of 
pain, careful history and observation), trigeminal neuralgia (pain over fifth cranial nerve distribution only), 
migraine (history of similar pain on previous occasions), temporal arteritis (location of pain and tenderness), 
erysipelas (swelling and stippling of skin surface), nasal diphtheria (extremely rare), typhoid fever (extremely rare) 



Diagnosis and Management of Infectious Diseases Page 3 



Infections of the Respiratory Tract and Associated Structures 



Treatment: oxymetazoline, tramazoline or xylometazoline 2-3 drops into each nostril 2-3 times daily for 5 d; 
pseudoephedrine; paracetamol ± codeine 

Pseudomonas aeruginosa: ticarcillin + gentamicin + surgical drainage 

Legionella pneumophila: erythromycin, fluoroquinolone 

Other Bacteria: amoxycillin 15 mg/kg to 500 mg orally 8 hourly for 5-7 d 

Amoxycillin Resistant or Unresponsive: amoxycillin-clavulanate 22.5/3.2 mg/kg to 
875/125 mg orally 8 hourly 

Penicillin Hypersensitive: cefuroxime 10 mg/kg to 500 mg orally 12 hourly for 5-7 d, 
cefaclor 375 mg orally 12 hourly (child: 10 mg/kg to 250 mg orally 8 hourly) for 5-7 d, doxycycline (not < 8 y) 
2.5 mg/kg to 100 mg orally daily for 5-7 d, levofloxacin 500 mg daily 
Chronic Sinusitis: symptoms persist > 8 w; 1.7% of ambulatory care visits in USA 
Agents: 31% Prevotells (71% of sphenoid), 22% anaerobic streptococci (57% of sphenoid), 21% other streptococci, 
16% Fusobacterium (57% of sphenoid), 16% Pseudomonas aeruginosa, 16% Haemophilus influenzae, 10% 
Staphylococcus aureus, 10% Moraxella catarrhalis, various fungi (acute (fulminant), chronic (indolent) invasive, 
fungus ball, allergic fungal sinusitis; 25% Aspergillus (Aflavus — frequently pansinusitis, especially in cancer 
patients — Mumigatus, Aniger, Aoryzae), 23% Curvularia, 16% Bipolaris (predominant agent in allergic fungal 
sinusitis), 12% Fusarium, 9% Penicillium, 8% Alternaria, 4% Cladosporium, 1% Drechslera, 1% Exserohilum, 1% 
Mortierella hyaline; also Acremonium, Chaetoconidium, Coniothyrium, Chrysosporium, Geotrichum, Paecilomyces, 
Scedosporium prolificans, Schizophyllum, Pseudallescheria boydii in immunocompromised); Klebsiella pneumoniae 
14% of sphenoid, Escherichia coli 14% of sphenoid, Pseudomonas aeruginosa 14% of sphenoid; 25-60% no growth 
Diagnosis: computed tomography, nasal cytology, nasal-sinus biopsy, tests for immunodeficiency, cystic fibrosis, 
ciliary dysfunction 

Bacterial: culture of antral washings 
Fnngal: 

Acnte: 70% in diabetics; also in chronic renal failure or diarrhoea, immunosuppressive states 
secondary to chemotherapy, hematological disorders, transplantation, AIDS; cranial nerve deficit, proptosis, facial 
swelling, palatal ulcer, coma, stupor; pale to red to black necrotic areas involving turbinates or septum; 
microscopy, culture and histology of biopsy; radiographic evaluation with CT and MRI 

Chronic Invasive: immunocompetent and atopic hosts; microscopy, culture and histology of 
biopsy 

Fnngns Ball: no symptoms, rhinorrhoea, nasal obstruction, facial fullness; X-rays or CT 
scan, microscopy and culture 

Allergic: nasal obstruction, polyposis, history of multiple sinus procedures; polyposis, allergic 
mucin and thick, tenacious debris on nasal endoscopy; type I hypersensitivity confirmed by history, skin testing or 
serology; characteristic CT scan (complete unilateral or bilateral opacification of multiple paranasal sinuses; sinus 
expansion and erosion of a wall of involved sinus; scattered areas of intrasinus high attenuation amid mucosal 
thickening on noncontrasted CT); histologic evidence of eosinophilic mucus without evidence of fungal invasion 
into sinus tissue; positive fungal stain or culture of sinus contents removed intraoperatively or during endoscopy 
Treatment: rule out allergy and structural abnormalities 

Bacterial: surgical debridement; antibiotics as for acute infections; nebulised culture-specific 
antibiotics 

Fnngal: 

Acnte and Chronic Invasive: radical debridement + amphotericin B 
{Pseudallescheria boydii: azole); intranasal amphotericin B 20 ml of 100 mg/L solution twice daily 

Fnngns Ball: complete removal via curettage with adequate ventilation 

Allergic: surgery + oral prednisone + topical nasal steroids + nasal irrigations; fungal 
directed immunotherapy 

Prophylaxis (Rspergillus Rhinosinnsitis in Neutropenics): amphotericin B nasal spray, oral fluconazole 
Sore Throat: 6% of patients in general practice; 46% tonsillar adenitis, 15% pharyngitis, 14% tonsillitis, 3% 
acute laryngitis, 3% globus hystericus, 2% stomatitis (1% due to drugs), 1% chronic laryngitis, 1% quinsy, 1% 
myasthenia of larynx, 0.5% dysphagia, 0.5% infected tonsillar remnant, 0.5% postcricoid carcinoma, 0.5% aphthous 
ulcer, 0.5% submandibular calculus 



Diagnosis and Management of Infectious Diseases Page 4 



Infections of the Respiratory Tract and Associated Structures 



Agents: see categories below; sore throat is also a symptom in 67% of cases of mycobacterial thyroiditis and 
69% of thyroiditis due to other bacteria, in 36% of Shigella infections, 33% of Rocky Mountain spotted fever, 25% 
of cases of traveller's diarrhoea, 22% of cases of salmonellosis, 22% of Korean hemorrhagic fever cases, 12% of 
Reromonas hydrophila infections, 10% of Norwalk gastroenteritis cases, 8% of enterotoxigenic Escherichia coli 
infections, 4% of cholera cases, and in cases of Lassa fever, reovirus infections, acute infectious nonbacterial 
gastroenteritis, aseptic meningitis, dengue, Ebola haemorrhagic fever, Marburg virus disease, measles, St Louis 
encephalitis, botulism, syphilis, toxic shock syndrome and toxoplasmosis 
Diagnosis: clinical; see categories below 
Treatment: see categories below 

Aboriginals: single dose benzathine penicillin 
Acute Throat Infections (Pharyngitis and Tonsillitis): incidence 30-40/1000; mainly in children and 
young adults; 3% of new episodes of illness in UK (streptococcal 0.04%); 1.7% of ambulatory care visits in USA 
(streptococcal 0.3%) 
Agents: 

Acnte Exndative Tonsillitis: 35% no pathogen found; 23% viruses other than adenovirus (50% of 
echovirus 9 infections, 10% with exudate; 72% of influenza A cases; 25% of parainfluenza cases; in 60% of cases 
of pneumonia and 32% of cases of bronchiolitis due to respiratory syncytial virus; human herpesvirus 1; Epstein- 
Ban virus (in 66-85% of cases of infectious mononucleosis), 19% adenovirus (types 1-4, 5, 7, 14, 16; white spots 
may be present), 19% p-haemolytic streptococci other than Streptococcus pyogenes (mainly 'large colony' group C; 
groups B and G cause mild and self-limiting infections), 14% more than 1 agent, 12% Streptococcus pyogenes 
(streptococcal pharyngitis, septic angina, septic sore throat, streptococcal angina, streptococcal sore throat; 
infection is of pharynx, nasopharynx, nasal cavities and paranasal sinuses, not tonsils, at least in earlier stages), 
5% Mycoplasma pneumoniae 

Non-exndative Pharyngitis and Tonsillitis: enteroviruses, influenza B (in 100% of infected 
young adults, 78% of infected school-age children, 59% of infected pre-school children, 28% of infected older 
adults), rhinovirus, coxsackievirus (Al-6, 8-10, 16, 21, B2, 3, 5; herpangia; febrile in children), Streptococcus 
pyogenes, Neisseria gonorrhoeae (frequently asymptomatic but may be associated with inflammation and 
discharge), Corynebacterium ulcerans, Rrcanobacterium haemolyticum (often with rash), Mycoplasma pneumoniae, 
Chlamydophila pneumoniae, diphtheria (uncommon in Australia; causes fever + exudate + pseudomembrane), mixed 
anaerobes (necrotising ulcerative pharyngitis, fusospirochaetal angina, fusospirochaetal pharyngitis, Plaut angina, 
pseudomembranous angina, ulceromembranous angina, ulceromembranous pharyngitis, Vincent's angina), 
Haemophilus influenzae, Actinomyces pyogenes, Candida albicans; Capnocytophaga and Fusobacterium in 
neutropenics; 1 case due to Cryptococcus neoformans in patient with leukemia; agranulocytosis, leukemia and a 
variety of irritant chemical and physical agents may also mimic acute throat infection 
Diagnosis: sore throat with pain on swallowing, fever, headache; Streptococcus pyogenes more likely in children 
4-15 y and in febrile patients with exudative tonsillitis and cervical lymphadenopathy; herpangia and exanthem in 
coxsackievirus, echovirus 16, 17; many rapid commercial test kits for Streptococcus pyogenes (throat swab) 
sensitivity 76-95%, specificity 93-97%; Gram stain and Albert or Neisser stain, bacterial and viral culture of throat 
and tonsils; viral and mycoplasmal serology; microimmunofluorescent antibody or PCR-EIA for Chlamydophila 
pneumoniae; differential white cell count; blood cultures and excisional biopsy in neutropenics 
Treatment: paracetamol, aspirin (adults) or ibuprofen; dexamethasone 10 mg single oral or i.m. dose; oral 
hydration; empirical treatment for streptococci is indicated for follicular tonsillitis with fever and local 
lymphadenitis, existing rheumatic heart disease, Streptococcus pyogenes prevalent in family or community, scarlet 
fever, quinsy 

Streptococci: phenoxymethylpenicillin 10 mg/kg to 500 mg orally 12 hourly for 10 d; ampicillin, 
amoxycillin or amoxycillin-clavulanate should not be used as they are not superior to penicillin and are more 
likely to produce a rash, especially with Lymphocryptovirus infection, but also with other viruses 

Remote Areas, Poorly Compliant, Intolerant of Oral Therapy: benzathine 
penicillin (3-6 kg: 225 mg; 6-10 kg: 337.5 mg; 10-15 kg: 450 mg; 15-20 kg: 675 mg; > 20 kg: 900 mg) i.m single 
dose 

Penicillin Hypersensitive: roxithromycin 300 mg orally daily (child: 4 mg/kg to 150 mg 
orally 12 hourly) for 10 d 



Diagnosis and Management of Infectious Diseases Page 5 



Infections of the Respiratory Tract and Associated Structures 



Recurrent or Treatment Failnre: clindamycin 150 mg orally 6 hourly (child > 8y: 
8-16 mg/kg daily in 3-4 divided doses) for 9 d, or amoxycillin-clavulanate 

Neisseria gonorrhoeae, ceftriaxone 250 mg i.m. in lignocaine hydrochloride 1% as single dose or 
ciprofloxacin 500 mg orally in a single dose (not children or pregnant) + (if chlamydial infection is not ruled out) 
azithromycin 1 g orally in single dose or doxycycline 100 mg orally twice daily for 7 d (not < 8 y or pregnant) 
Anaerobes: penicillin + metronidazole 

Corynebacterium, Rrcanobacterium hacmolyticum: erythromycin 250 mg 4 times daily for 
10 d 

Mycoplasma pneumoniae, Chlamydophila pneumoniae: doxycycline 100 mg twice daily for 
10 d, roxithromycin 

Human herpesvirus: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 
hourly for 7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Freqnent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 
Cryptococcus neoformans: 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 

More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 
mg/kg i.v. or orally 6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally 
initially then 400 mg daily for 8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or 
itraconazole 200 mg orally daily 

Other Viruses and Other Agents: saline gargles 
Peritonsillar Abscess (Quinsy) 

Agents: 30% Peptostreptococcus, 28% Streptococcus pyogenes, 16% Peptococcus, 9% Fusobacterium, 5% 
Streptococcus pneumoniae, 5% microaerophilic streptococci, 2% Bacteroides fragilis, 2% Haemophilus influenzae, 2% 
Propionibacteriunr, also Corynebacterium ulcerans, Actinomyces pyogenes 
Diagnosis: Uni-Gold Streptococcal A Test and culture of deep swab of abscess 
Treatment: surgical drainage or aspiration; benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly + metronidazole 
12.5 mg/kg to 500 mg i.v. or 10 mg/kg to 400 mg orally 12 hourly till significant improvement then amoxycillin 
+ clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 hourly; clindamycin 10 mg/kg to 450 mg i.v. or 
orally 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly till significant improvement then clindamycin 10 
mg/kg to 450 mg orally 8 hourly 

Scarlet Fever (Canker Rash, Febris Rubra, Febris Scarlatinae, Fothergill Disease, 
Scarlatina, Scarlatina Anginosa): affects mainly children 6 mo to 3 y; latent period 1-2 d, incubation 
period 2-3 d, infectious period 14-21 d, interepidemic period 3-6 y 
Agent: Streptococcus pyogenes producing erythrogenic toxin 

Diagnosis: acute streptococcal infection (pharyngitis, wound infection, burn infection, puerperal fever) associated 
with skin rash (characteristically, punctate and erythematous) and 'strawberry' or 'raspberry' tongue ± 
conjunctivitis, rhinitis; desquamation of skin usually occurs; may be other toxic manifestations, including liver 
involvement; arthritis may occur; severity varies widely but, in general, disease is mild today; culture of nasal 
swab, throat swab; blood cultures; moderate neutrophilia 
Treatment: penicillin, erythromycin, clindamycin 

Diphtheria (Diphteritis): acute infectious disease involving the upper respiratory tract and, sometimes, skin; 
clinical manifestations primarily those of exotoxin; endemic and epidemic, world-wide; last reported case in 
Australia in 1993; tonsillar diphtheria (most common form, in which membrane is confined mainly to tonsils), 
pharyngeal (Bretonneau angina, Bretonneau diphtheria, Bretonneau disease, diphtheria cyanache, faucial diphtheria, 
malignant angina; uncommon form, occurring especially in persons without tonsils, in which membrane extends 
beyond faucial pillars; generally more severe than tonsillar form); 8% larynx (diphtheric laryngitis, garrotilla 
morbus suffocans; form that begins either in larynx — with frequent involvement of tonsils, nasopharynx or 
nose — or in trachea or bronchi; most common in children 2-5 y; relatively high rate of suffocation), nasal 
(membranous rhinitis; uncommon; relatively mild; membrane limited to mucosa of anterior nares) and 
nasopharyngeal (severe form with membrane formation on nasal, tonsillar and pharyngeal tissues), 
pharyngotracheobronchial diphtheria and tracheobronchial diphtheria, in which membrane extends into 



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Infections of the Respiratory Tract and Associated Structures 



tracheobronchial airways, causing increased risk of suffocation; myocarditis in 10% of cases, mortality 50%; 

bronchopneumonia in 8%, mortality 70%; bulbar paralysis in 4%, mortality 20%; peripheral nerve palsies in 2%, 

mortality 15%; latent period 2-5 d, incubation period 2-5 d, infectious period 14-21 d, interepidemic period 4-6 

years 

Agent: Corynebacterium diphtheriae 

Diagnosis: sore throat, fever, malaise, headache, chills; death may result from either myocarditis or asphyxia 

Tonsillar Diphtheria: pseudomembranous tonsillitis, cervical lymphadenopathy and a nasal watery 
discharge; occasionally complicated by otitis media or peritonsillar abscess 

Severe Pharyngeal Diphtheria (Malignant Diphtheria, Diphtheria Gravis) and 
Nasopharyngeal Diphtheria: marked toxemia and massive swelling of neck Cbullneck'), sometimes followed 
by endocarditis 

Albert's or Neisser stain, culture of blood agar, Tinsdale agar and Loeffler's medium of throat membrane fragments 
or throat swab in which membranous structure is sampled, and nasal swab; isolates of Corynebacterium 
diphtheriae and Corynebacterium ulcerans should be tested for toxin production 

Treatment: antitoxin (500-1000 U/kg in nasal or mild pharyngeal, 1500 U/kg in moderately severe pharyngeal, 
2000 U/kg in severe pharyngeal, 2500 U/kg in laryngobronchial) (always preceded by tests for allergy to horse 
serum and desensitisation if necessary) + procaine benzylpenicillin 1.2 MU/d (child: 25 000-50 000 U/kg/d) or 
parenteral erythromycin 40-50 mg/kg/d to maximum 2 g/d until patient can swallow comfortably, then oral 
erythromycin or phenoxymethylpenicillin 125-250 mg 4 times daily for total 14 d; endotracheal intubation for 
maintenance of airways; steroids for impending airways obstruction 

Carriers: erythromycin 500 mg orally 6 hourly (child: 30-40 mg/kg daily in 3 divided doses) for 7 d, 
procaine penicillin 600 000 U (child: 12 500-25 000 U/kg) l.m. 12 hourly for 10 days + surveillance 
Prophylaxis: highly effective live vaccine; hyperimmune immunoglobulin; isolation of cases until negative 
cultures of 2 samples at least 24 h apart after completion of antimicrobial therapy 

Close Contacts: benzylpenicillin (< 6 y: 600 000 U; > 6 y: 1.2 MU) i.m. single dose or erythromycin 
(child: 40 mg/kg/d; adult: 1 g/d) for 7-10 d 
Oropharyngeal Candidiasis 
Agent: Candida albicans 
Diagnosis: swab culture 
Treatment: 

Mild: miconazole 2% gel 50 mg (child < 1 y: 25 mg) orally 6 hourly for 1-2 w; amphotericin B 
10 mg lozenge or 100 mg/mL suspension 1 mL orally 6 hourly for 1-2 w; nystatin 1 lozenge 100 000 U dissolved 
slowly in mouth 6 hourly for 7-14 d, or 1 mL 100 000 U/mL suspension orally 6 hourly for 7-14 d if lozenge not 
tolerated, clotrimazole 10 mg troche 5 times daily; gentian violet paint; cleaning of dentures and correction of poor 
fits if present 

Severe (Immnnocompromised inclnding AIDS): fluconazole 3 mg/kg to 50 mg orally daily for 
10-14 d or itraconazole 100 mg (10 mL) oral suspension daily for 10-14 d or miconazole 2% gel 2.5 mL orally 6 
hourly for 10-14 d or nystatin liquid 100 000 U/mL 1 mL orally 6 hourly for 10-14 d, then fluconazole 50 mg 
orally daily or 150 mg weekly if frequent recurrences 

Failnre of Response: Does patient have diabetes mellitus? Is patient receiving oral antibiotics? 
Would eradication of gastrointestinal reservoir help? Is there a defect in immunity or any history of treatment 
with immunosuppressive drugs? 

Prophylaxis (Immnnosnppressed Patients): clotrimazole 10 mg 8 hourly as a lozenge; 
fluconazole 400 mg orally or i.v. daily 

Pharyngoconjunctival Fever: occurs in children; associated with swimming pools 
Agent: adenovirus 3, 4, 7, 14 

Diagnosis: fever, sore throat, upper respiratory tract symptoms, conjunctivitis; viral culture of nasopharyngeal 
swab, conjunctival swab or scraping, faeces; serology 
Treatment: non-specific 

Acute Laryngitis: 0.8% of new episodes of illness in UK 

Agents: parainfluenza 1 and 3, respiratory syncytial virus, adenovirus, influenza B, 4% of hospitalised measles 
cases 



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Diagnosis: hoarseness, barking or brassy cough without stidor in absence of lower respiratory tract signs; 

serology 

Treatment: non-specific 

Acute Laryngeal Dyspnea: includes croup (acute laryngotracheobronchitis), acute epiglottitis and 

supraglottitis, laryngeal diphtheria; may also be due to angioneurotic oedema, foreign body or other laryngeal 

irritant, acute retropharyngeal abscess, papillomata of larynx, large infected prolapsing tonsils, peritonsillar abscess 

Agents: 

Cronp: 80% viral (parainfluenza 1, 2, 3, influenza A (11% of total cases) and B, respiratory syncytial 
virus, adenovirus, enteroviruses, rhinovirus, measles virus, human metapneumovirus), 20% bacterial (Streptococcus 
pneumoniae, other streptococci, Staphylococcus aureus, Corynebacterium diphtheriae) 

Acnte Epiglottitis: Haemophilus influenzae (usually type b; also acute obstructive laryngotracheal 
infection), Haemophilus parainfluenzas, Haemophilus paraprophilus, Streptococcus pneumoniae (10% of adult cases), 
Streptococcus pyogenes, group C Streptococcus (single case) 

Snpraglottitis: Haemophilus influenzae, Neisseria meningitidis (0.3% of meningococcal infections) 

Diphtheria: Corynebacterium diphtheriae 
Diagnosis: 

Cronp: coryzal prodrome, hoarseness or husky voice, barking or brassy cough, inspiratory stridor + 
sonorous rhonchi and coarse crepitation, variable airway obstruction; viral culture of nasal washings 

Acnte Epiglottitis and Snpraglottitis are life-threatening situations which will usually be 
diagnosed clinically; typically children 2-7 y and adults; fever, sore throat, shortness of breath, rapid onset of 
dysphagia, pooling of secretions and drooling, sudden deterioration and death due to airway obstruction; note that 
fatal reactions have occurred on attempting to take swabs or even on examination of the oropharynx in acute 
epiglottitis; also that isolation of Haemophilus influenzae from throat swabs rarely implies acute epiglottitis; 
counterimmunoelectrophoresis or latex agglutination of serum may provide a diagnosis, while blood cultures are 
positive in 79-90% of cases 

immunofluoresecence of pharyngeal aspirate or nasopharyngeal swab; Gram stain and Albert's or Neisser stain, 
bacterial and viral culture of laryngeal swab, nasal washings, nasopharyngeal aspirate; serology 
Treatment: 

Cronp: usually self-limiting, lasting 2-7 d 

Moderate to Severe: dexamethasone 0.3 mg/kg orally, prednisolone 1 mg/kg orally, 
budesonide 2 mg by nebuliser 

Significant Airway Obstrnction or Fatigne: hospitalisation; dexamethasone 0.6 mg/kg 
orally or i.m. or prednisolone 1 mg/kg orally + nebulised adrenaline 0.05 mL/kg/dose to 0.5 mL of 10 mg/mL 
solution diluted up to 3 mL with sodium chloride 0.9% solution or 0.5 mL/kg/dose to 5 mL of 1 mg/mL solution 
+ nebulised budesonide 2 mg/4 mL; tracheostomy or intubation if needed 
Bacterial: erythromycin or penicillin + streptomycin 

Epiglottitis and Snpraglottitis: hospitalisation; intermittent positive pressure breathing with mask 
or bag or tracheostomy; ceftriaxone 25 mg/kg to 1 g i.v. once daily for 5 d or cefotaxime 25 mg/kg to 1 g i.v. 8 
hourly for 5 d or (if severe penicillin hypersensitivity) chloramphenicol 50 mg/kg to 1 g i.v. immediately, followed 
by 25 mg/kg to 1 g i.v. 8 hourly 

Diphtheria: antitoxin + parenteral penicillin 
Prophylaxis 

Haemophilus influenzae type b: given to index case before discharge, and within 7 d to all 
household contacts of index case, including incompletely immunised children < 4y and any immunocmpromsed 
child; also adults and children at day care centres with 2 or more cases of invasive disease in 60 d period and 
with incompletely immunised children; rifampicin 20 mg/kg to maximum 600 mg (child < 1 mo: 10 mg/kg) orally 
daily for 4 d (not pregnant; give ceftriaxone 1 g in lignocaine hydrochloride 1% i.m. as single dose); vaccine to 
index case under 2 y even if previous immunisation and to unvaccinated contacts < 5 y; all children should be 
routinely vaccinated beginning at 2 mo (95-100% efficacy; swelling, redness and pain at injection site in 5-30%, 
fever and irritability uncommon, serious reactions rare; contraindicated if anaphylaxis to vaccine components or 
previous dose and serious illnesses) 

Neisseria meningitidis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose 
(preferred if pregnant), ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral 



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contraceptive), rifampicin 10 mg/kg (< 1 mo: 5 mg/kg) to 600 mg orally 12 hourly for 2 d (not pregnant, 

alcoholic, severe liver disease; preferred for children); vaccines (quadrivalent polysaccharide, quadrivalent 

conjugate, and serogroup conjugate) available 

Acute Tracheitis: secondary bacterial infection following primary viral respiratory infection, most commonly 

parainfluenza 

Agents: Staphylococcus aureus, Haemophilus influenzae, Streptococcus pyogenes, Moraxella catarrhalis, 

Mnetobacter calcoaceticus, Bordetella bronchiseptica (rare), 1 case of Corynebacterium pseudodiphtheriticum 

Diagnosis: URTI with stridor, fever and variable degree of respiratory distress; Gram stain and culture of 

tracheal aspirate 

Treatment: humidification, endotracheal intubation or tracheostomy; amoxyc illin -clavulanate 

Upper Airways Aspergillosis: necrotising bronchitis, mass in trachea, laryngitis, epiglottitis 

Agents: Aspergillus species 

Diagnosis: fibreoptic examination; micro and culture of biopsy 

Treatment: amphotericin B; excision possibly helpful; removal of infected suture essential for bronchial stump 

aspergillosis 

Whooping Cough: world-wide; acute tracheobronchitis, mainly in children, sometimes in elderly whose immunity 

has waned; also common cause of persistent cough in adults; * 4000 notified cases/y in Australia (« 32% in 

New South Wales); incidence 0.8/100 000 in USA; 0.3% of new episodes of illness in UK; death rate from 

0.003/1000 infants in USA to 5/1000 in Guatemala; case-fatality rate 0.5-15% (29% pneumonia, 4% seizures, 0.4% 

encephalopathy; all < 1 y, unvaccinated; « 300,000 deaths in children worldwide in 2000); complications include 

inguinal or umbilical hernia, rectal prolapse, mucosal hemorrhage, petechiae, pneumothorax (rare), subcutaneous 

emphysema (rare), subdural haematoma (rare), convulsions, paralysis, deafness, blindness, aphasia, mental 

retardation, bronchopneumonia, atelectasis, ? bronchiectasis; respiratory transmission; incubation period 5-10 d, 

latent period 6-7 d, infectious period 21-28 d, interepidemic period 2-5 years 

Agents: Bordetella pertussis (pertussis, chin cough, morbus cucullaris; acute respiratory disease, common in 

childhood), Bordetella parapertussis (parapertussis; less common and usually mild respiratory disease), Bordetella 

bronchiseptica (uncommon acute tracheobronchitis); parainfluenza 4 and adenovirus may produce a similar 

syndrome 

Diagnosis: initial stage of mild upper respiratory symptoms, followed by a second stage of paroxysmal coughing, 

with each paroxysm ending (but not invariably, especially in infants) in an inspiratory 'whoop' and post-tussive 

vomiting, and a long period of convalescence; fever usually absent or of low grade; may be transiently 

indistinguishable from adenoviral respiratory diseases; cough > 14 d duration (CDC definition) has 100% 

sensitivity but only 35% specificity; spasmodic cough > 21 d (WHO definition) has 80% sensitivity but only 41% 

specificity; > 14 d cough + lymphocytosis has sensitivity 84%, specificity 67%, predicted value positive 68%; 

culture of nasopharyngeal swab plated directly to charcoal agar + antibiotics (overall sensitivity 53%, specificity 

100%; the organism does not survive transport in Stuart's medium even for a few minutes; the chance of isolating 

the organism falls rapidly from 93% at time of onset to zero at > 4 w after onset); serology (IgA or rise in IgG 

or IgM); PCR on nasopharyngeal swab or aspirate; direct fluorescent microscopy of organisms in sputum 

(sensitivity 63%, specificity 86%); ELISA (IgG for filamentous haemagglutinin sensitivity 88-89%, detects both 

Bordetella pertussis and Bordetella parapertussis, IgG for pertussis 100% sensitive in unvaccinated children, 

specificity 97%; IgA); neutropenia becoming lymphocytosis 

Treatment: mainly supportive, but clarithromycin 7.5 mg/kg to 500 mg orally twice daily for 7 d (not < 1 mo), 

azithromycin 10 mg/kg to 500 mg initially then 5 mg/kg to 250 mg orally daily for further 4 d (< 6 mo: 10 

mg/kg to 500 mg orally daily for 5 d), erythromycin 10 mg/kg to 250 mg orally 6 hourly for 7 d (not < 1 mo), 

erythromycin ethyl succinate 10 mg/kg to 400 mg orally daily for 7 d (not < 1 mo), or cotrimoxazole 4/20 

mg/kg to 160/800 mg orally 12 hourly for 7 d may shorten the course of the disease if treatment is initiated 

very early and may limit spread to susceptible contacts 

Prophylaxis: vaccine (3 doses) 70% effective; 50% minor complications (40% swelling, 35% redness, 35% 

irritability, 30% pain, 25% fever > 38°C, 15% anorexia, 15% drowsiness, 5% fever > 39°C, 1% fever > 40°C), 

0.03% moderate complications, 0.003% severe complications (70-2000/M persistent screaming, 60-300/1)11 collapse 

or shock, 40-700/M convulsions + fever), 0.0006% encephalitis (males predominate; not related to age at 

immunisation, size of dose or whether first or subsequent dose; manifestations: changes in consciousness, 

convulsions, paresis; mortality * 15%; permanent sequelae * 30%); paracetamol ISmg/kg at time of vaccination 



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Infections of the Respiratory Tract and Associated Structures 



and every 4-6 h for 48-72 h reduces incidence of fever and seizures; further immunisation contraindicated if 
collapse or shock within 48 hours, persistent screaming episode or uncontrollable crying lasting > 3 h within 48 
hours, temperature > 40.5°C within 48 h, convulsions + fever within 3 d, alteration in consciousness or 
neurologic abnormality within 7 days, systemic allergic reaction, thrombocytopenia or hemolytic anemia following 
previous immunisations or if neurologic disease; duration of immunity 6 y; new acellular vaccine 87% fewer 
febrile episodes, 75% fewer hypotonic-hyporesponsive episodes; cost effective 

Chemoprophylaxis: contacts with index case who are infants < 1 y regardless of immunisation 
status, children 1-2 y who have received < 3 doses of vaccine, women in last month of pregnancy, or who attend 
or work in a childcare facility; as for treatment 
Tracheobronchitis 

Agents: parainfluenza 1, 2, 3, influenza A, B, adenovirus 1, 2, 3, 4, 5, 7; also Bordetella (see Whooping Cough), 
Mycoplasma pneumoniae, Aspergillus (ulcerative and plaque-like in AIDS patients; see Upper Airways 
Aspergillosis) 

Diagnosis: bronchoscopy; serology; culture of biopsy 
Treatment: steam, hydration 

Epidemic Influenza: 20% of acute illness (* 20 000 deaths/y) in USA, 0.9% of new episodes of illness in UK; 
causes 5% of fever in returned travellers to Australia; attack rate 34%, case-fatality rate 0.9%; particularly severe 
in those in third trimester of pregnancy, in elderly, in patients with underlying cardiovascular disease, renal 
disease, metabolic diseases such as diabetes mellitus, anemia, and in immunosuppression; initial pneumonitis often 
progresses to secondary bacterial pneumonia, often due to Haemophilus influenzae but particularly severe form due 
to Staphylococcus aureus, common complications include pneumonia, otitis media, tracheobronchitis and acute 
sinusitis; others include Reye's syndrome, myocarditis, pericarditis, myositis, myoglobinuria, encephalitis, transverse 
myelitis, Guillain-Barre syndrome, rhabdomyelitis, respiratory transmission; incubation period 1-4 d 
Agents: 70% influenza A (world-wide epidemics and pandemics), 27% influenza B (smaller epidemics), 3% 
influenza C (local outbreaks, often inapparent); 'influenza-like illness' also occurs with infections due to 
adenovirus, enteroviruses, parainfluenza, hepatitis C, Q fever, Rift Valley fever, Ross River virus, lymphocytic 
choriomeningitis virus, and in malaria, perfringens poisoning (mild, lasting 24 h), rabies, staphylococcal food 
poisoning, as well as in rifampicin overdosage 

Diagnosis: abrupt onset of fever, chills, severe myalgia, severe arthralgia, anorexia, severe headache, severe 
malaise, severe nonproductive cough, severe chest discomfort, fatigue lasting 2-3 w; viral culture of oropharyngeal 
or nasopharyngeal swab or garglings, sputum, serum (lung tissue post mortem) in chick embryo amnion, human, 
monkey, pig or calf kidney cells; serology (complement fixation test, microagglutination, indirect fluorescent 
antibody titre, passive hemagglutination, hemagglutination inhibition antibody, neutralisation, ELISA (antibody), 
radioimmunoassay); sensitivity of rapid commercial kits 51-96% (greater with nasopharyngeal specimen), 
specificity 52-100% (influenza A and B); relative or absolute lymphocytosis with neutropenia, becoming 
neutrophilia if secondary bacterial infection 
Treatment: 

Influenza (High Risk Individual in Context of Proven Inflnenza Epidemic and 
Within 48 Honrs of Onset of Illness): zanamivir 10 mg by inhalation 12 hourly for 5 d or until 48 h after 
recovery (not < 7 y) or oseltamivir (< 15 kg: 30 mg; 16-23 kg: 45 mg; 24-40 kg: 60 mg; > 40 kg: 75 mg) orally 
twice daily for 5 d (influenza A and B) 

Q fever: doxycycline 100 mg orally 12 hourly for 14 d (not < 8 y), chloramphenicol 12.5 mg/kg to 
500 mg orally or i.v. 6 hourly for 14 d 

Others: symptomatic 
Prophylaxis (Inflnenza A and B): vaccination + rimantidine most cost-beneficial; killed vaccine 
administered parenterally 77-91% efficacy in children 1-15, 70-90% in adults < 65 y, 50-80% in > 65 y, rare 
systemic reactions, duration of immunity 1-3 y; persons at increased risk (aged > 50 y; children 6-59 months; 
residents of nursing homes and other chronic care facilities; > 6 mo with chronic disorders of pulmonary 
(including asthma) or cardiovascular systems (not including hypertension); > 6 mo who have required regular 
medical follow-up or hospitalisation during preceding year for chronic metabolic diseases (including diabetes 
mellitus), renal dysfunction, haemoglobinopathies or immunodeficiency caused by medications or HIV; aged 6 mo - 
18 y and receiving long term aspirin therapy; ; > 6 mo with any condition that can compromise respiratory 
function or handling of respiratory secretions or increases risk for aspiration, cognitive dysfunction, spinal cord 



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Infections of the Respiratory Tract and Associated Structures 



injuries, seizure disorders or other neuromuscular disorders; women who will be pregnant during the influenza 
season) and groups with potential of nosocomially transmitting influenza to high-risk patients (physicians, nurses 
and other personnel in both hospital and outpatient care settings, including emergency response workers; 
employees of nursing homes and chronic care facilities who have contact with patients or residents; employees of 
assisted living and other residences for persons in groups at high risk; persons who provide home care to persons 
in groups at high risk; individuals who live with or care for high-risk individuals, including healthy household 
contacts and caregivers for children age 0-59 mo) should be immunised each year, 1-2 mo before expected 
epidemic; also consider for overseas travellers; group vaccination of school-aged children highly cost effective; not 
recommended if < 6 mo age; 6 mo - 3 y: 2 x 0.25 mL doses split virus; 3-8 y: 2 x 0.5 mL doses split virus; 
> 9 y: 1 x 0.5 mL dose whole or split virus; side effects: pain at injection site; fever, malaise, myalgia mainly in 
previous recipients;fever, rash and seizures in children 6-23 mo; Guillain-Barre syndrome 1/1M; allergic reactions 
to eggs or other components; increased side effects in asthmatic children, ? systemic lupus erythematosus; 
decreased response in malignancy patients on therapy, patients with chronic renal failure, and transplantation 
patients (particularly if azotemic), and in patients with systemic lupus erythematosus or with rheumatic diseases 
receiving corticosteroids; exercise improves response; cost saving relative to oseltamivir or supportive care; live 
attenuated vaccine administered intranasally (5-8 y: 1 or 2 doses; 9-49 y: 1 dose; efficacy 86-93% in healthy 
children, 71-85% in healthy adults) may be given to those not on above list (not immunosuppressed, pregnant or 
with prior history of Guillain-Barre syndrome); amantadine and rimantidine give similar, but probably inferior, 
protection (influenza A only); oseltamivir (< 15 kg: 30 mg; 16-23 kg: 45 mg; 24-40 kg: 60 mg; > 40 kg: 75 mg) 
orally once daily during influenza season (> 13 y; 84% efficacy; cost saving relative to supportive care alone); 
zanamivir 10 mg 2 inhalations twice daily (not < 5 y) to prevent spread within families 
Acute Chest Infections 
Agents 

<4 y: 33% respiratory syncytial virus, 13% influenza A and B, 9% parainfluenza 1, 2 and 3, 5% 
adenovirus, 5% Mycoplasma pneumoniae, 2% coronavirus, 2% Simplexvirus, 8% mixed infections, 25% unknown 

4-8 y: peak incidence; 'acute wheezy chest' (acute diffuse bronchitis with airway obstruction), 
segmental pneumonia, acute bronchiolitis; agents as for conditions listed 

Diagnosis: acute wheezing common with respiratory syncytial virus; Gram stain, bacterial and viral culture and 
immunofluorescence of sputum, pharyngeal aspirate and nasopharyngeal aspirate; Becton Dickinson Directigen RSV 
on nasopharyngeal wash or aspirate sensitivity 93-97%, specificity 90-97%; serology 
Treatment: ampicillin, cotrimoxazole; humidified oxygen; bronchoscopic suction or tracheostomy 
Bronchitis: 2% of new episodes of illness in UK; 9-30 M cases in USA; acute bronchitis (0.4% of ambulatory 
care visits in USA) develops as a sequel to an acute upper respiratory infection, usually of viral origin; in chronic 
bronchitis (1.4% of ambulatory care visits in USA), there is almost daily production of sputum for 3 consecutive 
months over 2 consecutive years; 90% of chronic obstructive pulmonary disease (fourth leading cause of death in 
USA); acute exacerbations are common 

Agents: viruses (influenza R and B, respiratory syncytial virus), nontypeable Haemophilus influenzae (13% of 
acute exacerbations of chronic obstructive pulmonary disease), Streptococcus pneumoniae (6% of exacerbations of 
chornic obstructive pulmonary disease), other streptococci, Staphylococcus aureus, Moraxella catarrhalis (4% of 
acute exacerbations of chronic obstructive pulmonary disease), Escherichia coli (in newborn and recurrent 
exacerbations of chronic), Klebsiella pneumoniae, Pseudomonas aeruginosa (6% of acute exaacerbations of chronic 
obstructive pulmonary disease), Chlamydophila pneumoniae, Bordetella pertussis, Bordetella bronchiseptica, 
Streptobacillus moniliformis, Corynebacterium diphtheriae, Mycoplasma pneumoniae, Candida albicans, mixed 
anaerobes 
Diagnosis: 

Acnte: productive cough with sputum, restrosternal pain on coughing, fever; purulent sputum usually 
indicates secondary bacterial infection 

Acnte Exacerbation of Chronic: change in sputum colour, consistency and quality; increasing 
cough, often with development of dyspnoea; chest tightness; general fatigue; Gram stain, bacterial culture of 
sputum 

Chlamydophila pneumoniae, culture, serology, PCR-EIA 
Treatment: usually not required for acute bronchitis consequent on viral infection 



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Infections of the Respiratory Tract and Associated Structures 



Haemophilus influenzae, Streptococcus pneumoniae, Empirical Treatment of Acute 
Exacerbation of Chronic With Increased Dyspnoea and Increased Spntnm Pnrnlence and 
Volnme: povidone iodine gargles may be as effective as antibiotics; amoxycillin 15 mg/kg to 500 mg orally 8 
hourly for 5 d, doxycycline 4 mg/kg to 200 mg orally statim followed by 2 mg/kg to 100 mg orally daily for 5 d 
(not < 8 y, pregnant or breastfeeding); if amoxycillin resistant Haemophilus influenzae isolated, amoxycillin- 
clavulanate 500/125 mg orally 8 hourly (< 40 kg: 40/10 mg/kg daily in 3 divided doses) for 10-14 d; if 
unsatisfactory clinical response, ensure optimal physiotherapy and bronchodilator use, review diagnosis and 
perform chest X-ray 

Resistant Streptococcus pneumoniae: clindamycin, grepafloxacin, levofloxacin, 
sparfloxacin, trovafloxacin 

Chlamydia, Mycoplasma: tetracycline 

Bordetella: erythromycin 

Other Bacteria: amoxycillin-clavulanate or cefuroxime + bromohexine or N-acetylcysteine 
Prophylaxis: oxytetracycline 
Bronchiectasis 

Agents: viruses, Haemophilus influenzae, Streptococcus pneumoniae, Pseudomonas aeruginosa 
Diagnosis: Gram stain and culture of sputum 
Treatment: 

Pseudomonas aeruginosa: oral ciprofloxacin + inhaled tobramycin 

Others: ampicillin, tetracycline, erythromycin 
Acute Bronchiolitis and Bronchopneumonia: infants < 6 mo 

Agents: respiratory syncytial virus (in 84% of cases), parainfluenza 1 and 3, influenza A and B, human 
metapneumovirus (in 59-68% of cases), Streptococcus pneumoniae, coliforms, Mycoplasma pneumoniae, Bordetella 
bronchiseptica 

Diagnosis: expiratory wheezing (more common with respiratory syncytial virus) + fine crepitation + 
tachypnoea, air trapping or chest wall retraction; no significant response to bronchodilator; immunofluorescent 
smear of pharyngeal aspirate; bacterial and viral culture of nasopharyngeal aspirate, pharyngeal swab and sputum 
(lung, trachea, blood post mortem); ELISA, RIA, serology; PCR 
Treatment: clarithromycin; dexamethasone 1 mg/kg single oral dose if < 2 y 
Prevention (Respiratory Syncytial Virns): humanised monoclonal antibody (palivizumab) 
Bronchopulmonary Candidiasis 
Agent: Candida albicans 

Diagnosis: lower lobe consolidation with repeated isolation of Candida albicans from sputum or single isolation 
from uncontaminated bronchial specimen; serology (immunodiffusion, latex agglutination, 
counterimmunoelectrophoresis) 
Treatment: nystatin aerosols + amphotericin B 

Pneumonia: fifth leading cause of death, first among infectious diseases; 3% of acute illnesses in USA (« 45,000 
deaths/y; 0.5% of ambulatory care visits); 0.1% of new episodes of illness in UK; 20/1000 in < 1 y, 40/1000 in 
1-5 y (90% viral) 

Agents: mainly indigenous flora; 35-75% unknown aetiology, 6% aspiration, 3% postobstructive, 1% noninfectious; 
Mycoplasma pneumoniae (Eaton agent pneumonia, Eaton pneumonia, Mycoplasma pneumonia, mycoplasmal 
pneumonia, pleuropneumonia-like-organism pneumonia, PPLO pneumonia; 33% of community acquired bacterial 
pneumonia, 1% of community acquired pneumonia requiring ICU admission; deaths related to ineffective initial 
therapy, non-pneumonia related complications; world-wide, sporadic, endemic and occasionally epidemic), 
Streptococcus pneumoniae (320,000-620,000 hospitalisations/y in USA in > 65 y; 36% of community acquired and 
50% of hospital-acquired bacterial pneumonia in adult; common, world-wide; increased risk in AIDS, 
immunosuppressive therapy, severe combined immunodeficiency, nephrotic syndrome, myeloma, chronic lymphocytic 
leukemia, common variable immunodeficiency, X-linked agammaglobulinemia; mortality rate from 1% in patients 
20 y treated with penicillin to 70% in patients > 70 y not treated), Chlamydiophila psittaci from birds, 
Chlamydophila pneumoniae 9% of community acquired pneumonia, Chlamydia trachomatis usual cause in infants 
< 20 w during spring, summer and autumn, Haemophilus influenzae (7% of community acquired bacterial 
pneumonia; nontypeable strains in adults suffering from some predisposing respiratory tract disease such as 
chronic bronchitis or with chronic alcoholism or malignancy or B cell disease or not otherwise predisposed, and in 



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Infections of the Respiratory Tract and Associated Structures 



children, either primary (type b; 4 mo - 4 y; rates greatly decreased with Hib immunisation) or secondary to 
fibrocystic disease; rates greatly decreased with Hib immunisation), Gram negative bacilli (5% of community 
acquired pneumonia; increased risk in neutropenia, chronic granulomatous disease; coliforms result of antibiotic 
treatment or aspiration and in neutropenics; Klebsiella 12% of nosocomial pneumonia; Klebsiella pneumoniae 10% 
of community acquired bacterial pneumonia requiring ICU admission, with 46% of these fatal, lower respiratory 
tract infection common, necrotising pneumonia caused by certain biochemically atypical strains uncommon, adult 
mortality rate 25-50%; Enterobacter 9% of nosocomial pneumonia; Serratia 6% of nosocomial pneumonia; 
Escherichia coli 6% of nosocomial pneumonia, common in neonatal; Proteus 4% of nosocomial pneumonia; 
Pseudomonas 17% of nosocomial pneumonia; Pseudomonas aeruginosa as for coliforms but mucoid strains in cystic 
fibrosis, 10% of ventilator associated pneumonia, rare cases of necrotising community-acquired pneumonia in 
immunocompetenet, adult mortality rate 35-80%; Burkholderia cepacia, Stenotrophomonas maltophilia following 
hospitalisation and antibiotic therapy; Stenotrophomonas maltophilia 15% of ventilator associated pneumonia; 
Acinetobacter baumannii 27% of ventilator associated pneumonia), Staphylococcus aureus (3% of community 
acquired bacterial pneumonia, 8% of community acquired pneumonia requiring ICU admission, with 50% fatal in 
these cases; 13% of nosocomial pneumonia; 24% of ventilator associated pneumonia; secondary to viral infection 
and in neutropenia and chronic granulomatous disease; adult mortality rate 10-20%; enterotoxin B aerosol possible 
biowarfare agent), Legionella pneumophila (from soil, water-cooling equipment; 3% of pneumonia cases (0-50% of 
nosocomial, with 40% mortality); « 300 notified cases/y in Australia; incidence 0.2/100,000 in USA; incubation 
period 2-10 d; immunocompromised patients (AIDS, chemotherapy, radiation therapy, corticosteroids, underlying 
immune deficiencies), dialysis patients, late middle-aged to elderly males, chronic underlying disease (organic heart 
disease, lung disease, renal disease, diabetes), alcoholics and smokers; 5% of community acquired pneumonia 
requiring ICU admission (20% mortality)), Legionella micdadei (Pittsburgh pneumonia, nosocomial pneumonia, 
particularly in renal transplant and bone marrow transplant recipients), Streptococcus pyogenes (in neutropenics), 
other streptococci (30% of community acquired pneumonia requiring ICU admission, with 19% of these fatal; 
Streptococcus agalactiae (neonates), Streptococcus milled, group C Streptococcus (mainly Streptococcus equisimilis] 
rare secondary to tonsillitis and bronchitis, viridans streptococci in neutropenia and chronic granulomatous 
disease), Staphylococcus epidermidis (relatively common nosocomial in neonates), Mycobacterium tuberculosis 
(increased risk in AIDS, immunosuppressive therapy, severe combined immunodeficiency), anaerobes (87% of cases 
of aspiration pneumonia — 50% alone, 50% in combination with aerobes; also necrotising pneumonia — 6% 
mortality; 34% Fusobacterium nucleatum, 31% Prevotella melaninogenica, 26% microaerophilic streptococci, 21% 
Bacteroides fragilis, 19% Peptostreptococcus, 16% Prevotella oralis, 15% Peptococcus, also Bacteroides ureolyticus, 
other Prevotella), uncommon cases due to actinomycetes, Bordetella bronchiseptica, Haemophilus parainfluenzae, 
anthrax (from cattle, swine, horses, wool, hides), Brucella (abattoir workers, veterinarians), Coxiella burnetii (from 
goats, cattle, swine), melioidosis (travel to SE Asia, S America), plague (from squirrels, chipmunks, rabbits, rats), 
tularemia (from rabbits, squirrels, infected fleas or ticks), leptospirosis (from rats, dogs, cats, cattle, swine), 
Neisseria meningitidis (6% of meningococcal infections; occasionally arising as result of spread from meningococcal 
nasopharyngitis; increased risk in nephrotic syndrome, myeloma, lymphocytic leukemia, immunosuppressive therapy, 
AIDS, common variable immunodeficiency, X-linked agammaglobulinemia), Neisseria mucosa, Neisseria sicca, 
Moraxella catarrhalis, Chromobacterium violaceum (in 33% of infections due to this agent), Clostridium botulinum, 
Vibrio vulnificus (in drowning victim), Acinetobacter (multiple clinical risk factors, especially cigarette smoking 
and alcoholism; 66% mortality), enterococci, Corynebacterium pseudodiphtheriticum (in trauma and 
immunodeficient), Salmonella (in renal transplant recipients), Actinobacillus actinomycetemcomitans, Alcaligenes 
faecalis, Achromobacter xylosoxidans, Erwinia herbicola, Aeromonas hydrophila, Pasteurella multocida (chronic), 
Haemophilus aprophilus, Streptobacillus moniliformis, Veillonella parvula (rare), Enterococcus, Listeria 
monocytogenes, Ureaplasma urealyticum, pertussis, Rhodococcus equi in immunocompromised, Lactobacillus 
(ventilator associated); also in 52% of cases of Q fever (febrile, sudden onset); viruses (influenza common in 
adults, infrequent in children; influenza A and B 47% of community acquired viral pneumonia (10% of total cases 
in season; influenza A 1% of total adult cases, influenza B 3%; influenza B in 3% of infected pre-school children 
and 1% of infected young adults; human human cytomegalovirus 26% of community acquired viral pneumonia, in 
AIDS, bone marrow and organ transplant recipients and others with impaired cell-mediated immunity; 
parainfluenza 21% of community acquired viral pneumonia; parainfluenza 1, 0.5% of cases in adults; parainfluenza 
3, 4%; common in children, 19% of cases in infants; respiratory syncytial virus 3% of community acquired viral 
pneumonia (increased risk in AIDS, immunosuppressive therapy, severe combined immunodeficiency); adenovirus (1, 



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Infections of the Respiratory Tract and Associated Structures 



2, 3, 5, 7, 21) 3% of adult cases, 2-24% in children; varicella-zoster 0.5% of adult cases, in impaired cell-mediated 
immunity and normal adults; Simplexvirus in impaired cell-mediated immunity; measles; coxsackievirus A7, A9, Bl; 
echovirus 9, 11 (exanthem); parvovirus B19; fflimivirus; rarely other viruses); Aspergillus and Candida (long-term 
intravenous catheterisation and broad spectrum antibiotics, neutropenia, chronic granulomatous disease), 
Coccidioides immitis (may present with interstitial granulomatous dermatitis), Cryptococcus neoformans (increased 
risk in AIDS, immunosuppressive therapy, severe combined immunodeficiency), Histoplasma capsulation, Mucor, 
Curvularia lunata (rare); Pneumocystis jiroveci (3-4% of community acquired pneumonia; 0.5% of adult cases; 
increased risk in AIDS, immunosuppressive therapy, severe combined immunodeficiency), Paragonimus, Toxoplasma, 
Strongyloides stercoralis (AIDS, immunosuppressive therapy, severe combined immunodeficiency), other parasites; 
predisposing factors include congenital anomalies (cleft palate, tracheoesophageal fistula, sequestration of lung), 
congenital or acquired immune defects, alteration in level of consciousness (seizures, stroke, anesthesia, 
intoxication, trauma), depressed pulmonary clearance (cigarette smoke, hypoxemia, acidosis, ethanol, uremia), 
steroids and immunosuppressive agents, mechanical obstruction 

Diagnosis: chills, fever, headache, malaise, fatigue, cough (bacterial: productive; viral: non-productive, hoarse, 
paroxysmal), tachypnea + chest wall retraction, fine to medium crepitation (rales) on auscultation; evidence of 
pulmonary infiltration or consolidation on chest X-ray; sputum Gram stain and culture low diagnostic yield 

Bacterial: causes 6% of fever in returned travellers to Australia; sudden onset, severe toxicity, signs 
of consolidation on physical common, rigours common, high fever (> 39°C), purulent sputum with neutrophils and 
abundant bacteria on Gram stain, pleuritic chest pain common, white cell count elevated with immature 
neutrophils, consolidation on X-ray; blood cultures; aspartate and alanine aminotransferase (levels increased with 
Legionella, Chlamydia psittaci, Coxiella burnetii], serum phosphorus (slightly decreased with Legionella), erythrocyte 
sedimentation rate or C-reactive protein (highly elevated in legionnaires disease) 

Streptococcus pneumoniae: abrupt onset of variable fever of 38-41 C usually sustained, 
severe rigours, usually single, shaking chills at onset, productive cough, pleuritic chest pain, productive cough of 
mucopurulent or rusty (bloody) sputum, shortness of breath, hypoxia, tachypnea, malaise, nausea, vomiting, 
headache; preceding upper respiratory infection common; herpes labialis frequent; diminished breath sounds, 
dullness to percussion, crackling, bronchial breath sounds; massive consolidation of entire lung; multilobar 
involvement in 10-30%; pleural effusion uncommon; empyema in 2%, pericarditis, atelectasis, lung abscess other 
complications; Gram stain (Gram positive diplococci), semi-quantitative microscopy-directed culture and 
coagglutination (sensitivity 82-93%, specificity 89%) of carefully collected sputum; rapid immunochromatographic 
membrane test on urine (sensitivity 66-70%, specificity 90-100%); counterimmunoelectrophoresis (serum sensitivity 
45-80%, urine sensitivity 50-66%, sputum sensitivity 27-100%, pleural fluid sensitivity 100%); ELISA; blood urea 
> 7 mmol/L in 55% of cases, liver function tests abnormal in 24%, serum sodium < 130 mmol/L in 23%, serum 
albumin < 2.5 g/dL in 41%, white cell count > 15,000/ pL with left shift in 40% 

Other Streptococci: hectic fever of 40 C or higher, multiple rigours, productive cough, 
pleuritic chest pain; purulent sputum, may be blood-streaked, Gram positive cocci in chains in Gram stain; white 
cell count 20,000-30,000/ pL with left shift; pleural effusion and empyema common; often follows influenza 

Legionnaires' Disease (Broad Street Pnenmonia, Legionellosis, Legionnaires 
Pnenmonia): world-wide; « 250 notified cases/y in Australia; often derived from showers and water cooling 
towers, also other industrial, commercial, hospital and domestic environmental sources; no person-to-person 
transmission; incubation period 2-10 d; risk factors older age, male, heavy smoker, underlying disease associated 
with immunodeficiency; characterised by extensive inflammation of pulmonary alveolar tissue, often hemorrhagic, 
with many intra- and extracellular bacilli present in alveoli and respiratory bronchioles; clinical manifestations 
range from nonprogressive pneumonia with a minimum of extrapulmonary involvement to severe pneumonia with 
rapidly progressive pulmonary infiltration, severe hypoxia and respiratory failure, with, in many cases, multi-organ 
dysfunction, including neurological symptoms with frequent central nervous system abnormalities, renal 
involvement (hematuria, oliguria, proteinuria, renal failure), severe myositis (elevated creatine kinase and lysine 
dehydrogenase), anemia, hepatic abnormalities (elevated aspartate aminotransferase and bilirubin), high frequency 
of band neutrophils, and gastrointestinal symptoms; presence of prodromal 'viral-like' illness, dry cough, confusion, 
diarrhoea, lymphopenia without neutropenia, hyponatremia most useful symptoms; flu-like symptoms, malaise, fever 
of 39.5-41°C, multiple rigours, shaking chills, nonproductive cough, pleuritic chest pain, tachypnea, rales, sputum 
mucoid (if present) with rare polys and mononuclear cells and no bacteria on stain, myalgias and arthralgias, 
watery diarrhoea in 50%, abdominal distension, abdominal pain, nausea and vomiting, relative bradycardia, 



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headache, confusion, disorientation, delirium, hepatomegaly, dense airspace opacification of upper and lower lobes, 
patchy infiltrates to frank consolidation on X-ray; culture of sputum, bronchoalveolar lavage, bronchoscopy 
material, transtracheal aspirate, lung tissue, pleural fluid or blood on charcoal yeast extract agar with and without 
decontamination with KC1-HC1 (sensitivity 80%, specificity 100% but « 1/3 of laboratories incapable of growing 
organism; turnaround time 3-5 d); detection of specific antigen in respiratory secretions or urine; direct fluorescent 
(within first 9 d of therapy; sensitivity 25-75%, specificity > 95%; turnaround time 12 h) and indirect fluorescent 
antibody testing (rise in titre to at least 1:128; sensitivity 60-80%; results may be delayed > 2 mo) of 
transtracheal aspirate, fresh lung scrapings; radioimmunoassay or enzyme immunoassay of urine (early in disease; 
sensitivity 85%, specificity 100%; Legionella pneumophila serotype 1 only; 24 h turnaround time; positive for days 
to weeks after initiation of antibiotics); 4X serum antibody rise on complement fixation test (other than serogroup 
1; sensitivity 40-60%, specificity 96-99%; turnaround time 24 h) or by direct immunofluorescent antibody test or 
microagglutination (serogroup 1); immunoalkaline phosphatase staining of lung tissue; polymerase chain reaction of 
respiratory specimens; blood urea > 7 mmol/L in 58% of cases, liver function tests abnormal in 79%, serum 
sodium < 130 mmol/L in 53% (syndrome of inappropriate ADH secretion), serum albumin < 2.5 g/dL in 47%, 
white cell count > 15,000/pL in 84% (mean 18,000/pL, 78% neutrophils, 15% lymphocytes, 7% monocytes, 50% 
with left shift), p(h 53 mm Hg; lumbar puncture studies normal 

Staphylococcus aureus, more common in neonates and infants < 12 mo; hectic or 
sustained fever of 39-41 °C, multiple rigours, productive cough, pleuritic chest pain; purulent sputum, may be 
blood-streaked; Gram positive cocci in clusters on Gram stain; white cell count > 15,000/ pL with left shift; 
affects infants, elderly, debilitated, may follow influenza; alveolar disease, pneumatocoeles, empyema, nonspecific 
pulmonary infiltrate, massive consolidation, lung abscess common; counterimmunoelectrophoresis of pleural fluid 
(sensitivity 86%) 

Staphylococcus aureus Enterotoxin B: incubation period < 4 h; fever (up to 41.1 °C) 
myalgias, headache; respiratory symptoms (dry, non-productive cough, dyspnea, orthopnea, chest pain, crackles) 
begin % 10 h after exposure; detection of toxin with ELISA or PCR on urine within several hours or in nasal 
swabs within 24 h 

Klebsiella pneumoniae: fever of 38-39°C, multiple rigours, productive cough, pleuritic 
chest pain; mucopurulent sputum, may be bloody, Gram negative bacilli with thick capsules in Gram stain; white 
cell count 20,000-40,000/ pL with left shift; affects upper lobes, dense infiltrate, abscesses, heavy exudate in lung 
parenchyma causing downward bulging of horizontal pulmonary fissure, cavitation in 3-5 d of infection; seen in 
diabetics, alcoholics and patients with chronic lung disease; counterimmunoelectrophoresis of serum (sensitivity 
100%), pleural fluid (sensitivity 50%) 

Anaerobes: 74% suspected aspiration, 70% pulmonary infection characterised by 
parenchymal necrosis, 57% subacute or chronic presentation, 53% putrid discharge; fever variable, often low grade, 
rigours infrequent, productive cough; sputum purulent and foul-smelling, with mixed flora on Gram stain; white cell 
count variable; associated with periodontal disease and altered state of consciousness; consolidating infiltrate in 
right lower lobe or upper lobes; lung abscess, empyema common; pulmonary specimens should be obtained by 
percutaneous transtracheal aspiration, direct lung puncture or double catheter and bronchial brush bronchoscopic 
specimen; pleural specimens should be obtained by thoracentesis 

Pseudomonas aeruginosa: counterimmunoelectrophoresis of serum (sensitivity 100%) 

Chlamydophila pneumoniae: mild; mean white cell count « 9100/ jllL; isolation, 
microimmunofluorescent antibody, PCR-EIA 

Chlamydia trachomatis: conjunctivitis, tachypnea, inspiratory crackles, failure to thrive; 
diffuse interstitial infiltrates with hyperaeration, peribronchial thickening, scattered areas of atelectasis 

Haemophilus influenza: consolidative pneumonia and pleural involvement; isolation from 
pleural fluid 

Other Gram Negative Bacilli: usually high fever, may be absent in elderly, debilitated; 
multiple rigours; productive cough; purulent sputum, Gram negative bacilli in Gram stain; white cell count variable; 
affects infants, elderly, debilitated, alcoholics, diabetics, those on antibiotics, steroids or immunosuppressive agents, 
ventilators; chest CT to exclude underlying fungal cause 

Pulmonary Anthrax: incubation period 1-60 d; at first (1-6 d post-exposure), mild signs of 
upper respiratory tract involvement (fever and chills, malaise, fatigue and lethargy in all, minimal nonproductive 
cough in 90%, nausea or vomiting in 90%, dyspnea in 80%, sweats, often drenching, in 80%, mild chest discomfort 



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or pleuritic pain in 70%, myalgias in 60%, headache in 50%, confusion in 40%, abdominal pain in 30%, sore throat 
in 20%, rhinorrhea in 10%; tachycardia, high hematocrit, low albumin and sodium); then, after a few days, several 
hours to days of improvement, followed by abrupt development of severe respiratory distress, hypoxia, dyspnea, 
cyanosis, stridor, high temperature, profuse sweating, with shock and death usual within 24-36 h; mediastinal 
widening with pleural effusions but without infiltrates on X-ray (computed tomography if inconclusive); Gram stain 
and culture of nasopharyngeal swab within 48 h of exposure, sputum, pleural fluid later; blood cultures; PCR of 
pleural fluid or blood if available; ELISA, Western blot, toxin detection, chromatographic assay, fluorescent 
antibody test; 86% case-fatality rate 

Pneumonic Plagne: incubation period 1-6 d; severe, rapidly progressing pneumonia; fever, 
dyspnea, chest pain, cough with bloody, watery or purulent sputum, nausea, vomiting, diarrhoea, abdominal pain, 
hypotension, altered mentation, oliguria, rarely cervical buboes; WCC 10,000-20,000/ pi with neutrophils 
predominant and toxic granulations; elevated liver enzyme levels; coagulopathy; disseminated intravascualr 
coagulation in severe cases; culture of blood, sputum or aspirates; direct fluorescent antibody staining, dipstick 
antigen detection tests; rapid monoclonal antibody test (sensitivity 100%, specificity 100%, positive predictive 
value 91%, negative predictive value 87%) 

Tularemia: severe atypical pneumonia often confused with legionellosis; incubation period 
1-14 d followed by influenza-like illness with fever (38-40°C), chills, rigours, myalgias, anorexia, sore throat, cough 
(usually non-productive), pleuritic chest pain, substernal tightness, dyspnea and pharyngitis; parenchymal 
infiltrates with patchy, ill-defined and multi-lobar opacities in 74%, pulse-temperature dissociation in nearly half, 
erythema nodosum, erythema multiforme or maculopapular, vesicular or urticarial rash in 35%, pleural effusions in 
20-55%; leucocytosis in 25-42%, elevated transaminase levels, hyponatremia, elevated creatine phosphokinase level, 
pyuria, myoglobinuria; 35% fatality rate untreated; smear and culture positive in 5%; blood cultures often give 
false negative; serology, ELISA, immunofluorescence, PCR, antigen skin testing 

Mycoplasmal: abrupt or slow onset, with malaise in 74-89% of cases and headache in 60- 
84%, followed a few days later by fever of 38-40°C in 96-100%, rales/wheezes in 80-84%, chilliness in 58-78%, 
sore throat in 53-71%, myalgias in 45%, chest discomfort in 42-69%, nasal stuffiness in 29-69%, cervical 
adenopathy in 18-27%, pharyngeal erythema without exudate in 12-73%, occasional rigours and paroxysmal cough, 
nonproductive in 93-100%; sputum mucoid if present, with rare polys and no bacteria in Gram stain; complications 
include skin rashes (usually maculopapular or urticarial, also Stevens-Johnson syndrome and erythema nodosum), 
otitis (including bullous hemorrhagic otitis), urethritis, glomerulitis, pleurisy, pneumothorax, hyperlucent lung 
syndrome, lung abscess, anemia (including hemolytic), thrombocytopenia, pericarditis, myocarditis, 
encephalitis/meningitis in 1/1000 cases (60% encephalitis/meningoencephalitis in slightly older patients; 10% 
mortality, 20% long term neurological morbidity; aseptic meningitis in younger age group; complete recovery with 
no neurological sequelae), poliomyelitis-like syndrome, Guillain-Barre syndrome, brain stem syndrome/cerebellar 
ataxia, psychosis; may be severe and rapidly progressive in children with sickle cell disease; incubation period 12- 
21 d; children and young adults (4-20 y); community acquisition; person-to-person transmission; 10-25% mild 
pleural effusion; physical unimpressive though X-ray shows patchy nodular infiltrates, bronchopneumonia often 
involving a single lower lobe, plate-like atelectasis or hilar adenopathy; lobar consolidation (alveolar-filling 
disease) rare; may have bullous myringitis; may be suggested by lack of response to penicillins and cotrimoxazole; 
bedside cold agglutination test 50% sensitivity but « 100% specificity; rising titre of cold agglutinins (sensitivity 
50%, specificity 50%); complement fixation test (2-3 w post onset; commercially available; 4X rise sensitivity 54%, 
not completely specific -may cross-react with Legionella); early IgM-ELISA (sensitivity 90%, specificity 75%); 
culture of bronchoalveolar lavage; all methods lack sensitivity and, except for the ELISA and bedside cold 
agglutination test if positive, are too slow to influence therapy; a commercially available DNA-RNA probe is very 
specific but sensitivity has varied between 22% and 100%); neutropenia with relative lymphocytosis becoming 
neutrophilia; white cell count > 15,000/ pL in 87% of cases; myelocytes, metamyelocytes and plasmocytosis; 
raised ESR; hemolytic anemia occasionally; blood urea > 7 mmol/L in 16%; serum sodium < 130 mmol/L in 5%; 
serum albumin never < 2.5 g/dL 

Differential Diagnosis: psittacosis, Q fever, viral pneumonia (adenovirus, 
rhinovirus, influenza B, parainfluenza 1, 2 and 3, enteroviruses, respiratory syncytial virus) and, occasionally, 
legionnaires disease (indirect immunofluorescence for antibody) and tularemia pneumonia (4X rise in direct 
agglutination test) may give similar symptoms; the 'group' term 'primary atypical pneumonia' is used but serves 
no useful purpose; other conditions that may mimic include Pneumocystis jiroveci pneumonia (in patients with 



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Infections of the Respiratory Tract and Associated Structures 



failure of the immune system due to AIDS, steroidal drugs or bone marrow depression), multiply resistant 
Streptococcus pneumoniae, Pseudomonas pneumonia (in granulocytopenia), Haemophilus influenzae pneumonia (in 
hypogammaglobulinemia), respiratory syncytial virus (ELISA for IgG and IgM antibodies), human human 
cytomegalovirus (4X rise in complement fixation test titre), Ureaplasma urealyticum (ELISA for IgG, IgM and IgA), 
Chlamydia trachomatis (rise in titre on serial microimmunofluorescence tests) 

Ventilator Associated: quantitative endotracheal aspirate (10 5 cfu/ml; sensitivity 93%, 
specificity 80%) or bronchoalveolar lavage fluid culture; direct E-Test 

Viral: incubation period 1-3 d; all ages; person-to-person transmission; underlying disease, smoking, 
alcohol in some cases; upper respiratory symptoms; pleural effusion rare; gradual onset, myalgia prominent, mild to 
moderate toxicity, minimal physical findings (consolidation rare), involvement on X-ray out of proportion to 
symptoms (usually patchy consolidation at bases of lungs, but also hyperexpansion, parahilar peribronchial 
infiltrates, atelectasis, hilar adenopathy; lower lobe and perihilar infiltrates in atypical measles and pneumonic 
infiltrate in one lobe in 2/3 of respiratory syncytial virus cases), rigours uncommon, low grade fever; sputum 
mucoid (if present) with mononuclear cells and rare bacteria on Gram stain; pleuritic chest pain uncommon; white 
cell count normal; complement fixation test for influenza A and B, parainfluenza 1 and 3, respiratory syncytial 
virus, adenovirus; also hemagglutination inhibition, neutralisation, ELISA; viral culture and immunofluorescence of 
nasopharyngeal aspirate, sputum, throat swab, lung biopsy 

Influenza: fever of 39.5-40.5°C, rigours uncommon, nonproductive, hacking cough; headache, 
photophobia, myalgia, gastrointestinal complaints; sputum scant, may be bloody, rare polys and no bacteria in 
Gram stain; white cell count 10,000-15,000/pL; seen in patients with chronic lung and heart disease, pregnancy; 
profound dyspnea, cyanosis; seen in autumn and winter; adult mortality rate 80-90%; viral culture 

Adenovirns: most common in < 18 mo; acute onset, high fever (> 39°C), rigours rare, 
persistent cough, sputum scant with no organisms or polys in Gram stain; associated with lethargy, diarrhoea, 
pharyngitis, severe conjunctivitis; epidemic in closed populations (up to 10% of military recruits infected; types 4 
and 7; 90% of pneumonia hospitalisations); dyspnea, tachypnea, diffuse wheezing, crackles; diffuse bilateral 
infiltrates, interstitial and peribronchial, with hyperinflation and lobar collapse and hilar adenopathy, on X-ray; 
pleural effusions extremely rare; may progress to hepatosplenomegaly, myocarditis, nephritis, hematological 
abnormalities and a disseminated intravascular coagulation-like picture; mortality rate (type 7) « 60% in 
immunocompromised and « 20% in young infants; sequelae (bronchiolitis obliterans, bronchiectasis, unilateral 
hyperlucent lung) associated with abnormal pulmonary function in up to 60%; white cell count < 10,000/ pL; 
direct fluorescent antibody staining of tracheal or nasopharayngeal aspirate 

Echovirns: low grade fever, rigours rare, cough variable, sputum scant with no organisms or 
polys in Gram stain; white cell count < 10,000/ pL; rash may be present; seen in summer 

Respiratory syncytial virns: more common in winter; fever of 38-40°C in 60%, rigours 
rare, cough variable, frequent wheezing, sputum scant with no organisms or polys in Gram stain; white cell count 
10,000-20,000/ pL; seen primarily in children; X-ray changes often more severe than in other viral; direct 
fluorescent staining or ELISA on tracheal or nasopharyngeal aspirate; culture of tracheal aspirate 

Parainfluenza: fever of 38-40 C, rigours rare, cough variable, may have 'croup'; sputum 
scant with no organisms or polys in Gram stain; white cell count < 10,000/ pL; seen primarily in children; direct 
fluorescent antibody staining of tracheal or nasopharyngeal aspirate 

Varicella: early in disease; fever up to 40.5°C; rigours rare, cough harsh and nonproductive; 
sputum scant, though may be bloody, no organisms in Gram stain; white cell count < 1 0,000/ pL; rare in children; 
affects 15-30% of adults with varicella; nodular densities on X-ray, later calcify 

Differentiation From Secondary Bacterial Pnenmonia In Varicella: 
latter usually children < 7 y, late in disease, white cell count elevated with left shift, positive sputum and 
(occasionally) blood cultures, segmented or lobar infiltrate or consolidation 

Human human cytomegalovirus, culture of tracheal aspirate 
Pneumocystis jiroveci: Wright-Giemsa, Papanicolaou, methenamine silver staining, direct 
immunofluorescence of induced sputum (sensitivity 30-90%), bronchoalveolar lavage (sensitivity 98-100%), 
pulmonary biopsy (sensitivity 90-95%) 

Paiagonimus. Far East, Latin America; incidence 5ffl/y; abnormal chest X-ray (infiltration, cavities, 
pleural effusion) in 88% of cases; ova in sputum or feces; complement fixation test 



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Infections of the Respiratory Tract and Associated Structures 



Differential Diagnosis: pulmonary infarction, acute bronchitis, pulmonary tuberculosis, congestive heart 

failure, lung abscess 

Treatment: supplemental oxygen, analgesia for pleuritic chest pain, bronchodilators to treat airflow limitation or 

to improve mucociliary clearance, physiotherapy, hydration, electrolytes, nutrition, control of co-morbidities as 

required 

Commnnity Acqnired 

Birth to 1 w: benzylpenicillin 60 mg/kg i.v. 12 hourly for 7 d + gentamicin (< 30 w 
gestation: 2.5-3 mg/kg; > 30 w gestation: 3.5 mg/kg) i.v. daily for 7 d 
1 w to < 4 mo 

Afebrile and Mildly to Moderately 111: azithromycin 10 mg/kg orally daily 
for 5 d or clarithromycin 7.5 mg/kg orally 12 hourly for 7 d (not < 1 mo) or erythromycin 10 mg/kg orally or 
i.v. 6 hourly for 7-14 d (not < 1 mo) or erythromycin ethyl succinate 20 mg/kg orally 6 hourly for 7-14 d (not 
< 1 mo) 

Febrile or Chlamydia Exclnded: benzylpenicillin 30 mg/kg i.v. 6 hourly for 
7d 

Severe Disease: cefotaxime 25 mg/kg i.v. 8 hourly for 7 d 
4 mo to < 5 y 

Mild: amoxycillin 25 mg/kg orally 8 hourly for 7 d 
Moderate: benzylpenicillin 30 mg/kg i.v. 6 hourly for 7 d [if hospitalisation 
difficult, procaine penicillin (3 - < 6 kg: 250 mg; 6 - < 10 kg: 375 mg; 10 - < 15 kg: 500 mg; 15 - < 20 kg: 
750 mg) i.m. daily for 5 d] 

Severe: 

Tropical Anstralia with Diabetes, Cystic Fibrosis, Congenital 
Heart Disease: meropenem 25 mg/kg to 1 g i.v. 8 hourly 

Others: cefotaxime 25 mg/kg i.v. 8 hourly for 7 d, ceftriaxone 25 mg/kg 
i.v. daily for 7 d + di/flucloxacillin 50 mg/kg i.v. 6 hourly for 7 d 
5-15 y 

Mild: amoxycillin 25 mg/kg to 1 g orally 8 hourly for 7 d + clarithromycin 
7.5 mg/kg to 250 mg orally 12 hourly for 7 d or roxithromycin 4 mg/kg to 150 mg orally 12 hourly for 7 d 
More Serions: 

Tropical Anstralia with Diabetes, Cystic Fibrosis, Congenital 
Heart Disease: meropenem 25 mg/kg to 1 g i.v. 8 hourly + clarithromycin 12.5 mg/kg to 500 mg orally 12 
hourly for 7 d or roxithromycin 4 mg/kg to 150 mg orally 12 hourly for 5 d 

Others: benyzlpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly for 7 d [if 
hospitalisation difficult, procaine penicillin (3 - < 6 kg: 250 mg; 6 - < 10 kg: 375 mg; 10 - < 15 kg: 500 mg; 15 

- < 20 kg: 750 mg) i.m. daily for 5 d] + clarithromycin 12.5 mg/kg to 500 mg orally for 7 d or roxithromycin 4 
mg/kg to 150 mg orally 12 hourly for 5 d 

Adnlt: calculate PSI score: to patient age in years (male) or patient age in years 

- 10 (female), add (for each listed condition): 30 if neoplastic disease, arterial pH < 7.35; 20 if liver disease, 
acutely altered mental state, respiratory rate > 30/min, systolic blood pressure < 90 mm Hg, serum urea 

> 11 mmol/L, serum sodium < 130 mmol/L; 15 if temperature < 35°C or > 40°C; 10 if nursing home patient, 
congestive cardiac failure, cerebrovascular disease, chronic renal disease, pulse rate > 125/min, serum glucose 

> 14 mmol/L, hematocrit < 30%, p(h < 60 mmHg or (h< 90% saturation, pleural effusion on chest X-ray 

PSI Score < 70: 30 d mortality 0.1-0.6%; treat as outpatient with 
amoxycillin 1 g orally 8 hourly for 7 d (procaine penicillin 1.5 g i.m. daily if oral therapy unsuitable) + 
doxycycline 200 mg orally first dose then 100 mg daily for further 5 d or roxithromycin 300 mg orally daily for 
5d 

Non-immediate Penicillin Hypersensitivity: replace 
amoxycillin with cefuroxime 500 mg orally 12 hourly for 7 d 

Immediate Penicillin Hypersensitivity: moxifloxacin 400 mg orally 
daily for 7 d as single drug 

PSI Score 71-130: 30 d mortality 0.9-9.3%; treat in ward or as hospital in home 



Diagnosis and Management of Infectious Diseases Page 18 



Infections of the Respiratory Tract and Associated Structures 



Tropical Australia with Diabetes, Alcoholism, Chronic Renal 
Failnre or Chronic Lnng Disease: gentamicin 4-6 mg/kg i.v. daily + ceftriaxone 2 g i.v. daily 

Others: benzylpenicillin 1.2 g i.v. 6 hourly or amoxy(ampi)cillin 1 g i.v. 6 
hourly until significant improvement then amoxycillin 1 g orally 8 hourly for total 7 d + doxycycline 100 mg 
orally daily for further 7 d or clarithromycin 500 mg orally 12 hourly for 7 d or roxithromycin 300 mg orally 
daily for 5 d 

Non-immediate Penicillin Hypersensitivity: replace 
penicillin with ceftriaxone 1 g i.v. daily or cefotaxime 1 g i.v. 8 hourly until significant improvement then 
cefuroxime 500 mg orally 12 hourly for total 7 d 

Immediate Penicillin Hypersensitivity: moxifloxacin 400 
mg orally daily for 7 d 

PSI Score > 130: 30 d mortality 27%; consider ICU admission 

Non-tropical Regions: azithromycin 500 mg i.v. daily or erythromycin 
0.5-1 g i.v. 6 hourly (preferably through central line) + ceftriaxone 1 g i.v. daily or cefotaxime 1 g i.v. 8 hourly 
or [benzylpenicillin 1.2 g i.v. 4 hourly + gentamicin 4-6 mg/kg i.v. daily (adjust dose for renal function)] 

Immediate Penicillin Hypersensitivity: azithromycin or 
erythromycin + moxifloxacin 400 mg i.v. daily 

Tropical Anstralia With Diabetes, Alcoholism, Chronic Renal 
Failnre or Chronic Lnng Disease: meropenem 25 mg/kg to 1 g i.v. 8 hourly or imipenem 25 mg/kg to I g 
i.v. 6 hourly + azithromycin 500 mg i.v. daily or erythromycin 500 mg to 1 g i.v. 6 hourly (preferably through 
central line) 

Aspiration Pnenmonia: benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly + metronidazole 
12.5 mg/kg to 500 mg i.v. or 10 mg/kg to 400 mg orally 12 hourly till significant improvement then amoxycillin- 
clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 12 hourly 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg 
i.v. or orally 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly till significant improvement then 
clindamycin 10 mg/kg to 450 mg orally 8 hourly 

Gram Negative Snspected (e.g, Alcoholic): metronidazole 12.5 mg/kg to 
500 mg i.v. or 10 mg/kg to 400 mg orally 12 hourly + ceftriaxone 25 mg/kg to 1 g i.v. daily or cefotaxime 
25 mg/kg to 1 g i.v. 8 hourly; piperacillin-tazobactam 100/12.5 mg/kg to 4/0.5 g i.v. 8 hourly or ticarcillin- 
clavulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly as single agent 
Hospital-acqnired 

Low Risk of Multidrug Resistant Organisms: 

Mild: amoxycillin-clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for 
7 d or if unable to take oral therapy benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly + gentamicin 4-6 mg/kg 
(< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg) i.v. daily (adjust dose for renal function) 

Penicillin Hypersensitive (Not Immediate) or Creatinine 
Clearance < 20 mL/minl: cefuroxime 10 mg/kg to 500 mg orally 12 hourly for 7 d 

Immediate Penicillin Hypersensitivity: moxifloxacin 400 mg orally 
daily for 7 d (adults only) 

Moderate or Severe: ceftriaxone 25 mg/kg to 1 g i.v. daily, cefotaxime 25 
mg/kg to 1 g i.v. 8 hourly, ticarcillin-clavulanate 50 + 1.7 mg/kg to 3 + 0.1 g i.v. 6 hourly, benzylpenicillin 30 
mg/kg to 1.2 g i.v. 6 hourly + gentamicin 4-6 mg/kg (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg) daily (adjust 
dose for renal function) 

Immediate Penicillin Hypersensitivity: moxifloxacin 400 mg orally 
or i.v. daily for 7 d (adults only) 

Diabetes, Coma, Renal Failnre or Head Injury: di(flu)cloxacillin 50 mg/kg 
to 2g i.v. 6 hourly + gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. daily 

MRSA Proven: vancomycin 20 mg/kg to 1 g i.v. 12 hourly 
High Risk of Mnltidrng Ressitant Organisms: gentamicin (< 10 y: 7.5 mg/kg; child 
> 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. daily + piperacillin-tazobactam 100/12.5 mg/kg to 4/0.5 g i.v. 8 hourly 
or ticarcillin-clavulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly or (if penicillin hypersensitive) cefepime 50 
mg/kg to 2 g i.v. 12 hourly; if high prevalence of MRSA, add vancomycin 20 mg/kg to 1 g i.v. 12 hourly; if 



Diagnosis and Management of Infectious Diseases Page 19 



Infections of the Respiratory Tract and Associated Structures 



indicated by susceptibility testing, imipenem 25 mg/kg to 1 g i.v. 6 hourly or meropenem 25 mg/kg to 1 g i.v. 8 
hourly; if immunosuppressed, on high-dose steroids, diabetic, with malignancy or end-stage renal failure, history of 
smoking or excessive alcohol usage, or known local prevalence of hospital-acquired Legionella, add erythromycin 
10 mg/kg to 0.5-1 g i.v. 6 hourly or ciprofloxacin 10 mg/kg to 400 mg i.v. or 500-750 mg orally 12 hourly 

Streptococcus pneumoniae, broad spectrum cephalosporin + vancomycin until sensitivities 
available 

Penicillin MIC < 2 mg/L: benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly until 
significant improvement, then amoxycillin 25 mg/kg to 1 g orally 8 hourly for total 7 d 

Penicillin Hypersensitive (Not Immediate): ceftriaxone 25 mg/kg to 1 g 
i.v. daily until significant improvement, then cefuroxime 10 mg/kg to 500 mg orally 12 hourly for total 7 d 

Immediate Penicillin Hypersensitivity: moxifloxacin 400 mg orally or i.v. 
daily for 7 d 

Penicillin MIC > 2 mg/L: vancomycin 

Other Streptococci, Neisseria meningitidis: penicillin, erythromycin; drainage of purulent 
material from pleural space 

Haemophilus influenzae: amoxycillin 25 mg/kg to 1 g orally 8 hourly for 7-14 d, benzylpenicillin 
30 mg/kg to 1.2 g i.v. 6 hourly for 7-14 d, amoxycillin-clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 
hourly for 7-14 d, cefotaxime 25 mg/kg to 1 g i.v. 8 hourly for 7-14 d, ceftriaxone 25 mg/kg to 1 g i.v. daily for 
7-14 d, cefuroxime 10 mg/kg to 500 mg orally 12 hourly for 7-14 d, doxycycline 2.5 mg/kg to 100 mg orally 12 
hourly for 7-14 d (not < 8 y) 

Staphylococcus aureus. di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly for 4-6 w, cephalothin 
50 mg/kg to 2 g i.v. 6 hourly for 4-6 w, cephazolin 50 mg/kg to 2 g i.v. 8 hourly for 4-6 w; substitute 
vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. over 60 min 12 hourly (monitor blood levels and adjust 
dose accordingly) for 4-6 w if methicillin resistant suspected or proven or if severe penicillin hypersensitivity 

Staphylococcus aureus Enterotoxin B: supplemental oxygen, hydration, pain relievers 

Mycoplasma pneumoniae, Chlamydophila pneumoniae, Chlamydophila psittaci: 
doxycycline 200 mg orally first dose then 100 mg orally daily for 14 d (not in pregnant or children < 14 y), 
clarithromycin 7.5 mg/kg to 250 mg orally 12 hourly for 14 d, roxithromycin 300 mg orally daily (child: 4 mg/kg 
to 150 mg orally 12 hourly) for 4 d 

Moraxella catarrhalis: amoxycillin-clavulanate 500/125 mg orally 8 hourly (< 40 kg: 40/10 
mg/kg/d in 3 equally divided doses) for 7-10 d, erythromycin 500 mg i.v. 6 hourly (child: 50 mg/kg/d to 
maximum 2 g/d i.v. in divided doses) for 10 d 

Anaerobes: 

Mild: amoxycillin-clavulanate 500/125 mg orally 8 hourly (child: 40/10 mg/kg/d to 
maximum 1.5/0.375 g/d in 3 equally divided doses) for 7-10 d; ampicillin-sulbactam 

Moderate to Severe: benzylpenicillin 1.2 g i.v. 4 hourly (neonates: 60 mg/kg/d in 3 or 4 
divided doses; child < 45 kg: 150 mg/kg/d in 6 divided doses) for 10-14 d + metronidazole 500 mg i.v. infused 
over 20 min 8 hourly for 1-2 d then 200-400 mg orally 8 hourly or 0.5-1 g rectally 8 hourly for 10-14 d; 
clindamycin 600 mg i.v. diluted in 100 mL and infused over at least 30 min 8 hourly (child: 15-25 mg/kg/d to 
maximum 1.8 g i.v. in 3 or 4 divided doses) then 150-300 mg orally 6 hourly 

Legionella pneumophila: azithromycin 500 mg i.v. or orally daily or doxycycline 100 mg i.v. or 
orally 12 hourly or erythromycin 7.5 mg/kg to 500 mg to 1 g i.v. (preferably through central line) 6 hourly or 
500 mg orally 6 hourly or erythromycin ethyl succinate 800 mg orally 6 hourly + (very severe cases requiring 
ICU) ciprofloxacin 400 mg i.v. or 750 mg orally 12 hourly or rifampicin 7.5 mg/kg to 600 mg i.v. or orally daily 
for 7-14 d if immunocmpetent or 14-21 d if immunocompromised 

Chromobacterium violaceum: chloramphenicol 

Francisella tularensis: streptomycin or gentamicin for 10 d 

Vibrio vulnificus: doxycycline 100 mg orally or i.v. twice daily + ceftazidime 2 g i.v. 3 times a 
day or ciprofloxacin 400 mg twice a day for 3 d or gentamicin 

Pseudomonas aeruginosa: gentamicin 4-6 mg/kg (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg) 
i.v. daily (adjust dose dor renal function) + piperacillin 50-75 mg/kg to 3-4 g i.v. 6 hourly or cefepime 50 mg/kg 
to 2 g i.v. 12 hourly or ceftazidime 50 mg/kg to 2 g i.v. 8 hourly or ciprofloxacin 10 mg/kg to 400 mg i.v. or 15 
mg/kg to 750 mg orally 12 hourly for 14-21 d 



Diagnosis and Management of Infectious Diseases Page 20 



Infections of the Respiratory Tract and Associated Structures 



Burkholderia cepacia: imipenem 

Burhholdcria pseudomallei: cotrimoxazole + ceftazidime or meropenem or imipenem 

Stenotrophomonas maltophilia: cotrimoxazole 

Enterobacter, Serratia: gentamicin 5 mg/kg i.v. daily (child: 7.5 mg/kg/d i.v. in 1-3 divided 
doses) + meropenem 10 mg/kg to 500 mg i.v. 8 hourly or ciproflxacin 5 mg/kg to 200 mg i.v. 8 hourly for 
7-14 d 

Rcinetobactei baumannii: meropenem 25 mg/kg to 1 g i.v. 8 hourly; colistin 

Other Aerobic Gram Negative Bacilli (Including Klebsiella pneumoniae): cefotaxime 25 
mg/kg to 1 g i.v. 8 hourly for 7-14 d, ceftriaxone 25 mg/kg to 1 g i.v. daily for 7-14 d, gentamicin 4-6 mg/kg 
(< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg) daily (adjust dose for renal function) for 7-14 d, piperacillin- 
tazobactam 100 + 12.5 mg to 4 + 0.5 g i.v. 8 hourly for 7-14 d, ticarcillin + clavulanate 50 + 1.7 mg/kg to 3 
+ 0.1 g i.v. 6 hourly for 7-14 d, ciprofloxacin 10 mg/kg to 400 mg i.v. or 15 mg/kg to 750 mg orally 12 hourly 
for 7-14 d, meropenem 12.5 mg/kg to 500 mg i.v. 8 hourly for 7-14 d 

Corynebacterinm pseudodiphtheriticum: vancomycin + tobramycin 

Rhodococcus equi: vancomycin ± imipenem for at least 3 w, then oral rifampicin + macrolide or 
tetracycline for at least 2 mo 

Anthrax: ciprofloxacin 10 mg/kg to 400 mg i.v. every 12 h or doxycycline 2.5 mg/kg to 100 mg i.v. 
every 12 h (not < 8 y) + rifampicin, vancomycin, benzylpenicillin, clindamycin, chloramphenicol, imipenem, 
amoxy/ampicillin or clarithromycin for 14-21 d then ciprofloxacin 15 mg/kg to 500 mg orally 12 hourly or 
doxycycline 2.5 mg/kg to 100 mg orally 12 hourly (not < 8 y) or amoxycillin 15 mg/kg to 500 mg orally 8 
hourly for total 60 d 

Plagne: gentamicin 4-7.5 mg/kg i.v. daily, doxycycline 5 mg/kg to 200 mg i.v. then 2.5 mg/kg to 
100 mg i.v. twice daily (not < 8 y), ciprofloxacin 15 mg/kg to 400 mg i.v. twice daily, chloramphenicol 
25 mg/kg i.v. 4 times a day 

Lactobacillus: vancomycin i.v. for 14 d 

Influenza A: amantidine or rimantidine 

Adenovirns: ribavirin i.v. loading dose 30 mg/kg/d then 15 mg/kg/d in divided doses every 6 h 

Pneumocystis jiroveci: 

Mild to Moderate (Pa0 2 > 70 mm Hg, Alveolar-Arterial Gradient 
> 35 mm Hg, Oxygen Saturation > 94%): cotrimoxazole 5 + 25 mg/kg to 7 + 35 mg/kg orally 8 hourly 
for 21 d or (if sulphamethoxazole contraindicated) dapsone 1-2 mg/kg to 100 mg orally daily + trimethoprim 5 
mg/kg to 300 mg orally 8 hourly for 21 d or (if hypersensitive to cotrimoxazole) atovaquone 750 mg orally 12 
hourly for 21 d 

Severe: cotrimoxazole 5 + 25 mg/kg orally or i.v. 6 hourly for 21 d or pentamidine 

4 mg/kg to 300 mg i.v. daily for 21 d if unresponsive + prednisolone 1 mg/kg to 40 mg orally 12 hourly for 

5 d then daily for 5 d then 0.5 mg/kg to 20 mg daily for 11 d in HIV 

Paragonimus. praziquantel, bithionol 
Prophylaxis: 

Streptococcus pneumoniae. 23-valent polysaccharide vaccine 80% efficacy; fever 4%, severe 
systemic reaction 0.01%, risk of Arthus reaction with second dose; duration of immunity 3-8 y, cost-benefit ratio 
0.13-0.77 for all adults, 0.38-2.32 for high risk adults (those with cardiovascular disease and chronic pulmonary 
disease entailing increased morbidity from respiratory infections, alcoholism, cirrhosis of liver, CSF leaks, HIV 
infection, lymphoma, leukemia, diabetes mellitus, Hodgkin's disease, immunosuppression, multiple myeloma, 
generalised malignancy, chronic renal failure, postrenal transplant, postsplenectomy, skull fractures with recurrent 
pneumococcal meningitis, splenic dysfunction, otherwise healthy adult > 65 y); also consider for children > 2 y 
with anatomic splenectomy or functional asplenia associated with sickle cells, CSF leaks, immunosuppression, 
nephrotoxic syndrome, splenectomy 

Haemophilus influenzae type b: given to index case before discharge, and within 7 d to all 
household contacts of index case, including incompletely immunised children < 4 y and any immunocmpromsed 
child; also adults and children at day care centres with 2 or more cases of invasive disease in 60 d period and 
with incompletely immunised children; rifampicin 20 mg/kg to maximum 600 mg (child < 1 mo: 10 mg/kg) orally 
daily for 4 d (not pregnant; give ceftriaxone 1 g in lignocaine hydrochloride 1% i.m. as single dose); vaccine to 
index case under 2 y even if previous immunisation and to unvaccinated contacts < 5 y; all children should be 



Diagnosis and Management of Infectious Diseases Page 21 



Infections of the Respiratory Tract and Associated Structures 



routinely vaccinated beginning at 2 mo (95-100% efficacy; swelling, redness and pain at injection site in 5-30%, 
fever and irritability uncommon, serious reactions rare; contraindicated if anaphylaxis to vaccine components or 
previous dose and serious illnesses) 

Neisseria meningitidis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose (preferred if 
pregnant), ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), 
rifampicin 10 mg/kg (< 1 mo: 5 mg/kg) to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver 
disease; preferred for children); vaccines (quadrivalent polysaccharide, quadrivalent conjugate, and serogroup 
conjugate) available 

Ventilator-associated Pneumonia: chest physiotherapy 

Anthrax (Post-exposnre): doxycycline 2.5 mg/kg to 100 mg orally twice daily for 60 d (not 
< 8 y), ciprofloxacin 15 mg/kg to 500 mg orally twice daily for 60 d, amoxycillin 15 mg/kg to 500 mg orally 3 
times daily for 60 d; consider 3 doses of anthrax vaccine 0, 2 and 4 w after exposure 

Tnlaremia (Post-exposnre): doxycycline 2 mg/kg to 100 mg orally 12 hourly for 14 d 

Plagne (Postexposure): doxycycline 2.5 mg/kg to 100 mg orally 12 hourly (not < 8 y), 
ciprofloxacin 15 mg/kg to 500 mg orally 12 hourly 

Asplenic and Postsplenectomy: pneumococcal, meningococcal, Hib and standard schedule 
immunisation (including annual influenza); antibiotic prophylaxis in asplenic children < 5 y, children < 5 y with 
sickle cell anaemia, for at least 2 y following splenectomy and patients with severe underlying 
immunosuppression: amoxycillin 125 mg orally 12 hourly (< 2 y: 20 mg/kg orally daily) or 
phenoxymethylpenicillin 250 mg (< 2 y: 125 mg) orally 12 hourly or if penicillin hypersensitive roxithromycin 
4 mg/kg to 150 mg orally daily or erythromycin 250 mg orally daily or erthryomycin ethyl succinate 400 mg 
orally daily 

Cirrhotic Patient with Gastrointestinal Bleeding: norfloxacin 400 mg orally commencing 1 h 
before endsocopy and then 12 hourly for 1-2 d or if oral therapy not feasible ciprofloxacin 400 mg i.v. at time of 
induction and then 12 hourly for 1-2 d 

Necrotising Pneumonia: extensive destruction of lung tissue resulting in formation of multiple small abscess 
cavities; often fatal 

Agents: Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, other Enterobacteriaceae, anaerobes, 
Panton-Valentine leukocidin positive strains of Staphylococcus aureus (young patients) 
Diagnosis: culture of lung aspirate 
Treatment: broad spectrum penicillin + aminoglycoside 

Cystic Fibrosis (Mucoviscoidosis): patients often suffer from chronic bacterial pulmonary infection 
Organisms: Pseudomonas aeruginosa in 30-40% of patients (colonisation to severe necrotising bronchopneumonia; 
mucoid strains in chronic infection), Burkholderia cepacia in 10-40% (associated with accelerated lung disease, 
sepsis and necrotising pneumonia), Haemophilus influenzae and Staphylococcus aureus common; also, 
Stenotrophomonas maltophilia, Pseudomonas alcaligenes, Rchromobacter xylosoxidans, Acinetobacter baumanii, 
Ralstonia, Pandoraea, Mycobacterium abscessus, fungi and yeasts 
Diagnosis: sputum culture 
Treatment: 

Haemophilus influenzae, amoxycillin-clavulanate 500/125 mg orally 8 hourly (< 40 kg: 
40/10 mg/kg orally daily in divided doses) + probenecid 500 mg orally 6 hourly (child: 10-15 mg/kg orally 
daily in divided doses); in penicillin allergy: erythromycin 500 mg orally 6 hourly (child: 50 mg/kg orally daily in 
divided doses) ± rifampicin 600-1200 mg (child: 15-20 mg/kg) orally daily in divided doses, or cotrimoxazole 
160/800 mg (6 w - 5 mo: 20/100 mg; 6 mo - 5 y: 40/200 mg; 6-12 y: 80/400 mg) orally 12 hourly; ceftazidime 
150 mg/kg to maximum 6 g i.v. daily in divided doses for 2 weeks; aztreonam (1 w - 2 y: 30 mg/kg; > 2 y: 
50 mg/kg) i.v. 6 hourly + amikacin 1.5 mg/kg i.v. daily in 2 or 3 divided doses 

Pseudomonas aeruginosa: 

First Isolate: colistin 1 MU inhaled twice daily + oral ciprofloxacin for 3 w 
Second Isolate: colistin 2 MU inhaled 3 times daily + oral ciprofloxacin for 3 w 
Third Isolate Within 6 mo: colistin 2 MU inhaled 3 times daily + oral ciprofloxacin 
for 3 mo 

Chronic Infection: chronic suppressive inhalation therapy with colistin 1 MU twice daily 
or tobramycin 80 mg twice daily, alternated monthly 



Diagnosis and Management of Infectious Diseases Page 22 



Infections of the Respiratory Tract and Associated Structures 



Acute Exacerbation: 

First Line: ciprofloxacin 

Second Line: ticarcillin 200-300 mg/kg i.v. daily in 4-6 equally divided doses or 
piperacillin 100-300 mg/kg/d to 16 g i.v. in 3 divided doses + tobramycin (pediatric: 6-7.5 mg/kg/d i.v. in 3-4 
divided doses daily; adults: 8-10 mg/kg/d i.v. in 3-4 divided doses daily) 

Third Line: piperacillin-tazobactam or ticarcillin-clavulanate + tobramcyin 
Fourth Line or Penicillin Hypersensitive: ceftazidime 100-150 mg/kg/d to 
2 g (paediatric) or 3 g (adult) 3 times daily + tobramycin 

Fifth Line: aztreonam + tobramycin 

Sixth Line: imipenem or meropenem 25-40 mg/kg to 2 g i.v. 8 hourly 
Seventh Line: high dose ceftazidime + tobramycin + oral chloramphenicol or 
trimethoprim or doxycycline 

clarithromycin and azithormycin lead to improvement in respiratory function through inhibition of alginate 
production by mucoid strains; possible benefit of piroxicam (NSAID) 

Burkholderia cepacia: tobramycin aerosol + i.v. meropenem + i.v. ceftazidime, chloramphenicol, 
cotrimoxazole or aztreonam; amiloride aerosol + tobramycin aerosol 

Stenotrophomonas maltophilia: cotrimoxazole, doxycycline, timentin 

Rchromobacter xylosoxidans: colistin, minocycline, imipenem, meropenem, piperacillin, piperacillin- 
tazobactam 

Heine tobactet baumanii: polymyxin B, sulbactam 

Staphylococcus aureus: cloxacillin/flucloxacillin 2 g i.v. 4 hourly (< 2 y: !4 dose; 2-10 years: l A 
dose) + fusidic acid 500 mg orally 8 hourly (child: 50 mg/kg orally daily in divided doses) + probenecid 500 mg 
orally 6 hourly (child: 10-15 mg/kg orally daily in divided doses) for 14 d; in persistent infection, methicillin 
500 mg by inhalation 12 hourly may be added; in penicillin allergy, use rifampicin 500 mg orally 12 hourly (child: 
15 mg/kg orally daily in divided doses) + fusidic acid 

Mycobacterium abscessus: dependent on susceptibility tests 
Prophylaxis: Haemophilus influenzae type b conjugate vaccine (diphtheria toxoid conjugate) at 18 mo or older 
Neonatal Pneumonia 

Agents: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus agalactiae (early onset; 75% mortality), 
Ureaplasma urealyticum, Simplexvirus (onset days 3-14) 
Diagnosis: chest X-ray; Gram stain and culture of gastric aspirate, pleural fluid or lung aspirate 

Staphylococcus aureus: alveolar disease, consolidation, presence of air bronchograms and pleural 
effusions on X-ray 

Herpes: prominent hila with central interstitial infiltrate on X-ray; thrombocytopenia, evidence of 
disseminated intravascular coagulation, elevated liver function tests, lymphoid pleocytosis in CSF; vesicular skin 
lesions may be present; antigen tests and culture 
Treatment: 

Ureaplasma urealyticum: erythromycin 

Other Bacteria: benzylpenicillin 60-120 mg/kg/d i.v. in 4-6 divided doses for 7-10 d + cloxacillin 

Herpes: aciclovir 
Primary Pneumonia in Infants (Eosinophilic Pertussoid Syndrome of Infancy): interstitial 
pneumonia affecting 1-2% of infants aged 1-4 mo (50% with conjunctivitis); transmitted from infected mothers 
during parturition; similar symptoms in AIDS 

Agent: Chlamydia trachomatis, note that Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus 
aureus may also cause pneumonia in infants 

Diagnosis: no or low grade fever, no rigours, somewhat pertussis-like staccato paroxysmal cough with wheezing 
but without an inspiratory whoop; no bacteria on Gram stain of sputum; absolute increase in eosinophils in blood 
smear; diffuse interstitial infiltrates and hyperinflation, peribronchial thickening and scattered areas of atelectasis 
on X-ray; immunofluorescence; serology (complement fixation test; IgM or high sustained IgG) 
Treatment: erythromycin base or ethylsuccinate 50 mg/kg/d orally in 4 divided doses for 14 d 
Tuberculous Pneumonia: occurs especially in impaired cell-mediated immunity and in 4% of tuberculous 
patients with underlying neoplasia (100% mortality in these cases) 
Agent: Mycobacterium tuberculosis 



Diagnosis and Management of Infectious Diseases Page 23 



Infections of the Respiratory Tract and Associated Structures 



Diagnosis: remittent or intermittent fever of 38-38.5°C, rigours rare, cough variable, usually productive; white 
cell count < 10,000/ pL; seen in children and the elderly; may be rapidly progressive; exposure to known 
tuberculosis source; upper lobe infiltrate; Ziehl-Neelsen stain and mycobacterial culture of sputum; PCR (sensitivity 
90%, specificity 99.6%) 

Treatment: rifampicin 10 mg/kg to 600 mg orally 1 h before breakfast daily or 15 mg/kg to 600 mg orally 3 
times weekly for 6 mo + isoniazid 10 mg/kg to 300 mg orally daily or 15 mg/kg to 600 mg orally 3 times 
weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby: 5 mg) with each dose] + ethambutol 15 mg/kg orally 
daily or 30 mg/kg orally 3 times weekly (not < 6 y) for 2 mo or until known to be susceptible to rifampicin and 
isoniazid (to 6 mo) + pyrazinamide 25 mg/kg to 2 g orally 8 daily or 50 mg/kg to 3 g orally 3 times a week 
for 2 mo or 6 mo if not known to be suceptible to rifampicin and isoniazid 

Prophylaxis: isoniazid 10 mg/kg to 300 mg orally daily for 6-9 mo in recent tuberculin converters, children 
with positive tuberculin reactions, persons with inactive tuberculosis who are immunosuppressed (HIV, long-term 
corticosteroids, immunosuppressive or cytotoxic drugs, radiotherapy) 
Diffuse Interstitial Pneumonia 

Agents: 36% Pneumocystis jiroveci (occurs in 85% of AIDS patients; associated with corticosteroids in 77% of 
non-AIDS patients; also in other adults with an impaired immune response, especially chemotherapeutically 
immunosuppressed, T cell deficiency; also plasma cell pneumonia in newborn infants); Gram negative enteric and 
non-fermentative aerobic bacilli (in granulocytopenia), Streptococcus pyogenes, Staphylococcus aureus (in 
granulocytopenia), Nocardia asteroides (in T cell deficiency), Mycobacterium (in T cell deficiency; M.avium- 
intracellulare hot tub lung in immunocompetent), Rhodococcus equi (in immunocompromised patients), Aspergillus 
(in granulocytopenia), Mucor (in granulocytopenia), Absidia, Rhizopus, Candida, Cryptococcus neoformans (in T cell 
deficiency and AIDS), Histoplasma capsulatum, Coccidioides immitis, human human cytomegalovirus (« 50% of 
cases in allogenic bone marrow transplant recipients), human herpesvirus 3, Simplexvirus (in T cell deficiency), 
Strongyloides stercoralis, Toxoplasma gondii, ? Mycoplasma, ? Ureaplasma; 27% due to underlying disease 
(particularly lymphomas, sarcoidosis); also due to radiation and chemotherapeutic agents 
Diagnosis: history as to underlying disease, radiation therapy and pulmonary toxic medications; Gram-Weigert, 
Gram, Ziehl-Neelsen, Giemsa, methenamine-silver and toluidine blue stains and KOH preparation of induced 
sputum and bronchoalveolar lavage (sensitivity 89%; Ringer's solution most suitable; can be performed despite 
bleeding tendencies but yield may not be as good as from biopsy; complications rare; contraindicated in severe 
hypoxemia), transtracheal aspiration (useful initial step in evaluation that bypasses oropharyngeal contamination; 
occasional bleeding), open biopsy (requires general anaesthesia; because of large sample obtained, gives highest 
yield; < 10% delayed pneumothorax), transbronchial biopsy (low morbidity, but limited sample; results superior to 
simultaneous brushing; 10% pneumothorax incidence), transtracheal bronchial brushing (limited sample; may be 
attempted after platelet transfusion; some complication in almost 20% of patients), percutaneous needle aspiration 
(reliable in diagnosing pneumocystosis in leukemic children, most of whom are in remission; limited sample; 
pneumothorax in 25% of patients), percutaneous trephine biopsy (limited sample; bleeding may be difficult to 
control; pneumothorax in up to 66% of attempts), fibreoptic bronchoscopy (relatively well tolerated but 
oropharyngeal contamination confuses results; occasional bleeding and pneumothorax if brushing also performed), or 
cutting needle biopsy (for more peripheral solid lesions rather than diffuse disease; complications greater in diffuse 
disease); blood culture; antibody serology for human human cytomegalovirus, Aspergillus, Toxoplasma, influenza 
virus, parainfluenza virus, adenovirus, human herpesvirus 3, Simplexvirus, Mycoplasma, Pneumocystis jiroveci 
(indirect fluorescent antibody test; restricted availability; suggests the diagnosis if positive but gives many false 
negatives and should not be relied on clinically), Legionella; cryptococcal antigen determination on serum; H&E 
and methenamine-silver stains of lung biopsy sections 

Pneumocystis jiroveci. severe dyspnea on exertion, low grade fever, non-productive cough, malaise 
and cyanosis; usually in patients with CD4 counts < 200 cells/ jliL; chest X-ray shows diffuse bilateral interstitial 
infiltrates; gallium scan shows diffuse bilateral pulmonary disease; in immunompromised, pneumonic exudate 
contains lymphocytes, macrophages and possibly eosinophils but not polymorphs; arterial blood gas analysis shows 
arterial plh of < 70 mm Hg or low respiratory diffusing capacity (< 80% of predicted value) or an increase in 
alveolar-arterial O2 gradient; Wright-Giemsa, Papanicolaou, methenamine silver staining, direct immunofluorescence 
of induced sputum (sensitivity 30-90%), bronchoalveolar lavage (sensitivity 98-100%), brush biopsy of bronchus or 
needle biopsy of lung (sensitivity 90-95%); counterimmunoelectrophoresis; indirect fluorescent antibody titre 



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Infections of the Respiratory Tract and Associated Structures 



Treatment: 

Pneumocystis jiroveci: 

Mild to Moderate: cotrimoxazole 5/25 mg/kg to 320/1600 mg orally 8 hourly for 
3 w; if cotrimoxazole undesirable, trimethoprim 5-7.5 mg/kg to 300 mg orally 12 hourly for 3 w + dapsone 
1-2 mg/kg to 100 mg orally daily for 3 w; atovaquone 750 mg orally twice daily with meals for 21 d 

Severe: cotrimoxazole 5/25 mg/kg to 320/1600 mg i.v. 6 hourly until improvement occurs, 
then oral cotrimoxazole as above; if no response to, or intolerant of, cotrimoxazole, consider desensitisation or use 
pentamidine isethionate 4 mg/kg daily to 300 mg by i.v. infusion over 1-2 h for 3 w or 600 mg in 6 mL of water 
as an aerosol 20 min daily for 21 d; eflornithine 400 mg/kg daily i.v. in 4 divided doses for 10 days, then 300 
mg/kg daily in 4 divided doses for 4 d, then 300 mg/kg daily orally thereafter; trimetrexate 30 mg/m 2 of body 
surface as i.v. bolus daily for 21 d + calcium folinate (leucovorin) 20 mg/m 2 of body surface as i.v. bolus 6 
hourly for 23 d + sulphadiazine 1 g orally 6 hourly for 6 d; clindamycin 600 mg i.v. 6 hourly for 3 w or 600 mg 
i.v. as a loading dose followed by 300-450 mg orally 6 hourly for 3 w + primaquine 15 mg base orally once 
daily for 3 weeks; if significant hypoxia (especially in HIV), prednisolone 1 mg/kg to 40 mg orally or i.v. for 5 d, 
then 1 mg/kg to 40 mg daily for 5 d, then 0.5 mg/kg to 20 mg daily for 11 d 

Maintenance Therapy and Primary Prophylaxis in HIV/AIDS (CD4 Connt 
< 200/uL): cotrimoxazole 80/400 or 160/800 mg orally daily or 160/800 mg orally 3 times weekly, dapsone 
100 mg orally 3 times weekly, pentamidine 300 mg i.v. or aerosolised every 2-4 w 

Bacterial: depending on specific agent (Rhodococcus equt rifampicin + erythromycin) 
Cryptococcus neoformans: 

Mild: fluconazole 20 mg/kg to 800 mg orally or i.v. initially, then 10 mg/kg to 400 mg 
orally daily for at least 4 w 

More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 
25 mg/kg i.v. or orally 6 hourly for 2 w; if clinical improvement after 2 w, change to fluconazole as for Mild 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or 
itraconazole 200 mg orally daily 
Other Fnngal: 

Non-nentropenic with Milder Disease: voriconazole 200 mg orally 12 hourly, 
itraconazole 7.5 mg/kg to 300 mg orally 12 hourly for 3 d then 5 mg/kg to 200 mg 12 hourly 

Immnnocompromised: voriconazole 6 mg/kg i.v. 12 hourly for 2 doses then 4 mg/kg 12 
hourly for at least 7 d then 4 mg/kg to 200 mg orally 12 hourly, amphotericin B desoxycholate 1 mg/kg i.v. 
daily 

Simplexvirus. famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly 
for 7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Freqnent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Human herpesvirus 3: famciclovir 500 mg orally 8 hourly for 7-14 d, valaciclovir 1 g orally 8 
hourly for 7-14 d, aciclovir 800 mg orally 5 times daily for 7-14 d 

Severe or Unable to Take Oral Therapy: aciclovir 10 mg/kg i.v. 8 hourly for 7-14 d 
(adjust dose for renal function) 

Human human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 
mg orally daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg 
i.v. 5 times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 
mg/kg i.v. 5 times weekly (adjust dose according to creatinine clearance), cidofovir 5 mg/kg i.v. weekly for 2 w 
(+ probenecid; not if proteinuria > 2+ or creatinine clearance < 55 mL/min) then as above every 2 w 
Other Viral: non-specific 

Toxoplasma gondii: sulphadiazine 1-1.5 g orally or i.v. 6 hourly for 3-6 w then 500 mg orally 6 
hourly or 1 g orally 12 hourly + pyrimethamine 50-100 mg orally loading dose then 25-50 mg daily for 3-6 w 
(continue if necessary) 

Snlphadiazine Hypersensitive: substitute clindamycin 600 mg orally or i.v. 6 hourly for 
3-6 w (treatment) or 600 mg orally 8 hourly (maintenance) for sulphadiazine 
Strongyloides stercoralis. thiabendazole 



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Infections of the Respiratory Tract and Associated Structures 



Prophylaxis: 

Pneumocystis jiroveci in AIDS Patients with Rapid Fall in Nnmber of CD4 + Cells, 
CD4 + 20-30%, CD4 + Total Connt < 200/ uL, Fever or Thrnsh, or to Prevent Recurrence of 
Infection: cotrimoxazole 80/400-160/800 mg orally once daily or 160/800 mg orally twice daily on 3 days of 
week or 12 hourly twice weekly; dapsone 100 mg orally 3 times a week; pentamidine isethionate 300 mg i.v. or 
in 6 mL of water as a 20 minute aerosol from nebuliser producing droplet size < 2 pm every 2-4 w; clindamycin 
+ primaquine; atovaquone 1500 mg daily; pyrimethamine + sulphadiazine; dapsone 100 mg orally twice a week 
+ trimethoprim 300 mg orally twice a week; pyrimethamine-sulphadoxine (Fansidarj 25/500 mg orally weekly; 
immunologic monitoring; zidovudine 

Human human cytomegalovirus: exclusive use of human human cytomegalovirus-mmqatiw 
blood products; gangiclovir 5 mg/kg i.v. every 12 h for 5-7 d, then 5-6 mg/kg i.v. daily for 5 d/w from 
engraftment until day 100 after haematopoietic stem cell transplantation 

Toxoplasma gondii: cotrimoxazole 1 double strength tablet orally daily or 1 single strength tablet 
orally daily or 1 double strength tablet orally 3 times/w to seropositive allogenic adult or adolescent 
hematopoietic stem cell transplant recipients as long as on immunosuppressive therapy and to HIV/AIDS patients 
with CD4 count < 200/ pL 

Giant Cell PneumoniaError! Bookmark not defined. 

Agent: measles virus; occurs in 4-75% of measles cases, causing 75% of measles deaths overall and 100% of 
deaths in patients < 5 y 

Diagnosis: patchy consolidation at bases of lungs; viral culture and cytology of throat swab; serology 
(complement fixation test, hemagglutination inhibiton) 
Treatment: non-specific 

Fungal Pneumonia: usually in immunosuppressed patients (aspergillosis, zygomycosis and cadidiasis especially 
in neutropenics; aspergillosis in 4% of bone marrow transplant recipients; cryptococcosis, ? histoplasmosis 
especially in impaired cell-mediated immunity; coccidioidomycosis (8% of symptomatic infections) risk factors 
diabetes, smoking, older age,) but may occur in general population (32% of Aspergillus isolates from sputum and 
66% from bronchial washings are associated with pulmonary infiltration; 40-45% of these cases are in non- 
immunocompromised patients, 20-40% of whom have invasive pulmonary aspergillosis); necrotising 
bronchopneumonia in 35% of patients with pulmonary aspergillosis, hemorrhagic infarction in 30%, miliary 
microabscesses in 10%, lobar pneumonia in 10%, bronchitis in 10%, focal abscesses in 5%, solitary abscess in 5% 
Agents: isolates of Blastomyces dermatitidis, Coccidioides immitis, Histoplasma capsulatum and Sporothrix 
schenckii are always significant; isolates of Absidia, Aspergillus (Aspergillus fumigatus, Aspergillus flaws, 
occasionally other Aspergillus species; most common cause of community acquired pneumonia (often with 
concurrent gram negative bacilli) in stem cell transplant recipients with graft versus host disease), Candida, 
Cryptococcus neoformans, Mucor, Rhizopus and Rhizomucor may be significant, especially in leukemics; also 
Trichosporon, Fusarium, Penicillium and Torulopsis in cancer patients, and Drechslera, Geotrichum, Pseudallescheria 
boydii, Scedosporium prolificans and Cunninghamella in disseminated infections 
Diagnosis: wet mount KOH phase contrast microscopy and fungal culture of bronchoalveolar lavage (100% 
sensitivity in diffuse pulmonary disease due to Aspergillus but not effective in patients with focal pulmonary 
lesions), Gomori methenamine silver sections and culture of lung biopsy; immunodiffusion; precipitin (positive in 
90% of aspergilloma cases, 60-75% of allergic bronchopulmonary aspergillosis, rare in other circumstances); halo 
sign on CT indicative of invasive aspergillosis 
Treatment: 

Cryptococcus neoformans: 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 
More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 
mg/kg i.v. or orally 6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally 
initially then 400 mg daily for 8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or 
itraconazole 200 mg orally daily 

Others: amphotericin B (not Pseudallescheria boydii, Scedosporium prolificans, disseminated 
aspergillosis: 0.5-1 mg/kg/d i.v. to total 2-8 g; blastomycosis: 0.5-1 mg/kg/d i.v. to total 1.5-2 g; 
coccidioidomycosis: 1-1.5 mg/kg/d i.v. to total 1.5-2 g; histoplasmosis: 0.6 mg/kg/d i.v to total 2-2.5 g; consider 



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Infections of the Respiratory Tract and Associated Structures 



administration through a percutaneous endobronchial catheter, combined with systemic administration, if this 

seems necessary; may be combined with flucytosine 10-20 g/d), voriconazole 6 mg/kg i.v. 12 hourly for 2 doses 

then 4 mg/kg 12 hourly for at least 7 d then 4 mg/kg to 200 mg orally 12 hourly, itraconazole + flucytosine, 

miconazole; early surgical resection in symptomatic aspergilloma, asymptomatic aspergilloma with reasonable 

complication, mucormycosis with persistent cavitations after treatment, and scedesporosis; decortication desirable 

in extensive pleural disease; interferon-gamma in pulmonary aspergillosis in chronic granulomatous disease 

Tropical Eosinophilic Pneumonia (Tropical Pulmonary Eosinophilia, Frimodt-Moller 

Syndrome, Tropical Eosinophilia, Tropical Eosinophilic Asthma, Tropical Eosinophilosis, 

Weingarten Disease, Weingarten Syndrome) 

Agents: Wuchereria bancrofti, Brugia malayi, Brugia pahangi, animal filaria; Corynebacterium pseudotuberculosis 

may cause similar syndrome 

Diagnosis: chronic pulmonary infiltration and opacities, cough, dyspnea, asthma with nocturnal wheezing, X-ray; 

marked blood eosinophilia; microfilariae present in lung tissue but absent from peripheral blood; high IgE; positive 

filarial serology (filaria-specific IgG and IgE) 

Treatment: diethylcarbamazine 

Pneumonitis 

Agents: respiratory syncytial vim (6-12 mo; in 25% of cases; wheezing common), parainfluenza, influenza A and 

B, adenovirus, measles virus, varicella, human metapneumovirus (in 17% of cases); Rhodococcus equi (in 

immunodeficient hosts exposed to animals), Yersinia pestis, Francisella tularensis, anaerobes (3% mortality), 

Mycoplasma pneumoniae (in immunodeficient), Haemophilus influenzae, Burkholderia pseudomallei, Mycobacterium 

szulgai, Mycobacterium xenopi, Nocardia asteroides, 12% of Rocky Mountain spotted fever cases; Cryptococcus 

neoformans (chronic; can lead to fatal meningitis), Candida albicans; migrating larvae of Maris lumbricoides, 

hookworm, Strongyloides stercoralis, Rcanthamoeba 

Diagnosis: immunofluorescence of nasopharyngeal aspirate; viral culture of throat swab, nasopharyngeal 

aspirate; Gram stain and culture of sputum, bronchial washing, open lung biopsy, transtracheal aspirate; serology; 

observation of larvae in sputum; Strongyloides stercoralis gives an initial neutrophilia becoming leucopenia with 

40% eosinophilia 

Treatment: 

Respiratory Syncytial Virns, Influenza, Parainfluenza: ribavirin aerosol 

Other Virnses: non-specific 

Rhodococcus equi. erythromycin + rifampicin + surgery 

Francisella tularensis: streptomycin, tetracycline 

Mycoplasma pneumoniae, Nocardia asteroides: minocycline 

Haemophilus influenzae: amoxycillin-clavulanate 

Anaerobes: clindamycin, metronidazole 

Burkholderia pseudomallei. tetracycline 40-50 mg/kg orally daily in 4 divided doses for 
60-150 d, cotrimoxazole 4/20-8/40 mg/kg (child: 6/30 mg/kg) daily orally in 2 divided doses, chloramphenicol 
40-100 mg/kg (child: 50-75 mg/kg) daily orally in 4 divided doses 

Mycobacterium szulgai: ethambutol 25 mg/kg to 1 g orally daily + rifampicin 600 mg daily + 
ethionamide 500 mg - 1 g orally daily in 3 divided doses or streptomycin 15 mg/kg i.m. daily or cycloserine 
500 mg orally daily in 2 divided doses 

Mycobacterium xenopi. isoniazid 300-450 mg orally daily as a single dose + rifampicin 600 mg 
orally daily + streptomycin 15 mg/kg i.m. daily 

Cryptococcus neoformans, Candida albicans. 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 
More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 
mg/kg i.v. or orally 6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally 
initially then 400 mg daily for 8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or 
itraconazole 200 mg orally daily 

Larvae: pyrantel embonate, thiabendazole, mebendazole 



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Infections of the Respiratory Tract and Associated Structures 



Acute Empyema: 50% mortality in hospital-acquired cases 

Agents: Staphylococcus aureus (25-35% in adults, 75-90% in children), anaerobes (15-35% in adults, 1% in 
children; Peptostreptococcus, Bacteroides, Prevotella, Fusobacterium, rare cases of Clostridium perfringens), 
Streptococcus pneumoniae (12-38% in adults, 2-5% in children), other streptococci (3-5% in adults, 2% in children; 
Streptococcus pyogenes, Streptococcus miileri, enterococci, Streptococcus cam's), Haemophilus influenzae (0-5% in 
adults, 1% in children), other Gram negative bacilli (15-30% in adults, 2% in children; Klebsiella-Enterobacter, 
Escherichia coli, Pseudomonas aeruginosa, Proteus, Acinetobacter calcoaceticus, Serratia marcescens, uncommonly 
Actinobacillus actinomycetemcomitans, Pseudomonas alcaligenes; rare cases of Capnocytophaga, Eikenella corrodens, 
Erwinia herbicola, Actinomyces pyogenes, Candida; also in tuberculosis 
Diagnosis: associated with pneumonia, thoracic surgery, tumour, spontaneous pneumothorax, lung or 
subdiaphragmatic abscess, bronchiectasis, asthma, foreign body, dental extraction, tonsillectomy; fever in 80%, 
dyspnea in 60%, chest pain in 50%, weight loss in 25%, chills in 25%, haemoptysis in 15%, night sweats in 12%; 
chest X-ray (presence of pleural effusions on an earlier film; extension of the air-fluid level to the chest wall; 
extension of the lesion across fissure line; a tapering border of the air-fluid pocket; location of the air pocket in 
the posterior costophrenic sulcus; a cavity of unequal dimensions); Gram, fungal and acid-fast stains and culture 
of aspirated pus from loculated empyema; total (> 2500/ pL) and differential (polys predominate = bacterial, 
lymphs predominate = fungal, tuberculosis) white cell count, biochemistry (protein > 3 g/dL and ratio of pleural 
fluid to serum content 0.5, glucose 50% that of serum, LDH > 200 IU and ratio of pleural fluid to serum content 
0.6, specific gravity < 1.018, pH < 7.2), Gram, fungal and acid-fast stains and culture of pleural fluid in 
nonloculated empyema 
Treatment: open drainage + 

Pseudomonas. ticarcillin + gentamicin 

Other Bacteria: chloramphenicol 

Candida, amphotericin B + flucytosine 
Chronic Empyema 

Agents: may be due to any of the organisms causing acute empyema, but is frequently due to, or complicated 
by, various fungi (mainly those causing fungal pneumonia) 
Diagnosis: as for Acute Empyema 
Treatment: surgery + appropriate antimicrobial 

Pulmonary Abscess: primary in oral sepsis and decreased cough reflex (alcohol, anesthesia, drugs, seizures, 
neurologic disorders, coma), esophageal disorders (diverticula, achalasia, strictures, motility disorders, cancer) with 
oral sepsis, endobronchial obstruction (cancer, foreign body) and in postnecrotising pneumonia; opportunistic in 
newborn (prematurity, congenital abnormalities of the heart or lung), elderly (blood dyscrasias, cancer of the lung 
and oropharynx, treatment with steroids, postoperatively), and nosocomial; hematogenous in septicemia and 
pulmonary infarct (bland or septic) 

Agents: 85-90% anaerobes (60-75% only; 50% Fusobacterium nucleatum, 45% Prevotella melaninogenica, 40% 
Peptostreptococcus, 25% Peptococcus, 20% Eubacterium, 15% Bacteroides fragilis, 10% Propionibacteriunr, other 
Bacteroides, other Prevotella, Bifidobacterium adolescentis), 23% Staphylococcus and Streptococcus, 10% 
Pseudomonas aeruginosa, 8% Klebsiella, 4% Haemophilus influenzae (18% of non-bacteremic invasive Haemophilus 
influenzae infections in older children and adults); Mycobacterium tuberculosis, Chromobacterium violaceum (in 
22% of infections due to this organism), Rhodococcus equi, Capnocytophaga, Salmonella (in renal transplant 
recipients), Lactobacillus (extremely rare), Selenomonas sputigena, Legionella, Nocardia, Entamoeba histolytica 
(amoebic abscess of lung or pleura is commonly secondary to an amoebic liver abscess that ruptures through the 
diaphragm into the lung, but may arise in the mesenteric blood vessels or lymphatics) 
Diagnosis: cavitary lesion on chest X-ray (may also be due to tuberculosis, fungi including histoplasmosis, 
blastomycosis, coccidioidomycosis and aspergillosis, primary or metastatic carcinoma, infected cyst, infected bullae, 
nontuberculous granulomatous disease, extension of a subphrenic process, pulmonary infarction); culture of biopsy; 
fever (average minimum 38.8°C rectally) in 95%, leucocytosis (average « 15,000/ pL) in 90%, anemia (average 
haematocrit 35%) in 90%, aspiration in 75%, weight loss (average 9 lb) in 55% 

Treatment: benzylpenicillin 600 mg i.v. 4-6 hourly (child: 100-120 mg/kg/d in 4-6 divided doses) for 10-14 d + 
metronidazole 500 mg i.v. 12 hourly (child: 20 mg/kg/d to 1 g in 3 divided doses) for 1-2 d then 400 mg orally 
(child: 20 mg/kg/d to 800 mg/d in 2 divided doses) or 1 g rectally 12 hourly (child: 80 mg/kg/d to 2 g in 2 
divided doses) for total 10-14 d; clindamycin 600 mg i.v. slowly 8 hourly (child: 30 mg/kg/d to 1.8 g/d in 3 



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Infections of the Respiratory Tract and Associated Structures 



divided doses), then 300 mg orally 6 hourly (child: 20-40 mg/kg/d to 1.2 g in 4 divided doses) for total 10-14 d; 
substitute cefotaxime 1 g (child: 50 mg/kg to 1 g) i.v. 8 hourly or ceftriaxone 1 g (child: 100 mg/kg to 1 g) i.v. 
once daily if Gram negative bacilli suspected; aggressive expectoration, chest physiotherapy, postural drainage; 
surgery (drainage of empyema secondary to lung abscess if tube drainage is inadequate; to differentiate lung 
abscess from carcinoma if other approaches are unsuccessful; life-threatening hemoptysis) 

Pseudomonas aeruginosa: oral ciprofloxacin for 12 w 
Pulmonary Gangrene 
Agents: Bacteroides, Peptostreptococcus 
Diagnosis: culture of biopsy 
Treatment: chloramphenicol 

Respiratory Syncytial Virus Infections: conditions include bronchitis, cold, croup, bronchiolitis, pneumonia 
and pneumonitis; major cause of lower respiratory tract infection in young children; most frequent nosocomial 
infection on pediatric wards 
Agent: respiratory syncytial virus 

Diagnosis: culture, EIA (Vidas sensitivity 93%, specificity 94%), direct immunofluorescence (sensitivity 66%, 
specificity 73%) of nasopharyngeal aspirate in first 3-4 d 
Treatment: ribavirin aerosol 
Bornholih Disease (Epidemic Pleurodynia) 
Agent: coxsackievirus Bl-5, echovirus 6 

Diagnosis: viral culture of throat and nasal swabs, faeces and CSF in tissue culture, suckling mice; serology 
(neutralisation); biochemistry normal; no neutrophilia 
Treatment: non-specific 

Ornithosis (Bedsonia Pneumonia, Papageienkronkheit, Parrot Fever, Psittacosis, Psittacosis 
Pneumonia): « 80 notified cases/y in Australia (« 80% in Victoria); incidence 0.05/100,000 in USA; incubation 
period 6-15 d; adults; person-to-person transmission rare; transmitted by excreta of infected birds, usually 
psittacines; usually acute pneumonitis but has been associated with embolisms and infective endocarditis 
Agent: Chlamydia psittaci 

Diagnosis: variable fever, infrequent rigours, productive cough with pleuritic chest pain; upper respiratory 
symptoms present or absent; pleural effusion rare; sputum mucoid, bloody, no bacteria on stain; headache, 
myalgias prominent; macular rash, splenomegaly may be present; patchy abnormal densities in lower segments of 
lower lobes; exposure to parrots or turkeys; complement fixation; culture of sputum; direct fluorescent antibody 
staining of respiratory secretions or tissue; microimmunofluorescence; PCR; abnormal liver function tests in 50% of 
cases, serum sodium < 130 mmol/L in 44%, serum albumin < 2.5 g/dL in 44%, blood urea > 7 mmol/L in 11%; 
white cell count > 15,000/ pL in 83% of cases 

Treatment: doxycycline 200 mg orally at once, then 100 mg orally daily for 14 d (not in children), 
roxithromycin for 14 d 

Prevention and Control: eliminate contact with infected birds 

Q fever: case-fatality rate < 1%; incubation period 14-35 d; adults; work in abattoir or on farm; « 500 notified 
cases/y in Australia (« 57% in Queensland) 
Agent: Coxielia burnetii 

Diagnosis: pleural effusion rare; chest X-ray normal or patchy consolidation at bases of lungs; inflammatory 
apical lung disease by radioactive isotope scan; indirect immunofluorescent antibody titre; complement fixation test 
(phase 2, second to fourth weeks); culture of blood, urine 

Treatment: doxycycline 100 mg orally 12 hourly for 14 d (not < 8 y), chloramphenicol 12.5 mg/kg to 500 mg 
orally or i.v. 6 hourly for 14 d 

Prophylaxis (Postexposnre): doxycycline 2.5 mg/kg to 100 mg orally 12 hourly 
Pulmonary Tuberculosis (Complicated Primary Tuberculosis, Fibrocaseous Pulmonary 
Tuberculosis, Koch Disease, Post-Primary Pulmonary Tuberculosis, Secondary Pulmonary 
Tuberculosis): infectious disease of the lung; may arise either by direct extension of a poorly localised 'primary 
tuberculous infection' or by reactivation of a quiescent lesion resulting from such an infection; if poorly localised, 
primary infection may occasionally progress to other areas of the lung (progressive primary pulmonary 
tuberculosis), sometimes leading to cavitation or extrapulmonary dissemination; in most cases, however, primary 
tuberculous infection heals, with or without calcification, or remains quiescent; when such a primary focus is 



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Infections of the Respiratory Tract and Associated Structures 



reactivated, or if exogenous superinfection occurs, characteristic inflammatory reaction takes place with tubercle 
formation, tissue necrosis (caseation), cavitation, fibrosis and, sometimes, calcification; pulmonary tuberculosis may 
lead to any of the following conditions: infiltrative tuberculosis of the lung, nodular tuberculosis of the lung 
(tuberculoma), tuberculosis of the lung with cavitation, tuberculous pneumonia, bronchial tuberculosis 
(endobronchial tuberculosis, tuberculosis of the bronchus, tuberculous bronchitis), tuberculous bronchiectasis, 
tuberculous pneumothorax, tuberculous pleuritis (pleural tuberculosis, tuberculosis of the pleura, tuberculous 
pleurisy), tuberculous emphysema; 85-90% of tuberculosis cases (+ 2% pleural) 
Agents: Mycobacterium tuberculosis, Mycobacterium bovis (from raw cow's milk; now virtually eliminated in 
many countries); Mycobacterium kansasii, Mycobacterium avium-intracellulare (cavitary and nodular disease in 
immunocompromised, diffuse pulmonary disease (hot tub lung) in immunocompetent), Mycobacterium fortuitum 
(emerging pathogen in AIDS), Mycobacterium chelonae, Mycobacterium szulgai, Mycobacterium xenopi and, 
infrequently, Mycobacterium gordonae, Mycobacterium malmoense, Mycobacterium scrofulaceum, Mycobacterium 
simiae cause clinically indistinguishable conditions 

Diagnosis: unresolved pneumonia, persistent cough, unexplained fever; contact; epidemiological history; unilateral 
or bilateral upper lobe or apical or multiple infiltration ± cavitation or consolidation or calcification 
{Mycobacterium fortuitum and Mycobacterium chelonae: 71% patchy, 38% bilateral, 17% cavitating, 8% empyema, 
8% middle lobe infiltrate); nontuberculous mycobacterial infections (especially those caused by Mycobacterium 
kansasii and Mycobacterium intracellulars) have a more indolent course and are more common in older white 
males with underlying disease; Ziehl-Neelsen stain (specificity 99.9%; 46% of Mycobacterium tuberculosis, 22% of 
other Mycobacterium positive; 59% abundant organisms in culture, 50% few organisms in culture positive; 57% 
cavitating, 32% non-cavitating positive) and culture of voluntary or induced sputum (positive in 85-90% of cases), 
laryngeal swab or aspirate, bronchial swab or lavage, gastric lavage, pleural fluid or pus (Bactec: 95% smear 
positive specimens culture positive in 5-8 d, 72% smear negative specimens culture positive in 4-17 d, sensitivity 
testing 4-7 d with 91% agreement with conventional, identification of 99-100% of Mycobacterium tuberculosis in 
5 d; conventional: 91% smear positive specimens culture positive in 18-19 d, 89% smear negative specimens 
culture positive in 18-43 days, sensitivity testing 14-32 d); DM probe; tuberculin test; interferon gamma assay, 
ELISPOT; Mycobacterium tuberculosis gives anemia (acute hemolytic in miliary tuberculosis), raised ESR and 
neutrophilia, becoming lymphocytosis in the acute disseminated stage and monocytosis during healing; 
Mycobacterium kansasii gives severe anemia, leucopenia with white cell count < 500/ pL, gross thombocytopenia 
Differential Diagnosis: blastomycosis (skin lesions often present), histoplasmosis (culture and serology helpful), 
coccidioidomycosis (history of residence or travel to endemic areas), lung abscess (location and predisposing factors 
different; cavity usually thick-walled with air-fluid level), cavitating bronchogenic carcinoma (history, cytology and 
biopsy of tissue) 
Treatment: vitamin A, zinc 

Mycobacterium tuberculosis, Mycobacterium bovis, Mycobacterium xenopi: isoniazid 
10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 times weekly for 6 mo [+ pyridoxine 25 
mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg orally once daily 1 h before 
breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally 
once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be susceptible to isoniazid 
and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; regular 
ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Mycobacterium kansasii: isoniazid 10 mg/kg to 300 mg orally daily + rifampicin 10 mg/kg to 
600 mg orally twice daily + ethambutol 15 mg/kg orally (not < 6 y) daily for 18 mo and 12 mo negative 
sputum cultures 

Mycobacterium szulgai. rifampicin + ethambutol + ethionamide or streptomycin 
Mycobacterium fortuitum, Mycobacterium chelonae. 2 of clarithromycin, doxycycline, 
ciprofloxacin, cotrimoxazole orally for 6-12 mo 

Mycobacterium avium-intracellulare: ethambutol 15 mg/kg orally daily or 25 mg/kg orally 3 
times weekly (not < 6 y) + clarithromycin 12.5 mg/g to 500 mg orally 12 hourly daily or 3 times weekly or 
azithromycin 10 mg/kg to 500 mg orally daily or 10 mg/kg to 600 mg orally 3 times weekly + rifampicin 10 
mg/kg to 600 mg orally daily or 3 times weekly or rifabutin 5 mg/kg to 300 mg orally daily 



Diagnosis and Management of Infectious Diseases Page 30 



Infections of the Respiratory Tract and Associated Structures 



Prophylaxis (Treatment of Latent Infection): 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally daily for 9 mo if tuberculin 

skin test > 5 mm in patient who has not had BCTG and no evidence of active disease [+ pyridoxine 25 mg 

(breastfed baby: 5 mg) with each dose] 

Mycobacterium avium complex in HIV Infection (CD4 Cell Connt < 50/|xL): 

azithromycin 1.2 g orally weekly or clarithromycin 500 mg orally 12 hourly or rifabutin 300 mg orally daily 
Pulmonary Histoplasmosis: clinical state varies from asymptomatic (usually in acute, 20% of chronic) to 
tuberculosis-like to widespread ulceration; pericarditis, mediastinal granuloma, mediastinal fibrosis, histoplasmoma 
rare complications; chronic infection with structural defect (males over 50 y; underlying chronic bronchitis and/or 
emphysema; respiratory insufficiency usual cause of death; mortality 55% untreated, 30% treated) 
Agent: Histoplasma capsulation 

Diagnosis: cough, malaise, easy fatigability, weight loss, low grade fever; chest pain, deep and aching, suggestive 
of carcinoma, and hemoptysis (usually in cavitary disease) in % 1/3 of chronic cases; dyspnea with progression; 
chest X-ray mimics tuberculosis; fungal culture of sputum at 25°C and 37°C; histoplasmin skin test of no diagnostic 
help; complement fixation test diagnostic in 35%, not helpful in determining prognosis or need for treatment 
Treatment: patients with chronic disease and patients with acute disease and a good history of exposure to the 
organism, acute ill with an illness of several weeks duration, a chest X-ray with diffuse involvement, or a positive 
culture or fourfold or higher rise in the complement fixation test should be treated with amphotericin B or 
ketoconazole 

Pulmonary Cryptococcosis: next to meningitis, most common clinical manifestation of cryptococccal infection 

Agent: Cryptococcus neoformans 

Diagnosis: fever in 66% of cases, chest pain in 45%, weight loss in 35%, dyspnea in 25%, night sweats in 25%, 

cough in 15%, haemoptysis in 7%, 15% asymptomatic; chest X-ray (predilection for lower lung fields; lesions range 

from solitary mass to diffuse infiltrates or scattered miliary nodules; cavitation, calcification, hilar 

lymphadenopathy, pulmonary collapse unusual); microscopy and culture of bronchoalveolar lavage (100% positive), 

open-lung biopsy (100% positive), pleural fluid (50% positive), sputum (35% positive), bronchoscopy (35% positive) 

Treatment: indicated if progression of chest X-ray findings, symptoms of increasing severity, stable disease in 

patient who is susceptible to dissemination (eg., malignancy, corticosteroid therapy); not indicated in asymptomatic 

carriers (eg., isolation of organism from sputum of patients with chronic bronchitis) 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 

More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 

mg/kg i.v. or orally 6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally 

initially then 400 mg daily for 8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or itraconazole 200 mg orally 

daily 

Bagassosis and Farmer's Lung 

Agents: Saccharopolyspora rectivirgula, Aspergillus fumigatus, Aspergillus niger, Aspergillus terreus, Aspergillus 

flavus, Aspergillus clavatus, Aspergillus nidulans, Penicillium, Coniosporum corticale, Mucor, Candida, Curvularia 

lunata (rare) 

Diagnosis: recurrent bouts of symptoms of acute bronchitis or pneumonia, with pulmonary infiltrates and 

eosinophilia in all cases, asthma in 95%, haemoptysis (blood-tinged) in 85%; bronchograms demonstrating proximal 

saccular bronchiectasis; serum precipitins (positive in 90%); skin test (types I and III; positive in 95% of cases of 

allergic bronchopulmonary aspergillosis); RAST test (positive in nearly all cases of allergic bronchopulmonary 

aspergillosis); organism cultured from sputum in 60% of cases 

Allergic Bronchopnlmonary Aspergillosis: double immunodiffusion (sensitivity > 10 i-ig/mL), 

ELISA (sensitivity 10-1000 ng/mL), immunoCflP (sensitivity > 0.35 kUfl/L), Western blot (sensitivity 

100-2000 ng/mL) 

Differential Diagnosis: cystic fibrosis, tuberculosis, cancer, eosinophilic pneumonia, mucous plug, atelectasis, 

bronchiectasis 

Treatment: prednisolone 0.5 mg/kg daily as a single dose for 2 w or until complete clearing of chest X-ray, 

then 0.5 mg/kg orally on alternate days for 2-3 mo then, monitoring IgE antibodies, taper off dose as appropriate; 

repeat chest X-ray 4 monthly X 6, 6 monthly X 4, then yearly if no exacerbations; serum IgE monthly for 2 y, 



Diagnosis and Management of Infectious Diseases Page 31 



Infections of the Respiratory Tract and Associated Structures 



then bimonthly; pulmonary function tests yearly; resume prednisolone therapy if significant worsening of 

symptoms, chest X-ray or pulmonary function tests, or significant increase in total serum IgE 

'Coin Lesions' 

Agent: Diro&laria immitis 

Diagnosis: primarily radiological; contact with dogs; rarely, microfilaria seen in sputum 

Treatment: none required, as adult worms do not survive in humans 

Hemoptysis 

Agents: may occur in acute pneumonia (17% of Legionella cases, 16% of Streptococcus pneumoniae, 3% of 

Mycoplasma pneumoniae), in 73% of cases of Paragonimus (Rafricanus, P.westermani) infections, 11% of 

psittacosis cases and 3% of brucellosis, also in pulmonary tuberculosis, invasive aspergillosis, Maris lumbricoides 

infection, strongyloidiasis, Crimean-Congo hemorrhagic fever, echinococcosis, other infections and conditions 

unrelated to infection (eg., carcinoma, rupture of blood vessels due to trauma or inherent fragility) 

Diagnosis: micro and culture of sputum; serology (complement fixation test); isolation of virus from blood; 

examination of stools for ova and parasites 

Paragonimus. pneumonitis, cough, hemoptysis, chest pain, pleurisy, low grade fever, breathlessness, 
epilepsy, possible development of bronchiectasis and lung abscesses; may simulate tuberculosis or coexist with it; 
metastatic lesions in other organs, including bone; geographic history {Paragonimus common in Far East; also in W 
Africa and Central S America); dietary history (eating undercooked or raw crabs or shrimp); abnormal chest X-ray 
(infiltration, cavities, pleural effusion) in 80% of cases; ova in aspirate, puncture, biopsy, stool, sputum; 
eosinophilia; hemoglobin may be decreased; serology by complement fixation test 
Treatment: 

Paragonimus. praziquantel 25 mg/kg orally 8 hourly for 2 consecutive days (90% cure rate), 
bithionol 30-50 mg/kg orally on alternate days for 10-15 d 

Others: dependent on agent; resection of nodules essential for management of invasive aspergillosis 
Hantavirus Pulmonary Syndrome: severe pulmonary illness; case-fatality ratio 40-50%; carried by deer 
mouse (Peromyscus maniculatus) and other rodents; Argentina, Brazil, Canada, Chile, Panama, Paraguay, Peru, USA 
(especially Southwest) 

Agent: sin nombre virus, New York virus, Bayou virus, Black Creek Canal virus, Andes virus 
Diagnosis: 3-4 d prodrome of fever, myalgia, malaise, nausea, vomiting, abdominal pain, occasional dizziness 
and vertigo; then tachypnea, tachycardia, hypotension, hypoxemia, interstitial pulmonary markings, pulmonary 
edema, severe respiratory compromise; bilateral infiltrates; thrombocytopenia, immunoblasts, haemoconcentration; 
serology 

Treatment: supportive 

Otitis media: 2% of new episodes of illness in UK; 2.6% of ambulatory care visits in USA; 5-7M cases/y in US; 
* 15% of infants have an attack by 6 mo, « 75% by 2 y (25-30% > 3 attacks by this age), > 90% by 7 y; 
hearing loss and impaired language development may occur as sequelae 

Agents: 66% mixed bacterial and viral, 30-45% Haemophilus influenzae (5-10% of isolates type b), 28-55% 
Streptococcus pneumoniae, 5-10% Moraxella catarrhalis, anaerobes, Pseudomonas aeruginosa (chronic and 
complicating endotracheal intubation and mechanical ventilation), Streptococcus pyogenes, Staphylococcus aureus, 
Neisseria meningitidis (1% of meningococcal infections), other Neisseria species (in infants); typically with viral 
coinfection: respiratory syncytial virus (in 39% of infected pre-school children; treatment failure in 30% of cases 
with bacterial coinfection), adenovirus (in 32% of infected pre-school children; treatment failure in 25% of cases 
with bacterial coinfection), influenza A (in 28% of infected pre-school children), influenza B (in 17% of infected 
pre-school children, 9% of infected school-age children), parainfluenza (in 16% of infected pre-school children), 
enteroviruses (in 16% of infected pre-school children; treatment failure in 17% of cases with bacterial coinfection), 
rhinovirus (in 10% of infected pre-school children; treatment failure in 78% of cases with bacterial coinfection), 
measles (in 4-22% of measles cases), echovirus 9 (in 10% of cases), human human cytomegalovirus (treatment 
failure in 17% of cases with bacterial coinfection); also Corynebacterium bovis (rare), Mycobacterium tuberculosis 
(chronic draining), Gram negative enteric bacilli (nosocomial), Moraxella lacunata, Rchromobacter xylosoxidans 
(nosocomial and community acquired chronic), Haemophilus haemoglobinophilus, Streptococcus cam's, Mycoplasma 
pneumoniae (bullous myringitis); male sex, family members with acute otitis media, child care outside home, 
parental smoking, not being breastfed, and pacifier use risk factors. 



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Infections of the Respiratory Tract and Associated Structures 



Diagnosis: acute onset of pain in ear, tugging of ear lobes, fever, otorrhoea, vertigo, disturbed sense of balance, 
feeding difficulties, night waking; pneumatic otoscopy (effusion characterised by bulging of the tympanic 
membrane, limited or absent movement of the tympanic membrane, air-fluid level behind the tympanic membrane 
or perforation of the tympanic membrane with otorrhoea; inflammation characterised by distinct erythema of the 
tympanic membrane or distinct otalgia); culture of ear swab if eardrum ruptured, otherwise tympanocentesis 
specimen; serology 
Treatment: paracetamol 20 mg/kg for pain relief; topical benzocaine; laser-assisted myringotomy 

Acnte Bacterial with Systemic Featnres or Child < 6 mo: 

Child < 2 y, Treated with Antibiotics within Previons 3 mo or Attending 
Day Care or If Unresponsive to Amoxycillin: amoxycillin-clavulanate 22.5 + 3.2 mg/kg to 875 + 125 
mg orally 8 hourly for 5-7 d 

Others: amoxycillin 15 mg/kg to 500 mg orally 8 hourly for 5 d or 30 mg/kg to 1 g orally 
12 hourly for 5 d 

Penicillin Hypersensitive: cefuroxime 10 mg/kg to 500 mg orally 12 hourly for 5 d, 
cefaclor 10 mg/kg to 250 mg orally 8 hourly for 5 d; cotrimoxazole 4/20 mg/kg to 160/800 mg/kg orally 12 
hourly for 7-10 d 

Remote Areas: procaine penicillin 50 mg/kg to 1.5 g i.m. once daily for 5 d, bicillin i.m. on 
days 1 and 3 or daily for 2-5 d 

Chronic Snppnrative: suction under direct vision or dry mopping with rolled tissue spears or 
equivalent 6 hourly until ear canal dry; oral antibiotics as above + dexamethasone 0.05% + framycetin 0.5 % + 
gramicidin 0.05% ear drops 3 drops instilled into ear 6 hourly for 7 d 

Streptococcus: phenoxymethylpenicillin 500 mg orally 6 hourly (child: 75 mg/kg orally daily in 3 
divided doses) for 7-10 d 

Haemophilus, Moraxella, Neisseria: amoxycillin-clavulanate 500/125 mg orally 8 hourly 
(< 40 kg: 40/10 mg/kg daily in 3 divided doses) for 10 d, cotrimoxazole 160/800 mg (6 w - 5 mo: 20/100 mg; 
6 mo - 5 y: 40/200 mg; 6-12 y: 80/400 mg) orally 12 hourly for 7-10 d, cefaclor 250-500 mg orally 8 hourly 
(child: 40-60 mg/kg orally daily in 3 divided doses) for 7-10 d 

Corynebacterium bovis: erythromycin + rifampicin 

Mycobacterium tuberculosis, isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 

Other bacteria: ticarcillin + gentamicin 

Virnses: non-specific, but pneumococcal infection may supervene 

Chronic (> 6 w) Discharging: ciprofloxacin or (dexamethasone 0.05% + framycetin 0.5% + 
gramicidin 0.005%) ear drops 3 drops 6 hourly until middle ear free of discharge for at least 3 d; at least daily 
wash with water, acetic acid 0.25% or povidone iodine 0.5% solution until cured; 4 times daily ear toilet with 
rolled paper spears repeating until ear is dry), followed each time by acetic acid 1% drops or by boric acid drops 
in acetic acid 

Prophylaxis: identification and correction of underlying causes and risk factors (smoke exposure, group child 
care, allergic rhinitis, adenoid disease, cleft palate, Down syndrome); insertion of typanostomy tubes; amoxycillin 
10-20 mg/kg orally in 2 divided doses or sulphisoxazole 80-100 mg/kg orally daily in 2 divided doses; acetic acid 
ear drops; polymyxin and neomycin ear drops; intranasal virosomal influenza vaccine 

Neisseria meningitidis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose (preferred if 
pregnant), ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), 
rifampicin 10 mg/kg (< 1 mo: 5 mg/kg) to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver 
disease; preferred for children); vaccines (quadrivalent polysaccharide, quadrivalent conjugate, and serogroup 
conjugate) available 

Mastoiditis: formerly worldwide in childhood but now, due to effective treatment of otitis media, almost 
eliminated in developed countries 



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Infections of the Respiratory Tract and Associated Structures 



Agents: Haemophilus influenzae (3% of non-bacteremic invasive Haemophilus influenzae infections in older 

children and adults), Staphylococcus aureus, anaerobes, Burkholderia cepacia (occasional), Streptococcus 

pneumoniae, Streptococcus pyogenes, Pseudomonas, anaerobes 

Diagnosis: otitis media + pain and tenderness over mastoid process; otoscopy; computed tomography; culture of 

surgical specimen 

Treatment: 

Acnte: amoxycillin 200 mg/kg i.v. daily in divided doses + cloxacillin/flucloxacillin 200 mg/kg i.v. 
daily in divided doses; dicloxacillin; cefuroxime; surgery for abscess or osteomyelitis 

Chronic: ceftazidime + clindamycin; tobramycin + ticarcillin-clavulanate; surgery required 
Prophylaxis (Otitis-Prone Child): sulphamethoxazole 25 mg/kg orally daily at bedtime 



Diagnosis and Management of Infectious Diseases Page 34 



Chapter 2 



Infections of the Gastrointestinal Tract and Associated Strnctnres 

Angular Cheilitis 

Agents: usually Candida albicans; also iron or riboflavin deficiency 

Diagnosis: swab culture 

Treatment: miconazole 2% gel or nystatin 100,000 U/g ointment topically to lesions 2-3 times daily for at least 

2 w 

Mouth Lesions 

Agents: chickenpox, measles, molluscum contagiosum, human papillomavirus in 1.2% of HIV patients, human 

human cytomegalovirus in AIDS, Lymphocryptovirus (oral hairy leucoplakia in AIDS), enteroviruses, Simplexvirus, 

Moraxella osloensis, Candida albicans (pseudomembranous, erythematous, hyperplastic) 

Diagnosis: viral culture and cytology of swab of lesions; serology; bacterial and fungal culture 

Treatment: 

Hnman Papillomavirus: surgical removal of lesion and surrounding tissue 
Human human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 
mg orally daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg 
i.v. 5 times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 
mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and 
creatinine clearance > 55 mL/min) then as above every 2 w 
Hairy Leukoplakia: high dose aciclovir 
Simplexvirus: 

Herpes labialis: penciclovir cream 

Internal Lesions: see Acute Herpetic Gingivostomatitis 
Candida albicans: 

Psendomembranons and Erythematous: miconazole 2% gel (< 1 y: 1.25 mL; > 1 y: 
2.5 mL) orally 6 hourly for 7-14 d, amphotericin 10 mg lozenge orally 6 hourly for 7-14 d (remove dentures while 
sucking if worn), nystatin suspension 100 000 units/mL 1 mL orally 6 hourly for 7-14 d; soak dentures in 1:100 
sodium hypochlorite solution at night 

Hyperplastic: fluconazole 3 mg/kg to 50-100 mg orally daily for 10-14 d, ketoconazole 5 
mg/kg to 200 mg orally daily for 10-14 d 

Others: non-specific 
Mouth Ulcers 

Agents: many aphthous (cause unknown; may be linked to nutritional or physiological factors or hypersensitivity 
to oral streptococci); syphilis, necrotising ulcerative gingivostomatitis, Mycobacterium tuberculosis, Simonsiella, 
viruses especially coxsackievirus and Simplexvirus, also occurs in Reiter syndrome, Crohn's disease and ulcerative 
colitis and as a response to radiation and some drugs 

Diagnosis: dark ground illumination, Gram stain or simple stain, viral and mycobacterial culture of tissue fluid 
and swab of lesions; direct immunofluorescence for herpes; serology; skin testing with autogenous streptococcal 
vaccine 
Treatment: 

Aphthons: saline rinse after each meal and at bedtime; chlorhexidine 0.2% mouthwash 10 mL 8 
hourly, held in mouth 1 min; triamcinolone acetonide 0.1% paste topically 8 hourly, betamethasone valerate 0.05% 
ointment 

More Severe: betamethasone dipropianate 0.05% ointment or cream 

Major Ulceration: prednisolone or prednisone 20 mg orally daily for 5 d 

AIDS: thalidomide 200 mg daily for 4 w 
Syphilis, Simonsiella: penicillin 



Diagnosis and Management of Infectious Diseases Page 35 



Infections of the Gastrointestinal Tract and Associated Structures 



Tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 
times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 
10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 
6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo 
(6 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not 
< 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 

Severe Herpes: famciclovir 125 mg orally 12 hourly for 5 d, valaciclovir 500 mg orally 12 hourly for 
5 d, aciclovir 5 mg/kg to 200 mg orally 5 times daily for 5 d; if unable to swallow, aciclovir 5 mg/kg i.v. 8 
hourly for 5 d 

Others: salt + sodium bicarbonate mouthwashes 
Mouth Abscess 

Agents: Rothia dentocariosa, Streptococcus milled 
Diagnosis: culture of swab 
Treatment: penicillin 

Necrotising Ulcerative Gingivostomatitis (Acute Infectious Gingivostomatitis, Fetid 
Stomatitis, Fusospirochetal Stomatitis, Plant Ulcer, Plant-Vincent Disease, Plant-Vincent 
Stomatitis, Putrid Sore Mouth, Putrid Stomatitis, Spirochaetal Stomatitis, Stomatitis 
Ulceromembranacea, Stomatitis Ulcerosa, Trench Mouth, Ulcerative Stomatitis, 
Ulceromembranous Stomatitis, Vincent Disease, Vincent Infection, Vincent Stomatitis): acute 
ulcerative necrotising condition of gum margins and other parts of mouth, often with pseudomembrane formation; 
may be restricted to gingival margins (necrotising ulcerative gingivitis, acute septic gingivitis, acute ulcerative 
gingivitis, acute ulceromembranous gingivitis, acute ulcerous gingivitis, fusobacillary gingivitis, fusospirillary 
gingivitis) or involve only parts of mouth other than gums (necrotising ulcerative stomatitis); rarely, may progress 
and become gangrenous (cancrum oris, fusospirochaetal gangrene, noma, stomatitis gangrenosa) 
Agents: probably a mixed infection with Leptotrichia buccalis, Treponema vincentii and possibly other 
Treponema 

Diagnosis: simple stain of swab 

Treatment: local debridement; metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5 d + povidone iodine 
mouthwash diluted as directed 10 mL rinsed in mouth for at least 15 s 6 hourly or chlorhexidine 0.2% mouthwash 
10 mL rinsed in mouth for 1 min 8-12 hourly or 0.12% mouthwash 15 mL rinsed in mouth 1 min 8-12 hourly 

More Severe Or Unresponsive: metronidazole 10 mg/kg to 400 mg orally 12 hourly + 
phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly or amoxycillin 10 mg/kg to 500 mg orally 8 hourly 
or (penicillin hypersensitive) clindamycin 7.5 mg/kg to 300 mg orally 8 hourly for 5 d 
Geographic Tongue, Hairy Tongue, Black Hairy Tongue 

Agents: successive stages of papillary hypertrophy due to toxic effects of a number of agents; black colour due 
to overgrowth of anaerobes; often confused with fungal infection in later stages 
Diagnosis: appearance 

Treatment: avoidance of precipitating factors if known; salt and sodium bicarbonate mouthwashes 
Lingual Cellulitis: extremely rare; following minor local trauma in neutropenics 
Agents: anaerobic streptococci, Pseudomonas aeruginosa 
Diagnosis: blood cultures 
Treatment: ticarcillin-clavulanate 
Acute Herpetic Gingivostomatitis 
Agent: Simplexvirus 

Diagnosis: viral culture of swab of lesions, throat swab or washing in tissue culture; cytology and 
immunofluorescence or electron microscopy of scraping from base of vesicle if accessible 
Treatment: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly for 7-10 d, 
aciclovir 200 mg orally 5 times daily for 7-10 d 

Frequent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg orally 12 
hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 



Diagnosis and Management of Infectious Diseases Page 36 



Infections of the Gastrointestinal Tract and Associated Structures 



Gingivitis, Periodontitis 

Agents: commonest non-contagious disease; Porphyromonas gingivalis (dominant organism in rapidly progressive 

periodontitis), Actinobacillus actinomycetemcomitans (dominant organism in juvenile periodontitis), mixed anaerobes 

(fusospirochaetal; dominant organisms in adult periodontitis), Porphyromonas asaccharolytica, Prevotella 

intermedins, Prevotella melaninogenica, Capnocytophaga, Campylobacter concisus, Treponema denticola, Bacteroides 

forsythus, HIV (linear gingival erythema, which may lead to necrotising ulcerative periodontitis and/or stomatitis); 

also due to cyclosporin, phenytoin, calcium channel antagonists 

Diagnosis: Gram or simple stain, anaerobic culture and culture in increased CO2 of swab 

Treatment: local dental care to control bacterial plaque; povidone iodine irrigation; debridement if necrosis; 

chlorhexidine 0.2% mouthwash 10 mL rinsed in mouth for 1 min 8-12 hourly or 0.12% mouthwash 15 mL rinsed in 

mouth for 1 min 8-12 hourly 

Linear Gingival Erythema: professional removal of plaques and daily rinses with chlorhexidine 
gluconate 

Pericoronitis, Root Canal Infection 
Agents: mixed normal mouth flora 
Diagnosis: clinical; culture usually not helpful 

Treatment: local dental care in absence of tooth abscess; vigorous warm mouth rinses with saline or 
chlorhexidine 0.2%; topical povidone iodine 
Tooth Abscess 
Agents: mixed oral flora 
Diagnosis: culture of aspirated pus 

Treatment: removal of infected pulp tissue + drainage; if systemic signs and symptoms, phenoxymethylpenicillin 
10 mg/kg to 500 mg orally 6 hourly or amoxycillin 10 mg/kg to 500 mg orally 8 hourly for 5 d; if more severe 
or unresponsive, + metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5 d or amoxycillin-clavulanate 
22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for 5 d alone 

Penicillin Hypersensitive: clindamycin 7.5 mg/kg to 300 mg orally 8 hourly for 5 d 
Other Dental Infections 
Agents: various anaerobes 

Diagnosis: culture of deep aspiration or surgical specimen 
Treatment: penicillin, clindamycin, chloramphenicol 
Salivary Calculi 
Agent: Actinomyces 
Diagnosis: anaerobic culture 
Treatment: removal; penicillin if necessary 
Parotitis and Submandibular Sialadenitis 

Agents: mumps virus (epidemic parotitis), coxsackievirus, parainfluenza 1 and 3, lymphocytic choriomeningitis 
virus, influenza A, Staphylococcus aureus (nosocomial and xerostomia-inducing process), streptococci, anaerobes, 
enteric Gram negative bacilli, Mycobacterium tuberculosis, Actinomyces, Actinobacillus actinomycetemcomitans 
(uncommon), Burkholderia pseudomaller, Pseudomonas aeruginosa, also in 4% of Rocky Mountain spotted fever 
cases; also neoplastic, cysts, drugs (iodides, bromides, phenothiazines, propylthiouracil, isoproteneol), obstruction, 
malnutrition, gout, uremia, sarcoidosis, Mikulicz's disease, Sjorgren's syndrome, cystic fibrosis; may be confused 
with lymphadenopathy, masseter hypertrophy, dental abscess 

Diagnosis: pain, swelling, dysphagia, tense swelling over parotid area, tenderness, pain on opening mouth; viral 
culture of saliva, throat swab, urine; serology (complement fixation test, haemagglutination inhibition); increased 
serum amylase; bacterial culture of purulent discharge from Stensen's duct or surgical drainage material 
Treatment: early surgical drainage may be necessary in suppurative sialadenitis 

Viral: none 

Staphylococcus aureus: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly then 12.5 mg/kg to 500 mg 
orally 6 hourly for total 10 d, clindamycin 10 mg/kg to 450 mg i.v. 8 hourly then 10 mg/kg to 450 mg orally 8 
hourly for total 10 d, lincomycin 15 mg/kg to 600 mg i.v. 8 hourly then clindamycin 10 mg/kg to 450 mg orally 
8 hourly for total 10 d 



Diagnosis and Management of Infectious Diseases Page 37 



Infections of the Gastrointestinal Tract and Associated Structures 



Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 

Burkbolderia pseudomallei: early surgical drainage + cotrimoxazole + ceftazidime or meropenem 
or imipenem 

Other Bacteria: cloxacillin + aminoglycoside + clindamycin or penicillin if anaerobes isolated or 
suspected; rehydration 

Gastrointestinal Tract Infections: Even under the best of conditions, a specific agent is not found in the 
majority of cases of gastrointestinal tract disturbances. This may be due to a number of factors: infection due to 
an uncommon and unlooked-for organism or to an organism not yet implicated in gastrointestinal tract infection; 
deficiencies in transport and/or isolation procedures for some organisms; the sporadic nature of the presence of 
some organisms in faeces; the existence of a dietary or physiological (eg., lactase deficiency, gluten sensitivity, 
Crohn's disease, etc) cause unrelated to infection 

Oesophagitis: mainly in immunocompromised patients; 0.1% of ambulatory care visits in USA 
Agents: Mycobacterium tuberculosis, Candida, Simplexvirus, enteroviruses, human human cytomegalovirus, also 
non-infectious ulcers in AIDS 

Diagnosis: dysphagia, odynophagia, retrosternal pain; esophagoscopy; barium swallow; KOH smear, viral culture 
and monoclonal antibody immunofluorescence to Simplexvirus and human cytomegalovirus on esophageal brushings; 
hematoxylin and eosin stain, Grocott methenamine silver stain, Ziehl-Neelsen stain, monoclonal antibody 
immunofluorescence to Simplexvirus, human cytomegalovirus, mycobacterial culture, fungal culture and viral 
culture on esophageal biopsy specimens 

Tnbercnlosis: positive tuberculin test, mediastinal adenopathy 

Candida: recent onset of retrosternal pain on swallowing + oral candidiasis diagnosed by gross 
appearance of white patches or plaques on an erythematous base or by the microscopic appearance of fungal 
mycelial filaments from a specimen cultured from oral mucosa 
Treatment: 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 

Candida: fluconazole 5 mg/kg to 200 mg orally initially then 2.5 mg/kg to 100 mg daily for 14 d or 
itraconazole 200 mg capsule orally daily or 100 mg (10 mL) oral suspension twice daily for 14 d; if resistant, 
voriconazole 200 mg orally 12 hourly for 14 d or amphotericin B desoxycholate 0.5 mg/kg i.v. daily for 14 d 
Repeated Episodes in HIV Infection: fluconazole 100 mg orally daily, itraconazole 
200 mg orally daily, ketoconazole 200 mg orally daily 

Simplexvirus: as for Herpetic Gingivostomatitis 

Human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally 
daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 
times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly or 180 mg/kg/d by 
continuous i.v. infusion for 14 d then 90-120 mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w 
(+ probenecid if proteinuria < 2+ and creatinine clearance > 55 mL/min) then as above every 2 w 

Non-infections: prednisone 



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Gastritis, Duodenal Ulcer, Peptic Ulcer, Dyspepsia: 0.5% of ambulatory care visits in USA 
Agents: 

Simple Gastritis, Duodenal Ulcer, Peptic Ulcer, Dyspepsia: Helicobacter pylori; peptic ulcer 
also due to NSAID ingestion; also gastritis and antral obstruction due to human cytomegalovirus in AIDS and 
posttransplantation 

Emphysematous Gastritis: 22% Escherichia coli, 22% streptococci, 19% Enterobacter, 11% 
Pseudomonas aeruginosa, others; mortality 61%, gastric constrictions 21% 
Diagnosis: 

Helicobacter pylori: silver or Gram stain, phase contrast microscopy and culture of multiple gastric 
mucosal biopsies on chocolate agar or brain heart infusion agar with and without nalidixic acid (50 mg/L), 
vancomycin (3 mg/L) and trimethoprim (5 mg/L) (histology sensitivity 88-95%, specificity 90-95%, very readily 
available, very expensive; culture 80-90% sensitivity, 95-100% specificity, less readily available, expensive); 13 C 
urea breath test (sensitivity 90-95%, specificity 90-95%, very readily available, expensive); 14 C urea breath test 
(sensitivity 86-95%, specificity 86-95%, readily available, less expensive; give drink containing 4 g citric acid 
before test if taking proton pump inhibitor), antigen in stool test (sensitivity 88-100%, specificity 70-96%, less 
readily available, less expensive); Stat Simple fingerstick antibody test (sensitivity 60-90%, specificity 70-85%, 
very readily available, relatively inexpensive); ELISA (sensitivity 80-95%, specificity 80-95%, readily available, 
inexpensive); rapid urease test (sensitivity 90-95%, specificity 90-95%, very readily available, relatively 
inexpensive); Leukostix rapid leucocyte strip test (sensitivity 98%, specificity 77%); barium study; testing should 
not be done less than 4 w after cessation of antibiotics or bismuth compounds or 1-2 w after proton pump 
inhibitors; serological tests for antibodies are unsuitable for post-treatment testing because antibody titres may 
take months to fall 

Human cytomegalovirus: endoscopy with biopsy; PCR on blood 

Emphysematous Gastritis: 37% ingestion of corrosive substances, 22% alcohol abuse; acute 
abdomen with systemic toxicity; X-rays show gas bubbles within stomach wall; computed tomography; culture of 
gastric aspirate 
Treatment: 

Helicobacter pylori: omeprazole 20 mg orally 12 hourly or lansoprazole 30 mg orally 12 hourly for 
7 d + clarithromycin 500 mg orally twice daily for 7 d + amoxycillin 1 g orally twice daily for 7 d or 
metronidazole 400 mg orally 3 times daily for 1 w 

Treatment Failure: colloidal bismuth subcitrate 1 tablet (107.7 mg) chewed and swallowed 
4 times daily for 2 w + tetracycline 500 mg 6 hourly for 2 w + metronidazole 200 mg orally 3 times daily and 
400 mg orally at night for 2 w + omeprazole 20 mg or lansoprazole 30 mg or pantoprazole 40 mg twice daily for 
14 d; rifabutin 300 mg 4 times/d + pantoprazole 40 mg twice a day + amoxycillin 1 g twice a day 

Human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally 
daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 
times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 
mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and 
creatinine clearance > 55 mL/min) then as above every 2 w 

Emphysematous Gastritis: i.v. fluid, nutritional support; tobramycin + imipenem; surgery as 
required 

Constipation is mainly due to dietary causes (including in infant metabolic alkalosis) but also occurs in 26% of 
cases of cryptosporidiosis (after initial diarrhoea in 22%), in 18% of brucellosis cases and 5% of cases of subdural 
empyema, and also in botulism, diphyllobothriasis, Entamoeba histolytica and Salmonella typhi infections and 
(alternating with diarrhoea) in strongyloidiasis 

Bloody Stools occur in enterohemorrhagic Escherichia coli infections, amoebic dysentery, 60% of cases of 
shigellosis, 31% of acute schistosomiasis, 26% of Campylobacter enteritis, 21% of salmonellosis, 12% of 
enterotoxigenic Escherichia coli infections, 7% of typhoid fever, 4% of cholera, and also in necrotising enterocolitis 
and Vibrio cholerae non-01 infections; also in ulcerative colitis 
Fatty Stools, when due to infectious causes, are usually due to Giardia intestinalis 
Acute Diarrhoea and/or Vomiting: 4% of new episodes of illness in UK; 99 million episodes/y among 
adults in USA (with 8 million doctor visits and 1.5% of hospitalisations; 85% of deaths in > 60 y) 



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Agents: due to infectious causes in 90% of cases; developed areas: 10-27% Norovirns, 8-50% Rotavirus, < 5% 
enteropathogenic Escherichia coii (atypical strains), 3-7% Oiardia intestinalis, 3-4% Cryptosporidium, 2-52% 
Salmonella, 2% enteric adenovirus (< 2 y), 1-40% Campylobacter, 1-16% enterotoxigenic Escherichia coli, 1-4% 
Shigella, 1-4% Yersinia, 0.6% Entamoeba histolytica, 0.2% Strongyloides, Vibrio, Aeromonas, Clostridium difficile, 
Bacteroides fragilis; developing areas: 7-50% enterotoxigenic Escherichia coli, 5-45% Rotavirus, 5-16% Shigella, 5- 
10% enteric adenovirus (< 4 y), 5% Strongyloides, 4-10% Cryptosporidium, 4-8% enteropathogenic Escherichia coli 
(typical strains), 2-15% Entamoeba histolytica, 2-14% Campylobacter, 1-44% Giardia lamblia, 1-6% Yersinia, 1-2% 
Norovirus, 0-15% Salmonella, Vibrio, Aeromonas, Clostridium difficile, Bacteroides fragilis, AIDS: Cryptosporidium, 
Microsporidium, Isospora belli, Pneumocystis jiroveci, Strongyloides, Entamoeba histolytica, Giardia lamblia, human 
cytomegalovirus, Mycobacterium avium-intracellulare, Mycobacterium tuberculosis, Salmonella, Campylobacter, AIDS 
'enteropathy'; acute diarrhoea may also be due to cancer of the colon and rectum, non-infectious food poisoning or 
ulcerative colitis; acute vomiting may also be caused by preformed toxins (vomitoxin, Staphylococcus aureus toxin, 
Bacillus cereus toxin, heavy metals, nitrites, Aminita mushrooms), acute nephritis, anemia, diabetic precoma, 
glaucoma, migraine, myocardial infarction, pregnancy and renal colic 

Diagnosis: feces examination (ulcerative colitis: 90% polymorphonuclears + * 10% eosinophils); collapsed 
patient: electrolytes and hematocrit; other investigations only if not resolved within 48 h 
Treatment: dietary restriction; oral fluids and i.v. fluids in dehydration; Lactobacillus > 10'° cfu > twice 
daily; specific treatment as indicated 

Diarrhoea: global incidence 4 billion/y; global morbidity 3-5 billion/y; global mortality 3-4 M/y; 90% simple 
diarrhoea (mainly viral (agents of Epidemic Viral Diarrhoea and echovirus 8, 19, 20, 22-24, 32) in 
industrialised countries, also bacterial and protozoal in less developed), 5-10% dysentery {Shigella, Campylobacter 
jejuni, enteroinvasive Escherichia coli), 3-4% protracted diarrhoea (> 14 d; enteropathogenic Escherichia coli, 
Giardia lamblia), 1% severe passing of rice water stools [Salmonella and enterotoxigenic Escherichia colim 
industrialised countries, cholera and enteropathogenic Escherichia coli in less developed); as well as in enteric 
infections, diarrhoea occurs as a symptom in 61% of measles cases occurring in malnourished (13% bloody), in 
57% of cases of neonatal listeriosis, in 41% of cases of Kawasaki syndrome (days 1-14), in 40% of cases of 
primary sepsis and 12% of wound infections due to Vibrio vulnificus, in 33% of cases of cranial epidural abscess, 
31% of brain abscess and 10% of subdural empyema due to Salmonella, in 33% of cases of Korean hemorrhagic 
fever, in 30% of peritonitis, in influenza A (in 27% of cases) and B (in 35% of infected school-age children, 10% 
of infected pre-school children, 4% of infected adults), in 21% of cases of Yersinia pseudotuberculosis infections, 
19% of cases of amoebic liver abscess, 19% of Rocky Mountain spotted fever (9% in first 3 d), 16% of brucellosis 
cases, and in AIDS, congenital malaria, Crimean-Congo hemorrhagic fever (liquid), Ebola hemorrhagic fever, grain 
itch, Lassa fever, Lyme disease (mild, watery), Marburg virus disease, plague (massive), psittacosis, toxic shock 
syndrome (84% profuse, watery at onset), Reye syndrome; also in chemical poisoning, gastroenteritis-type 
mushrooms [Amanita, Phalloidin, Gyromitrin toxin group) ingestion, in protein-energy malnutrition (non-bloody), and 
due to antibiotics and other medications or to diet 

Diagnosis: feces micro and culture; unexplained abdominal pain and fever persisting or suggesting an 
appendicitis-like syndrome suggests Yersinia enterocolitica; bloody diarrhoea, especially if without fecal leucocytes, 
suggests enterohemorrhagic (shiga toxin-producing) Escherichia coli or amoebiasis (where leucocytes are destroyed 
by the parasite); ingestion of inadequately cooked seafood should prompt consideration of Vibrio infections or 
Norovirus, cytotoxigenic Clostridium difficile should be considered in diarrhoea associated with antibiotic use; 
persistence > 10 d with weight loss should prompt consideration of giardiasis or cryptosporidiosis; travel to 
tropical areas or consumption of untreated water increases the chance of enterotoxigenic Escherichia coli as well 
as viral (eg., Norwalk-like or rotaviral), parasitic (eg., Giardia intestinalis, Entamoeba histolytica, Strongyloides, 
Cryptosporidium, Cyclospora cayetanensis) and, if faecal leucocytes are present, invasive bacterial pathogens (eg. 
Shigella, Salmonella, Campylobacter); outbreaks should prompt consideration of Staphylococcus aureus, Bacillus 
cereus, Anisakis (incubation period < 6 h), Clostridium perfringens (incubation period 12-18 h), enterotoxigenic 
Escherichia coli or Vibrio (noninflammatory), Salmonella, Campylobacter, Shigella, enteroinvasive Escherichia coli 
infection, enterohemorrhagic Escherichia coli, Vibrio parahaemolyticus, Yersinia enterocolitica and Entamoeba 
histolytica (inflammatory); short incubation period also suggests metal or monosodium glutamate poisoning; 
neurologic symptoms suggest botulism, fish poisoning (scombroid, ciguatera, tetrodon), shellfish poisoning 
(neurotoxic, paralytic, amnesic), mushroom poisoning, organophosphate pesticides, thallium poisoning, Guillain-Barre 
syndrome associated with Campylobacter jejuni diarrhoea; systemic illness suggests Listeria monocytogenes, 



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Infections of the Gastrointestinal Tract and Associated Structures 



Brucella, Vibrio vulnificus, Trichinella spiralis, Toxoplasma gondii, hepatitis A virus (0.8% of foodborne disease 
outbreaks in USA, 0.8% of cases, no deaths; incubation period 15-50 d; from shellfish, foods prepared by infected 
food handler); if unexplained, consider saving Escherichia coli for labile toxin, stable toxin, invasiveness, adherence 
testing and serotyping, and save stool for Rotavirus, and stool + paired sera for Norovirus testing; sigmoidoscopy 
in symptomatic homosexual males should distinguish proctitis in the distal 15 cm only (caused by Simplexvirus, 
gonococcal, chlamydial or syphilitic infection) from colitis (with Campylobacter, Shigella, Clostridium difficile or 
Chlamydia infections) or non-inflammatory diarrhoea (due to giardiasis); immunocompromised hosts should have a 
wide range of viral (eg., human cytomegalovirus, Simplexvirus, coxsackievirus, Rotavirus), bacterial (eg., 
Salmonella, Mycobacterium avium-intracellulare, Listeria), fungal (eg., Candida) and parasitic (eg., Cryptosporidium, 
Strongyloides, Entamoeba histolytica and Giardia lamblia) agents considered 

Treatment: hydrate with oral replacement solution (child: fruit juice drinks or carbonated beverages diluted 1 in 
4 with warm water) or i.v.; antibiotics should only be used for dysentery and suspected cholera; otherwise, they 
are ineffective and should not be given; antiparasitic drugs should only be used for amoebiasis (after antibiotic 
treatment of bloody diarrhoea for Shigella has failed or trophozoites of Entamoeba histolytica containing red blood 
cells seen in feces) and for giardiasis (when diarrhoea has lasted at least 14 d and cysts or trophozoites of 
Giardia lamblia are seen in feces or small bowel fluid); antidiarrhoeal drugs and antiemetics should never be used 
since none has proven practical value and some are dangerous 

Epidemic Viral Diarrhoea: 80% of acute diarrhoea; incubation period 16-36 h; duration of illness 1-2 d 
Agents: Norovirus (in 84% of infections; low infectious dose, prolonged asymptomatic shedding, environmental 
stability, substantial strain diversity, lack of lasting immunity; 4% of foodborne disease outbreaks in Australia; 
23 M estimated cases/y in USA, 7% of foodborne related deaths, 0.3% of foodborne disease outbreaks, 1% of 
cases), Rotavirus A (mainly infants; > 9% of children worldwide infected by 3 y; causes « 1/3 diarrhoea- 
associated hospitalisations (in Australia, « 50% of those in children; rate from 9.2/1000 in Victoria to 50/1000 in 
Northern Territory) and 800,000 deaths/y; adult outbreaks in hospitals, nursing homes, isolated communities and 
travellers; 0.9% mortality), adenovirus (6% of hospitalised children with diarrhoea; 0.2% mortality in infants; types 
40, 41 and others in AIDS; 15% of nosocomial), Mrovirus (7% of hospitalised children with diarrhoea), 3% 
parvovirus (in 47% of infections; 19% of water-borne outbreaks), Sapovirus, poliovirus 2 and 3, coxsackievirus (A, 
B3 probable etiologic agents), echovirus (probable etiologic agent; 7, 9, 11 (in 23% of infections), 12 (in 100% of 
infections), 14 and 18), measles, parainfluenza (in 15% of cases), ? Human torovirus, ? Human picobirnavirus 
Diagnosis: abrupt onset, diarrhoea, abdominal pain, vomiting common, fever uncommon, upper respiratory 
symptoms common, convulsions rare, anal sphincter laxness rare; stools loose, more or less malodorous, blood rare, 
colour variable, mucus absent; no leucocytes in feces; viral culture of feces; radioimmunoassay, ELISA (antigen 
and antibody), agglutinations, direct immunofluorescence, electron microscopy and immune electron microscopy 
(research method) of feces; hemagglutination inhibition antibody technique, neutralisation antibody titre 

Rotavirus: from fecally contaminated foods, ready to eat foods touched by infected food workers 
(salads, fruits); age 6 mo - 2 y, incubation period 1-3 d, diarrhoea ++++ (75% watery), vomiting in 85%, 
abdominal pain in 62%, low grade fever in 28%, myalgia, headache; duration of symptoms 3-5 d; at d3-d6, 2-3 mm 
pink-red macules on trunk, spreading to limbs and face; no leucocytes or erythrocytes in stool micro; antigen 
detection by enzyme immunoassay 

Norovirus: adults and school-aged children, incubation period 1-2 d, nausea in 90-97% of cases, 
watery vomiting ++++ in 85-97%, abdominal pain and cramps ++ in 80-86%, chills in 78%, muscle aches in 
67%, fever + in 64-66%, headache in 61-70%, large volume diarrhoea in 58-84%, sore throat in 10%; duration of 
symptoms 12-60 h; shedding from patients up to 3 w; 72% of sourced infections from food (poorly cooked shellfish, 
raw seafood, ready to eat foods touched by infected food workers, salads, sandwiches, ice, cookies, fruit), 22% 
person-to-person and 6% waterborne; no leucocytes or erythrocytes in stool micro; electron microscopy and 
immune electron microscopy; > 4X increase in antibody titre (enzyme immunoassay); nucleic acid hybridisation 
assay and reverse transcriptase-polymerase chain reaction 

Sapporo virus: children < 5 y; 95% diarrhoea during first 5 d, 60% vomiting on first day; shedding 
up to 14 d; laboratory tests as for Norovirus 

Other Viral Agents: from faecally contaminated foods or water, ready to eat foods touched by 
infected food workers, some shellfish; incubation period 10-70 h; nausea, vomiting, diarrhoea, malaise, abdominal 
pain, headache, fever; duration of illness 2-9 d; virus isolation, serology 



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Treatment: rehydration, restricted diet; dehydration requires hospitalisation and fluid replacement under 
biochemical control 

Norovhus: bismuth sulphate 

Rotavirus: severe diarrhoea may require fluid and electrolyte replacement; infants, children, elderly 
and immunocompromised especially vulnerable 

Prophylaxis (Rotavirus): tetravalent rhesus-human reassortant Rotavirus vaccine (49-68% protection against 
diarrhoea, 61-100% against severe disease) no longer recommended because of substantial increase in 
intussusception; live oral pentavalent vaccine also possibly linked to intussesception; hyperimmune bovine 
colostrum containing Mi- Rotavirus antibodies 

Hakuri (Alimentary Toxicosis, Cholera Infantum, Pseudocholera Infantum, Sakamoto Disease) 
Agent: ? Rotavirus 

Diagnosis: vomiting and diarrhoea with whitish, watery stools; low grade fever in most cases, cough in some 
Treatment: rehydration, restricted diet; dehydration requires hospitalisation and fluid replacement under 
biochemical control; oral human gamma globulin or bovine milk concentrate containing antibody to Rotavirus 
Infantile Diarrhoea 
Agents: certain serotypes of Escherichia coli 

Diagnosis: age 0-5 y, no diarrhoea in household, gradual onset, vomiting uncommon, fever absent, convulsions 
rare, anal sphincter normal; stools loose, slimy, foul odour, blood rare, colour green, mucus variable; laboratory 
tests to identify relevant strains are grossly inadequate; serotyping against the limited range of serotypes believed 
to be important enteropathogenic strains is the only method suitable for routine use; complement lysis is used in 
research 

Treatment: ampicillin or aminoglycoside in systemic infection 

Traveller's Diarrhoea (Aden Gut, Aztec Two Step, Backdoor Sprint, Basra Belly, Canary 
Disease, Casablanca Crud, Coeliac Flux, Dehli Belly, Gis, Greek Gallop, Gyppie Tummy, Hong 
Kong Dog, Le Turista, Malta Dog, Mexican Call It, Montezuma's Revenge, Passion, Poonah 
Poohs, Rangoon Runs, San Franciscitis, Summer Complaint, Tourist Trots, Turkey Trots): mild 
cholera-like disease in adults; incidence 3-54% 

Agents: 20-62% none identified, 8-75% enterotoxigenic strains of Escherichia coii (744-1000 million episodes with 
4-6 M deaths annually in Africa, Latin America and Asia excluding China), 0.5-2% enteroinvasive Escherichia coii, 
0-36% Rotavirus, 0-30% Shigella (17% of notified cases in Australia), 0-25% Salmonella (8% of Salmonella 
notifications in Australia), 0-15% enteroadherent Escherichia coli, 0-15% Campylobacter jejuni, 0-10% Giardia 
lamblia, 0-8% Aeromonas, 0-7% Vibrio parahaemolyticus (diarrhoea in 95% of infections), 0-7% Plesiomonas 
shigelloses, 0-5% Entamoeba histolytica, 0-2% Vibrio cholerae non-01, 0-2% Cryptosporidium, 0-1% Vibrio fluvialis, 
0-1% Yersinia enterocolitica (diarrhoea in 86% of infections), 0-1% enterohemorrhagic Escherichia coli, 0-0.3% 
Vibrio cholerae 01, Vibrio vulnificus, Vibrio alginolyticus, Vibrio mimicus, Vibrio furnissii 
Diagnosis: 3-8 stools/d in 80% of cases; abdominal pain and cramps in most cases; fever, vomiting, bloody 
stools in 10-20%; typically lasts 3-5 d but > 1 w in 10%; micro for parasites, bacterial and viral culture of feces 

Enterotoxigenic Escherichia coli: highest in summer; 99% diarrhoea, 79-82% abdominal pain and 
cramps, 49% nausea, 17-22% fever, 14-54% vomiting; from water or food contaminated with human feces; 
incubation period 1--3 d; duration of illness 3->7 d; 87% of cases 5-10 stools/d, 78% watery, 40% mucus, 12% 
blood, no leucocytes; test for toxin production in Chinese hamster ovary cells 

Invasive Escherichia coli and Shigellosis: 78% of cases 5-10 stools/d, 60% blood, 70% mucus, 
24% watery; 85% polymorphonuclears in feces 

Salmonella: 75% of cases 5-10 stools/d, 50% mucus, 33% watery, 21% blood 

Campylobacter jejuni: highest in winter; diarrhoea in all cases; 82% explosive, watery; 66% > 10 
stools/d; 26% with blood, 61% mucus; 8% persisting or recurring 2 w or more 

Reromonas: 56% of cases 5-10 stools/d, 51% watery, 37% mucus, 15% blood, 33% guiac test 
positive, 50% diarrhoea 3-10 d, 50% > 10 d 

Cryptosporidium: from contaminated water, vegetables, fruits, unpasteurised milk, swimming pools; 
incubation period 2-28 d; diarrhoea in 84% of infections (5-10 watery, frothy bowel movements/d), cramping, 
abdominal pain, sometimes fever, vomiting; usually lasting 1-5 d in noncompromised and months in compromised 

Vibrio cholerae 01: bloody, watery 



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Vibrio vulnificus: vomiting, diarrhoea, abdominal pain, bacteremia, may be wound infections; more 
common in immunocompromised and patients with chronic liver disease (associated bullous skin lesions); 
incubation period 1-7 d; duration of illness 2-8 d; from undercooked or raw shellfish (especially oysters), other 
contaminated seafood (also open wounds exposed to sea water); stool cultures on thiosulphate citrate bile sucrose 
agar; wound and blood cultures if indicated 

Vibrio parabaemolyticus: acute watery diarrhoea, abdominal cramps, nausea, vomiting; incubation 
period 2-48 h; from undercooked or raw seafood (especially shellfish); stool culture on thiosulphate citrate bile 
sucrose agar 

Vibrio fiuvialis: diarrhoea in 100% (75% bloody), vomiting in 97%, abdominal pain in 75%, 
dehydration in 67%, fever in 35% 
Treatment: 

Mild (1-2 Loose Stools/24h, Tolerable Symptoms): rehydration, dietary restriction 

Moderate to Severe: azithromycin 20 mg/kg to 1 g orally as single dose or norfloxacin 20 mg/kg 
to 800 mg orally as single dose; if no improvement of if fever or bloody stools, azithromycin 10 mg/kg to 500 mg 
orally daily for 2-3 d or norfloxacin 10 mg/kg to 400 mg orally 12 hourly for 2-3 d or ciprofloxacin 10 mg/kg to 
500 mg orally 12 hourly fo 2-3 d 

Persistent (> 3 w) and No Clear Diagnosis: tinidazole 2 g orally with food as a single dose 
Prophylaxis: 

High Risk Host (Immunodeficiency Including AIDS, Insnlin Dependent Diabetes 
Mellitns, Active Inflammatory Bowel Disease, Cardiac or Renal Failnre, Use of Potent H2- 
receptor Antagonists or Omeprazole): norfloxacin 10 mg/kg to 400 mg orally daily or ciprofloxacin 10 
mg/kg to 500 mg orally daily for not more than 3 w 

Pnrpose of Trip Wonld be Rnined by Illness: colloidal bismuth subcitrate 2 tablets chewed 
with meals and at bedtime to 8 tablets/d for not more than 3 w 

consumption of beverages ready bottled or heated and of food immediately after cooking; avoidance of 
unpasteurised milk and fruits and salads washed in suspect water; disinfection of water by boiling or chlorination 
Amoebiasis (Amebiasis, Amoebosis, Entamoebiasis): global mortality 40,000-1 10,000/y, global morbidity 
35-50 M; transmitted by cysts of carriers; invasive infection in * 10% of symptomatic cases, extraintestinal 
amobeiasis in « 5% 

Agents: Entamoeba histolytica; Entamoeba polecki in Australian Aborigines and Papua New Guineans, also S E 
Asian refugees 

Diagnosis: dependent on presentation; ELISA superior to indirect haemagglutination assay in diagnosis of 
extraintestinal amoebiasis and helps in detecting Entamoeba histolytica in otherwise undiagnosed hepatomegaly 
Treatment: 

Intestinal: see below 

Extraintestinal: metronidazole 750 mg 3 times a day for 5-10 d + iodoquinol 650 mg 3 times a day 
for 20 d; dehydroemetine 1 mg/kg/d to maximum 90 mg/d s.c. or i.m. for 5 d + chloroquine phosphate 600 mg 
base daily for 2 d then 300 mg base daily for 2-3 w 

Intestinal Amoebiasis: incubation period 2 d - 4 w; duration of illness months; fecal-oral transmission and 
may contaminate water and food; 1% of infective diarrhoea in adults; may be either noninvasive or invasive; 
carrier state occurs in noninvasive intestinal amoebiasis or may follow any invasive stage; chronic intestinal 
amoebiasis (chronic amoebic colitis, chronic amoebiasis, chronic amoebic dysentery) has been described 
Agent: Entamoeba histolytica 
Diagnosis: 

Noninvasive Intestinal Amoebiasis: as a rule, asymptomatic; no hematophagous trophozoites, 
changes observable at endoscopy or specific antibodies 

Invasive Intestinal Amoebiasis: intermittent diarrhoea, acute dysentery with bloody, mucous 
stools, colicky pain and rectal tenesmus; may be weight loss and dehydration, fever, constipation, headache, 
drowsiness, colonic lesions and perforations; incubation period 1 to several weeks 

Fnlminating Amoebic Colitis: severe form characterised by passage of numerous bloody stools, 
generalised abdominal discomfort, colicky pains preceding evacuation and rectal tenesmus (often constant and 
intense), with fever, dehydration and prostration; may be intestinal hemorrhage or perforation 



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Amoeboma (Amoebic Granuloma): granulomatous tumour-like mass that occasionally develops on 
intestinal wall 

Other Complications: megacolon, peritonitis, amoebic appendicitis and cecitis, cutaneous amoebiasis, 
rectovaginal amoebic cuffs, hemorrhage, rectovesicular fistulas; acute necrotising colitis with toxic megacolon in 
0.5% (associated with > 40% of deaths) 

geographic history; incubation period < 21 d; 97% of stools with macroscopic mucus, 37% with macroscopic and 
57% with microscopic blood (often in rouleaux), 98% with leucocytes (59% > 10/hpf, variable numbers of 
mononuclears), 74% pH alkaline; microscopic examination of fresh, warm, liquid feces for hematophagous 
trophozoites; merthiolate iodine formalin concentration and staining of multiple stool specimens, concentrated by 
modified Ritchie formalin-ether, and examined stained (iron hematoxylin, trichrome) and as wet mounts for 
trophozoites and cysts (sensitivity 30-50%, specificity < 60%); sigmoidoscopic swabs and scrapings from large 
bowel ulcers and biopsies of rectal mucosa; culture adds little in the way of sensitivity or precision to 
microscopic methods; indirect hemagglutination (10% asymptomatic cyst carriers, < 50% amoebic diarrhoea, 85% 
invasive amoebic dysentery, > 90% amoebic abscess = 256), counterimmunoelectrophoresis, complement fixation 
test (diagnostic titre 1:4), latex agglutination, immunodiffusion, ELISA (antigen; stool, sensitivity > 95%, specificity 
>95%; serum sensitivity > 65%, specificity 90%; salivary IgA diagnostic accuracy 91.5%); indirect 
immunofluorescence with monoclonal antibodies distinguishes pathogenic (Histolytica) from nonpathogenic 
(Edispar) strains; negative tests do not exclude intestinal amoebiasis; active infection indicated by presence of 
specific IgM and IgG; culture and isoenzyme analysis (sensitivity 30-60%, 100% specificity; requires 1-2 w); PCR 
on stool (sensitivity > 85%, specificity > 90%); colonoscopy; anemia (erythrocyte count and hemoglobin 
decreased) 
Differential Diagnosis: 

Dysentery: infections due to Shigella, Campylobacter jejuni, Yersinia enterocolitica, invasive 
Escherichia coli, Vibrio parahaemolyticus 

Mild Diarrhoea Syndrome: Salmonella, giardiasis, enterotoxigenic Escherichia coli diarrhoea, many 
other diarrhoeas of infectious origin, irritable bowel syndrome 
Treatment: 

Cyst Passers: diloxanide furoate 500 mg orally 3 times daily (child: 20 mg/kg/d in 3 divided doses) 
for 10 d, iodoquinol 650 mg 3 times daily (child: 30-40 mg/kg/d to 2 g in 3 doses) for 20 d, paromomycin 
25-30 mg/kg/d in 3 divided doses for 7 d 

Symptomatic: tinidazole 50 mg/kg to 2 g orally daily for 3 d or metronidazole 15 mg/kg to 600 mg 
orally 8 hourly for 7-10 d, followed by diloxanide furoate 7 mg/kg to 500 mg orally 8 hourly for 10 d or 
paromomycin 10 mg/kg to 500 mg orally 8 hourly for 7 d or iodoquinol 650 mg 3 times daily for 20 d 
Prevention and Control: sanitation, control of carriers 
Bacillary (Bacterial) Dysentery (Shigellosis and Coliforih Enteritis) 

Shigellosis: « 500 notified cases/y in Australia (« 24% in Queensland); incidence in USA 8/100,000 
in general population and 494/100,000 in Indian reservations (450,000 estimated total cases, 20% foodborne, 0.8% 
of foodborne related deaths; 2% of foodborne disease outbreaks, 2% of cases); 2% of infectious diarrhoea (7% in 
adults; 15% of bloody diarrhoea); transmission by contaminated water and food (usually person-to-person fecal-oral 
route through ready to eat foods touched by infected workers, raw vegetables, egg salads); duration of illness 
4-7 d; case-fatality rate 0.06%; increased risk in men who have sex with men 
Agents: Shigella sonnei (group D shigellosis, Sonne dysentery; 93% of cases in institutions, 74% in general 
population, 41% in Indian reservations; very mild infection), Shigella flexneri (Flexner dysentery, group B 
shigellosis, Hiss-Russel dysentery; 7% of cases in institutions, 23% in general population, 58% in Indian 
reservations), Shigella boydii (Boyd dysentery, group C shigellosis; 2-3% of cases), Shigella dysenteriae (group A 
shigellosis, Shiga-Kruse dysentery; serotype 1: Shiga dysentery; serotype 2: Schnitz dysentery; tropics; more 
serious; 1% of cases), enteroinvasive strains of Escherichia coli (« 40 notified cases/y in Australia) 
Diagnosis: incubation period 12 h - 7 d (usually 24-48 h) in shigellosis, 1-18 h in enteroinvasive Escherichia 
coli, severe diarrhoea, abdominal pain and cramps in 82% of Shigella and 91% of enteroinvasive Escherichia coli, 
moderate fever in 40-42% of Shigella and 40% of enteroinvasive Escherichia coli, slight vomiting in 66% of 
Shigella and 73% of enteroinvasive Escherichia coli, age 6 mo - 6 y (rare in neonates), > 50% diarrhoea in 
household, onset abrupt, bronchitis common, convulsions common, anal sphincter lax tone (rarely rectal prolapse); 
feces watery and consists largely of mucus (macroscopic in 66-94% of Shigella and 66% of enteroinvasive 



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Escherichia coh) and blood (macroscopic in 37-63% of Shigella and 18% of enteroinvasive Escherichia coliani 
microscopic in 75% of cases), relatively odourless, yellow-green (almost colourless in severe cases) and contains 
large numbers of neutrophils (in 99% of cases; 44-80% > 10/hpf; 85% of leucocytes) and erythrocytes (18-43% 
> 10/hpf; scattered), large macrophages may be present and may have ingested red cells, pH alkaline in 68% of 
cases; diffuse colitis by sigmoidoscopy; micro, culture (Gram negative broth, xylose lysine deoxycholate agar, 
MacConkey) and immunofluorescent staining of feces or rectal swab; presence of toxin confirmed by DNA 
hybridisation and ELISA test; neutrophilia in blood smear; anemia (erythrocyte count and hemoglobin decreased); 
no satisfactory routine test for identification of Escherichia coli strains 

Treatment: supportive; antibiotics recommended in all cases for public health reasons; norfloxacin 10 mg/kg to 
400 mg orally 12 hourly for 5d (contraindicated in children), cotrimoxazole 4/20 mg/kg to 160/800 mg orally 12 
hourly for 5 d, ampicillin 25 mg/kg to 1 g orally 6 hourly for 5 d; in severely ill or immunocompromised, 
ciprofloxacin 10 mg/kg to 500 mg orally 12 hourly for 5 d; zinc 20 mg/d for 2 w 
Prevention and Control: identification and enteric isolation of cases; good hygiene 
Cholera (Algid Cholera, Asiatic Cholera, Asphyctic Cholera, Cholera Gravis, Cholera Indica, 
Cholera Orientalis, Cholera Sicca, Cholera Siderans, Dry Cholera, Epidemic Cholera, Indian 
Cholera, Malignant Cholera, Pandemic Cholera, Spasmodic Cholera): illness characterised by 
diarrhoea and/or vomiting; severity is variable; transmission by contaminated water, fish, shellfish, street-vended 
food; incubation period 24-72 h; duration of illness 3-7 d; principally Africa, Arab countries, India, Indonesia, S 
America but becoming widespread over Indo-Pacific; few sporadic indigenous cases in Australia (« 3 notified 
cases/y); indigenous focus of infection in crustaceans in Gulf of Maine in USA; incidence in USA 0.3/100,000; 
global incidence 384,000/y; global mortality 20,000/y; death due to dehydration produced by excess water 
secretion into small intestine in response to increased activity of adenyl cyclase stimulated by exotoxin of 
organism; case-fatality rate 0.7% 

Agent: Vibrio cholerae 01 biotype cholerae (classical cholera; infection:case ratio 5:1-10:1) and biotype eltor 
(cholera el Tor, cholera El Tor, cholera el tor, cholera eltor; infection:case ratio 25:1-100:1) 
Diagnosis: 75% asymptomatic, 18% mild, 5% moderate, 2% severe; abrupt onset of profuse watery diarrhoea; 
58% > 10 stools/d, 88% watery, 8% mucus, 4% blood; explosive), occasional vomiting, fever absent, respiratory 
symptoms absent, occasional convulsions, anal sphincter normal, saline depletion, hypotension; stools innocuous 
odour, clear, rice water; geographic history; micro (leucocytes absent; organisms seen in Gram or on phase or dark 
field) and culture of feces or vomit on thiosulphate citrate bile sucrose medium (enrichment in alkaline peptone 
water will increase yield), with isolation of cholera toxin-producing Vibrio cholerae 01 or 0139 (confirmed by DNA 
hybridisation and ELISA test); serologic evidence of recent infection (ELISA; sensitivity 85-100%) 
Treatment: rehydration and electrolyte replacement (severe dehydration: i.v. Ringer's lactate; less severe: oral 
rehydration with sodium chloride 3.5 g/L + sodium citrate dihydrate 2.9 g/L or sodium bicarbonate 2.5 g/L + 
potassium chloride 1.5 g/L + anhydrous glucose 20 g/L + zinc 40 mg/L in clean drinking water); antibiotics 
reduce volume and duration of diarrhoea; doxycycline 2.5 mg to 100 mg orally 12 hourly for 3 d (not in < 8 y, 
pregnant or breastfeeding), ciprofloxacin 25 mg/kg to 1 g orally single dose (not pregnant or children), norfloxacin 
400 mg twice a day for 3 d (not pregnant or children), tetracycline 30-40 mg/kg to 500 mg orally 6 hourly for 
3 d (not in < 8 y, pregnant or breastfeeding), erythromycin 250 mg orally 4 times daily (child: 10 mg/kg 3 times 
daily) for 3 d, azithromycin 20 mg/kg single dose, cotrimoxazole 

Pregnant, < 8 y: amoxycillin 10 mg/kg to 250 mg orally 6 hourly for 5 d 

Carriers: oral streptomycin or neomycin 
Prophylaxis: no vaccine currently licensed and available; 'boil it, cook it, peel it or forget it'; improved 
sanitation; postexposure: doxycycline 2 mg/kg to 100 mg orally daily 
Enterotoxemia: preformed toxin in food 

Agents: Staphylococcus aureus (185,000 estimated cases/y in USA, all foodborne, 0.1% of foodborne related 
deaths; 2% of foodborne outbreaks, 2% of cases; heat-stable toxin in unrefrigerated or improperly refrigerated 
cream pastries, meats, potato and egg salads; duration of illness 24-48 h), Clostridium perfringens type A (heat- 
stable toxin in meats, poultry, gravy, dried or precooked foods kept warm for several hours; duration of illness 24- 
48 h; 18% of foodborne disease outbreaks in Australia; 250,000 estimated cases/y in USA, all foodborne, 0.4% of 
foodborne related deaths; 2% of foodborne disease outbreaks, 3% of cases), Clostridium botulinum (8-66% mortality; 
heat-labile toxin in home-canned foods with low acid content, improperly canned commercial foods, home-canned 
or fermented fish, herb-infused oils, baked potatoes in aluminium foil, cheese sauce, bottled garlic, foods held 



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warm for extended periods; no notified cases in Australia in past decade), Bacillus cereus (diarrhoeal toxin from 
meats, stews, gravies, vanilla sauce; vomiting toxin from improperly refrigerated cooked and fried rice, meats; 
27,000 estimated cases/y in USA, all food borne, no deaths; 0.5% of foodborne disease outbreaks, 0.8% of cases) 
Diagnosis: isolation of organism from suspect food (chopped meat, blood agar, phenylethyl alcohol blood agar, 
mannitol salt agar, tryptose sulphite cycloserine agar) and feces; identification of toxin (ELISA) from feces, serum 
(« 3-5 mL transported at 4°C) and foodstuff; CSF pressure, cell count, glucose and protein normal 

Staphylococcus aureus: sudden onset of very severe nausea, retching and vomiting and abdominal 
pain and cramps, slight diarrhoea in 39% of cases, little or no fever, acute prostration; incubation period 0.5-6 h 

Clostridium perfringens: very severe abdominal pain and cramps, moderate watery diarrhoea in 
91% of cases, vomiting rare, little or no fever, nausea and headache rare; incubation period 8-16 h; toxin test on 
stool 

Clostridium botulinum: moderate bulbar signs, vertigo, double or blurred vision, loss of reflex to 
light, difficulty in swallowing, speaking and breathing, dry mouth, descending muscle weakness, respiratory 
paralysis; slight vomiting, diarrhoea in some cases; incubation period 2 h - 8 d; duration of illness days to months; 
toxin test on stool, serum and food 

Bacillus cereus: diarrhoeal toxin: abdominal cramps, nausea, watery diarrhoea, incubation period 
10-16 h, duration of illness 24-48 h; vomiting toxin: sudden onset of nausea and vomiting ± diarrhoea, incubation 
period 1-6 h, duration of illness 24 h; test food and stool for toxins in outbreaks 
Treatment: supportive 

Clostridium botulinum: antitoxin 
Prophylaxis (Botnlism): hyperimmune immunoglobulin 

Ciguatera Fish Poisoning: pantropical; 13% of foodborne disease outbreaks in Australia; 2% of foodborne 
disease outbreaks in USA, 0.2% of cases, no deaths 

Agent: ciguatoxin and 5 other toxins produced by Gambierdiscus toxicus (a diatom) eaten by fish (coral reef fish, 
barracuda, grouper, amberjack, red snapper), which concentrate toxin and remain toxic 2 y 
Diagnosis: clinical: gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhoea) 2-6 h post-ingestion, 
neurologic (paresthesias of lips, tongue and extremities, reversal of hot and cold, pain and weakness of lower 
extremities, acral tingling, myalgia, itching, insomnia, headache, numbness and aching teeth usually present; 
dizziness, dry mouth, dilated pupils, blurred vision, paralysis, seizures, coma and death (rarely) also occur) 3 h 
post-ingestion, cardiovascular (bradycardia, hypotension, increase in T wave abnormalities) after 2-5 d; duration of 
illness days to months; radioassay for toxin in suspect fish 

Treatment: supportive, i.v. mannitol, tocanide, amitryptyline (25 mg twice a day), nifedipine 
Neurotoxic Shellfish Poisoning: Caribbean, Gulf of Mexico 

Agent: > 10 brevetoxins produced by Karenia kerns and concentrated by shellfish; most common in US Gulf 
States; marine mammal deaths 

Diagnosis: clinical (incubation period 2 min-4 h; reversal of hot and cold sensation, nausea, vomiting, diarrhoea, 
tingling and numbness of lips, mouth, tongue, throat and face, muscle aches, dizziness, ataxia, asthma-like 
respiratory distress, often a feeling of floating); history of shellfish (mussels, plankton feeders) ingestion; detection 
of toxin in shellfish 

Treatment: supportive; activated charcoal and cathartic if severe 

Paralytic Shellfish Poisoning: subarctic to tropic (primarily American Samoa, California, Washington, New 
England 

Agent: saxitoxin (blocks sodium channels) and > 21 other toxins produced by Gonyaulax and Mexandrium and 
concentrated by finfish and shellfish 

Diagnosis: clinical (incubation period 30 min to 3 h; diarrhoea, nausea, vomiting, abdominal pain, paresthesias 
of extremities, tingling, burning, numbness of mouth and lips, drowsiness, incoherent speech, ataxia (rare), 
respiratory paralysis (rare), death (rare)); history of shellfish (mussels, clams, scallops, cockles) ingestion; duration 
of illness days; detection of toxin in food or water where fish located 

Treatment: supportive; activated charcoal and cathartic if severe; may be life-threatening and need respiratory 
support 

Diarrhoeic Shellfish Poisoning: Europe, Canada, Japan, New Zealand, South America, seen in US waters 
Agent: dinophysis toxin, okadaic acid, pectenotoxin, yessotoxin produced by Dinophysis 



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Infections of the Gastrointestinal Tract and Associated Structures 



Diagnosis: ingestion of a variety of shellfish, primarily mussels, oysters, scallops, shellfish from Florida coast 

and Gulf of Mexico; incubation period 30 min to 2 h; abdominal pain, vomiting, nausea, headache, diarrhoea, chills, 

fever; duration of illness hours to 3 d; demonstration of toxin in shellfish 

Treatment: supportive 

Scombroid Poisoning: 4% of foodborne disease outbreaks in Australia; 3% of foodborne disease outbreaks in 

USA, 0.3% of cases, no deaths 

Agent: histamine produced by bacterial action on flesh of certain fish (tuna, mackerel, mahi-mahi, bonito, bluefin, 

skipjack, marlin) 

Diagnosis: incubation period 1 min-3 h; dizziness, headache, respiratory symptoms, nausea, vomiting, peppery 

taste, burning of mouth, throat and skin, facial swelling and flushing, stomach pain, itching of skin, rash, 

urticaria, paresthesias; duration of illness 3-6 h; demonstration of histamine in food 

Treatment: gastric lavage, antihistamine, cimetidine, bronchodilators if wheezing or asthmatic 

Tetrodoxin Poisoning: kills 70-100/y in Japan 

Agent: tetrodoxin from blowfish (puffer, globefish, swellfish, fugu) 

Diagnosis: tingling about lips and tongue and feeling as though floating, followed by motor incoordination 

within 10-45 min, then paralysis, difficulty swallowing and loss of voice; death due to respiratory paralysis in 

> 60% 

Amnesic Shellfish Poisoning: Canada, NE USA, Washington, Oregon, California 

Agent: domoic acid produced by Pseudo-nitzchia pungens and other species and concentrated by shellfish 

(especially mussels) and finfish 

Diagnosis: gastroenteritis, memory defects/amnesia, confusion, death (4%) 

Treatment: snpportive 

Infant Botulism: in infants < 12 mo; associated with honey, home-canned vegetables and fruits, infant 

formula 

Agent: Clostridium botulinum 

Diagnosis: incubation period 3-30 d; duration of illness variable; weakness or floppiness in 88%, poor feeding in 

79%, constipation in 65%, weak cry in 18%, irritability in 18%, respiratory difficulties in 11%, seizures in 2%; 

electromyogram (compound muscle action potentials of decreased amplitude in at least 2 muscle groups; tetanic 

and post-tetanic facilitations defined by an amplitude of > 120% of baseline; prolonged post-tetanic facilitation of 

> 120 s and absence of post-tetanic exhaustion); toxin identification (mouse bioassay, ELISA) from stool (25-50 g 
without transport medium transported at 4°C), serum, food; recovery of Clostridium botulinum from stool and 
suspect materials 

Treatment: supportive; botulism immune globulin 

Bacterial Gastroenteritis (Bacterial Enteritis): although toxins may be produced and play a role in 
disease causation, the condition arises from a true infection and is not only an intoxication; most common cause 
(14%) of fever in returned travellers to Australia 

Agents: Salmonella (« 7000 notified cases/y in Australia (« 31% in Queensland), 46% of foodborne disease 
outbreaks; incidence 12/100,000 in USA (1.4 M estimated total cases, 95% foodborne, 31% of foodborne related 
deaths; 13% of foodborne disease outbreaks, 38% of cases); 34% of infectious diarrhoea in adults; 6% of bloody 
diarrhoea; mortality < 1%; infection from contaminated eggs, poultry, fish, ham, beef, gravy, meat pies, sausages, 
raw fruits and vegetables, unpasteurised milk or juice, soft cheese or fecal contamination; duration of illness 
4-7 d), Yersinia enterocolitis (2% of infectious diarrhoea; « 140 notified cases/y in Australia (general decline; 
« 70% in Queensland); incidence 0.5/100,000 in USA (100,000 estimated total cases, 90% foodborne, 0.1% of 
foodborne related deaths); vehicle contaminated water and unpasteurised milk, juice or soft cheeses in outbreaks, 
undercooked pork in sporadic cases), Plesiomonas shigelloides (1% of infectious diarrhoea in adults; occasional 
bloody diarrhoea; occasional outbreaks and sporadic cases, chiefly in tropical areas), Vibrio parahaemolyticus (0.7% 
of infectious diarrhoea in adults; from fish, shellfish and processed seafood; duration of illness 24-72 h), Aeromonas 
hydrophila (0.7% of infectious diarrhoea in adults), enterotoxigenic (undercooked hamburger, unpasteurised juices) 
and enteropathogenic adhesion factor positive Escherichia coli (dyspepsiacoli diarrhoea, Escherichia coli diarrhoea; 
< 1% of infectious diarrhoea; > 10 6 bacteria in food or water), Clostridium perfringens (uncommon), Vibrio 
cholerae non-01, Vibrio mimicus, Vibrio fluvialis, Vibrio furnissi, Vibrio hollisae and Vibrio vulnificus (vehicle 
shellfish), Listeria monocytogenes (usually milk products (unpasteurised soft cheeses); also raw hot dogs, deli 
meats; « 60 notified cases/y in Australia, 4% of foodborne disease outbreaks; incidence 0.4/100,000 in USA (3000 



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Infections of the Gastrointestinal Tract and Associated Structures 



estimated total cases, 99% foodborne, 28% of foodborne related deaths; 0.1% of foodborne disease outbreaks, 0.1% 
of cases)), rarely Enterococcus faecalis, Enterococcus faecium, Proteus, JUcaligenes faecalis, Pseudomonas 
aeruginosa ('Shangai fever'; presentation similar to typhoid fever), Edwardsiella tarda 
Diagnosis: micro (leucocytes (75% polymorphonuclears) but usually not erythrocytes) and culture (blood agar, 
enteric and differential agar media) of feces; ELISA for antibody (Salmonella enteritidis sensitivity 92%, specificity 
100%; Salmonella typhimurium sensitivity 100%; Yersinia enterocolitica sensitivity 86%, specificity 100%); toxin 
assay (Clostridium perfringens] 

Salmonella: moderate vomiting in 56%, diarrhoea, abdominal pain and cramps in 75%, variable fever 
in 27%, chills, malaise, nausea, headache, prostration, respiratory symptoms uncommon, convulsions rare, anal 
sphincter normal; stools loose, slimy, foul odour (rotten eggs), blood in 26%, colour green, mucus variable; 
incubation period 1-3 d; TUBEX detects IgM antibodies to Salmonella enteritidis (sensitivity 93%, specificity 95%) 

Vibrio parahaemolyticus. nausea and vomiting, severe abdominal pain and acute watery diarrhoea; 
incubation period 2-48 h 

Vibrio vulnificus: vomiting, diarrhoea, abdominal pain, bacteremia, may be wound infections; more 
common in immunocompromised and patients with chronic liver disease (associated bullous skin lesions); 
incubation period 1-7 d; duration of illness 2-8 d; from undercooked or raw shellfish (especially oysters), other 
contaminated seafood (also open wounds exposed to sea water); stool cultures on thiosulphate citrate bile sucrose 
agar; wound and blood cultures if indicated 

Yersinia enterocolitica: diarrhoea, vomiting, fever, abdominal pain; appendicitis-like symptoms 
primarily in older children and young adults; incubation period 24-48 h; duration of illness 1-3 w; occasionally 
bloody diarrhoea; culture of stool or vomitus on CIN medium; blood culture; serology (research and reference 
laboratories) 

Enterotoxigenic Escherichia coir. 99% diarrhoea, 79-82% abdominal pain and cramps, 73% 
watery stool, 49% nausea, 17-22% fever, 14-54% vomiting; 10% severe hemorrhagic colitis; median incubation 
period 42 h (72-120 h); duration of illness 24-265 h; 87% of cases 5-10 stools/d, 78% watery, 40% mucus, 12% 
blood, no leucocytes; test for toxin production in Chinese hamster ovary cells 

Enteropathogenic adhesion factor positive Escherichia coir. 81% watery stool, 69% 
vomiting, 44% abdominal pain, 19% fever; incubation period 12-74 h 

Treatment: antibiotics are not usually required and, especially in salmonellosis, prolong carriage, as do agents 
(eg., Lomotil™) decreasing intestinal motility; patients with AIDS or lymphadenopathic syndrome, oncology 
patients and, possibly, patients > 50 y, infants < 3 mo and malnourished children should, however, receive 
antibiotic treatment, as should systemic infections; dehydration requires hospitalisation and fluid replacement 
under biochemical control 

Salmonella: ciprofloxacin 10 mg/kg to 500 mg orally 12 hourly for 5-7 d, azithromycin 20 mg/kg to 

1 g orally on first d then 10 mg/kg to 500 mg daily for further 6 d; if oral therapy cannot be tolerated, 
ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly until oral ciprofloxacin can be tolerated, ceftriaxone 50 mg/kg to 

2 g i.v. daily until oral ciprofloxacin or azithromycin can be tolerated 

Yersinia enterocolitica (Severe Cases): gentamicin 1.3 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 
hourly, cefotaxime, ceftriaxone, ciprofloxacin, doxycycline 

Vibrio parahaemolyticus (Severe Cases): tetracycline, doxycycline, gentamicin, cefotaxime 

Vibrio vulnificus: supportive care + tetracycline, doxycycline or ceftazidime 

Reromonas: chloramphenicol, ciprofloxacin, aminoglycosides, third generation cephalosporins, 
aztreonam, imipenem 

Plesiomonas shigelloides: chloramphenicol, aminoglycosides, cotrimoxazole, fluoroquinolones, 
tetracycline, third generation cephalosporins, imipenem 

Listeria monocytogenes: ampicillin, cotrimoxazole 

Enterotoxigenic Escherichia coli: cotrimoxazole 

Enteropathogenic Escherichia coli: ampicillin, cotrimoxazole 

Enteroinvasive Escherichia coli (Severe Cases): quinolones 
Gastroenteritis also occurs with infections with Taenia saginata, Taenia solium, Trichinella spiralis, on 
ingestion of ciguatera toxin, tetraodon toxin and Muscaria-iyyt mushrooms and in organic phosphate poisoning. 
Gastrointestinal distress is common in influenza and occurs in 15% of parainfluenza cases. Gastrointestinal 



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Infections of the Gastrointestinal Tract and Associated Structures 



hemorrhage is extensive in Ebola hemorrhagic fever and occurs in neonatal Simplexvirus infection and in 13% of 
cases of brucellosis. Gastrointestinal symptoms are also seen in 94% of cases of toxic shock syndrome. 
Enteric Fever (Eberth Disease): acute febrile disease; transmission by contact, water or food; epidemics 
often related to fecal contamination of water supplies or street-vended foods; may take numerous clinical forms; 
80% in Asia, 20% in Latin America, Africa; global incidence 16M/y (600,000 deaths/y) 
Agents: Salmonella typhi (typhoid fever, continued fever, febris typhoidea, ileotyphus, lent fever, nightsoil fever, 
pythogenic fever, typhoenteritis, typhogastric fever, typhus abdominalis; prevalent in Africa, Asia (13 M cases and 
> 440,000 deaths/y) and Mediterranean basin; causes epidemics anywhere; 0.4% of infectious diarrhoea; « 70 
notified cases/y in Australia (« 53% in NSW; causes 3% of fever in returned travellers); incidence 0.2/100,000 in 
USA; case-fatality rate 0.1-41%; perforation (case-fatality rate 0-100%) in 0-21% of cases), Salmonella 
paratyphi R (febris paratyphoidea A, paratyphoid A fever, paratyphoid fever A, paratyphus A; largely confined to 
tropics but also other Asia, Western Europe), Salmonella enterica subsp Salmonella enteric I serovar paratyphi B 
(Brion-Kayser disease, febris paratyphoidea B, paratyphoid B fever, paratyphoid fever B, paratyphus B, 
Schottmueller disease; Europe), Salmonella enterica subsp Salmonella enteric I serovar paratyphi c (febris 
partyphoidea C, paratyphoid C fever, paratyphoid fever C, paratyphus C) 

Diagnosis: gradual onset (incubation period 7-28 d), prolonged fever (> 39°C in 90%), malaise, headache, 
nausea, constipation, abdominal pain, chills, myalgia, rose spots, splenomegaly, hepatomegaly, diarrhoea and 
vomiting uncommon, nonproductive cough common, occasional convulsions, anal sphincter normal; stools foul odour, 
brown; 49% of cases with 10 stools/d, lasting 6+ d, 98% watery, 7% bloody, 2% soft, 29% guiac test positive, 
52% 1-9 erythrocytes/hpf, 74% 0-19 leucocytes/hpf, 4950 leucocytes/ pL, 70% polymorphs, 30% mononuclears, 
protein 9.3 g/L, sodium 47 mEq/L, potassium 48 mEq/L, chloride 43 mEq/1, pH 6.1; history of foreign travel, 
especially Mexico and India; blood culture X2 + bone marrow culture (most reliable single method) + duodenal 
string culture; hypochromic anemia (erythrocyte count and hemoglobin decreased), neutropenia or neutrophilia; 
serum alkaline phosphatase 30 IU/L, serum bilirubin 2 mg/dL, serum glutamic pyruvic acid transaminase 
16-170 U/mL in 35% of cases, serum C(h 24 mmol/L; elevated antibody titres to hemagglutinin; Widal test 
(agglutinins to antigens of groups A, B, C or D or H antigen elevated in infections; cross-reactions between 
groups B, C and D common; high H titre in prior immunisation); radioimmunoassay (sensitivity 94%, specificity 



Treatment: ciprofloxacin 15 mg/kg to 500 mg orally or 10 mg/kg to 400 mg i.v. 12 hourly for 7-10 d; if 
reduced susceptibility to quinolones or fever > 7 d, ceftriaxone 50 mg/kg to 2 g i.v. once daily or azithromycin 
20 mg/kg to 1 g i.v. or orally daily till clinical response, then amoxicillin 25 mg/kg to 1 g orally 6 hourly for 
further 14 d, azithromycin 20 mg/kg to 1 g orally daily for total 10 d or cotrimoxazole 4/20 mg/kg to 
160/800 mg orally 12 hourly for 14 d; + dexamethasone 3 mg/kg in critically ill patients in shock; + aggressive 
resuscitation, prompt operative intervention and careful postoperative attention to hydration and nutrition in 
perforation 

Carriers: norfloxacin 400 mg orally 12 hourly for 28 d, ciprofloxacin 750 mg orally twice daily for 
28 d, ofloxacin; amoxycillin 50-75 mg/kg daily in 3 divided doses orally or i.v. + probenecid 30 mg/kg (child: 
10-15 mg/kg) orally daily in divided doses for 6 w 

Prophylaxis (Salmonella typhi): heat-killed whole cell vaccine (protection rate 70-90%; contraindicated in 
pregnancy and convalescence from serious illness); Vi conjugate vaccine (71-88% efficacy after single dose, 92% 
after 2 doses; lower fever and systemic adverse effects); live oral vaccine (protection rate 70-95%; contraindicated 
in pregnancy, acute gastrointestinal infections, AIDS, treatment with antimitotic or immunosuppressive drugs); good 
sanitation 

Diarrhoea Related to Bacterial Overgrowth 
Agents: mixed bacterial species in high numbers 

Diagnosis: chronic diarrhoea; culture of duodenal aspirate; glucose ingestion hydrogen breath test 
Treatment: norfloxacin 800 mg/d for 7 d, amoxycillin-clavulanate 1500 mg/d for 7d, rifaximin 1600 mg/d 
Enteritis: 0.2% of new episodes of illness in UK 

Agents: Giardia lamblia (2 M estimated cases/y in USA (10% foodborne, 0.1% of foodborne related deaths); 1% 
of infective diarrhoea in adults; swallowing water while swimming, recreational fresh water contact, drinking 
treated tap water, eating lettuce), Chilomastix mesnili, Cystoisospora belli (probably worldwide infection of 
mammals; frequently asymptomatic infection of workers in contact with farm animals, usually pigs; frequent cause 
(15% in Haiti) of severe diarrhoea in AIDS), Sarcocystis, Cryptosporidium (worldwide in most mammals; incidence 



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Infections of the Gastrointestinal Tract and Associated Structures 



varies widely from 2.4/100,000 in USA (300,000 estimated total cases (10% foodborne), 0.4% foodborne related 
deaths) to 9.2% in parts of Africa), Cyclospora cayetanensis (Americas, Africa, Indian subcontinent, South-east 
Asia; incidence 0.1/100,000 in USA (16,000 estimated total cases, 90% foodborne, no deaths); transmitted in 
contaminated water, berries, lettuce, basil, salad), Blastocystis hominis (claimed to cause an acute enteritis but 
probably rarely, if ever, a human pathogen), Encephalitozoon cumuli, Enterocytozoon bieneusi and Encephalitozoon 
intestinalis (chronic diarrhoea in AIDS), Nosema (immunocompromised), Microsporidium (immunocompromised), 
Balantidium coli (balantidiasis, balantidial colitis, balantidial dysentery, balantidiosis, balantidosis, ciliary 
dysentery, ciliate dysentery; worldwide; derived from pigs' feces), Schistosoma japonicum, Schistosoma mansoni, 
Fasciola hepatica, Fasciolopsis buski, Dicrocoeiium dendriticum, Dicrocoeiium hospes, Paragonimus westermani, 
Nanophyetus saimincola (10 cases in USA from eating raw, smoked or incompletely cooked salmon or steelhead 
trout), Skrjabinophytus neomidis (endemic in Siberia; infection rates up to 98%), Opisthorchis, Cionorchis sinensis 
(Southeast Asia; incidence 28ffl/y; no deaths reported), Heterophyes, Metagonimus, Taenia saginata (beef 
tapeworm), Taenia solium (pork tapeworm; cysticerci ingested in inadequately cooked pork; adult worm in 
intestines; eggs in feces), Echinococcus granulosus and Echinococcus multilocularis (hydatid disease; 15 cases/y in 
Australia), Hymenolepis diminuta, Hymenolepis nana, Dipylidium caninum, Diphyllobothrium (fish tapeworm; foci in 
Finland, Japan, Romania, Switzerland and Northern USSR; also found in Canada and Alaska in USA), Trichinella 
spiralis (incidence 0.06/100,000 in USA; attack rate 81%; case-fatality rate 9-10/1000; prevalence in USA 2%; 
farm-raised hogs 1/1000, garbage-fed hogs 5/1000; transmission by raw or undercooked infected meat (usually 
pork or wild game such as bear or moose); incubation period 1 d-8 w; prevention and control by adequate cooking 
or freezing), Trichuris trichuria (whipworm; worldwide prevalence 350 M; especially hot, wet areas, also temperate 
areas), Capillaria philippinensis, Strongyloides fuelleborni and Strongyloides stercoralis (usually chronic or 
recurrent — 40+ y; persistent in 20% of all World War II prisoners in Burma-Thailand camps and in 50% of those 
with symptoms), hookworm {Rncyclostoma ceylanicum, Rncyclostoma duodenale, Necator americanus, all tropical 
and subtropical countries; 700 M cases/y worldwide; transmission by skin contact with contaminated soil; 
incubation period 2-10 w; prevention by sanitation, wearing of shoes), Trichostrongylus, Enterobius vermicularis 
(pinworm; worldwide; commonly seen in children), Ascaris lumbricoides and Ascaris suum (150M cases/y 
worldwide; Africa, Asia, Latin America; 60 000 deaths/y; > 2000 cases/100,000 in China; fecal transmission; 
incubation period 2 mo; prevention and control by sanitation), Anisakis simplex, Pseudoterranova, Physaloptera 
caucasia, Toxoplasma gondii (225, ,000 estimated cases/y in USA, 50% foodborne, 21% of foodborne related deaths); 
larvae of flies of Order Diptera (Calliphora vomitoria, Chrysomya chloropyga, Chrysomya putoria, Clogmia 
albipunctata, Eristalis tenax, Fannia canicularis, Gasterophilus haermorrhoidalis, Gasterophilus intestinalis, 
Gasterophilus nasalis, Musca domestica, Piophila, Sarcophaga bullata, Sarcophaga hirtipes, Sarcophaga ilerminieri, 
Sarcophaga peregrina, Sarcophaga ruficornis, Sarcophaga sarraceniae, Sarcophaga striata); human cytomegalovirus 
in AIDS 
Diagnosis: 

Giardia lamblia: vehicle drinking water, contaminated food; incubation period 1-4 w; malaise, 
gastric pain, malabsorption; diarrhoea > 5 d, recurrent, mucoid, fatty stools; bloating, flatulence, nausea, vomiting, 
anorexia, weight loss, no fever; no leucocytes or erythrocytes in stool micro; trophozoites in diarrheic and cysts in 
formed faeces (modified Ritchie formalin-ether concentration); trophozoites in duodenal or jejunal aspirate or 
biopsy; solid phase qualitative immunochromographic assay (ColorPac Giardia/Cryptosporidium; « 1% false 
positives, no false negatives); serology for Giardia lamblia IgG; ELISA (sensitivity 84-98%, specificity 97-100%, 
positive predictive value 73%, negative predictive value 97%) 

Chilomastix mesnili: trophozoites in unformed and cysts in formed stools 

Cryptosporidium and Isospora: vehicle water, vegetables, fruits, unpasteurised milk; incubation 
period 2-28 d; usually mild and self-limited but severe clinical symptoms reported; acute onset malaise, bloating, 
abdominal pain and cramping, weight loss, watery mucoid diarrhoea, malabsorption ± fever, vomiting; no 
leucocytes or erythrocytes in stool micro; oocysts in fresh warm stools; iodine stained wet preparation; phase 
contrast examination of Sheather's sugar flotation concentrate; sedimentation and modified acid-fast staining; 
indirect fluorescent antibody; solid phase qualitative immunochromographic assay (ColorPac 
Giardia/Cryptosporidium; « 1% false positives, no false negatives); duodenal aspirate; histology of small or large 
bowel biopsy 

Cyclospora: incubation period 1-11 d; protracted intermittent diarrhoea (may alternate with 
constipation, often relapsing) in 96% (watery in 96%, mucus in 61%, no blood), flatulence in 96%, weight loss in 



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92%, nausea in 92%, abdominal cramps in 79%, vomiting in 53%, fever in 43%, fatigue, indigestion, malaise, 
bloating, anorexia, myalgia, 'flu-like' symptoms; symptoms last up to 7 w in immunocompetent and up to 4 mo in 
AIDS patients; Reiter syndrome and Guillain-Barre syndrome reported; characteristic unsporulated oocysts in wet 
film or modified acid-fast stain 

Sarcocystis: usually asymptomatic; may be acute episode of abdominal pain and diarrhoea or, in 
prolonged infections, recurrent abdominal manifestations; patients with at least 500 flukes show rumbling on 
palpation of sigmoid and cecum, diarrhoea and gastric pain 

Blastocystis hominis: visualisation of parasite in wet films or stained by modified Ziehl-Neelsen 
stain 

Microsporidia: incubation period 1-2 w; malabsorptive diarrhoea with bloating; no fever; systemic 
dissemination to liver, gall bladder, sinuses, muscle, eye and central nervous system can occur with 
Encephalitozoon intestinalk, no leucocytes or erythrocytes in stool micro; examination of stool by modified 
trichrome stain (technique of Weber et al) or fluorescence, Giemsa stained smear of small intestinal biopsy 

Balantidium coli: may be asymptomatic, acute or chronic; alternating diarrhoea and constipation, 
dysentery, abdominal colic, tenesmus, nausea, vomiting; especially in malnourished children, deep penetrating 
ulceration of colon may be caused; fulminating dysentery, intestinal perforation, hemorrhage and shock are rare, 
sometimes fatal, complications; trophozoites in diarrheic and cysts in formed feces; anemia (erythrocyte count and 
hemoglobin may be decreased) 

Schistosoma: diarrhoea in 66% of cases of acute schistosomiasis (31% bloody); urogenital 
disturbances; ova in faeces (acid-ether concentration) or in rectal and colonic granulomata; 
counterimmunoelectrophoresis, indirect hemaglutination titre; eosinophilia in all cases of acute schistosomiasis 

Fasciola hepatica: vomiting, irregular fever, right upper quadrant pain, diarrhoea, jaundice, 
hepatomegaly; may be fatal; geographic history; dietary history; ova in feces; complement fixation test, precipitin, 
counterimmunoelectrophoresis, indirect haemagglutination (experimental); eosinophilia, increased ESR, erythrocyte 
count and hemoglobin may be decreased 

Fasciolopsis buski: abdominal pain, nausea, diarrhoea with greenish-yellow stools containing 
undigested food; may be edema of face, abdomen and legs, dry skin and extreme prostration; may be fatal; 
geographic history; dietary history; ova and sometimes adult trematodes in feces; anemia (erythrocyte count and 
haemoglobin decreased) and eosinophilia 

Diciocoelium hospes: constipation and diarrhoea, flatulence, vomiting, hepatomegaly, toxemia; 
presence of eggs in feces not necessarily proof of infection 

Paragonimus westermani: cough, hemoptysis, chest pain, epilepsy; geographic history; dietary 
history; ova in feces and sputum; complement fixation test; eosinophilia, anemia (erythrocyte count decreased) 

Nanophyetus salmincola: ingestion of salmonid fish; diarrhoea, abdominal discomfort, anorexia, 
vomiting, weight loss; blood eosinophilia; visualisation of ova in feces 

Opistorchis: mild disease usually asymptomatic; heavy infection manifested by fever, anorexia, 
epigastric pain, diarrhoea, weight loss, hepatosplenomegaly, jaundice; ingestion of raw or inadequately cooked 
freshwater fish 

Clonorchis sinensis: mild infection usually asymptomatic; fever, anorexia, epigastric pain, 
hepatomegaly, jaundice, obstruction of bile ducts, diarrhoea, cirrhosis, portal hypertension; eating raw or 
inadequately cooked freshwater fish; ova in stools, bile or urine; complement fixation test, indirect 
hemagglutination; eosinophilia, anemia (erythrocyte count and hemoglobin may be decreased) 

Heterophyes and Metagonimmr. mild disease usually asymptomatic; heavy infection characterised 
by diarrhoea with bloody mucoid stools, abdominal pain, neurasthenia, eosinophilia; ingestion of raw or 
inadequately cooked freshwater fish 

Taenia saginata: ingestion of beef; most frequently, disagreeable sensation in perianal area due to 
migratory proglottids; may be abdominal pain, hunger pains, diarrhoea, weight loss or gain, nervousness, insomnia, 
anorexia; incubation period 3-6 mo; at times, proglottids inside appendix or bladder causing appendicitis or 
cholecystitis; segments or motile proglottids may be passed; gravid segments, ova (by formalin-ether 
concentration), scolices in faeces; ova on cellophane swab of perianal area; serology by indirect fluorescent 
antibody titre; eosinophilia in 10% of cases 

Taenia solium: ingestion of pork; often asymptomatic, but may be manifested by vague abdominal 
pain, headache, indigestion, alternating diarrhoea and constipation, weight loss, insomnia, hunger pains, anorexia; 



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Infections of the Gastrointestinal Tract and Associated Structures 



in children and debilitated adults, may be nervous manifestations (nervousness, epilepsy, mental disorders); 
incubation period 3-6 mo; segments may be passed; segments, ova (by formalin-ether concentration), scolices in 
feces or from perianal area; serology by indirect fluorescent antibody titre; eosinophilia commoner in simple 
enteritis than in cysticercosis 

Echinococcus: cysts in liver, lung, brain, spleen, orbit, soft tissues; abdominal ultrasound or CT and 
CT or MRI of chest and brain 

Hymenolepis: mild infection usually asymptomatic, but severe toxemia, manifested by abdominal 
pain, diarrhoea, headache, nasal and oral pruritus, dizziness, epileptiform convulsions and other disturbances of 
CNS, may occur; ova in faeces 30 d after infection; anaemia, eosinophilia 

Dipylidium caninum: usually asymptomatic; sometimes, epigastric pain, indigestion, loss of 
appetite, diarrhoea, anal pruritus 

Diphyllobothrium: often asymptomatic; abdominal pain and discomfort, constipation, diarrhoea, 
vomiting, intestinal obstruction; ingestion of uncooked freshwater fish; segments may be passed; ova or proglottids 
in faeces or vomitus; scolex required for species identification; if attached high in small intestine, segments 
vomited; occasionally produces megaloblastic anaemia with low serum Bu 

Trichuris trichuria: light infections very common and usually asymptomatic; heavy infections 
usually manifested by headache and abdominal pain; rectal prolapse may occur, especially in children; 
haemorrhagic colitis rare complication; ingestion of soil, raw vegetables or fruit; ova in faeces (modified Ritchie 
formalin-ether concentration); larvae and adult worms in surgical specimens of appendix and caecum; 
counterimmunoelectrophoresis; eosinophilia in 25% of cases, anaemia (erythrocyte count and haemoglobin may be 
decreased) 

Capillaria philippinensis: recurrent abdominal pain and intermittent diarrhoea; severe protein- 
losing enteropathy with malabsorption of fats and sugars; weight loss, anorexia and vomiting common; case- 
fatality ratio high; several relapses over 2-3 y usual after recovery from initial attack; transmitted by eating 
undercooked and raw fish; microscopy of faeces for ova 

Stiongyloides stercoralis: mild to severe gastrointestinal symptoms (mucous diarrhoea, frequently 
alternating with constipation; abdominal crampy pain, heartburn) in 42%, 25% asymptomatic, 22% skin complaints 
(recurrent pruritic rash in 25% of all World War II prisoners in Burma-Thailand), 7% pruritus ani, 4% fever; 100% 
mortality in untreated hyperinfection in immunocompromised; rhabditiform and occasionally filariform larvae in 
fresh stools (Baerman stool concentration most sensitive), duodenal aspirate; larval antigen ELISA; indirect 
haemagglutination; neutrophilia followed by leucopenia, up to 40% eosinophilia (83% > 400 eosinophils/ pL; 
increased mortality with lower eosinophilia), anaemia (erythrocyte count and haemoglobin may be decreased); 
ELISA (sensitivity 95%) 

Hookworm: usually asymptomatic; severe disease characterised by diarrhoea with blood-stained stools, 
epigastric pain, mental apathy or retardation, weight loss, oedema, puffy face, changes in renal function, ulcer, 
retarded growth; may be cardiovascular complications and secondary malabsorption syndrome; ova and larvae in 
faeces by brine flotation; indirect haemagglutination; iron deficiency anaemia (erythrocyte count and haemoglobin 
decreased), hypoproteinemia, eosinophilia 

Necator americanus: initial dermatitis occurs less often; anaemia usually less severe 

Trichostiongylus: usually no signs or symptoms but heavy infections may result in change to 
mucosa, anaemia, dry skin and emaciation; ova or adult worms in stool 

Enterobius vermicularis: perianal pruritus, poor appetite, irritability and insomnia due to female 
worms migrating through anus at night, abdominal pain, dysentery, rectal prolapse; secondary migration of worms 
into unusual sites elicits granuloma formation in appendix, fallopian tubes and peritoneal cavity; distant metastatic 
spread in liver and lung and in urethra of homosexual men; ova in perianal scrapings or sticky tape preparation, 
occasionally in faeces; adult worms in faeces and occasionally in appendices at operation; eosinophlia common, 
sometimes neutrophilia 

Rscaris: eosinophilia common 

Rnisakis, Pseudoterranova: ingestion of raw, pickled or undercooked fish or squid, white sushi; 
America, Hawaii, Netherlands, Scandinavia; fever, intestinal colic, abdominal abscess, eosinophilic granulomata; 
sometimes intestinal obstruction or perforation and peritonitis, occasionally throat infection; larvae in faeces and 
pharynx; biopsy 



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Trichinella spiralis: nausea, vomiting, diarrhoea and abdominal discomfort followed by fever, 
myalgias and periorbital oedema; serology; demonstration of larvae in muscle biopsy; increase in eosinophils 

Toxoplasma gondii: serology 

Intestinal Myiasis: usually transient; may be manifested by nausea, vomiting, intestinal discomfort 
and diarrhoea; arises through ingestion of food contaminated with larvae 

Human cytomegalovirus: barium study 
Treatment: 

Cryptosporidium: none unless > 2 w; discontinuation of immunosuppressive drugs; oral rehydration 
in acute phase; antidiarrhoeal drugs; paromomycin 7.5 mg/kg to 500 mg orally 6 hourly, nitazoxanide (1-3 y: 
100 mg, 4-11 y: 200 mg, > 11 y: 500 mg) orally 12 hourly for 3 d; immune bovine dialyzable leucocyte extract 

Encephalitozoon intestinalis: albendazole 400 mg (< 10 kg: 200 mg) orally 12 hourly 
for 21 d (not in pregnant or < 6 mo) 

Enterocytozoon bieneusi: fumagillin 60 mg orally daily for 14 d 

Cyclospora cayetanensis: cotrimoxazole 4/20 mg/kg to 160/800 mg orally 12 hourly for 7 d in 
immunocompetent and 10-14 d in immunocompromised 

Isospora belli: cotrimoxazole 4/20 mg/kg to 160/800 mg orally 6 hourly for 10 d, followed by 
160/800 mg orally 3 times a week to prevent relapse in HIV infection 

Toxoplasma gondii: pyrimethamine 50-100 mg (child: 2 mg/kg to 25 mg) orally first dose then 25- 
50 mg daily (infants: 1 mg/kg every second or third day) for 3-6 w + sulphadiazine 1-1.5 g (child: 50 mg/kg) 
orally or i.v. 6 hourly for 3-4 w (clindamycin 600 mg orally or i.v. if hypersensitive) + folinic acid 3-6 mg orally 
daily; spiramycin 2-4 g (child: 50-100 mg/kg) orally daily for 4 w; cotrimoxazole 160/800 mg (child: 1.5/7.5 
mg/kg) twice daily for 4 w 

Maintenance Therapy in HIV/AIDS: pyrimethamine 25-50 mg orally daily + 
sulphadiazine 500 mg orally 6 hourly or 1 g orally 12 hourly (clindamycin 600 mg orally 8 hourly if 
hypersensitive) 

Dientamoeba fragilis: doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 3-7 d (not < 8 y), 
metronidazole 10 mg/kg to 400 mg orally 8 hourly for 3-7 d 

Giardia lamblia: tinidazole 50 mg/kg to 2 g orally as single dose, metronidazole 30 mg/kg to 
2 g orally daily for 3 d 

Treatment Failnre: metronidazole 10 mg/kg to 400 mg orally 8 hourly for 7 d 

Blastocystis hominis: probably none required; metronidazole 10 mg/kg to 400 mg orally 8 hourly 
for 7 d, metronidazole benzoate suspension 30 mg/kg/d to maximum 1.2 g/d orally in 3 divided doses for 7 d, 
furazolidone 150 mg orally (not for infants < 1 mo; 1 mo - 1 y: 6.25-12.5 mg; 1-4 y: 25 mg; > 5 y: 50 mg) 6 
hourly for several months 

Balantidium coli: tetracycline 500 mg orally 6 hourly for 10 d, metronidazole 800 mg (child: 
10-15 mg/kg) orally for 5 d, paromomycin 1 g (child: 11 mg/kg) every 15 minutes for 4 doses 

Schistosoma: praziquantel, niridazole or sodium stibogluconate + dexamethasone 

Fasciolopsis buski: hexylresorcinol 

Nanopbyetus salmincola: niclosamide 2 g orally on alternate days for 3 doses, bithionol 50 mg/kg 
as a single dose on alternate days for 2 doses 

Other Flnkes: praziquantel 25 mg/kg orally 8 hourly for 1 d, tetrachloroethylene 0.1 mL/kg to 5 mL 
orally 

Taenia: praziquantel 10 mg/kg orally as a single dose, niclosamide 2 g (child 11-34 kg: 1 g; > 34 kg: 
1.5 g) in single dose chewed thoroughly then purgative 3-4 h later, paromomycin 1 g (child: 11 mg/kg) every 15 
minutes for 4 doses 

Hymenolepis: praziquantel 25 mg/kg orally as a single dose, niclosamide 2 g dose chewed 
thoroughly daily for 7 d (child: 11-34 kg: 1 g as a single dose then 500 mg daily for 6 days; > 34 kg: 1.5 g as a 
single dose then 500 mg daily for 6 d), paromomycin 45 mg/kg orally daily for 7 d 

Dipbyllobotbrium: niclosamide 2 g chewed thoroughly (child 11-34 kg: 1 g; > 34 kg: 1.5 g) given 
once as a single dose, praziquantel 10-20 mg/kg orally as a single dose, paromomycin 1 g (child: 11 mg/kg) 
every 15 minutes for 4 doses 

Other Tapeworms: niclosamide, dichlorophen, mepacrine 



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Trichuris trichuria: mebendazole 100 mg (< 10 kg: 50 mg) twice daily orally for 3 d (not in first 
trimester or < 6 mo), albendazole 400 mg (< 10 kg: 200 mg) orally daily for 3 d (not in pregnancy, lactation or 

< 6 mo); precede with loperamide (initial dose 4 mg, then 2 mg after each unformed stool to maximum daily dose 
16 mg) if diarrhoea 

Strongyloides stercoralis: ivermectin 200 jag/kg orally with fatty food (not children < 5 y) on 
day 1 and repeat after 7-14 d (days 1, 2, 15 and 16 in immunocompromised), albendazole 400 mg (< 10 kg: 
200 mg) orally with fatty food once daily for 3 d and repeat after 7-14 d (not in pregnancy, lactation or < 6 mo; 
repeat after 1 w in complicated or disseminated infections), thiabendazole 25 mg/kg to 1.5 g orally 12 hourly for 
3 d (not in first trimester or < 6 mo), mebendazole 

Hookworms, Rscaris: pyrantel embonate 20 mg/kg to 750 mg orally as a single dose (repeat after 
1 w if heavy infection), mebendazole 100 mg (< 10 kg: 50 mg) orally twice daily for 3 d (not in first trimester or 

< 6 mo), albendazole 400 mg (< 10 kg: 200 mg) orally as single dose (not in pregnancy, lactation or < 6 mo) 

Enterobius vermicularis: pyrantel embonate 10 mg/kg to 750 mg orally single dose, mebendazole 
100 mg (child < 10 kg: 50 mg) orally single dose (not in first trimester or < 10 kg), albendazole 400 mg (child 

< 10 kg: 200 mg) orally single dose (not in pregnancy, lactation or < 6 mo) 

Rnisakis, Pseudoterranova: thiabendazole 25 mg/kg to maximum 3 g orally twice daily for 3 d; 
surgery usually required 

Ttichinella spiralis: mebendazole 

Other Helminths: thiabendazole 
Prophylaxis: 

Communities with Heavy Intestinal Helminth Exposnre: albendazole (< 10 kg: 200 mg; 
> 10 kg: 400 mg) orally single dose every 4-6 mo to children 6 mo-12 y 

Toxoplasma gondii in HIV/AIDS CD4 connt < 200/ uL: cotrimoxazole 80/400 or 
160/800 mg orally daily or 160/800 mg orally 3 times weekly 
Enterocolitis 

Agents: Campylobacter (91% Campylobacter jejuni, 9% Campylobacter fetus subsp fetus; Campylobacter coli in 
some geographical areas; also Campylobacter concisus, Campylobacter hyointestinalis, Campylobacter lari, 
Campylobacter upsaliensis, Helicobacter cinaedi, Helicobacter fennelliae; 5% of cases of diarrhoea, 8% of infectious 
diarrhoea, 43% of infectious diarrhoea in adults; * 13,000 notified cases/y in Australia (« 37% in Victoria); 
incidence 20/100,000 in USA (estimated 2.5 M total cases, 80% foodborne, 5% of foodborne related deaths); 
sporadic disease from environment (up to 50%), raw and undercooked poultry, beef and gravy, salad vegetables, 
bottled water; outbreaks (0.9% of foodborne related outbreaks, 0.6% of cases, 3% of deaths) from unpasteurised 
milk (present in 40% of dairy cattle) or juice or soft cheeses and contaminated water), Staphylococcus aureus 
(usually following tetracycline treatment), Bacteroides, see also Bacillary Dysentery, Infantile 
Diarrhoea, Travellers' Diarrhoea, Bacterial Gastroenteritis, Proctitis, Enteritis, 
Necrotising Enterocolitis; may also be due to spirochaetes and several fungi {Candida, Cryptococcus 
neoformans, Paracoccidioides brasiliensis, Histoplasma capsulatum, Blastomyces dermatitidis, Sporothrix schenckii, 
Aspergillus, Coccidioides immitis, Mucoraceae) 
Diagnosis: 

Campylobacter, cases present with clinical, sigmoidoscopic, radiographic and histologic features 
similar to ulcerative colitis — often bloody diarrhoea (6% of bloody diarrhoea; watery diarrhoea in 63%, 
macroscopic mucus in 55-87%, macroscopic blood in 7-30%, microscopic blood in 35%) and severe abdominal pain 
and cramps; fever in 28-90%; incubation period 2-5 d; duration of illness 2-10 d; polymorphonuclears in 96% (1- 
10/hpf in 56%), pH acidic in 68%; Gram stain and culture (Skirrow's medium or equivalent directly and after 
enrichment in medium of Martin et al microaerophilically at 42°C, mannitol salt agar aerobically at 35°C, blood 
agar with vancomycin and kanamycin anaerobically) of faeces 
Treatment: 

Campylobacter, erythromycin 10 mg/kg to 500 mg or erythromycin ethyl succinate 20 mg/kg to 
800 mg orally 6 hourly for 5-7 d; norfloxacin 10 mg/kg to 400 mg orally 12 hourly for 5 d (13% require 
treatment, though treatment in all cases shortens symptomatic period, carriage and shedding; Guillain-Barre 
syndrome possible sequela) 

Staphylococcus aureus: i.v. cloxacillin + oral neomycin 

Bacteroides: metronidazole 



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Necrotising Enterocolitis (Enteritis Necroticans, Pig-Bel): common in Papua New Guinea and China 
Agent: Clostridium perfringens C, Clostridium butyricum 

Diagnosis: severe abdominal pain developing up to 4 d after a protein meal, often associated with vomiting, 
abdominal distension and either mild diarrhoea with blood or constipation; culture of surgical specimens and 
typing of isolate 

Treatment: surgical resection of affected length of intestine; if surgery impossible, metronidazole 500 mg (child: 
7.5 mg/kg) i.v. 8 hourly or 1 g (child: 500 mg) rectally 8 hourly 

Neonatal Necrotising Enterocolitis: 1-7.5% of neonates; significantly higher rates in infants given 
amoxycillin-clavulanate 

Agents: Escherichia coli, Klebsiella pneumoniae 

Diagnosis: clinical; X-ray (pneumotosis intestinalis); platelet count < 100,000/|.iL 
Treatment: withdrawal of enteric feeding; oral and parenteral aminoglycoside 
Prophylaxis: sodium deoxycholate 

Pseudomembranous Colitis and Antibiotic-Associated Diarrhoea: 10% of infective diarrhoea in adults 
Agents: Clostridium difficile (necrotising enterocolitis, 90% of pseudomembranous colitis, 30% of antibiotic- 
associated diarrhoea), Klebsiella oxytoca (hemorrhagic colitis), Staphylococcus aureus (antibiotic-associated 
diarrhoea) 
Diagnosis: 

Clostridium difficile: abdominal pain, fever, nausea, vomiting, diarrhoea; feces may be blood- 
stained; history of antibiotic treatment (especially clindamycin and third generation cephalosporins) or 
antineoplastic chemotherapy; microtitre cytotoxicity toxin assay of faeces (5 d old human foreskin fibroblast or 
WI-38 cells; read after 4 and 24 h; sensitivity 97-100%, specificity 95%); culture of feces (sensitivity 89%, 
specificity 74%); counterimmunoelectrophoresis of faeces (antiserum to toxin absorbed with cells; sensitivity 41- 
100%, specificity 78-100%); ELISA (Premier Toxin A and B most sensitive commercial kit); latex agglutination 
(sensitivity 88-91%, specificity 91-99%); flexible sigmoidoscopy 

Staphylococcus aureus: profuse watery diarrhoea with dehydration; feces culture 
Treatment (Clostridium difficile): cessation of antibiotic treatment; metronidazole 10 mg/kg to 400 mg 
orally 8 hourly for 7-10 d 

Metronidazole Intolerant: bacitracin 20,000-25,000 U orally 6 hourly for 7-10 d, fusidic 
acid 

Unresponsive, Relapsing or Severe: vancomycin 3 mg/kg to 125 mg orally 6 hourly 
for 7-10 d ± Saccharomyces boulardii 

Severely 111 with Toxic Megacolon: metronidazole 12.5 mg/kg to 500 mg i.v. 12 hourly 
+ vancomycin 12.5 mg/kg to 500 mg orally or via nasogastric tube 6 hourly for 10 d; resection of the inflamed 
colon may be required 

Prophylaxis: 100 g Saccharomyces boulardii or other probiotic drink twice daily during course of antibiotics 
and for 1 w after 
Hemorrhagic Colitis 

Agent: shigatoxin-producing Escherichia coli (3% of bloody diarrhoea; incidence 3/100,000 in USA (110,000 
estimated total cases, 85% foodborne, 1% of foodborne related deaths; 3% of foodborne disease outbreaks, with 4% 
of cases and 28% of deaths; undercooked meat (ground beef) or poultry, unpasteurised milk or juice, unpasteurised 
soft cheeses, unchlorinated water supplies, animal contact at petting zoo, farm animal hides; most sporadic cases 
from environment); mainly serotype 0157:H7; cases due to Oil 1:H8 in Australia; also 0173:H55 and 0166); may 
lead to development of hemolytic uremic syndrome or thrombotic thrombocytopenic purpura, particularly in 
children < 15 y and adults > 65 y (hypochlorhydria and coincidental antibiotics significant risk factors) 
Diagnosis: severe, often bloody, diarrhoea, abdominal pain and vomiting following ingestion of undercooked 
beef, unpasteurised milk or juice, raw fruits and vegetables, salami, salad dressing, contaminated water; 
incubation period 1-8 d; duration of illness 5-10 d; fever in « 1/3 cases, more common in < 4 y; culture of feces 
on sorbitol MacConkey agar or Rainbow Agar VTEC + serotyping of isolate; toxin assay (false positives) 
Differential Diagnosis: inflammatory bowel disease, polyps, Meckel's diverticulum, intussusception, 
coagulopathy, infectious enteritis 

Treatment: supportive; monitor renal function, hemoglobin and platelets closely; antibiotics may be harmful 
(though recent research suggests azithromycin may be beneficial) 



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Typhlitis: necrotising colitis in neutropenics, especially children with acute leukemia 
Agents: Escherichia coli, Enterobacter cancerogenus, Morganella morganii, Pseudomonas aeruginosa, Clostridium, 
other Gram negative bacilli 

Diagnosis: temperature > 38.5°C in all, diarrhoea in 92% (bloody in 54%), nausea in 75%, vomiting in 67%, 
decreased bowel sounds in 62%, rebound/guarding in 58%, abdominal distension in 54%; computed tomography 
and ultrasonography of pelvis show pathognomonic bowel thickening; may progress to perforation, peritonitis, 
fistulous communications and sepsis; potentially lethal 
Treatment: surgical excision if clinical deterioration; appropriate antibiotics 
Cytomegaloviral Colitis 
Agent: human cytomegalovirus 
Diagnosis: barium enema; IgG seroconversion; viral culture 

Treatment: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally daily, ganciclovir 5 mg/kg 
i.v. twice a day for 2 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 times a week during continued 
immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly or 180 mg/kg/d by continuous i.v. infusion for 2 w then 
90-120 mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and 
creatinine clearance > 55 mL/min) then as above every 2 w 

Gastrointestinal Anthrax (Mycosis Intestinalis; Splenic Fever in Animals): form of anthrax 
acquired by man through consumption of contaminated raw or undercooked meat or by dissemination from 
pulmonary or cutaneous forms; no cases in USA; considered rare but probably greatly underreported in rural 
endemic areas (Thailand, India, Iran, Gambia, Uganda); case-fatality rate 25-60% 
Agent: Bacillus anthracis 

Diagnosis: oropharyngeal anthrax: fever and toxemia, inflammatory lesions in oral cavity or oropharynx, 
enlargement of cervical lymph nodes, edema of soft tissue of cervical area; lower areas: abdominal distress 
characterised by nausea, vomiting, anorexia, fever and malaise followed by abdominal pain, hematemesis, fever 
and, sometimes, bloody diarrhoea; incubation period 2 d to weeks; duration of illness weeks; Gram stain and 
culture of stools; blood cultures; ELISA, Western blot, toxin detection, chromatographic assay, fluorescent antibody 
test 

Treatment: procaine penicillin 600 000 U 12 hourly l.m. (child: 25 000-30 000 U/kg daily in 2 divided doses) 
for 5-7 d, ciprofloxacin, tetracycline 500 mg orally 4 hourly for 5 days, erythromycin 500 mg orally 6 hourly 
(child: 30 mg/kg/d in 4 divided doses) for 5 d 
Proctitis 

Agents: Neisseria gonorrhoeae (anorectal gonococcal disease of the rectal columnar mucosa arising either by 
direct extension from a urogenital process (in female) or as the result of primary infection; frequently inapparent 
but may give rise to severe proctitis), Simplexvirus, Chlamydia trachomatis (LGV), Treponema pallidum, single 
cases due to Neisseria cinerea (in 8 year old boy) and Plesiomonas shigelloides (with fatal septicemia); also non- 
specific proctitis (analogous to ulcerative colitis) 

Diagnosis: Gram stain and bacterial and viral culture of pus; immunofluorescence; biopsy; CT scan 
Treatment: 

Neisseria gonorrhoeae: ceftriaxone 125 mg i.m. + doxycycline 100 mg orally twice a day for 7 d 

Treponema pallidum: penicillin + probenecid 

Chlamydia trachomatis: tetracycline, doxycycline, erythromycin 

Simplexvirus: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly 
for 7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Freqnent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Non-specific: prednisolone suppositories 
Proctocolitis 

Agents: Campylobacter jejuni, Campylobacter hyointestinalis, Helicobacter cinaedi and Helicobacter fennelliae 
(homosexual men), Shigella, Entamoeba histolytica, Chlamydia trachomatis (LGV; rare), human cytomegalovirus in 
AIDS 

Diagnosis: wet mount, Gram stain and culture of pus 
Treatment: 

Campylobacter, Helicobacter, erythromycin 



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Human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally 
daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 
times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 
mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and 
creatinine clearance > 55 mL/min) then as above every 2 w 

Shigella: ceftriaxone 125 mg i.m. for 7 d 

Chlamydia trachomatis: tetracycline, doxycycline, erythromycin 

Entamoeba histolytica: metronidazole 
Acute Abdomen Syndromes 

Agents: infectious causes include (in order of frequency) acute appendicitis, diverticulitis of colon, acute 
tonsillitis (in young children), pneumonia, herpes zoster (T8-12), Bornholm disease, intestinal worms, acute 
hemolytic crisis in malaria 

Diagnosis: examination of patient; X-rays of chest and abdomen; blood, urine and feces examination 
Treatment: dependent on cause 

Abdominal Cramps are very severe in staphylococcal food poisoning, severe in 98% of cases of Salmonella 
gastroenteritis, 95% of Shigella infections and 84% of Campylobacter enteritis, and moderate in 67% of cases of 
cryptosporidiosis. Abdominal cramps also occur in 92% of Vibrio parahaemolyticus and 87% of enterotoxigenic 
Escherichia coli infections, in 82% of cases of traveller's diarrhoea, 79-86% of Norwalk virus gastroenteritis, 74% 
of Clostridium perfringens food poisoning, 63% of Aeromonas hydrophila infections, 59% of cholera cases, and 25% 
of trichinosis, as well as in other cases of acute infectious nonbacterial gastroenteritis, in food poisoning due to 
Salmonella enteric subsp enteric serovar Arizona, Bacillus cereus, Enterobacteriaceae, Pseudomonas aeruginosa, 
Enterococcus faecalis, Enterococcus faecium and Yersinia enterocolitica, in botulism, diphyllobothriasis, giardiasis, 
psittacosis, tick paralysis, Vibrio cholerae non-01 infections and chemical poisoning. 
Abdominal Discomfort of lesser degree is also seen in 22% of hospitalised measles cases, intermittently in 
rabies, and in echinococcosis and wound botulism. 

Abdominal Distension is a feature of 66% of cases of typhoid fever, 14% of peritonitis, 6% of amoebic liver 
abscess, and also occurs in diphyllobothriasis, giardiasis and necrotising enterocolitis. 
Abdominal Guarding is prominent in 23% of cases of amoebic liver abscess and 18% of peritonitis. 
Abdominal Mass is found in 17% of cases of pyogenic liver abscess, in 10% of amoebic liver abscess, and in 
echinococcosis (non-tender). 

Abdominal Rigidity is associated with chromobacteriosis and spider bite (Latrodectus mactans et al) 
Abdominal Symptoms also occur in legionellosis. 
Colic is particularly associated with ascariasis and (in severe form) shigellosis. 
Crohn's Disease: found more often in children than in adults 
Agent: ? Mycobacterium avium subsp paratuberculosis 

Diagnosis: fever, abdominal pain, diarrhoea, weight loss, often resembling acute appendicitis; failure to isolate 
causative organism; macroscopic appearance of gut (involvement of terminal ileum, often with extensions to 
proximal colon; crypt abscesses and microgranulomas) when abdomen opened for suspected appendicitis 
Appendicitis 

Agents: coliforms, mixed anaerobes, Streptococcus pyogenes, Streptococcus viridans, staphylococci, Arcobacter 
butzleri, Campylobacter jejuni, Aggregatibacter segnis, Streptococcus milled, Enterobius vermicularis, Entamoeba 
histolytica, Taenia saginata, Angiostrongylus costaricensis, Ascaris lumbricoides, Trichuris trichuria, Schistosoma 
mansoni, Strongyloides stercoralis, Cryptosporidium, Balantidium coli (exceedingly rare) 
Diagnosis: usually based on clinical symptoms + neutrophilia (96% of cases > 10,000 leucocytes/ pL or 
> 75% neutrophils) and absence of other infection such as UTI; barium enema, laparoscopy, sonography; 
Enterobius vermicularis, a rare cause, produces eosinophilia as well as neutrophilia; cultures of swabs taken at 
surgery may be performed to confirm diagnosis and to provide the basis for therapy if peritonitis should develop 

Amoebic Appendicitis: diarrhoea with blood-stained stools 

Rngiostrongylus costaricensis: intraabdominal mass, usually localised in right iliac fossa; in most 
cases, lesions localised in appendix but, at times, they may reach terminal portion of ileum, cecum and colon; 
abdominal pain, anorexia, vomiting and fever that may persist for 2 mo; abdomen distended; marked leucocytosis 
with eosinophilia of 11-81% may be present 
Treatment: surgery after 1 d ceftizoxime 



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Infections of the Gastrointestinal Tract and Associated Structures 



Diverticulitis 

Agents: anaerobes {Bifidobacterium, Eubacterium), enterics 

Diagnosis: radiology; culture not necessary 

Treatment: dietary restriction; fluids (oral or i.v.); surgery if necessary; if perforation, treat as for 

Peritonitis; amoxycillin / clavulanate 875/125 mg orally 12 hourly for 5-10 d; metronidazole 400 mg orally 12 

hourly + cephalexin 500 mg orally 6 hourly for 5-10 d 

Immediate Penicillin Hypersensitive: metronidazole 400 mg orally 12 hourly + cotrimoxazole 
4/20 mg/kg to 160/800 mg orally 12 hourly for 5-10 d 
Prophylaxis: psyllium hydrophilic mucilloid 
Biliary Cirrhosis 

Agents: Clonorchis sinensis, Fasciola gigantica, Fascioia hepatica, Opisthorchis viverrini (Thailand and Laos), 
Opisthorchis feiineus (Eastern Europe) 

Diagnosis: geographic history; dietary history; ova in stools, biliary drainage, duodenal drainage; indirect 
hemagglutination, counterimmunoelectrophoresis, complement fixation test; anti-mitochondrial antibody test +++ 

Fasciola: fever, pain in epigastrium or right hypochondrium, anorexia, nausea, vomiting, sometimes 
alternating diarrhoea and constipation, hepatomegaly, biliary colic; occasionally halzoun; often eosinophilia; may be 
asymptomatic 

Clonorchis sinensis, Opisthorchis: fever, abdominal pain, jaundice 
Treatment: bithionol 30-50 mg/kg orally on alternate days for 20-30 d (only treatment for Fasciola), 
praziquantel 25 mg/kg orally 8 hourly for 5-8 d, metronidazole 1.5 g orally in divided doses daily 
Cholecystitis 

Agents: 58% Escherichia coii, 34% Enterococcus faecalis, 23% Enterobacter, 19% Clostridium perfringens 
(emphysematous in older diabetic males), 14% Klebsiella oxytoca, 11% Klebsiella pneumoniae, 9% a-hemolytic 
streptococci; other streptococci (including Streptococcus millen), staphylococci, other coliforms, anaerobes; rarely, 
Pseudomonas, Campylobacter, Achromobacter xylosoxidans, Vibrio metschnikovii, Plesiomonas shigelloides, 
Haemophilus aprophilus, Desulphovibrio desulfuricans, Listeria monocytogenes, Ascaris lumbricoides, Clonorchis 
sinensis, Opisthorchis feiineus, Opisthorchis viverrini, Cryptosporidium, Taenia saginata; human cytomegalovirus 
and Candida in AIDS 

Diagnosis: clinical; radiographic; culture of bile and other surgical specimens 
Treatment: cholecystectomy + 

Pseudomonas: gentamicin 

Campylobacter, erythromycin 

Other Bacteria: amoxy(ampi)cillin 25 mg/kg to 1 g i.v. 6 hourly + gentamicin 4-6 mg/kg i.v. as 
single daily dose (penicillin hypersensitive or gentamicin contraindicated: ceftriaxone 25 mg/kg to 1 g i.v. once 
daily or cefotaxime 25 mg/kg to 1 g i.v. 8 hourly) + metronidazole 400 mg orally 2 hourly if biliary obstruction 
till afebrile; follow with amoxycillin-clavulanate 500 mg orally 8 hourly if required till afebrile 48 h and normal 
neutrophil count 

Clonorchis sinensis, Opisthorchis: praziquantel 25 mg/kg orally 8 hourly for 1 d, chloroquine 
phosphate 600 mg base orally daily for 6 w 

Other Helminths: praziquantel, thiabendazole 
Ascending Cholangitis 

Agents: Escherichia coli, Enterobacter, Klebsiella, Pseudomonas, anaerobes 

Diagnosis: right upper quadrant pain, fluctuating jaundice, swinging pyrexia, rigors, leucocytosis, raised serum 
albumin and alkaline phosphatase, bacteremia 

Treatment: relief of biliary obstruction; amoxy/ampicillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin 
4-6 mg/kg (child < 10 y: 7.5 mg/kg; > 10 y: 6 mg/kg) i.v. daily for up to 3 d (adjust dose for renal function) 
+ metronidazole 12.5 mg/kg to 500 mg i.v. if previous biliary tract surgery or known biliary obstruction, then 
(when afebrile) amoxycillin + clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 hourly for total of 7 d 

Penicillin Hypersensitive or Gentamicin Contraindicated: ceftriaxone 25 mg/kg to 1 g i.v. 
daily, cefotaxime 25 mg/kg to 1 g i.v. 8 hourly 

Lack of Response to 3 d i.v. Therapy: piperacillin + tazobactam 100 + 12.5 mg/kg to 4 + 
0.5 g i.v. 8 hourly, ticarcillin + clavulanate 50 + 1.7 mg/kg to 3 + 0.1 g i.v. 6 hourly 
Pancreatitis 



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Infections of the Gastrointestinal Tract and Associated Structures 



Agents: mumps virus, coxsackievirus B (may result in diabetes), coliforms (usually complicating chronic non- 
infectious cases), human cytomegalovirus (59% of cases in AIDS), adenovirus, Cryptococcus neoformans (18% of 
cases in AIDS), Mycobacterium avium-intraceilulare (14% of cases in AIDS), Toxoplasma gondii (7% of cases in 
AIDS), Mycobacterium tuberculosis (uncommon), Maris lumbricoides, also gallstones, alcohol, medicines (2-5%) 
Diagnosis: serology; viral culture of saliva; histology and culture of biopsy; check for abscess formation; serum 
aldolase inconsistently increased, serum amylase increased, serum leucine aminopeptidase inconsistently increased, 
serum lipase increased; endoscopic retrograde cholangiopancreatography 
Treatment: 

Human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally 
daily, ganciclovir 5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 
times a week during continued immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 
mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and 
creatinine clearance > 55 mL/min) then as above every 2 w 

Other Viral: non-specific 

Coliforms: amoxycillin-clavulanate 

Cryptococcus neoformans. 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 
More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 
25 mg/kg i.v. or orally 6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg 
orally initially then 400 mg daily for 8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or 
itraconazole 200 mg orally daily 

Mycobacterium avium-intracellulare: ethambutol 15 mg/kg orally daily (not < 6 y) + 
clarithromycin 12.5 mg/kg to 500 mg orally 12 hourly or azithromycin 10 mg/kg to 500 mg orally daily + 
rifampicin 10 mg/kg to 600 mg orally daily or rifabutin 5 mg/kg to 300 mg orally daily 

Toxoplasma gondii: pyrimethamine 50-100 mg (child: 2 mg/kg to 25 mg) orally first dose then 25- 
50 mg daily (infants: 1 mg/kg every second or third day) for 3-6 w + sulphadiazine 1-1.5 g (child: 50 mg/kg) 
orally or i.v. 6 hourly for 3-4 w (clindamycin 600 mg orally or i.v. if hypersensitive) + folinic acid 3-6 mg orally 
daily; spiramycin 2-4 g (child: 50-100 mg/kg) orally daily for 4 w; cotrimoxazole 160/800 mg (child: 1.5/7.5 
mg/kg) twice daily for 4 w 

Maintenance Therapy in HIV/AIDS: pyrimethamine 25-50 mg orally daily + 
suphadiazine 500 mg orally 6 hourly or 1 g orally 12 hourly (clindamycin 600 mg orally 8 hourly if 
hypersensitive) 

Severe Necrotising: meropenem 500 mg i.v. 8 hourly for 7 d, imipenem 500 mg i.v. 6 hourly for 7 d, 
piperacillin + tazobactam 4 + 0.5 g i.v. 8 hourly for 7 d 

Rscaris lumbricoides: mebendazole, albendazole 
Prophylaxis: 

Mycobacterium avium Complex in HIV/ AIDS (CD4 cell connt < 50/ uL): azithromycin 
1.2 g orally weekly, clarithromycin 500 mg orally 12 hourly, rifabutin 300 mg orally daily 

Toxoplasma gondii in. HIV/AIDS (CD4 Connt < 200/uL): cotrimoxazole 80/400 or 160/800 
mg orally daily or 160/800 mg orally 3 times weekly 

Pancreatic Abscess: 3-4% of acute pancreatitis cases; mortality * 100% untreated, « 40% treated 
Agents: Staphylococcus aureus, Streptococcus pneumoniae, Salmonella typhi, coliforms, Haemophilus influenzae, 
Eikenella corrodens, Ochrobactrum anthropi, Plesiomonas shigelloides (1 case postoperative), Candida albicans (very 
rare) 

Diagnosis: ultrasound; Gram stain, Grocott-Gomori methenamine-silver stain and culture of aspirate 
Treatment: 

Bacteria: surgery + amoxycillin-clavulanate 

Candida albicans: drainage + amphotericin B 



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Chapter 3 

Infections of the Urinary Tract 

Urinary Tract Infection 

Urinary tract infection constitutes 0.9% of ambulatory care visits in the USA (= 6M/y) and is the most 
common bacterial infection. 

The prevalence of UTI varies with age and sex. In the < 1 y group, prevalence in both sexes is « 1% 
and is related to congenital urologic abnormalities. At 1 - 5 y, the prevalence increases in females but remains 
< 5%, while that in males is < 1%. In both sexes, infections are related to congenital urologic abnormalities, 
vesiculoureteral reflux and (in males) an intact foreskin. Prevalence rates remain the same in the 6 - 15 y age 
group, with nearly all infections related to vesiculoureteral reflux. 

In the 16-35 y age group, prevalence in females increases to « 20%; these infections are usually 
associated with sexual intercourse and involve organisms colonising the colon and perineum (other factors 
associated with increased frequency are first degree female relative with UTI, nonsecretor status, prior UTI, 
spermicide use and diaphragm use). In this age group, 14% of women with symptoms of urinary tract infection 
have a sexually transmitted disease, while only half are urine culture positive. Therefore, screening for sexually 
transmitted disease should also be performed. In men, prevalence remains at < 1% and is related to complicating 
factors. For both sexes, risk factors for complicated UTI include current or recent hospitalisation or residence in a 
long-term care facility, medullary sponge kidney, nephrocalcinosis, diabetes mellitus, exposure to nosocomial 
pathogens, functional (neurogenic bladder, vesicourethral reflux, foreign bodies) or anatomic abnormalities of the 
urinary tract (bladder outlet obstruction due to calculi, congenital anomaly, benign prostatic hypertrophy, stricture, 
tumour; nonobstructing calculi, bladder diverticula; obstruction in the upper urinary tract due to calculi, 
pericaliceal junction obstruction, renal cyst, ureteric stricture, tumour; presence of foreign body such as ureteral 
stent, urethral or urinary catheter, nephrostomy tube; surgically created ileal conduit), immunosuppression, 
pregnancy, recent antibiotic use, recent urinary tract instrumentation, renal transplantation, renal failure, 
symptoms for > 7 d, use of immunosuppressive drugs. 

At 36 - 65 y, prevalence increases to 35% for females and 20% for males, the increase being due 
mainly to gynecologic surgery and bladder prolapse in both sexes, menopause in females, and prostatic 
hypertrophy in males. 

Prevalence in the > 65 y group is 40% for females and 35% for males. These infections are almost 
invariably complicated and relate to gynecologic surgery, bladder prolapse, prostatic hypertrophy, incontinence, 
catheterisation, debility, estrogen lack. 

The dangers of evaluation and treatment are related mainly to age and renal status, low in the young 
and high in the elderly. Prognosis in boys is relatively bad without therapy because of the high incidence of 
abnormalities, especially obstructive uropathy. Prognosis in girls without therapy is related mainly to reflux, 
infection in the presence of reflux often damaging kidneys, causing clubbing and scarring, and therapy protecting 
the kidneys. Long-term antimicrobial prophylaxis is probably justified in young girls with nonrefluxing ureters who 
have had 3 or 4 recurrences of urinary tract infection. Surgical correction of ureterovesical reflux in girls with 
recurrent urinary tract infections is recommended only if good control of the infection cannot be obtained with 
antimicrobial therapy. In young and middle-aged males, prognosis without therapy is relatively bad because of the 
presence of anomalies. At least 25% of women with bacteriuria in early pregnancy develop acute pyelonephritis 
later in pregnancy and this group should be screened and bacteriuria eliminated. In other adult females, prognosis 
without therapy is good. Women with recurrent infections, repeated infections with the same organism which 
resists eradication, clinical evidence of pyelonephritis, infection by unusual organisms, poor response to treatment, 
or infections associated with persistent hematuria should be evaluated radiographically. In children and men, it is 
mandatory to look for surgically correctable abnormalities such as obstructive uropathy and stones. 

Causes of unresolved bacteriuria include bacterial resistance to the drug selected for treatment, 
development of resistance by initially susceptible bacteria, bacteriuria caused by two different bacterial species 
with mutually exclusive susceptibilities, rapid reinfection with a new resistant species during therapy for the 



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Infections of the Urinary Tract 



original susceptible organism, azotemia, papillary necrosis from analgesic abuse, giant staghorn calculi in which 
the 'critical mass' of susceptible bacteria is too great for antimicrobial inhibition. 

Causes of bacterial persistence include infected renal calculi, chronic bacterial prostatitis, unilateral 
infected atrophic pyelonephritis, infected pericalyceal diverticula, infected nonrefluxing ureteral stumps following 
nephrectomy for pyelonephritis, medullary sponge kidneys, infected urachal cysts, infected necrotic papillae from 
papillary necrosis. 

Acute Cystitis: infection of the bladder accompanied by clinical symptoms; 1% of new episodes of illness in 
UK; 10 - > 50% of cases represent occult pyelonephritis; may be emphysematous in diabetics 
Agents: Escherichia coli (89% of infections in pregnant women, 72% of all cases, 66% of recurrent infections, 
58% of outpatient female, 48% of hospitalised female, 42% of outpatient male, 29% of hospitalised male patients), 
Staphylococcus saprophytics (21% of outpatient female, 0.9% of hospitalised female, 0.7% of outpatient male, 0.4% 
of hospitalised male patients), Klebsiella/ Enterobacter (14% outpatient male, 12% hospitalised male and female, 8% 
outpatient female cases), Proteus (13% hospitalised male, 10% hospitalised female and outpatient male, 10% of 
recurrent infections, 3% of outpatient female cases), enterococci (12% hospitalised male, 9% outpatient male, 7% 
hospitalised female, 2% outpatient female cases), Staphylococcus epidermidis (6% outpatient male, 5% hospitalised 
male, 3% hospitalised female, 2% outpatient female cases), Pseudomonas (5% outpatient male, 4% hospitalised 
male, 0.9% hospitalised female, 0.1% outpatient female cases), Staphylococcus aureus (4% hospitalised male, 3% 
outpatient male, 0.7% hospitalised female, 0.6% outpatient female cases), Streptococcus agalactiae (2% hospitalised 
male and female, 0.8% outpatient female, 0.7% outpatient male cases; urinary tract abnormalities in 60%, chronic 
renal failure in 26%), yeasts (mainly Candida albicans, 0.9% hospitalised male, 0.7% hospitalised female, 0.3% 
outpatient female cases); Corynebacterium urealyticum (immunosuppressed, urologic procedures, previous 
antimicrobials, age > 66 y), Actinobacillus actinomycetemcomitans (in association with endocarditis), Ureaplasma 
urealyticum, Gardnerella vaginalis, Mycoplasma hominis, Streptococcus mitis, Bacteroides fragilis, Rgrobacterium 
tumefaciens (non-functioning kidney), Rlcaligenes faecalis (nosocomial), Achromobacter xylosoxidans, Citrobacter, 
Enterobactre agglomerans, Serratia marcescens, Reromonas (occasional), Haemophilus influenzae (non-type b and 
nontypeable), Schistosoma boms, Mycobacterium avium-intracellulare (rare cases in renal transplant recipients) 
Diagnosis: frequency in 89% of cases, urgency in 82%, dysuria in 25%, suprapubic tenderness; dysuria and 
frequency without vaginal irritation gives probability of 90%; dipstick (nitrite sensitivity 25%, specificity 90%; 
leucocyte esterase); bacteria on Gram stain sensitivity 80%, specificity 90%; micro (leucocytes + bacteria + 
erythrocytes) and culture (30-40% > 10 5 cfu/mL) of midstream urine; culture of bladder aspiration urine for low 
counts and fastidious species in culture negative symptomatic patients; those with risk factors above (under 
Urinary Tract Infection) should have serum creatinine concentration for baseline assessment of renal 
function and ultrasound examination of the urinary tract if structural anomaly or obstruction is suspected 
Treatment: trimethoprim 300 mg orally daily for 3 d (non-pregnant women) or 14 d (men) or 4 mg/kg to 
150 mg orally 12 hourly for 5 days (children), cephalexin 500 mg orally 12 hourly for 5 d (non-pregnant women) 
or 10 d (pregnant women) or 14 d (men) or 12.5 mg/kg to 500 mg orally 12 hourly for 5 d (children), amoxycillin- 
clavulanate 500/125 mg orally 12 hourly for 5 d (non-pregnant women) or 10 d (pregnant women) or 14 d (men) 
or 12.5/3.1 mg/kg to 500/125 mg orally 12 hourly for 5 d (children), nitrofurantoin 50 mg orally 6 hourly for 5 d 
(non-pregnant women) or 10 d (pregnant women) or 14 d (men), cotrimoxazole 4/20 mg/kg to 160/800 mg orally 
12 hourly for 5 d (children); if resistant to all above agents, norfloxacin 400 mg orally 12 hourly for 3 d (non- 
pregnant women) or 14 d (men), levofloxacin 250 mg daily for 3 d (non-pregnant women) 
Remote Areas: 

Children < 10 y: gentamicin 5 mg/kg i.m. single dose, cefaclor syrup orally 8 hourly for 
7-10 d, cotrimoxazole orally 12 hourly for 7-10 d, trimethoprim orally daily for 7-10 d 

Females > 10 y: nitrofurantoin 200 mg orally as single dose, trimethoprim 600 mg orally 
as single dose or 300 mg orally daily for 3 d 

Males > 10 y: cephalexin 500 mg orally 8-12 hourly for 7-14 days, amoxycillin-clavulanate 
250/125 mg orally 8 hourly for 7-14 d, trimethoprim 300 mg orally daily for 7-14 d 

Recurrent Infection: trimethoprim 6 mg/kg to 300 mg orally once daily for 10-14 d, amoxycillin- 
clavulanate 10/2.5 mg/kg to 250/125 mg orally 8 hourly for 10-14 d; if resistance to both above agents, 
norfloxacin 400 mg orally 12 hourly (not in children or pregnant) or hexamine hippurate 1 g orally twice daily for 
10-14 d (+ ascorbic acid 1 g orally twice daily if urine alkaline); recent promising trials of multivalent pessary 
vaccine 



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Infections of the Urinary Tract 



Klebsiella: cefotaxime 1 g i.v. 12 hourly (child: 25 mg/kg i.v. 8 hourly), norfloxacin 400 mg orally 12 
hourly (not pregnant or child) 

Pseudomonas aeruginosa: norfloxacin 400 mg orally 12 hourly (not pregnant or child), tobramycin 
1.3 mg/kg (child: 1.5-2.5 mg/kg) 8 hourly, ceftazidime 500 mg (child: 50 mg/kg) i.v. daily in divided doses 

Burkholderia cepacia: imipenem 

Corynebacterium urealyticum: vancomycin 

Candida (High Risk Patient with Localised Infection): fluconazole 5 mg/kg to 200 mg 
orally daily for 7 d 
Prophylaxis: 

Recurrent Infections in Females Related to Sexnal Interconrse: nitrofurantoin 50 mg 
orally or cephalexin 250 mg orally or trimethoprim 150 mg orally within 2 h after intercourse; cranberry juice 

Recnrrent Cystitis Not Related to Sexnal Interconrse: nitrofurantoin 1 mg/kg to 50 mg orally 
nightly for 3-6 mo, cephalexin 12.5 mg/kg to 250 mg orally nightly for 3-6 mo, trimethoprim 4 mg/kg to 150 mg 
orally nightly for 3-6 mo, cotrimoxazole 4 + 20 mg/kg to 160 + 800 mg orally nightly (children if suitable 
trimethoprim formulation not available); intravaginal estrogen in postmenopausal women 

Cirrhotic Patient with Gastrointestinal Bleeding: norfloxacin 400 mg orally commencing 1 h 
before endsocopy and then 12 hourly for 1-2 d or if oral therapy not feasible ciprofloxacin 400 mg i.v. at time of 
induction and then 12 hourly for 1-2 d 

Acute Pyelonephritis: inflammatory process of the renal parenchyma; 0.07% of new episodes of illness in UK 
Agents: Escherichia coli (may, rarely, cause acute renal failure, especially when NSAIDs administered), Proteus, 
Staphylococcus aureus, Staphylococcus saprophyticus, other coagulase negative staphylococci, Enterococcus faecalis, 
Pseudomonas aeruginosa, Stenotrophomonas maltophilia (associated with hospitalisation and antimicrobial therapy), 
Salmonella (in renal transplant recipients), Campylobacter, Streptococcus agalactiae, Mycoplasma hominis (rare), 
others 

Diagnosis: dysuria, fever and chills, loin pain, costovertebral tenderness, nausea and vomiting, bacteremia, 
suprapubic tenderness + urgency, frequency; leucocytosis present or absent; increased ESR; C-reactive protein 
present; blood procalcitonin elevated; micro (bacteria + leucocytes + erythrocytes + leucocyte casts) and culture 
of urine; note that renal bacteriuria may be intermittent and low colony counts may be significant; 
counterimmunoelectrophoresis of serum; radioimmunoassay (sensitivity 96%, specificity 100%); blood cultures 
(positive in 41% of cases of ascending pyelonephritis); those with risk factors above (under Urinary Tract 
Infection) should have serum creatinine concentration for baseline assessment of renal function and ultrasound 
examination of the urinary tract if structural anomaly or obstruction is suspected 
Treatment: ultrasonogram and cystogram in child with first episode 

Stenotrophomonas maltophilia, Campylobacter, cotrimoxazole 

Others: 

Severe: gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) + 
amoxy(ampi)cillin 50 mg/kg to 2 g i.v. 6 hourly for 10-14 d (cephalothin 25-50 mg/kg to 2 g i.v. 4-6 hourly if 
mild penicillin hypersensitivity; gentamicin alone if severe penicillin hypersensitivity) 

Elderly, Renal Failure, Previous Adverse Reaction to 
Aminoglycoside: ceftriaxone 25 mg/kg to 1 g i.v. daily, cefotaxime 25 mg/kg to 1 g i.v. 8 hourly for 10-14 d 

Mild to Moderate (Not Pseudomonas aeruginosa): cephalexin 12.5 mg/kg to 
500 mg orally 6 hourly for 10 d (safe in pregnancy), amoxycillin-clavulanate 22.5/3.2 mg/kg to 875/125 mg 
orally 12 hourly for 10 d (probably safe in pregnancy), trimethoprim 4 mg/kg to 150 mg orally 12 hourly for 10 d 
(safety in pregnancy not established), cotrimoxazole 4 + 20 mg/kg to 160 + 800 mg orally 12 hourly for 10 d 
(children where suitable trimethoprim formulation not available) 

Pseudomonas aeruginosa and Other Organisms Resistant to All 
Above Agents: norfloxacin 10 mg/kg to 400 mg orally 12 hourly for 10 d or ciprofloxacin 10 mg/kg to 500 mg 
12 hourly for 10 d (both drugs safety not established in pregnancy; not in children unless microbiologically 
necessary) 

Penicillin Allergic Patient with Gram Positive Canse: vancomycin 
colchicine or single dose cyclophosphamide may protect against chronic pyelonephritis in acute obstructive 
pyelonephritis 



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Infections of the Urinary Tract 



Prophylaxis (Cirrhotic Patient with Gastrointestinal Bleeding): norfloxacin 400 mg orally 

commencing 1 h before endsocopy and then 12 hourly for 1-2 d or if oral therapy not feasible ciprofloxacin 

400 mg i.v. at time of induction and then 12 hourly for 1-2 d 

Dysuria-Frequency Syndrome (Acute Urethral Syndrome) 

Agents: Chlamydia trachomatis, Neisseria gonorrhoeae, Gram negative bacilli including Haemophilus influenzae; 

may result from acute cystitis, urethritis or vaginitis 

Diagnosis: dysuria, frequency, urgency, > 8 leucocytes/ pL in first void urine specimen; growth of > 10 2 of an 

aerobic Gram negative bacillus from a midstream urine culture; culture and immunofluorescence of urethral swab; 

note that patients with pyuria, renal symptoms, proteinuria and microscopic hematuria but sterile cultures or 

colony counts of lOVpL may also have occult renal infection, perhaps with intermittent renal bacteriuria (culture 

of suprapubic aspirate may be necessary to eliminate this possibility) 

Treatment: 

Neisseria gonorrhoeae: see Gonorrhoea in Chapter 4 

Chlamydia trachomatis: tetracycline, doxycycline, erythromycin (pregnancy: erythromycin) 

Gram Negative Bacilli (Including Haemophilus influenzae): cotrimoxazole 
Management of Women with Recurrent Nonvenereal Attacks of Dysnria-Freqnency 
Syndrome: 

Precipitated by Sexnal Interconrse: scrupulous hygiene; lubricants; bladder emptying after 
intercourse; alternative positions; pillow under buttocks; nitrofurantoin 50 mg after intercourse; psychosexual 
history 

Precipitated by Psychological Stress: counselling; psychosexual history; consider short course of 
a sedative or (if indicated) antidepressive therapy 

Precipitated by Cold Weather: warm underclothing; trousers rather than skirts or dresses 

Precipitated by Allergies: psychosexual history; avoid known allergens; consider antihistamines or 
desensitisation 

Related to Menopause: psychosexual history; dienestrol pessaries (1 nightly for 1 week every 
3 mo); dienestrol cream; pentovis (2 capsules twice daily for 2 w) 

Related to Menstruation: scrupulous hygiene; a simple diuretic for a few days before a period 
starts; trial of oral contraceptives 
Dysuria Without Frequency 

Agents: herpes genitalis, urethritis (in 82% of gonococcal, 73% of non-gonococcal, 67% of Haemophilus 
influenzae, 75% of Haemophilus parainfluenzae), vaginitis (in 18% of trichomonal, 12% of other) 
Diagnosis and Treatment: see Chapter 4 

Frequency Without Dysuria occurs in prostatic abscess and vulvovaginal candidiasis 
Asymptomatic Bacteriuria: presence of bacteria in the urine in the absence of clinical symptoms; prevalence 
varies from 0.001% in infants to 25-50% in female nursing home residents; 20-60% of women with bacteriuria in 
early pregnancy develop acute pyelonephritis later in pregnancy and routine screening in populations in which the 
prevalence of asymptomatic bacteriuria is > 5% is recommended; patients undergoing urological procedures 
producing mucosal bleeding should be screened beforehand and treated if positive 

Agents: 60-89% Escherichia coli, 8% Klebsiella, 0.7% Proteus, Streptococcus agalactiae, Enterococcus, Salmonella 
(in renal transplant recipients), Citrobacter, mixed infections 

Diagnosis: cloudy urine; micro (leucocytes, bacteria, leucocyte casts present or absent) and culture of urine 
(pure culture > 10VL consistent with bacteriuria); note that, particularly in the absence of leucocytes, this 
condition may represent contamination, even if a pure growth of a single organism is obtained; in cases of doubt, 
particularly where multiple organisms, single organisms with a high probability of extraneous source (eg., Proteus 
vulgaris, Citrobacter), or a succession of different organisms in repeat specimens, are isolated, a suprapubic 
aspiration may be necessary 

Treatment: depends on patient's age and available safe agents; avoid repeated or prolonged courses of therapy 
in asymptomatic elderly females; neonates and preschool children should be treated and investigated for 
vesicoureteric reflux and other anatomical abnormalities; pregnant women should be treated because of risk of 
developing pyelonephritis; men < 60 y should be treated and investigated for chronic prostatitis; young children 
with vesicoureteric reflux and patients with genitourinary abnormalities that may become secondarily infected, 
nonfunctioning renal segments, medullary sponge kidneys, polycystic kidneys, calculi, ureteral obstruction, prostatic 



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Infections of the Urinary Tract 



hyperplasia, increased intrarenal voiding pressure, renal papillary necrosis, valvular heart disease, prosthesis or 

diabetes or who are immunocompromised, or those growing fungi, mycobacteria, Klebsiella, Proteus mirabilis or 

Staphylococcus aureus or undergoing genitourinary instrumentation or manipulation should be treated and 

investigated; others (including diabetics) do not require treatment 

Chronic Bacteriuria: more or less continued presence of bacteria in the urine, due to inability to eradicate 

infection or to recurrent infections; possible causes include chronic pyelonephritis, chronic bacterial prostatitis 

(creatine and creatinine are usually increased), infected renal or bladder stones, bladder diverticulum, renal 

abscess, indwelling catheter 

Agents: Proteus and Staphylococcus saprophyticus in infected stones; Proteus, Providencia stuartii, Morganella 

morganii and numerous others in indwelling catheter; mixed infections 

Diagnosis: urine micro and culture (in patients with indwelling catheter, only if signs of systemic infection); 

prostatic localisation test for suspected chronic bacterial prostatitis 

Treatment: correction of underlying cause if possible; antimicrobial treatment as indicated by susceptibility of 

isolates (note that clearing of infection from a patient with an indwelling catheter is virtually impossible; 

antimicrobial treatment should be restricted to acute episodes; a single 2 mg/kg dose of gentamicin given 30-60 

minutes before changing catheter may help control infections; amdinocillin may be used in short term; most 

important factor is preventing blockage by encouraging adequate fluid intake and changing catheter regularly or 

immediately if poorly functioning or obstructed; suprapubic cather should be considered for long-term use) 

Prophylaxis: nitrofurantoin 2.5 mg/kg to maximum 100 mg orally nightly (safe in pregnancy), trimethoprim 

2 mg/kg to maximum 150 mg orally nightly (not in pregnancy) 

Hemolytic Uremic Syndrome: most common cause of acute renal failure in children (mainly < 10 y); 

mortality « 5%, sequelae in « 50%; 24 cases in Australia in 1999 

Agents: Escherichia coli (usually 0157:H7; also 0111); also Streptococcus pneumoniae, Salmonella typhi, Shigella, 

Proteus, variety of other bacteria, viruses and drugs 

Diagnosis: microangiopathic hemolytic anemia (hematocrit < 30%), thrombocytopenia (platelet count 

< 160,000/ pL) and acute renal failure (blood urea nitrogen > 20 mg/dL) after respiratory or gastrointestinal 

symptoms or bacteremia; elevated serum aminotransferases, triglycerides, bilirubin and uric acid, reduced serum 

protein, albumin, C3 and C4; feces culture on 0.5% sorbitol MacConkey agar (within 6 d of onset of diarrhoea) + 

serotyping; enzyme immunoassay; blood cultures 

Treatment: red blood cells or platelet transfusions as required, dialysis if required, plasma exchange; avoid 

antimicrobials and antimotility agents 

Genitourinary Tuberculosis: 0.6% of tuberculosis cases 

Agent: Mycobacterium tuberculosis 

Diagnosis: Ziehl-Neelsen stain and culture of urine on Lowenstein-Jensen or similar medium; red cells and 

neutrophilia present in urine in urinary tuberculosis; proteinuria without elevated cells occurs in non-urinary 

tuberculosis; tuberculin test; interferon gamma assay; ELISPOT 

Treatment: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 times weekly for 

6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg 

orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 

25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to 

be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine 

> 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be 

susceptible to isonazid and rifampicin (to 6 mo); relief of ureteric obstruction if required 

Urinary Fungal Infections: pelvic infection (including acute uteropelvic obstruction) occurs particularly in 

diabetics, while parenchymal disease is more common in leukemia and chronic granulomatous disease; mortality 

rate 57% in pediatric patients 

Agents: Candida, Torulopsis glabrata, Aspergillus, Penicillium citreum, Cryptococcus neoformans, phycomycetes 

Diagnosis: micro and culture of urine; sonography; in Candida infections, urethral, vulval, vaginal swabs may 

be necessary to exclude genital infection 

Treatment: in diabetics, primary effort should be towards stabilising diabetes, though bladder irrigation with 

amphotericin B 5-10 mg/L or single dose of amphotericin B may be used if necessary (also with indwelling 

catheter); if renal insufficiency is present, radiography should be performed, any obstruction found relieved and 

cultures repeated; if infection persists or any evidence of pyelonephritis and/or papillary necrosis is found, 



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Infections of the Urinary Tract 



infection should be treated with flucytosine or amphotericin B; immunocompromised and paediatric patients, even 

if asymptomatic, should be treated with flucytosine or fluconazole 5 mg/kg to 200 mg orally daily for 7 d or 

amphotericin B 

Urinary Viral Infections 

Agents: human rubella virus and human cytomegalovirus (prenatal), measles virus, mumps virus, Simplexvirus, 

virus agent of other generalised viral infections, ? Lymphocryptovirus in infectious mononucleosis, human 

adenovirus 11 (acute hemorrhagic cystitis in immunosuppressed patients), polyomaviruses in renal transplant 

recipients 

Diagnosis: viral culture of urine; serology 

Treatment: non-specific 

Urinary Schistosomiasis 

Agent: Schistosoma haematobium 

Diagnosis: hematuria, dysuria, pyuria, chyluria; ova in urine, scrapings of lesions in bladder wall; severe iron 

deficiency anemia, eosinophilia, raised ESR; serology 

Treatment: praziquantel 20 mg/kg orally for 2 doses after food 4 h apart 

Poststreptococcal Glomerulonephritis: immune mediated glomerulonephritis usually occurring 5-10 d 

after an upper respiratory infection or longer after the onset of a skin infection 

Agents: almost invariably Streptococcus pyogenes (respiratory infections caused by a single type; skin infections 

caused by several types), occasionally Group C and Group G streptococci 

Diagnosis: hematuria + edema, with hypertension and azotemia in more severe cases; anti-streptolysin test 

(normal in « 50% of cases (especially following skin infection); peaks at 2-4 w; false positives due to activity of 

other substances neutralising hemolytic properties of streptolysin (eg., serum (3-lipoprotein in liver disease) and 

bacterial growth in serum specimens); anti-deoxyribonuclease B (consistently elevated; rises later than ASOT, peaks 

at 4-6 w and remains elevated longer than ASOT; magnitude of response may be suppressed by antimicrobial 

therapy; detergents, heavy metals, azide and other chemicals interfere with enzyme and colour reaction); C'4 

decreased (distinguishes from hypocomplementemic) 

Treatment: supportive 

Quartan Malarial Nephropathy (Malarial Nephrosis, Malaria Nephrosis, Nephrotic Syndrome 

of Quartan Malaria, Quartan Nephrosis): relatively rare complication of malariae malaria, especially in 

children 

Agent: Plasmodium (Plasmodium) malariae 

Diagnosis: glomerulonephritis with generalised edema, severe proteinuria and hypoproteinemia 

Treatment: usually fatal 

Genitourinary Myiasis: infestation of bladder, urethra and/or vagina by larvae of certain flies; rare 

Agents: Calliphora vomitoria, Chrysomya bezziana, Chrysomya chloropyga, Chrysomya putoria, Piophila, 

Wohlfahrtia 

Diagnosis: abdominal pain, dysuria, frequent urination, haematuria; may be urethral obstruction 

Treatment: removal of larvae 



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Chapter 4 
Infections of the Genital System 

Genital Tract Infections 

In the male, except for some cases of prostatitis and orchitis and the occasional infection of external genitalia by 
normal skin-infecting organisms, almost all infections of the genital tract are classical sexually transmitted diseases. In the 
female, though sexually transmitted diseases occur with more or less equal frequency, the majority of genital tract 
infections are not in this category, though many may be related to sexual activity. The presence of a vaginal discharge is 
a relatively common event and, in the majority of cases, is not primarily of infectious origin. However, overgrowth of 
endogenous organisms such as Candida albicans can set up a true vaginitis or, in the case of organisms such as 
Gardnereiia vaginalis, anaerobes and coliforms, a vaginosis in which organisms colonise epithelial cells or mucus in large 
numbers, converting an inoffensive discharge into an offensive one. The presence of intrauterine contraceptive devices is 
associated with overgrowth of endogenous organisms and sometimes with true uterine infection; in the latter case, removal 
of the device is the essential, and usually the only necessary, treatment. Infections post-partum, post-abortion or post- 
surgery may resemble post-traumatic and post-surgery infections in other sites. Gynecologic infection constitutes 8% of non- 
bacteremic infection in older children and adults. 

Gonorrhoea (Gonorrhea, Blennorrhagia): Worldwide venereal disease and important cause of neonatal infection; 
acute or chronic disease of urogenital tract (vulvovaginitis, endocervicitis, urethritis); extension of the disease within the 
urogenital tract may lead to endometritis, salpingitis, oophoritis, epididymitis, orchitis, spermatocystitis, cystitis; disease 
may extend to adjacent tissues, giving rise to prostatitis, bartholinitis, pelvic inflammatory disease, or become systemic; 
disseminated infection results from bacteremia and often causes petechial or pustular acral skin lesions, asymmetrical 
arthralgia, tenosynovitis or septic arthritis, occasionally perihepatitis and, rarely, endocarditis or meningitis; subclinical 
infections (urethral, cervical, anal, pharyngeal) are frequent; eye infections also occur; « 6000 notified cases/y in Australia 
(steady increase); incidence 443/100,000 (1.6-2 M cases/y) in USA (13% of cases in homosexual men); 38% of male 
sexually transmitted disease, 31% of female; 40% incidence in homosexuals; transmission by mucous membrane contact; 
incubation period 1-14 d (most symptoms develop within 2-5 d); 0.04% of new episodes of illness in UK; 50-90% of female 
sexual partners of infected men infected after 1 exposure; once urethritis disappeared, most men not infectious; 20% of men 
infected after 1 exposure, 60-80% after 4 exposures; 2-50% of infants exposed during birth develop eye infections 
Agent: Neisseria gonorrhoeae 

Diagnosis: women may have no symptoms or vaginal discharge, pain on urination, spotting after sexual intercourse, 
lower abdominal pain; men: urethral discharge of pus, pain on urination; Gram stain (presence of Gram negative cocci 
inside polymorphs; sensitivity 90-95%, specificity > 95%) and culture of urethral, cervical, rectal, throat swabs (note that 
vaginal lubricants are inhibitory and should not be used on speculums, etc); isolates may be identified by biochemistry or 
DNA hybridisation; PCR or ligase chain reaction if culture not possible (sensitivity > 96%, specificity probably « 100%); 
note possibility of salpingitis (in 10-20% of cases), endometritis, cervicitis, urethritis, Bartholinitis, epididymitis (in up to 
20% of infected men without antibiotics); arthritis (85% of disseminated cases), meningitis (5% of disseminated cases), 
endocarditis (5% of disseminated cases), bacteremia without arthritis (5% of disseminated cases), pericarditis (2% of 
disseminated cases), abscesses, septic gonococcal dermatitis in complicated cases 

Treatment: (since 20-60% coinfected with Chamydia trachomatis, CDC recommends concurrent treatment for this 
organism); ceftriaxone 25-50 mg/kg to 250 mg i.m. single dose + (if chlamydial infection not ruled out) azithromycin 1 g 
orally single dose (> 45 kg) or doxycycline 100 mg orally twice daily for 10 d (> 8 y) or erythromycin 50 mg/kg/d 
divided into 4 doses for 10-14 d (< 8 y); if prevalence of penicillin resistance is low (e.g., Northern Territory, Western 
Australia), amoxycillin 3 g orally as single dose + probenecid 1 g orally as single dose + azithromycin 1 g orally as 
single dose 

Disseminated Infection: 

Neonates: ceftriaxone 25-50 mg/kg/d i.v. or i.m. as single daily dose for 7 d or 10-14 d if 
meningitis documented, cefotaxime 25 mg/kg/d i.v. or i.m. every 12 h for 7 d or 10-14 d if meningitis documented 

Others: ceftriaxone 1 g i.v every 24 h or cefotaxime 1 g i.v every 8 h or ceftozoxime 1 g i.v. 
every 8 h 

Prevention and Control: exposure prevention; identification and treatment of cases (symptomatic and asymptomatic) 
and contacts 



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Infections of the Genital System 



Non-gonococcal Urethritis (Non-specific Urethritis): 39% of sexually transmitted disease in male; 3 ffl cases/y 
in USA; « 14,000 notified cases/y in Australia (« 32% in Queensland); 25% incidence in homosexuals, 10% in 
heterosexuals; transmission by venereal contact; in 1 study, 45% of women and 30% of men whose sexual partners had 
Chlamydia were infected; 60-70% of infants exposed at birth develop respiratory infection or chlamydial ophthalmia; 
incubation period 7-21 d 

Agents: 30-40% Ureaplasma urealyticum, 28% Mycoplasma genitalium, 15-55% Chlamydia trachomatis, 8% Haemophilus 
parainfluenzas, 2% Haemophilus influenzae; Bacteroides, Porphyromonas asaccharalytica, Prevotella melaninogenica, 
anaerobic cocci, Mnetobacter, Staphylococcus aureus, Moraxella catarrhalis, other bacteria in association with urinary tract 
infection, acute prostatitis, urethral stricture or following instrumentation; Trichomonas vaginalis (usually asymptomatic in 
male), Candida (uncommon cause in male), humanherpesvirus, Entamoeba histolytica described in homosexual males; also 
trauma 

Diagnosis: often asymptomatic; women: vaginal discharge, pain on urination, spotting after sexual intercourse, lower 
abdominal pain; men: mucopurulent or purulent urethral discharge, dysuria; pyuria (> 10 polymorphs/hpf in sediment from 
first few mL of freshly voided specimen); Gram stain (> 5 polymorphs per oil immersion field) and culture of urethral 
swab; leucocyte esterase test on first void urine 

Chlamydia: 

Males: can cause urethritis and epididymitis; urethral swabs or first void urine specimens may be 
used for immunofluorescence (sensitivity 40-75%), ELISA ((sensitivity 40-75%), PCR (sensitivity > 90%), DNA probe 
(sensitivity 40-75%), ligase chain reaction (sensitivity > 90%) or culture (sensitivity 50-90%) 

Females: 9% of sexually active women under 25 infected; can cause endometritis, cervicitis, 
Bartholinitis, premature rupture of membranes and preterm delivery; all women 19-24 y and women > 24 y with new 
partner or multiple partners should be screened annually; cervical swab culture and direct immunofluorescence or ELISA; 
sensitivity is 70-96% for direct immunofluorescence and 60-96% for ELISA; specimens must contain mucosal epithelial cells 
(ie., columnar, not squamous); specimens for immunofluorescence may be refrigerated if read within 24 h, must be frozen if 
not read within 24 hours, and diagnosis should be based on the presence of elementary bodies only, reticular bodies being 
indistinguishable from bacteria; specimens for immunoassay keep at room temperature for up to 7 d; specificity for both 
these procedures is 94-99%; culture (McCoy cells or Cellmatics™) is more sensitive than either procedure if urethral swabs 
are used but gives low yields from urine; iodine staining and immunofluorescence of isolates are equivalent; all these 
methods are being supplanted by PCR (sensitivity 90%, specificity 99.8%) or ligase chain reaction; VMS ELFA also used 
(sensitivity 71%, specificity 100%, PVP 100%, PVN 98.5%); DNA probe also available; complement fixation test detects 
antibody to both Chlamydia trachomatis and Chlamydia psittaci 
Treatment: 

Chlamydia trachomatis: azithromycin 1 g orally as a single dose, doxycycline 100 mg orally 12 hourly for 
7 d, tetracycline 500 mg orally 4 times daily for 7 d, erythromycin base or equivalent salt 500 mg orally 6 hourly for 7 d 
(can be used in pregnancy), sulphisoxazole or equivalent 500 mg orally 4 times daily for 10 d, ofloxacin 300 mg twice a 
day for 7 d, levofloxacin 500 mg once daily for 7 d; rescreen 3-4 mo after treatment 

Haemophilus: amoxycillin 500 mg orally 8 hourly for 5 d, erythromycin 500 mg orally 4 times daily for 7 d, 
amoxycillin-clavulanate 500/125 mg orally 8 hourly for 8 d 

Ureaplasma urealyticum: erythromycin 500 mg orally 8 hourly for 7 days, minocycline 100 mg orally 12 
hourly for 7 days 

Mycoplasma genitalium: azithromycin 

Treatment Failnre: metronidazole 2 g orally in a single dose + erythromycin base 500 mg orally 4 times a 
day for 7 d or erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 d 
Prevention and Control: exposure prevention, treatment of cases 

Urethral Discharge occurs in 99% of cases of gonococcal urethritis (63% scanty, 78% yellow-green), 95% of non- 
gonococcal urethritis (96% scanty, 66% clear; Haemophilus influenzae: 40% moderate, 40% profuse, 60% clear; Haemophilus 
parainfluenzae: 47% moderate, 88% clear), and in acute epididymitis, acute prostatitis and prostatic abscess 
Prostatitis and Seminal Vesiculitis: may need to be considered as the cause of protein, mucus and neutrophils (and 
sometimes bacteria) in urine of males; patients may have relapsing urinary tract infections 
Agents: Neisseria gonorrhoeae, Escherichia coli and other Enterobacteriaceae, Staphylococcus saprophytics, 
Mycobacterium avium-intracellulare (rare; granulomatous), Haemophilus parainfluenzae, Ureaplasma urealyticum, Candida 
albicans and Aspergillus (uncommon cases in hemotologic malignancies, diabetes, corticosteroid use, AIDS), Trichomonas 
vaginalis 



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Infections of the Genital System 



Diagnosis: 

Acute: lower urinary tract symptoms + fever, systemic symptoms, perineal pain, exquisite tenderness of 
prostate 

Chronic: little inflammation, prostate normal on examination; may be recurrent UTIs 
culture of semen; quantitative counts of urine, comparing initial voided urine with midstream urine with urine after 
prostatic massage (or, preferably, ejaculate); semen acid phosphatase elevated for day or more following prostatic massage 
(in absence of prostatic carcinoma); white cell count usually elevated with neutrophilia 
Treatment: 

Mycobacterium avium-intracellulaie: ethambutol 15 mg/kg orally daily or 25 mg/kg orally 3 
times weekly (not < 6 y) + clarithromycin 12.5 mg/g to 500 mg orally 12 hourly daily or 3 times weekly or 
azithromycin 10 mg/kg to 500 mg orally daily or 10 mg/kg to 600 mg orally 3 times weekly + rifampicin 
10 mg/kg to 600 mg orally daily or 3 times weekly or rifabutin 5 mg/kg to 300 mg orally daily 

Other Bacteria: 

Severe Acnte: amoxy(ampi)cillin 2 g i.v. 6 hourly + gentamicin 4-6 mg/kg (adjust dose for renal 
function) i.v. daily 

Less Severe: cotrimoxazole 160/800 mg orally 12 hourly for 5 days; trimethoprim 240 mg orally daily 
initially then 80 mg orally daily + rifampicin 900 mg daily initially then 300 mg orally daily; minocycline 200 mg orally 
initially followed by 100 mg orally 12 hourly; norfloxacin 800 mg/d for 5 d 

Chronic: norfloxacin 400 mg orally 12 hourly for 4 w, ciprofloxacin 500 mg orally 12 hourly for 4 w, 
trimethoprim 300 mg orally daily for 4 w, doxycycline 100 mg orally 12 hourly for 2-4 w 

No Organism Isolated: erythromycin 500 mg orally 6 hourly, doxycycline 100 mg orally 12 hourly 

Fnngi: amphotericin B ± flucytosine; prostatic resection 

Trichomonas vaginalis: metronidazole, tinidazole 
Prophylaxis (Mycobacterium avium complex in HIV/ AIDS; CD4 connt < 50/ uL): azithromycin 1.2 g 
orally weeekly, clarithromycin 500 mg orally 12 hourly, rifabutin 300 mg orally daily 
Prostatic Abscess 

Agents: Staphylococcus aureus (in younger patients without urinary obstruction), Escherichia coli and other Gram negative 
bacilli (in older patients with prostatic hypertrophy and urinary obstruction), Candida albicans (in catheterised diabetics 
receiving broad spectrum antibiotics), Neisseria gonorrhoeae, anaerobes, Mycobacterium (rare cases), Burkholderia 
pseudomallei (in 18% of male melioidosis cases) 

Diagnosis: pus and bacteria in urine; computerised tomography of pelvis or transrectal ultrasonography; culture of 
abscess fluid; white cell count usually increased 
Treatment: perineal needle drainage or transurethral incision and drainage +: 

Neisseria gonorrhoeae: ciprofloxacin 

Burkolderia pseudomallei: ceftazidime 2 g i.v. 6 hourly or imipenem 1 g i.v. every 8 h for 2 w, then 
double strength cotrimoxazole twice daily for at least 3 mo (amoxycillin-clavulanate, doxycycline or fluoroquinolones if 
unable to tolerate sulphonamides) 

Other Bacteria: cotrimoxazole 

Candida albicans: amphotericin B 
Acute Epididymitis and Epididyihoorchitis: 0.02% of new episodes of illness in UK 
Agents: Neisseria gonorrhoeae (22% of cases in heterosexual men, rare in homosexual men), Chlamydia trachomatis (46% 
of cases in heterosexual men, rare in homosexual men), Escherichia coli and Klebsiella pneumoniae (67% of cases in 
homosexual men, rare in heterosexual men < 35 y, usual cause in children and heterosexual men > 35 y), Haemophilus 
influenzae (11% of cases in homosexual men, rare in heterosexual men; 5% of cases of non-bacteremic invasive Haemophilus 
influenzae infections in older children and adults), Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus, 
Salmonella, Treponema pallidum, Mycobacterium tuberculosis, Brucella (in 5-9% of brucellosis cases), Neisseria meningitidis, 
human cytomegalovirus (in AIDS) 

Diagnosis: swelling in 100%, pain in 96%, erythema in 72%, temperature > 37.7° in 40%; white cell count 
> 10,000/ja.L in 44%; cloudy urine; Gram stain, immunofluorescence and culture of aspirate, urine, urethral discharge; PCR 
for Neisseria gonorrhoeae and Chlamydia trachomatis on intraurethral swab or first void urine; blood and stool cultures; 
serology; exclude urinary tract infection, testicular torsion 
Treatment: infiltration of spermatic cord above testicle with procaine hydrochloride +: 



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Infections of the Genital System 



Sexually Acquired: ceftriaxone 250 mg i.m. single dose + doxycycline 100 mg orally twice a day or 
roxithromycin 300 mg orally daily for 14 d; amoxycillin / clavulanate 500 mg orally 8 hourly for 10-14 d or ciprofloxacin 
500 mg orally 12 hourly for 10-14 d or amoxycillin 500 mg orally 8 hourly for 10-14 d + doxycycline 100 mg orally 12 
hourly 10-14 d 

Associated with Urinary Tract Infection: 

Mild to Moderate: trimethoprim 6 mg/kg to 300 mg orally daily for 14 d, cephalexin 12.5 mg/kg 
to 500 mg orally 12 hourly for 14 d, amoxycillin-clavulanate 12.5/3.1 mg/kg to 500/125 mg orally 12 hourly for 14 d, 
norfloxacin 400 mg orally 12 hourly for 14 d 

Severe: amoxy(ampi)cillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin (< 10 y: 7.5 mg/kg; > 10 y: 
6 mg/kg) i.v. daily (adjust dose for renal function) till substantial clinical improvement then appropriate oral agent to 
complete 14 d course; ofloxacin 300 mg orally twice a day for 10 d; levofloxacin 500 mg orally once daily for 10 d 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 

Pseudomonas aeruginosa: gentamicin + ticarcillin 

Salmonella: cotrimoxazole 160/800 mg orally 12 hourly 
Orchitis 

Agents: mumps (usually unilateral; in 20-38% of postpubertal males with mumps), coxsackievirus B, Rocky Mountain 
spotted fever (in 1% of infections), Salmonella (in renal transplant recipients), Chlamydia trachomatis 
Diagnosis: proteinuria; white cell count may be elevated; serology 
Treatment: infiltration of spermatic cord just above testis with procaine hydrochloride 

Salmonella: cotrimoxazole 160/800 mg orally 12 hourly 

Chlamydia trachomatis: doxycycline 
Bartholinitis 

Agents: wide variety of aerobic and anaerobic bacteria, mycobacteria, Chlamydia, fungi, parasites and viruses 
Diagnosis: clinical; swab culture 
Treatment: dependent on agent 
Vulvitis 

Agents: Candida albicans, Simplexvirus 
Diagnosis and Treatment: see Vaginitis, Genital Herpes 

Vaginitis: conditions involving actual infections which of themselves may cause discharge and other symptoms 
Agents: Neisseria gonorrhoeae (prevalence 0-4/1000), Chlamydia trachomatis (21% of female sexually transmitted disease), 
Trichomonas vaginalis (worldwide; 19% of female sexually transmitted disease; up to 85% of female sexual partners of 
infected men infected; 30-40% of male partners of infected women infected; about 5% of girls born to infected women 
infected at birth; may also be transmitted at gynecological examination; incubation period 3-28 d; 5 ffl cases/y in USA; 
prevalence 32-70/1000; amplifies HIV transmission), human herpesvirus 2 (occasionally human herpesvirus 1), Candida 
albicans and other Candida species (11% of female sexually transmitted disease; prevalence 36-93/1000; 15-20% C.glabrata), 
Saccharomyces cerevisiae, Haemophilus influenzae, ? Mycoplasma hominis, ? echovirus 4, Balantidium coli (extremely rare) 

Prepubertal Girls and Elderly Women: Staphylococcus aureus, Streptococcus pyogenes, other p- 
streptococci, coliforms, fecal streptococci, Haemophilus influenzae, Actinomyces pyogenes 

Infant Girls: Streptococcus pneumoniae, Haemophilus influenzae, Enterobius vermicularis 
Diagnosis: symptoms and signs have little value (vaginal discharge in candidiasis varies from clear and watery to 
creamy or cottage cheese-like, and occurs in only 55% of trichomoniasis cases, 69% of such discharges being non-frothy 
leucorrhoea and 12% frothy leucorrhoea); however, a foul odour is more likely to be associated with Trichomonas vaginalis 
or nonspecific or foreign body vaginitis, pruritus is usually intense in Candida infections, mild with Trichomonas vaginalis 
and absent or minimal in other conditions, and inflammation is usually intense in candidiasis, obvious in trichomoniasis and 
minimal in atrophic and foreign body states; pH 5.5-6.0 with Trichomonas vaginalis, < 4.5 with Candida albicans, wet 
preparation (motile trichomonads, yeasts, pseudomycelium; using phase contrast, even non-motile trichomonads can be 
detected, with sensitivity equal to that of culture; sensitivity of ordinary wet mount is only 60%; that of cytology is even 



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less at 55%), Gram stain and culture of vaginal pool found in posterior fornix when patient is in lithotomy position; direct 
immunofluorescence for Trichomonas vaginalis (sensitivity 86%, specificity 99%, PVP 96%, PVN 98%); serology; sticky tape 
preparation of anal area (children) 

Recurrent Candidiasis: associated with pregnancy, uncontrolled diabetes mellitus, estrogens, corticosteroids, ? 
oral contraceptives, antibiotics, tight-fitting and synthetic clothing (panty hose, underwear), local allergy (commercial 
douches, perfumes), idiopathic, acquired antigen-specific immunodeficiency (cell-mediated immunity), AIDS, resistance of 
organism to antimycotic agents, ? switching colonies; culture of swabs from urethra, rectum, fingernails, throat, perineum; 
skin test; RAST 
Treatment: 

Neisseria gonorrhoeae: 

|3 -lactamase Negative: amoxycillin 3 g orally as single dose + probenecid 1 g orally as single 
dose + azithromycin 1 g orally as a single dose or doxycycline 100 mg orally 12 hourly for at least 10 d (pregnant or 
breastfeeding: erythromycin 500 mg orally twice daily or roxithromycin 300 mg orally once daily for at least 10 d) 

P -lactamase Positive or Penicillin Hypersensitive: ceftriaxone 250 mg in 1% lignocaine 
hydrochloride i.m. as a single dose or spectinomycin 2 g i.m. as a single dose + azithromycin or doxycycline as above 
(pregnancy or breastfeeding: erythromycin or roxithromycin as above) 
Chlamydia trachomatis, Mycoplasma hominis: 

Preadolescent Girls: consider sexual abuse as possible cause of chlamydial infection 

< 45 kg: erythromycin base or ethylsuccinate 50 mg/kg/d orally in 4 divided doses for 
14 d 

> 45 kg bnt < 8 y: azithromycin lg orally in single dose 

> 8 y: azithromycin 1 g orally in single dose, doxycycline 100 mg orally twice a day for 
7d 

Pregnant or Breastfeeding: erythromycin base 500 mg orally 4 times daily for 7 d or 250 mg 
orally 4 times daily for 14 d, amoxycillin 500 mg orally 3 times daily for 7 d, erythromycin ethylsuccinate 800 mg orally 4 
times a day for 7 d or 400 mg orally 4 times a day for 14 d, roxithromycin 300 mg orally once daily for 10-14 d 

Others: azithromycin 1 g orally as a single dose, doxycycline 100 mg orally 12 hourly for 7-10 d, 
erythromycin base 500 mg orally 4 times daily for 7 d, erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 d 
Streptococci: phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly for 7 d 
Other Bacteria: tetracycline; triple sulpha cream at night 

Candida glabrata, Saccharomyces cerevisiae: boric acid 600 mg in gelatin capsule intravaginally 
10-14 d (not pregnant), flucytosine 

Other Candida: butoconazole 2% cream 5 g intravaginally for 3 d or sustained release 2% cream 5 g single 
intravaginal application, intravaginal clotrimazole 500 mg pessary once only or 100 mg pessary 2 each night for 3 nights 
or 1 each night for 6 nights or 1% cream 5g nightly for 6 nights or 2% vaginal cream 1 applicator full for 3 nights or 
10% vaginal cream 1 applicator full as single dose at night, miconazole nitrate 2% vaginal cream 5 g nightly for 7 nights 
or 200 mg vaginal suppository nightly for 3 nights, nystatin 100 000 U pessary or 100 000 U/5 g cream 1 applicatorful 
inserted high into vagina 12 hourly for 7 d, tioconazole 6.5% ointment 5 g intravaginally once, terconazole 0.4% cream 5 g 
intravaginally for 7 d or 0.8% cream 5 g intravaginally for 3 d or 80 mg vaginal suppository 1 nightly for 3 nights, 
fluconazole 150 mg orally single dose (not pregnant); ± clotrimazole 1% cream to vulvovaginal and perianal areas 

Recurring or Unresponsive: clotrimazole 500 mg vaginal tablet inserted high into vagina at night, 
then weekly for 6 mo; fluconazole 50 mg orally daily, then 150-300 mg orally weekly; itraconazole 100 mg orally daily, 
then 100-200 mg orally weekly; nystatin 100 000 U/5 g vaginal cream 1 applicatorful or 100 000 U pessary intravaginally 
weekly 

Male Partner: nystatin cream locally for 14 d 
Mnltisite Carriage: oral ketoconazole 
Hypersensitisation: desensitisation 
Anergy: hyperimmune Candida transfer factor 
Trichomonas vaginalis: 

Nonlactating Adnlts: metronidazole 2 g single oral dose, tinidazole 2 g orally single dose with 
food, nimorazole 250 mg orally twice a day for 3 d or 2 g single oral dose 

Relapse: metronidazole 400 mg orally 12 hourly for 5 d 



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Infections of the Genital System 

Lactating Women: interrupt breastfeeding for 24 h after giving metronidazole 2 g orally as a 
single dose 

Children: metronidazole (< 3 y: 1/6 dose; 3-7 y: !4 dose; 7-12 years: l A dose) 
Simplexvirus: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly 
for 7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Frequent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Enteiobius vermicularis: pyrvinium embonate 
Vaginosis: conditions in which diminution in numbers of protective hydrogen peroxide-producing Lactobacilli, with 
excessive overgrowth of endogenous flora, occurs due to physiological or local factors (eg. hormonal effects, sex, douching, 
IUD, use of some local preparations); associated complications include increased risk of HIV, recurrent cystitis, pelvic 
inflammatory disease (including post-abortion and subclinical), cervicitis, abnormal Papanicolaou smears, postsurgical 
gynecologic infections, early spontaneous abortion, miscarriage after 13 weeks, preterm labour, premature rupture of 
membranes, chorioamnionitis, postpartum endometritis 

Agents: Prevotella, Peptostreptococcus, Bacteroides, Eubacterium, Gardnerella vaginalis, Mobiluncus, Mycoplasma hominis, 
enterococcus, Streptococcus agalactiae 

Diagnosis: coaty, homogenous, white, non-inflammatory vaginal discharge, pH > 4.5, amine odour with 10% KOH; Gram 
stain (clue cells with few, or no, lactobacilli) and culture of vaginal swab; DM probe-based test; card test for detection of 
elevated pH and trimethylamine; prolineaminopeptidase card test 

Treatment: metronidazole 400 mg orally 12 hourly for 7 d, tinidazole 500 mg orally daily for 7 d, nimorazole 250 mg 
orally twice daily for 3 d, metronidazole gel 0.75% 5 g intravaginally once a day for 5 d, clindamycin phosphate 2% 
vaginal cream 5 g intravaginally at bedtime for 7 nights, clindamycin 300 mg orally twice a day for 7 d, clindamycin 
ovules 100 g intravaginally once at bedtime for 3 d; restoration of acid pH with Acigel™ etc 

Pregnancy: treatment in early pregnancy reduces preterm birth by 60%; clindamycin 300 mg orally twice 
daily for 7 d, metronidazole 400 mg orally 12 hourly for 7 d 

Vaginal Discharge also occurs in 28% of cases of Staphylococcus saprophytics urinary tract infection. Nonvenereal 
vaginal discharge is responsible for 0.7% of new episodes of illness in the UK. Non-infective causes include cervical 
ectropion; pregnancy; estrogen deficiency (atrophic vaginitis); inflammation due to douches, deodorants, bath salts, perfumes, 
etc. Syphilis may also present with vaginal discharge. 

Genital Tract Listeriosis: usually inapparent disease of genital tract; may be transmitted from pregnant female to 
offspring either transplacental^ or by contact with infected secretions during delivery; hospital infections not uncommon 
and probably transmitted via hands of nurse 
Agent: Listeria monocytogenes 
Diagnosis: culture of vaginal swab 
Treatment: amoxycillin/ampicillin 
Mucopurulent Cervicitis 

Agents: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, Trichomonas vaginalis, Candida albicans 
Diagnosis: Gram stain and culture of cervical swab; direct immunofluorescence [Chlamydia] of cytobrush (nonpregnant) or 
swab 

Treatment: see Vaginitis 
Nonpurulent Cervicitis 

Agent: human herpesvirus 2, human adenovirus 37; human cytomegalovirus in AIDS 
Diagnosis: viral culture and immunofluorescent stain of cervical swab 

Treatment (human herpesvirus 2): famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg 
orally 12 hourly for 7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Freqnent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 
Cervical Carcinoma: associated with sexual promiscuity (early coitus and multiple sexual partners) 
Agent: certain strains of human papillomavirus (HPV-16, HPV-18) 
Diagnosis (HPV-16, HPV-18): real time PCR 
Salpingitis: 0.03% of new episodes of illness in UK 

Agents: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, Campylobacter fetus subsp fetus, Escherichia 
coli, Bacteroides capillosus, Bacteroides putredinis, Prevotella disiens, Actinomyces israelii 



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Infections of the Genital System 



Diagnosis: clinical; Gram stain and culture of endocervical swab, culdocentesis material, material taken at operation; 

leucocytosis (white cell count > 10,000/f.iL); ultrasound (pelvic abscess or inflammatory complex) 

Treatment: doxycycline + benzylpenicillin 

Tubo-Ovarian Abscess 

Agents: 37% Escherichia coli, 22% Bacteroides fragilis, 26% other Bacteroides species, 19% aerobic streptococci, 17% 

Peptostreptococcus, 11% Peptococcus, 7% Neisseria gonorrhoeae 

Diagnosis: clinical and physical examination; ultrasonography; laparoscopy or laparotomy; culture of needle aspirate or 

surgical specimen; white cell count > 10,000/|.iL in 75% of cases 

Treatment: benzylpenicillin 20 M U/d i.v. in 4 divided doses + gentamicin 3-5 mg/kg/d i.v. in 3 divided doses + 

clindamycin 2.4 g/d i.v. in 4 divided doses; surgery 

Oophoritis 

Agents: mumps virus, varicella 

Diagnosis: serology 

Treatment: nonspecific 

Perihepatitis 

Agents: Neisseria gonorrhoeae, Chlamydia trachomatis 

Diagnosis: culture and immunofluorescence of cervical, urethral and rectal swabs; serology; laparoscopy 

Treatment: doxycycline + benzylpenicillin 

Rape: gonorrhoea in 2-28% of victims, syphilis in < 1%, Chlamydia in 3-16%, Trichomonas in 6-27%, bacterial vaginosis 

in 12-20% 

Investigations: history; physical examination of external genitals, of vaginal aspirate in female children presenting 

solely because of behavioural symptoms and with no genital abnormalities on external examination, of oral and anal 

mucosa (evaluate men for relaxed external sphincter, anal fissures and hemorrhoids, ascertain condition of prostate gland 

and perform proctoscopy if anorectal injury present or infection suspected); complete speculum and bimanual examination in 

women and female children if external examination shows any genital abnormality or if there is a history of recent vaginal 

penetration or if child presents with genital symptoms alone rather than with a history of sexual assault (general 

anesthesia may be necessary); culture or nucleic amplification test (confirm with second nucleic acid amplification test 

targeting different sequence if positive) for Neisseria gonorrhoeae and Chlamydia from any sites of penetration or 

attempted penetration, wet preparation and culture of vaginal swab for Trichomonas vaginalis, bacterial vaginosis and 

candidiasis; serology for syphilis, HIV and hepatitis B 

Prophylaxis: if assailant is infected, victim is unlikely to return for follow-up or has signs or symptoms of infection, 

assault by a stranger, or prophylaxis requested by victim; ceftriaxone 250 mg (child: 125 mg) i.v. or i.m. as single dose 

(spectinomycin 40 mg/kg to 2 g i.m. if allergic to cephalosporins) + azithromycin 20 mg/kg to 1 g orally single dose + 

metronidazole 30 mg/kg to 2 g orally single dose or tinidazole 50 mg/kg to 2 g orally single dose; hepatitis B vaccine if 

unvaccinated + hepatitis B immunoglobulin if assailant known to be infected; HIV prophylaxis if unprotected receptive or 

insertive anal or vaginal intercourse and assailant known or suspected infected (consult HIV physician) 

Follow-up: after 7 d, above tests less syphilis serology; after 6 w, syphilis serology 

Genital Ulceration 

Agents: Treponema pallidum, Haemophilus ducreyi, simplexvirus, Chlamydia trachomatis, Calymmatobacterium granulomatis 

Diagnosis and Treatment: serology and darkfield examination or direct immunofluorescence test for Tpallidum, 

culture or antigen test for simplexvirus, culture for Haemophilus ducreyi; see Syphilis, Chancroid, Genital Herpes, 

Chlamydial Lymphogranuloma, Granuloma Inguinale 

Syphilis: a treponematosis; three forms recognised: acquired syphilis, congenital syphilis and nonvenereal syphilis 

Acquired Syphilis (Great Pox, Lues, Lues Venerea, Morbus Gallicus, St Job Disease, St Sement 

Disease): worldwide; « 2000 notified cases/y in Australia (« 42% in Queensland); incidence in USA 2.2/100,000; 3% of 

male sexually transmitted disease, 2% of female; 15% incidence in homosexuals; transmission by intimate contact with 

infectious exudates, almost exclusively during sexual contact; 30-60% of sexual partners become infected after 1 exposure; 

may pass through the placenta as early as ninth week of pregnancy in 2/3 or more of pregnancies, causing spontaneous 

abortion, stillbirth or neonatal death in 40% of cases; incubation period 10-90 d (mean 21 d); manifested in 3 stages: 

primary syphilis, secondary syphilis, tertiary syphilis; for public health purposes, it is convenient to classify cases either as 

early syphilis (covering both primary and secondary stages) or late syphilis 

Agent: Treponema pallidum subsp pallidum 

Diagnosis: 



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Primary: the initial stage, during which widespread dissemination of Treponema pallidum occurs; history of 
sexual contact often of doubtful reliability; only clinical manifestations are the chancre (dry papule, hard chancre, hard 
sore, hard ulcer, Hunter chancre, hunterian chancre, primary syphilitic sore, ulcus durum, ulcus induratum) — a hard lesion 
or painless ulcer on genitalia, perianal area, pharynx, tongue, lips appearing 10-90 d after infection and usually healing 
spontaneously in 4-6 w — and nontender, rather firm, unilateral regional lymphadenitis (primary syphilitic lymphadenitis); 
every lump, ulcer or fissure on, in or near the genitalia or anus should be suspected as being possibly primary syphilis; 
dark ground illumination and direct immunofluorescence of tissue fluid from chancre 3-4 w post-infection; TPHA or ELISA 
(sensitivity 97-100%, specificity 99.5-100%), quantitative RPR if positive, FTA-ABS if negative and clinical suspicion (all 
may be negative in AIDS); Western blotting; PCR or ligase chain reaction of lesion, tissue, CSF, blood 

Secondary: begins at end of primary syphilis and lasts a few weeks to a year of more; principal 
manifestations a wide variety of skin lesions — macular, papular, maculopapular, pustular, ulcerative, follicular or nodular 
rash (syphilids), mucous patches (highly infectious lesions of a mucous membrane; 'snail-track ulcers'), condylomata lata 
(pale-coloured raised papular lesions, often with a flat surface, most frequently in genital and anal areas) — in « 90%; 
generalised lymphadenopathy (diffuse, rubbery, symmetric, painless, small inguinal, posterior cervical, occipital, axillary, 
epitrochlear) in « 85%; headache, fever, arthralgias, sore throat, rhinitis, tearing in « 70%; rare meningismus, aseptic 
meningitis, cranial nerve involvement, oculopathy (cyclitis, iritis, choroiditis, retinitis), visceral (hepatitis, pericholangitis, 
mild nephrotic syndrome, rarely hemorrhagic nephritis), osteochondropathy (usually periostitis of long bones), myositis; any 
anogenital lump, generalised rash, mouth ulcer, alopecia or generalised lymphadenopathy should be suspected as being 
possibly due to secondary syphilis; dark ground examination of mucosal or cutaneous lesion; positive VDRL (99% positive) 
in the presence of positive FTA-ABS (99% positive) or TPHA (96% positive) 

Latent: no physical signs; history of syphilis inadequately treated; positive FTA-ABS (96-99% positive) or TPHA 
(* 95% positive); VDRL positive for « 75%; CSF negative 

Recurrent Secondary Syphilis (Recurring Secondary Syphilis, Secondary Syphilitic Relapse): 
secondary syphilis, of any form, recurring after a period (of any duration) of latent syphilis 

Late (Tertiary): not infectious; 25% of untreated patients asymptomatic (elevated protein, pleocytosis, positive 
serology of CSF); 6% symptomatic neurosyphilis (5-10 y: neurolues — meningovascular neurosyphilis, characterised by 
obliterative endarteritis, may cause syphilitic hydrocephalus, meningoencephalitis, seizures, stroke, transverse myelitis; 
15-20 y: general paresis (cerebral tabes, syphilitic meningoencephalitis, dementia paralytica, general paralysis of the insane, 
general progressive paralysis, paralytic dementia, paretic dementia) — generalised meningoencephalitis as a manifestation of 
neurosyphilis, leading to fibrosis of meninges and atrophy of the brain with ultimately dementia and paralysis; 25-30 y: 
tabes dorsalis (locomotor ataxia, posterior sclerosis, syphilitic posterior spinal sclerosis, tabetic neurosyphilis) — degeneration 
of posterior column of spinal cord as a late manifestation of neurosyphilis, complications including Charcot joint resulting 
from neurotrophic disturbances, and severe gastric functional disturbances with paroxysm ('gastric crisis'); neuritis arising 
as a manifestation of neurosyphilis most commonly affects the acoustic and optic nerves, the Argyll-Robertson pupil being 
a classic manifestation); 10% cardiovascular symptoms (mesaortitis with aortic aneurism as possible consequence, 
endocarditis, pericarditis, aortic valve insufficiency, aortic ectasia particularly ascending aorta, coronary artery stenosis); 
uncommonly cutaneous (one or more indolent nodules and/or gummata distributed symmetrically) or mucocutaneous; 
gummata may affect skin, mucous membrane, bone, soft tissue, almost any organ; osteochondropathy affecting cranial 
bones, tibia, clavicle, fingers, toes, causing bone pain, pathologic fractures, joint destruction, nasal septal and/or palatal 
perforation; myositis; visceral (most frequently hepatitis, nephropathy 

Late Benign or Cardiovascnlar: positive FTA-ABS (97% positive) or TPHA (« 95% positive) on serum and 
a normal CSF examination 

Nenrosyphilis: CSF leucocyte count > 5/mm 3 ; VDRL on CSF (sensitivity 30-70%); if negative, 
microhemagglutination or FTA-ABS on CSF; if these positive, TPHA index, IgG TPHA ratio, quantitative MHA-TP 
Treatment: 

Primary, Secondary or Early Latent: benzathine penicillin G 37.5 mg/kg to 1.8 g i.m. as a single dose at 
once, giving '/a dose into each buttock, followed if possible by 1.8 g after 7 d; aqueous procaine penicillin 1 g i.m. daily for 
10 d; treat all sexual contacts within last 3 mo even if RPR negative 

Penicillin Hypersensitive: consider desensitisation; doxycycline 100 mg orally 12 hourly for 14 d 
(not pregnant or breastfeeding) 

Hnman Immunodeficiency Virus Infected Patients: benzylpenicillin 2.4 MU i.v. 4 hourly for 
10 d, aqueous procaine penicillin 2.4 MU i.m. daily + probenecid 500 mg orally 6 hourly 



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Late Latent: benzathine penicillin 37.5 mg/kg to 1.8 g i.m. once weekly for 3 w, procaine penicillin 1 g i.m. 
once daily for 15 d 

Penicillin Hypersensitive: consider desensitisation; doxycycline 100 mg orally 12 hourly for 28 d 
(not pregnant or breastfeeding) 

Tertiary: benzylpenicillin 1.8 g i.v. 4 hourly for 15 d 

Cardiovascnlar Syphilis, Neurosyphilis: + prednisolone or prednisone 20 mg orally 12 hourly for 3 doses 
Follow-up: 

Primary: serology every 3 mo for 1 y 

Secondary, Latent and Late: serology every 3 mo for 1 y, then at 18 and 24 mo 
Prophylaxis (Exposnre <30 d): procaine benzylpenicillin 2.4-4.8 MU i.m., ceftriaxone 125 mg single dose 
Prevention and Control: exposure prevention, identification and treatment of cases 
Congenital syphilis: see Chapter 5 

nonvenereal syphilis (bejel (euphrates valley), dlchuchwa (botswana), endemic syphilis, endemic 
Syphilis of the Bedouins, Njovera (Zimbabwe), Siti (Gambia, Senegal), Skerljevo or Skrlevo (Bosnia- 
Herzegovina, Macedonia)) 
Agent: Treponema pallidum subsp endemicum 

Diagnosis: similar to Acquired Syphilis except primary stage often passes unnoticed and more serious late 
manifestations are rare; all serological tests for syphilis positive; differential diagnosis from acquired syphilis only possible 
within epidemiological setting 
Treatment: as for Acquired Syphilis 

Chancroid (Chancrelle, Chancre NIou, Chancre Simplex, Ducrey Chancre, Ducrey Disease, Genital 
Ulcer, Simple Chancre, Soft Chancre, Soft Sore, Ulcus Molle): worldwide; acute, sexually transmitted 
infectious disease of the genitalia; people infectious as long as they have ulcers; no transmission from mother to fetus or 
during delivery; rare cases in Australia; « 700 cases/y in USA; incubation period 1-10 d (usually 3-7 d); found in 15% of 
primary syphilitic chancres and 28% of patients with herpes genitalis 
Agent: Haemophilus ducreyi 

Diagnosis: women may have no symptoms; 1 or more painful pustular lesions, at entrance to vagina and around anus in 
women and on penis in men, that may rupture to form suppurative ulcers; women may have pain on urination or 
defecation, rectal bleeding, pain on intercourse or vaginal discharge; regional lymphadenopathy (inguinal adenitis with 
softening appearing after 7-10 d) in up to l A of cases; microscopy (characteristic arrangement of bacteria) and culture (high 
humidity at 33-35 C on enriched gonococcal agar + 1% bovine hemoglobin + 5% serum and on Muller-Hinton agar + 5% 
chocolatised horse blood, repeating culture on first medium at 48 h) of swab of lesion or aspirate from flocculant node 
(sensitivity 92%; negative cultures 38% prior medication, 38% syphilis, others ?); occasionally, a biopsy may be required; 
tests for syphilis and simplexvirus virus negative 

Treatment (Patients and Sexnal Partners): ulcers disappear without treatment usually in about a month but may 
last up to 12 w; azithromycin 1 g orally as single dose (not in pregnant or breastfeeding), ceftriaxone 250 mg i.m. as a 
single dose, ciprofloxacin 500 mg twice a day orally for 3 d (not in pregnant or lactating women), erythromycin 500 mg 
orally 8 hourly for 7 d, cotrimoxazole 160/800 mg orally 12 hourly for minimum 10 d, tetracycline 500 mg orally 6 hourly 
for 14-21 d, sulphisoxazole 1 g orally 6 hourly for 10 d, amoxycillin-clavulanate 500/125 mg 8 hourly for 7 d, rosoxacin 
450 mg 12 hourly orally for 3 d; reexamine 3-7 d after initiation of therapy; incision and drainage of buboes if required 
Prevention and Control: exposure prevention 

Genital Herpes: 5% of sexually transmitted disease in male, 4% in female; 0.2-0.5 ffl cases/y in USA (20% 
seroprevalence in > 12 y old; 30% increase in past decade); 10% incidence in homosexuals; 30/100,000 physician's visits; 
17% of women and 4% of men infected when living with infected partner for median 344 d; > 90% of persons with 
genital simplexvirus 2 shed virus asymptomatic ally; incubation period 1-26 d (average 6-7 d) 
Agent: simplexvirus (up to 30% simplexvirus 1 (recurrences much less frequent), remainder simplexvirus 2) 
Diagnosis: 60% unrecognised with symptoms, 20% recognised genital herpes, 20% truly asymptomatic; painful, multiple, 
blisterlike, ulcerating lesions in and around vagina, around anus or on thighs in women or on penis in men; can cause 
vulval/perianal fissures, internal lesions, reddening on buttocks/thighs, painful urination, vaginal/urethral discharge, 
aching lower limbs, headache, radicular or lower back pain, fever, malaise, stiff neck, abnormal sensitivity to light; may 
mimic cystitis, candidiasis or prostatitis; can lead to cervicitis and proctitis; '/a of those infected have recurrences, 
involving smaller and fewer lesions and less severe systemic reactions, though pain, numbness or tingling in buttocks, legs 
or hips may precede outbreak; immunofluorescence, viral culture (Cellmatics™ mink lung cells most useful cell line for 



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Infections of the Genital System 



isolation and typing; if other viruses also sought, MRC-5 is probably the most suitable cell line; virus isolated from cervix 
in 70-90% of primary, but only 30-50% of recurrent, cases), Tzanck preparation (insensitive and nonspecific), ELISA 
(antigen and antibody; commercial systems inaccurate or misleading regarding virus type), PCR (100% specificity, greater 
sensitivity than culture), electron microscopy, Western immunoblot assay (type specific; sensitivity and specificity « 100%), 
glycoprotein G-2 immunoblot assay (type specific; sensitivity 80-98%, specificity > 96%) 

Treatment: paint with povidone iodine 6 times daily for 7 d; famciclovir 500 mg orally 12 hourly for 5 d, valaciclovir 
500 mg orally 12 hourly for 5 d, aciclovir 400 mg orally 8 hourly for 5 d (preferred in pregnancy); lignocaine 2% jelly may 
be used in first 24-36 h for pain relief 

Infrequent, Severe Recurrences: commence at onset of prodromal symptoms or within 1 d of 
lesion onset; aciclovir 400 mg orally 8 hourly for 5 d (preferred in pregnancy), famciclovir 1 g orally for 1 d or 
125 mg orally 12 hourly for 5 d or 500 mg orally 12 hourly for 7 d (in immunocompromised), valaciclovir 500 mg 
orally 12 hourly for 3 d 

Frequent, Severe Recurrences: famiclovir 250 mg (500 mg in immunocompromised) orally 12 
hourly for up to 6 mo, valaciclovir 500 mg orally 12 hourly (in immunocompromised) or 500 mg orally daily (< 10 
recurrences per year on suppressive therapy) or 1 g orally daily (> 10 recurrences per year on 
immunosuppressive therapy) for up to 6 mo, aciclovir 200 mg (400 mg in late pregnancy) orally 1 hourly for up to 
6 mo 

Chlamydial Lymphogranuloma (Benign Inguinal Lymphogranuloma™, Climatic Bubo, Durrant- 
Nicholas-Farre Disease, Frei Disease, Inguinal Lymphogranulomatis, Lymphogranuloma inguinale, 
Lymphogranuloma Inguinalis, Lymphogranuloma Tropicum, Lymphogranuloma Venereum, Lymphoma 
Inguinale, Lymphomatosis Inguinales Suppurativa Subacuta, Lymphopathia Venerea, Lymphopathia 
Venereum, Nicholas-Farre Disease, Poradenitis Inguinalis, Poradenitis Nostras, Poradenitis Venerea, 
poradenolymphitis, poradenolymphitis nostras, poradenolymphitis suppurativa, suppurative inguinal 
Adenitis, Tropical Bubo, Venereal Lymphogranuloma, Venereal Lymphopathy): principally tropical 
countries, including Australia (last notified case in 1995); incidence 0.09/100,000 in USA; < 1% of sexually transmitted 
disease; transmission by venereal contact; probably less transmissible than gonorrhoea; incubation period 3-12 d for genital 
lesion, 10-30 d for inguinal bubo 
Agent: Chlamydia trachomatis U-U serovars 

Diagnosis: transient small papule (cutaneous or mucosal), subsequent slowly suppurating, tender inguinal and femoral 
buboes (most commonly unilateral) and lymphadenopathy, often with microabscess formation; women and homosexual men 
have no symptoms or lower abdominal or back pain, proctocolitis or inflammatory involvement of perirectal or perianal 
lymphatic tissues resulting in fistulas or strictures; 20-30% of women have inguinal buboes; systemic symptoms; anal 
intercourse may lead to rectal infection; 2/3 of buboes shrink and form fibrous masses, 1/3 rupture and leave scars; may 
be anorectal and/or vulvar lesions and genito-anorectal strictures (esthiomene) as a manifestation of chronic stage; 
prostatitis has been described as a subacute phenomenon; in 20%, inguinal lymph nodes separate from femoral lymph nodes 
to form inguinal groove; other sequelae include fistula, chronic inflammation of lymph nodes, cervicitis, urethritis and 
enlargement of genitalia; cytology and microimmunofluorescence of pus or biopsy; serology (complement fixation titres 
> 1:64); dark ground illumination, tests for Haemophilus ducreyi and acid-fast bacilli negative; skin test (Frei test); white 
cell count 20,000/nl 

Treatment: doxycycline 100 mg orally twice daily for 21 d (not in pregnant or breastfeeding), roxithromycin 300 mg 
orally daily for 21 d, azithromycin 1 g orally weekly for 3 w (not in pregnant or breastfeeding), erythromycin 30 mg/kg to 
500 mg 4 times a day for 21 d; aspiration of infected buboes; surgical treatment of strictures 
Prevention and Control: exposure prevention, treatment of cases 

Granuloma Inguinale (Chronic Venereal Sores, Donovaniasis, Donovaniosis, Fifth Venereal Disease, 
Granuloma Contagiosa, Granuloma Genito-inguinale, Granuloma Inguinale Tropicum, Granuloma 
Pudendi, Granuloma Pudendi Tropicum, Granuloma Venereum, Granuloma Venereum Genito-inguinale, 
Infective Granuloma, Lupoid Form of Groin Ulceration, Pudendal Ulcer, Sclerosing Granuloma, 
Serpiginous Ulceration of the Genitals, Serpiginous Ulceration of the Groin, Ulcerating Granuloma 
of the Genitals, Ulcerating Granuloma of the Pudenda, Ulcerating Sclerosing Granuloma, Venereal 
Granuloma): a chronic mucocutaneous disease; endemic in India, Papua New Guinea, central Australia, southern Africa; 
16 notified cases in Australia (tropical and near tropical areas) in 1999, showing steady decrease from 119 notified cases 
in 1994; incidence 0.02/100,000 in USA; usually transmitted by sexual contact; incubation period 8-80 d 
Agent: Klebsiella granulomatis 



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Infections of the Genital System 



Diagnosis: women may have no symptoms; painless, spreading, ulcerating, granulomatous lesions of genitalia (usually 
labia, prepuce or glans) and adjacent areas (extragenital lesions uncommon); lesion is covered by beefy-red granulation 
tissue and has raised-rolled, but not undermined, margins, and bleeds easily on contact; without treatment, may erode 
genitalia or block urethra; no regional lymphadenopathy; Giemsa stain of tissue scrapings from granuloma or aspirate from 
enlarged lymph glands (Donovan bodies' seen in cytoplasm of mononuclear cells); precipitin and complement fixation tests 
Treatment: 

Not Pregnant or Breastfeeding: azithromycin 500 mg orally once daily for 7 d or 1 g orally once weekly 
for 4 w or until healing occurs, doxycycline 100 mg orally 12 hourly or 200 mg orally daily for 3-6 w, cotrimoxazole 
160/800 mg orally 12 hourly for 3-6 w, chloramphenicol 500 mg orally 6 hourly for 2-6 w (average total dose required 
may reach 33.6 g in Papua New Guinea), gentamicin 1 mg/kg i.v. 8 hourly for up to 21 d, ciprofloxacin 750 mg orally 4 
times a day for at least 3 w 

Pregnant or Breastfeeding: erythromycin 500 mg orally 6 hourly for 3-6 w, roxithromycin 300 mg orally 
once daily for 2-6 w 

Prevention and Control: exposure prevention 
Venereal Warts (Condylomata Acuminata): 20% incidence in homosexuals 
Agent: human papillomavirus (types 6 and 11 > 90%) 
Diagnosis: cytology 
Treatment: 

Vaginal: cryotherapy with liquid nitrogen; bichloroacetic acid or trichloroacetic acid 80-90% weekly 

Urethral: cryotherapy with liquid nitrogen, podophyllin 10-25% in compound tincture of benzoin weekly 

Anal: cryotherapy with liquid nitrogen, trichloracetic acid or bichloracetic acid 80-90% weekly, surgical removal 

Oral: cryotherapy with liquid nitrogen, surgical removal 

Others: podofilox 0.15% cream or 0.5% solution or gel topically twice daily for 3 consecutive days each week 
for 4-6 w until warts disappear (not pregnant or breastfeeding); imiquimod 5% cream topically once daily at bedtime and 
washed off after 6-10 h 3 times a week for up to 16 w (not pregnant or breastfeeding); cryotherapy repeated every 1-2 w 
until resolved; podophyllin resin 25% in compound tincture of benzoin topically and washed off after 6 h weekly until 
warts disappear (not pregnant); trichloroacetic acid or bichloroacetic acid 80-90% weekly; electrosurgery; surgical removal; 
intralesional interferon; laser surgery 

Note: human papillomavirus 16 and 18 cause 70% of cervical cancers; they may be detected by PCR or dot-blot; 13 other 
high risk types cause the remainder; all high risk types can (uncommonly) cause penile intraepithelial neoplasia; types 16 
and 18 also cause 25% of low-grade squamous intraepithelial lesions, while types 6 and 11 cause 5-25%; types 6 and 11 do 
not cause cervical cancer 

Erythroplasia of Queyrat: carcinoma in situ of penis 
Agent: human papilloma virus 16 
Diagnosis: cytology 
Treatment: 5% imiquimod cream 
Molluscum Contagiosum: benign cutaneous viral disease 
Agent: molluscum contagiosum virus (poxvirus) 
Diagnosis: cytology 

Treatment: deroof aseptically with a needle or sharp pointed stick and express contents or treat as for warts 
Balanitis 

Agents: superficial skin infection with Staphylococcus aureus, Streptococcus pyogenes, overgrowth of normal skin 
organisms due to poor hygiene; balanoposthitis due to Candida, Bacteroides, Porphyromonas asaccharolytica, Prevotella 
melaninogenica, anaerobic cocci, Treponema species other than Treponema pallidum subsp pallidum and Treponema pallidum 
subsp pertenue (may be acute ulcerative necrotising (Corbus disease, corrosive balanitis, erosive balanitis, fourth venereal 
disease, ulcerative balanoposthitis, venereal balanitis); severe tissue destruction may result and gangrene (balanitis 
gangrenosa, gangrenous balanitis, specific and ulcerative balanoposthitis) may occur), simplexvirus, Neisseria gonorrhoeae, 
Trichomonas vaginalis, circinate balanitis in Reiter's syndrome 
Diagnosis: inflammation of the glans penis + inflammation of prepuce; culture of swab 
Treatment: cleaning with normal saline 

Candida: clotrimazole 1% + hydrocortisone 1% cream topically 12 hourly or miconazole 2% + hydrocortisone 
1% topically twice daily for 2 w after symptoms resolve; screen for diabetes; consider circumcision in extreme recurrent 
relapsing 



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Infections of the Genital System 



Sexually Transmitted Diseases: see relevant sections 
Staphylococcus: di(flu)cloxacillin 12.5 mg/kg orally or i.v. 6 hourly for 5-7 d 
Streptococcus pyogenes: phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly for 10 d 
Other Bacteria: erythromycin orally 12 hourly for 5-7 d, roxithromycin orally once daily for 5-7 d 



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Chapter 5 

Prenatal, Perinatal and Puerperal Infections 

Abortion 

Agents: rubella, human cytomegalovirus, vaccinia, hepatitis B, Lassa fever virus, smallpox, varicella (20% 

mortality), Listeria monocytogenes (infection in first trimester found in Middle East, not in Western Europe, where 

infection in third trimester occurs), Haemophilus influenzae, Campylobacter fetus subsp fetus, Campylobacter jejuni, 

Campylobacter coli, Leptospira, Streptococcus agalactiae, Coxiella burnetii, Streptococcus equinus 

Diagnosis: serology (complement fixation test, hemagglutination inhibition); bacterial and viral culture of saliva, 

gastric washings, urine, liver biopsy; post-mortem histology of salivary glands, adenoids, kidneys, liver, lymph 

glands, myocardium, spleen, pancreas, adrenals; serology 

Prophylaxis: 

Listeria monocytogenes in Pregnancy: benzylpenicillin 15-20 MU i.v. daily in divided doses for 
2 w + gentamicin 1.3 mg/kg i.v. 8 hourly 

Coxiella burnetii in Pregnancy; cotrimoxazole for duration of pregnancy 

Rubella: mass immunisation of girls and boys; pre-pregnancy screening for rubella antibodies, followed 
by immunisation of susceptible women; antenatal screening for rubella antibodies, followed by post-partum 
immunisation of susceptible women 

Varicella: live attenuated vaccine (44-85% effective; do not administer if pregnant) 
Stillbirth 

Agents: 14% parvovirus B19, rubella virus, human cytomegalovirus, hepatitis B, Treponema pallidum, Toxoplasma 
gondii, Listeria monocytogenes, Campylobacter fetus subsp fetus 

Diagnosis: bacterial and viral culture of lymph nodes, lung, spleen, other tissues; serology (rubella: 
hemagglutination inhibition, complement fixation test) 

Parvovirus B19: ELISA (IgM, IgG (kits using recombinant protein more sensitive and specific than 
those using a synthetic peptide)), PCR of maternal serum or amniotic fluid 

Toxoplasma gondii: isolation from placenta, umbilical cord or infant blood; PCR of white blood 
cells, CSF or amniotic fluid (reference laboratory); IgM and IgA serology; IgG avidity (urea dissociable) 
Prophylaxis: 

Listeria monocytogenes in Pregnancy: benzylpenicillin 15-20 MU i.v. daily in divided doses for 
2 w ± gentamicin 1.3 mg/kg i.v. 8 hourly 

Coxiella burnetii in Pregnancy; cotrimoxazole for duration of pregnancy 

Toxoplasma gondii in Pregnancy: spiramycin 3 g orally in divided doses 

Rubella: see under Abortion 

Syphilis: routine antenatal screening and treatment of infected women 
Teratogenic Effects 

Agents: rubella (transient common: intrauterine growth retardation, large anterior fontanelle; transient uncommon: 
cloudy cornea; permanent common: sensorineural deafness, spastic diplegia, patent ductus arteriosus, pulmonic 
stenosis, cataract and microphthalmia, retinopathy; permanent uncommon: glaucoma, inguinal hernia, 
cryptorchidism; permanent developmental common: central language disorders, mental retardation, behavioural 
disorders; permanent development uncommon: severe myopia), human cytomegalovirus, human immunodeficiency 
virus, lymphocytic choriomeningitis virus (from pet rodents) 

Diagnosis: serology (rubella specific IgM present or infant's IgG titre does not fall off at expected rate of 1 
doubling dilution per month); viral culture of throat swab and urine; ELISA, Western blot 
Prophylaxis (Rubella): see under Abortion 
Prenatal Generalised Disease 

Agents: human cytomegalovirus (3-15% of pregnancies, 0.4-7% of live births; multisystem involvement 
(cytomegalic inclusion disease), usually a sequel of primary maternal infection; microcephaly, seizures, mental 
retardation, periventricular calcification, deafness (inner ear involvement), chorioretinitis, hepatosplenomegaly, 
jaundice, thrombocytopenia, petechial rash; sequelae in 90% of survivors — 70% microcephaly, 60% mental 



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Prenatal, Perinatal and Puerperal Infections 



retardation; most disappear within 4 y, but 29% IQ < 90, 16% IQ < 80, 16% microcephaly, 12% bilateral hearing 
loss, 2% chorioretinitis), simplexvirus (5% of neonatal herpes, 1 in 300,000 deliveries; 10% risk if infection > 32 
w gestation; if mother has first episode, 50% infected at birth; during recurrent episode, 3-5%; most transmission 
occurs while mother has no symptoms), rubella (0.1-4% of pregnancies, 0.05-3% of live births; transient common: 
thrombocytopenic purpura, hepatosplenomegaly, meningoencephalitis, bone lesions; transient uncommon: generalised 
adenopathy, hepatitis, hemolytic anemia, pneumonia, myocarditis), Neisseria gonorrhoeae, Treponema pallidum 
subsp pallidum, varicella-zoster (malformations, 18% disseminated infections), Listeria monocytogenes (neonatal 
disseminated listeriosis (disseminated infantile listeriosis, granulomatosis infantiseptica, listeriosis of the newborn) 
contracted transplacental^ and widely distributed in the fetus, resulting in abortion, premature birth, stillbirth or 
death shortly after delivery), Plasmodium, Candida (low birth weight, pneumonia and skin rash), Campylobacter 
fetus subsp fetus, Campylobacter jejuni, Toxoplasma gondii (meningitis) 

Diagnosis: cultures of blood and urine; Giemsa stain of blood film; demonstration of specific IgM antibody in 
cord or neonatal serum (hemagglutination inhibition, passive hemagglutination, immunofluorescence, ELISA); 
serology of CSF; viral culture of throat swab, saliva, gastric washings, urine 

Congenital Human cytomegalovirus Disease: hepatomegaly in 100%, splenomegaly in 100%, 
mental retardation in 80%, microcephaly in 80%, motor disability in 75%, jaundice in 66%, petechiae in 55%, 
chorioretinitis in 30%, cerebral calcification in 25%; increased cord serum IgM in 85%, atypical lymphoctosis in 
80%, increased SGOT in 80%, thrombocytopenia in 60%, increased bilirubin in 60%, increased CSF protein in 45%; 
viral culture positive at birth or within 1-2 w, characteristic inclusions seen on cytological examination of urine, 
IgG antibody; early marker of fetal infection is depression of cellular immunity in mother during pregnancy when 
exposed to primary human cytomegalovirus infection 

Maternal Rubella Infection dnring Pregnancy: rising titres in hemagglutination and 
complement fixation tests; high titres of specific IgM 

Congenital Malaria: platelet count 32,500/ pL, serum bilirubin 4.1 mg/dL, white cell count 
6900/ pL, haematocrit 28% 

Congenital Syphilis (Antenatal Syphilis, Foetal Syphilis, Prenatal Syphilis): syphilis 
arising in a neonate, infant or child as a result of intrauterine infection of fetus; fetus is infected transplacental^ 
as early as the ninth to tenth week of gestation in 2/3 or more of pregnancies; incidence 13/100,000 live births 
in USA; CSF analysis for VDRL, cell count and protein; complete blood count, differential and platelet count; long 
bone radiographs; other tests as clinically indicated 

Early (Not Before Third Week Postpartnm in 80% of Infants): rhinitis (snuffles; 
early congenital/prenatal syphilitic coryza; obstruction and discharge — often bloody; one of most characteristic 
features of early congenital syphilis; severe cases may lead to permanent cracks or fissures (rhagades) about nose 
or mouth); laryngitis causing characteristic aphonic cry; often fatal pneumonia (early congenital syphilitic 
pneumonia, indurative syphilitic pneumonia of the newborn, pneumonia alba, primary congenital syphilitic 
pneumonia) in about 20% of cases, with diffuse interstitial fibrosis and fatty degeneration of lung parenchyma; 
bullae and vesicles; diffuse maculopapular or papulosquamous desquamative rash, most commonly on palmar, 
plantar, facial and anal areas; mucous patches; condylomata lata; osteitis (syphilitic osteitis of the newborn; nasal 
osteitis may cause destruction of vomer and saddle nose), osteomyelitis, periostitis (a hypertrophic, progressive 
condition affecting tibia leads to sabre shin), osteochrondritis (syphilitic osteochondritis of the newborn, Wegner 
disease, Wegner osteochondritis; femur and humerus most frequently affected; severe osteochondritis may lead to 
epiphysial separation, causing early congenital syphilitic paralysis — Bednar-Parrot disease, Parrot disease, Parrot 
pseudoparalysis, syphilitic pseudoparalysis), epiphysitis, chondroepiphysitis, perichondritis may be present at birth; 
hepatosplenomegaly; jaundice; thrombocytopenia, leucocytosis, anemia; paroxysmal cold hemoglobinuria; nephropathy 
(mild, acute nephritis, nephrotic syndrome or both); neurologic signs; lymphadenopathy 

Latent Congenital Syphilis: serum is serologically positive and CSF negative and there 
are no symptoms 

Late Congenital Syphilis (Syphilis Hereditaria Tarda): 2-30 y; interstitial keratitis 
gives cornea ground-glass appearance, becomes bilateral and leads to blindness; nerve deafness ('eight nerve 
deafness' affecting vestibulomandibular (eighth cranial) nerve); recurrent arthropathy (hydrarthosis; Clutton joint, 
Clutton syndrome; most frequently knee); odontopathy (notched incisors — Hutchinsonian teeth, Hutchinson's 
incisors, Huthinson teeth; domed front molars — Moon molars, Moon teeth; first molars with botryoidal occlusal 
surface — mulberry molars, mulberry teeth); frontal bosses a common result of hypertrophic periostitis; poor 



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Prenatal, Perinatal and Puerperal Infections 



maxillary development; protruding mandible; high palatal arch; rhagacles; thickening of inner part of right clavicle 
(clavicular sign, Higoumenakis sign); flaring scapulas; neurosyphilis; gumma; (Hutchinson triad = congenital 
syphilitic keratitis with eighth nerve deafness and notched incisors); rising VDRL titre diagnostic; positive FTA- 
ABS-IgM suggestive but not diagnostic (10% false positive); negative FTA-ABS-IgM does not exclude diagnosis 
(35% false negative); results for both improved using 19S reagent; DFA Tp monoclonal; EIA IgM; immunoblot Igffl 
of serum; PCR of serum or blood 

Listeria monocytogenes: respiratory distress, vomiting, diarrhoea, maculopapular skin lesions, 
hepatosplenomegaly, meningitis; blood cultures, CSF examination 

Toxoplasma gondii: mostly few symptoms at birth; later, generally develop mental retardation, 
severely impaired eyesight, cerebral palsy, seizures unless treated; isolation from placenta, umbilical cord or infant 
blood; PCR of white blood cells, CSF or amniotic fluid (reference laboratory); IgM and IgA serology; IgG avidity 
(urea dissociable) on mother in pregnancy 

Herpes: scarring, active lesions, hypopigmentation, hyperpigmentation, aplasia cutis, erythematous 
macular exanthem, microophthalmia, retinal dysplasia, optic atrophy, chorioretinitis, microcephaly, 
encephalomalacia, hydranencephaly, intracranial calcification; PCR of CSF, blood 
Treatment: 

Gonorrhoea: benzylpenicillin 45-60 mg/kg i.v. daily in 4 divided doses for 7-10 d 

Syphilis: 

Mother Adequately Treated Before 28 w Gestation and Not Reinfected: 
benzathine penicillin 37.5mg/kg i.m. as a single dose 

Not As Above or Symptoms Present: benzylpenicillin 50 mg/kg i.m. or i.v. 12 hourly 
for 10 d, procaine penicillin 50 mg/kg i.m. daily for 10 d 

Listeria monocytogenes: benzylpenicillin 50 000-1 MU daily i.v. for 2 w 

Candida: amphotericin B 

Simplexvirus: aciclovir 

Rubella: none; consider abortion if infection detected during pregnancy 

Plasmodium: chloroquine 

Toxoplasma (in Pregnancy): spiramycin 3 g orally daily in divided doses + sulphadoxine- 
pyrimethamine 500/75 mg orally every 10 d + folinic acid; spiramycin 3 g orally in divided doses for 3 w, 
alternating with pyrimethamine-sulphadiazine 50 mg/3 g orally daily for 3 w + folinic acid 
Prophylaxis: 

Listeria monocytogenes in Pregnancy: benzylpenicillin 15-20 MU i.v. daily in divided doses 
Prevention and Control: 

Rubella: mass immunisation of girls and boys; pre-pregnancy screening for rubella antibodies, followed 
by immunisation of susceptible women; antenatal screening for rubella, followed by postpartum immunisation of 
susceptible women 

Hnman cytomegalovirus: viral isolation from amniotic fluid 

Syphilis: routine antenatal screening and treatment of infected women 

Gonorrhoea: Gram stain and culture of cervical swab of pregnant women in population groups in 
which gonorrhoea is more common, with symptoms suggestive of gonococcal infection or in a high risk group for 
STD 

Varicella: live attenuated vaccine (44-85% effective; do not administer if pregnant) 
Perinatal Generalised Disease: 25% of perinatal deaths 

Agents: Staphylococcus epidermidis (16% of neonatal sepsis/meningitis), Klebsiella pneumoniae (15% of neonatal 
sepsis/meningitis), Streptococcus agalactiae (12-25% of neonatal sepsis/meningitis; early onset pneumonia, 
septicemia, late onset meningitis, endocarditis, abscess, myocarditis, osteomyelitis), Escherichia coli (10-16% of 
neonatal sepsis/meningitis), Staphylococcus aureus (7% of neonatal sepsis/meningitis), viridans streptococci (6% 
of neonatal sepsis/meningitis; Streptococcus mitis 0-5%), Enterobacter cloacae (5% of neonatal sepsis/meningitis), 
Enterococcus (4% of neonatal sepsis/meningitis), nn-Enterococcus group D streptococci (3% of neonatal 
sepsis/meningitis), group C streptococci (0.6% of neonatal sepsis/meningitis), Streptococcus milled (0-5% of 
neonatal sepsis/meningitis), other streptococci (2% of neonatal sepsis/meningitis), Listeria monocytogenes (2% of 
neonatal sepsis/meningitis), Serratia marcescens (2% of neonatal sepsis/meningitis), Proteus (2% of neonatal 
sepsis/meningitis), Haemophilus influenzae (nontypeable strains; 0.6-8% of neonatal sepsis/meningitis; 



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Prenatal, Perinatal and Puerperal Infections 



sepsis/respiratory distress syndrome; 83% early postnatal onset, 44-66% associated maternal complications, 83-88% 
premature, 50-90% mortality), Corynebacterium (0.6% of neonatal sepsis/meningitis), Citrobacter (0.6% of neonatal 
sepsis/meningitis), Candida albicans (0.6% of neonatal sepsis/meningitis), Bacteroides fragilis (0.3-5% of neonatal 
sepsis/meningitis), Salmonella (0.3% of neonatal sepsis/meningitis), Prevotella disiens (0-5% of neonatal 
sepsis/meningitis), Peptostreptococcus magnus (0-5% of neonatal sepsis/meningitis), Clostridium perfringens, 
Neisseria gonorrhoeae, Haemophilus aprophilus, coxsackievirus B (myocarditis, hepatitis), simplexvirus (1-1.5% of 
pregnancies, 85% of neonatal herpes; risk 3-60% if present at delivery; increased risk if maternal primary 
infection, premature rupture of membranes, delayed delivery; subsp 1 and 2 both of equal severity, subsp 2 most 
common; maternal genital source in « 75%, also maternal non-genital and non-maternal (indirect transmission from 
another infant in nursery, « 10% of symptomless hospital staff excrete simplexvirus in saliva); mortality 61% in 
disseminated disease; 50% of survivors have severe sequelae; 43% skin, eye and mouth (complete recovery with 
rapid antiviral treatment, < 75% untreated advance to CNS or disseminated disease), 34% CNS (> 50% mortality), 
23% disseminated (70% mortality)), human cytomegalovirus (10% localised to salivary glands, 1-2% disseminated; 
88% kidney, 79% liver, 69% lung, 57% pancreas; 60% of neonates breastfed by mothers excreting human 
cytomegalovirus in breast milk, 55% of neonates born to mothers excreting human cytomegalovirus in cervical 
secretions; no neonates infected by mothers excreting only in urine or saliva; asymptomatic viruria in 20% of 
infants of seropositive mothers, 30% of third semester viruric mothers, 57% of postpartum and third semester 
viruric mothers, viruria delayed for 6 w; pneumonia in premature or (uncommonly) full term infants — 'gray 
pallor', hepatosplenomegaly, respiratory distress, viruria), echovirus 6, 11, 14, 19 (hepatitis), HIV (transmission rate 
from 15% in Europe to 50% in Africa), Streptococcus pneumoniae, Hafnia alvei, Streptococcus pyogenes 
Diagnosis: Gram stain and culture of gastric aspirate, throat swab, eye swab; Gram stain, immunofluorescence 
or PCR, electron microscopy, bacterial and viral culture of skin lesions swabs; Gram stain, culture and latex 
agglutination of CSF; blood cultures; viral culture of saliva, gastric washings and urine; serology; ELISA; C-reactive 
protein and interleukin levels (combined sensitivity 58-96%) 

Listeria monocytogenes: septicemia, often with meningitis; white cell count 13,600/(.iL, 36% 
neutrophils, 4% bands, 55% lymphocytes, 3% monocytes, 0.4% eosinophils 

Human cytomegalovirus: culture negative specimens at birth but positive specimens at > 4 w; 
IgG antibody 

HIV: ELISA, Western blot (immunoblot) 

Enteroviruses, Simplexvirus: virus isolation; PCR; 1/3 herpes cases with CNS disease, 23% 
disseminated 
Treatment: 

Streptococcus, Peptostreptococcus, Corynebacterium and Clostridium: benzylpenicillin 

Other Anaerobes: metronidazole 

Coliforms: gentamicin, chloramphenicol 

Neisseria gonorrhoeae: benzylpenicillin 75,000-100,000 U/kg i.v. daily in 4 divided doses for 
7-10 d 

Penicillinase-prodncing: cefotaxime or gentamicin 

Staphylococcus aureus: cloxacillin 

Listeria monocytogenes: benzylpenicillin 500,000-1 MU daily i.v. for 2 w or ampicillin + 
gentamicin 5 mg/kg daily in divided doses for 14-21 d 

Haemophilus influenzae: 

p -lactamase Negative: ampicillin for 7 d 

P -lactamase Positive: ceftriaxone or cefotaxime 

Simplexvirus: aciclovir 20 mg/kg i.v. every 8 h (preterm: 12 h) for at least 14 d (localised) or 21 d 
(disseminated) (adjust dose for renal function) 
Prevention and Control: 

Neonatal simplexvirus: good hygiene (soap and water inactivate simplexvirus); monitor patients 
with history of herpes genitalis or with a history of sexual contact with a simplexvirus-mftntti partner; culture 
cervix and any recurrence site at 32, 34 and 36 w and once a week subsequently and tell patient to report any 
prodrome to her physician; patients with active disease (lesion visible) or positive culture should have elective 
caesarean section before membrane rupture 



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Prenatal, Perinatal and Puerperal Infections 



Streptococcus agalactia?, screening of pregnant women at 35-37 w gestation by culture of 
combined vaginal and rectal swabs or by PCR at time of labour, and administration of benzylpenicillin (1.2 g i.v. 
stat, then 600 mg i.v. 4 hourly until delivery), or clindamycin (450 mg i.v. 8 hourly until delivery) or lincomycin 
(600 mg i.v. 8 hourly until delivery) if penicillin hypersensitive, to carriers 

HIV: zidovudine 2 mg/kg i.v. over 1 h to mother 4 h before caesarean section before membrane 
rupture (reduces transmission rate to 2%), then 1 mg/kg per hour i.v. until the umbilical cord is clamped; 
zidovudine 2 mg/kg orally 6 hourly or 4 mg/kg orally 12 hourly to baby after umbilical cord is clamped or 
within 6-8 h of delivery and continued for first 6 w 
Postnatal Generalised Infections 

Agents: late-developing or postpartum infection with any of the agents listed in Prenatal Generalised 
Disease and Perinatal Generalised Disease 
Postnatal Gastroenteritis 
Agent: echovirus 

Diagnosis: serology; viral culture of feces 
Treatment: rehydration 

Abortional and Puerperal Infection: 0.01% of new episodes of illness in UK 
Agents: 75% Peptostreptococcus + Bacteroides, 5% Bacteroides alone, 15% Mycoplasma hominis, Streptococcus 
pyogenes (produces peritonitis and septicemia), coliforms (post-abortion; produce endotoxic shock), Staphylococcus 
aureus (produces pneumonia and septicemia; derived from hospitalisation, i.v. therapy), Enterococcus faecalis, 
Pseudomonas (gives endotoxic shock), Clostridium (post-abortion, uterine tumours, complicated deliveries requiring 
mechanical intervention; endometritis, gross hemolysis, shock, uterine gas gangrene with fulminant septicemia), 
Haemophilus influenzae, Reromonas (incomplete abortion); anaerobes isolated from blood cultures in 76% of cases 
of septic abortion complicated by bacteremia 

Diagnosis: Gram stain and culture of swabs, pus; when possible, use culdocentesis to obtain specimens from the 
female genital tract after decontaminating the vagina with povidone iodine; double catheter and bronchial brush or 
sterile swab may be used for specimens from the uterine cavity; blood cultures 
Treatment: 

Patient Febrile bnt Not Clinically 111: amoxycillin-clavulanate 500/125 mg orally 8 hourly for 
3d 

Fever > 48 h: as above + erythromycin 500 mg orally 8 hourly or clindamycin 300 mg orally 8 
hourly until fever resolves 

Severely 111: see Septicemia 

Clostridium: penicillin 20-30 MU/d i.v., chloramphenicol, metronidazole, clindamycin, cefoxitin 
Aihnionitis 

Agents: Streptococcus agalactiae, Listeria monocytogenes, Haemophilus influenzae, Capnocytophaga, Gardnerella 
vaginalis, Streptobacillus moniliformis, anaerobes 
Diagnosis: culture of amniotic fluid 
Treatment: ampicillin + metronidazole 
Chorioaihnionitis 

Agents: 22% anaerobes, 17% Streptococcus agalactiae, 22% other p-haemolytic streptococci, 17% coliforms, 6% 
Mycoplasma hominis, 6% Ureaplasma urealyticum, 6% Haemophilus influenzae, 6% Gardnerella vaginalis, 
Corynebacterium striatum (rare), Capnocytophaga (rare) 
Diagnosis: culture of membrane 
Treatment: 

Mycoplasma, Ureaplasma: erythromycin 

Others: amoxycillin-clavulanate, cefotaxime 
Endometritis: early (< 48 h) postpartum following caesarean section, late (48 h - 6 w) postpartum usually 
following vaginal delivery 

Agents: Gardnerella vaginalis, Peptococcus, Staphylococcus epidermidis, Streptococcus agalactiae, Mycoplasma 
hominis (34% of post-caesarean sections), Ureaplasma urealyticum, Chlamydia trachomatis, Streptococcus 
pneumoniae; also non-postpartum due to Bacteroides, Prevotella bivia, Haemophilus influenzae and Actinomyces 
israelii (IUD-related), Vibrio vulnificus (in a woman engaging in sex in sea water) 



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Diagnosis: protected, triple lumen transcervical culture (double catheter and bronchial brush or sterile swab 
specimens are not suitable because of contamination with vaginal flora) 
Treatment: piperacillin, cefoxitin 



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Chapter 6 



Infections of the Central Nervous System 

Meningitis: in children with bacteremia, 15% of all children and 5% of children < 1 y not receiving antibiotic at 
time develop meningitis after lumbar puncture; poor prognosis if coma, delay in starting therapy, CSF glucose 

< 10 mg/dL, protein > 300 mg/dL, bacteremia (found in nearly all fatal cases), coexisting illness; overall fatality 
rate 4-20%; total rate of sequelae in survivors 4%; complications: 32% headache, 31% difficulty in concentrating, 
24% loss of memory, 23% hearing impairment, 21% dizziness, 18% visual disturbances, 5% convulsions, 20% no 
complaint 

Agents (Bacterial): 45-46% Haemophilus influenzae type b (case-fatality rate 3-7%), 14-27% Neisseria 
meningitidis (47% of meningococcal infections; case-fatality rate 0.4-14%), 13-19% Streptococcus pneumoniae (cm 
rates 1-2/100,000; case-fatality rate 19-30%; 3% in < 5 y, 31-60% in > 60 y; neurologic sequelae widespread in 
survivors), 3-6% Streptococcus agalactiae (case-fatality rate 12-24%), 2-3% Listeria monocytogenes (case-fatality 
rate 22-30%), anthrax 

Diagnosis: sudden onset of fever, headache, nausea, vomiting, signs of meningeal irritation, delirium, coma; 
blood cultures within 30 minutes of initial assessment; lumbar puncture if patient has none of anticoagulant 
therapy, bleeding diasthesis, signs of localised spinal sepsis, history of CNS disease, focal neurological signs, 
papilledema, new onset seizure, abnormal level of consciousness (adults) or rapidly deteriorating consciousness or 
obtundation (children) or immunosuppression, or if CT scan shows lumbar puncture not contraindicated; 
microscopy, Gram stain (positive in 25% of bacterial with < 10 3 cfu/mL and 97% with > 10 s , 70% positive in 
Haemophilus influenzae), chemistry and culture of CSF; acridine orange stain detects bacteria causing meningitis 
at > 10 4 cfu/mL in 10 minutes; CSF lactate (elevated in bacterial meningitis; enzymatic method or gas liquid 
chromatography < 1 h; distinguishes bacterial from viral meningitis; false positive and negative reactions occur); 
C-reactive protein determination on CSF (97% positive in bacterial meningitis, 50% in intracranial hemorrhage, 
44% in Kawasaki syndrome, 30% in malignancies, 20% in neurological symptoms without infection, 6% in fever 
without bacterial meningitis and in increased intracranial pressure secondary to pseudotumour cerebri or 
hydrocephalus, negative in viral meningitis); coagulation (common organisms causing meningitis detected in CSF in 
< 5 min; may require treating specimen to eliminate nonspecific agglutination; Haemophilus influenzae type b 
sensitivity 77-100%, specificity 97-100%; Streptococcus pneumoniae sensitivity 71%, specificity 96%; Neisseria 
meningitidis, Streptococcus agalactiae); latex agglutination (false positives and negatives); 
counterimmunoelectrophoresis (difficult, less sensitive, more time-consuming) of CSF (results in < 1 h; Haemophilus 
influenzae type b sensitivity 67%, specificity 67%; Neisseria meningitidis A, B, C and W135 sensitivity 50%, 
specificity 50%; Streptococcus pneumoniae; Streptococcus agalactiae), serum (Haemophilus influenzae, Streptococcus 
pneumoniae, Neisseria meningitidis) and urine (Haemophilus influenzae, Streptococcus pneumoniae); gas liquid 
chromatography (detects anaerobes and selected aerobes in CSF in < 1 h; difficult sample preparation; research 
tool); limulus lysate (research tool; endotoxin determination detects Gram negative bacteria in CSF in < 2 h; 97% 
sensitivity and 99% specificity for Haemophilus/ Neisseria); ELISA (higher sensitivity than 
counterimmunoelectrophoresis but more time-consuming and results not available same day); if tests normal, look 
for other explanation of signs and symptoms; if clearly suggestive of viral etiology, no specific therapy; if unclear, 
observe patient and repeat lumbar puncture if condition worsens or in 8-24 h; if clearly suggestive of 'chronic 
meningitis', perform appropriate smears and cultures and start immediate therapy or await results and further 
testing depending on clinical situation; if clearly suggestive of suppurative bacterial etiology, start appropriate 
antimicrobial therapy as indicated by Gram stain and/or other tests immediately or treat empirically as below 

Bacterial Meningitis: CSF white cell count > 1000/ pL (if > 50,000/ pL, consider ruptured brain 
abscess), > 60% polymorphs, red blood cells absent, glucose < 45 mg/dL (< 1 mmol/L; < 40-66% of blood 
glucose; normal in 40-50%), protein > 80 mg/dL, Gram stain positive in 80% (60% in partially treated), culture 
positive in 90% (66% in partially treated); peripheral blood leucocyte count > 16xlOVL; broad range bacterial 
PCR (sensitivity 100%, specificity 98%, positive predictive value 94%, negative predictive value 100%) 



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Infections of the Central Nervous System 



Viral Meningitis: CSF white cell count < 1000/ pL in 83% (rarely > 2800/ pL), polymorphs 
increased in 10%, lymphocytes increased, red blood cells variable, glucose normal, protein normal or slightly 
increased, Gram stain and bacterial culture negative 

Fnngal Meningitis: CSF white cell count < 5000/ pL, lymphocytes increased, red blood cells 
absent, glucose normal or slightly decreased, protein > 60 mg/dL, Gram stain and bacterial culture negative 

Tnbercnlons Meningitis: CSF white cell count < 1000/ pL, polymorphs increased, red blood cells 
absent, glucose < 45 mg/dL, acid-fast stain positive in 80% if 10 mL of CSF centrifuged and sediment examined 
for 30-90 minutes, acid-fast bacilli culture positive in 85% 

Carcinomatons Meningitis: CSF white cell count 0-500/ pL, 0-95% polymorphs, red blood cells 
variable, glucose decreased or normal, protein usually increased, Gram stain and bacterial culture negative 

Brain Abscess: CSF white cell count 10-500/jliL, red blood cells variable, glucose decreased in 25%, 
protein increased in 75%, Gram stain positive in < 10%, culture positive in 16% 

Endocarditis: CSF white cell count < 50/j.iL, polymorphs increased in 28%, lymphocytes increased 
in 25%, red blood cells occasionally raised, glucose normal or decreased, protein normal or increased, bacterial 
culture positive in 16% 

Tranmatic Tap: leucocytes:erythrocytes « 1:500 
Note that contaminating bacteria may be obtained from slides on which smears are made, tubes in which CSF is 
collected, needles and syringes in which CSF taken, stains used for staining smear 
Treatment: see categories below; if bacterial meningitis is suspected, immediately administer benzylpenicillin 
(< 1 y: 300 mg; 1-9 y: 600 mg; > 10 y: 1200 mg) or ceftriaxone 50 mg/kg to 2 g i.v. if penicillin hypersensitive 
or likely delay of > 6 h in further therapy and transfer to hospital; in hospital, dexamethasone 0.15 mg/kg to 10 
mg i.v. + 

Commnnity Acqnired: ceftriaxone 100 mg/kg to 4 g i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly 
for 7-10 d or cefotaxime 50 mg/kg to 2 g i.v. 6 hourly for 7-10 d (+ benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 
4 hourly for 7-10 d or amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly for 7-10 d if Listeria monocytogenes 
suspected or immunosuppressed) 

Gram Positive Cocci Seen, Pnenmococcal Antigen Assay Positive, 
Neutrophils Bnt No Organisms Seen: add vancomycin 12.5 mg/kg to 500 mg (child < 12 y: 15 mg/kg to 
500 mg) i.v. 6 hourly by slow infusion (monitor blood levels and adjust dose accordingly) 

Immediate Penicillin or Cepahlosporin Hypersensitivity: vancomycin 12.5 mg/kg 
to 500 mg (child < 12 y: 15 mg/kg to 500 mg) i.v. 6 hourly by slow infusion (monitor blood levels and adjust 
dose accordingly) + ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly or moxifloxacin 10 mg/kg to 400 mg i.v. 
daily 

Neisseria meningitidis: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly for 3-5 d, then ceftriaxone 
250 mg (child 125 mg) i.m. as single dose or ciprofloxacin 500 mg orally as single dose (> 12 y) or rifampicin 
10 mg/kg to 600 mg (< 1 mo: 5 mg/kg) orally 12 hourly for 2 d and/or immunisation; activated protein C; 
steroids 

Penicillin Hypersensitive (Not Immediate): ceftriaxone 100 mg/kg to 4 g i.v. daily 
for 3-5 d or 50 mg/kg to 2 g i.v. 12 hourly for 3-5 d or cefotaxime 50 mg/kg to 2 g i.v. 6 hourly for 3-5 d 

Immediate Penicillin or Cephalosporin Hypersensitive: ciprofloxacin 10 mg/kg to 
400 mg i.v. 12 hourly for 3-5 d 

Streptococcus pneumoniae: 

Penicillin MIC < 0.125 mg/L: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly for 10- 
14 d 

Penicillin MIC > 0.125 mg/L: vancomycin 15 mg/kg to 500 mg i.v. 6 hourly + 
cefotaxime 50 mg/kg to 2 g i.v. 6 hourly or ceftriaxone 50 mg/kg to 2 g i.v. 12 hourly 

Haemophilus influenzae fype b: 

Penicillin Snsceptible: benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly for 7 d or 
amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly for 7 d 

Penicillin Resistant: ceftriaxone 100 mg/kg to 4 g i.v. daily for 7 d or 50 mg/kg to 2 g 
i.v. 12 hourly for 7 d or cefotaxime 50 mg/kg to 2 g i.v. 6 hourly for 7 d 

Immediate Penicillin or Cephalosporin Hypersensitive: chloramphenicol 
20-25 mg/kg to a g i.v. 6 hourly for 7 d or ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly for 7 d 



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Infections of the Central Nervous System 



Listeria monocytogenes: benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly or amoxy/ampicillin 
50 mg/kg to 2 g i.v. 4 hourly 

Penicillin Hypersensitive: cotrimoxazole 4/20 mg/kg to 160/800 mg i.v. 6 hourly 

Anthrax: ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly + benzylpenicillin or amoxy/ampicillin or 
chloramphenicol 

Health Care-Associated: vancomycin 12.5 mg/kg to 500 mg (child < 12 y: 15 mg/kg to 500 mg) 
i.v. 6 hourly + ceftazidime 50 mg/kg to 2 g i.v. 8 hourly or meropenem 40 mg/kg to 2 g i.v. 8 hourly 
Prophylaxis 

Neisseria meningitidis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose (preferred if 
pregnant), ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), 
rifampicin 10 mg/kg (< 1 mo: 5 mg/kg) to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver 
disease; preferred for children); vaccines (quadrivalent polysaccharide, quadrivalent conjugate, and serogroup 
conjugate) available 

Haemophilus influenzae type b: given to index case before discharge, to all household contacts 
of another child who is incompletely immunised against Haemophilus influenzae type b and to all household 
contacts of index case < 2 y; rifampicin 20 mg/kg to maximum 600 mg (child < 1 mo: 10 mg/kg) orally daily 
for 4 d (not pregnant; give ceftriaxone lg in lignocaine hydrochloride 1% i.m. as single dose); vaccine to index 
case under 2 y even if previous immunisation and to unvaccinated contacts < 5 y 

Streptococcus pneumoniae: pneumococcal polysaccharide vaccine recommended to adults > 65 y, 
individuals > 2 y with chronic illness, anatomic or functional asplenia, immunocompromise (disease, 
chemotherapy, steroids), HIV infection, environment or settings with increased risk, or cochlear implants; pain, 
swelling and redness at injection site in 30-50%, fever and muscle aches in < 1%, rare severe reactions; 
revaccination after 5 y for > 2 y with functional or anatomic asplenia, immunsuppression, malignancy, transplant, 
chronic renal failure, nephritic syndrome, HIV infection, chronic systemic steroids, or < 65 y at time of first 
vaccination; pneumococcal conjugate vaccine recommended for routine vaccination of children < 24 mo and 
24-59 mo with high risk medical conditions; pain, swelling and redness at injection site in 10-20%; reduces 
invasive disease due to serotypes in the vaccine by 97% and to those not in the vaccine by 89% 
Neonatal Meningitis: incidence 28/100 000 live births; case-fatality rate 26-27%; high morbidity; ventriculitis 
Agents: 50-60% Gram negative bacilli (11-47% Escherichia coli (early and late; increased risk in galactosemia), 
5% Pseudomonas aeruginosa, 0-16% Klebsiella pneumoniae (mainly late), 0-7% Serratia, 0-3% Haemophilus 
influenzae (50% of cases associated with maternal complication; 83% in premature infants; 33% mortality); Proteus, 
Salmonella, Citrobacter diversus (brain abscess common), Enterobacter sakazaki, other coliforms, Flavobacterium 
meningosepticum (virulent; always nosocomial), Campylobacter fetus subsp fetus), 24-34% Streptococcus agalactiae 
(mainly early; case-fatality rate 24%), 2-10% Listeria monocytogenes (early and late; case-fatality rate 30%), 0-7% 
Streptococcus pneumoniae (early), 0-5% Staphylococcus aureus (late), 0-5% Enterococcus (early), group C 
Streptococcus, Streptococcus mitis, Bacillus (very rare), Neisseria gonorrhoeae, Sphingobacterium mizutaii 
(prematures), Mcaligenes xylosoxidans, Reromonas 

Diagnosis: Gram stain and acridine orange stain of cytocentrifuged specimen of CSF; micro and culture of CSF; 
latex agglutination of concentrated urine, CSF and serum; counterimmunoelectrophoresis of CSF; ELISA 

Haemophilus influenzae: CSF protein 486 mg/dL, glucose 39 mg/dL, leucocytes ll,500/(.iL, 90% 
polymorphonuclears; latex agglutination on CSF (sensitivity 77-100%, specificity 97-100%); radioimmunoassay 
(sensitivity 95%) 

Listeria monocytogenes: opening pressure > 200 mm H2O, protein 100-200 mg/dL, glucose 
30-100 mg/dL (> 50% serum glucose), leucocytes 100-4000/ pL, 75-100% polymorphs, Gram stain positive in 50% 

Streptococcus agalactiae: latex agglutination on concentrated urine (sensitivity 93%), CSF 
(sensitivity 80%), serum (sensitivity 27%); radioimmunoassay 
Treatment: dexamethasone or oxindanac +: 

Enteric Gram Negative Bacilli or Organism Nor Known: cefotaxime 200 mg/kg daily in 4 
equal divided doses or ceftriaxone 100 mg/kg daily in 2 equal divided doses + aminoglycoside for 21 d 

Flavobacterium meningosepticum: rifampicin 

Streptococcus pneumoniae: 

Penicillin MIC < 0.125 mg/L: benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly for 
10 d 



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Penicillin MIC > 0.125 mg/L: ceftriaxone or cefotaxime + vancomycin or rifampcin 
Streptococcus agalactiac: benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly for 14-21 d 
Listeria monocytogenes: cotrimoxazole 5/25 mg/kg to 160/800 mg i.v. 6 hourly + 
benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly or amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly 

Pseudomonas aeruginosa: azlocillin 225 mg/kg i.v. daily in 3 divided doses or ceftazidime 100- 
200 mg/kg i.v. daily in divided doses + amikacin 5 mg/kg i.v. 8 hourly during first week; ticarcillin 
200-300 mg/kg i.v. daily in divided doses every 4-6 h + tobramycin 1.5-2.5 mg/kg 8 hourly 

Neisseria gonorrhoeae: benzylpenicillin 100 000 U/kg i.v. daily in 4 divided doses for at least 
10 d 

Post-Neonatal Purulent Meningitis: commonly related to upper respiratory infection with invasion of 
subarachnoid space by organisms arising from nasopharynx or by septicemic spread from lungs; also to urinary 
tract infection in the aged; « 9 cases/100,000 person-years; case-fatality rate 14% 
Agents: 40-46% (40-60% in aged 1 mo - 15 y, 1-3% in > 15 y) Haemophilus influenzae (usually type b; 
cosmopolitan; 1.2/100,000 total, 59/100,000 age 6-8 mo; case-fatality rate 4-7%; exclude CSF leak in adult; 29% 
associated with acute otitis media; more common isolate in antibody-mediated deficiency and asplenism, less 
frequent isolate in granulocyte disorders; also associated with spinal cord trauma; 8% of bacteremic and 8% of 
nonbacteremic invasive Haemophilus influenzae infections in older children and adults; « 40 notified cases/y in 
Australia; neurologic sequalae (hearing impairment, mental retardation, seizure disorder, developmental delay, 
paralysis) in 15-30%), 27-29% (25-40% in aged 1 mo - 15 y, 10-35% in > 15 y) Neisseria meningitidis (epidemic 
cerebrospinal meningitis, epidemic meningitis, diplococcal meningitis, meningitis Neisseria, meningococcic 
meningitis; usually types A, B, C; particularly prevalent in Subsaharan Africa, Middle East and upland parts of 
Indian subcontinent; 0.7/100,000 total, 13/100,000 age 3-8 mo; case-fatality rate 0.4-14%; « 600 notified cases/y 
in Australia (« 40% in New South Wales); usually arising as a result of hematogenous spread from asymptomatic 
colonisation of nasopharynx or from meningococcal nasopharyngitis, with an intervening phase of meningococcal 
septicemia or of asymptomatic meningococcal bacteremia; 14% associated with acute otitis media; epidemics and 
may be acute (sometimes fulminant) or chronic; spread may affect optic and other nerves; less frequent isolate in 
granulocyte disorders and antibody-mediated deficiency, infrequent isolate in asplenism; transmission respiratory; 
incubation period 2-10 d), 11-13% (10-20% in aged 1 mo - 15 y, 30-50% in > 15 y) Streptococcus pneumoniae 
(0.3/100,000 total, 8/100,000 age 3-5 mo; case-fatality rate 19-28%; sequelae common in survivors: 54% 
neurological, 42% neuropsychological, 25% otological, 16% various degrees of cerebral and cerebellar atrophy; 33% 
associated with acute otitis media; also from pulmonary focus, sinusitis; common isolate in granulocyte disorders, 
antibody-mediated deficiency and asplenism; also associated with cranial defect from previous head and spinal 
cord trauma; more common in infants, elderly, alcoholics), 3% Streptococcus agalactiae (0.1/100,000 total, 
42/100,000 age < 1 mo; case-fatality rate 12-24%), 1% other streptococci (case-fatality rate 44%; 22% associated 
with brain abscess; also associated with ventriculoatrial and other shunts; Streptococcus pyogenes and 
Enterococcus faecalis infrequent isolates in granulocyte disorders and AIDS; Streptococcus pyogenes less common 
isolate in antibody-mediated deficiency, infrequent isolate in asplenism; community acquired; otitis media, 
pharyngitis or sinusitis usually present; Streptococcus suis in pig workers; Streptococcus cam's), 1-9% 
Staphylococcus aureus (case-fatality rate 27% overall, 56% in hematogenous, 18% in postoperative; 18% associated 
with acute otitis media, 18% associated with pneumonia; common isolate in granulocyte disorders, less common 
isolate in antibody-mediated deficiency; also associated with surgery, ventriculoatrial and other shunts, nosocomial 
infections, foreign body, parameningeal or brain abscess), 1% mixed bacteria (children, adults with contiguous 
infection or tumour or fistulous communication with CNS); Listeria monocytogenes (1-2% in age 1 mo - 15 y, 5% 
in > 15 y; in lymp ho pro life rati ve malignancy, lung carcinoma, neonates, immunosuppressed, elderly, others; case- 
fatality rate 22-30%), enteric Gram negative bacilli (1-2% in age 1 mo - 15 y, 1-10% in > 15 y; Escherichia coli 
(usually Kl; sepsis — respiratory tract infection or pneumonia; immunocompromised and immunosuppressed; common 
isolate in granulocyte disorders, infrequent isolate in asplenism; also associated with head trauma, neurological 
procedure and nosocomial infections), Klebsiellla (less frequent isolate in granulocyte disorders), Enterobacter (less 
frequent isolate in granulocyte disorders), Proteus (infrequent isolate in granulocyte disorders), Serratia 
(nosocomial; mainly neonates and infants), Salmonella), Pseudomonas aeruginosa (10% of cases in cancer patients; 
common isolate in granulocyte disorders, less common isolate in antibody-mediated deficiency; also associated with 
surgery and nosocomial infections), Burkholderia cepacia, Stenotrophomonas maltophilia, Neisseria gonorrhoeae, 
Neisseria lactamica (following skull trauma), Neisseria mucosa (female infants and children with predisposing 



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Infections of the Central Nervous System 



conditions), Neisseria subliava, Neisseria fiavescens, Moraxella catarrhalis, Moraxella lacmata, Moraxella osloensis, 
Bacteroides (associated with surgery), Dialister pneumosintes (chronic), Francisella tuiarensis (rare), Campylobacter 
/etosubsp fetus (rare), Campylobacter jejuni (rare), Aeromonas hydrophila (infrequent isolate in granulocyte 
disorders, others), Aeromonas sobria (rare isolates in chronic alcoholic liver disease), Flavobacterium 
meningosepticum (in immunocompromised), Acinetobacter (nosocomial; mainly associated with indwelling 
ventriculostomy tubes or CSF fistulae in patients receiving antimicrobials), Yersinia pestis (rare complication of 
bubonic plague), Pasteurella multocida (rare; animal contact; case-fatality rate 30%), Bacillus (Bacillus anthracis. 
hemorrhagic meningitis (anthrax meningitis, meningeal anthrax) as complication in about 5% of cases of anthrax 
(39% inhalational, 29% cutaneous, 17% gastrointestinal, 16% unknown); and cases with no primary focus (up to 
59% in some outbreaks in India), other species (especially Bacillus cereus) in immunocompromised, infrequent 
isolate in granulocyte disorders), Clostridium (infrequent isolate in granulocyte disorders; also associated with head 
and spinal cord trauma), diphtheroids (associated with ventriculoatrial and other shunts), Corynebacterium bovis 
(rare), Nocardia asteroides (common in impaired cell-mediated immunity; case-fatality rate 57%), Shigella kingae 
(sickle cell anemia), Bergeyella zoohelcum, Capnocytophaga canimorsus, Bordetella bronchiseptica (posttraumatic), 
Vibrio cincinnatii, Plesiomonas shigelloides, Haemophilus parainfluenzae, Actinobacillus actinomycetemcomitans, 
Cardiobacterium hominis, Eikenella corrodens, Aerococcus viridans (rare), Fusobacterium necrophorum (uncommon), 
Candida (infrequent isolate in granulocyte disorders and asplenism; also nosocomial and in AIDS), Coccidioides 
immitis (25% of AIDS patients in endemic areas), Histoplasma capsulatum (in AIDS; « 60% fatality rate), 
Ajellomyces dermatitidis (AIDS), Aspergillus (rare in AIDS), Plasmodium malariae (infrequent isolate in asplenism), 
Plasmodium falciparum (in therapy for nutritional deficiency), Trichomonas (associated with surgery), almost any 
other pathogen 

Diagnosis: micro (> 1000 polymorphs/ pL), protein (100-1000 mg/dL), glucose (< 1/3 of blood), culture, latex 
agglutination and C-reactive protein on CSF; Gram stain and acridine orange stain on cytocentrifuged CSF; 
counterimmunoelectrophoresis on serum and urine; ELISA on urine; latex agglutination on serum; increased lactic 
acid in CSF 

Neisseria meningitidis: hemorrhagic skin lesions; protein 770 mg/dL, glucose 6 mg/dL, leucocytes 
20,700-212,000/ pL, 98% neutrophils, multiple extracellular and intracellular Gram negative diplococci; direct 
immunofluorescence and ELISA of CSF; latex agglutination of CSF (sensitivity 33%, specificity 100%) 

Streptococcus pneumoniae: slight enlargement of lateral ventricles on air encephalogram; mild 
communicating hydrocephalus on computerised axial tomography; CSF 9000 neutrophils/ pL, 100 lymphocytes/ pL; 
direct immunofluorescence of CSF; latex agglutination of CSF (sensitivity 71-100%, specificity 96%); 
radioimmunoassay; white cell count 17,400/ pL, 87% neutrophils, 2% bands 

Haemophilus influenzae: septic arthritis, cellulitis of face or upper extremity; can be fulminant 
but commonly mild illness followed by significant deterioration; protein 486 mg/dL, glucose 39 mg/dL, leucocytes 
11,500/pL, 90% polymorphonuclears; ELISA on CSF; latex agglutination on CSF (sensitivity 77-100%, specificity 97- 
100%), radioimmunoassay (sensitivity 75%) 

Listeria monocytogenes: opening pressure > 200 mm H2O, protein 100-200 mg/dL, glucose 
30-100 mg/dL (> 50% serum glucose; depressed in 60%), leucocytes 100-4000/pL, 75-100% polymorphs changing 
to 98% mononuclears; Gram stain positive in 50% 

Staphylococcus aureus: fever in 75-90%, altered mental status in 38-55%; CSF protein 

> 80 mg/dL in 83-86%, CSF glucose < 50% of serum level in 57-67%, CSF white cell count > S/jiL in 83-88%, 

> 1000/ pL in 34%, > 66% neutrophils in 80-100%; Gram stain positive in 40-62%; blood culture positive in 60- 
86% 

Nocardia asteroides: subacute to chronic presentation; 68% fever, 66% stiff neck, 55% headache; 
neutrophil pleocytosis; 83% > 500 leucocytes/nL, 66% < 40 mg glucose/dL, 61% > 100 mg/dL protein; 43% 
associated brain abscess; histology and culture of tissue 

Anthrax: fever, malaise, meningeal signs, hyperreflexia, delirium, stupor, coma; hemorrhagic meningitis, 
multifocal subarachnoid and intraparenchymal hemorrhages, vasculitis, cerebral edema; 94% case-fatality rate (75% 
within 24 h of presentation); Gram stain, India ink stain and culture of CSF sediment; ELISA, Western blot, toxin 
detection, chromatographic assay, fluorescent antibody test 

Bacillus cereus: diarrhoea, fever, altered mental status; Gram stain and culture of CSF 

Candida: glucose decreased and protein increased in 60% of cases; leucocytes 6000/ (.iL (lymphocytes 
and neutrophils); organisms in Gram stain in 40%; culture of biopsy 



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Infections of the Central Nervous System 

Coccidioides immitis: EIA of CSF using combination of antigens (sensitivity 100%, specificity 96%), 
RIA of CSF (sensitivity 100%), overnight binding complement fixation test on CSF (sensitivity 95%) 

Histoplasma capsulation: RIA or EIA for histoplasma polysaccharide antigen in body fluids 
(sensitivity 90-97%), culture of bone marrow, lymph nodes, ulcers (positive in 90%), CSF (often negative) 

Rjellomyces dermatitidis: EIA using purified antigen A (false positives in some cases of 
histoplasmosis and sporotrichosis) 

Aspergillus: stroke or intracranial hemorrhage in immunosuppressed HIV-positive patient with single 
or multiple contrast-enhancing lesions; CSF nonspecifically abnormal, culture usually negative; serology insensitive 
Treatment: dexamethasone 3 mg/kg i.v. initially followed by 1 mg/kg 6 hourly over period of 48 h or 
oxindanac +: 

Neisseria meningitidis: benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly for 5-7 d; i.v. heparin 
+ i.v. hydrocortisone if any evidence of Waterhouse-Friderichsen syndrome 

Neisseria gonorrhoeae: ceftriaxone 1-2 g i.v. every 12 h 

Penicillin Susceptible Streptococci (MIC < 0.125 mg/L): benzylpenicillin + aminoglycoside 
if warranted 

Penicillin Hypersensitive Patient with Neisseria, Any Patient With Relatively 
Resistant (MIC 0.125- < 1 mg/L) Streptococcus pneumoniae: cefotaxime 50 mg/kg to 2 g i.v. 6 
hourly for 5-7 d or ceftriaxone 200 mg/kg to 4 g i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly for 5-7 d 

Penicillin Resistant (MIC > 1 mg/L) or Cefotaxime Resistant Streptococcus 
pneumoniae: ceftriaxone + vancomycin 2 g every 12 h or rifampicin; seek specialist advice 

Haemophilus influenzae: cefotaxime 50 mg/kg to 2 g i.v. 6 hourly for 7-10 d, ceftriaxone 
100 mg/kg to 4 g i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly for 7-10 d, (amoxy)ampicillin 50 mg/kg to 2 g i.v. 
4 hourly for 7-10 d (if susceptible) 

Staphylococci: oxacillin 200 mg/kg/d to 12-16 g/d 4-6 hourly, vancomycin 60 mg/kg/d up to 
2 g/d 6-12 hourly 

Francisella tularensis, Yersinia pestis: streptomycin 

Campylobacter, chloramphenicol 

Flavobacterium meningosepticum: sulphadiazine + rifampicin 

Pseudomonas aeruginosa: azlocillin 3 g i.v. 4 hourly (child: 225 mg/kg i.v. daily in 3 divided 
doses) or ceftazidime 6-12 g (child: 100-200 mg/kg) i.v. daily in divided doses for 9-50 d + amikacin 5mg/kg i.v. 
8 hourly during first week; ticarcillin 3 g i.v. 4 hourly (< 40 kg: 200-300 mg/kg i.v. daily in divided doses every 
4-6 h) + tobramycin 1.3 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 hourly, meropenem 

Burkholderia cepacia: imipenem 

Stenotrophomonas maltophilia: cotrimoxazole + rifampicin 

Moraxella catarrhalis: amoxycillin-clavulanate 

Salmonella typhi: chloramphenicol lOOmg/kg daily i.v. in 4 equally divided doses, substituting oral 
treatment as soon as possible 

Enteric Gram Negative Bacilli: cefotaxime 2g i.v. 4 hourly (child: 200 mg/kg daily in 4 equally 
divided doses) or ceftriaxone 2-4 g i.v. daily (child: 100 mg/kg daily in 2 equally divided doses) + 
aminoglycoside for 21 d 

Bacteroides: metronidazole 

Rcinetobacter. imipenem, minocycline, ciprofloxacin, polymyxin, ampicillin-sulbactam, cefperazone- 
sulbactam 

Pasteurella multocida, Kingella kingae: penicillin, ampicillin, third generation cephalosporin, 
chloramphenicol 

Listeria monocytogenes: cotrimoxazole 5/25 mg/kg to 160/800 mg i.v. 6 hourly + 
benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly or (amoxy)ampicillin 50 mg/kg to 2 g i.v. 4 hourly 

Nocardia asteroides: sulphonamides, cotrimoxazole, minocycline 200 mg bid, amikacin for at least 
6 mo; cefotaxime 2g i.v. 8 hourly + imipenem 500 mg i.v. 6 hourly in severely ill 

Anthrax: ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly + penicillin or amoxy/ampicillin or 
chloramphenicol for 14-21 d then ciprofloxacin 15 mg/kg to 500 mg orally 12 hourly or doxycycline 2 mg/kg to 
100 mg orally 12 hourly (child: amoxycillin 15 mg/kg to 500 mg orally 8 hourly) for total 60 d 

Bacillus cereus: vancomycin + carbapenem 



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Fnngal: amphotericin B + flucytosine 

Plasmodium: chloroquine 

Others or Unknown: chloramphenicol 1 g i.v. 6 hourly + benzylpenicillin 1.2-2.4 g i.v. 4 hourly 

Hospital Acqnired: vancomycin 15 mg/kg to 500 mg i.v. 6 hourly + cefotaxime 50 mg/kg to 2 g 
i.v. 6 hourly or ceftriaxone 50 mg/kg to 2 g i.v. 12 hourly or meropenem 40 mg/kg to 2 g i.v. 8 hourly 
Prophylaxis: 

Meningococcal (Index Case After Treatment and Close Contacts): ceftriaxone 250 mg 
(child 125 mg) i.m. as single dose (preferred if pregnant), ciprofloxacin 500 mg orally as single dose (not < 12 y; 
preferred for women taking oral contraceptive), rifampicin 10 mg/kg to 600 mg orally 12 hourly for 2 d (not 
pregnant, alcoholic, severe liver disease; preferred for children); single 0.5 mL s.c. dose (adults and children 
> 2 y) of vaccine for Neisseria meningitidis types A, C, Y and W135 recommended for patients with deficiency of 
terminal complement component, travellers and long-term residents who will be living in or travelling through 
such endemic and hyperendemic areas as rural communities in Brazil, Burkina Faso, Chad, Egypt, Ghana, Mali, 
Mongolia, Nepal, Nigeria, Sudan, Vietnam, health care workers going to Saudi Arabia and Gulf States, in 
conjunction with antimicrobial prophylaxis for intimate contacts; mass immunisation may be indicated if several 
cases appear over a period of several weeks or if attack rates exceed 0.66-1.25/100,000 of population 

Haemophilus influenzae type b: given to index case before discharge, and within 7 d to all 
household contacts of index case, including incompletely immunised children < 4y and any immunocmpromsed 
child; also adults and children at day care centres with 2 or more cases of invasive disease in 60 d period and 
with incompletely immunised children; rifampicin 20 mg/kg to maximum 600 mg (child < 1 mo: 10 mg/kg) orally 
daily for 4 d (not pregnant; give ceftriaxone 1 g in lignocaine hydrochloride 1% i.m. as single dose); vaccine to 
index case under 2 y even if previous immunisation and to unvaccinated contacts < 5 y; all children should be 
routinely vaccinated beginning at 2 mo (95-100% efficacy; swelling, redness and pain at injection site in 5-30%, 
fever and irritability uncommon, serious reactions rare; contraindicated if anaphylaxis to vaccine components or 
previous dose and serious illnesses) 

Streptococcus pneumoniae: 1 dose of a 23 valent pneumococcal vaccine is recommended for 
adults with cardiovascular disease and chronic pulmonary disease entailing increased morbidity from respiratory 
infection, alcoholism, cirrhosis of liver, CSF leaks, diabetes mellitus, Hodgkin's disease, immunosuppression 
(preferably administered 6 w before initiation of immunosuppressive therapy), multiple myeloma, post-renal 
transplant, postsplenectomy, skull fracture with recurrent pneumococcal meningitis, splenic dysfunction and 
otherwise healthy adults aged 66 or older, and in children aged 2 y or older with anatomic splenectomy or 
persistent asplenism associated with sickle cells, CSF leaks, immunosuppression, nephrotic syndrome or splenectomy 
(administer 2 w before operation if possible) 

Asplenic and Postsplenectomy: pneumococcal, meningococcal, Hib and standard schedule 
immunisation (including annual influenza); antibiotic prophylaxis in asplenic children < 5 y, children < 5 y with 
sickle cell anemia, for at least 2 y following splenectomy and patients with severe underlying immunosuppression: 
amoxycillin 125 mg orally 12 hourly (< 2 y: 20 mg/kg orally daily) or phenoxymethylpenicillin 250 mg (< 2 y: 
125 mg) orally 12 hourly or if penicillin hypersensitive roxithromycin 4 mg/kg to 150 mg orally daily or 
erythromycin 250 mg orally daily or erthryomycin ethyl succinate 400 mg orally daily 
CSF Fistula: may result in recurrent meningitis 
Agent: especially Streptococcus pneumoniae 

Diagnosis: recurrent meningitis, history of trauma, congenital anomalies; unilateral, clear, watery rhinorrhoea; 
hearing loss, especially unilateral; protein electrophoresis or ring test on fluid (rhinorrhoeal or otic) suspected of 
being CSF; high resolution CT in axial and coronal plane; MRI; contrast cisternography with iopanidole or iohexal, 
intrathecal injections of fluorescein diluted in CSF and observation of pledgets placed in sphenoethmoid region, 
cribriform area, roof of nasal cavity and eustachian tube orifice 

Treatment: head elevation at angle of 45°; spinal drain if necessary; surgical correction (extracranial approach 
preferred) if persistent rhinorrhoea (> 5-7 d), recurrent meningitis or spontaneous rhinorrhoea from anterior, 
middle or posterior fossa 

Non-pyogenic (Lymphocytic, Aseptic) Mexingitis 

Agents: 70% of cases unclassified; 70-79% of documented cases enterovirus (transmission fecal and respiratory; 
incubation period 1 to several weeks; infrequent infections in impaired cell-mediated immunity and in antibody- 
mediated deficiency); 54% human echovirus (23% of human echovirus infections; attack rate 107/100,000; 38% 



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human echovirns 11, 26% human echovirus 30, 21% human echovirus 7, 6% human echovirus 4, 3% human 
echovirus 1, 3% human echovirus 17, 3% human echovirus 25], 22% human coxsackievirus B3, 22% human 
coxsackievirus B4, 1% human coxsackievirus B5, remainder human coxsackievirus Al, R2, R4-R7, R9, RIO, R12, 
R14, RIO, R22, echo 9 virus, human coxsackievirus Bl, B2, BO, human echovirus 2-7, 11, 13-21, 24, 25, 30, 31, 33, 
human parechovirus 1, human parechovirus 2, other enteroviruses), 6% influenza A, 4-10% simplexvirus (common 
in impaired cell-mediated immunity), 4% measles virus, 4% arboviruses, 2-15% human adenovirus, 1-4% mumps 
virus (0.7/1000 mumps cases symptomatic but CSF pleocytosis in > 50%), poliovirus (in 28% of poliovirus cases; 
infrequent infections in antibody-mediated deficiency and cell-mediated immunity deficiency), lymphocytic 
choriomeningitis virus (probably worldwide but not in Australia; often spread from mice and probably pet 
hamsters; frequently in children), mengo encephalomyocarditis virus, simplexvirus 3 (common in impaired cell- 
mediated immunity), hepatitis viruses, Epstein-Barr virus (Duncan's syndrome), Kawasaki syndrome, reoviruses, 
vaccinia virus (postvaccination; infrequent infections in impaired cell-mediated immunity), rubella virus, 
parainfluenza 3, many other viruses, Nocardia asteroides (common in impaired cell-mediated immunity), 
Mycobacterium tuberculosis (1% of tuberculosis cases; fatality rate 15-40%; less common infection in impaired 
cell-mediated immunity; also in therapy for nutritional deficiency), Brucella (< 5% of cases of systemic 
brucellosis; infrequent infections in impaired cell-mediated immunity; also in therapy for nutritional deficiency), 
Listeria monocytogenes (common in impaired cell-mediated immunity), Leptospira, Treponema pallidum subsp 
pallidum (uncommon), Mycoplasma hominis (rare), Mycoplasma pneumoniae, Cryptococcus neoformans (see 
Cryptococcal Meningitis), Coccidioides immitis (see Coccidioidosis; travel to San Joaquin Valley), 
Histoplasma capsulatum (see Histoplasmosis), Rspergillus (infrequent infections in neutropenics and impaired 
cell-mediated immunity), Mucor (infrequent infections in neutropenics and impaired cell-mediated immunity), 
Rbsidia (infrequent infections in neutropenics and impaired cell-mediated immunity), Rhizopus (infrequent 
infections in neutropenics and impaired cell-mediated immunity), Drechslera (associated with lymphoma), Candida 
(uncommon), Pseudallescheria boydii (uncommon), Toxoplasma gondii (in immunosuppressed, particularly Hodgkin's 
disease; infrequent infections in impaired cell-mediated immunity), Strongyloides stercoralis (associated with 
corticosteroid treatment; extremely infrequent infections in impaired cell-mediated immunity), Taenia solium 
(infrequent infections in impaired cell-mediated immunity), Trichinella spiralis, myiasis (extremely infrequent 
infections in impaired cell-mediated immunity), Naegleria (see Amoebic Meningoencephalitis); also cancer, 
sarcoidosis, Behcet's disease, Mollaret's meningitis, systemic lupus erythematosus, Sjogren's syndrome, reaction to 
ibuprofen and other NSAIDS, azathioprine, tolmentin, zimeldin, trimethoprim and other antibiotics, carbamazepine, 
allopurinol, i.v. immunoglobulins, 0ET3 monoclonal antibodies 

Diagnosis: fever, signs of meningeal irritation (eg., stiff neck), variable degree of drowsiness, confusion, stupor, 
rarely coma, > 10 lymphocytes/ pL in CSF, no neurologic abnormality of recent onset; human coxsackievirus A2, 
A7, A9, Bl, B2, B4, B5, human echovirus 3, 4, 0, 9, 11, 14, 17, 18, 25, 30, 33, human parechovirus 1 and 2 and 
human enterovirus 71 produce exanthem; Gram stain, acridine orange stain and acid-fast stain, culture and 
serology of CSF; blood culture using DuPont Isolator or Bactec fungal medium; viral culture of serum in RD and 
BGM cells; viral culture of feces and throat swab; complement fixation test, hemagglutination inhibition, 
neutralisation 

Viral: protein normal or increased, glucose normal, chloride normal, cell counts normal to 25-100 
lymphocytes/ pL, polymorphs early in illness 

Arboviruses: paired sera 

Enieroviral: protein 15-100 mg/dL, glucose 44-86 mg/dL, 17-912 leucocytes/ jliL; positive 
serology in 17%; virus isolation 

Simplexvirus: PCR on CSF 

Lymphocytic choriomeningitis virus, paired sera 

Mumps virus, age 5-14 y, males > females, with parotitis in spring, without parotitis in 
summer; up to 2000 leucocytes/ pL, usually lymphocytes predominant, but may be polymorphs; protein normal or 
very mildly increased, glucose normal or mildly decreased; sequelae extremely rare; encephalitis « 1:5000 cases; 
virus isolation 

Epstein-Barr virus, persevereation, impulsivity, complex-partial seizures, emotional lability, 
obsessive-compulsive behaviour; CSF PCR 



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Infections of the Central Nervous System 

Mycobacterium tuberculosis: most commonly, complication of primary lung lesions in very young 
children, but also in adults; ophthalmoplegia or facial paralysis; headache in 86%, abnormal mental state in 57%, 
fever in 55%, night sweats or rigours in 52%; CSF: protein > 200 mg/dL in 70-80% of cases (36% 
1000-1500 mg/dL), glucose < 45 mg/dL in 70-85% (26% 2.3-2.6 mmol/L), > 100 leucocytes/ pL in 60-80% (26% 
200-400/|.iL), increased lymphocytes + increased neutrophils (29% 0-10%); serial AFB smears positive in 87%; 
latex agglutination (sensitivity 100%, specificity 99%); ELISA; adenosine deaminase activity; PCR 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, 
profuse sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; 
isolation; Brucella tube agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, 
complement fixation test, Coombs, fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, 
counterimmunoelectrophoresis 

Leptospira: protein increased, cell count 300-2000/|_lL; neutrophilia becoming lymphocytosis 

Treponema pallidum subsp pallidum: VDRL positive in 90% of cases; protein 50-150 mg/dL 
(IgG increased), glucose normal, lymphocytes 10-500/(.iL 

Listeria monocytogenes: protein generally increased, glucose decreased in 60%, leucocytes few to 
several thousand, polymorphs 0-100% 

Aspergillus: protein increased, glucose decreased, cells variable 

Zygomycetes: CSF normal 

Metastatic Carcinoma, Lymphoma, Meningeal Sarcoma: glucose reduced 
Differential Diagnosis: partially treated pyogenic meningitis, brain abscess, parameningeal focus of infection, 
subdural hematoma, subarachnoid hemorrhage, brain tumour, multiple sclerosis, malignant hypertension, thrombotic 
thrombocytopenic purpura, systemic lupus erythematosus, temporal arteritis, carcinomatous meningitis 
Treatment: 

Simplexvirur. aciclovir 5 mg/kg i.v. 8 hourly as a 1 h infusion for 14 d or vidarabine 15 mg/kg 
daily as a 12-24 h infusion for 10 d + dexamethasone 

Other Viral: non-specific (disoxaril in persistent enteroviral infections in agammaglobulinemic 
individuals; corticosteroids in Epstein-Ban) 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 12 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 12 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (12 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 12 mo) + prednisolone 60 mg (child: 1-3 
mg/kg) daily for 1-2 w, gradually reducing over next 4-6 w 

Nocardia: cotrimoxazole, sulphonamides, minocycline, amikacin, imipenem for at least 6 mo 

Brucella: doxycycline 100 mg orally twice a day + rifampicin 600 mg orally 4 times a day or 
streptomycin 1 g i.m. 4 times a day for 45 d, ciprofloxacin 500 mg orally twice a day + rifampicin 600 mg 
orally twice a day for 30 d 

Treponema pallidum subsp pallidum: penicillin 

Leptospira: oxytetracycline 

Listeria monocytogenes: cotrimoxazole 5/25 mg/kg to 160/800 mg i.v. 6 hourly + 
benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly or amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly 

Fnngal: amphotericin B 0.75 mg/kg i.v. daily + flucytosine 25 mg/kg i.v. or orally 6 hourly for 14 d; 
diagnostic and therapeutic resection possibly helpful 

Toxoplasma gondii: pyrimethamine 100-200 mg loading dose, then 50-100 mg/d orally + folinic 
acid 10 mg/d orally + sulphadiazine 4-8 g/d in divided doses; pyrimethamine 100-200 mg loading dose, then 50- 
100 mg/d orally + folinic acid 10 mg/d orally + clindamycin 900-1200 mg i.v. every 6 h or 300-450 mg orally 
every 6 h; spiramycin 

Taenia solium: mebendazole 

Strongyloides stercoralis: thiabendazole, albendazole 
Prophylaxis: immunisation against Poliovirus; experimental antiviral drugs 



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Cryptococcal Meningitis: « 0.2 cases/100,000 person-years; occurs in impaired cell-mediated immunity 
(particularly associated with lymphomas) but also in others 
Agent: Cryptococcus neoformans, Cryptococcus gatii 

Diagnosis: intermittent headache of increasing frequency and severity, usually frontal, temporal or postorbital, 
may be accompanied by vomiting and vertigo, confusion, personality change, decreased memory, meningeal signs 
(nuchal rigidity, positive Kernig's and Brudzinski's signs) in 50% of cases, cranial nerve involvement (hearing loss, 
diplopia, ophthalmoplegia, facial nerve palsy) in 20%, increased cranial pressure hyperreflexia, pathologic reflexes, 
ataxia, convulsions, fever, progressive delirium and psychosis in 10%; CSF protein increased (50-200 mg/dL), 
glucose normal to slightly low, 25-500 leucocytes/(.iL, lymphocytes usually predominate; India ink preparation 
(budding yeasts with wide capsules; positive in 30-60%) and culture (positive in 40-70%) of CSF; latex 
agglutination of CSF and serum for antigen (positive in 80-90%); serology (tube agglutination test for antibody 
positive in « 40%); evaluate inner and middle ear for temporal bone involvement; poor prognosis if markedly 
positive India ink test, spinal fluid pressure > 300 mm, CSF glucose < 20 g/dL, CSF leucocytes < 20/ pL, 
cryptococci isolated from other sources (eg., blood, urine), no detectable cryptococcal antibody, CSF antigen 
> 1:32, patient with malignancy or receiving corticosteroids 

Treatment: measure opening pressure and consider means to reduce pressure if > 25 cm H2O; amphotericin B 
desoxycholate 0.7 mg/kg i.v. daily for 6-10 w (adjust dose according to tolerance) + flucytosine 25 mg/kg i.v. or 
orally 6 hourly for 6-10 w (monitor plasma levels); fluconazole 20 mg/kg to 800 mg/kg orally or i.v. initially, 
then 10 mg/kg to 400 mg daily for at least 10 w (in immunocompromised, follow with fluconazole 5 mg/kg to 
200 mg orally daily indefinitely as prophylaxis); itraconazole + flucytosine; intrathecal amphotericin B for patients 
who relapse or fail to respond or if nephrotoxicity precludes i.v. (many complications of therapy); increased 
chance of relapse following therapy if no detectable antibody, persistent malignancy and/or corticosteroid therapy; 
surgical excision of focal brain lesions associated with high mortality; transfer factor (investigational) 
Viral Meningoencephalitis 

Agents: Crimean-Congo hemorrhagic fever virus, mumps virus (1:6000 mumps cases), enteroviruses (especially 
chronic human echovirus 11 infections in agammaglobulinemic patients), rubella virus (rare), simplexvirus 1, 
Russian spring-summer encephalitis virus, human parainfluenza virus 4, human adenovirus 
Diagnosis: clinical; CSF examination; serology; isolation of virus from blood, CSF or autopsy specimens 

Mumps virus: decreased consciousness, focal neurologic deficits; death rate 0.5-2.3%; protein 
146-320 mg/dL, glucose 24-43 mg/dL, 208-774 leucocytes/^, 2-26% polymorphs, 74-98% lymphocytes, 66-6000 
erythrocytes/^ 

Treatment: oral prednisone; intraventricular immunoglobulin; supportive 
Bacterial Meningoencephalitis 

Agents: Listeria monocytogenes (> 6 d postnatal; may be preceded by septicemia in adult; may mimic 
tuberculous meningitis), Brucella, Coxiella burnetii, Mycoplasma (rare); also in 2% of cases of Lyme disease 
Diagnosis: micro and culture of CSF 
Treatment: 

Listeria monocytogenes: ampicillin + gentamicin 

Brucella: rifampicin 900 mg/d orally for 90 d + cotrimoxazole 5/25 mg/kg/d orally or i.v. for 90 d 
(add corticosteroid briefly) 

Coxiella burnetii, Mycoplasma: doxycycline for 2-3 w 
Rabies (Hydrophobia): meningoencephalitis prevalent in Africa, India, Indonesia, Philippines, Mexico; > 50,000 
deaths/y worldwide; * 3 cases/y (74% from bats) in USA; few bat-associated cases in Australia; in Europe, 70% 
of cases are in foxes; in Thailand, 95% are in dogs; transmission by saliva of infected animal; human to human 
transmission by corneal transplantation recorded; incubation period 10 d to 6 mo; « 100% mortality 
Agent: Lyssavirus 

Diagnosis: no signs or symptoms during incubation period; fever, malaise, anorexia, headache, paresthesias or 
pain at site of bite during prodrome lasting 2-10 d; agitation, hyperventilation, aphasia, paralysis, hydrophobia 
(17-50% of cases), pharyngeal spasms, delirium during acute neurological stage lasting 2-7 d; hypotension, cardiac 
arrhythmia, hypoventilation, pituitary dysfunction, coma, infection, thromboembolism in coma stage which lasts 
days to weeks; death or recovery (only 2 case reports) after months; CAT scan normal or temporal lobe edema; 
diffuse, slow, non-focal dysrhythmia in electroencephalogram; fluorescent antibody staining or PCR on corneal 
impressions (positive in 50% of cases), skin, temporal lobe biopsy, neck biopsy, brain tissue postmortem or after 



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inoculation of saliva, tissue (Ammon horn of brain) postmortem or CSF into cell culture, mice or suckling mice; 
light microscopy (hematoxylin-eosin stained sections of tissue postmortem show Negri bodies) and electron 
microscopy (Lyssavirus) of fixed biopsy material; high antibody titres (rapid fluorescent focus-inhibition titres) in 
serum or CSF; neutralisation antibody titre of CSF (unvaccinated); virus isolation from clinical specimens followed 
by direct fluorescent antibody testing; CSF protein 85-133 mg/dL, glucose 105-158 mg/dL, 4-6 neutrophils/ pL, 6- 
43 lymphocytes/ pL, 8-16 red cells/jLtL; white cell count increased; possible complications include hydrophobia 
(spasms of pharynx), seizures, cerebral edema, inappropriate ADH secretion, diabetes insipidus, hypothermia and 
hyperthermia, arrhythmia, congestive heart failure, hypotension, aspiration, atelectasis, hypoxemia, pneumonia, 
gastrointestinal haemorrhage 

Treatment (All Persons Exposed to a Bite, Scratch or Abrasion Inflicted by a Brain-positive 
Animal, in an Unprovoked Attack by a Domestic Dog or Cat in a Rabies Area or in a 
Provoked or Unprovoked Attack by an Escaped Carnivorons Wild Animal in Snch an Area): 
thorough immediate cleansing of wounds with soap solution or detergent and thorough rinsing under running 
water, followed by 0.1% benzalkonium chloride or other quaternary ammonium detergent or, if unavailable, 70% 
alcohol or tincture of iodine +: 

Unimmnnised: rabies immune globulin 20 U/kg, half applied by instillation deep into the wound and 
half i.m., followed by human diploid cell vaccine 6 doses i.m. on days 0, 3, 7, 14, 28, 90 

Previonsly Immnnised: human diploid cell vaccine 2 doses i.m. on days and 3 
leave wound unsutured for a few days; give tetanus antiserum and systemic antibiotics 
Prophylaxis: highly effective killed vaccine (human diploid cell); 5 doses lead to > 1:16 titre in 100%; no 
rabies cases have resulted in > 120 persons who have received HDCV and been bitten by rabid animals; pain 
and swelling at injection site in « 25%, mild systemic (eg., headache, dizziness) in « 20%, 1 reported case of 
Guillain-Barre syndrome; local or mild systemic reactions should be treated with aspirin; not contraindicated in 
pregnancy 

Prevention and Control: animal immunisation and other control procedures aimed at stray and wild animals 
Fungal Meningoencephalitis 
Agent: Bipolaris (2 cases in patients with cancer) 
Diagnosis: histology and culture of biopsy 
Treatment: resection of localised lesions; itraconazole 
Eosinophilic Meningoencephalitis 

Agents: Angiostrongylus cantonesis (China, Far East, Hong Kong, Papua New Guinea), Angiostrongylus 
malaysiensis (Malaysia), Baylisascaris procyonis (cases in USA from raccoons), Toxocara, Gnathostoma spinigerum, 
also Neurocysticercosis, ventriculoperitoneal shunt 

Diagnosis: history of exposure to snails, slugs, molluscs; severe headache, nausea, vomiting, paresthesias, low 
grade or absent fever, cranial nerve abnormalities, moderate to high eosinophilia in CSF and blood; parasite may 
be recovered from CSF or anterior chamber of eye; serology {Angiostrongylus cross-reacts with Toxocara cam's in 
ELISA test) 

Differential Diagnosis: cerebral cysticercosis (computed tomography), gnathostomiasis (involvement of nerve 
roots, bloody or xanthochromic CSF, sudden impairment of sensorium due to cerebral hemorrhage), paragonimiasis 
(chronic hemoptysis, cavities on chest X rays, punctate nodular calcifications on skull X-rays; skin testing, 
serology of blood and CSF), schistosomiasis (clinical, recovery of Schistosoma japonicum eggs from stool), fungal 
infections (fungal cultures), allergic conditions, multiple sclerosis (characteristic CSF immunoglobulin pattern and 
chronic clinical course without symptoms of increased intracranial pressure), neurosyphilis (syphilis serology), 
tuberculous meningitis (mycobacterial culture), Hodgkin's disease (lymphadenopathy, bone marrow involvement, 
weight loss, night sweats, pruritus, deteriorating course of illness), reaction to foreign bodies (eg., neurological 
shunts), lymphocytic choriomeningitis (viral culture) 

Treatment: dexamethasone + analgesics; death common and neurological deficits usual with Bayliascaris 
procyonis, with other agents, recovery in mild disease is usually spontaneous, but occasionally disease has been 
fatal 

Amoebic meningoencephalitis 

Agents: Naegieria fowled (primary amoebic meningoencephalitis; rare; acute; probably worldwide in heated 
water such as swimming pools, warm springs and in brackish water; invasion of CNS via nasal mucosa and 
olfactory nerve after bathing in amoeba-infested water or inhaling dust contaminated with viable cysts), 



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Mcanthamoeba (granulomatous amoebic meningoencephalitis; rare; more insidious onset and more prolonged course; 
in chronically ill, diabetic, alcoholic, immunocompromised, immunosuppressed; no history of swimming; route of 
infection probably hematogenous, with portal of entry primary focus in skin, lung, kidney, eye, grafts), Balamuthia 
mandrillaris (granulomatous amoebic meningoencephalitis; 5 cases in Australia; not yet detected in environment) 
Diagnosis: mental status abnormalities, headache, fever, nausea and vomiting, stiff neck, seizures, anorexia, 
diplopia and blurred vision, photophobia, visual hallucinations, papilledema, cranial nerve palsies, nystagmus, gait 
ataxia, Babinski's sign, Kernig's sign 

Naegleriasis: sudden onset, sore throat, rhinitis, ageusia, parosmia, anisocoria, disconjugate gaze, 
coma on admission or shortly thereafter; death by cardiorespiratory arrest, pulmonary edema, brain edema 

Acanthomoebiasis: sleep disturbances, hearing difficulties, hemiparesis, aphasia, coma at end of 
clinical course; death from bronchopneumonia and liver or kidney failure 

multifocal areas of decreased density in subcortical gray matter, gyriform pattern of enhancement in computerised 
axial tomography; cerebral angiography normal; wet mount (motile trophozoites 8-15 urn), Giemsa-Wright and 
modified trichome stains and culture of CSF and pus; amoebic trophozoites on electron microscopy, indirect 
fluorescent antibody test of brain biopsy (positive in 67% of cases); serology (positive in 50%); white cell count 
8000/jLtL; CSF protein increased, glucose normal or decreased, 20-7300 leucocytes/ jliL, all mononuclears to 
predominance of polymorphs 
Differential Diagnosis: 

Naegleria: bacterial meningitis (including partially treated), early viral meningitis 

Mcanthamoeba: partially treated bacterial meningitis, viral meningonecephalitis, tuberculous 
meningitis, fungal meningitis, parameningeal infectious focus, carcinomatous meningitis, CNS vasculitis 
Treatment: recovery very rare; amphotericin B 1.5 mg/kg/d i.v. in 2 divided doses then 1 mg/kg/d for 6 d 
+ amphotericin B 1.5 mg intrathecally for 2 d then 1 mg intrathecally on alternate days for 8 d + miconazole 
350 mg/m 2 daily i.v. in 3 divided doses for 9 d + miconazole 10 mg intrathecally daily for 2 d then 10 mg 
intrathecally on alternate days for 8 d + rifampicin 10 mg/kg daily in 3 divided doses for 9 d 
Encephalitis: « 7 cases/100,000 person-years; arboviral, enteroviral, associated with childhood infections 
(measles virus, mumps virus, simplexvirus 3, rubella virus), associated with respiratory infections, other infectious 
agents (< 1% of total cases, no deaths) 

Agents: 70-74% indeterminate (69% of total encephalitis deaths, case-fatality rate 11%); 21-27% of documented 
cases childhood viral (5% of total encephalitis deaths, case-fatality rate 6%; transmitted by aerosolised droplets; 
10% simplexvirus 3 (also common in impaired cell-mediated immunity), 6-10% mumps virus (1:6000 mumps cases; 
0.5-2.3% case-fatality rate), 6-7% measles virus (33% of measles deaths, 67% of measles deaths in patients > 18 
y; 0.6/1000 cases; case-fatality rate 14%), rubella virus (< 1% of total cases; 1/5000-1/6000 cases; in 4% of 
adults with rubella; 20-50% case-fatality rate)), 12-21% simplexvirus (15% of total encephalitis deaths, case-fatality 
rate 40-70% untreated, 10-20% treated with acyclovir; most common cause of sporadic fatal encephalitis in USA; 
all age groups but usually newborn, children and young adults; whites > blacks; no seasonal predominance; 
usually reactivation; common in impaired cell-mediated immunity; may result in late persistent or recurrent 
disease of CNS; 67% of affected neonates with significant neurologic sequelae), 10-53% several arboviruses (6% of 
total encephalitis deaths; case-fatality rate 4%; transmission by mosquito bite and other arthropods; incubation 
period 4-21 d; mainly in summer, autumn, early winter; St Louis encephalitis (9% of total cases in USA; 5% of 
total encephalitis deaths; case-fatality rate 7%; USA, Central America, Caribbean Islands, Colombia, Brazil, 
Argentina; reservoir birds and bats; vector Culex mosquito), California encephalitis (4% of total cases in USA; rare 
deaths; North-Central USA; reservoir rabbits, squirrels, mice; vector Redes and Culex mosquitoes), Western equine 
encephalitis (3% of total cases in USA; case-fatality rate 10%; all of USA, Canada, Central America, Guyana, 
Brazil, Argentina; reservoir birds and horses; vector Culex tarsalis mosquito), Eastern equine encephalitis (« 8 
cases/y in USA; case-fatality rate 30-75%; < 1% of total encephalitis deaths; Eastern USA, Central America, 
Caribbean Islands, Brazil, Guyana, Argentina; reservoir horses (attack rate 18/1000) and birds; vector Redes 
mosquito; also highly infectious as aerosol, possible biowarfare agent), Japanese B encephalitis (> 50,000 cases/y 
worldwide; mosquito vector and reservoir; other reservoirs pigs, water birds; attack rate 
4/100 000; case-fatality rate > 20%), Venezuelan equine encephalitis (Florida, Texas, Central America, Northern S 
America; reservoir horse, rodents, dogs, bats, birds; vector Culex, Redes and Deinocerites mosquitoes; also highly 
infectious as aerosol (10-100 organisms required for infection), possible biowarfare agent; case-fatality rate 1% but 
morbidity and mortality may be much higher in biological attack; no person-to-person spread), Powassan 



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encephalitis (NE and Central Europe, Canada, Northern USA; reservoir rodents; vector tick; case-fatality rate 10- 
20%), Russian spring-summer encephalitis virus, Rio Bravo virus, Murray Valley encephalitis virus, Ilheus virus, 
Colorado tick fever virus, West Nile virus, Bunyavirus La Crosse (20-30/100,000 children/y in many parts of US 
Midwest; mainly children < 15 y)), 6% influenza A virus (postinfectious encephalomyelitis), 6% human adenovirus 
(especially serotype 7), 3-40% enteroviral (< 1% of total encephalitis deaths, case-fatality rate 6%; 15% human 
echovirus 11, 9% human echovirus 7; human echovirus 2-4, 6, 16, IS, 19, 30, Coxsackievirus, Poliovirus, human 
enterovirus 71; infrequent infections in impaired cell-mediated immunity; may cause chronic disease in primary 
hypogammaglobulinemia), 3% simplexvirus 3 (4% of total encephalitis deaths, case-fatality rate 50%); infectious 
mononucleosis (< 1% of total cases; < 1% of total encephalitis deaths), vaccinia virus (postvaccination; 
infrequent infections in impaired cell-mediated immunity), Rift Valley fever (in < 1% of infections), rabies, JC 
polyomavirus (progressive multifocal leucoencephalopathy; infrequent infections in impaired cell-mediated immunity; 
also in AIDS), Human cytomegalovirus (extremely infrequent infections in impaired cell-mediated immunity and in 
AIDS), cercopithecine herpesvirus 1 (herpesvirus of monkeys; occasional fatal encephalitis and ascending paralysis 
in man), lassa virus, bunyaviruses, lymphocytic choriomeningitis virus, Nipah virus, slow infections, rickettsias, 
Coxiella burnetii, Mycoplasma (rare), Chlamydia, bacteria associated with brain abscess and meningitis, Listeria 
monocytogenes (rhomboencephalitis; nonimmunosuppressed adults; case-fatality rate 51%; sequelae in 61% of 
survivors), spirochetes, mycobacteria, Drechslera (granulomatous), Cryptococcus neoformans, Coccidioides immitis, 
Candida, Histoplasma capsulatum, Aspergillus, phycomycetes, Toxoplasma gondii (3-40% of AIDS patients), 
Trichinella spiralis, Baylisascaris procyonis (from raccoons) 

Diagnosis: fever, neurologic abnormality of recent onset; MRI; culture of blood, CSF, throat washings, rectal 
swab, urine, fluid from skin lesions, brain biopsy in embyronated eggs, laboratory animals, tissue culture; serology 
(complement fixation test, microagglutination, indirect fluorescent antibody titre, hemagglutination inhibition, 
neutralisation); immunofluorescent antibody tests on CSF, brain biopsy; PCR on CSF (HSV, CMV, VZV, EBV, JE, 
rabies, HIV, enteroviruses, certain arboviruses) 

Viral: CSF protein increased in 75% of cases, glucose normal, cells 200-2000/nL, 60-90% neutrophils in 
early stages, lymphoid pleocytosis in 80% of later cases, erythrocytes or xanthochromia frequently present 
Measles: 

Acute: recrudescence of fever during convalescence from measles, headache, 
seizures, changes in mental status; generalised swelling of brain on computerised axial tomography; diminished 
activity on electroencephalogram; protein increased in 75% of cases, glucose normal, lymphoid pleocytosis in 80% 
of cases 

Atypical: CSF protein 104 mg/dL, glucose 50 mg/dL, 9 leucocytes/nL, 2 
erythrocytes/^ 

Subacute: 1-7 mo after measles attack; immunocompromised patients (70% acute 
lymphoblastic leukemia); 100% altered levels of consciousness, 97% seizures (78% focal); histologic and PCR 
studies of brain tissue 

Subacute Sclerosing Panencephalitis (Subacute Inclusion 
Panencephalitis, Von Brogaert's Disease): rare and fatal; stage 1: « 6 y after attack of measles; subtle 
changes in intellectual skills, mood swings, inappropriate affect, drooling and changes in speech (less common); 
stage 2: myoclonic jerks, clumsiness, ataxia, choreoathotosis, ocular changes (cortical blindness, optic atrophy, etc) 
in « 50%; stage 3: marked mental deterioration, coma, opisthotomus, decerebrate or decorticate posturing, 
autonomic nervous dysfunction, often death due to infection; stage 4: patient calmer, nearly total loss of cortical 
function, purposeless responses (eye movements, episodic laughing or crying), severe autonomic nervous 
dysfunction, death from vasomotor collapse or infection; electroencephalogram (60% 'pseudoperiodic' patterns, 40% 
atypical alterations); ELISA titres on 1:5 CSF and 1:2000 serum; microscopy, electron microscopy and 
immunofluorescence of brain tissue 

Arboviral: culture of acute phase blood and CSF; serology (paired sera; complement fixation 
test, hemagglutination, ELISA (IgM), hemadsorption); inoculation of suckling mouse with blood, brain post mortem 

St Louis Encephalitis: temporal lobe lesions on computerised axial 
tomography; protein > 50 mg/dL in 91% of cases, glucose > 45 mg/dL in 81%, leucocytes « 10/ pL in 75% of 
cases, lymphocytes « 50% in 71% 

Venezuelean Equine Encephalitis: 

Influenzal: only constitutional symptoms, febrile course 1-4 d 



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Fulminant: short febrile course with rapid progression to shock, coma 
and convulsions, disseminated intravascular coagulation; survivors often have sequelae 

Encephalitic: fever for 2 w or more, sometimes diphasic; CNS 
symptoms and signs develop during latter phase; usually no sequelae 

Eastern Eqnine Encephalitis: may have influenzalike prodrome with fever, 
headache, vomiting, malaise and, rarely, relatively mild encephalitic phase with somnolence but, more commonly, 
abrupt illness with high fever, convulsions and rapidly progressive coma; may exhibit diffuse or focal signs 
mimicking herpes encephalitis; magnetic resonance imaging 

West Nile Virus: oculomotor abnormalities, movement disorders, myoclonus, 
features of Parkinson's disease; isolation from tissue, blood, CSF, other body fluid; PCR on tissue, blood, CSF, other 
body fluid; IgM capture EIA on CSF or serum; plaque reduction neutralising antibody titre on serum or CSF (> 4X 
change in paired, appropriately timed specimens); EIA for IgM + EIA or HI (confirmed by plaque reduction 
neutralising antibody titre) in single serum specimen 

Bunyavirus La Crosse: fever in 86%, headache in 83%, vomiting in 70%, 
seizures in 46%, disorientation in 42%; indirect immunofluorescence of serial IgM and IgG titres 

Simplexvirus: focal neurologic signs in 85-90%, fever in 80-95%, headache in 55-70%, stiff 
neck in 45-55%, herpes labialis in 15-20%; CSF abnormal in 85-100%, 10-100 leucocytes/ pL in 80-100%, 
> 10 erythrocytes/ pL in 66-75%, elevated protein in 55-90%, hypoglycorrhachia in 0-25%; localised findings on 
EEG, brain scan or arteriogram, usually localised to temporoparietal lobe, in 60-95%; MRI — T2 prolongation or 
gyriform enhancement of medial temporal lobe, insular cortex or cingulate gyrus, petechial hemorrhage of temporal 
or orbitemporal lobes, effacement of adjacent CSF spaces; PCR on CSF; brain biopsy positive in » 90% and may 
discover another treatable cause — cryptococcal meningoencephalitis, tuberculosis, brain abscess, brain tumour 
Enteroviral: virus isolation; PCR 
Mumps virus: virus isolation 

Nipah virus: associated with pigs in Malaysia and Singapore; headache, drowsiness, fever; 
low lymphocyte counts in 82%, high levels of CSF protein in 73%, elevated white blood cell counts in 64%, low 
platelet counts, low serum sodium levels and elevated aspartate aminotransferase in 46%; MRI (small lesions 
primarily within white matter, with transient punctate cortical hyperintensities on Tl-weighted images); 
immunohistochemistry + serology 

Listeria monocytogenes: prodrome of headache, nausea or vomiting and fever, lasting several 
days, followed by progressive asymmetrical cranial nerve palsies, cerebellar signs, hemiparesis or hypesthesia and 
impairment of consciousness; culture of blood (61% positive), CSF (41% positive); magnetic resonance imaging 
Mycoplasma pneumoniae: 78% meningeal signs/symptoms, 53% temperature > 39 C 
Trichinosis: enlarging areas of hemorrhage in parietal regions on computerised axial tomography 
Toxoplasma: focal or generalised neurologic abnormalities; contrast-enhanced computerised axial 
tomography (ring or nodular enhancement in > 90%); magnetic resonance imaging; serology (IgG and IgM); 
Giemsa-Wright stained smears of centrifuged sediment of CSF or brain aspirate, or impression smears of brain 
biopsy 
Treatment: 

Measles: ribavirin 20 mg/kg/d i.v. 
Simplexvirus, Nipah virus: 

Neonates: aciclovir 20 mg/kg i.v. 8 hourly for 21 d (adjust dose for renal function) 
Others: aciclovir 10 mg/kg i.v. 8 hourly for at least 14 d (adjust dose for renal function) 
Chlamydia, Mycoplasma, Rickettsia: i.v. doxycycline 

Toxoplasma: pyrimethamine 2 mg/kg to 50-100 mg orally as loading dose then 1 mg/kg to 50 mg 
orally daily + sulphadiazine 50 mg/kg to 1-1.5 g orally or i.v. 6 hourly or clindamycin 15 mg/kg to 600 mg 
orally or i.v. 6 hourly if allergic to sulphonamides + calcium folinate acid 15 mg orally daily (to reduce incidence 
of bone marrow suppression) for 3-6 w; 5-fluorouracil; spiramycin 

Maintenance Therapy in HIV/AIDS: pyrimethamine 25-50 mg orally daily + 
sulphadiazine 500 mg orally 6 hourly or 1 g orally 12 hourly or clindamycin 600 mg orally 8 hourly if 
hypresensitive to sulphonamides 

St Lonis Encephalitis: interferon a-2b 
Others: see under Meningitis and Brain Abscess 



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Prophylaxis: 

Varicella-zoster in Patients with Lenkemia, Congenital or Acqnired 
Immunodeficiency, < 24 mo after Haemopoietic Stem Cell Transplant, on 
Immnnosnppressive Medication or with Chronic Graft-versns-host Disease, or Newborn of 
Mother with Varicella: varicella-zoster immune globulin 625 U i.m. within 96 h of exposure to varicella or 
zoster from household contact, playmate contact (> 1 h play indoors), hospital contact (in same 2-4 room bedroom 
or adjacent beds in a large ward), or newborn whose mother contracted varicella 5 d before delivery or within 
48 h of delivery), if negative or unknown prior disease history and age < 15 y; live attenuated vaccine (all 
susceptible health care workers, household contacts and family members > 12 mo and not pregnant or 
immunocompromised; 85% effective) 

Japanese B Encephalitis: effective vaccine 

Toxoplasma gondii in HIV/ AIDS CD4 Connt < 200/ ug: cotrimoxazole 80/400 or 
160/800 mg daily or 160/800 mg orally 3 times weekly 

Encephalitis Lethargica: epidemics in 1920s, sporadic cases reported in recent years 
Agent: inffuenzavirus 

Diagnosis: Parkinsonian signs in a young person after influenza 
Treatment: ? steroids 

Noninfectious Nontyphoidal Salmonella Encephalopathy 
Agent: non-typhoidal Salmonella 

Diagnosis: diffuse and rapidly progressive brain dysfunction and circulatory failure following enteritis; elevated 
CSF opening pressure, minimal ischemic damage and mild edema on brain CT, slow waves on EEG, microvesicular 
fatty change in liver, severe enterocolitis 
Treatment: supportive 
Encephaloihyocarditis 
Agent: encephalomyocarditis virus 
Diagnosis: on symptoms; exposure to rodents 
Treatment: non-specific 

Neurosyphilis: generalised or focal seizures; stroke; changes in personality, affect, sensorium, intellect, insight, 
judgment; hyperactive reflexes; Argyll-Robertson pupil; optic atrophy; ataxia; impotence; bladder disturbances; 
peripheral neuropathy; Romberg's sign; cranial nerves II-VII involvement 
Agent: Treponema pallidum subsp pallidum 
Diagnosis: see Syphilis 

Treatment: benzylpenicillin 3-4 MU i.v. 4 hourly or 18-24 fflU/d as continuous infusion for 10-14 d, procaine 
penicillin 2.4 MU i.m. once daily + probenecid 500 mg orally 4 times a day for 10-14 
Neurocysticercosis: 12% of admissions to neurological wards and leading cause of acquired epilepsy in adults 
in Central and South America, sub-Saharan Africa, east and south Asia; > 50,000 deaths/y; 58% parenchymal 
calcifications, 48% arachnoiditis, 26% hydrocephalus secondary to meningeal inflammation, 13% parenchymal cysts, 
4% hydrocephalus secondary to meningeal fibrosis, 2% brain infarction secondary to vasculitis, 1% mass defect 
due to large cyst or clump of cysts, 0.7% intraventricular cysts, 0.7% spinal cysts, rare optic nerve 
Agent: Taenia solium 

Diagnosis: epilepsy in 70%; CSF monocytes 300-5000/jllL, protein 50-1600 mg/dL, glucose low in 18%; 
computed tomography; magnetic resonance; IgG and IgM ELISA (sensitivity 87%, specificity 95%) and complement 
fixation test (sensitivity 22-83%) on CSF; histology of biopsy from brain or spinal cord 
Treatment: 

Intraventricular Cyst, Spinal Cysts: surgical extirpation (+ ventricular shunt with 
intraventricular cyst) 

Parenchymal Cysts, Vascnlitis and Encephalitis, Arachnoiditis, Intraocular Cysts: 
albendazole 15 mg/kg/d for 1 mo, praziquantel 50 mg/kg/d for 2 w; + antiepileptic drugs if epilepsy; + 
dexamethasone 24-32 mg/d in vasculitis and encephalitis; + ventricular shunt in arachnoiditis with 
hydrocephalus; + periocular methylprednisolone acetate 80 mg every 30-60 d and aspiration of intravitreous cysts 
in intraocular cysts 

Granulomas or Calcifications: symptomatic treatment (eg, antiepileptic drugs) 

Hydrocephalus Due to Basal Fibrosis: ventricular shunt 



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Infections of the Central Nervous System 

Cranial Nerve Dysfunction Dne to Basal Fibrosis: specific treatments (eg, surgery for 
diplopia) 

Optic Nerve: dexamethasone sodium phosphate 100 mg i.v. daily for 3 d then oral steroids 
Cerebral Coenurosis 
Agent: Multiceps species 

Diagnosis: paraplegia and hemiplegia or leptomeningitis 
Treatment: usually fatal 
Cerebral Spiroihetrosis 
Agent: Spirometra 

Diagnosis: computed tomography and MRI, followed by stereotactic biopsy 
Treatment: surgical resection 
Cerebral Malaria 
Agent: Plasmodium falciparum 

Diagnosis: clinical manifestations of acute falciparum malaria; coma, convulsions, other neurological signs and 
symptoms (particularly inability to localise a painful stimulus) compatible with an acute diffuse meningitis or with 
an encephalitic process; peripheral asexual Plasmodium falciparum parasitemia 
Treatment: see Malaria; often fatal 

Brain Abscess and Subdural Empyema: « 1 case/100,000 person-years; case-fatality rate 10-22% (90% if 
comatose, 80-90% if rupture into ventricles, 70-100% if multiple, 100% if distant source of infection, 51-53% in 
pituitary infection); may spread from nearby tissue such as paranasal sinuses, ear and mastoid process, or by 
metastatic spread from distant organs following, eg, trauma 

Agents: 61% Staphylococcus aureus (common after trauma or surgery), 18% aerobic Gram negative bacilli 
(including Haemophilus aprophilus and enterics (common with site of origin in ear or paranasal sinuses; 
Citrobacter diversus in neonates; Klebsiella pneumoniae hematogenous spread, frequent in diabetics); uncommonly, 
Salmonella, Actinobacillus actinomycetemcomitans, rarely, Brucella melitensis, Haemophilus parainfluenzae, 
Enterobacter agglomerans, Pasteurella multocida (infants and adults), Haemophilus paraprophilus, Streptobacillus 
moniliformis, anaerobic Campylobacter), 8% streptococci (including Streptococcus milled, Streptococcus sanguis in 
intermittently treated jaw infections; occasionally, Streptococcus pneumoniae; hematogenous spread, paranasal 
sinusitis), 2% anaerobes (nontraumatic; especially Peptostreptococcus and Propionibacteriunr, also Actinomyces, 
Prevotella bivia), 2% Staphylococcus epidermidis; Nocardia asteroides (in impaired cell-mediated immunity), 
Listeria monocytogenes (especially in leukemia and renal transplant recipients; case-fatality rate 57%), 
Mycobacterium tuberculosis, Actinomyces pyogenes, Corynebacterium equii (heart transplant recipient), any 
vascular pathogen secondary to bacteremia (especially in neutropenics), Aspergillus (in neturopenics), Mucor (in 
neutropenics), Absidia (in neutropenics), Rhizopus (in neutropenics), Pseudallescheria boydii (in malignant 
lymphoma and immunosuppression), Exophila dermatitidis, Fonsecaea pedrosoi, Dactylaria constricta, Bipolaris 
hawaiiensis, Bipolaris spicifera, Curvularia pallescens, Cladophialophora bandana, Rhinocladiella atrovirens (1 case 
in HIV-infected i.v. drug abuser), Curvularia lunata (rare), Scedosporium apiospermum (in immunosuppressed), 
Entamoeba histolytica (amoebic brain abscess usually arises from hematogenous spread of causative organism from 
lungs or liver; fatal), Toxoplasma gondii (in impaired cell-mediated immunity) 

Diagnosis: headache in 70%, fever in 50%, retarded consciousness in 50%, papilledema in 50%, focal neurologic 
deficits in 40%, seizures in 25%, nuchal rigidity rare; culture and histology (Gomori's methenamine silver or PAS 
shows broad, septate hyphae in mycetoma; Brown and Breen modification of Gram stain shows Gram positive 
filamentous or branching rods in actinomycetoma, and cocci, coccobacilli or bacilli in botryomycosis) of biopsy; 
blood cultures; computerised axial tomography (« 100% accurate); radionuclide scan (« 100% accurate); do not do 
lumbar puncture (risk of cerebral herniation; CSF, if obtained, will show protein 20-600 mg/dL, glucose 
16-93 mg/dL, 0-2300 leucocytes/jaL, 30-100% polymorphs); agglutinations; analysis of pus from primary organ and 
obtained by aspiration or biopsy of abscess 

Fnngal: Fontura-Masson stained histology and culture of biopsy 

Pitnitary Gland Infection: headache in all cases, fever in 75% of tuberculous and 100% of other 
bacterial infections, visual disturbances in all tuberculous and 88% of other bacterial infections, associated tumour 
or cyst in 94%, sellar erosion or enlargement in 63% of tuberculous and 90% of other bacterial infections, 
associated sphenoid sinusitis in 89%, abnormal carotid angiogram in 50% of tuberculous and 86% of other 
bacterial infections, hypopituitarism in 80% of tuberculous and 73% of other bacterial infections, abnormal 



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pneumoencephalogram in 50% of tuberculous and 75% of other bacterial infections; smear and culture usually 
negative in tuberculous, positive in 55% of other bacterial infections; > 10,000 leucocytes/ pL in all tuberculous 
and 21% of other bacterial infections 

Treatment: surgical drainage or excision; benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly + metronidazole 
12.5 mg/kg to 500 mg i.v. 8 hourly + ceftriaxone 100 mg/kg to 4 g i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly 
or cefotaxime 50 mg/kg to 2 g every 6 h 

Post Neurosurgery: vancomycin 12.5 mg/kg to 500 mg (child < 12 y: 15 mg/kg to 500 mg) i.v. 6 
hourly + ceftazidime 50 mg/kg to 2 g i.v. 8 hourly or meropenem 40 mg/kg to 2 g i.v. 8 hourly 

From Frontal Sinuses, Teeth: metronidazole + cefotaxime 

From Ear and Mastoid: amoxicillin + metronidazole 

Secondary to Penetrating Trauma: penicillin + cefotaxime 

Metastatic: penicillin + cefotaxime + metronidazole 

Staphylococci: fusidic acid 20 mg/kg i.v. 12 hourly as 2 h infusion + clindamycin 600 mg i.v. 8 
hourly (child: 15-40 mg/kg i.v. daily in divided doses) 

Nocaidia asteroides: cotrimoxazole 4/20 mg/kg to 160/800 mg i.v. or orally 6 hourly for 3-4 w, 
then orally 12 hourly for 3-6 mo 

Streptococcus pneumoniae: 

Penicillin MIC < 0.125 mg/L: benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly for 
10 d 

Penicillin MIC > 0.125 mg/L: ceftriaxone or cefotaxime + vancomycin or rifampicin 

Other Streptococci, Rctinomyces: high dose benzylpenicillin 

Listeria monocytogenes: cotrimoxazole 5/25 mg/kg to 160/800 mg i.v. 6 hourly + 
benzylpenicillin 60 mg/kg to 1.8-2.4 g i.v. 4 hourly or amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly 

Haemophilus: cefotaxime 50 mg/kg to 2 g i.v. 6 hourly for 7-10 d, ceftriaxone 100 mg/kg to 4 g 
i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly for 7-10 d, amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly for 
7-10 d (if susceptible) 

Brucella: cotrimoxazole 

Other Aerobic Gram Negative Bacilli: chloramphenicol 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 
600 mg orally 3 times weekly for 12 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + 
rifampicin 10 mg/kg to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a 
week for 12 mo + pyrazinamide 25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly 
for 2 mo (12 mo if not known to be susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily 
(not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 
2 mo or until known to be susceptible to isonazid and rifampicin (to 12 mo) + corticosteroids for first few weeks 

Anaerobes: benzylpenicillin 2.4 g i.v. 4-6 hourly + metronidazole 500 mg i.v. infused over 20 minutes 
8 hourly, chloramphenicol 1 g i.v. 6 hourly 

Fungi: 

Bipolaris, Bbinocladiella atrovirens: resection; itraconazole 
Others: amphotericin B + flucytosine; decompression of spinal cord essential in management 
of epidural abscess 

Entamoeba histolytica: metronidazole 

Toxoplasma gondii: sulphadiazine 50 mg/kg to 1-1.5 g orally or i.v. 6 hourly + pyrimethamine 
2 mg/kg to 50-100 mg orally initially then 1 mg/kg to 25-50 mg orally daily + calcium folinate 15 mg orally 
daily for 3-6 w 

Sulphonamide Hypersensitive: clindamycin 600 mg orally or i.v. 6 hourly + 
pyrimethamine as above 

Maintenance Therapy in HIV/AIDS: pyrimethamine 25-50 mg orally daily + 
suphadiazine 500 mg orally 6 hourly or 1 g orally 12 hourly or if hypersensitive to sulphonamides clindamycin 
600 mg orally 8 hourly 

Prophylaxis (Toxoplasma gondii in HIV/AIDS CD4 Count < 200/uL): cotrimoxazole 80/400 or 
160/800 mg orally daily or 160/800 mg orally 3 times weekly 



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Epidural Abscess: 0.2-2 episodes/10,000 hospital admissions; frequently associated with adjacent osteomyelitis 

or disc infection 

Agents: 63-79% Staphylococcus aureus, 4% Streptococcus pneumoniae; 4% Streptococcus viridans, single report of 

Streptococcus pyogenes; also other organisms causing osteomyelitis 

Diagnosis: spinal ache, root pain, weakness (including bowel and bladder dysfunction), paralysis, focal 

neurologic deficits rare; MRI or CT with contrast medium; blood cultures positive in 62%; Gram stain and culture 

of operative material or aspiration; lumbar puncture contraindicated 

Treatment: urgent surgery essential; di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin 4-6 mg/kg 

(child < 10 y: 7.5 mg/kg; > 10 y: 6 mg/kg) i.v. daily (adjust dose for renal function) 

Raised Intracranial Pressure 

Agent: Echinococcus granulosus (hydatid cyst) 

Diagnosis: X-ray; serology; exposure to dogs 

Treatment: surgery ± albendazole 7.5 mg/kg to 400 mg orally 12 hourly (not < 6 y) 

Cerebrospinal Fluid Shunt Infections 

Agents: Staphylococcus epidermidis, Staphylococcus aureus, streptococci, Enterococcus, aerobic Gram negative 

bacilli, diphtheroids, Propionibacterium, Haemophilus influenzae, Pseudomonas 

Diagnosis: fever, evidence of increased intracranial pressure, abdominal pseudocyst; culture of CSF and 

peritoneal fluid 

Treatment: externalisation of peritoneal catheter + intraventricular and systemic antibiotics and later 

replacement of catheter 

Staphylococci: vancomycin 10-20 mg intrashunt daily + rifampicin 10 mg/kg orally 12 hourly + 
cotrimoxazole 5 mg/kg orally 8 hourly or vancomycin 15 mg/kg i.v. 8 hourly 

Enterococcus faecalis and Streptococci with Penicillin MIC > 0.2 mg/L: vancomycin 
10-20 mg intrathecal daily + 15 mg/kg i.v. 8-12 hourly + gentamicin 8 mg intrathecal daily 

Streptococci with Penicillin MIC < 0.1 mg/L: gentamicin 8 mg intrathecal daily + i.v. 
benzylpenicillin 

Aerobic Gram Negative Bacilli: gentamicin 8 mg intrathecal daily + cefotaxime 50 mg/kg i.v. 
12 hourly to 30 mg/kg 4 hourly 

Diphtheroids and Propionibacterium: intrathecal vancomycin 10-20 mg daily + i.v. 
vancomycin 15 mg/kg 8-12 hourly or cotrimoxazole 15 mg/kg orally 8 hourly 

Guillain-Barre Syndrome (Acute Polyradiculoneuritis): symmetrical ascending paralysis, usually self- 
limited and reversible but 5-10% fatal; 1-2 cases/100,000; 0.7 deaths/million doses of influenza vaccine 
Agent: influenza A virus, hepatitis B virus, human cytomegalovirus, Epstein-Barr virus, simplexvirus 3, rubella 
virus, human immunodeficiency virus, mumps virus (rare), HIV, Campylobacter jejuni, Mycoplasma pneumoniae, 
Plasmodium falciparum 

Diagnosis: acute or subacute onset of distal paraesthesia, weakness and muscle pain, with tendency for 
proximal spread over 2 w and with albuminocytologic dissociation in CSF; fever absent at onset of paralysis, 
meningeal irritation usually absent, residual paralysis usually absent, sensation may be diminished (cramps, 
tingling, hypesthesia of palms and soles), deep tendon reflexes diminished but may return in several days 
Differential Diagnosis: poliomyelitis (high fever always present at onset of flaccid paralysis, severe myalgia 
and backache, dysautonomia, inflammatory CSF, abnormal electromyogram at 3 w, severe asymmetrical atrophy at 
3 mo), traumatic neuritis (pain in gluteus, hypothermia, frequent blood pressure alterations, sweating, blushing and 
body temperature fluctuations, CSF normal, symmetrical atrophy of peroneal muscles at 3 mo), transverse myelitis 
(anesthesia of lower limbs with sensory perception, hypothermia in affected limb, CSF normal to mild increase in 
cells, moderate atrophy of affected lower limb at 3 mo) 
Treatment: none specific 

Acute Paralytic Poliomyelitis: 1948 laboratory confirmed cases in 2005; Afghanistan, India and Pakistan 
major reservoirs; eradicated in Western Hemisphere in 1994; last notification of wild poliovirus infection in USA in 
1979 and in Australia in 1986; transmission fecal and respiratory; incubation period 1-3 w, latent period 1-3 d, 
infectious period 14-20 d, interepidemic period 2-5 y 

Agents: human poliovirus 1-3; also some coxsackieviruses (sustained paralysis with human coxsackievirus A4, Al, 
A9, echo 9 virus, transient paralysis with human coxsackievirus A2, B2-BS], human echovirus 1, 2, 4, 6, 7,11, 16, 
18, 30, human cytomegalovirus in AIDS, West Nile virus 



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Diagnosis: 95% asymptomatic; 4-5% mild febrile illness (upper respiratory tract infection, gastrointestinal illness, 
flulike illness); 1-2% mild prodromal illness followed by aseptic meningitis; <1% acute flaccid paralysis; fever at 
onset of paralysis, meningeal irritation (stiff neck, headache, vomiting) usually present, severe pain in muscles, 
backache, paralysis usually asymmetrical, progression of paralysis 3-4 d, residual paralysis usually present, 
paresthesia rare, sensation normal, deep tendon reflexes diminished or absent, electromyogram at 3 w abnormal, 
severe asymmetrical atrophy at 3 mo, skeletal deformation developing later; spinal disease 79% of cases, bulbar 
2%, combination 19%; case-fatality rate for paralytic illness 2-5% in children, 15-30% in adults and 25-75% in 
bulbar disease; viral culture of feces or rectal swab (2 specimens at least 24 h apart) or spinal cord, grey matter, 
medulla, pons, cerebrum, Peyer's patches, intestinal contents post mortem (within 24 h of death) in monkey or 
human cell culture; CSF protein 38-154 mg/dL, glucose 81 mg/dL, 10-335 leucocytes/j-tL, 5% polymorphs, 80% 
lymphocytes, 15% monocytes, 9 erythrocytes/ (.iL; neutralisation antibody titre or complement fixation test on 
serum (> 4X increase or > 1:512) 

Differential Diagnosis: Guillain-Barre syndrome (fever not common, cramps, tingling, hypesthesia of palms 
and soles, CSF albumin-cytological dissociation, normal EMG at 3 w, mild sequelae at 3 mo), traumatic neuritis 
(pain in gluteus, hypothermia, frequent blood pressure alterations, sweating, blushing and body temperature 
fluctuations, CSF normal, EMG normal at 3 w, symmetrical atrophy of peroneal muscle at 3 mo), transverse 
myelitis (fever rarely present, anesthesia of lower limbs with sensory perception, hypothermia in affected limb, 
CSF normal or mild increase in cells, EMG normal at 3 w, moderate atrophy in affected limb at 3 mo) 
Treatment: non-specific 

Prophylaxis (human poliovhus): oral vaccine phased out in USA by 2000 because of continued vaccine- 
associated paralytic poliomyelitis, but is still recommended for mass vaccination during polio outbreaks; all infants 
and children, incompletely vaccinated children, travellers to areas or countries where polio is epidemic or endemic, 
immuncompromised individuals, communities or population groups with disease caused by wild poliovirus, 
laboratory workers who handle poliovirus specimens, healthcare warkers who have contact with patients excreting 
wild poliovirus, and unvaccinated adults whose children will receive oral poliovirus vaccine should receive 4 
doses inactivated vaccine (contraindicated if severe febrile illness, allergy to streptomycin or neomycin, vomiting 
or diarrhoea, some malignant conditions, HIV infection in individual or household contacts, pregnant woman in 
first 4 months of gestation); vaccine 90-100% efficacy, lifetime immunity, marginally cost effective 
Post-polio Syndrome: development of new muscle weakness and fatigue in skeletal or in bulbar-controlled 
muscles, unrelated to any known cause, that begins between 25 and 40 y after an acute attack of paralytic 
poliomyelitis; occurs in 25-40% of survivors infected in childhood 
Agent: human poliovirus 

Diagnosis: history of acute paralytic poliomyelitis in childhood or adolescence; history of partial recovery of 
motor function and maintenance of function for at least 15 y; residual muscle atrophy in at least one limb, 
accompanied by weak or missing reflexes but normal sensation; normal functioning of sphincter muscle 
Treatment: supportive 

Botulism: paralytic illness caused by neurotoxin; associated with home-canned foods with low acid content, 
improperly canned commercial foods, home-canned or fermented fish or other marine or freshwater animals, herb- 
infused oils, baked potatoes in aluminium foil, cheese sauce, bottled garlic, foods held warm for extended periods; 
0.5% of foodborne disease outbreaks in USA, 0.1% of cases, 3% of deaths; 226 cases from 114 outbreaks in Alaska 
in 1950-2000 (all from fermented foods); last case in Australia in 1998; also inhalational 
Agent: Clostridium botulinum 

Diagnosis: incubation period 2 h - 10 d (usually 12-36 h); vomiting, diarrhoea; developing cranial nerve 
paralysis causing blurred vision, ptosis, mydriasis, diplopia, dilated and fixed pupils, dysphonia, dysphagia and dry 
throat; dysarthria, symmetrical, descending, progressive skeletal muscle weakness, respiratory impairment, motor 
palsy, diffuse flaccid paralysis follow; sometimes postural hypotension; patient alert and afebrile; duration of 
illness days to months; electromyogram with rapid repetitive stimulation of affected area at 20-50 Hertz, tensilon 
test, CSF protein normal, computerised tomography scan of head, magnetic resonance imaging; ELISA test for 
botulinum toxin in serum, stool and food or from swab of nares; mouse bioassay 
Differential Diagnosis: Guilllain-Barre syndrome, myasthenia gravis, poliomyelitis, tick paralysis, cerebral 
vascular accident, heavy metal (thallium, arsenic, lead) or organophosphate toxicity 
Treatment: supportive + antitoxin (no deaths if early diagnosis) 
Prophylaxis: passive with antitoxin or active with toxoid 



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Infections of the Central Nervous System 



AIDS Dementia Complex (HIV Encephalopathy) 
Agent: human immunodeficiency virus 

Diagnosis: 'subcortical dementia' with slowing of mental and motor functions, diffuse cognitive impairment, 
behavioural torpor, in human immunodeficiency virus positive individual; computed tomography and magnetic 
resonance imaging; CSF examination 
Treatment: zidovudine 
Tick Paralysis: case-fatality rate 10% 

Agents: various hard tick species {Ixodes holocyclus in Australia, Dermacentor andersoni in southern and western 
USA, Dermacentor variabilis and Mblyomma americanum in southern and eastern USA) 
Diagnosis: weakness, pulmonary complication (respiratory failure; bilateral raised hemidiaphragms on chest X- 
ray); presence of tick; history; CSF protein and cell count normal; compound action potentials of nerves and 
associated muscles decreased, nerve conduction velocity decreased 
Treatment: tick removal; usually supportive only, but antitoxin may be given 
Kuru: age > 4 y, insidious onset, dementia ±, sensory defects ±; mainly women and children of an isolated 
tribe (Fore) in Papua-New Guinea; transmitted by eating infected brain tissue in ritual ceremony for dead tribal 
member 
Agent: prion 

Diagnosis: clinical (ambulant stage: subjective unsteadiness, ataxic gait, convergent strabismus, shivering-like 
truncal tremor, dysarthria; sedentary stage: needs support for walking, rigidity of limbs, clonus, emotional lability 
with outbursts of pathologic laughter, no mental deterioration or sensory changes; terminal: unable to sit without 
support, urinary and fecal incontinence, bulbar signs, inanition, decubitus ulcers, pneumonia) 
Treatment: none 

Creutzfeldt-Jakob Disease: age > 18 y (average 63 y), insidious onset, dementia and sensory defects 
present; disease duration 1 mo - 10 y; inherited form with worldwide incidence « 1:1,000,000 and apparently 
infectious form 
Agent: prion 

Diagnosis: muscular spasms, reduced mental function, loss of higher brain function, abnormal behaviour; 
periodic sharp waves in EEG in 65-70%; CSF 14-3-3 protein in « 90%; histology 
Treatment: none 

Variant of Creutzfeldt-Jakob Disease: form associated with bovine spongiform encephalopathy, occurring 
in younger patients 
Agent: prion 

Diagnosis: psychiatric signs, depression or schizophrenia, stickiness of the skin, instability, walking difficulties, 
involuntary movements, prostration and death; median age at death 29 y; pulvinar sign (high T2 signal in 
posterior thalamus on magnetic resonance imaging; « 75% of cases); no periodic sharp waves on EEG; CSF 14-3-3 
protein in 50%; histology of tonsils (presence of disease-associated glycoforms of protease-resistant prion protein) 
Treatment: none; possible benefit from quinacrine, chlorpromazine 

Gerstman-Straussler-Scheinkers Disease: discoordination followed by increasing dementia; « 50 families 
affected; inheritance of PrP gene mutation involved 
Agent: prion 
Treatment: none 

Fatal Familial Insomnia: sleep problems and autonomic nervous system manifestations, followed by full- 
blown insomnia and dementia; described in 9 families; inheritance of PrP gene mutation involved; disease lasts 
about 1 y 
Agent: prion 



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Chapter 7 



Skin Infections 

Skin Infections: Many skin infections are primarily a result of irritation, allergy, hypersensitivity, or a reflection of 
systemic disorders. Nonetheless, there are a considerable number of primary skin infections which are commonly encountered, 
and bacterial and fungal superinfection is common. Patient history is essential for meaningful investigation. 
Localised Skin Lesions 

Agents: simplexvirus, human papillomavirus, molluscum contagiosum (2% of male sexually transmitted disease, 0.6% of 
female), cowpox (from cattle), orf (contagious pustular dermatitis; from sheep; rare in man), paravaccinia (milker's nodes, 
milker's nodules, pseudocowpox; from cattle), human echovirus 25 and 32 (hemangioma-like lesions), Streptococcus pyogenes, 
Neisseria meningitidis, Neisseria gonorrhoeae, Francisella tularensis, Clostridium botulinum, Listeria monocytogenes (rare), 
Gram negative bacilli (Aeromonas hydrophila (often fatal), Vibrio parahaemolyticus, Escherichia coli, Pseudomonas aeruginosa 
(ecthyma gangrenosum), Serratia marcescens, Proteus, Klebsiella), Staphylococcus aureus, Corynebacterium jeikeium, 
Rickettsia, Blastomyces dermatitidis, Candida, Drechslera (in neutropenia), Rhizopus, Aspergillus, Mucor, Leishmania tropica 
(anthroponotic cutaneous leishmaniasis, dry cutaneous leishmaniasis, urban cutaneous leishmaniasis), Leishmania major (rural 
cutaneous leishmaniasis, wet cutaneous leishmaniasis, zoonotic cutaneous leishmaniasis), Leishmania aethiopica (Cuncir, 
diffuse cutaneous leishmaniasis, Ghisua, leishmaniasis diffusa, lepromatous leishmaniasis), Leishmania mexicana (New World 
cutaneous leishmaniasis), Leishmania braziliensis complex, Leishmania donovani (rare), Prototheca; also painless vesicles in 
fflucha-Haberman disease 

Diagnosis: viral culture of vesicle fluid; direct fluorescent antibody staining or cytological examination of scraping from 
base of vesicle or other cellular material (herpes: Tzanck smear using Paragon Multiple stain rapid, simple, inexpensive and 
easy to interpret but sensitivity only 50%), vesicle fluid or pus (cowpox: virions and cytoplasmic inclusions), aspirate, 
puncture, biopsy (tularemia, leishmaniasis); immunofluorescence; electron microscopy (warts); bacterial and fungal culture of 
swab of lesions; histology of biopsy; blood cultures; serology 

Simplexvirus: creams, ointments, lotions, ice, alcohol, vaginal sprays and sitz baths may reduce viral yield 
significantly and should be avoided; vesicular lesions should be sampled if possible, a swab for culture and scrapings from 
the base of the lesion for microscopy being collected, after opening with a sterile hypodermic needle; with ulcerative lesions, 
any pus should first be removed with a sterile swab; crusts from dried lesions may be lifted with a sterile needle and the 
same procedure followed; eczema herpeticum potentially life-threatening (hepatitis, disseminated intravascular coagulation) 
herpetic superinfection of preexisting skin disease 

Molluscum Contagiosnm: chronic, proliferative epithelial lesions 

Cowpox: self-limited, localised vesicular lesions 

Orf (Contagions Ecthyma): small, firm, reddish blue papule enlarging to form hemorrhagic pustule or bulla 2- 
5 cm in diameter, with central crust surrounded by greyish white or violaceous ring, surrounded in turn by zone of 
erythema; on hand (95%), face or eyelids; history of exposure to sheep or goats; electron microscopy of material from crust 
or biopsy; rise in antibody by ELISA or Western blot 

Paravaccinia: smooth or warty painless lesions and mild systemic complaints 

Streptococcus pyogenes: vesicles, forming crusts, especially in children 

Neisseria meningitidis: purpuric, petechial or maculopapular lesions containing bacteria 

Francisella tularensis: papules resembling insect bites becoming necrotic, ulcerating 

Clostridium botulinum: small subcutaneous, non-erythematous, non-tender cyst 

Gram Negative Bacilli: cutaneous bullae, erythema multiforme and peripheral lesions in septicemia and 
endocarditis 

Ecthyma Gangrenosnm: may be first manifestation of systemic infection (often, bacteremia and sepsis); 
initial localised edema, rapidly developing to erythematous, usually painless or slightly tender macules 2-3 cm diameter, 
which progress to indurated subcutaneous nodules over 12-18 h and then vesiculate, with the vesicular fluid often 
hemorrhagic, slough the vesicle roof to form a deep ulcer with dark central necrosis and violaceous rim expanding into 
surrounding tissue, and finally may coalesce to form lesions up to 5 cm diameter and covered by a black eschar; histology 
and culture of skin biopsy; blood cultures 

Corynebacterium jeikeium: hemorrhagic or erythematous papular rash, often tissue abscess, necrotic soft 
tissue lesion 

Rickettsia: multiple purpuric lesions in seriously ill patients 

Rjelloomyces dermatitidis: papule or pustule developing into granuloma; lesions contain organisms 

Candida: macropapular lesions in disseminated candidiasis 

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Skin Infections 

Bhizopus: vesiculo-pustular eruptions 

Leishmaniasis: examination of smears of tissue or aspirate from lesion or biopsy of ulcer to reveal amastigote; 
culture of tissue or exudate; erythrocyte count and hemoglobin may be decreased 

Leishmania tropica Complex: small raised papules, usually ulcerating to form crusted sores; 
infectious; Middle East, India, Mediterranean, North Africa; gerbil, dog and human reservoirs; sandfly (Phiebotomus) vector 
Leishmania tropica: dry ulcer 
Leishmania major, faster-growing wet ulcer 
Leishmania aethiopica: usually multiple lesions (simple or diffuse) 
Leishmania mexkana: Mexico, British Honduras, Amazon River Basin; forest rodent reservoir; 
sandfly (Lutzomyia) vector; similar to leishmaniasis due to Leishmania tropica complex but infection with Leishmania 
mexkana often results in destruction of ear cartilage (bahia ulcer, bay sore, chiclero sore, chicle ulcer, ulcera de los 
chicleros) 

Leishmania braziiiensis Complex: forest rodent reservoir in Central and South America, dog 
reservoir in Peru 

Leishmania braziiiensis: single or multiple ulcers that seldom heal spontaneously 
Leishmania braziiiensis guayanensis (Forest Yaws, Pian Bois): single lesion or 
many crateriform ulcers over body, lymphadenitis as result of metastasis along lymphatics 

Leishmania panamensis: single crateriform ulcer or a few such ulcers; metastasis may 
occur along lymphatics 

Leishmania peruviana (Uta): single lesion or a limited number of lesions, which usually 
heal spontaneously; occurs mainly in children; not associated with forest areas 

Leishmania donovani: primary cutaneous lesions rare; in 'post-kala-azar leishmaniasis' (leishmanoid, 
PKDL, post-kala-azar dermal leishmaniasis), nodular, macular or maculopapular lesions may occur on body 1-2 y after 
treatment of visceral disease 

Prototheca: non-tender, pyoderma-like or infiltrating lesions 
Treatment: 

Simplexvirus: 

Cold Sores: 

Minor: aciclovir 5% cream every 4 h while awake for 5 d, commencing at first signs of 
onset 

Severe Primary or Recurrent or Complicated by Erythema Multiforme: 
famciclovir 125 mg orally 12 hourly for 5 d, valaciclovir 500 mg orally 12 hourly for 5 d, aciclovir 10 mg/kg to 400 mg 
orally 8 hourly for 5 d (preferred for children and pregnant) 

Unable to Swallow: aciclovir 5 mg/kg i.v. 8 hourly for 5 d (adjust dose for 
renal function) 

Freqnent Disabling Recurrences, Frequent Recurrences Complicated by 
Erythema Multiforme, HIV-infected Patients with Chronic Lesions: valaciclovir 500 mg orally daily for up to 
6 mo, aciclovir 5 mg/kg to 200 mg orally 12 hourly for up to 6 mo (preferred for children or pregnant) 

Mucocutaneous simplexvirus in Immunocompromised: aciclovir (preferred in children and 
pregnant) 5 mg/kg i.v. (adjust dose for renal function) or 10 mg/kg to 400 mg orally 5 times daily 8 hourly for 7-10 d, 
valaciclovir 1 g orally 12 hourly for 7 d, famciclovir 250 mg orally 8 hourly for 7 d (500 mg orally 8 hourly for 10 d in 
immunocompromised) 

Frequent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg 
orally 12 hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Eczema Herpeticum: valaciclovir 500 mg orally 12 hourly until healed, famciclovir 250 mg orally 12 
hourly until healed, aciclovir 5 mg/kg to 200 mg orally 5 times daily until healed 

More Severe: aciclovir 5 mg/kg i.v. 8 hourly then as above 
Orf: typically resolve spontaneously in 4-6 w; liquid nitrogen cryosurgery speeds resolution; razor blade shaving 
effective when lesions persist; 35% idoxuridine in dime thyls ulf o xide on eyelids; 0.5% idoxuridine ointment in conjunctival 
infection 

Other Viruses: non-specific 

Streptococcus pyogenes, Neisseria: penicillin, erythromycin 
Francisella tularemia streptomycin 
Other Gram Negative Bacilli: gentamicin 

Staphylococcus aureus: penicillin (if isolate susceptible), penicillinase-resistant penicillin, clindamycin, 
erythromycin, cephalosporin, tetracycline 

Corynebacterium jeikeium: vancomycin 

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Skin Infections 

Listeria monocytogenes: erythromycin 500 mg orally 6 hourly (child: 30 mg/kg daily in 4 divided doses) for 
5d 

Clostridium botulinum: penicillin + antitoxin 

Rickettsia: tetracycline, chloramphenicol 

Candida: topical nystatin, clotrimazole, miconazole ± oral ketoconazole, fluconazole 

Rjellomyces dermatitidis: amphotericin B 

Drechslera: excision biopsy + amphotericin B 

Rhizopus: debridement + topical povidone iodine 

Aspergillus: high dose amphotericin B + flucytosine 

Leishmanial 

Leishmania braziliensis and Leishmania mexicana: sodium stibogluconate 200 mg Sb/kg/d 
i.m. or i.v. daily for 20 d or until decided improvement, amphotericin B 0.25-1 mg/kg daily on alternate days i.v. for up to 
8 w, metronidazole 200 mg (child: 7.5 mg/kg) orally 3 times daily for 10 d, ketoconazole, pentamidine isethionate, 
allopurinol; intranodular injection of recombinant interleukin 2; lesions due to Leishmania mexicana mexicana, Leishmania 
amazonensis and Leishmania pifanoi may be incurable 

Leishmania aethiopica: sodium stibogluconate 18-20 mg/kg i.v. twice daily for 30 d 
Leishmania tropica: sodium stibogluconate lOmg/kg daily i.m. or i.v. for 6 d; paromomycin 15% or 
methylbenzethonium 12% ointment applied twice daily; oral fluconazole 200 mg daily for 6 w 
Prophylaxis (Cutaneous Leishmaniasis): 100% successful frozen vaccine trialled in Brazil 
Warts (Verruca): common (verruca vulgaris: solid, circumscribed, elevated tumour with multiple horny projections), flat 
(verruca plana juvenilis: smooth, slightly raised, occurring in large numbers), plantar (verruca plantaris: conical, bulging from 
skin surface on sole of foot), venereal (condyloma acunimatum: clusters of soft, fleshy lesions), laryngeal papillomas; 0.6% of 
new episodes of illness in UK; 0.4% of ambulatory care visits in USA 
Agent: human papillomavirus 

Diagnosis: cytology; cytoplasmic fluorescence (smooth muscle) 
Treatment: 

Oral, Cervical, Rectal, Anorectal, Pregnancy: cryotherapy, electrosurgery, surgical removal, 
bichloroacetic acid, trichloroacetic acid, intralesional interferon-a 

Urethral: 5-fluorouracil, thiotepa 

Others: podophyllin, podofilox, imiquimod, cryosurgery, surgical removal, duct tape occlusion 
Pinta (Carate, Azul, Boussarole, Mepeines, Lota, Mal De Los Pintos, Mal Del Pinto, Painted Sickness, 
Tian): acute and chronic; transmission by direct contact 
Agent: "Treponema carateum' (invalid name) 

Diagnosis: first stage (primary pinta) manifested as small erythematous scaly papule (chancre of pinta) at site of 
inoculation 3-60 d after infection; satellite lesions may appear and coalescence occur; second stage (secondary pinta) 
manifested by generalised papular eruption appearing 5-12 mo after primary papule; papules (pintids) may show striking 
colours (pink, red, yellow, brown, blue, violet, black); third stage (late pinta, tertiary pinta) manifested principally by 
depigmentation (chromia, vitiligo) of lesions, which ultimately become white and atrophy, resulting in disfigurement; may be 
latent stage; serology 
Treatment: penicillin 

Acne Vulgaris (Pimples): 0.7% of ambulatory care visits in USA 

Agents: primarily physiological, but Propionibacterium acnes may considerably aggravate symptoms by stimulating 
inflammation, and Staphylococcus aureus infection may supervene 

Diagnosis: pus swab (restricted to Staphylococcus aureus superinfection; despite its undoubted role, (anaerobic) culture for 
Propionibacterium acnes is pointless; other organisms that may be isolated are also irrelevant 
Treatment: 

Mild: face washes with 2% w/w Triclosan liquid soap; adapalene 0.1% or water-based benzoyl peroxide 2.5 % 
increasing to 10% or isotretinoin 0.05% or tretinoin 0.025% increasing to 0.1% topically at night 

Moderate Not Responding to Measures Above: clindamycin 1% lotion or erythromycin 2% gel topically in 
the morning; if insufficient response, replace with doxycycline 50-100 mg orally daily (not pregnant or breastfeeding), 
minocycline 50-100 mg orally daily (not pregnant or breastfeeding) or erythromycin 250-500 mg orally 12 hourly reducing to 
250-500 mg daily 

Severe or Cystic: refer to dermatologist 
Pyoderma (Purulent Dermatitis), Boil, Carbuncle, Furunculosis, Pustulosis, Stye, Sycosis Barbae, 
Folliculitis (Bockhardt Folliculitis, Bockhardt Impetigo, Superficial Pustulosis Perifolliculitis), 
Hiradenitis: boil = furuncle = nodule found in cutaneous and subcutaneous tissues, usually around a hair follicle, 
characterised by inflammation and having a central core; carbuncle = network of furuncles connected by sinus tracts; 

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Skin Infections 

folliculitis = papular or pustular inflammation of hair follicles; sycosis barbae = multiple folliculitis of the bearded area of 
the face; hiradenitis = disease of sweat glands; 0.7% of new episodes of illness in UK; exclude diabetes if recurrent; friction, 
perspiration, obesity, blood dyscrasias, corticosteroid therapy and defective neutrophils other predisposing factors; also 
eosinophilic folliculitis in HIV-infected patients on triple therapy 

Agents: Staphylococcus aureus, occasionally in association with Streptococcus pyogenes, Reromonas hydrophila; 
Pseudomonas aeruginosa (pyoderma; folliculitis associated with spas and whirlpools), Mycobacterium fortuitum (furunculosis 
associated with nail salon footbaths); folliculitis also Maiassezia, dermatophytes and simplexvirus 
Diagnosis: culture of swab of lesions 
Pseudomonas aeruginosa: 

Pyoderma: pre-existing lesion (exfoliative skin disease, venous stasis ulcer, eczema) colonised and 
subsequently invaded (especially when treated with occlusive dressings); characteristic moth-eaten appearance and 
erythematous border; acute and invasive or chronic indolent (slowly progressive, burrowing inflammation, forming coalescent 
papulopustular lesions covered with malodorous crust); swab culture, clinical differentiation of true infection from 
colonisation 

Folliculitis: discrete, maculopapular lesions few mm in diameter, developing vesicle or pustule on 
apex, on trunk or proximal extremities, predominantly axillae and pelvis 
Treatment: 

Staphylococcus aureus: if extensive lesions, cellulitis or systemic symptoms, di(flu)cloxacillin 12.5 mg/kg to 
500 mg orally 6 hourly for 5 d 

Penicillin Hypersensitive (Not Immediate): cephalexin 12.5 mg/kg to 500 mg orally 6 hourly 
for 5 d 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg orally 8 hourly for 
5d 

Remote Areas: di/flucloxacillin orally 12 hourly for 5-10 d + probenecid orally 12 hourly for 5-10 d; 
di/flucloxacillin orally 6 hourly for 5-10 d; erythromycin orally 12 hourly for 5-10 days; roxithromycin orally daily for 
5-10 d 

Reromonas hydrophila: gentamicin, ciprofloxacin 
Pseudomonas aeruginosa: 

Pyoderma: long-term oral ciprofloxacin 

Folliculitis: usually self-limiting; topical 0.1% polymyxin B or washing with antibacterial soap 
followed by alcohol-based drying solution can be used if necessary 

Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, ciprofloxacin, cotrimoxazole orally for 6-12 mo 
Prophylaxis (Recurrent Staphylococcus aureus Infections): sorbolene cream with glycerol 10% before and after 
showering; mupirocin 2% nasal ointment applied to nostrils 3 times daily for 5 d + triclosan 1% wash or chlorhexidine 2% 
wash daily as a shampoo and for showering, and wash clothes, towels and sheets in hot water on 2 separate occasions 

Continued Recurrence Despite Above Measures: + rifampicin 7.5 mg/kg to 300 mg orally 12 
hourly for 7 d + di/flucloxacillin 12.5 mg/kg to 250 mg orally 6 hourly for 7 d or cotrimoxazole 4 + 20 mg/kg to 160 + 
800 mg orally 12 hourly for 7 d or fusidate sodium 12 mg/kg to 500 mg orally 12 hourly for 7 d or fusidic acid suspension 
18 mg/kg to 750 mg orally 12 hourly for 7 d 

Impetigo: bullous (Cortell pyosis, impetigo bullosa, impetigo contagiosa bullosa, impetigo neonatorum, impetigo 
staphylogenes, Manson pyosis, pemphigus contagiosus, pemphigus neonatorum, pyoderma superficialis, staphylococcal impetigo) 
and non-bullous (Fox impetigo, impetiginous dermatitis, impetigo contagiosum, impetigo vulgaris, school sores) forms; 0.4% of 
new episodes of illness in UK; especially in children; transmission by contact with lesions, inoculation with person's own 
indigenous flora; incubation period 1-5 d 

Agents: Staphylococcus aureus (both forms), Streptococcus pyogenes (non-bullous; streptococcal pyoderma — especially US; 
glomerulonephritis may follow within 8 w), Group C Streptococcus 
Diagnosis: swab culture 

Bullous: superficial skin blebs (bullae), which usually rupture and form yellowish crusts; may spread by 
autoinoculation, with appearance of satellite lesions in the vicinity; in neonates and young children 

Non-bullous: vesicles which become pustular and form honey-coloured crusts, each lesion being surrounded by 
an erythematous zone 

Treatment: remove crusts 8 hourly with saline or soap and water or aluminium acetate solution or potassium 
permanganate solution 

Streptococcus pyogenes Primary Pathogen: phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly 
for 5 d, benzathine penicillin 30-45 mg/kg to 900 mg i.m. as single dose 

Penicillin Hypersensitive: roxithromycin 300 mg orally daily (child: 4 mg/kg to 150 mg orally 12 
hourly) for 10 d 

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Skin Infections 

Staphylococcus aureus: mupirocin 2% topically 8 hourly for 7 d 

Severe Cases or if Cellulitis Present or if Recurrent: di(flu)cloxacillin 12.5 mg/kg to 250 mg orally 6 
hourly for 10 d; cephalexin 12.5-25 mg/kg to maximum 250 mg orally 6 hourly for 10 d if penicillin hypersensitive (not 
immediate); roxithromycin 300 mg orally daily (child: 4 mg/kg to 150 mg orally 12 hourly) for 10 d if immediate penicillin 
hypersensitivity 

Prevention and Control: hygiene; in recurrent or resistant cases, nasal and/or perineal swabs of whole family and 
close contacts and treatment if positive (see Prophylaxis (Recurrent Staphylococcus aureus Infections) above 
Toxic Epidermal Neurolysis (Allergic Bullous Dermatosis, Dermatitis Erysipelatosa, Dermatitis 
Exfoliativa Infantum, Dermatitis Exfoliativa Neonatorum, Epidermiolysis Acuta Toxica, 
Epidermiolysis Combustiformis Acuta, Keratolysis Neonatorum, Lyell Disease, Lyell Syndrome, Ritter 
Dermatitis, Ritter Disease, Ritter von Rittershain Disease) 

Agents: Staphylococcus aureus (reaction to toxin, exfoliatin, produced by certain strains), certain other microorganisms, 
certain pharmaceuticals (including numerous antibiotics) 

Diagnosis: erythema, formation of bullae, separation of epidermis, continued desquamation; swab culture 
Treatment: penicillinase-resistant penicillin, erythromycin, clindamycin; healing is usually complete in 2 w with adequate 
treatment 

Erysipelas (Ignis Sacer, St Anthony's Fire, St Francis' Fire): acute disease of skin and subcutaneous tissues; 
predisposing factors newborn and elderly, nephrotic syndrome, preexisting lymphatic obstruction or edema, prior episode of 
erysipelas, any break in skin; 0.01% of new episodes of illness in UK; considerable toxic component 
Agents: Streptococcus pyogenes, similar condition due to Yersinia enterocolitica 

Diagnosis: raised, edematous, red area of inflammation that is well demarcated, especially when it affects a part of the 
body where the skin is taut (eg., the forehead); culture of skin blebs swab (also throat swab and wound swab); blood 
cultures; serology (ASOT, anti-DNAse B); neutrophilia in most cases 

Differential Diagnosis: early herpes zoster, contact dermatitis, giant urticaria, inflammatory carcinoma 
Treatment: 

Streptococcus pyogenes: possibility of glomerulonephritis developing with toxigenic strains should be borne in 
mind 

Severe: benzylpenicillin 30 mg/kg to 600 mg i.v. 4 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 
hourly, cephazolin 50 mg/kg/d to 2 g i.v 8 hourly 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg i.v. or orally 
8 hourly, lincomycin 25 mg/kg to 600 mg i.v. 8 hourly, vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. slowly 12 
hourly (monitor blood levels and adjust dose accordingly) 

Less Severe: procaine penicillin 50 mg/kg to 1.5 g i.m. daily for at least 3 d, phenoxymethylpenicillin 
10 mg/kg to 500 mg orally 6 hourly for 10 d 

Penicillin Hypersensitive (Not Immediate): cephalexin 12.5 mg/kg to 500 mg orally 6 
hourly for 7-10 d 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg orally 8 
hourly for 7-10 d 

Yersinia enterocolitica: cotrimoxazole 
Erysipeloid (Fish Handler's Disease; Diamondback, Diamond Skin Infection, Swine Erysipelas in 
Animals): cutaneous erysipeloid (erythema migrans, erythema serpens, Rosenbach disease, Rosenbach erysipeloid, Rosenbach 
rouget) and disseminated erysipeloid (Klauder disease; rare) 
Agent: Erysipeiothrix rhusiopathiae 

Diagnosis: contact with pigs or fish; butcher, cook or fish handler; culture of swab of material under skin over 
inflammatory swelling 

Cntaneons Erysipeloid: most frequently on skin of hand or forearm; pruritic, purplish-red patch that is 
slightly indurated and has a slightly raised margin, which spreads centrifugally while centre heals; recovery usually 
spontaneous after 2-3 w 

Disseminated Erysipeloid: diffuse generalised skin lesions with fever and generalised lymphadenopathy 
Treatment: penicillin, erythromycin 
Erythrasma 

Agent: Corynebacterium minutissimum 

Diagnosis: pink to brown irregular patches with fine creasing; coral pink fluorescence of lesion and scrapings under 
Wood's light; oil immersion microscopy of skin scraping (diphtheroids seen) 
Treatment: erythromycin 1 g/d for 5-7 d 



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Dermatophilosis (Contagious Dermatitis, Epidemic Eczema, Sporotrichosis; Lumpy Wool in Sheep): 

common in cattle and, especially, sheep; rare in man 

Agent: Dermatophilus congolensis 

Diagnosis: multiple painless pustules on the dorsal surface of the hands 2-7 d after exposure to cattle, sheep or goats; 

Giemsa stain and culture of scabs and exudates 

Treatment: penicillin + streptomycin 

Cutaneous Anthrax (Malignant Carbuncle, Malignant Pustule): most common form of anthrax (> 95%); 

acquired from handling contaminated hides, carcasses, wool, etc; case-fatality rate 20% without antibiotic treatment, < 1% 

with antibiotics 

Agent: Bacillus antkacis 

Diagnosis: incubation period 1-6 d; pruritus at site of inoculation, followed by small, painless but itchy raised bump or 

papule, resembling insect bite, enlarging into 1-3 cm vesicles within 1-2 d and rupturing, draining serosanguineous fluid and 

leaving a painless depressed eschar 1-3 cm diameter with a characteristic black necrotic area in the centre and, sometimes, 

satellite vesicles, with edema out of proportion to size of lesion and regional lymphadenopathy in many cases; > 90% of 

lesions on exposed face, neck, arms and hands; occasionally, extensive local involvement, with severe edema, formation of 

bullae and septicemia (septicaemic cutaneous anthrax, malignant anthrax, malignant oedema); contact with cattle, sheep, pigs, 

hides; Gram stain (Gram positive rods and few neutrophils) and culture of vesicle fluid or from under edge of eschar; ELISA, 

Western blot, toxin detection, chromatographic assay, fluorescent antibody test 

Treatment: ciprofloxacin 15 mg/kg to 500 mg orally twice a day or doxycycline 2.5 mg/kg to 100 mg orally twice a day 

(not < 8 y) till clinical improvement then amoxicillin 15 mg/kg to 500 mg orally 3 times a day for total 60 d 

Severe or Associated with Systemic Symptoms: ciprofloxacin 400 mg i.v. every 12 h or doxycycline 
100 mg i.v. every 12 h + rifampicin, vancomycin, clindamycin, penicillin, chloramphenicol, imipenem, amoxy/ampicillin or 
clarithromycin 

Prophylaxis (Post-exposnre): oral doxycycline or ciprofloxacin as above; consider 3 doses of anthrax vaccine 0, 2 and 
4 w after exposure 

Cutaneous Diphtheria: disease of the skin that, on rare occasions, has been associated with diphtheric throat infections; 
more commonly, especially in tropics, disease is result of infection of open sores, wounds and eczematous skin lesions; cases 
in Aborigines in Central Australia 
Agent: Corynebacterium diphtheriae 

Diagnosis: primary cutaneous diphtheria may occur as a single or several pustules, usually on lower extremity, 
progressing to a punched-out ulcer covered by grey-brown membrane; often fatal myocarditis or diphtheric polyneuritis (post- 
diphtheric paralysis) may occur; Albert's or Neisser stain and culture of swab of lesion 

Treatment: isolation and bed rest + antitoxin 10,000-100,000 U depending on severity; always precede by test for allergy 
to horse serum 

Carriers: erythromycin 500 mg orally 6 hourly (child: 30-40 mg/kg daily orally in 3 divided doses), procaine 
penicillin 600,000 U l.m. 12 hourly for 10 d (child: 25,000-50,000 U/kg l.m. daily in 2 divided doses) 
Cutaneous and Mucocutaneous bartonellosis (Bouton Des Andes, Peruvian Wart, Verruga Andicola, 
Verruga Peruana): appears weeks or months after termination of systemic bartonellosis or, on rare occasions, without 
primary history of systemic illness 
Agent: Bartonella bacilliformis 

Diagnosis: pleomorphic eruption of hemangiomatous papules and nodules that gradually assume aspect of warts, usually 
localised in skin but sometimes in subcutaneous tissue, mucous membranes, muscles, bones or viscera; organisms seen in 
endothelial cells in stained smears of material from granulomatous skin lesions; blood cultures 
Treatment: tetracycline 
Acute Skin Ulcers 

Agents: Francisella tularensis, Chromobacterium violaceum (in 11% of infections), Flavobacterium meningosepticum 
(waterborne), Pseudomonas paucimobilis 
Diagnosis: culture of lesion swab, lymph node aspirate, blood 
Treatment: 

Francisella tularensis: streptomycin, tetracycline 

Chromobacterium violaceum: chloramphenicol 

Flavobacterium meningosepticum: clindamycin 

Pseudomonas paucimobilis: ciprofloxacin 
Chronic Skin Ulcers 

Agents: Mrcanobacterium haemolyticum, Corynebacterium bovis, Mycobacterium marinum (swimming pool granuloma, 
swimming pool granuloma disease), Mycobacterium ulcerans (Bairnsdale ulcer, Buruli ulcer, Searl ulcer; third most prevalent 



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Skin Infections 

mycobacterial disease), Mycobacterium chelonae, other mycobacteria; may be complicated by superinfection with 

Streptococcus pyogenes and Staphylococcus aureus 

Diagnosis: Gram stain and Ziehl-Neelsen stain and culture at 30-34°C and 37°C of ulcer swab or biopsy 

Mycobacterium marinum: chronic granulomatous nodules or cutaneous or subcutaneous ulcers 

Mycobacterium ulcerans: painless, firm nodule with erythema and induration progressing to painless ulcer 
with undermined edges and necrotic slough containing extracellular acid-fast bacilli 

Differential Diagnosis: blastomycosis (pulmonary lesions commonly present; biopsy and culture), chromoblastomycosis 
(biopsy and culture), foreign body granuloma (history of trauma may be available; absence of significant bacteria on stain 
and culture), inoculation tuberculosis (rare; occupational history; biopsy and culture of lesion), sporotrichosis (history of work 
or hobby; biopsy and culture), nocardial infection (acid fast stain and culture), nodular fasciitis, injection abscess and 
panniculitis (biopsy with special stains) 
Treatment: 

Rrcanobacterium haemolyticum, Corynebacterium bovis: erythromycin + rifampicin 

Mycobacterium marinum: may resolve spontaneously or on curettage; clarithromycin 12.5 mg/kg to 500 mg 
orally 12 hourly, cotrimoxazole 4/20 mg/kg to 160/800 mg orally 12 hourly, doxycycline 2.5 mg/kg to 100 mg orally (not 
< 8 y) 12 hourly 

Mycobacterium ulcerans: wide excision and skin grafting, local heat + rifampicin and amikacin for 8 w 

Mycobacterium chelonae: clarithromycin 500 mg twice a day 

Other Mycobacteria: excision; streptomycin + dapsone ± ethambutol 
Tropical Ulcer (Aden Ulcer, Cochin Sore, Malabar Ulcer, Mozambique Ulcer, Nagana Sore, Necrotising 
Ulcer of the Skin Surface, Phagedana Tropica, Tropical Phagedaena, Tropical Phagedena, Tropical 
Phagedenic Ulcer, Tropical Sloughing Phagedena, Ulcus Tropicuih, Yemen Ulcer): causes 2% of fever in 
returned travellers to Australia 

Agents: believed to be due to a mixed infected with Treponema vincentii and 'fusiform' bacteria such as Leptotrichia 
buccalis 

Diagnosis: chronic, usually solitary, ulcer occurring most commonly in tropical areas and characterised by sloughing of 
tissue; Gram stain or simple stain of swab of lesion 
Treatment: metronidazole 
Ischemic, Varicose and Decubitus Skin Ulcers 
Agents: colonised by various bacteria 

Diagnosis: clinical; culture of deep tissue biopsy; computed tomography, magnetic resonance imaging, bone biopsy and 
histopathological evaluation to detect osteomyelitis 

Treatment: antibiotics are not required unless cellulitis or osteomyelitis is present or the patient is diabetic (treat as for 
Ulcers in Diabetics); extirpation by physical means or enzymes or maggot debridement may sometimes be indicated; 
bismuth formic iodide powder or povidone iodine gauze pads may sometimes be useful in controlling excessive colonisation; 
treatment should be aimed at correction or prevention of the precipitating cause 
Skin Ulcers in Diabetics (Foot and Leg Sores) 

Agents: coliforms, Proteus, anaerobes, Staphylococcus, Streptococcus, numerous others; all isolates may be significant except 
coagulase negative staphylococci, Micrococcus, skin flora coryneforms 

Diagnosis: Gram stain of direct smear, culture of swab in Stuart's transport medium of sore (deeper specimens give no 
greater information) 

Treatment: should always be regarded as serious and treated vigorously; surgical or maggot debridement if necessary; 
consider underlying osteomyelitis 

Severe: ticarcillin-clavulanate 3/0.1 g i.v. 6 hourly, piperacillin-tazobactam 4/0.5 g i.v. 8 hourly, meropenem 
500 mg i.v. 8 hourly; recombinant granulocyte colony stimulating factor reduces amputation rate in limb-threatening foot 
infections 

Penicillin Hypersensitive: ciprofloxacin 400 mg i.v. or 750 mg orally 12 hourly + clindamycin 
900 mg i.v. 8 hourly by slow infusion or lincomycin 900 mg i.v. 8 hourly by slow infusion 

Less Severe: metronidazole 400 mg orally 12 hourly + cephalexin 500 mg orally 6 hourly; amoxycillin- 
clavulanate 875/125 mg orally 12 hourly for at least 5 d 

Penicillin Hypersensitive: ciprofloxacin 500 mg orally 12 hourly + clindamycin 600 mg orally 8 
hourly for at least 5 d 

Trichosis Axillaris (lepothrix, Trichomycosis Axillaris): superficial disease of axillary or pubic hairs 
Agent: 'Corynebacterium tenuis' (invalid name) 

Diagnosis: adherent yellow, red or black nodules on hair shaft; microscopy of hair 
Treatment: shaving; sulphur ointment 
Black Piedra: mainly tropical 

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Skin Infections 

Agent: Piedraia hortae 

Diagnosis: micro and culture of nodules on hair shafts 

Treatment: shaving; sulphur ointment 

White Piedra 

Agent: Trichosporon cutaneum 

Diagnosis: microscopy and culture of infected hairs 

Treatment: shaving; sulphur ointment 

Chromoblastomycosis (Verrucous Dermatitis, Chroihoihycosis, Mossy Foot) 

Agents: Cladophialophora carrionii (in Australia, SIfrica, Venezuela), Fonsecaea compacta and Fonsecaea pedrosoi (in Far 

East), PMalophora verrucosa, Rhinocladiella 

Diagnosis: slow development of warty skin nodules, with subsequent development of elephantiasis when lymphatics 

involved in chronic inflammation, accompanied by fibrotic change in deeper tissues; visualisation of fungus in wet 

preparations; fungal culture of crusts, pus, biopsy; complement fixation test 

Treatment: surgical excision; flucytosine 25 mg/kg orally 6 hourly (< 50 kg: 1.5-4.5 g/m 2 orally daily) + thiabendazole 

25 mg/kg orally daily or amphotericin B under expert supervision; ketoconazole 200-400 mg orally (child < 20 kg: 50 mg; 

20-40 kg: 100 mg; > 40 kg: 200 mg) daily + flucytosine 25 mg/kg orally 6 hourly (< 50 kg: 1.5-4.5 g/m 2 orally daily); 

itraconazole 200-400 mg orally (child: 3.5 mg/kg) once daily (not in pregnancy) 

Phaeohyphoihycosis 

Agents: Mternaria alternata, Cochliobolus hawaiiensis, Cladophialophora bandana, Curvularia geniculata, Exophiala 

jeanselmei, Exophiala moniliae, Exophiala pisciphila, Bipolaris spicifera, Exserohilum rostratum, Phaeoannellomyces elegans, 

Lecythophora hoffmannii, Phaeoacremonium parasiticum (may disseminate to contiguous joint), Pleurostomophora repens, 

Pleurostomophora richardsiae, Exophiala spinifera, PMalophora verrucosa, Phoma, Pleurophoma, Exophiala dermatitidis 

Diagnosis: biopsy and culture of lesions 

Treatment: surgical excision; amphotericin B, topical miconazole, topical dry heat 

Cutaneous Cryptococcosis: found in « 10% of cases, usually in disseminated cases; rarely primary; cystic or firm 

subcutaneous swellings which ulcerate, crusted granulomas, plaques or nodules, ulcers; mucosal lesions in * 3% 

Agent: Cryptococcus neoformans 

Diagnosis: biopsy and culture of lesions 

Treatment: 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 

More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 mg/kg i.v. or orally 
6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally initially then 400 mg daily for 
8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or itraconazole 200 mg orally 
daily 

Cutaneous Candidiasis: intertriginous, thrush, perleche on angles of lips, paronychia, 5% of tinea pedis; 0.2% of 
ambulatory care visits in USA 
Agent: Candida albicans, other Candida species 

Diagnosis: micro (small oval budding yeast cells, sometimes with pseudohyphae, which do not take up Quink ink) and 
culture of swab of scrapings 

Treatment: keep affected area as clean and dry as possible; nystatin 100,000 U/g, miconazole 2%, clotrimazole 1% or 
econazole 1% applied topically 8-12 hourly, continuing for 2 w after symptoms resolve 
Cutaneous Blastomycosis 
Agent: Ajellomyces dermatitidis 

Diagnosis: visualisation of buds in wet preparations, confirmed by culture 

Treatment: ketoconazole 200-400 mg orally daily for up to 1 y, hydroxystilbamidine isethionate 225-250 mg (child: 
3-4.5 mg/kg) i.v. daily to total dose of 8 g, itraconazole 
Cutaneous Histoplasmosis 
Agent: Histoplasma capsulatum 

Diagnosis: visualisation of fungi in pus or skin biopsy, confirmed by culture; may become disseminated in patients 
infected with human immunodeficiency virus 
Treatment: surgery 

Tinea and Ringworm: transmission from human and animal lesions, contaminated objects; 0.8% of new episodes of illness 
in UK; 0.3% of ambulatory care visits in USA; common worldwide 

Agents: Epidermophyton iloccosum (anthropophilic; groin and other intertrigo infections, especially under breasts, less 
commonly elsewhere on body, including feet and nails), Microsporum audounii (epidemic scalp infections, tinea corporis), 
Microsporum cam's (zoophilic; ringworm and nonepidemic scalp infections; 75% of tinea capitis in Queensland; reservoir cats 

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Skin Infections 

and dogs), Microsporum gypseum (geophilic; ringworm; 11% of tinea capitis in Queensland; severe infection with kerion), 
Mroderma cajetani (foot), Microsporum ferrugineum (ringworm of scalp and glabrous skin; Africa, India, China, Japan), 
Athroderma fulvum (sporadic tinea corporis, tinea capitis, tinea barbae), Athroderma obtusion (body), Scedosporium (rare 
onychomycosis), Trichophyton mentagrophytes var granulosum (zoophilic; ringworm on arms, legs, torso, scalp and beard 
infections), Trichophyton interdigitale (anthropophilic; tinea pedis, tinea mannus, tinea cruris, tinea unguium), Trichophyton 
erinacei (scalp, body), Trichophyton rubrum (anthropophilic; tinea pedis, tinea cruris, lesions and rashes elsewhere on body, 
including beard, arms, legs, torso, hands, nails), Trichophyton schoenleinii (tinea favosa of scalp, torso), Trichophyton 
tonsurans (epidemic scalp infections, tinea corporis, sycosis, onychomycosis; common in Aborigines; 11% of tinea capitis in 
Queensland, 96% in USA), Trichophyton verrucosum (nonepidemic scalp infections, tinea barbae, ringworm), Trichophyton 
vioiaceum (tinea favosa of scalp, torso, onychomycosis), Trichophyton concentricum (body), Trichophyton equinum (from 
horses), Trichophyton Soudanese (tinea capitis, tinea corporis), Trichophyton terrestre (all sites except scalp, face), Curvuiaria 
lunata (rare onychomycosis) 

Diagnosis: Wood's UV light of infected skin; micro of EOH-Parker Quink preparation (long, branching, hyaline, septate 
strands of hyphae) of skin, histopathologic sections of biopsy material stained with periodic acid-Schiff, culture 
(dermatophyte test medium most sensitive) of appropriate specimen: 

Skin Lesions: scraping from periphery 

Nail Infections: nail clippings and scrapings of inner margin of infected area, subungual debris 

Scalp: plucked hairs (especially Wood's light positive ones), scraping from lesion 

Tinea Pedis with Vesicnlar Ernption: domes of vesicles snipped off, swab of fluid and scraping from base 
of vesicle (note that tinea pedis frequently-especially under occlusion-becomes secondarily infected with Gram negative 
bacteria (particularly Pseudomonas aeruginosa), which change the normal dry, scaling condition into a painful, hyperkeratotic 
or erosive process with exudation and intense inflammation; under such conditions, dermatophytes will be demonstrated in 
only about 25% of cases) 
Treatment: 

Tinea Corporis, Pedis and Crnris: bifonazole 1% topically once daily, terbinafine 1% topically once or twice 
daily, clotrimazole 1% topically 2 or 3 times daily, econazole 1% topically 2 or 3 times daily, ketoconazole 2% topically 
twice daily, miconazole 2% topically twice daily, continuing for 2 w after symptoms resolve 

Unresponsive Cases: terbinafine (< 20 kg: 62.5 mg; 20-40 kg: 125 mg; > 40 kg: 250 mg) orally once 
daily for at least 2 w, griseofulvin fine particle 10 mg/kg to 500 mg or ultrafine particle 5.5 mg/kg to 330 mg (not < 2 y) 
orally once daily for at least 4 w 

Web Infections Dne to Pseudomonas Aeruginosa: cleaning, debriding infected skin, avoiding wetness, 
dilute acetic acid 

Tinea Capitis: terbinafine (< 20 kg: 62.5 mg; 20-40 kg: 125 mg; > 40 kg: 250 mg) orally daily for 4 w, 
griseofulvin microsize (fine particle) 10 mg/kg to 500 mg orally once daily with milk for 4-8 w, griseofulvin ultramicrosize 
(ultrafine particle) 5.5 mg/kg to 330 mg orally daily crushed and taken with chocolate chip ice cream for 4-8 w (not 
< 2 y); + 1% selenium sulphide or 2% ketoconazole shampoo 

Tinea Ungninm (Onychomycosis): terbinafine (< 20 kg: 62.5 mg; 20-40 kg: 125 mg; > 40 kg: 250 mg) 
orally daily for 6 w (finger nails) or 12 weeks (toe nails), amorolfine nail lacquer applied to affected nail after filing down 
once or twice weekly for at least 6 months, griseofulvin or ketoconazole as for Tinea Capitis 
Prevention and Control: hygiene 

Tinea Versicolor (Chromophytosis, Dermatomiysosis, Furfuracea, Pityriasis, Pityriasis Versicolor, 
Pityriasis Versicolor Tropica, Tinea Flava) 
Agent: Malassezia furfur 

Diagnosis: micro of KOH-Parker Quink preparation of skin scrapings from macules especially those fluorescing under 
Wood's light (round, budding yeast cells and occasionally branched, truncate hyphae of variable length) 
Treatment: econazole 1% solution topically to wet skin and left overnight for 3 nights; ketoconazole 2% shampoo topically 
daily for 10 minutes and washed off, for 10 d; selenium sulphide 2.5% suspension topically to wet skin for at least 10 min 
or overnight, for 1-2 w, topical sodium thiosulphate 25% (wash off after 10 min) for 2-4 w 

Unresponsive: ketoconazole 200 mg orally daily for 10 d, itraconazole 200 mg orally daily for 5 d 
Tinea Nigra 
Agent: Hortaea werneckii 

Diagnosis: micro (dematiaceous tortuous hyphae with abundant branching and elongated yeast cells) and culture of skin 
scrapings or biopsy 
Treatment: amphotericin B 

Cutaneous Aihoebiasis (Amoebiasis Cutis, Amoebic Skin Ulceration): usually arises as extension of intestinal 
amoebiasis, hepatic amoebiasis or amoebic lung abscess but on occasion results from primary infection; 'genital amoebiasis' 
may lead to destruction of external genitalia 

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Skin Infections 

Agent: Entamoeba histolytica 

Diagnosis: painful, rapidly spreading edematous ulceration of skin; usually fever and leucocytosis; biopsy 
Treatment: metronidazole 

Cutaneous Larva Migrans (Creeping Eruption, Dermatitis Linearis Migrans, Plumber's Itch): humid 
tropical areas; parasites migrate in dermis 

Agents: mainly Rncylostoma braziliense (hookworm larvae of dogs and cats); also Ancylostoma caninum, Rncyclostoma 
ceyianicum, Ancyclostoma duodenale, Necator americanus, Strongyloses stercoralis and nonhuman Strongyloses species, 
Uncinaria stenocephala, Anatrichosoma haycocki (very rare) 

Diagnosis: multiple, subcutaneous, reddish-purple, pruritic, progressive, linear, papulovesicular lesions on sole of feet, with 
raised serpiginous lines developing; histology (may be local eosinophilic or round-cell infiltration); eosinophilia and anemia; 
neutrophilia in children 

Treatment: usually self-limiting but treatment alleviates symptoms; individual larvae can be killed by spraying the tracks 
with ethyl chloride; ivermectin 200 jag/kg orally as single dose (not < 5 y), albendazole (< 10 kg: 200 mg; >10 kg: 
400 mg) once daily for 3 d (not in pregnancy, lactation or < 6 mo) 
Spirometrosis (Larval Diphyllobothriasis, Sparganosis, Sparganum Infection) 
Agent: Spirometra species; larvae migrate through subcutaneous tissue 

Diagnosis: inflammation and edema of skin; migration around eye produces painful edematous conjunctivitis and 
lacrimation; histology 

Treatment: as for Cutaneous Larva Migrans 

Dracunculiasis (Dracontiasis, Dracunculosis, Guinea Worm Disease, Medina Infection, Medina Worm 
Infection): 69% in Sudan, remainder in 12 other sub-Saharan African countries; incidence 96,000 in 1999; no deaths 
reported 

Agent: Dracunculus medinensis 

Diagnosis: incubation period (~ 1 y) with no symptoms; urticaria, erythema, dyspnoea, vomiting, diarrhoea, intense 
pruritus, giddiness (great variability) prior to eruption of cutaneous blister which ruptures and discharges larvae on contact 
with water and may develop into ulcer; infection gives rise to cellulitis and abscesses, 40% of patients having severe 
disability lasting 43 d, while 0.5-1% of cases suffer permanent damage from joint infection; larvae in aspirate from fresh 
cutaneous ulcer; appearance of worm on emergence through skin; radiology may reveal calcified worms 
Treatment: metronidazole 400 mg orally 8 hourly (child: 25 mg/kg daily in 3 divided doses) for 5 d, niridazole 
12.5 mg/kg orally twice daily for 10 d, thiabendazole 25 mg/kg orally daily for 3 d 
Prevention and Control: straining of water before drinking; step wells 
Gnathostomiasis (Gnathomiasis, Wandering Swelling, Yangtse Oedema) 
Agent: Gnathostoma species 

Diagnosis: local inflammation and transient granulomatous eosinophilic swelling; eosinophilia; history of travel to SE Asia 
or S America and ingestion of raw or inadequately cooked fish, poultry or pork 
Treatment: removal of worm when appropriate 
External Hirudinasis 

Agents: leeches (Haemadipsa spp, Phinobdella spp) 

Diagnosis: history; punctured skin heals slowly and there is often secondary pyogenic infection; multiple punctures have 
been fatal owing to loss of blood 
Treatment: removal; treatment of secondary infection 

Tungiasis (Burrowing Flea Infestation, Chigoe Disease, Jigger Disease, Nigua, Sandflea Infestation) 
Agent: Tonga penetrans; pregnant female sandfleas burrow into epidermis, usually sole of foot or interdigital spaces 
Diagnosis: intense pruritus and inflammation; may be severe secondary infection; identification of female removed from 
burrows in skin (usually of toes) 
Treatment: removal 

Cutaneous Myiasis (Dermal Myiasis, Dermamyiasis, Furuncular Myiasis, Myiasis Dermatosa): infestation of 
skin or subcutaneous tissues by larvae of certain flies 

Agents: Cochliomyia hominivorax, Cochliomyia macellaria, Cordylobia anthropophaga, Dermatobia hominis, Phormia regina, 
Sarcophaga, Rhagoletis meigeni, Wohlfahrtia vigil 

Diagnosis: maculopapular, erythematous, intensely pruritic, becoming nodular boil-like furuncles, 1-2 cm diameter, volcano- 
like, episodically painful, centrally necrotic, with small amounts of bloody, serous or purulent drainage; recovery of larvae 
from lesions 

Treatment: removal of larvae; debridement as necessary 

Creeping Myiasis (Myiasis Linearis): form of cutaneous myiasis caused by larvae of certain flies; migration of larvae 
may be either superficial or deeply penetrating; resembles cutaneous larva migrans 

Diagnosis and Management of Infectious Diseases Page 1 13 



Skin Infections 

Agents: Gasterophilus haemorrhoidalis, Gasterophilus intestinalis, Gasterophilus nasalis, Hypoderma bovis, Hypoderma 

lineatum 

Diagnosis: recovery of larvae 

Treatment: removal of larvae 

Pediculosis and Phthriasis (Crab-Louse Infestation, Phthirosis): pediculosis and phthriasis pubis 5% of male 

sexually transmitted disease, 4% of female; 66% incidence in homosexuals 

Agents: Pediculus humanus capitis, Pediculus humanus corporis, Phthirus pubis 

Diagnosis: 

Pediculus humanus capitis: infestation of scalp and/or back of neck; severe pruritus, often pustular 
eczema; secondary infection resulting from scratching common 

Pediculus humanus corporis: infestation of body, usually parts in close contact with clothing; furuncles and 
erythematous maculopapular rash; often a pigmented thickening of skin with parallel scratch marks ('vagabond's disease'); 
secondary infection resulting from scratching common 

Phthirus pubis: infestation of pubic region; slight to severe pruritus; secondary infection resulting from 
scratching common; usually transmitted by sexual contact; may invade eyelids, causing disease resembling staphylococcal 
blepharitis; rare scalp infestation in children 
Treatment: 

Scalp and Body (Including Groin): malathion (maldison) 0.5% lotion (not < 6 mo), permethrin 1% creme 
rinse or pyrethrins 0.165% + piperonyl butoxide 1.65-4% in foam base to affected area, leave for 10 min, then wash off 
thoroughly, repeat in 1 w if necessary; lindane 1% shampoo applied for 4 minutes then washed off thoroughly (not pregnant 
or lactating or < 2 y); treat household child contacts and sexual contacts; wash underwear and bedclothes after treatment; 
use of fine tooth comb; shaving hair; hot air 

Treatment Failnre: 1% permethrin creme rinse + oral cotrimoxazole; ivermectin single dose 

Eyelashes: occlusive ophthalmic ointment twice daily for 10 d 
Scabies (Itch, St Main Evil, Sarcoptic Itch, Sarcoptic Mange): skin disease in which mites burrow under skin 
and feed on subcutaneous tissues; worldwide among poor and in geriatric homes; 2% of male sexually transmitted disease, 
0.9% of female; 0.2% of new episodes of illness in UK 

Agent: Sarcoptes scabiei (human strains cause scabies in humans; host-specific animal strains (dogs, horses, camels, etc) 
may produce a contact dermatitis) 

Diagnosis: severe pruritus, usually vesiculation and papule formation; scratching often leads to secondary infection; under 
conditions such as immunosuppressive therapy, may become severe, mites multiplying in enormous numbers, with formation 
of extensive crusted lesions (crusted scabies, Norwegian scabies); mites obtained by scraping between fingers or toes or 
other infected areas with oil-moistened blade to microscope slide (scraping should be deep enough that flecks of blood appear 
in the oil) 
Treatment: 

< 6 mo: sulphur 10% (< 2 mo: 5%) in white soft paraffin daily for 2-3 d, crotamiton 10% cream daily for 2-3 d 

Others: permethrin 5% cream, applied to whole body including face and hair (avoid eyes and mucous membranes, 
hot baths or scrubbing before application), left overnight and washed off thoroughly (not < 6 mo; recommended in 
pregnancy and lactation); benzyl benzoate 25% emulsion (2 mo - 2 y: dilute 1:3; 2-12 y and sensitive adults: dilute 1:1) 
applied to whole body including face and hair (avoid eyes and mucous membranes, hot baths or scrubbing before 
application), washed off after 24h; repeat after 1 w 

Crnsted Scabies: as above + ivermectin 200 jag orally on days 1 and 8 (less severe), 1, 2 and 8 (moderate) or 
days 1, 2, 8, 9 and 15 (severe; + days 22 and 29 if extremely severe) (not pregnant, lactating, < 5 y); repeat topical 
treatment twice weekly for 2-6 w; sailcyclic acid 5-10% in sorbolene cream or lactic acid 5% + urea 10% in sorbolene 
cream daily after washing on days scabicide not applied 

Resistant Scabies in HIV: ivermectin 200 pg/kg orally weekly until scrapings negative and no further 
clinical evidence of infestation 
Acarine Dermatitis 

Agents: Dermanyssus gallinae, Ornithonyssus sylvarum, Pyemotes, Demodex folliculonim, Tryophagus longior, Tryophagus 
putrescentiae (cheese itch, copra itch, grocer's itch), Beams siro, Glycyphagus domesticus (grocer's itch) 
Diagnosis: recovery of mite 

Dermanyssus gallinae: lesions resemble those of scabies 

Ornithonyssus sylvarum: urticarial weals, papules and vesicles; scratching may lead to secondary infection 

Demodex folliculonim: hair follicles and sebaceous glands; usually mild pruritus and fibrous tissue response; 
rarely, dry chronic erythema with burning irritation and scaling of epidermis 

Glycyphagus domesticus: temporary pruritus 
Treatment: symptomatic 

Diagnosis and Management of Infectious Diseases Page 1 14 



Skin Infections 

Troihbiculosis (Chigger Infestation, Scrub Itch, Trombiculiasis, Trombidiasis, Troihbidiosis) 

Agents: Leptotrrombidium akamushi 

Diagnosis: severe dermatitis; usually pustular lesion at point of entry and severe itching; may be allergic reactions; 

recovery of mite 

Treatment: symptomatic 

Bee Sting: reactions, when occurring, usually anaphylactic; no consistent blood changes 

Hornet Sting: in cases of multiple stings, toxic muscle damage with myoglobinemia and myoglobinuria and increased 

serum alanine aminotransferase, serum aspartate aminotransferase, creatine phosphokinase and lactate hydrogenase may 

occur; nephrotoxic effects with developing renal failure may also occur 

Agent: Vespa af&nis 

Scorpion Sting: causes marked neutrophilia and, in young children, acute pancreatitis, acute hemolytic anemia and 

defibrination syndrome 

Wasp Sting: reactions, when occurring, usually acute anaphylactic 

Spider Bite: causes neutrophilia, acute hemolytic anemia with thrombocytopenia 

Disseminated Rash 

Agents: syphilis, yaws (infectious; 2-3 mo) 

Diagnosis: serology 

Treatment: penicillin 

Erythematous Rash 

Agents: Kawasaki disease (primarily trunk), rubella (transient; conjunctivitis ±, pharyngitis ±, rhinitis ±, enanthem ±; 

incubation period 12-23 d; children, occasionally adults; spring), Streptococcus pyogenes (scarlet fever; caused by toxin; 

pharyngitis ++, conjunctivitis ±, rhinitis ±, enanthem absent), Staphylococcus aureus ('staphylococcal scalding'; diffuse or 

palmar erythroderma in all cases of toxic shock syndrome), Pseudomonas aeruginosa (' Pseudomonas hot foot syndrome'; 

exquisitely tender erythematous plantar nodules traced to wading pool), Marburg virus disease (transient, shoulders and 

arms), enteroviruses; also niacin associated illness 

Diagnosis: clinical; hemagglutination inhibition, complement fixation test; culture of nose swab, throat swab, lesions 

Treatment: 

Virnses: non-specific 

Scarlet Fever: penicillin, erythromycin 

Staphylococcus aureus: cloxacillin 

Pseudomonas aeruginosa: cold compresses, analgesics, elevation of feet 
Erythema Nodosum occurs in brucellosis, coccidioidomycosis, leptospirosis, toxoplasmosis, tuberculosis, 18% of cases of 
yersinosis, and in Pasteurella, Streptococcus and Mycoplasma pneumoniae infections; may also be due to contraceptive pills, 
malignant disease, sarcoidosis, sulphonamides, ulcerative colitis 
Erythema Chronicum Migrans 
Agent: Borrelia burgdorferi 

Diagnosis: pruritic, erythematous papule or ring at location of tick bite, giving large, erythematous, macular, non-scaling, 
centrifugally spreading ring with trailing cast to 35 cm diameter, fading; biopsy 
Treatment: tetracycline 
Erythema Infectiosum (Fifth Disease) 
Agent: human parvovirus B19 

Diagnosis: clinical ('slapped cheek' appearance; maculopapular, vesicular or petechial rash may be present; joint symptoms, 
numbness and tingling in fingers; incubation period 4-14 d; children and adults; summer, early autumn; duration 2-5 d); dot 
hybridisation and capture ELISA of serum; PCR 
Treatment: none 

Erythema Marginatum: occurs in 10% of cases of acute rheumatic fever 
Agent: immunomediated reaction to preceding infection with Streptococcus pyogenes 

Diagnosis: roughly circular lesions spreading centrifugally at the same time as they clear centrally and producing a 
serpiginous outline; anti-streptolysin 0, anti-DNAse B, anti-hyaluronidase, streptozyme 

Prophylaxis: benzathine penicillin 1.2 MU (< 6 y: 600,000 U) i.m. at 4 weekly intervals, phenoxymethylpenicillin 250 mg 
(child: 125 mg) orally 12 hourly, sulphadiazine (< 27 kg: 500 mg orally once daily; > 27 kg: 1 g orally daily), erythromycin 
250 mg orally 12 hourly; continue until patient in early twenties and until 5 y have elapsed since last attack of rheumatic 
fever 

Erythema Mutliforme/Stevens-Johnson Syndrome 

Agents: coxsackievirus A9, 10, 16, B4, 5, echovirus 6, 11, Mycoplasma pneumoniae; numerous antibiotics 
Diagnosis: clinical 
Treatment: careful fluid management and wound care 

Diagnosis and Management of Infectious Diseases Page 1 15 



Skin Infections 

Hemorrhagic Rash 

Agents: several arboviruses, rickettsioses (typhus), spotted fevers (in 49% of cases (13% in first 3 d) of Rocky Mountain 
spotted fever), atypical measles (petechial over face, blanching) 
Diagnosis: clinical; serology 
Treatment: 

Virnses: non-specific 

Rickettsia: tetracycline, doxycycline, chloramphenicol, cotrimoxazole 
Macular Rash 

Agents: Ross River virus (arms, palms, feet), St Louis encephalitis (transient, extremities), human coxsackievirus Bl, 2, 5, 
human echovirus 2, 4, 5, 13, 14, 17-19, 30, human enterovirus 71, Reoseolovirus, Rickettsia (typhus), spotted fevers, 
Mycoplasma pneumoniae (mainly on arms, legs, trunk and face), pityriasis (desquamating); also niacin-associated illness (on 
face or upper arms) 

Diagnosis: culture of serum; serology 
Treatment: 

Virnses: non-specific 

Rickettsia: tetracycline, doxycycline, chloramphenicol, cotrimoxazole 

Pityriasis: selenium sulphide, sodium thiosulphate, ketoconazole 
Maculopapular Rash 

Agents: measles, atypical measles, rubella, human echovirus 1-7, 11, 13, 14, 16-19, 25, 27, 30, 33, echo 9 virus, human 
parechovirus 1, human coxsackievirus R2, R4-R7, R9, RIO, RIO, B1-B5, enterovirus 71, several arboviruses (including 31% of 
cases of dengue), infectious mononucleosis, Reovirus, adenovirus, roseola, erythema infectiosum, Rotavirus, Chromobacterium 
violaceum, Pseudomonas aeruginosa whirlpool-associated dermatitis, rickettsioses (including Mediterranean spotted fever and 
82% of cases (46% in first 3 d) of Rocky Mountain spotted fever), Neisseria gonorrhoeae, Neisseria meningitidis, Treponema 
pallidum subsp pallidum, Yersinia enterocolitica, Yersinia pseudotuberculosis, Mycoplasma pneumoniae, Trichinella spiralis (in 
70% of cases) 

Diagnosis: viral culture of throat washings, throat swab, nasal swab; cytology of Eoplik spots; serology; histology and 
immunofluorescence of skin biopsy; bacterial culture of skin lesions, blood; muscle biopsy 

Measles: confluent, on face, spreading to extremities; very characteristic; conjunctivitis ++, rhinitis +, 
enanthem +, pharyngitis absent; incubation period 10-14 d; children, occasionally adults; winter, spring; duration 7-10 d; IgM 
antibody 

Atypical Measles: over entire body 

Rnbella: faint, even non-existent; incubation period 12-23 d; children, occasionally adults; spring; duration 3-5 d; 
conjunctivitis ±, pharyngitis ±, rhinitis ±, enanthem ±; IgM antibody 

Enterovirnses: pharyngitis ±, rhinitis ±, conjunctivitis and enanthem absent; virus isolation 

Arbovirnses: diffuse; extremities, torso, face 

Infections Mononncleosis: pharyngitis +, conjunctivitis, rhinitis and enanthem absent 

Chromobacterium violaceum: all skin surfaces except face, hands, feet 

Pseudomonas aeruginosa: becoming vesiculopustular 

Mediterranean Spotted Fever: on trunk and extremities in 99% of cases, on palms and soles in 89% 

Neisseria: nonsymmetrical, scattered 

Mycoplasma pneumoniae: measles-like confluent or rubella-like discrete 
Treatment: 

Virnses: non-specific 

Chromobacterium violaceum: chloramphenicol 

Rickettsia: tetracycline, doxycycline, chloramphenicol, cotrimoxazole 

Neisseria: penicillin 

Pseudomonas aeruginosa: usually none required; silver nitrate or silver sulphadiazine if required 

Yersinia: gentamicin, cefotaxime, doxycycline or ciprofloxacin if invasive disease 

Mycoplasma pneumoniae: doxycycline, tetracycline, erythromycin 

Trichinella spiralis: mebendazole 
Roseola (Exanthema Rubitum) 

Agents: human herpesvirus 0, human coxsackievirus RO, R9, Bl, B2, B4, B5, human echovirus 11, 10, 25, 27, 30, echo 9 
virus, adenovirus, parainfluenza, measles vaccine virus 

Diagnosis: maculopapular rash appears as fever falls; conjunctivitis ±, rhinitis ±, pharyngitis and enanthem absent; 
incubation period 10-15 d; infants; spring, autumn; duration 5-7 d; serology 
Treatment: non-specific 

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Skin Infections 

Fine Rash 

Agents: atypical measles (on arms, spreading to trunk and face), chromobacteriosis (generalised) 
Diagnosis: clinical; epidemiological; viral culture of throat swab or washings; blood cultures; serology 
Treatment: 

Atypical Measles: supportive 

Chromobacteriosis: chloramphenicol 
Polymorphous Rush 

Agents: atypical measles (petechial, maculopapular, pustular component), erythema infectiosum (maculopapular, vesicular, 
petechial or absent), Neisseria gonorrhoeae (maculopapular, vesicular), Neisseria meningitidis (maculopapular, vesicular), 
Salmonella, Kawasaki syndrome (in 90% of cases; nonvesicular or crusting), Pseudomonas aeruginosa (nonpruritic to intensely 
pruritic, maculcopapular, vesiculopapular, vesicular, pustular) 

Diagnosis: clinical; immunofluorescent antibody testing on serum and CSF; bacterial culture of skin lesions; blood cultures 
Treatment: 

Atypical Measles: supportive 

Neisseria: penicillin 

Salmonella: chloramphenicol 

Pseudomonas aeruginosa: usually none required; topical 0.1% polymyxin B or washing with antibacterial 
soap followed by topical alcohol-based drying lotion if required 
Pruritic Rash 

Agents: caterpillar contact (on arms in 75% of cases, on neck in 23%, on legs in 21%), cercarial dermatitis (bather's itch, 
clam-digger's itch, hunter's itch, lakeside disease, rice-paddy itch, sawah itch (Bahasa, Malaysia), schistosome dermatitis, sea 
bather's itch, swimmer's itch; Austrobilharzia spp, Gigantobilharzia spp, Heterobilharzia americana, Orientobilharzia spp, 
Schistosoma bovis, Schistosoma mattheei, Schistosoma spindale, Schistosomatium douthitti, Trichobilharzia spp), grain itch 
(Pyemotes); similar reactions may occur to fleas (Ctenocephalides cam's from dogs, Ctenocephalides felis from cats, Pulex 
irritans from man), bedbugs, 'Ornithonyssus bursa' (\>ixi mite, paper mite), Ornithonyssus sylvarum (Northern fowl mite), 
'Ornithonyssus bacoti' (tropical rat mite), Dermanyssus gallinae (chicken mite), Dermanyssus hirudinis (from cage birds, 
swallows), Tyrophagus (bulb mites; from foods), Glycyphagus domesticus (house itch mite), Dermatophagoides pteronyssinus 
and Dermatophagoides farinae (house-dust mites), Trombicula autumnalis' (from vegetation), Haloclava producta (ghost 
anemone dermatitis) 
Diagnosis: patient history 

Cercarial Dermatitis: produced in sensitised persons as a result of penetration of skin by cercariae, which 
subsequently die but cause irritation, pruritus, macules and papules at site of penetration; demonstration of Schistosoma- 
infected snails at site of exposure 

Grain Itch: thin-walled central vesicles and erythematous areolae on torso and extremities, spreading to face 
and resolving to hypopigmented macules; demonstration of Pyemotes on patient or in environment (vegetation, grain, wood) 
Treatment: antihistamines, antipruritics 

Caterpillar Contact: remove affected clothing; remove hairs by applying adhesive tape and immediately pulling 
off 

Grain Itch and Other Infestations: lindane to skin; pyrethrin-based fogging 
Pustular Rash 

Agent: Pseudomonas aeruginosa whirlpool-associated dermatitis 
Diagnosis: culture of skin lesions 

Treatment: usually none required; topical 0.1% polymyxin B or washing with antibacterial soap followed by topical 
alcohol-based drying lotion if required 
Splotchy Rash 

Agent: Chlamydia psittaci (face and neck) 
Diagnosis: clinical; serology 
Treatment: erythromycin, tetracycline 
Generalised Urticarial Rash 

Agents: human coxsackievirus AS, A16, B4, B5, echovirus 11, Mycoplasma pneumoniae; hypersensitivity reaction to foods or 
drugs or local irritants 

Diagnosis: appearance (Mycoplasma pneumoniae papular or giant), history; serology 
Treatment: 

Virnses: non-specific 

Mycoplasma pneumoniae: doxycycline, erythromycin 

Hypersensitivity: withdrawal of reactant, antihistamines 

Diagnosis and Management of Infectious Diseases Page 1 17 



Skin Infections 

Vesicular Rash 

Agents: simplexvirus 3 (shingles, chickenpox; worldwide; usually a mild disease, but serious disease in population with no 
previous exposure and in immunocompromised; in 25% of patients with Hodgkin's disease and 3% of patients with solid 
tumours; trunk, extremities, palms, fingers), human coxsackievirus R4, R5, R7-R10, RIB, Bl, B3, B5 and human enterovirus 71 
(hand, foot and mouth syndrome), human echovirus 5, 6 (zoster-like rash), 9, 11, 17, erythema infectiosum, neonatal 
simplexvirus 1 and 2 infection (papulovesicular), smallpox, monkeypox, Pseudomonas aeruginosa whirlpool-associated 
dermatitis, Neisseria gonorrhoeae, Neisseria meningitidis, Mycoplasma pneumoniae (varicella-like; legs, trunk, face) 
Diagnosis: bacterial and viral culture of vesicle fluid and scrapings; viral culture of feces, throat swab; cytology (Tzanck 
smear stained with Paragon Multiple stain simple, inexpensive and easy to interpret) of scraping from base of vesicle; 
immunofluorescence; complement fixation test, hemagglutination inhibition, neutralisation; histology of biopsy; electron 
microscopy of skin lesions, vesicle fluid or pus; gel diffusion of vesicle fluid or pus 

Simplexvirus 3: direct fluorescent antibody staining of cells scraped from ulcerative lesions; characteristic 
multinucleate giant cells in vesicles seen histologically; visualisation of virus in vesicles by electron microscopy; virus 
isolation 

Poxvirnses: antigen detection 
Treatment: 

Simplexvirus 1 and 2: aciclovir, penciclovir 

Simplexvirus 3: saline packs 12 hourly for 10 min, calamine lotion 12 hourly, povidone iodine 6 hourly 
topically; oral antibiotics according to bacteriology of superinfection 

Varicella in Normal Patient With Pnenmonitis or Encephalitis or in 
Immnncompromised: aciclovir 10 mg/kg i.v. 8 hourly, each infusion administered over a period of 1 h, for 7-10 d 
(adjust dose for renal function) 

Herpes Zoster in Immnnocompromised and in Any Patient Seen Within 72 h of Onset 
of Vesicles: famciclovir 250 mg orally 8 hourly for 7 d, valaciclovir 1 g orally 8 hourly for 7 d, aciclovir 20 mg/kg to 
800 mg orally 5 times daily for 7 d; prednisolone 40 mg orally daily for 10 d, tapering off over 2 w, may be useful in 
averting or reducing post-herpetic neuralgia; herpes zoster neuralgia may be treated with nortriptyline, gabapentin, sustained 
release oxycodone or topical lidocaine patches 

Other Virnses: non-specific; discontinue steroids 

Neisseria: penicillin 

Pseudomonas aeruginosa: usually none required; topical 0.1% polymyxin B or washing with antibacterial 
soap followed by topical alcohol-based drying lotion if required 
Rose Spots 

Agent: Salmonella (enteric fever, 15% of cases of Salmonella brain abscess) 

Diagnosis: clinical; culture of feces, blood, bone marrow; computerised axial tomography, radionuclide scan, culture and 
histology of brain biopsy where indicated 
Treatment: chloramphenicol 
Petechial or Purpuric Rash 

Agents: human coxsackievirus R4, R9 (anaphylactoid), B2, 5, human echovirus 3, 4, 7 (anaphylactoid), 18 (anaphylactoid), 
Mycoplasma pneumoniae (rare) 
Diagnosis: clinical; serology 
Treatment: supportive 

Mycoplasma pneumoniae: doxycycline, erythromycin 
Papular-Purpuric Gloves and Socks Syndrome 
Agent: human parvovirus B19 

Diagnosis: pruritic erythema with edema, papular-purpuric lesions of hands and feet with sharp demarcation at wrists and 
ankles, lymphadenopathy, mucosal lesions, asthenia, anorexia, fever, arthralgias, mild anemia, leucocytosis or leucopoenia, 
transient neutropenia; IgM, IgG seroconversion, serum PCR 
Treatment: supportive 

Non-specific Rash is also seen in 40% of cases of Q fever endocarditis, 15% of acute viral hepatitis cases, 11% of 
enterovirus infections (conjunctivitis and enanthem absent, pharyngitis ±, rhinitis ±), in 6% of infectious mononucleosis 
cases due to Epstein-Barr virus (rarely in human cytomegalovirus cases, occasionally in Toxoplasma gondii syndromes), in 
2% of cases of influenza A, in human adenovirus B serotype 16 (but not human adenovirus E serotype 4] infections, in 
aseptic meningitis, in infections with human coxsackievirus R2, R4, R9, R16 and B4, in Staphylococcus aureus endocarditis 
and toxic erythema, and in infections with dermatophytes; also in dermatomyositis (over extensor surfaces of finger joints 
and over large joints, heliotrope rash of eyelids), and in reactive states to local application of chemicals or to ingestion of 
drugs (conjunctivitis, pharyngitis, rhinitis and enanthem absent), other chemicals or foods 

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Skin Infections 

(An exanthem and pulmonary involvement may be seen in infections with human adenovirus B serotype 7, human adenovirus 

7a, simplexvirus 1, simplexvirus 3, Epstein-Barr virus, human coxsackievirus A9, human echovirus 11, mammalian 

orthoeovirus type 3, measles virus, Chlamydia psittaci, Mycoplasma pneumoniae, Neisseria meningitidis, Mycobacterium 

tuberculosis, Histoplasma capsulatum, Cryptococcus neoformans, Coccidioides immitis) 

Paronychia 

Agents: Candida albicans, Pseudomonas aeruginosa (may lead to 'green nail syndrome'), Staphylococcus aureus, 

Streptococcus, anaerobes, Haemophilus paraprophilus, Eikenella corrodens, Fusarium (neutrophilia) 

Diagnosis: culture of pus swab 

Treatment: avoidance of precipitating factors (beer, milk, perspiration, water immersion, etc); topical povidone iodine 

paint, magenta paint, clioquinol cream; antibiotics as for Cellulitis if present 

Candida: miconazole 2% tincture twice daily for 5-7 d 

Chronic or Unresponsive: fluconazole 50 mg orally daily for at least 2 w, itraconazole 100 mg 
orally daily for at least 2 w, ketoconazole 200 mg orally once daily for at least 2 w 

Fusarium: nail removal, amphotericin B 1.25 mg/kg daily + 5-flucytosine 

Pseudomonas aeruginosa: 0.25-1% acetic acid, 0.1% polymyxin B 

Staphylococcus aureus: di/flucloxacillin 25 mg/kg to 500 mg orally 6 hourly, cephalexin 12.5 mg/kg to 
500 mg orally 6 hourly 
Herpetic Whitlow 
Agent: simplexvirus 1 

Diagnosis: may masquerade as acute pyogenic infection; swab culture 

Treatment: valaciclovir 500 mg orally 12 hourly for 7-10 d, famciclovir 250 mg orally 12 hourly for 7-10 d, aciclovir 
5 mg/kg to 200 mg orally 5 times daily for 7-10 d 
Dandruff 

Agent: ? Malassezia spp 
Diagnosis: clinical 
Treatment: selenium sulphide shampoo 

Otitis Externa: 0.6% of new episodes of illness in UK; 0.4% of ambulatory care visits in USA; most common cause of 
localised area pain 

Agents: includes 'swimmer's ear 1 (acute diffuse otitis externa) due to infections with Pseudomonas aeruginosa (35-70% of 
all cases of otitis externa), Proteus (2% of all cases), Escherichia coli (2% of all cases), Klebsiella pneumoniae (2% of all 
cases), other coliforms, Alcaligenes, Vibrio alginolyticus, Vibrio mimicus (after exposure to sea water), Aeromonas, acute 
localised otitis externa due to Staphylococcus aureus (16% of all cases), coagulase negative Staphylococcus (7% of all cases), 
group C Streptococcus (0.8% of all cases), Streptococcus pyogenes, otomycosis due to Candida albicans (7% of all cases), 
Aspergillus fumigatus, Aspergillus flaws and Aspergillus niger (primary or secondary to eczemoid reactions), Scedosporiunr, 
very rare specific infections with Mycobacterium species (including Mycobacterium tuberculosis], Corynebacterium 
diphtheriae and Actinomyces israelii, mixed infections due to obligate anaerobes (Peptostreptococcus, Propionibacterium acnes, 
Fusobacterium necrophorum, Bacteroides, Porphyromonas asaccharolytica, Prevotella intermedia) and Gram negatives in 
chronic conditions (29% of total cases); and malignant (necrotising) otitis externa (infection spreads to temporal bone, 
zygomatic bone and bones at base of skull, causing cranial neuropathies and significant mortality) due to Pseudomonas 
aeruginosa (rarely, Aspergillus fumigatus, Klebsiella oxytoca, Proteus mirabilis, Staphylococcus aureus, coagulase negative 
Staphylococcus] in elderly and diabetics; allergy and sensitivity reactions (eczema, psoriasis, seborrheic dermatitis, lupus 
erythematous) may simulate infection 

Diagnosis: itch, otorrhoea, pain varying from moderate to severe; hearing loss may occur if auditory canal occluded by 
lesion; culture of ear swab 

Malignant Otitis Externa: > 60 y, diabetes mellitus; otalgia in 75-100%, headache (usually temporal or 
occipital and often excruciating), periauricular tenderness and swelling, profuse purulent otorrhoea, edema and erythema of 
ear canal, granulation tissue in external auditory canal; facial nerve palsy late complication; raised ESR (often 
> 100 mm/h); computerised axial tomography or magnetic resonance imaging; isolation of organism from external auditory 
canal or mastoid 

Treatment: relieve pain with codeine or, if severe, pethidine or morphine; clean auditory canal by suction (do not syringe) 
or dry mopping with cotton wool on a thin carrier (not cotton bud); at least daily toilet with acetic acid 0.25% or povidone 
iodine 0.5% solution 

Swimmer's Ear (Acnte Diffnse Otitis Externa): dexamethasone 0.05% + framycetin sulphate 0.5% + 
gramicidin 0.005% ear drops 3 drops 3 times daily or as wick soaked in combination for 3-7 d; flumethasone 0.02% + 
clioquinol 1% ear drops 3 drops instilled into ear after cleaning twice daily or as wick soaked in combination for 3-7 d; 
triamcinolone/neomycin/gramicidin/nystatin combination 2-3 drops twice daily or inserted as saturated gauze wick; 
avoidance of swimming during attack; use of acetic acid + isopropyl alcohol or acetic acid + benzedthonium chloride 4-6 

Diagnosis and Management of Infectious Diseases Page 1 19 



Skin Infections 

drops instilled into each ear after shaking water out following water immersion, or insertion of plugs of nonabsorptive 
material (eg., paraffin-impregnated cotton wool) may help prevent recurrence 

Acute Localised Otitis Externa: di(flu)cloxacillin 12.5 mg/kg to 500 mg orally 6 hourly for 5 d 

Aspergillus: if eardrum intact, clean with alcohol, then instil 2 drops 4% boric acid in 5% alcohol 6 hourly for 
up to 3 w 

Malignant Otitis Externa: 

Pseudomonas aeruginosa: gentamicin 5-7 mg/kg i.v. daily (child: 7.5 mg/kg i.v. in 1-3 divided 
doses) + tic arc illin- c lavulanate 50 mg/kg to 3 g i.v. 4-6 hourly or ceftazidime 25 mg/kg to 1 g i.v. 8 hourly; ciprofloxacin 
1.5-2.5 g/d orally for 6-10 w; piperacillin 3-4 g i.v. 4-6 hourly + tobramycin 1.3 mg/kg i.v. 8 hourly for 4-8 w 

Aspergillus: incision and drainage of pinna; itraconazole 200 mg/d for 3 mo, amphotericin B ± 
flucytosine 

Staphylococcus aureus: as for Swimmer's Ear; if severe, flucloxacillin 500 mg orally 6 hourly 
(< 2 y: 14 dose; 2-10 y: [ A dose), erythromycin 500 mg orally 6 hourly (child: 30-50 mg/kg daily in divided doses) 

Candida albicans: cleansing; clotrimazole lotion 3 drops 8 hourly for 7 d, econazole 1% solution 2 drops 12 
hourly 

Mycobacterium: streptomycin, paraminosalicylic acid or other anti-tuberculous drugs depending on 
susceptibility of isolates 

Corynebacterium diphtherial antitoxin + penicillin, cephalosporin, erythromycin 

Actinomyces israelii: penicillin ± streptomycin; tetracycline, erythromycin, cephalosporin 

Others: penicillin, chloramphenicol, ticarcillin, metronidazole 



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Chapter 8 



Wound and Soft Tissne Infections, Local and Generalised Sepsis 

Human Bite and Clenched Fist Infections: human bites 2-23% of all bite wounds; 15-20% on head and neck 
Agents: Fusobacterium, p-lactamase-producing anaerobes, Eikenella corrodens, Enterobacter, Klebsiella, Streptococcus, 
diphtheroids, Neisseria, coagulase negative Staphylococcus, Pseudomonas, Proteus, Escherichia coli, Staphylococcus aureus, 
Haemophilus influenzae 
Diagnosis: culture of wound swab 

Treatment: forced pulsatile irrigation of wound, debridement, scrubbing with 1% povidone iodine; elevation; immobilisation; 
do not suture or surgically close wound before 24 h post injury; procaine penicillin 50 mg/kg to 1.5 g i.m. as single dose, 
then amoxycillin-clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for 5 d; assess tetanus immune status and 
administer tetanus toxoid if no history of 3 or more doses of toxoid in previous 5 y, and tetanus immunoglobulin if uncertain 
vaccination history or < 3 doses of toxoid 

Established Infection: metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5-10 d + ceftriaxone 
25 mg/kg to 1 g i.v. daily for 5-10 d or cefotaxime 25 mg/kg to 1 g i.v. 8 hourly for 5-10 d; piperacillin-tazobactam 
100/12.5 mg to 4/0.5 g i.v. 8 hourly for 5-10 d; ticarcillin-clavulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly for 5-10 d 

Penicillin Hypersensitive: metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5-10 d + 
doxycycline 5 mg/kg to 200 mg first dose then 2.5 mg/kg to 100 mg orally daily for 5-10 days (not < 8 y, pregnant or 
breastfeeding) or cotrimoxazole 4/20 mg/kg to 160/800 mg orally 12 hourly for 5-10 d or ciprofloxacin 10 mg/kg to 
500 mg orally 12 hourly for 5-10 d 
Cat and Dog Bite Infections 

Agents: Pasteurella multocida (> 50% of cat bites, 15-30% of dog bites), Staphylococcus aureus (20-30% of dog bites), 
other Pasteurella species, Capnocytophaga canimorsus, Capnocytophaga cynodegmi, Streptomyces sp EF-4, Streptomyces 
coelicolor], Actinobacillus actinomycetemcomitans, Haemophilus aprophilus, Staphylococcus intermedius and other coagulase 
negative Staphylococcus, Streptococcus (a, p and y), Micrococcus, Actinomyces, Fusobacterium, Peptostreptococcus, 
Eubacterium, Veillonella parvula, Leptotrichia buccalis, rarely Gram negative enteric bacilli, Pseudomonas fluoresces, 
Francisella tularensis,ZK Group NO-1 
Diagnosis: culture of wound swab 

Treatment: as for Human Bite and Clenched Fist Infections, but suture or delayed primary closure may be 
performed 

Fish Spine Injury and Other Water-Related Infections 

Agents: Vibrio species (especially Vibrio vulnificus, Vibrio alginolyticus, rapidly developing life-threatening infection may 
occur in cirrhosis or iron overload), Shewanella putrefaciens (salt or brackish water), Aeromonas hydrophila (fresh or 
brackish water; high risk of fulminant infection in hepatic disease, chronic illness, immunocompromised), Edwardsiella tarda 
(similar to Aeromonas], Pseudomonas species, Klebsiella, Escherichia, Staphylococcus species, Streptococcus pyogenes (often 
associated with coral cuts), Mycobacterium marinum (fish tanks) 
Diagnosis: swab culture 

Treatment: irrigation, exploration; tetracycline + broad spectrum (3-lactamase-stable (3-lactam or narrow spectrum 
P-lactamase-stable penicillin + gentamicin 

Vibrio: incision, drainage, debridement; doxycycline 5 mg/kg to 200 mg orally or i.v. twice daily then 2.5 mg/kg 
to 100 mg orally or i.v. 12 hourly (not < 8 y); ceftazidime 2 g i.v. 3 times a day; cefotaxime; ceftriaxone; ciprofloxacin 
400 mg twice a day for 3 d, minocycline 

Aeromonas hydrophila, Edwardsiella tarda: ciprofloxacin 10 mg/kg to 400 mg i.v. or 10 mg/kg to 
500 mg orally 12 hourly 

Streptococcus pyogenes: phenoxymethylpenicillin 500 mg orally 6 hourly 
Burn Infections 

Agents: Pseudomonas aeruginosa (only in burns affecting > 50% of total body surface and involving destruction of 
cutaneous structures), Staphylococcus aureus, Acinetobacter, Flavobacterium meningosepticum, other bacteria, Aspergillus, all 
isolates should be considered of possible significance 

Diagnosis: Gram stain, quantitative culture (> lOVg = sepsis) and histology of biopsy 
Treatment: early and frequent debridement of necrotic tissue 

Flavobacterium meningosepticum: ciprofloxacin, clindamycin 

Pseudomonas aeruginosa: mafenide; parenteral aminoglycoside + p-lactam if frank infection 

Other Bacteria: gentamicin; topical povidone iodine; nonsteroidal antiinflammatory drugs 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Aspergillus: i.v. amphotericin B; radical debridement/ amputation essential for management 
Surgical Prophylaxis: The most important single factor in preventing infection is the surgeon's technique. Others are 
short preoperative hospital stay; preoperative bathing and showering with antibacterial soap; no shaving or shaving to take 
place immediately before operation; reduction of risk factors such as obesity, diabetes, malnutrition; spraying of wounds with 
povidone iodine; postoperative vitamin C. Nasal application of mupirocin in Staphylococcus aureus carriers may reduce risk 
of nosocomial infection. Risk factors for surgical wound infection include prolonged preoperative stay, old age, morbid 
obesity, infection at other sites, ASA class, disease severity index, immunosuppression, razor shave, low abdominal incision, 
no prophylactic antibiotics, specific procedure, intraoperative contamination, prolonged duration of surgery, surgical wound 
class; probably malnutrition, low albumin, prolonged admission, tissue trauma, multiple procedures; possibly cancer, diabetes 
mellitus, inexperienced surgeon, low procedure volume, number of people in operating room, emergency surgery, no 
preoperative scrub, failure to obliterate dead space, poor hemostasis, foreign material, glove puncture, drains. Antibiotics 
should be administered systemically at start of anesthesia and, except where indicated, when skin sutures are being inserted. 

Insertion of Synthetic Biomaterial Device or Prosthesis, Clean Operations in Patients with 
Impaired Host Defences (Likely Pathogens Staphylococcus aureus, Coagnlase Negative 
Staphylococcus, Escherichia coli): cefazolin 1 g i.v. or cefuroxime 750 mg i.v. 30 mins before skin incision, second 
dose if procedure > 3 h 

Clean Wonnds (Elective, Primarily Closed, No Acnte Inflammation or Transection of 
Genitonrinary, Oropharyngeal, Gastrointestinal, Biliary or Tracheobronchial Tracts; No Techniqne 
Breaks): exogenous infection, especially Staphylococcus, infection rate < 2% 

Cardiac Snrgery (Valve Replacement, Coronary Artery Bypass Snrgery, Cardiac 
Transplant, Insertion of Permanent Pacemaker), Peripheral Vascnlar Procednres, Arterial 
Reconstructive Snrgery of Abdominal Aorta or Lower Limb (Likely Pathogens Staphylococcus aureus, 
Coagnlase Negative Staphylococcus, Diphtheroids, Aerobic Gram Negative Bacilli), Breast (Likely 
Pathogen Staphylococcus aureus), Dialysis Access (Likely Pathogens Coagnlase Negative 
Staphylococcus, Staphylococcus aureus): cephalothin 50 mg/kg to 2 g i.v. at time of induction (continue 6 hourly 
for 48 for arterial reconstructive surgery involving abdominal aorta or lower limb); cephazolin 25 mg/kg to 1 g (> 80 kg: 
2 g) i.v. at time of induction (continue 8 hourly for 48 h for arterial reconstructive surgery involving abdominal aorta or 
lower limb); gentamicin 2 mg/kg i.v. at time of induction (continue 6 hourly for 48 h for arterial reconstructive surgery 
involving abdominal aorta or lower limb) + di(flu)cloxacillin 50 mg/kg to 2 g i.v. at time of induction (continue 6 hourly for 
48 h for arterial reconstructive surgery involving abdominal aorta or lower limb); vancomycin 25 mg/kg (< 12 y: 
30 mg/kg) to 1.5 g i.v. over at least 1 h, ending infusion just prior to induction + gentamicin 2 mg/kg i.v. at time of 
induction 

Orthopedic (Prosthetic Large Joint Replacement, Insertion of Prosthetic or 
Transplant Material, Internal Fixation of Fractures of Large Bones): likely pathogens Staphylococcus aureus, 
coagulase negative Staphylococcus, diphtheroids, aerobic and anaerobic Gram negative bacilli; cephalothin 50 mg/kg to 2 g 
i.v. at time of induction, or cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) i.v. at time of induction 

Craniotomy (Prolonged Procednres, Reexplorations, Microsurgery, Insertion 
of Prosthetic Material), Clean Head and Neck Surgery (Skin Excision, Neck Dissections): likely pathogens 
coagulase negative Staphylococcus, Staphylococcus aureus, diphtheroids, less commonly aerobic Gram negative bacilli and 
anaerobes; di(flu)cloxacillin 50 mg/kg to 2 g i.v. at time of induction, cephalothin 50 mg/kg to 2 g i.v. at time of induction, 
cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) i.v. at time of induction; vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1.5 g 
i.v. by slow infusion ending just before procedure if MRSA known or suspected or penicillin hyersensitive 

Clean-contaminated Wounds (Urgent or Emergency Case That is Otherwise 'Clean'; Elective, 
Controlled Opening of Gastrointestinal, Oropharyngeal, Biliary or Tracheobronchial Tract; Minimal 
Spillage and/or Minor Technique Break; Reoperation Through 'Clean' Incision Within 7 d; Blunt 
Trauma, Intact Skin; Negative Exploration): endogenous bacteria > 10 6 /g of tissue; infection rate 5-10% 

Head, Neck (Including Ear, Nose, Throat and Dental Procedures, Laryngectomy and 
Other Head and Neck Cancer Operations) and Thoracic Surgery: likely pathogens mixed aerobic and anaerobic 
upper respiratory flora, Staphylococcus aureus, cephalothin 50 mg/kg to 2 g or cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) 
at time of induction 

Mandibular Fractures (Likely Pathogens Oral Flora): penicillin 2 MU (4 MU if > 60 kg) i.v. 
30 mins before skin incision 

Colorectal, Appendicectomy, Upper Gastrointestinal Tract, Biliary Surgery, 
Laparoscopic Surgery (All Persons): likely pathogens anaerobic streptococci, Enterococcus faecalis, enteric aerobic 
and anaerobic Gram negative bacilli, Clostridia; 10% mannitol clearance; metronidazole 1 g rectally 2-4 h before surgery or 
12.5 mg/kg to 500 mg i.v. ending infusion at time of induction (omit for patients with normal gastric acid and motility, no 
obstruction, no bleeding and no malignancy or previous gastric surgery undergoing upper gastrointestinal surgery and for 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

patients < 60 y and non-diabetic undergoing biliary tract surgery and for elective cholecystectomy with low risk of 
exploration of common bile duct) + cephalothin 50 mg/kg to 2 g or cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) i.v. or 
gentamicin 2 mg/kg i.v. at time of induction; cefoxitin 40 mg/kg to 2 g i.v. at time of induction as single drug 

Endoscopic Procedures Involving Biliary Tract, Sclerotherapy, Esophageal 
Dilation, Endoscopic Retrograde Cholangiopancreatography, Percntaneons Endoscopic Gastrostomy, 
Jejnnostomy Tnbe Insertion: cephalothin 50 mg/kg to 2 g i.v. at time of induction or cephazolin 25 mg/kg to 1 g 
(> 80 kg: 2 g) i.v. or gentamicin 2 mg/kg i.v. at time of induction; if endoscopic retrograde cholangiopancreatography and 
biliary stasis, + amoxycillin + clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 hourly for 3 d 

Beta-lactam Allergy or MRSA Colonisation: vancomycin 25 mg/kg (< 12 y: 
30 mg/kg) to 1.5 g i.v. by slow infusion ending just before the procedure 

Hernia Repair with Prosthetic Maaterial: cephalothin 50 mg/kg to 2 g i.v. at time of induction, 
cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) i.v. at time of induction 

Hysterectomy, Termination of Pregnancy (All Women): screen for vaginosis and Chlamydia 
trachomatis and treat before operation; otherwise, likely pathogens anaerobic bacteria, enteric Gram negative bacilli, 
Streptococcus, Enterococcus, tinidazole 2 g orally 6-12 h prior to surgery or metronidazole 500 mg i.v. ending infusion at 
time of induction + cephalothin 2 g i.v. at time of induction or cephazolin 1 g i.v. at time of induction (doxycycline 100 mg 
i.v. if p-lactam allergy) or cefoxitin 40 mg/kg to 2 g i.v. at time of induction 

Caesarean Section: likely pathogens anaerobic bacteria, Enterococcus faecalis, aerobic Gram negative 
bacilli, streptococci; cephalothin 2 g i.v. or cephazolin 1 g (> 80 kg: 2 g) i.v. immediately after clamping cord; p-lactam 
allergy: clindamycin 900 mg i.v. + gentamicin 1.5 mg/kg i.v. at time of cord clamping 

Urinary Tract Snrgery: likely pathogens Enterococcus faecalis, enteric Gram negative bacilli; not 
needed for patients with sterile urine; patients with urinary tract infection should be treated preoperatively on basis of 
culture and susceptibility results; if this is not possible, gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 
4-6 mg/kg) i.v. single dose (adjust dose for renal function) 

Renal Transplantation: likely pathogens Staphylococcus, Streptococcus, enteric Gram negative 
bacilli; cephalothin 2 g or cephazolin 1 g i.v. or cefuroxime 750 mg i.v. at time of induction 

Liver Transplantation: likely pathogens Staphylococcus, Streptococcus, enteric Gram negative bacilli, 
Enterococcus, cephalothin 2 g or cephazolin 1 g i.v. at time of induction + metronidazole 500 mg i.v. at time of induction; 
cefotetan 2g or cefoxitin 2 g i.v. at time of induction; ampicillin-sulbactam 3 g i.v. 30 mins before skin incision (second dose 
if procedure > 3 h) 

Pancreas or Pancreas/Kidney Transplantation: likely pathogens coagulase negative 
staphylococci, Enterococcus, yeasts; ampicillin-sulbactam 3 g i.v. + fluconazole 400 mg i.v. 30 mins before skin incision 

Lower Limb Ampntation Snrgery: likely pathogen Clostridium perfringens; benzylpenicillin 
30 mg/kg to 1.2 g i.v. at time of induction then 6 hourly for 24 h, metronidazole 1 g rectally commencing 2-4 h before 
surgery or 12.5 mg/kg to 500 mg i.v. ending at time of induction then 12 hourly for 24 h; iodine skin antisepsis 

Prostatectomy: likely pathogens coliforms, staphylococci, Pseudomonas; gentamicin 2 mg/kg i.v. as a 
single dose at time of induction 

Transrectal Prostatic Biopsy: trimethoprim 300 mg orally as single dose 1 h before procedure 

Arterial Reconstrnctive Snrgery Involving Abdominal Aorta and/or Lower Limb, 
Especially if Groin Incision Or Implantation of Foreign Material: cephalothin 50 mg/kg to 2 g i.v. at time 
of induction and then 6 hourly for 48 h, cephazolin 25 mg/kg to 1 g (> 80 kg: 2 g) i.v. at time of induction and then 6 
hourly for 48 h, di/flucloxacillin 50 mg/kg to 2 g i.v. at time of induction and then 6 hourly for 48 h + gentamicin 
4-6 mg/kg (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg) i.v. at time of induction and 24 h later (adjust dose for renal 
function) 

Known or Snspected HIRSA or Penicillin Hypersensitive: vancomycin 25 mg/kg 
(< 12 y: 30 mg/kg) to 1.5 g i.v. by slow infusion ending just before procedure + gentamicin 4-6 mg/kg (< 10 y: 
7.5 mg/kg; child > 10 y: 6 mg/kg) i.v. at time of induction and 24 h later (adjust dose for renal function) 

Contaminated Wonnds (Acnte Non-pnrnlent Inflammation; Major Techniqne Break or Major 
Spill from Hollow Organ; Penetrating Tranma < 4 h Old; Chronic Open Wonnds to be Grafted or 
Covered): as for Clean-contaminated Wonnds, but infection rate 12-20% 

Dirty Wonnds (Pnrnlence or Abscess; Preoperative Perforation of Gastrointestinal, 
Oropharyngeal, Biliary or Tracheobronchial Tracts; Penetrating Tranma > 4 h Old): primary pathogen, 
endogenous organisms; surgical technique most important; delayed primary closure reduces infection rate from 50% to 0% 

Rnptnred, Perforated or Gangrenous Viscns: likely pathogens anaerobic bacteria, Enterococcus 
faecalis, aerobic Gram negative bacilli; tetracycline lavage; metronidazole 500 mg i.v. 8 hourly + amoxycillin 2 g 4 hourly 
+ gentamicin 1.3 mg/kg 8 hourly 

Fnngal Prophylaxis in Critical Snrgical Patients (> 3 d in Snrgical ICU): fluconazole 400 mg/d 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Burns (Extensive Skin Loss): likely pathogens Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas 
aeruginosa, enteric Gram negative bacilli; silver sulphadiazine 1% with chlorhexidine gluconate 0.2% cream topically at each 
dressing change 

Ophthalmic Snrgery: likely pathogens Staphylococcus aureus, coagulase negative Staphylococcus, Streptococcus 
viridans, gentamicin or chloramphenicol eye drops or ointment for 1-2 d only 
Muscular, Skeletal and Soft Tissue Trauma, Crush Injuries and Stab Wounds 
Agents: Staphylococcus aureus, Streptococcus pyogenes, Clostridium perfringens, aerobic Gram negative bacilli 
Diagnosis: swab or tissue culture 

Treatment: careful cleaning, debridement, immobilisation, elevation; tetanus toxoid if uncertain vaccination history, < 3 
doses of tetanus toxoid, > 10 y since vaccination or 5-10 y and dirty or major wound; tetanus immunoglobulin if uncertain 
vaccination history or < 3 doses of tetanus toxoid and dirty or major wound 

Hospitalisation Not Required: di(flu)cloxacillin 12.5-25 mg/kg to 500 mg orally 6 hourly for 5-7 d + 
metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5-7 d 

Hospitalisation Required: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin 5-7 mg/kg i.v. as 
single daily dose (child: 7.5 mg/kg/d i.v. in 1-3 divided doses)+ metronidazole 12.5 mg/g to 500 mg i.v. 12 hourly for at 
least 5 d; cephalothin 25 mg/kg to 2 g i.v. 6 hourly or cephazolin 15 mg/kg to 2 g i.v. 8 hourly + metronidazole as above; 
if possibility of gas gangrene, benzylpenicillin 60 mg/kg to 2.4 g i.v., repeating in 4 h if necessary 
Suppurative Wound Infections 

Agents: organisms causing Local and Generalised Sepsis in low numbers; low pathogenicity organisms such as 
coagulase negative Staphylococcus 

Diagnosis: swab culture after microscopic screening; semiquantitative culture using plastic i.v. catheter on blood agar in 
surgical incisional wounds 

Treatment: antibiotics usually not required; thorough cleansing; surgical drainage; irrigation with isotonic saline or 
isotonic stabilised 0.05% sodium hypochlorite 12 hourly; local antiseptics (10% mercurochrome or 1% chlorhexidine cream 12 
hourly after bathing) or saline dressings 

Postoperative: 

Mild to Moderate with Surrounding Cellulitis: di(flu)cloxacillin 12.5 mg/kg to 500 mg orally 6 
hourly for at least 5 d or cephalexin 12.5 mg/kg to 500 mg orally 6 hourly for at least 5 d if penicillin hypersensitive; if 
Gram negative bacilli suspected or proven, amoxycillin-clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for at 
least 5 d as single agent 

Severe, Systemic Symptoms: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly or cephalothin 
50 mg/kg to 2 g i.v. 6 hourly or cephazolin 50 mg/kg to 2 g i.v. 8 hourly if penicillin hypersensitive; if Gram negative 
bacilli suspected or proven, add gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. daily (adjust 
dose for renal function); if immediate penicillin hypersensitivyt or high incidence of MRSA, substitute vancomycin 25 mg/kg 
(< 12 y: 30 mg/kg) to 1 g i.v. 12 hourly by slow infusion (monitor blood levels and adjust dose accordingly) for 
di/flucloxacillin, cephalothin or cephalzolin 

Post-traumatic: 

Clean Wounds Where Management Delayed or Debridement Difficult: di/flucloxacillin 
12.5 mg/kg to 500 mg orally 6 hourly for 5 d + metronidazole 10 mg/kg to 400 mg orally 12 hourly for 5-7 d; amoxycillin- 
clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for 5 d 

Penicillin Hypersensitive (Not Immediate): substitute cephalexin 12.5 mg/kg to 
500 mg orally 6 hourly for 5 d 

Immediate Penicillin Hypersensitvity or Possible Pseudomonas: ciprofloxacin 
10 mg/kg to 500 mg orally 12 hourly for 5 d + clindamycin 10 mg/kg to 450 mg orally 8 hourly for 5 d 

Contaminated Wounds: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin (< 10 y: 
7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. daily (adjust dose for renal function) + metronidazole 12.5 mg/kg 
to 500 mg i.v. 12 hourly 

Pencillin Hypersensitive (Not Immediate): metronidazole 12.5 mg/kg to 500 mg i.v. 
12 hourly + cephalothin 50 mg/kg to 2 g i.v. 6 hourly or cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Immediate Penicillin Hypersensitivity: gentamicin 4-6 mg/kg (< 10 y: 7.5 mg/kg; 
child > 10 y: 6 mg/kg) i.v. daily (adjust dose for renal function) + clindamycin 15 mg/kg to 600 mg i.v. or orally 8 hourly 
or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly 

Local and Generalised Sepsis: 750,000 cases/y in USA; sepsis = a systemic inflammatory response to infection; severe 
sepsis = sepsis with one or more dysfunctional organs or systems (death rate 30-35%); systemic inflammatory response 
syndrome = a syndrome in which inflammatory mediator release causes alterations in body temperature (> 38°C or 
< 36°C), heart rate > 90 beats/min, alterations in respiratory function (rate > 20 breaths/min or P(h < 32 mmHg, 
alterations in WBC count (> 12000/mm 3 or < 4000/mm 3 or > 10% immature forms); compensatory anti-inflammatory 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

response syndrome = syndrome in which anti-inflammatory mediator release overcompensates for the systemic inflammatory 
response; septic shock = severe sepsis with hypotension that is resistant to fluid resuscitation and requires pharmacological 
intervention (death rate « 50%); multiple organ dysfunction syndrome = syndrome in which hypotension and hypoperfusion, 
secondary to pathophysiological alterations in severe sepsis, result in dysfunction in multiple organs 
Agents: Staphylococcus aureus (always significant; 15% of hospital infections); Streptococcus (Groups A, C and G, others in 
hospital infections, Streptococcus milled m abscesses; Group A 0.7% of hospital infections, Group B 2%, Group D 10%); 
coliforms (mainly in hospital-acquired infections, diabetics, immunosuppressed and severely debilitated patient; also in 
agricultural wounds; Escherichia coli 15% of hospital infections (83% of infections following major abdominal surgery), 
Proteus 7%, Klebsiella 5%, Enterobacter 4%); Pseudomonas aeruginosa (5% of hospital infections) and other Pseudomonas 
species; Bacteroides fragilis (3% of hospital infections, 73% of intraabdominal wounds); other anaerobes (other Bacteroides, 
Clostridium, Peptococcus, 7% of hospital infections, 85% of infections following major abdominal surgery); Pasteurella; Vibrio 
vulnificus (case-fatality rate 67% in primary sepsis, 22% in wound infections), Vibrio cholerae, Vibrio mimicus, Vibrio 
parahaemolyticus, Vibrio alginolyticus, Vibrio damsela and Aeromonas (trauma and exposure to water); Yersinia pestis; 
Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium smegmatis (primary and post-surgical (especially 
cardiac) infections, catheter tunnel infections); Mycobacterium haemophilum (immunocompromised); Chromobacterium 
violaceunr, Campylobacter fetus subsp fetus (abscesses); Campylobacter concisus (foot ulcer); Clostridium botulinum; 
Achromobacter; Acinetobacter calcoaceticus; Eikenella corrodens (55% of cases related to human bites or fist-fight injuries); 
Corynebacterium jeikeium (local infections at sites of biopsy or catheter insertion or perianal fissure in granulocytopenic 
patients); Corynebacterium striatum (infection of exit sites of central venous catheters); Corynebacterium urealyticum 
(immunosuppressed); Actinobacillus actinomycetemcomitans (soft tissue abscess; may be associated with infection with 
Actinomyces); Moraxella (rare); Sarcina (rare); Salmonella (in renal transplant recipients); Bacillus cereus (principal cause of 
traumatic wound infections in tropics); Streptococcus pneumoniae (associated with connective tissue disease); Haemophilus 
influenzae (soft tissue abscesses; 45% of nonbacteremic Haemophilus influenzae infections in older children and adults); 
Capnocytophaga (granulocytopenics); Selenomonas sputigena (in alcoholics); Desulphovibrio desulfuricans; Candida albicans 
(sternal in coronary artery bypass grafting); Pseudallescheria boydii (cancer patients); Trichosporon, Fusarium and Geotrichum 
(mainly disseminated infections in cancer patients); Aspergillus, Alternaria 

Diagnosis: in severe sepsis, organ dysfunction, hypoperfusion or hypotension, fever, tachycardia, tachypnea and elevated 
white cell count may be present; micro and culture of wound swab, aspirate, body fluids, blood (repeat if negative); serology, 
counterimmunoelectrophoresis of serum; immunodiffusion, latex agglutination, ELISA [Bacteroides fragilis sensitivity 81%, 
specificity 95%; Staphylococcus aureus teichoic acid), radioimmunoassay [Bacteroides fragilis sensitivity 75%, specificity 



Wound Botulism: 66% traumatic, 15% injection site, 11% surgical, 6% unknown site, 4% sinusitis; culture of 
wound, cyst aspirate, stool; electromyogram (median nerve conduction and F-responses normal, amplitude of evoked muscle- 
action potential low but increased by repetitive stimulation at 10 Hertzogs by 50%); hypercapnia (pC(h = 110) 
Treatment: in severe sepsis, i.v. fluids if hypotensive or hypoperfusion, vasopressors if hypotension not corrected by i.v. 
fluids, intubate and ventilate as necessary, control source of sepsis where possible, maintain adequate glycemic control; 
where not contraindicated, drotrecogin alpha (activated) (recombinant human activated protein C) reduces mortality by 20% 

Organism Not Known: as for Muscular, Skeletal and Soft Tissue Trauma or, if severe, as for 
Bacteremia, Septicemia, Septic Shock 

Streptococcus pyogenes: aqueous benzylpenicillin 6-8 MU i.v. daily, procaine benzylpenicillin 1.2-2.4 MU i.m. 
twice daily, phenoxymethylpenicillin 1-2 g daily orally 

Staphylococcus aureus: oxacillin or flucloxacillin 6-12 g i.v. daily in divided doses, cephazolin 3-4 g/d, 
vancomycin 500 mg every 6 h, dicloxacillin 250-500 mg 4 times a day orally, erythromycin, cephalexin 250-500 mg 4 times 
a day orally 

Enterococci: benzylpenicillin 9-12 MU daily or ampicillin 6-12 g i.v. daily + gentamicin 1 mg/kg 8 hourly 

Mycobacterium: debridement, drainage, excision + sulphamethoxazole 1 g orally 8 hourly for 10 w or more; 
amikacin 500 mg i.v. 12 hourly + cefoxitin 1.2 g 4-8 hourly; amikacin 300 mg i.v. 12 hourly + doxycycline 100 mg orally 8 
hourly 

Corynebacterium jeikeium, Corynebacterium urealyticum, Corynebacterium striatum: 
vancomycin 

Chromobacterium violaceum: chloramphenicol 

Campylobacter fetus snbsp fetus: gentamicin 

Salmonella: drainage + ampicillin 

Vibrio: debridement; doxycycline 100 mg orally or i.v. twice daily + ceftazidime 2 g i.v. 3 times a day or 
ciprofloxacin 400 mg twice a day for 3 d or gentamicin 

Reromonas: thorough cleaning of wound, topical antiseptics; consider delayed primary closure; surgical drainage 
+ gentamicin 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Pseudomonar. ciprofloxacin 

Anaerobes: clindamycin 

Clostridium botulinum: wound debridement, intensive care, mechanical ventilation when appropriate, 
antitoxin; tetracycline, metronidazole, chloramphenicol, penicillin 

Bacillus cereus: 

Mild: flucloxacillin 50 mg (< 2 y: l A dose; 2-10 y: Vi dose) orally 6 hourly 

Severe: clindamycin 450 mg orally 6 hourly (child: 20 mg/kg daily in equally divided doses) 

Candida: ketoconazole 200-400 mg orally daily, fluconazole 50-100 mg orally daily 

Aspergillus: amphotericin B; radical debridement essential for management 

Rltemaria: resection; itraconazole 

Fusarium: 

Non-neutropenic: itraconazole 200 mg twice daily orally 

Neutropenic: amphotericin B 1.0 - 1.5 mg/kg daily, liposomal amphotericin B 5 - 15 mg/kg daily 
Metbicillin Resistant Staphylococcus aureus Control: povidone iodine gauze pads, application of 2% mupirocin 
calcium ointment to nares of carriers twice daily for 5 d or to wounds daily for 2 w, showering and shampooing with 
triclosan 2% liquid soap 12 hourly, shortening period of perioperative antibiotic cover, routine postoperative perineal swabs, 
wearing masks while tending infected patients 

Cellulitis, Fasciitis, Gangrene, Myonecrosis, Myositis, Pyomyositis: 0.7% of new episodes of illness in UK; 
0.5% of ambulatory care visits in USA; cellulitis = painful, erythematous infection of deep skin with poorly demarcated 
borders 

Agents: Streptococcus pyogenes (may be gangrenous or pyomyositis in diabetics; also perianal in young children), 
Staphylococcus aureus (> 90% of pyomyositis — myositis purulenta tropica, staphylococcal pyomyositis, tropical myositis, 
tropical pyomyositis), Mycobacterium fortuitum (emerging pathogen in AIDS), Mycobacterium smegmatis, Pseudomonas 
aeruginosa (punctures or surgical wounds), Aeromonas hydrophila (soft tissue trauma associated with water; cellulitis + 
bullae, abscesses and crepitant, necrotising, myonecrosis), Edwardsiella tarda (similar to Aeromonas), Yersinia enterocolitica 
(pyomyositis in diabetics), halophilic Vibrio ( Vibrio alginolyticus, Vibrio parahaemolyticus, Vibrio vulnificus), Serratia 
marcescens (rare pyomyositis), Haemophilus influenzae (usually type b; buccal, associated with otitis media; rare 
pyomyositis), Streptococcus milled, Streptococcus cam's, Group C Streptococcus, Streptococcus pneumoniae (children, chronic 
illness, alcoholics and i.v. drug users), Streptococcus agalactiae (rare; diabetics; including pyomyositis), Salmonella (in renal 
transplant recipients), Erysipelothrix rhusiopathiae, Corynebacterium jeikeium (biopsy sites in granulocytopenic patients), 
Mycoplasma hominis, Shewenella putrefaciens (lower limb), Edwardsiella tarda (associated with trauma to mucosal surfaces), 
Clostridium perfringens and other Clostridium [Clostridium fallax, Clostridium novyi, Clostridium oedematiens, Clostridium 
septicum, Clostridium sporogenes, gas gangrene, clostridial cellulitis, clostridial myonecrosis (anaerobic myositis, clostridial 
myositis) from contamination of wounds, incubation period hours; Clostridium septicum also spontaneous nontraumatic 
associated with colon lesions, diabetes, leucopenia), anaerobic streptococci, Peptococcus, Neisseria gonorrhoeae (rare 
pyomyositis), Neisseria mucosa (rare), Klebsiella oxytoca (uncommon pyomyositis), Legionella pneumophila (one case 
associated with pneumonia), Acinetobacter calcoaceticus, Capnocytophaga canimorsus, Succinimonas amylolytica (single case 
of groin cellulitis and abscess), Stenotrophomonas maltophilia (associated with neutropenia, prolonged hospitalisation, 
intensive care unit stay, broad spectrum antibiotic exposure), mixed aerobes and anaerobes, Mucorales (uncommon; fulminant 
necrotising or indolent), Scedosporium (post-traumatic), Bipolaris, Cryptococcus 

Diagnosis: excruciating pain, swelling of tissues, crepitance, bulla formation; Gram stain and culture of swab from deep in 
necrotic tissue; specimens from sinus tracts or draining wounds may be taken by aspiration by syringe and small plastic 
catheter introduced as deeply as possible through decontaminated skin orifice, but a specimen obtained at surgery from the 
depths of the wound or underlying bone lesion is always preferable; curettings and tissue biopsies provide excellent material; 
Gram stain will frequently be an important clue to nature of infection; blood cultures; Doppler imaging to rule out deep vein 
thrombosis in absence of visible port of entry or recognisable predisposing factor in elderly 

Necrotising Infections: edema > erythema, skin vesicle, subcutaneous gas, absence of 
lymphadenitis/lymphangitis; later, skin echymoses, anesthesia, fever, hypotension 

Anaerobic Cellulitis: will often be suspected clinically because of smell and appearance of wound 

Clostridial Cellulitis: production of gas in subcutaneous tissue, resulting in their destruction; some 
local pain, moderate fever and crepitation common 

Clostridial Myonecrosis: local pain in region of wound, toxemia, toxic delirium, edema, production 
of bullae, tissue necrosis (in that order) 

Gas Gangrene: necrosis and production of gas in tissues; gas in soft tissues may be due to 
Clostridium, Escherichia coli, Klebsiella, Peptostreptococcus, Bacteroides, Fusobacterium, Streptococcus pyogenes, mixed 
facultative and anaerobic bacteria, or noninfectious (eg., trapped air following trauma or surgery) 

Streptococcal: extremely rapid spread; patient appears toxic; lymphangitis prominent 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Staphylococcal: more indolent, central fluctuance 

Pyomyositis: fever, muscle pain; needle aspiration if visible mass; ultrasonography, X-ray, radionuclide bone 
scintigraphy, gallium scan, MRI 

Haemophilus: primarily in children aged 3 mo - 3 y; bluish tinge; frequently facial 
Reromonas. inflammation of connective tissue often resembling p-haemolytic streptococcal cellulitis; occasionally 
seen as a granulomatous ulcer; rarely hemorrhage, necrosis and liquefaction of soft tissues (muscle), subcutaneous gas 
formation, muscle fibres separated and lysed (high mortality associated with positive blood culture); usually results from 
exposure of lesion to fresh water 

Vibrio: exposure to marine water; widespread fasciitis and myonecrosis; case-fatality rate 7-33% 
Other Gram Negative Bacilli: immunocompromised host 

Erysipelothrix rhusiopathiae: summer peak; exposure to fish, shellfish; erysipeloid; joint involvement common 
Mycoplasma hominis: postcaesarean and others; culture on A7B or Mycotrim-GU (Hana) 
Treatment: surgical incision and drainage of abscesses and surgical debridement of all necrotic tissue + antimicrobial; 
planned relook 24-48 h 

Mild Early: di/flucloxacillin 12.5 mg/kg to 500 mg orally 6 hourly for 7-10 d 

Penicillin Hypersensitive (Not Immediate): cephalexin 12.5 mg/kg to 500 mg orally 6 hourly 
for 7-10 d 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg orally 8 hourly for 7- 
10 d 

Severe: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 hourly, 
cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg i.v. or orally 8 hourly, 
lincomycin 15 mg/kg to 600 mg i.v. 8 hourly, vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. 12 hourly by slow 
infusion (monitor blood levels and adjust dose accordingly) 
Streptococcus pyogenes: 

Severe: benzylpenicillin 30 mg/kg to 600 mg i.v. 4 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 hourly 
or cephazolin 25 mg/kg to 1 g i.v. 8 hourly 

Immediate Penicillin Hypersensitivity: clindamycin 10 mg/kg to 450 mg i.v. then 
10 mg/kg to 450 mg orally 8 hourly; lincomycin 15 mg/kg to 600 mg i.v. 8 hourly, then clindamycin 10 mg/kg to 450 mg 
orally 8 hourly; vancomycin 20 mg/kg to 1 g i.v. slowly 12 hourly 

Home-based Therapy: cephalzolin 2 g i.v. 12 hourly for 4-7 d; cephalzolin 2 g i.v. daily 
for 4-7 d + probenecid 1 g orally daily for 4-7 d 

Less Severe: procaine penicillin 50 mg/kg to 1.5 g daily, phenoxymethylpenicillin 10 mg/kg to 500 mg 
orally 6 hourly for 7 d 

Penicillin Hypersensitive: clindamycin 10 mg/kg to 450 mg orally 8 hourly 
Staphylococcus aureus: 

Less Severe: di(flu)cloxacillin 25 mg/kg to 500 mg orally 6 hourly 

Penicillin Hypersensitive: clindamycin 10 mg/kg to 450 mg orally 8 hour 
Severe: di/flucloxacillin 50 mg/kg to maximum 2 g i.v. 6 hourly 

Penicillin Hypersensitive, Home-based Therapy: as for Streptococcus pyogenes 
Methicillin Resistant Staphylococcus aureus. 

Mild: fusidic acid 500 mg (5-12 y: 250 mg) orally 8 hourly + rifampicin 600 mg orally twice 
daily (not pregnant; child: 1 mo - 1 y: 10 mg/kg daily; > 1 y: 20 mg/kg to maximum 120 mg daily) 

Severe: vancomycin 500 mg i.v. 6 hourly over 60 min for 4 w (child: 44 mg/kg i.v. daily in 
divided doses) + gentamicin 1 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 hourly for at least 2 w or rifampicin as above 

Clostridium: complete surgical wound debridement of necrotic tissue; hyperbaric oxygen if severe; 
benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly; if immediate penicillin hypersensitivity, metronidazole 12.5 mg/kg to 
500 mg i.v. 8 hourly 

Other Anaerobes: chloramphenicol 500 mg orally 6 hourly (child > 2 w: 50 mg/kg daily orally in 4 divided 
doses; premature, newborn and those with immature metabolism: 25 mg/kg daily in 4 divided doses), metronidazole as for 
Clostridium 

Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, ciprofloxacin, cotrimoxazole orally for 6-12 mo 
Mycobacterium smegmatis: extensive skin debridement followed by skin grafting 



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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Haemophilus influenzae: 

Severe: cefotaxime 500 mg i.v. 6 hourly (child: 30-50 mg/kg i.v. 6-8 hourly), chloramphenicol as for 
Other Anaerobes 

Less Severe: amoxycillin-clavulanate 40/10 mg/kg/d to maximum 1.5/0.375 g in 3 divided doses 

Reromonas hydrophila, Edwardsiella tarda: ciprofloxacin, aminoglycoside, third generation cephalosporin 

Vibrio: doxycycline 100 mg orally or i.v. twice daily + ceftazidime 2 g i.v. 3 times a day or ciprofloxacin 
400 mg twice a day for 3 d or gentamicin 

Mycoplasma hominis: doxycycline 

Stenotrophomonas maltophilia: resection + cotrimoxazole + ticarcillin-clavulanate + aztreonam 

Other Aerobic Gram Negatives: ticarcillin + gentamicin 

Erysipelothrix rhusiopathiae: penicillin 

Fungi: amphotericin B 0.75mg/kg/d 
Prophylaxis (Recurrent Streptococcus pyogenes Cellulitis): phenoxymethylpenicillin 250 mg orally twice daily 
for up to 6 mo 

Necrotising Fasciitis: incidence in adults 0.4/100,000, in children 0.08/100,000; mortality rates up to 73%; diabetes 
mellitus, immunosuppressive medications and AIDS predispose 

Type I (Progressive Synergistic Bacterial Gangrene) 
Agents: classically microaerophilic streptococci + Staphylococcus aureus (Meleney's synergistic gangrene) but also applied 
to situations involving other streptococci (30% of isolates), Staphylococcus aureus (gives a chronic condition), Gram negative 
bacilli (especially Escherichia coli, Pseudomonas, Shigella, Enterobacter, Proteus, Serratia), Enterococcus faecalis and various 
anaerobes (particularly Bacteroides, Peptostreptococcus, Clostridium, Peptococcus); may develop as a complication of foot and 
leg sores in diabetics, occasionally in other situations; Fournier's gangrene is necrotising fasciitis of scrotum rapidly 
progressing to penis and is caused by Peptostreptococcus in association with Proteus, Escherichia coli, Staphylococcus 
aureus, (3-haemolytic streptococci (rarely Streptococcus agalactiae associated with diabetes) and various anaerobes; may 
follow use of nonsteroidal antiinflammatory drugs in treating inflammatory cutaneous lesions 

Type II (Hemolytic Streptococcal Gangrene): prior injury (penetrating injuries, cuts, burns, blunt trauma, 
muscle strain, surgical incisions, irradiation, cancer, diabetes, infection on trunk, alcoholism, HIV infection, cardiovascular 
and pulmonary disease, puerperium predisposing factors; also associated with use of nonsteroidal antiinflammatory drugs in 
varicella; 74% mortality 

Agents: Streptococcus pyogenes, occasionally in combination with Staphylococcus aureus 
Diagnosis: localised pain ± swelling, tenderness or erythema in 87%, gastrointestinal complaints (nausea, vomiting, 
diarrhoea) in 53%, influenza-like symptoms (aches, chills, fever) in 47%; culture of swab or biopsy from deep in wound; 
blood cultures; C reactive protein > 16 mg/dL (positive predictive value 44%, negative predictive value 99%), creatine 
kinase > 600 U/L (positive predictive value 58%, negative predictive value 95%); MRI (94% accuracy) or CT scan (exudates 
extending along fascial planes); frozen section; 'finger test' pathognomonic 

Treatment: operative removal of devitalised tissue; meropenem 25 mg/kg to 1 g i.v. 8 hourly + clindamycin 15 mg/kg to 
600 mg i.v. 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly; supportive care in ICU critical 

Streptococcus pyogenes: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly + clindamycin 15 mg/kg to 
600 mg i.v. 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly + normal immunoglobulin 0.4-2 g/kg i.v. for 1 or 2 
doses during first 72 h; debridement; hyperbaric oxygen 

Penicillin Hypersensitive: substitute cephalothin 50 mg/kg to 2 g i.v. 6 hourly or cephazolin 
50 mg/kg to 2 g i.v. 8 hourly for benzylpenicillin 

Pseudomonas aeruginosa: extensive debridement and resection; combination antipseudomonas antimicrobial 
therapy; leucocyte transfusions or colony-stimulating factors 

Polymicrobial: meropenem 25 mg/kg to 1 g i.v. 8 hourly 
Lyihphocutaneous Syndrome 

Agents: Sporothrix schenckii (most common), Nocardia brasiliensis (very common), Mycobacterium marinum (very common), 
Leishmania braziliensis (very common in endemic areas), Leishmania tropica (common in endemic areas), Coccidioides immitis 
(common), Francisella tularensis (common), Mycobacterium chelonaei (common), less frequent Ajelloomyces dermatitidis, 
Cryptococcus neoformans, Fusarium, Histoplasma capsulatum, Scedosporium apiospermum, Scopulariopsis, Nocardia asteroides, 
Nocardia otitidiscaviarum, Nocardia transvalensis, Staphylococcus aureus, Streptococcus pyogenes, Mycobacterium avium- 
intracellulare, Mycobacterium flavescens, Mycobacterium fortuitum (emerging pathogen in AIDS), Mycobacterium kansasii, 
Mycobacterium tuberculosis, Leishmania major, cowpox virus, simplexvirus 
Diagnosis: biopsy and culture of skin lesion, lymph node 
Treatment: 

Scedosporium apiospermum: ketoconazole, fluconazole, flucytosine 

Sporothrix schenckii: itraconazole 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Other Fungi: amphotericin B 0.75 mg/kg i.v daily for 2-4 w + flucytosine 25 mg/kg i.v. or orally 6 hourly for 
14 d 

Francisella tularensis: streptomycin, tetracycline 

Staphylococcus aureus: cloxacillin, flucloxacillin, cephalothin 

Streptococcus pyogenes: penicillin, erythromycin 

Nocardia, Mycobacterium chelonae, Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, 
ciprofloxacin, cotrimoxazole orally for 6-12 mo 

Mycobacterium avium-intracellulare: ethambutol 15 mg/kg orally daily or 25 mg/kg orally 3 times 
weekly (not < 6 y) + clarithromycin 12.5 mg/g to 500 mg orally 12 hourly daily or 3 times weekly or azithromycin 
10 mg/kg to 500 mg orally daily or 10 mg/kg to 600 mg orally 3 times weekly + rifampicin 10 mg/kg to 600 mg orally 
daily or 3 times weekly or rifabutin 5 mg/kg to 300 mg orally daily 

Mycobacterium kansasii: isoniazid 10 mg/kg to 300 mg orally daily + rifampicin 10 mg/kg to 600 mg 
orally twice daily + ethambutol 15 mg/kg orally (not < 6 y) daily for 18 mo and 12 mo negative sputum cultures 

Mycobacterium marinum: clarithromycin 12.5 mg/kg to 500 mg orally 12 hourly, cotrimoxazole 4/20 mg/kg 
to 160/800 mg orally 12 hourly, doxycycline 2.5 mg/kg to 100 mg orally (not < 8 y) 12 hourly 
Severe or Unresponsive: clarithromycin + rifampicin or ethambutol 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Leishmania: sodium stibogluconate 

Simplexvirus: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly for 
7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Frequent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg orally 12 
hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Prophylaxis (Mycobacterium avium Complex in HIV/ AIDS, CD4 Count < 50/ uL): azithromycin 1.2 g orally 
weekly, clarithromycin 500 mg orally 12 hourly, rifabutin 300 mg orally daily 
Rhabdomyolysis: 5% due to infectious causes 

Agents: influenza virus, human parainfluenza virus, coxsackievirus, echovirus, Epstein-Ban virus, hepatitis B virus, 
simplexvirus, adenovirus, Clostridium, Streptococcus pneumoniae, other Streptococcus, Staphylococcus aureus, Salmonella typhi, 
Shigella sonnei, Shigella ilexneri, Legionella, Haemophilus parainfluenzae, Escherichia coli, Vibrio vulnificus, Klebsiella 
pneumoniae, Leptospira 

Diagnosis: culture of muscle biopsy, blood; test of urine for myoglobin; serology; raised serum aldolase, serum creatine 
kinase 

Treatment: ticarcillin + tobramycin 
Sarcocystosis 
Agent: Sarcocystis suihominis 
Diagnosis: histology of cysts in muscle 
Treatment: none satisfactory 

Symmetrical Peripheral Gangrene: complication of septicemia 
Agents: usually Gram negative bacilli; also staphylococci and streptococci 
Diagnosis: culture of blood and urine 
Treatment: dependent on isolate 
Nasal Septal Abscess 

Agents: Staphylococcus aureus, Streptococcus pneumoniae, p-haemolytic streptococci, Haemophilus influenzae, Pseudomonas 
aeruginosa, Escherichia coli 
Diagnosis: culture of aspirate 

Treatment: cephalexin + gentamicin + aspiration, drainage and nasal packing 
Ischiorectal Abscess 

Agents: Clostridium, Bacteroides, Staphylococcus aureus (coliforms and enterococci which may be isolated are not 
significant) 

Diagnosis: culture of swab from deep in abscess 
Treatment: penicillin, cephalosporin or erythromycin + metronidazole 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Perianal and Perirectal Abscess and Cellulitis in Patients with Malignant Disease 

Agents: Escherichia coli, Group D Streptococcus, Bacteroides fragilis, Clostridium, Klebsiella pneumoniae, Pseudomonas 

aeruginosa (55% of patients with acute leukemia; > 50% case-fatality rate in these cases), Proteus mirabilis, Citrobacter 

freundii, Staphylococcus aureus, Enterobacter cloacae, Candida albicans 

Diagnosis: swab culture 

Treatment: ceftazidime + clindamycin, piperacillin + tobramycin + clindamycin; + vancomycin if progression; + 

surgery if inadequate response 

Perianal Cellulitis in Young Children 

Agent: Streptococcus pyogenes 

Diagnosis: culture of anal swab 

Treatment: phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly for 7 d 

Psoas Abscess: « 12 reported cases/y worldwide; predisposing conditions diabetes, immunosuppression, renal failure 

Agents: Staphylococcus aureus (80% of primary), Pseudomonas aeruginosa, Haemophilus aphrophilus, Proteus mirabilis, 

Escherichia coli, Streptococcus viridans, p-haemolytic streptococci, Enterobacter, Salmonella enteritidis, Enterococcus, Serratia 

marcescens, Bacteroides fragilis, Mycobacterium tuberculosis (uncommon), Mycobacterium kansasii, Mycobacterium xenopi, 

Pasteurella multocida, Salmonella typhi (rare), Candida tropicalis, Torulopsis glabrata 

Diagnosis: computerised tomography; Gram stain and culture of aspirate; culture of blood and urine 

Treatment: surgical drainage +: 

Staphylococcus aureus: cloxacillin 

Streptococci, Pasteurella multocida: penicillin 

Serratia marcescens: gentamicin 

Anaerobes: metronidazole 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Salmonella typhi: ciprofloxacin 1.5 g/d orally 

Candida, Torulopsis: amphotericin B 

Organism Not Known: cloxacillin + gentamicin + clindamycin 
Intraabdominal Abscess: 12% from pancreatitis, 10-20% from appendicitis, 10% from genitourinary tract, 8% from 
biliary tract, 7% from diverticulitis, 3% from trauma, 3% from perforating tumours, 2% from peptic ulcer, 2% from leaking 
suture line, 15-30% from miscellaneous sources, 10% from unknown source 

Agents: 80-95% Bacteroides fragilis, 80-95% Escherichia coli, 60% Enterococcus, 50% anaerobic streptococci, 50% 
Clostridium, 40% Fusobacterium, 38% Proteus, Eikenella corrodens, other Bacteroides, Prevotella, Desulfovibrio desulfuricans 
Diagnosis: fever in 82%, abnormal chest film in 61%, abdominal pain in 38%, persistent drainage in 18%, abnormal plain 
film of abdomen in 14%, chest dullness in 12%, abdominal mass by palpation in 7%; liver-lung scan (98% accurate), CT scan 
(98% accurate), ultrasound (96% accurate), gallium scan (82% accurate); culture of aspirate or surgical specimen 
Treatment: clindamycin, chloramphenicol 
Perinephric abscess 

Agents: Staphylococcus (36% of cases in renal transplant recipients), aerobic Gram negative bacilli (32% of cases in renal 
transplant recipients), anaerobes (28% of cases in renal transplant recipients), Candida albicans (4% of cases in renal 
transplant recipients), Mycobacterium intracellular 

Diagnosis: fever, abdominal tenderness; computed tomography, intravenous pyelogram, cystogram; culture of material 
obtained by surgery or percutaneous drainage 
Treatment: surgical drainage + appropriate antimicrobials 

Pelvic Abscess, Pelvic Inflammatory Disease, Parametritis: 62% salpingitis, 22% normal findings, 5% ovarian 
cysts, 4% ectopic pregnancy, 3% appendicitis, 1% endometriosis; important cause of ectopic pregnancy, sterility and 
tuboovarian abscess; increasing importance in Australia and other developed nations; vaginal douching a risk factor 
Agents: Neisseria gonorrhoeae, Chlamydia trachomatis (1/4 - l A of the million recognised cases in USA each year), 
Bacteroides, anaerobic Gram positive cocci, Escherichia coli, Actinomyces israelii (almost exclusively associated with use of 
IUD), Mycoplasma hominis, Ureaplasma urealyticum, Haemophilus influenzae (IUD related and maternal), Streptococcus 
pyogenes, Streptococcus milled, Streptococcus pneumoniae (IUD, recent birth, gynecologic surgery), Clostridium perfringens, 
Candida (associated with suture, IUD) 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Diagnosis: diffuse pelvic (uterine/adnexal, cervical motion) tenderness associated with pelvic pain and abnormal cervical 
or vaginal mucopurulent discharge, oral temperature > 38.3°C, leucocytes on saline microscopy of vaginal secretions, 
elevated erythrocyte sedimentation rate, elevated C-reactive protein; increased frequency in patients with IUDs; endometrial 
biopsy with histopathologic evidence of endometriosis; transvaginal sonography or magnetic resonance imaging showing 
thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex; laparoscopy; Gram stain and culture of 
swab or pus; direct immunofluorescence on cervical smears (Chlamydia, Actinomyces israelii) 
Treatment: hospitalise if surgical emergencies cannot be excluded, the patient is pregnant, the patient does not respond 
clinically to oral antimicrobial therapy, the patient is unable to follow or tolerate an outpatient oral regimen, the patient has 
severe illness, nausea and vomiting or high fever, or the patient has a tubo-ovarian abscess 

Likely to be Sexually Acqnired: 

Mild to Moderate: azithromycin 1 g orally as single dose weekly for 2 w + ceftriaxone 250 mg i.m. 
or i.v. as single dose + metronidazole 400 mg orally 12 hourly for 14 d or tinidazole 500 mg orally daily for 14 d 

Severe: doxycycline 100 mg orally or i.v. 12 hourly + cefoxitin 2 g i.v. 8 hourly, doxycycline 100 mg 
orally or i.v. 12 hourly + metronidazole 500 mg i.v. 12 hourly + ceftriaxone 1 g i.v. daily or cefotaxime 1 g i.v. 8 hourly 

Penicillin Hypersensitive: gentamicin 4-6 mg/kg (adjust dose for renal function) i.v. 
daily + clindamycin 600 mg i.v. 8 hourly or lincomycin 600 mg i.v. 8 hourly 

Treatment for Sexnal Partners: doxycycline 100 mg orally twice daily for 7 d, tetracycline 
500 mg 6 hourly for 7 d, erythromycin 500 mg 6 hourly for 7 d 

Mild to Moderate Infection, Not Sexually Acqnired: remove any IUD or retained products of conception 
as soon as possible; amoxycillin-clavulanate 875/125 mg orally 12 hourly + doxycycline 100 mg orally 12 hourly for 14 d 
Pregnant or Breastfeeding: substitute roxithromycin 300 mg orally daily for 14 d for doxycycline 

Related to Tranma or Pregnancy: amoxy/ampicillin 2 g i.v. 6 hourly + metronidazole 500 mg i.v. infused 
over 20 min 12 hourly or 1 g rectally 8 hourly + gentamicin 4-6 mg/kg i.v 8 daily (adjust for renal function) 

Streptococci, Clostridium perfringens: benzylpenicillin 2.4 g i.v. 4 hourly 

Candida albicans: amphotericin B 
Peritonitis: primary; secondary due to obstruction, infarction, perforation, neoplasm, foreign body, inflammatory bowel 
disease; spontaneous in patients with ascites due to cirrhosis of liver or nephrotic syndrome; during peritoneal dialysis 
Agents: coliforms (primary, secondary, spontaneous; Klebsiella 1-6 % of infections in continuous ambulatory peritoneal 
dialysis, Escherichia coli 0-15% of infections in continuous ambulatory peritoneal dialysis; Enterobacter cloacae, Citrobacter 
freundii, infrequently Kluyvera ascorbata), anaerobes (primary and secondary, < 5% of infections in continuous ambulatory 
peritoneal dialysis; Bacteroides, Prevotella, Gram positive cocci, Clostridium perfringens, Bifidobacterium, Eubacterium), 
Streptococcus agalactiae (primary and secondary), Streptococcus pneumoniae (primary and spontaneous), Streptococcus 
pyogenes (primary and secondary), Enterococcus (primary and secondary and 2-11% of infections in continuous ambulatory 
peritoneal dialysis), Streptococcus milled (primary and secondary), Streptococcus viridans (5-21% of infections in continuous 
ambulatory peritoneal dialysis), Staphylococcus aureus (primary and 9-24% of infections in continuous ambulatory peritoneal 
dialysis), coagulase negative Staphylococcus (primary and adherent strains in 32-45% of infections in continuous ambulatory 
peritoneal dialysis), Neisseria gonorrhoeae (primary; gonococcal perihepatitis (Fitz-Hugh syndrome, Fitz-Hugh and Curtis 
syndrome, Fitz-Hugh-Curtis syndrome, gonococcic perihepatitis, gonococcic peritonitis of the upper abdomen, Stojano subcostal 
syndrome, Stojano syndrome, subcostal syndrome); upper abdominal peritonitis arising by extension of gonococcal salpingitis, 
with string-like adhesions between liver and abdominal wall), Chlamydia trachomatis, Actinomyces israelii, Mycoplasma 
hominis, Pseudomonas (primary and secondary and in 0-8% of infections in peritoneal dialysis), Mycobacterium tuberculosis 
(primary; 0.2% of tuberculosis cases), Capnocytophaga (primary and secondary), Listeria monocytogenes, Neisseria 
meningitidis, Aeromonas (nosocomial), Haemophilus influenzae (13% of non-bacteremic invasive Haemophilus influenzae 
infections in older children and adults), Campylobacter fetus subsp fetus, Pseudomonas luteola and Pseudomonas 
oryzihabitans (in continuous ambulatory peritoneal dialysis), Agrobacterium tumefaciens (in continuous ambulatory peritoneal 
dialysis), Rothia mucilaginosa (in continuous ambulatory peritoneal dialysis), Mycobacterium chelonae and Mycobacterium 
fortuitum (in < 3% of infections in continuous ambulatory peritoneal dialysis; emerging pathogen in AIDS), Corynebacterium 
jeikeium (in continuous ambulatory peritoneal dialysis), Sphingobacterium multivorum (spontaneous), Alcaligenes xylosoxydans 
xylosoxydans, Bordetella bronchiseptica, Pasteurella multocida (infant appendicial), Nocardia (infrequent in continuous 
ambulatory peritoneal dialysis), Bacteroides fragilis in continuous ambulatory peritoneal dialysis complicating colon cancer, 
fungi (in < 5% of infections in continuous ambulatory peritoneal dialysis; 42% Candida albicans, 14% Candida tropicalis, 8% 
Candida parapsilosis, 3% Candida guilliermondii, 2% Candida glabrata, 1% Candida krusei, 6% other Candida, 7% Fusarium, 
3% Rhodotorula rubra, 2% Bipolaris spicifera, 1% Mucor, 1% Aspergillus flavus, 1% Aspergillus fumigatus, 1% Dreschslera, 1% 
Trichoderma longibrachiatum and Trichoderma viride, 1% Exophiala jeanselmei, 1% Cephalosporium, rare Alternaria, 
Curvularia, Trichosporon beigelii, Cochliobolus australiensis, Bipolaris spicifera; Cryptococcus up to 6% and Coccidoides up to 
4% in some series) , amoebae (secondary), Strongyloides (secondary), Balantidium coli (very rare) 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Diagnosis: culture of swab or pus; counterimmunoelectrophoresis of serum, peritoneal fluid; urinalysis reagent strip test for 
leucocyte esterase on ascitic fluid ( > 3 = +ve gives sensitivity 89%, specificity 99%, positive predictive value 98%; > 2 
= +ve gives sensitivity 96%, specificity 89%, negative predictive value 99%; direct immunofluorescence of cervical smears 
(Chlamydia, Actinomyces israelii); serum lipase often increased 

Gonococcal Perihepatitis: right upper quadrant pain and tenderness 

Tnbercnlons: laparoscopy 

Continnons Ambulatory Peritoneal Dialysis: cloudy dialysis effluent in 95% of cases, abdominal pain in 
78%, abdominal tenderness in 76%; peritoneal dialysis fluid white cell count (90-2880 cells/mL with 56-99% 
polymorphonuclears in fungal peritonitis) and culture as for blood culture (Isolator, Bactec, BacT/Alert Aerobic FAN) 
Treatment: 

Snspected Associated with PID: doxycycline + cefoxitin 2 g i.v. 8 hourly 

Snspected Bowel Origin: amoxy(ampi)cillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin (< 10 y: 7.5 mg/kg; 
child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose (adjust dose for renal function) + metronidazole 
12.5 mg/kg to 500 mg i.v. infused over 20 min 12 hourly 

Gentamicin Contraindicated: piperacillin-tazobactam 100/12.5 mg/kg to 4/0.5 g i.v. 8 hourly, 
ti c arc illin - c la vulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly 

Penicillin Hypersensitive (Not Immediate): metronidazole 12.5 mg/kg to 500 mg i.v. 12 hourly 
+ cefotaxime 25 mg/kg to 1 g i.v. 8 hourly or ceftriaxone 25 mg/kg to 1 g i.v. daily 

Immediate Penicillin Hypersensitive: vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. 12 
hourly by slow infusion (monitor blood levels and adjust dose accordingly) + gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 
6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose (adjust dose for renal function) + metronidazole 12.5 mg/kg to 500 mg 
i.v. infused over 20 min 12 hourly 

Spontaneons: ceftriaxone 25 mg/kg to 1 g i.v. once daily or cefotaxime 25mg/kg to 1 g i.v. 8 hourly or 
ticarcillin + clavulanate 50 + 1.7 mg/kg to 3 + 0.1 g i.v. 6 hourly + (if receiving cotrimoxazole or norfloxacin 
prophylaxis or enterococcal infection likely) amoxy/ampicillin 25 mg/kg to 1 g i.v. 6 hourly 

Continnons Ambnlatory Peritoneal Dialysis: flush 2 X 1 L exchanges of dialysate 

Gram Positive Organisms Seen in Dialysate: cephalothin 15 mg/kg added to 1 bag/d 
(intermittent) or 500 mg/L initially then 125 mg/L (continuous with each bag exchange), cephazolin 15 mg/kg added to 1 
bag/d (intermittent) or 500 mg/L initially then 125 mg/L (continuous with each bag exchange), vancomycin 25 mg/L in 
each bag of dialysate or 50 mg/kg to 2 g i.p. as single dose, repeated after 7 d 

Gram Negative Bacilli Seen in Dialysate: gentamicin 4-8 mg/L to each bag of dialysate to 
maximum 40 mg/d in dialysate for 10-20 d or 50 mg i.p. as single daily dose for 10-21 d 

Diverticnlar Disease or Bowel Involvement Snspected: as above + metronidazole 400 mg 
orally or 500 mg i.v. 12 hourly 

Streptococci and Neisseria gonorrhoeae: penicillin 100,000 U/kg/d 

Staphylococci: 

Primary: penicillinase-resistant penicillin 150-200 mg/kg/d 

Peritoneal Dialysis: as for Continnons Ambnlatory Peritoneal Dialysis 

Mixed Aerobes and Anaerobes: gentamicin or tobramycin 5-7 mg/kg/d + clindamycin 30 mg/kg/d or 
chloramphenicol 50-100 mg/kg/d 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Mycobacterium chelonae, Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, ciprofloxacin, 
cotrimoxazole orally for 6-12 mo 

Sothia mucilaginosa: vancomycin 

Capnocytophaga, Listeria monocytogenes: ampicillin 

Fnngi: amphotericin B total dose of 2-10 mg/kg X 7-14 d i.v. + 1.5-2 mg/L in dialysate up to a total dose of 
1500 mg + flucytosine, followed by catheter removal (essential for management); Trichoderma resistant to most agents 
Prophylaxis (Spontaneons Bacterial in Patients with Ascites and Gastrointestinal Bleeding or Ascitiic 
Protein Concentration < 10 g/L or With Previous History): cotrimoxazole 4/20 mg/kg to 160/800 mg orally 
daily or, if contraindicated or previous failure, norfloxacin 10 mg/kg to 400 mg orally daily 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Cervical Fascial Space Infections: submandibular (Ludwig's angina; follows infection of second or third mandibular 
tooth in 70-85% of cases; potentially life-threatening), lateral pharyngeal (postanginal sepsis (necrobacillosis, Lemierre's 
disease); dental infections, rarely parotitis, otitis, mastoiditis), retropharyngeal, danger and prevertebral spaces (suppurative 
adenitis following upper respiratory tract infection, traumatic penetration, odontogenic) 
Agents: Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus, Bacteroides, Peptostreptococcus, 
Fusobacterium necrophorum, Eikenella corrodens, Arcanobacterium haemolyticum 

Diagnosis: ultrasonography, computerised axial tomography; blood cultures; serum alkaline phosphatase 81-330 IU/mL, 
serum bilirubin total 0.4-10.8 mg/dL, direct 0-7.5 mg/dL, serum gamma-glutamyl transferase 106-258 U/mL, serum glutamic- 
oxaloacetic acid transaminase 93-192 U/mL, serum glutamic-pyruvic acid transaminase 16-66 U/mL, serum lactic 
dehydrogenase 212-393 IU/mL, white cell count 7200-31,400/nL 

Snbmandibnlar: pain, minimal trismus, swelling of mouth floor and submylohyoid region, dysphagia and 
dyspnoea present if bilateral involvement 

Anterior Lateral Pharyngeal: severe pain, prominent trismus, swelling of anterior lateral pharynx and angle 
of jaw, dysphagia, occasional dyspnoea; followed by bacteremia and metastatic abscesses in necrobacillosis 

Posterior Lateral Pharyngeal: minimal pain, minimal trismus, swelling of posterior lateral pharynx (hidden), 
dysphagia and severe dyspnoea 

Retropharyngeal/Danger: pain, minimal trismus, swelling of posterior pharynx, dysphagia and dyspnoea 
Treatment: airway management, heparin + surgical drainage or computed tomography-guided needle aspiration +: 
metronidazole 12.5 mg/kg to 500 mg i.v. 12 hourly + benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly or amoxy/ampicillin 
50 mg/kg to 2 g i.v. 6 hourly; with clinical improvement, change to metronidazole 10 mg/kg to 400 mg orally 12 hourly + 
phenoxymethylpenicillin 10 mg/kg to 500 mg orally 6 hourly or amoxycillin 10 mg/kg to 500 mg orally 8 hourly, or 
amoxycillin + clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 hourly alone, for further 5 d 

Penicillin Hypersensitive: clindamycin 10 mg/kg to 450 mg i.v. 8 hourly or lincomycin 15 mg/kg to 600 mg 
i.v. 8 hourly then clindamycin 10 mg/kg to 450 mg orally 8 hourly for total 10 d 

Cranial Paraiheningeal Deep Fascial Space Infections: direct extension from sinusitis, otitis media, mastoiditis, 
petrous osteomyelitis; also odontogenic and following cranial surgery 

Agents: Bacteroides, Peptostreptococcus, Veiiloneila, Actinomyces, Fusobacterium, microaerophilic Streptococcus, enteric Gram 
negative bacilli, Pseudomonas aeruginosa and Staphylococcus aureus in immunocompromised and otogenic infection 
Diagnosis: ultrasonography, computerised axial tomography, blood cultures 
Treatment: 

Normal Patient: 

Otogenic: benzylpenicillin 2-4 MU i.v. every 4-6 h or ciprofloxacin 0.4 g i.v. every 12 h + 
metronidazole 0.5 g i.v. every 6 h or chloramphenicol 0.5 g i.v. every 6 h 

Rhinogenic/Odontogenic: benzylpenicillin 2-4 MU i.v. every 4-6 h + metronidazole 0.5 g i.v. 
every 6 h or chloramphenicol 0.5 g i.v. every 6 h 

Following Cranial Snrgery: flucloxacillin 1.5 g i.v. every 4-6 h + tobramycin 2 mg/kg i.v. every 
8 h or ciprofloxacin 0.4 g i.v. every 12 h 

Immunocompromised: 

Otogenic/Rhinogenic/Odontogenic: cefotaxime 2 g i.v. every 6 h, ceftizoxime 4 g i.v. every 8 
hours, imipenem 500 mg i.v. every 6 h 

Following Cranial Snrgery: vancomycin 0.5 g i.v. every 6 hours + cefotaxime, ceftizoxime or 
imipenem 

Mastitis and Breast Abscess 

Agents: usually Staphylococcus aureus in acute; most commonly coagulase negative Staphylococcus, Peptostreptococcus, 
Propionibacterium, Eubacterium and Bacteroides in chronic; also a-haemolytic streptococci, Streptococcus pyogenes, 
microaerophilic streptococci, Proteus, Escherichia coli, Prevotella disiens, Corynebacterium minutissimum (1 case; recurrent) 
and others 

Diagnosis: culture of pus swab, milk 
Treatment: 

Acnte: di(flu)cloxacillin 500 mg orally 6 hourly for at least 5 d; cephalexin 500 mg orally 6 hourly for at least 
5 d if penicillin hypersensitive (not immediate); clindamycin 400 mg orally 8 hourly for at least 5 d if immediate penicillin 
hypersensitivity; if severe cellulitis, di(flu)cloxacillin 2 g i.v. 6 hourly or cephalothin 2 g i.v. 6 hourly or cephazolin 2 g i.v. 
8 hourly if penicillin hypersensitive (not immediate) or clindamycin 450 mg i.v. or orally 8 hourly or lincomycin 600 mg i.v. 
8 hourly or vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g 12 hourly (monitor blood levels and adjust dose accordingly); 
prevention of milk stasis by suckling or expression manually or by pump; if no improvement in 2-3 d, surgical drainage 

Chronic: amoxycillin-clavulanate or ampicillin-sulbactam; drainage with duct excision in advanced chronic 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Mycetoma (Madura Foot, Maduromycosis): 60% actinomycetoma (actinomycotic mycetoma) due to bacteria, 40% 
eumycetoma due to fungi; chronic progressive disease of skin, subcutaneous tissue and bone, usually arising secondary to 
trauma 

Agents: Nocardia asteroides, Nocardia brasiliensis, Nocardia caviae, Actinomadura madurae, Actinomadura pelletieri, 
Streptomyces somaliensis, Streptomyces paraguayensis, Actinomyces israelii, Pseudallescheria boydii, Aspergillus nidulans, 
Fusarium falciforme, Streptomyces recifensis, Neotestudina rosatii, Exophiala jeanselmei, Madureiia mycetomatis, Streptomyces 
pseudoechinosporeus, Curvularia geniculata, Curvularia lunata, Leptosphaeria senegalensis, Pyrenochaeta romeroi 
Diagnosis: swelling and formation of granulomata, abscesses and deep sinuses; most characteristic feature presence of 
granules; brown to black grains produced by Exophiala, Madureiia, Curvularia, Leptosphaeria, Pyrenochaeta, Streptomyces 
paraguayensis, yellow to brownish by Streptomyces somaliensis, bright red by Actinomadura pelletieri, white to yellowish by 
others; Gram stain, modified Ziehl-Neelsen stain and EOH preparation, bacterial and fungal culture (BHI and Sabaroud's at 
30°C) of pus, curettings, biopsy or grains from draining sinuses; X-rays of affected part, and radionuclide scanning if 
negative, for underlying bone involvement 
Treatment: surgery +: 

Rctinomyces: penicillin 

Nocardiforms; i.v. cotrimoxazole or dapsone + amikacin or streptomycin, penicillin, tetracycline, rifampicin 
Fnngi: may show some response to amphotericin B, flucytosine, ketoconazole, miconazole, itraconazole, 
thiabendazole 

Bacteremia, Septicemia, Septic Shock: 1.8-13/1000 (13-15/1000 age > 60 y) hospital admissions; case-fatality rate 
5-50% (5% in < 60 y, 22% in > 60 y); community acquired: 24% from respiratory tract, 23% urinary tract, 11% meningitis, 
6% gastrointestinal tract, 6% cellulitis and decubitus, 3% bone and joint, 2% abdomen, 2% shunt; nosocomial: 18% from 
urinary tract, 17% hyperalimentation of intravenous site, 12% respiratory tract, 11% surgical wound, 8% abdomen, 8% 
gastrointestinal tract, 5% cellulitis and decubitus, 1% shunts; transient bacteremia characteristic of dental treatment; 
overflow bacteremia may be seen in patients with meningococcal meningitis, pneumonia, pyelonephritis; intermittent or 
constant bacteremia in infective endocarditis; 46% of bacteremic patients in long term care have cardiovascular disease 
Agents: Escherichia coli (12-29% of total cases, 20-33% of community acquired, 12-18% of nosocomial, 13% of long term 
care; fifth most common organism in nosocomial infection in cancer patients; 24% of cases in leukemia, lymphoma, solid 
tumours; common in neutropenics (14%); case-fatality rate 25% in leukemia and lymphoma, 12% in solid tumours, 12% in 
nosocomial, 13% overall; 98-100% of isolates true infection; 96% clinically significant; 58% hospital acquired; 43-55% from 
genituourinary tract, 17% abscess, 15-16% unknown, 8-17% bowel, 8-15% hepatobiliary, 6% multiple, 4% wound, 2-11% 
respiratory; also neonatal), Staphylococcus aureus (10-30% of total cases, 9% of community acquired (25% of these associated 
with arteriosclerotic heart disease), 14% of nosocomial (80% of these associated with intravascular devices), 15% of long 
term care (5% methicillin resistant); second most common organism in cancer patients; 9% of cases in leukemia and 
lymphoma, 11% solid tumours; 57% in narcotic addicts (24% methicillin resistant); common in neutropenics (5%); case-fatality 
rate 14% in leukemia and lymphoma, 22% in solid tumours, 12% in nosocomial, 30% overall; 75-99% of isolates true 
infection; 94% clinically significant; 60% hospital acquired; 20-33% associated with intravenous catheters, 20-21% unknown, 
11-16% from postoperative wounds, 7-29% from respiratory tract, 7% from skin infections, 7% from endocarditis, 7% from 
multiple, 6% from bone and joint; septicemia (staphylococcal pyaemia), with the presence of large numbers of multiplying 
staphylococci and of their toxic products in the bloodstream, may take a fulminant course and lead to septicemic adrenal 
haemorrhage syndrome), coagulase negative Staphylococcus (74% Staphylococcus epidermidis, 14% Staphylococcus hominis, 
14% Staphylococcus haemolyticus, 6% Staphylococcus warnerr, 5% of total cases, 3% of community acquired, 15% of 
nosocomial, 4% of long term care; common in neutropenics (14%; catheter-induced); most common organism in nosocomial 
infections in cancer patients; 11-37% case-fatality rate in nosocomial (septic shock in 22%), 25% overall; 56-94% of isolates 
contaminants; 20% significant; 31-68% from intravascular catheter, 19% wound, 16% multiple, 9% gastrointestinal tract, 4% 
bone and joint, 3-50% genitourinary tract, 3% endocarditis, 3% oropharyngeal, 0-50% CNS), Streptococcus pneumoniae (50,000- 
63,000 cases/y in US; case rate 15-30/100,000 for adults and 50-83/100,000 for > 65 y; 4-8% of total cases, 3% of long 
term care; all isolates true infection; 96% clinically significant; 81% community acquired; 85-94% from respiratory tract, 9% 
from meningitis; common in neutropenics; also in neonates; case-fatality rate 20% in adults, 60% in elderly; rare cases of 
hemorrhage and septic shock in infants; bacteremia without a focus of infection responsible for 70% of invasive 
pneumococcal disease in children < 2 y), Klebsiella (4-8% of total cases, 3% of community acquired, 3% of nosocomial, 1% 
of neonatal, 9% of long term care; eighth most common organism in nosocomial infections in cancer patients; 11% of cases in 
leukemia and lymphoma, 10% in solid tumours; common in neutropenics (19%); case-fatality rate 66% in leukemia and 
lymphoma, 29% in solid tumours, 28% in nosocomial, 27-34% overall; 99-100% of isolates true infection; 93% clinically 
significant; 80% hospital acquired; 24% multiple, 22% urinary tract, 20% unknown, 19% hepatobiliary, 12% gastrointestinal 
tract, 7-31% respiratory tract, 3-15% surgical wound, 3% oropharyngeal, 2-15% i.v. catheter), Salmonella (4% of community 
acquired, 2% of nosocomial; in renal transplant recipients and in AIDS; intermediate frequency in neutropenics; case-fatality 
rate 14% overall, 10% in nosocomial; all isolates true infection; all clinically significant; most common Salmonella 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

choleraesuis, Salmonella typhi 1% of community acquired), Pseudomonas (3-6% of total cases; case-fatality rate 51%; 99-100% 
of isolates true infection; 95% clinically significant; 32-33% unknown source, 19% multiple, 18-23% genitourinary tract, 17% 
wound, 14-43% respiratory tract, 9% gastrointestinal tract, 8% hepatobiliary, 7% intravascular, 2% endocarditis; Pseudomonas 
aeruginosa 3% of community acquired, 12% of nosocomial, 5% of long term care; seventh most common organism in 
nosocomial infection in cancer patients; common in neutropenics (27%); 15% of cases in leukemia and lymphoma (case- 
fatality rate 54%); overall case-fatality rate 39%, 31% in nosocomial, 9% in narcotic addicts; 83% hospital acquired; 
Pseudomonas akaligenes neonatal; other species (Pseudomonas cepacia, Pseudomonas paucimobilis, Pseudomonas pickettu) all 
hospital acquired, 42% from respiratory tract, 15% from genitourinary tract, 12% biliary; uncommon in neutropenics; case- 
fatality rate 31%; also Shewanella putrefaciens in patients with chronic infection of lower extremity or associated with 
severe underlying debility, liver disease, malignancy; Burkholderia pseudomallei common in Southeast Asia in rice farmers or 
their families, associated with diabetes and renal failure; case-fatality rate 85-95%;), Streptococcus pyogenes (common in 
neutropenics, 0.5% of long term care; also chronic heart disease, malignancy and others; 4% of cases nosocomial; 72% from 
cutaneous or subcutaneous infections, 28% from i.v. drug abusers; 10% mixed infections) and other (3-haemolytic streptococci 
(3-5% of total cases; 3% of cases in leukemia, lymphoma and solid tumours; 5% in neutropenics; case-fatality rate 20% in 
leukemia and lymphoma, 33% in solid tumours, 17% overall; 91-97% of isolates true infection; 92% clinically significant; 50% 
community acquired; 33% genitourinary tract, 10% bone and joint, 9-33% respiratory tract, 8-48% surgical wounds, 8% skin, 
5% intravascular, 2-8% bowel, 2% endocarditis, 2% multiple, 2% meningitis; Streptococcus cam's 0.8% of total cases (from 
cellulitis or abscess in patients with malignancies; 63% > 75 y; 80% men; 93% from skin or soft tissue infection), 
Streptococcus agalactiae in neonates (46% of cases) and also in hospitalised elderly patients with underlying disease, 
especially diabetes mellitus (4% of long term care; 19% from pneumonia, 19% from soft tissue infections, 11% from urinary 
tract infections, 8% from arthritis, 8% from osteomyelitis, 6% from lymphadenitis, 3% from meningitis, 3% from mastitis, 3% 
from ascending cholangitis, 3% from prostatitis); Streptococcus milled from abscesses; Group C Streptococcus [Streptococcus 
equisimilis, Streptococcus zooepidemicus, Streptococcus eqm) in cardiovascular disease and malignancy; 21% from respiratory 
tract, 18% gastrointestinal tract, 17% skin; case-fatality rate 25%), Group D streptococci (3-5% of total cases, 2% of 
community acquired, 3% of nosocomial, 1% of neonatal, 8% of long term care; case-fatality rate 32% overall, 7% in 
nosocomial; 87-99% of isolates true infection; 81% hospital acquired; 30% from wound, 22% multiple, 22% abscess, 12-22% 
genitourinary tract, 8-17% hepatobiliary, 6% gastrointestinal tract, 4% endocarditis, 2% pneumonia; Enterococcus common in 
neutropenics, in immunosuppression with debilitation, following instrumentation, after long term hospitalisation, and 
subsequent to use of cephalosporins; third most common organism in nosocomial infections in cancer patients; Enterococcus 
avium in gastrointestinal tract abnormalities; Streptococcus equinus indicator of possible colonic carcinoma and may cause 
such complications as endocarditis, spondylodiskitis, vertebral osteomyelitis and splenic abscess), Streptococcus viridans (41% 
Streptococcus mitis, 22% Streptococcus sanguis, 13% Streptococcus morbillorum, 7% Streptococcus intermedius, 7% 
Streptococcus constellatus, 2% Streptococcus salivarius, 2% Streptococcus mutans, 3-5% of all cases, 23% of neonatal; 
common in neutropenics; case-fatality rate 13%; 52-72% of isolates true infection; 31% clinically significant; 43% from 
respiratory tract, 29% from abscess, 17% unknown; predisposing factors epistaxis, bone marrow transplantation, treatment 
with cotrimoxazole, neutropenia), Bacteroides (2-6% of total cases, 2% of community acquired, 4% of nosocomial, 11% of 
neonatal; 11% of cases in solid tumours (case-fatality rate 4%); intermediate frequency in neutropenics; case-fatality rate in 
nosocomial 35%, overall 9-32%; all isolates true infection; 6-86% of isolates significant; 51% community acquired; 44% from 
gastrointestinal tract, 35% abscess, 20% wound, 12% hepatobiliary, 4-26% genitourinary tract, 4% bone and joint, 4% 
pneumonia; Bacteroides fragilis 70% of anaerobes isolated, involved in 62% of septicemia associated with infections of the 
female genital tract; 33% of isolates clinically significant; case-fatality rate 24%; other Bacteroides species 6-9% of 
anaerobes isolated), Serratia (2-4% of total cases, 1% of community acquired, 2% of nosocomial, 1% of long term care; 
uncommon in neutropenics; 93-100% of isolates true infection; 98% clinically significant; 92% nosocomial; 35% multiple, 30- 
31% respiratory, 8% wound, 8% gastrointestinal tract, 4-30% genitourinary tract, 4% endocarditis, 4% hepatobiliary; case- 
fatality rate 18-54% overall, 40% in nosocomial), Brucella (2% of community acquired; all isolates true infection; septicemia 
due to Brucella melitensis is known as Bruce septicemia or melitensis septicemia), Tsukamurella pulmonis and Tsukamurella 
tyrosinosolvans immunosuppressed patients with indwelling venous catheters), Candida (1-4% of all cases, 6% of nosocomial, 
1% of long term care; fourth most common organism in cancer patients; 5% in leukemia and lymphoma, 9% in solid tumours; 
case-fatality rate 72% in leukemia and lymphoma, 42% in solid tumours, 29% in nosocomial; Candida albicans 51% of fungal 
isolates, Candida tropicalis 13%, Candida kruseifA, Candida parapsilosis 6%, Candida guilliermondii 6% (1% of catheter 
associated); Candida lusitaniae 1% of catheter associated fungal, Candida pseudotropicalis 1%; 57% of Candida tropicalis 
isolates contaminants, all isolates of other species true infection; 93% clinically significant; 96% hospital acquired; 39% from 
i.v. cannula, 22% unknown source, 20% from gastrointestinal tract; largely in cancer patients receiving parenteral 
antimicrobials or alimentation; significant risk in patients with urological pathology undergoing surgery or manipulation; also 
in pregnancy, following abortion or postpartum), Proteus (1-3% of total cases, 4% of community acquired, 2% of nosocomial, 
13% of long term care; intermediate frequency in neutropenics; 6% of cases in solid tumours (case-fatality rate 42%); overall 
case-fatality rate 20%, 8% in nosocomial; all isolates true infection; 93% clinically significant; 71% hospital acquired; 25-50% 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

from genitourinary tract, 25% multiple, 17% abscess, 10% intravascular, 10% wound, 5-17% hepatobiliary, 0-17% respiratory 
tract), Enterobacter (1-3% of total cases, 1% of community acquired, 5-6% of nosocomial, 1% of long term care; intermediate 
frequency in neutropenics (11%); tenth most common organism in nosocomial infections in cancer patients; 85-100% of 
isolates true infection; 96% clinically significant; significant underlying conditions, including malignancy, in nearly all cases; 
29% from wound, 19% multiple, 12% hepatobiliary tract, 7% intravascular catheter, 7% gastrointestinal tract, 5-33% 
genitourinary tract, 2-33% respiratory tract, 2% endocarditis; case-fatality rate 18-29% overall, 10% in nosocomial), 
Clostridium (1-2% of total cases, 2% of community acquired; intermediate frequency in neutropenics; 3% of cases in solid 
tumours (case-fatality rate 67%); overall case-fatality rate 43%; 28% of anaerobes isolated; 99-100% of isolates true infection; 
vast majority of cases follow septic abortion; also from gastrointestinal tract; Clostridium perfringens 6% of anaerobes 
isolated, 50% of isolates true infection, 10% of isolates clinically significant, 58% hospital acquired, case-fatality rate 43%; 
Clostridium septicum 2% of anaerobic isolates, 3% of isolates clinically significant, case-fatality rate 40%; Clostridium 
oedematiens, Clostridium difficile in immunocompromised; Clostridium tertium in neutropenics and aspiration pneumonia, 13% 
of anaerobes isolated), Peptostreptococcus (1% of total cases; common in neutropenics; 3% of anaerobes isolated; all isolates 
true infection; 3% of isolates clinically significant; 25% from surgical wound, 25% from urinary catheter, 25% from i.v. 
catheter, 25% biliary; case-fatality rate 9%), Neisseria meningitidis (meningococcal bacteraemia (meningococcaemia; 43% of 
meningococcal infections;) is a mild systemic disease which, on rare occasions, may become chronic; meningococcal 
septicemia (meningococcal fever; 5-20% of meningococcal infections) is a severe disease with large numbers of meningococci 
in bloodstream, usually accompanied by severe toxemia due to meningococcal endotoxins, but without disseminated 
intravascular coagulation and, as a rule, without meningitis, and which may be acute or chronic; incidence 0.2/100,000; 1% 
of community acquired; all isolates true infection; case-fatality rate 25%), Haemophilus influenzae (nontypeable strains; 0.7- 
4% of total cases, 1% of community acquired, 1% of nosocomial, 1% of neonatal, 0.5% of long term care; intermediate 
frequency in neutropenics; 94-100% of isolates true infection; 94% clinically significant; 60% community acquired; 100% from 
respiratory tract; clinical presentation in older children and adults: 52% pneumonia, 27% septicemia, 8% meningitis, 5% 
gynecologic infection, 5% epiglottitis; 31-36% mortality), diphtheroids (3% of isolates; 71% of isolates contaminants; 16% 
clinically significant), Bacillus (1% of total isolates; 91-94% of isolates contaminants; 4% clinically significant; in 
compromised; uncommon in neutropenics; usually Bacillus cereus; Bacillus anthracis marked toxic effects), Neisseria species 
other than Neisseria meningitidis and Neisseria gonorrhoeae (0.5% of isolates; 33% contaminants; 50% clinically significant; 
Neisseria cinerea, Neisseria flavescens, Neisseria lactamica, Neisseria subflava; uncommon in neutropenics and other 
immunodeficient), Peptococcus (0.4% of isolates; 88% of isolates true infection; 78% clinically significant; mainly obstetrical 
patients during peripartum period; also 1% of neonatal cases; uncommon in neutropenics), Fusobacterium (0.3% of isolates, 9% 
of anaerobic isolates; 50% clinically significant, 50% transient bacteremia; intermediate frequency in neutropenics; 
Fusobacterium necrophorum all isolates true infection; 33% from genitourinary tract, 33% respiratory, 33% abscess; 1% of 
neonatal cases; intermediate frequency in neutropenics), Citrobacter (0.3% of isolates; all isolates clinically significant; 
uncommon in neutropenics; 0.5% of long term care; case-fatality rate 17%), Listeria monocytogenes (0.2% of isolates; all 
isolates true infection; 75% clinically significant; 57% community acquired; 60% from CNS; 4% of neonatal cases; uncommon 
in neutropenics), Campylobacter (0.1% of all isolates; all isolates clinically significant; Campylobacter fetus subsp fetus, 
Campylobacter jejuni (in conjunction with gastroenteritis in people at extremes of age or with cirrhosis, diabetes, renal 
failure, cancer, HIV), Campylobacter coli, Campylobacter upsaliensis, Campylobacter lari, kcobacter butzlen), Capnocytophaga 
(0.1% of isolates; all clinically significant; especially with oral mucositis; uncommon in neutropenics; Capnocytophaga 
canimorsus in hemochromatosis, asplenia or alcoholism following dog or cat bite), Moraxella (0.1% of isolates; 33% 
contaminants, 67% transient bacteraemia; uncommon in neutropenics; Moraxella catarrhalis rare in immunodeficient; Moraxella 
osloensis), Providencia (0.1% of isolates; all isolates clinically significant; uncommon in neutropenics; case-fatality rate 9%; 
Providencia stuartii 13% of long term care; Providencia rettgerif\5% of long term care), Eubacterium lentum (0.08% of 
isolates; 50% contaminants, 50% clinically significant), Haemophilus aegytius (Brazilian purpuric fever), Haemophilus 
aphrophilus, Chromobacterium violaceum (acute septicemia associated with abscesses in multiple organs; uncommon in 
neutropenics), Yersinia pestis, Yersinia enterocolitica (in iron overload cirrhosis; uncommon in neutropenics), Mycoplasma 
hominis (6% of neonatal cases), Ureaplasma urealyticum (1% of neonatal cases, puerperal), Mycobacterium fortuitum and 
Mycobacterium chelonae (catheter related), Vibrio vulnificus (elevated iron due to hemochromatosis or alcoholism), Vibrio 
metschnikovii, Vibrio cholerae non-01 (in cirrhosis and leukemia), Tibrio cincinnatii, Vibrio hollisae and Vibrio 
parahaemolyticus (following ingestion of seafood), Flavobacterium meningosepticum (in leukemia; uncommon in neutropenics), 
Reromonas (uncommon in neutropenics; Aeromonas hydrophila « 50% case-fatality rate in immunocompromised), Rlcaligenes 
(uncommon in neutropenics; Rlcaligenes xylosoxidans xylosoxidans rare catheter related and gastrointestinal, especially in 
cancer patients), Francisella tularensis, Kingella kingae (mainly children; uncommon in neutropenics), Anaerobiospirillum 
succiniciproducens, Corynebacterium (27% of isolates contaminants; Corynebacterium jeikeium 90% catheter related; 
Corynebacterium urealyticum in immunosuppressed; Corynebacterium striatum in imunocompromised or anatomically altered 
patients), Staphylococcus saprophytics (rare cases associated with sexual intercourse and/or urinary obstruction), 
Leuconostoc (rare cases associated with parenteral nutrition, other catheters and previous antibiotic therapy), Oerskovia 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

(catheter related), Propionibacterium acnes (associated with foreign body; intermediate frequency in neutropenics; 33% of 
anaerobic isolates; 3% of isolates clinically significant; case-fatality rate 45%), Gardnerella vaginalis (obstetric patients, 
rarely from prostate in males; uncommon in neutropenics), Zymomonas (uncommon in neutropenics), Legionella (uncommon in 
neutropenics), Eikenella corrodens (uncommon in neutropenics), Mnetobacter (uncommon in neutropenics; Mnetobacter 
baumannii nosocomial; Mnetobacter johnsonii vascular catheter related), Shigella (uncommon in neutropenics), Erwinia 
(uncommon in neutropenics), Hafnia (uncommon in neutropenics), Edwardsiella tarda (exposure to aquatic environments or 
exotic animals, preexisting liver disease, iron overload, raw fish ingestion; uncommon in neutropenics), Morganella (uncommon 
in neutropenics; 3% of long term care), Actinobacillus (uncommon in neutropenics; Actinobacillus actinomycetemcomitans also 
associated with oral infection), Veillonella (uncommon in immunocompromised), Pediococcus acidilacti (severely compromised), 
Neisseria gonorrhoeae, Erysipelothrix rhusiopathiae, Actinomyces israelii (usually from pulmonary actinomycosis), 
Stenotrophomonas maltophilia (0.5% of long term care; nosocomial infection in immunocompromised patients receiving broad 
spectrum antimicrobials), Leptotrichia buccalis (in cancer patients), Pseudomonas luteola and Pseudomonas oryzihabitans 
(prosthetic materials, corticosteroids), Rothia mucilaginosa (i.v. drug abuse, cardiac valve disease, vascular catheters, 
immunocompromised), Ochrobacterium anthropi (catheter associated), Methylobacterium extorquens (catheter related), 
Agrobacterium tumefaciens (intravascular catheter), Prevotella melaninogenica (8% of septicemia associated with female 
genital tract infection), Sphingobacterium multivorum (haemodialysis, lymphoma), Weeksella virosa (postsurgical), Plesiomonas 
shigelloides (secondary to cellulitis and prostatitis), Pasteurella multocida (following pneumonia), Helicobacter cinaedi and 
Helicobacter fennelliae (in homosexual men), Cardiobacterium hominis, Succinivibrio dextrinosolvens (rare cases associated 
with gastrointestinal or oesophageal sepsis), Ochrobactrum anthropi (patients on haemodialysis), Brevibacterium casei 
(associated with Hickmann catheter in AIDS), Bartonella quintana (homeless), Bartonella bacilliformis (Oroya fever), Candida 
glabrata (solid tumours and nononcologic; 13% of fungal isolates; 4% of catheter associated), Malassezia furfur and 
Malassezia pachydermatis (patients receiving i.v. fat emulsions; 1% of catheter associated fungemia in cancer patients), 
Saccharomyces cerevisiae (1% of catheter associated fungemia in cancer patients), Trichosporon, Fusarium, Rhodotorula rubra 
and Pichia in cancer patients; 6-14% of cases polymicrobial (82% hospital acquired; 74% severe underlying illness; case- 
fatality rate 21->50%) 

Diagnosis: blood cultures; counterimmunoelectrophoresis of serum; white cell count 4,300-11,400 (mean 8160/(.iL), 
neutrophils 24-83% (mean 61%), shift to left with 5-56% (mean 25%) bands, toxic granulation, lymphocytes 5-17% (mean 
10%), monocytes 0-6% (mean 3%), eosinophils 0-35% (mean 1%), basophils 0-1% (mean 1%); fibrin degradation products 
normal or elevated (significant elevation in 70% of cases), daily estimations may indicate patient's progress; platelet 
aggregation normal in 30-50% of cases; platelet count 90,000-468,000/jllL; infarction, Addisonian crisis (extremely rare) may 
simulate 

Gram Negative: increasing age, underlying medical condition, surgery or trauma, invasive diagnostic procedures, 
mechanical ventilatory support, antimicrobial treatment, immunosuppressive agents, vascular or bladder indwelling catheters; 
fever in 90-95%, change in mental status in 60-70%, increased respiratory rate in 50-60%, chills in 50%, hypotension in 40- 
60%, oliguria in 30-50%, bleeding from needle-sticks or mucosal surfaces in 7-10%, hypothermia in 5-10%, skin lesions in 5- 
10%; positive blood cultures in 100%, leucocytosis in 85-90%, acidosis in 50-80%, elevated blood urea nitrogen and/or 
creatinine in 50-80%, thrombocytopenia in 50-60%, abnormal liver function tests in 20-30%, leucopenia in 10-15% 

Brazilian Pnrpnric Fever: child 3 mo - 1 y, acute febrile illness, abdominal pain or vomiting, hemorrhagic 
skin lesions, history of conjunctivitis in 30 d preceding fever, no evidence of meningitis 

Gonococcal Septicemia: often fever and rigours 

Meningococcal Septicemia: retinal haemorrhages common 

Septicemia Dne to Clostridium: high fever, extensive intravascular haemolysis, acute renal tubular necrosis; 
usually fatal 

Listerial (Listeric) Septicemia: usually predominant involvement of liver 

Erysipelothrix rhusiopathiae Septicemia: fever, generalised myalgia, anorexia, weight loss; often results in 
endocarditis 

Neonatal: absence of specific antibodies, polymorphonuclear dysfunction, decreased complement, prematurity, 
prolonged rupture of membranes, complicated delivery, maternal infection, ventilatory support equipment, intravascular 
monitoring devices, bladder catheters; temperature may be normal or low (elevated in only 40%), evidence of respiratory 
distress including apnoea, poor feeding, jaundice; leucopenia with increased percentage of band forms; positive cultures 

Anthrax: Gram stain, India ink stain and culture of blood; ELISA, Western blot, toxin detection, chromatographic 
assay, fluorescent antibody test 

Bacillus cereus: diarrhoea, fever, altered mental status; Gram stain and culture of blood 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, profuse 
sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; isolation; Brucella tube 
agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, complement fixation test, Coombs, 
fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 

Diagnosis and Management of Infectious Diseases Page 137 



Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Treatment: volume repletion (including colloids), rapidly infused; oxygen under pressure if necessary; vasopressor amines 
in elderly patients with coronary insufficiency and normal central venous pressure; ? polymxyin B in Gram negative; monitor 
blood glucose 

Infection From Female Genital Tract: amoxy(ampi)cillin 2 g i.v. 6 hourly + gentamicin 4-6 mg/kg i.v. as 
single daily dose + metronidazole 500 mg i.v. 12 hourly or 1 g rectally 8 hourly 

Penicillin Hypersensitive (Not Immediate), Sexually Acqnired: doxycycline 100 mg orally 
or i.v. 12 hourly + cefoxitin 2 g i.v. 8 hourly, doxycycline 100 mg orally or i.v. 12 hourly + metronidazole 500 mg i.v. 12 
hourly + ceftriaxone 1 g i.v. daily or cefotaxime 1 g i.v. 8 hourly 

Immediate Penicillin Hypersensitivity, Postpartum: gentamicin 4-6 mg/kg as single daily 
dose (adjust dose for renal function) + clindamycin 600 mg i.v. slowly 8 hourly or lincomycin 600 mg i.v. 8 hourly 

Elderly, Diminished Renal Fnnction: cefotaxime 1 g i.v. 8 hourly or ceftriaxone 1 g once daily 
+ metronidazole as above; piperacillin-tazobactam 4/0.5 g i.v. 8 hourly or ticarcillin-clavulanate 3/0.1 g i.v. 6 hourly 
Infection from Respiratory System: 

Adnlts: erythromycin 0.5-1 g i.v. slowly 6 hourly + cefotaxime 1 g i.v. 8 hourly or ceftriaxone 1 g i.v. 
once daily or benzylpenicillin 1.2 g i.v. 4-6 hourly + gentamicin 5-7 mg/kg i.v. daily 

Children: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly + cefotaxime 50 mg/kg to 2 g i.v. 6-8 
hourly or ceftriaxone 50 mg/kg to 2 g i.v. once daily or chloramphenicol 75 mg/kg/d to 3 g/d i.v. in 3 divided doses 

Focns Probably Biliary or Gastrointestinal Tract (Including Ascending Cholangitis): gentamicin 
(< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose (adjust dose for renal function) + 
metronidazole 12.5 mg/kg to 500 mg i.v. infused over 20 min 12 hourly or 1 g (< 12 y: 500 mg) rectally 8-12 hourly + 
amoxy(ampi)cillin 50 mg/kg to 2 g i.v. 6 hourly; clindamycin 600 mg i.v. 8 hourly (child > 1 mo: 15-40 mg/kg daily in 
divided doses) + gentamicin as above; when afebrile, change to amoxycillin-clavulanate 22.5/3.2 mg/kg to 875/125 mg 
orally for total of 7 d 

Elderly Patients With Diminished Renal Fnnction, Significantly Elevated Sernm 
Creatinine or Other Contraindication to Gentamicin: piperacillin-tazobactam 100/12.5 mg/kg to 4/0.5 g i.v. 8 
hourly or ticarcillin-clavulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly 

Penicillin Hypersensitive (Not Immediate): metronidazole 12.5 mg/kg to 500 mg i.v. 12 hourly 
+ ceftriaxone 25 mg/kg to 1 g i.v. once daily or cefotaxime 25 mg/kg to 1 g i.v. 8 hourly 

Immediate Penicillin Hypersensitivity: substitute vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 
1 g 12 hourly by slow infusion (monitor blood levels and adjust dose accordingly) for amoxy/ampicillin 

Focns Probably Urinary Tract: amoxy(ampi)cillin 50 mg/kg to 2 g i.v. 6 hourly + gentamicin (< 10 y: 
7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose (adjust dose for renal function) 

Penicillin Hypersensitive: gentamicin alone 

Aminoglycoside Contraindicated: ceftriaxone 50 mg/kg to 1 g i.v. once daily, cefotaxime 
50 mg/kg to 1 g i.v. 8 hourly 

Focns Probably Open Skin Infection/Cellnlitis: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly; if 
penicillin hypersensitive, cephalothin 50 mg/kg to 2 g i.v. 6 hourly or cephazolin 50 mg/kg to 2 g i.v. 8 hourly if not 
immediate, or clindamycin 10 mg/kg to 450 mg i.v. or orally 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly or 
vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. 12 hourly by slow infusion (monitor blood levels and adjust dose 
accordingly) 

Children < 4 y with Facial or Periorbital Cellulitis: as above + cefotaxime 50 mg/kg to 2 g 
i.v. 8 hourly or ceftriaxone 50 mg/kg to 2 g once daily or chloramphenicol 75 mg/kg/d to maximum 3 g/d i.v. in 3 divided 
doses 

Focus Probably Decubitus or Ischaemic Ulcer or Diabetic Foot Infection: surgical debridement of 
necrotic tissue; piperacillin + tazobactam 4 + 0.5 g i.v. 8 hourly, ticarcillin-clavulanate 3/0.1 g i.v. 6 hourly, meropenem 
500 mg i.v. 8 hourly; if penicillin hypersensitive, ciprofloxacin 400 mg i.v. or 750 mg orally 12 hourly + clindamycin 
900 mg i.v. 8 hourly by slow infusion or lincomycin 900 mg i.v. 8 hourly by slow infusion 

Focus Probably Intravascular Device (Including Central Venous Lines): remove and culture 
cannula; di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly for 2 w + gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; 
adult: 4-6 mg/kg) as single daily dose (adjust dose for renal function) 

Penicillin Hypersensitive (Not Immediate): substitute cephalothin 50 mg/kg to 2 g i.v. 6 
hourly or cephazolin 50 mg/kg to 2 g i.v. 8 hourly for di/flucloxacillin 

Immediate Penicillin Hypersensitivity or NIRSA a Possibility: substitute vancomycin 25 
mg/kg (< 12 y: 30 mg/kg) to 1 g i.v. slowly 12 hourly (monitor blood levels and adjust dose accordingly) for 
di/flucloxacillin 

Elderly, Diminished Renal Function: flucloxacillin + cefotaxime 1-2 g i.v. 8 hourly or 
ceftriaxone 1-2 g i.v. once daily 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 
Unidentified Sonrce: 

Normal Adnlt: gentamicin 4-6 mg/kg i.v as single daily dose (adjust dose for renal function) + 
di(flu)cloxacillin 2 g i.v. 4-6 hourly or (if non-immediate penicillin hypersensitivity) cephalothin 2 g i.v. 6 hourly or 
cephazolin 2 g i.v. 8 hourly or (immediate penicillin hypersensitivity) vancomycin 25 mg/kg to 1 g i.v. by slow infusion 12 
hourly (monitor blood levels and adjust dose accordingly) 
Child: 

Meningitis Not Exclnded: 

< 6 mo: amoxy/ampicillin 50 mg/kg i.v. 6 hourly + cefotaxime 50 mg/kg i.v. 6 
hourly + (if pneumococcal meningitis likely) vancomycin 15 mg/kg i.v. 6 hourly by slow infusion (monitor blood levels and 
adjust dose accordingly) 

> 6 mo: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly + cefotaxime 50 mg/kg to 
2 g i.v. 6 hourly or ceftriaxone 100 mg/kg to 4 g i.v. daily or 50 mg/kg to 2 g i.v. 12 hourly + (if pneumococcal 
meningitis is likely) vancomycin 15 mg/kg to 500 mg i.v. 6 hourly by slow infusion (monitor blood levels and adjust dose 
accordingly) 

Meningitis Exclnded: 

< 4 mo: amoxy/ampicillin 50 mg/kg i.v. 6 hourly + gentamicin 7.5 mg/kg i.v. 
daily (adjust dose for renal function) 

> 4 mo: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly + cefotaxime 25 mg/kg to 
1 g i.v. 6 hourly or ceftriaxone 25 mg/kg to 1 g i.v. daily 

Febrile Nentropenic Patients: ceftazidime 50 mg/kg to 2 g i.v. 8 hourly, piperacillin + 
tazobactam 100 + 12.5 mg/kg to 4 + 0.5 g i.v. 8 hourly, gentamicin 4-6 mg/kg (< 10 y: 7.5 mg/kg; child > 10 y: 6 
mg/kg) i.v. daily (adjust dose for renal function) + ticarcillin-clavulanate 50/1.7 mg/kg to 3/0.1 g i.v. 6 hourly; + (if 
Gram positive organism resistant to other agents isolated or clinical progression) vancomycin 25 mg/kg (< 12 y: 30 mg/kg) 
to 1 g i.v. 12 hourly by slow infusion (monitor blood levels and adjust dose accordingly) 
In every case, institute appropriate specific therapy as soon as laboratory results are available: 

Salmonella: amoxycillin 1 g i.v. 6 hourly (< 20 kg: 25-50 mg/kg daily in divided doses), chloramphenicol 
500 mg orally 6 hourly (child > 2 w: 50 mg/kg/d orally in 4 divided doses; premature, newborn and those with immature 
metabolism: 25 mg/kg/d in 4 divided doses), cotrimoxazole 160/800 mg i.v. or orally (6 w - 5 mo: 20/100 mg i.v.; 6 mo - 
5 y: 40/200 mg i.v.; 6-12 y: 80/400 mg) 12 hourly (severe infection in child: 6/30 mg/kg i.v. daily in 2 divided doses), 
ofloxacin 

Shigella: ampicillin 200 mg/kg i.v. in divided doses daily + gentamicin 1.3 mg/kg i.v. 8 hourly 

Other Gram Negative Enteric Bacteria: gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 
4-6 mg/kg) i.v. daily (adjust dose for renal function), ceftriaxone 50 mg/kg to 1 g i.v. daily, cefotaxime 50 mg/kg to 1 g 
i.v. 8 hourly 

Staphylococci: careful investigation to determine if associated endovascular or metastatic focus 

Penicillin Snsceptible Staphylococcus aureus: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 
hourly 

Penicillin Resistant Methicillin Snsceptible Staphylococcus aureus: di(flu)cloxacillin 
50 mg/kg to 2 g i.v. 6 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 
hourly, cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Methicillin Resistant Staphylococcus aureus, Coagnlase Negative Staphylococci, 
Immediate Penicillin Hypersensitivity: vancomycin 25 mg/ kg (< 12 y: 30 mg/kg) to 1 g i.v. 12 hourly over 
60 min (monitor blood levels and adjust dose accordingly) 

Streptococcus pneumonia: broad spectrum cephalosporin + vancomycin until sensitivities available 

Burkholderia pseudomallei: cotrimoxazole + ceftazidime or meropenem or imipenem 

Rnaerobiospirillum succiniciproducens: cephamandole 1 g every 8 h 

Neisseria meningitidis: i.v. fluids, oxygen and ventilation support, inotropic agents if fluid resuscitation 
unsuccessful, dexamethasone 0.6 mg/kg/d in 4 divided doses if cerebral edema and increased intracranial pressure; 
activated protein C; benzylpenicillin (< 1 y: 300 mg; 1-9 y: 600 mg; > 10 y: 1200 mg) i.v. or i.m. before hospital transfer, 
then 45 mg/kg to 1.8 g i.v. 4 hourly for 3-5 d 

Penicillin Hypersensitive (Not Immediate) or Remote Areas: ceftriaxone 50 mg/kg to 2 g 
i.v. immediately, then ceftriaxone 100 mg/kg to 4 g i.v. daily, 50 mg/kg to 2 g i.v. 12 hourly for 3-5 d or cefotaxime 
50 mg/kg to 2 g i.v. 6 hourly for 3-5 d 

Capnocytophaga canimorsus, Leptotrichia buccalis: penicillin 

Pseudomonas aeruginosa: ticarcillin-clavulanate 50/1.7 mg/kg to 3/0.1 g 4 hourly + gentamicin (< 10 y: 
7.5 mg/kg; child > 10 y: 6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 
Penicillin Hypersensitive (Not Immediate Hypersensitivity): ceftazidime 50 mg/kg to 2 g 
i.v. 8 hourly by infusion over 30 minutes or cefepime 50 mg/kg to 2 g i.v. 12 hourly or cefpirome 50 mg/kg to 2 g i.v. 12 
hourly + gentamicin as above 

Immediate Penicillin Hypersensitivity: ciprofloxacin 10 mg/kg to 400 mg i.v. 12 hourly + 
gentamicin as above 

Burkbolderia cepacia: imipenem 

Rlcaligenes xylosoxidans: cotrimoxazole, ciprofloxacin 

Leuconostoc: high dose penicillin, clindamycin; removal of intravascular catheters when appropriate 

Oerskovia: ampicillin + cotrimoxazole 

Bacillus, Bothia mucilaginosa, Corynebacterium jeikeium, Corynebacterium striatum, 
Corynebacterium urealyticum: vancomycin 500 mg i.v. over 60 minutes 6 hourly (child: 44 mg/kg i.v. daily in 
divided doses over 60 minutes) + carbapenem 

Yersinia enterocolitica, Campylobacter fetus snbsp fetus, Methylobacterium extorquens, 
Rgrobacterium tumefaciens: gentamicin 1.3 mg/kg (child 1.5-2.5 mg/kg) i.v. 8 hourly + amoxycillin-clavulanate, 
piperacillin, cotrimoxazole, rifampicin, fluoroquinolone 

Other Campylobacter, ciprofloxacin 

Stenotrophomonas maltophilia, Ochrobacterium antropi: cotrimoxazole 

Rcinetobacter. colistimethate sodium 2.5 mg/kg to 300 mg i.v. 12 hourly 

Enterococcus: ampicillin + gentamicin (streptomycin if high level resistance to gentamicin and streptomycin 
susceptible); vancomycin 

Vibrio: doxycycline 100 mg orally or i.v. twice daily + ceftazidime 2 g i.v. 3 times a day or ciprofloxacin 
400 mg twice a day for 3 d or gentamicin 

Candida albicans: fluconazole 10 mg/kg to 400 mg i.v. once daily till clinical improvement, then 10 mg/kg to 
400 mg orally daily to complete total of at least 2 w 

Other Fnngi: catheter removal + amphotericin B desoxycholate 0.5-1 mg/kg in glucose 5% i.v. infusion 
(preferably through a central line) slowly over 2-6 h (following test dose) once daily till clinical improvement then 
fluconazole 10 mg/kg to 400 mg orally daily for at least 14 d or {Candida krusei, Candida glabrata) voriconazole or 
caspofungin 
Prophylaxis: 

Post-Splenectomy: asplenic children and children with sickle cell anemia < 5 y, first 2 y following 
splenectomy, patients with severe underlying immunosuppression 

< 24 mo Old: amoxycillin 20 mg/kg orally once daily, phenoxymethylpenicillin 125 mg orally twice 
daily 

> 2 y Old: amoxycillin 250 mg orally once daily, phenoxymethylpenicillin 250 mg orally 12 hourly 
Penicillin Hypersensitive: roxithromycin 4 mg/kg to 150 mg orally once daily, 
erythromycin 250 mg orally once daily, erythromycin ethyl succinate 400 mg orally daily 

Neisseria meningitidis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose (preferred if pregnant), 
ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), rifampicin 10 mg/kg 
(< 1 mo: 5 mg/kg) to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver disease; preferred for children); 
vaccines (quadrivalent polysaccharide, quadrivalent conjugate, and serogroup conjugate) available 

Cirrhotic Patient with Gastrointestinal Bleeding: norlfloxacin 400 mg orally commencing 1 h before 
endoscopy and then 12 hourly for 1-2 d or if oral therapy not feasible ciprofloxacin 400 mg i.v. at time of induction and 
then 12 hourly for 1-2 d 

Streptococcus pneumonia: pneumococcal polysaccharide vaccine recommended to adults > 65 y, individuals 
> 2 y with chronic illness, anatomic or functional asplenia, immunocompromise (disease, chemotherapy, steroids), HIV 
infection, environment or settings with increased risk, or cochlear implants; pain, swelling and redness at injection site in 
30-50%, fever and muscle aches in < 1%, rare severe reactions; revaccination after 5 y for > 2 y with functional or 
anatomic asplenia, immunsuppression, malignancy, transplant, chronic renal failure, nephritic syndrome, HIV infection, chronic 
systemic steroids, or < 65 y at time of first vaccination; pneumococcal conjugate vaccine recommended for routine 
vaccination of children < 24 mo and 24-59 mo with high risk medical conditions; pain, swelling and redness at injection site 
in 10-20%; reduces invasive disease due to serotypes in the vaccine by 97% and to those not in the vaccine by 89% 
Septicemic Adrenal Hemorrhage Syndrome (Adrenal Hemorrhage Syndrome, Sepsis Acutissima 
Hyperergica Fulminans, Septicemic Adrenal Hemorrhage): fulminating, usually fatal, form of septicemia; 
mechanism not clearly understood 

Agent: usually Neisseria meningitidis (fulminating purpuric meningococcemia, Marchand-Waterhouse-Freiderichsen syndrome, 
meningococcal hemorrhagic adrenalitis, meningococcal adrenal syndrome, Waterhouse-Friderichsen syndrome); also 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus, Haemophilus influenzae, Pseudomonas aeruginosa, several 

members of Enterobacteriaceae 

Diagnosis: sudden onset of fever, chills, myalgia, vomiting, headache, cyanosis/hemorrhage of skin and mucous 

membranes, bilateral adrenal hemorrhage, disseminated intravascular coagulation and shock; blood cultures 

Treatment: supportive; antimicrobials depending on agent 

Subacute Febrile Disease 

Agents: streptococci (mainly Streptococcus viridans), any bacterium 

Diagnosis: blood cultures 

Treatment: dependent on isolate 

Chronic and Sub-acute Fever 

Agents: Candida albicans, Candida lusitaniae (in immunocompromised), Cryptococcus neoformans, Histoplasma capsulatum 

Diagnosis: blood cultures (DuPont Isolator, Bactec); moderate anemia (normochromic normocytic becoming hypochromic); 

raised ESR 

Treatment: amphotericin B 0.75 mg/kg i.v. daily for 2-4 w + flucytosine 25 mg/kg i.v. or orally 6 hourly for 2 w; 

fluconazole 800 mg/kg orally or i.v. initially, then 400 mg daily 

Sweating Disease (Miliary Fever, Sweating Sickness): acute febrile infectious disease; no reference in literature 

during past 25 years 

Agent: ? Chlamydia 

Diagnosis: profuse sweating and formation of numerous papules 

Treatment: presumably, doxycycline or erythromycin 

Pseudobactereihia: 11% of nosocomial epidemics; 55% contaminated during specimen collection, handling and processing 

(non-sterile blood collection tubes, cross contamination by obtaining blood culture and other specimens from same 

venipuncture, contaminated skin preparation material, contaminated blood culture tube holders, contaminated commercial 

culture media, contaminated commercial radiometric analyser, contaminated tincture of thiomersal used to sterilise blood 

culture bottle tops, inadequately sterilised integral stoppers, other contaminated equipment, disinfectants and vascular 

catheters) 

Agents: variety of organisms, including Rerococcus viridans, Burkholderia cepacia, Stenotrophomonas maltophilia 

Transfusion Reactions Due to bacterial Contamination of Blood and Blood Products: mortality 35% 

Agents: wide range of bacteria, most commonly Pseudomonas fluoresces and other Pseudomonas species 

Diagnosis: 80% fever, 53% chills, 37% hypotension, 26% nausea/vomiting; smear and culture of transfused product at 4°C, 

25°C and 35°C; culture of patient's blood 

Treatment: antimicrobials as suggested by smear 

Endotoxineihia 

Agents: Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter agglomerans 

Diagnosis: fever, chills; limulus test, SimpliRED endotoxin agglutination test 

Treatment: supportive; removal of contaminated equipment (eg, hemodialysis); polymxyin B 

Toxic Shock Syndrome (Tampon Disease, TSS): a characteristic generalised toxemia associated with toxin production 

at a carrier site (including, notably, the vagina) or in a local lesion; case-fatality rate 3% 

Agent: toxin-producing strains of Staphylococcus aureus, associated with tampons, barrier contraceptives, postpartum, 

surgical wound infections, focal staphylococcal infections, nasal surgery, sinusitis, influenza in children; also due to 

Streptococcus pyogenes (mainly associated with cellulitis, varicella and use of non-steroidal antiinflammatory drugs); cases 

due to Campylobacter intestinalis, Streptococcus agalactiae and Streptococcus cam's reported 

Diagnosis: 

Staphylococcal: fever > 38.9°C in all cases; generalised scarlatiniform (diffuse macular erythematous) skin 
rash in all cases; mild skin desquamation (particularly of palms and soles) in convalescence (1-2 w after onset of illness) in 
all cases; hypotension, tachycardia, myocarditis, pericarditis, tachyarrhythmia in 91-95%; diarrhoea or vomiting at onset of 
illness, ileus, melena, hepatomegaly, hepatic necrosis, acute pancreatitis, acute abdomen in 42-62%; disorientation, 
meningismus, coma, seizure, cerebral edema in 24-50%; profound myalgia or arthralgia lasting > 5 d in 25-52%; tachypnoea, 
pleural effusion, pleural edema, acute respiratory distress syndrome in 24-33%; pharyngitis or conjunctivitis lasting > 5 d, 
strawberry tongue in 21-29%; oliguria, azotemia, acute tubular necrosis, acute renal failure in 0-17%; vaginal, oropharyngeal, 
conjunctival hyperemia, vulvar edema; late sequelae: nail or hair loss, delayed venous capillary filling in 45-56%, impaired 
memory or concentration, ataxia, dysarthria in 38-67%, neuromyasthenia, chronic fatigue in 33-54%, menstrual irregularity, 
menorrhagia, dysmenorrhoea in 25-31%, cardiomyopathy, congestive heart failure, recurrent syncope in 0-23%, chronic 
diarrhoea, weight loss, anorexia; electrocardiogram (decreased voltage and ST-T wave changes in 20% of cases, new gallop 
rhythms in 5%); elevated blood urea nitrogen (> 2X upper limit normal in 52% of cases), serum creatinine (> 2X ULN in 
52%), bilirubin (> 1.5X ULN in 54%), creatine phosphokinase (> 2X ULN in 59%), SGOT (> 2X ULN in 42%), SGPT (> 2X 

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Wound and Soft Tissue Infections, Local and Generalised Sepsis 

ULN in 42%); white cell count with marked left shift, platelet count low in first week (< 100,000/|oL in 42%), usually high 
in second week (> 400,000/jo.L in 27%); urinalysis (> 5 leucocytes/hpf, > 1 erythrocyte/hpf and protein 
> 1+ in 88%); isolation of Staphylococcus aureus from cervical or vaginal swabs confirmatory but never diagnostic; tests 
for toxin production not suitable for routine laboratory use; negative tests for blood (bacteremia in < 3%), throat, CSF 
cultures and serological tests for Rocky Mountain spotted fever, leptospirosis and measles 

Streptococcal: severe pain, fever, shock, hypotension, renal impairment, coagulapathy, liver involvement, adult 
respiratory disease, generalised erythematous rash (less likely), soft tissue necrosis; blood cultures positive in 60% 
Differential Diagnosis: mild forms of toxic epidermal necrolysis (absence of Nikolsky's sign in TSS), Kawasaki 
syndrome, staphylococcal scarlet fever (skin biopsy, serologic evidence of exfoliatin), streptococcal scarlet fever (ASOT), 
Rocky Mountain spotted fever (petechial rash), leptospirosis, meningococcemia (petechial or purpuric rash), Stevens-Johnson 
syndrome 
Treatment: 

Staphylococcus aureus: remove tampon; administer fluid replacement therapy; search for possible sites of 
infection (culture from vagina, oropharynx, conjunctiva, wounds, blood and urine) 

Methicillin Sensitive: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 
hourly, cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Methicillin Resistant, Immediate Penicillin Hypersensitivity: vancomycin 500 mg i.v. 6 
hourly over 60 minutes (child: 44 mg/kg i.v. daily in divided doses) 

Streptococci: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly + clindamycin 15 mg/kg to 600 mg i.v. 8 hourly 
or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly; normal immunoglobulin 0.4-2 g/kg i.v. for 1 or 2 doses in first 72 h 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 hourly, 
cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Campylobacter intestinalis: erythromycin 
Tetanus (Lockjaw): 2 notified cases in Australia in 1999; incidence 0.04/100,000 in USA; case-fatality rate 0.5 or higher 
in general tetanus and 0.01 in local form; neonatal tetanus (tetanus neonatorum, tetanus of the newborn), contracted through 
contamination of umbilical cord or stump, kills at least 800,000 worldwide each year; transmission by contamination of 
wound (most frequently, puncture wound; on rare occasions, surgical wound, usually due to faulty sterilisation; 10-20% of 
cases no wound implicated; 5-10% minor wound or only chronic skin lesions); incubation period few days to several weeks 
Agent: Clostridium tetani (exotoxin) 

Diagnosis: general: spasms of voluntary muscles and episodes of respiratory arrest; local: spasms and muscular rigidity 
near site of wound (may progress to general); neonatal: usually towards end of first week of life, dysphagia, spasms of 
facial and neck muscles leading to generalised convulsions and rigidity and death from spasms of respiratory muscles; Gram 
stain and culture of pus or tissue scrapings; although presence of Clostridium tetani is not significant in a fully immunised 
individual, other Clostridium species of very similar morphology may be found in wounds, and diagnosis of tetanus will 
probably be obvious clinically before it is made in the laboratory, the presence of Gram positive bacilli with typical 
drumstick morphology of Clostridium tetani in primary Gram stain or on culture should be reported immediately to the 
attending clinician 

Treatment: 500-1000 U human tetanus immunoglobulin i.m. or 10 000 U anti-tetanus serum i.v. (? intrathecal tetanus 
immunoglobulin) + benzylpenicillin 10 MU (child: 50 000-250 000 U/kg) daily i.v. in 4 divided doses for 4 d or 
cephalosporin or erythromycin (? + prednisolone 40 mg/d orally for 10 d); pyridoxine 100 mg/d; wound debridement 
Prophylaxis: highly effective vaccine (3 s.c. injections tetanus-diphtheria toxoid in infancy, with booster doses every 
10 y); toxoid in wounded patients + tetanus immunoglobulin if immunisation history uncertain or 0-1 doses (also 2 doses if 
wound > 24 h old) 

Wound Myiasis (Traumatic Myiasis): infestation of wounds by larvae of certain flies 
Agents: Chrysomya megacephala, Cochliomyia hominivorax, Lucilia sericata, Musca domestica, Lucilia cuprina, Lucilia 
sericata, Phormia regina, Sarcophaga albiceps, Sarcophaga bullata, Sarcophaga carnaria, Peckia chrysostoma, Sarcophaga 
crassipalpis, Gasterophilus haemorrhoidalis, Sarcophaga misera, Sarcophaga peregrina, Blaesoxipha plinthopyga, Sarcophaga 
ruficornis, Sarcophaga tibialis, Wohlfahrtia vigil 
Diagnosis: direct visualisation of larvae 
Treatment: removal of larvae 



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Chapter 9 

Infections of the Cardiovascular System 

Aplastic Crisis 

Agent: human parvovirus B19 in persons with underlying hemolytic disorders 

Diagnosis: dot hybridisation, capture ELISA on serum (Biotrin and Dako 100% sensitivity and specificity), PCR 

Treatment: supportive 

Chronic Anemia 

Agent: human parvovirus B19 in immuncompromised (especially HIV/AIDS) 

Diagnosis and Treatment: as above 

Babesiosis (Piroplasihosis): America, Ireland, Scotland; transmitted by Ixodes tick (black-legged tick, sheep tick) that 

feeds on deer as an adult but on mice and man in immature stages 

Agent: Babesia bovis and Babesia divergens in splenectomised persons (usually fatal), Babesia microti in persons with 

intact spleen (usually self-limited) 

Diagnosis: organisms seen in erythrocytes in Giemsa stained blood films; serology by indirect fluorescent antibody titre; 

inoculation of patient's blood into splenectomised hamsters or guinea pigs, followed by microscopy of animal's blood 

Babesia bovis and Babesia divergens: rapid onset, fever, chills, jaundice, dark urine with hemoglobinuria, 
hypotension, severe anorexia, renal insufficiency 

Babesia microti: gradual onset, fever, chills, diaphoresis, myalgia, anemia, fatigue, headache, pulmonary 
complication (cough, acute respiratory distress; pulmonary edema on chest X-ray) 

Treatment: usually not necessary for patients with intact spleen; chloroquine phosphate 1.5 g orally initially followed by 
500 mg orally daily for 2 w or clindamycin 1.2 g i.v. 12 hourly (child: 20-40 mg/kg daily in 3 divided doses) or 600 mg 
orally 8 hourly for 7-10 d + quinine 600 mg orally 8 hourly (child: 25 mg/kg daily in 3 divided doses) for 7-10 d or 
pentamidine isethionate produce symptomatic improvement but do not reduce parasitemia; exchange transfusion reliably 
affects rapid reduction of parasite load 

(There have been a few reports of intaerythrocytic parasitoses with Nuttalia and Entopolypoides) 
Malaria (Ague, Cameroon Fever, Chagues Fever, Chills and Fever, Coastal Fever, Congestive 
Remittent Fever, Corsican Fever, Intermittent Bilious Fever, Intermittent Fever, Jungle Fever, 
Marsh Fever, Miasmatic Fever, Paludism, Remittent Congestive Fever, Remittent Gastric Fever, 
Tropical Fever): Africa, Southeast Asia, India, South America; 300-500 M clinical cases/y worldwide (2 M deaths/y); 
* 700 notified cases/y in Australia (« 42% in Queensland); incidence 0.9/100,000 in USA; case-fatality rate 4%; claimed to 
be responsible for 50% of all human deaths from disease since Stone Age; transmitted by female Anopheles mosquito bite 
and, occasionally, congenitally, by blood transfusion (most frequently Plasmodium malariae) and by syringes (especially in 
drug addicts); variable incubation period (not < 7 d); greatly increases risk of HIV infection and death from AIDS 
Agents: 73% Plasmodium vivax, 22% Plasmodium falciparum, 3% Plasmodium ovale, 2% Plasmodium malariae, 0.4% mixed; 
malaria due to simian Plasmodia — Plasmodium brasilianum, Plasmodium cynomolgi, Plasmodium inui, Plasmodium knowlesi, 
Plasmodium simium — is very rare, may be acquired in nature or the laboratory, and is of moderate severity 
Diagnosis: fever, chills, splenomegaly, decreased consciousness; sometimes dehydration, non-bloody diarrhoea, vomiting, 
jaundice, headache, muscle pains, anorexia; geographic history, transfusion or i.v. drug addict; Giemsa or Romanowski stain 
of thick and thin blood smears (3 in 48-72 h); indirect immunofluorescence when clinical diagnosis consistent with malaria 
but parasite not detected in thick blood films; dipstick antigen tests accurate when used by health professionals but not 
when used by travellers; indirect hemagglutination (experimental), immunodiffusion, ELISA (antibody); hyperbilirubinemia 
(total bilirubin 9.4 mg/dL), moderately elevated SGPT (15-56 U/mL) and SGOT, blood urea nitrogen 101 mg/dL, creatinine 
6.8 mg/dL, anemia (hematocrit 24%, hemoglobin 8.3 g, erythrocyte count decreased), thrombocytopenia (platelets 
180,000/nL) 

Congenital: fever in 100%, splenomegaly in 93%, irritability in 85%, hepatomegaly in 84%, icterus in 79% 

Vivax Malaria (Benign Tertian Malaria, Tertian Agne, Vivax Fever): usually non-fatal; incubation 
period 12-18 d; fever, headache, myalgia, malaise, nausea; after some time, paroxysms of fever and chills, ending in profuse 
sweating tend to occur every other day; tendency to relapse; sometimes associated with anemia, hepatomegaly and 
nonspecific hepatitis; occasionally complicated by spontaneous splenic rupture 

Falciparnm Malaria (Acnte Pernicions Fever, Aestivo-Antnmnal Fever, Aestivo-Antnmnal 
Malaria, Algid Malaria (Gastrointestinal Symptoms Predominate), Chagnes Fever, Continned Malarial 
Fever, Falciparnm Fever, Malignant Tertian Fever, Malignant Tertian Malaria, Pernicions 
Intermittent Fever, Pernicions Malaria, Plasmodium Falciparnm Malaria, Quotidian Malaria, 
Snbtertian Fever, Snbtertian Malaria Fever, Snbtertian Malignant Tertian Malaria, Tertian 
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Infections of the Cardiovascular System 

Malignant Malaria, Tropical Malaria): severe and, in nonimmune persons, rapidly fulminating; incubation period 8- 
15 d; high fever, chills, headache, myalgia, rapid pulse rate, splenomegaly, sometimes delirium; often a high level of 
parasitemia (to 72%) and capillary obstruction; initial fever may last several days, with some remissions; after initial illness, 
periodic pattern of paroxysms, with fever and chills, usually lasting 12-24 h and tending to be repeated every 48 h; coma, 
excessive destruction of erythrocytes, convulsions and heart failure may lead to death; the disease may produce very serious 
complications (cerebral malaria, hemoglobinuric falciparum malaria) and neurologic sequelae (memory impairment and diffuse 
white matter damage on magnetic resonance imaging) 

Ovale Malaria (Ovale Tertian Malaria, Plasmodinm Ovale Fever): relatively mild; incubation period 
12-18 d; clinical manifestations similar to those of vivax malaria but paroxysms of fever and chills less severe; after initial 
stage, paroxysms tend to occur every other day; recovery often spontaneous; relapses not unusual 

Malariae Malaria (Qnartan Malaria, Qnartan Agne, Qnartan Fever): incubation period 20-40 d; 
clinical manifestations similar to those of vivax malaria but paroxysms of fever and chills commonly occur at intervals of 

3 d; recovery often spontaneous but tendency for recrudescences to occur over many years; children may develop malarial 
nephropathy 

Differential Diagnosis: fever and chills can suggest acute viral or bacterial infection; jaundice, anemia and 
splenomegaly other causes of hemolytic anaemia; leucopoenia and thrombocytopenia hematolgic malignancy, other severe 
infections; proteinuria and edema other causes of nephrotic syndrome; acute renal failure other causes of acute renal failure; 
hepatosplenomegaly and lymphocytic infiltration of hepatic sinusoids lymphoma; altered mental status, seizures and coma 
viral or bacterial meningitis, encephalitis, Reye's syndrome; bilateral pulmonary infiltrates acute respiratory distress 
syndrome related to shock from various causes 
Treatment: 

Uncomplicated Plasmodium falciparum: artemether + lumefantrine (5-14 kg: 1 20 + 120 mg tablet; 15- 
24 kg: 2 tablets; 25-34 kg: 3 tablets; > 34 kg: 4 tablets) orally with fatty food at 0, 8, 24, 36, 48 and 60 h, quinine sulphate 
10 mg/kg to 600 mg orally 8 hourly for 7 d + doxycycline 2.5 mg/kg orally 12 hourly for 7 d (not in pregnant or < 8 y) 
or clindamycin 5 mg/kg to 300 mg orally 8 hourly for 7 d (in pregnant and < 8 y) 

Severe (Altered Conscionsness, Janndice, Olignria, Severe Anemia, Hypoglycemia, Vomiting, 
Acidotic, Parasite Connt > 100,000/mm 3 Or > 2% Erythrocytes Parasitised): artesunate 2.4 mg/kg i.v. 
immediately and repeated at 12 h and 24 h, then once daily until oral therapy possible, then as above; if parenteral 
artesunate not available, quinine dihydrochloride 20 mg/kg i.v. over 4 h or 7 mg/kg i.v. over 30 min then 10 mg/kg i.v. 
over 4 h, after 4 h 10 mg/kg i.v. over 4 h 8 hourly 

Others: chloroquine phosphate 10 mg/kg base to 620 mg orally as a single dose initially, then 5 mg/kg to 
310 mg at 6, 24 and 48 h (severe cases: 10 mg base/kg rate controlled i.v. infusion over 8 h, followed by 15 mg/kg over 
24 h or 3.5 mg base/kg i.m. or s.c. every 6 h until patient can take oral drugs) then primaquine 0.5 mg/kg base to 30 mg 
orally daily with food or, if nausea, 0.25 mg/kg to 15 mg orally 12 hourly with food for 14 d (Plasmodium vivaiij or 
0.25 mg/kg to 15 mg orally daily with food for 14 d (Plasmodium ovale) (avoid in persons with G6PD deficiency or, in mild 
cases, administer 45 mg base orally weekly for 6 w; avoid during pregnancy; not required in congenital or transfusion) 
Prophylaxis: 

Areas Withont Chloroqnine Resistant Plasmodium falciparum: chloroquine phosphate 5 mg/kg base 
to 310 mg orally once a week 1 w before entering to 4 w after leaving area, hydroxychloroquine sulphate 5 mg/kg base to 
310 mg once a week 2 w before entering to 4 w after leaving area; where chloroquine cannot be administered: proguanil 
hydrochloride (< 2 y: 50 mg; 2-6 y: 100 mg; 7-10 y: 150 mg; > 10 y: 200 mg) orally daily 1 d before entering to 4 w after 
leaving area, doxycycline 1 mg/kg to 100 mg (not < 8 y) orally daily 1 d before entering to 2 d after leaving area (short 
stay only), mefloquine 250 mg orally weekly 

Areas With Chloroqnine Resistant Plasmodium falciparum: atovaquone + proguanil (11-20 kg: 62.5 
+ 25 mg; 21-30 kg: 125 + 50 mg; 31-40 kg: 187.5 + 75 mg; > 40 kg: 250 + 100 mg) orally with fatty food daily 1-2 d 
before entering to 7 d after leaving area, doxycycline 2.5 mg/kg to 100 mg orally daily (not < 8 y) 2 d before entering to 

4 w after leaving area, mefloquine (5-9 kg: 31.25 mg; 10-19 kg: 62.5 mg; 20-29 mg: 125 mg; 30-44 kg: 187.5 mg; 

> 44 kg: 250 mg) orally weekly 2-3 w before entering to 4 w after leaving area, proguanil (< 2 y: 50 mg; 2-6 y: 100 mg; 
7-10 y: 150 mg; >10 y: 200 mg) orally daily 1 w before entering to 4 w after leaving area + chloroquine 5 mg base/kg to 
310 mg base orally weekly 1 w before entering to 4 w after leaving area if others contraindicated or not tolerated 

To Prevent Delayed Attacks of Plasmodium vivax and Plasmodium ovale: primaquine 0.3 mg/kg 
to 15 mg daily for 14 d or 0.9 mg/kg to 45 mg weekly for 8 w (tafenoquine may replace) 

Personal Protective Measnres: wear light coloured long-sleeved shirts and long trousers in the evening; 
apply insect repellent containing not more than 35% die thylme tato luamide sparingly to exposed skin; at dusk, spray 
aerosolised "knock down' insecticide (eg., containing pyrethrins) in living and sleeping areas; sleep in a screened or air 
conditioned room or use bed netting of small mesh and good quality that is not damaged and is, preferably, impregnated 



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Infections of the Cardiovascular System 

with permethrin; use mosquito coils or electrically operated insecticide generators containing pyrethroids; avoid outside 
activities between dusk and dawn; avoid stagnant water; avoid perfume and aftershave 
Prevention and Control: mosquito control, treatment of cases 
Myocarditis and Pericarditis 

Agents: human coxsackievirus B2-B5 (myocarditis of the newborn, interstitial myocarditis and valvulitis in infants and 
children, pericarditis; > 50% of all cases), human coxsackievirus A, human echovirus 6, 19, several arboviruses, mumps virus 
(in 0.04% of mumps cases; may be fatal or followed by endocardial fibroelastosis), measles virus, influenza A virus, influenza 
B virus, adenovirus (common in paediatric HIV infection), human cytomegalovirus (common in pediatric HIV infection), 
rubella, human hepatitis A virus, hepatitis B virus, simplexvirus 3, rabies virus, Lassa virus, human parvovirus B19 (in 
infants and heart transplant recipients), Epstein-Barr virus, Neisseria meningitidis (4% of purulent pericarditis), Haemophilus 
influenzae (3% of purulent pericarditis), Pseudomonas aeruginosa, Campylobacter jejuni, Staphylococcus aureus (23% of 
purulent pericarditis), Actinobacillus actinomycetemcomitans (rare), group C Streptococcus (rare), Yersinia enterocolitica, Q 
fever, Listeria monocytogenes (cardiac transplantation and others), Actinomyces (rare), Mycoplasma pneumoniae, Mycoplasma 
hominis, Ureaplasma urealyticum, Rocky Mountain spotted fever (in 5% of infections), Corynebacterium diphtheriae (toxic 
manifestation occurring 2 d - 1 mo after onset of, especially, pharyngeal diphtheria), Mycobacterium tuberculosis, 
Streptococcus pneumoniae (33% of purulent pericarditis), Rickettsia helvetica, Haemophilus aphrophilus (rare), Streptococcus 
pyogenes (11% of purulent pericarditis), other Gram negative organisms (19% of purulent pericarditis), anaerobes (2% of 
purulent pericarditis), Candida (cardiac surgery, impaired host defences, severe debilitating disease), Aspergillus (pericarditis 
in 4% of disseminated cases), Trichinella spiralis (rare) 

Diagnosis: viral culture of throat swab, feces, myocardium; serology; immunofluorescent antibody test on impression smear 
of myocardium; PCR of endomyocardial biopsy; bacterial and fungal culture of pericardial fluid or pericardium; histology of 
pericardium; latex agglutination and counterimmunoelectrophoresis of serum and pericardial fluid; blood cultures; when 
hemorrhagic pericardial effusions of undetermined cause are determined, the heart and great vessels should be evaluated as 
potential sources of the hemorrhage 

Human parvovirus B19: PCR; bone marrow biopsy (pure red cell aplasia, giant proerythroblasts, vacuolisation 
of cytoplasm and intranuclear inclusions in paltry surviving precursors) 

Diphtheric Myocarditis: thready pulse, faint heart sounds, cardiac arrhythmia; cardiac failure may occur 

Pericardial Actinomycosis: 68% dyspnoea, 68% pleural effusion, 63% tachypnoea, 63% cough, 58% 
hepatomegaly, 53% fever, 53% chest pain 
Treatment: 

Influenza Virns: i.v. ribavirin 

Human parvovirus B19: human immunoglobulin 0.5-1 g/kg/d i.v. for 4-5 d, erythropoietin 

Other Virnses: non-specific 

Actinomyces: benzylpenicillin 12-20 MU/d i.v. for 4-6 w, then phenoxymethylpenicillin or amoxycillin 2-4 g/d 
orally for 6-12 mo; tetracycline or erythromycin + rifampicin 300 mg/d; clindamycin; chloramphenicol; third generation 
cephalosporin 

Neisseria meningitidis, Streptococci: benzylpenicillin 

Haemophilus influenzae, Listeria monocytogenes: ampicillin 

Pseudomonas aeruginosa: azlocillin + tobramycin 

Campylobacter jejuni: erythromycin 

Staphylococcus aureus: vancomycin 

Rctinobacillus actinomycetemcomitans, Rickettsia: tetracycline, chloramphenicol 

Coxiella burnetii: doxycycline, tetracycline, erythromycin, rifampicin 

Yersinia enterocolitica: pefloxacin 400 mg twice daily + tobramycin 75 mg twice daily 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) + prednisone 40-80 mg daily, decreasing over several weeks 

Mycoplasma, Ureaplasma: tetracycline, erythromycin 

Candida: amphotericin B + pericardiectomy 

Aspergillus: itraconazole, amphotericin B 

Trichinella spiralis: albendazole, mebendazole 



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Infections of the Cardiovascular System 

Prophylaxis (Neisseria meningitidis) ceftriaxone 250 mg (child 125 mg) i.m. as single dose (preferred if pregnant), 

ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), rifampicin 10 mg/kg 

to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver disease; preferred for children) 

Carditis 

Agents: adenovirus, human echovirus 7, 11, 30, poliovirus, Streptococcus pyogenes (rheumatic fever; carditis due to host 

immune response and local cross-reactive antigen; < 200 cases/y in USA); highest incidence in 3-4 y group 

Diagnosis: 

Viral: isolation from infected tissue 

Rheumatic Fever: carditis in 40-50% of cases, polyarthritis in 75%, chorea in 15%, erythema marginatum in 
10%, subcutaneous nodules, previous rheumatic fever or rheumatic heart disease, arthralgia, fever; acute phase reactants; 
prolonged PR interval; heart murmurs (tend to be variable from day to day), cardiac enlargement, pericardial friction rub, 
tachycardia persisting during sleep, congestive cardiac failure; recent scarlet fever; anti-streptolysin test (normal in « 20% 
of early cases; peaks at 2-4 w; false positives due to activity of other substances neutralising hemolytic properties of 
streptolysin (eg., serum (3 -lipoprotein in liver disease) and bacterial growth in serum specimens), anti-DNAse B test 
(consistently elevated; rises later than ASOT, peaks at 4-6 w and remains elevated longer than ASOT; magnitude of response 
may be suppressed by antimicrobial therapy; detergents, heavy metals, azide and other chemicals interfere with enzyme and 
colour reaction), anti-hyaluronidase, anti-streptozyme (almost all patients have levels > 200 U); culture of nasal and throat 
swabs and swab of impetiginous lesions 
Treatment: 

Viral: non-specific 

Rheumatic Fever: benzathine penicillin 1.2 MU (child: 600 000 U) i.m. once as a single dose, 
phenoxymethylpenicillin 250 mg orally 8 hourly for 10 d, or erythromycin 250 mg orally 6 hourly (child: 40 mg/kg/d in 4 
divided doses) for 10 d for initial attack, followed by continuous, long term (well into adulthood, perhaps life-long) 
benzathine penicillin 900 mg (< 20 kg: 450 mg) i.m. every 3-4 w, phenoxymethylpenicillin 250 mg orally 12 hourly, or 
erythromycin 250 mg orally 12 hourly or erythromcyin ethyl succinate 400 mg orally 12 hourly (penicillin hypersensitive); 
aspirin or non-steroidal anti-inflammatory drugs for synovitis/arthritis 

Endocarditis: 4% of community acquired and 1% of nosocomial bacteremia; commonly associated with aortic regurgitation, 
mitral regurgitation, congenital aortic stenosis (bicuspid valve), prosthetic heart valves, tricuspid regurgitation, ventricular 
septal defects, patent ductus arteriosus, coarctation of the aorta, arteriovenous fistula; native valves in 76% 
Agents: 31-46% oral streptococci {Streptococcus milled, Streptococcus mutans, Streptococcus salivarius, Streptococcus 
sanguis; 25-27% in late, and 1-6% in early, infections in prosthetic valve patients; 10% in drug addicts; 19% in recurrent 
episodes; 18% in children), 16% anaerobic and microaerophilic Gram positive cocci, 10-32% Staphylococcus aureus (50-61% in 
drug addicts; 7-20% in early, and 11-15% in late, infections in prosthetic valve patients; 26% in recurrent episodes; cause of 
> 50% of cases of acute progressive infective endocarditis; more frequent in children (37% of cases) and in elderly; involves 
previously normal valves in « 50% of cases; only cause of eustachian valve endocarditis; should be considered in any 
patient with staphylococcal bacteremia), 8-10 % enterococci (9% in late, and 3-4% in early, infections in prosthetic valve 
patients; 8% in drug addicts; 13% in recurrent episodes; 14% in bone marrow transplant recipients), 7-14% equines 
(associated with gastrointestinal lesion, especially colon carcinoma), 7-9% coagulase negative staphylococci (25-44% in 
prosthetic valve patients; 2% in drug addicts; 4% in recurrent episodes; 57% of cases in bone marrow transplant recipients; 
12% in children), 7% Gram negative bacilli (Pseudomonas (3% of primary, and 4% of recurrent, episodes; Pseudomonas 
aeruginosa 14% of cases in drug addicts, 4% in children; Pseudomonas alcaligenes in bone marrow transplant recipients; 
Burkholderia cepacia 0.6% in children, associated with cystic fibrosis and chronic granulomatous disease, also in injection 
heroin abusers and patients with prosthetic heart valves), Stenotrophomonas maltophilia (associated with i.v. drug abuse and 
prosthetic valve surgery), Haemophilus (1% of primary, and 2% of recurrent, episodes; oral source; Haemophilus influenzae 
0.6% in children; Haemophilus aphrophilus 0.6% in children; Haemophilus parainfluenzae 2% in children; Haemophilus 
paraphrophilus, Aggregatibacter segnis, Haemophilus aegytius); Kingella kingae (5-20% of early, and 10-18% of late, infections 
in prosthetic valve patients; also native valves); Prevotella melaninogenica (oral source; polymicrobial), Fusobacterium 
nucleatum and Fusobacterium necrophorum (oral source), Bacteroides, Brucella (1% in children), Cardiobacterium hominis (oral 
source), Rctinobacillus actinomycetemcomitans (oral source; associated with periodontitis and prosthetic valves), Eikenella 
corrodens (oral source), Yersinia enterocolitica, Flavobacterium meningosepticum (in rheumatic heart disease, open heart 
surgery and i.v. drug abuse), Salmonella enterica subsp enteric serotype paratyphi C, Salmonella choleraesuis and other 
Salmonella (54% AIDS patients, 34% oncology patients; also elderly with previous valvular heart disease; 70% fatality rate), 
Coxiella burnetii (0.6% in children; 17% chronic; 37% mortality), Chlamydophila pneumoniae, Legionella (prosthetic valves), 
Streptobacillus moniliformis (rare complication of rat bite fever), Mcaligenes (0.6% in children), Achromobacter xylosoxydans 
xylooxydans (catheter related in bone marrow transplant recipients), Campylobacter fetus subsp fetus (0.6% in children), 
Escherichia coli (3% in children; 47% previous heart disease; 47% from urinary tract; 47% nosocomial; 84% new or changing 
murmur; 58% mitral valve; case-fatality rate 53%), Proteus mirabilis (0.6% in children), other Enterobacteriaceae, Suttonella 

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Infections of the Cardiovascular System 

indologenes (rare), Moraxella osloensis, Acinetobacter cakoaceticus, Capnocytophaga canimorsus, Agrobacterium tumefaciens 
(prosthetic valve), Bordetella bronchiseptka, Aeromonas, Tropheryma whipplei), 3% Streptococcus pyogenes (1% in recurrent 
episodes; 0.6% in children) and other (3-haemolytic streptococci (including Streptococcus agalactiae (postpartum and 
postabortion, diabetics and alcoholics; 83% affecting native valve; case-fatality rate 44-47% overall, 100% if affecting 
prosthetic valve; 2% in recurrent episodes; 1% in children), Group C Streptococcus [Streptococcus zooepidemkus, 
Streptococcus equisimilis, rarely Streptococcus eqm) and Streptococcus cam's (rare)), 3% other streptococci (including 
Streptococcus pneumoniae), 2% Corynebacterium (especially Corynebacterium jeikeium (6-8% in early, and 2-4% in late, 
infections in prosthetic valve patients; 2% in drug addicts; 14% in bone marrow transplant recipients); Corynebacterium 
xerosis (0.6% in children; also in i.v. drug abusers with AIDS); Corynebacterium pseudodiphtheriticum (1% in children); non- 
toxigenic strains of Corynebacterium diphtheriae), 2% fungi (10% in drug addicts; 6-10% in early, and 2-6% in late, 
infections in prosthetic valve patients; mainly Candida (3% in recurrent episodes; 14% in bone marrow transplant recipients; 
Candida parapsilosis in i.v. drug addicts, invasive procedure, prosthetic devices, hyperalimentation, 0.6% in children; also 
Cryptococcus neoformans, Histoplasma capsulatum, Chrysosporium (associated with prostheses), Drechslera (post surgery for 
ventricular septal defect), Aspergillus (coronary artery surgery, liver transplantation); Aspergillus flaws 0.6% in children; 
Aspergillus fumigatus 0.6% in children), Pseudallescheria boydii (in prosthetic valves and in AIDS); rarely, Curvularia lunata), 
Neisseria gonorrhoeae (0.6% in children), Erysipelothrix rhusiopathiae (animal contact (slaughterhouse workers, fish handlers, 
butchers, farmers), alcohol abuse; case-fatality rate 38%), Listeria monocytogenes (complicating rheumatic fever or prosthetic 
heart valve, malignancy, immunosuppressed, following coronary artery bypass surgery; case-fatality rate 29%), Rothia 
dentocariosa (rare; i.v. drug abuse, poor dentition, congenital heart disease), Mycobacterium chelonae and Mycobacterium 
fortuitum (infecting prosthetic valves), Lactobacillus (very rare; oral source; usually patient with preexisting structural heart 
disease and recent dental infection or manipulation; mortality 5-25%), Propionibacterium acnes (oral source), Veillonella 
parvula (oral source; polymicrobial; rare), Neisseria mucosa (i.v. drug abuser; oral source), Neisseria sicca, Neisseria subflava 
(i.v. drug abusers with AIDS; oral source), Neisseria flavescens (i.v. drug abusers with AIDS), Neisseria elongata, Oerskovia 
(prosthetic valves), Rothia mucilaginosa (i.v. drug abusers, cardiac valve disease, vascular catheter, immunocompromised), 
Enterococcus faecalis (5% in children), Micrococcus (0.6% in children), Bacillus cereus (infrequent; valvular heart disease, i.v. 
drug abuse), Acinetobacter (rare), Actinomyces (rare), Staphylococcus lugdunensis (mainly community acquired, usually 
preexisting cardiac abnormality), Peptostreptococcus magnus (oral source), Aerococcus viridans (rare), Bartonella, Mycoplasma 
hominis, Pasteurella dagmatis, Yersinia enterocolitics, Cunninghamella bertholletiae (after kidney transplantation) 
Diagnosis: prior heart disease in 60-80%; constitutional symptoms in 90-100%, fever in 85-100%, heart murmur in 60-95%, 
emboli in 33%, petechiae in 30-79%, microscopic hematuria in 30-50%, heart failure in 25-66%, splenomegaly in 23-60%, 
mycotic aneurism in 2-11%; 2-dimensional echocardiogram (abnormalities in 34%; vegetations usual in Streptococcus viridans 
infections and in 40% of Q fever endocarditis; right bundle branch block in gonococcal endocarditis), colour flow Doppler 
technology, transesophageal echocardiography; blood cultures (take 3 sets before starting therapy; positive in 80%; bone 
marrow culture and combined arterial/venous blood cultures if negative); complement fixation tests, microagglutination tests, 
indirect fluorescent antibody titre, ELISA (antibody), counterimmunoelectrophoresis of serum; histology and PCR of diseased 
valves; elevated erythrocyte sedimentation rate in 90-100% of cases; total hemolytic complement decreased when 
glomerulonephritis also present; white cell count elevated in 20-66% of cases; rheumatoid factor in 50-80% of bacterial cases; 
anemia in 40-80% 

Staphylococcus aureus: right-sided usually involves tricuspid valve, occurs mainly in young users of injecting 
drugs but also as nosocomial infection associated with indwelling central venous catheters, and presents acutely with fever, 
chills, leucocytosis, bacteremia and with focal, rounded, sometimes cavitary infiltrates on chest radiograph; left-sided usually 
associated with community acquired bacteremia of unknown origin and carries high mortality 

Q Fever: work in abattoir or on farm; usually preceded by atypical pneumonia and acute hepatitis; fever in 67% 
of cases, cardiac failure in 66%, hepatosplenomegaly in 57%, increased y-globulin in 94%, increased ESR in 89%, increased 
SGOT in 83%, increased alkaline phosphatase in 80%, thrombocytopenia in 67%; serology (complement fixation test, indirect 
immunofluorescence); isolation from cardiac valves; liver biopsy 

Erysipelothrix rhusiopathiae: erysipeloid present in 36% 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, profuse 
sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; isolation; Brucella tube 
agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, complement fixation test, Coombs, 
fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 
Differential Diagnosis: acute rheumatic fever, marasmic endocarditis, systemic lupus erythematosus, vasculitis, atrial 
myxoma, atrial thrombus, hpyernephroma, carcinoid, human cytomegalovirus in patients recently having valve replacement 
Treatment: benzylpenicillin 45 mg/kg to 1.8 g i.v 4 hourly + di(flu)cloxacillin 50 mg/kg to 2 g i.v. 4 hourly + 
gentamicin 4-6 mg/kg ( child: < 10 y: 7.5 mg/kg; > 10 y: 6 mg/kg) i.v. daily (adjust dose for renal function) 

Nosocomial, Immediate Penicillin Hypersensitive, Patients with Prosthetic Valves, 
Commnnity-associated Methicillin Resistant Staphylococcus aureus Snspected: vancomycin 25 mg/kg to 1 

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Infections of the Cardiovascular System 

g ( child < 12 y: 30 mg/kg to 1 g) i.v. 12 hourly slowly over 60 min (monitor blood levels and adjust dose to trough 10-20 
mg/L) + gentamicin 4-6 mg/kg (child: < lOy: 7.5 mg/kg; > 10 y: 6 mg/kg) i.v. daily (monitor blood levels and adjust 
dose to trough 0.5-1 mg/L) + early removal and replacement of prosthesis 

Streptococci with Benzylpenicillin MIC < 0.12 mg/L: 

Uncomplicated: benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly for 14 d + gentamicin 1 mg/kg i.v. 
8 hourly for 14 d (monitor plasma levels); benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly for 4 w 

Complicated (Large Vegetation, Multiple Emboli, Symptoms > 3 mo, Secondary 
Sepsis): benzylpenicillin 45 mg/kg to 1.8 g i.v. 4 hourly for 4 w + gentamicin 1 mg/kg i.v. 8 hourly for 14 d (monitor 
plasma levels) 

Streptococci with Benzylpenicillin MIC > 0.12 & < 0.5 mg/L: benzylpenicillin 45 mg/kg to 1.8 g i.v. 

4 hourly for 4 w + gentamicin 1 mg/kg i.v. 8 hourly for 14 d (monitor palsma levels) 

Streptococci with Benzylpenicillin MIC > 0.5 bnt < 4 mg/L, Rbiotrophia, Granulicatella, 
Snsceptible Enterococci, Rothia dentocariosa, Cnltnre Negative Where Q Fever or Fnngal Infection 
Not snspected: gentamicin 1 mg/kg i.v. 8 hourly for 6 w (monitor plasma levels and adjust dose to trough 0.5-1 mg/L) 
or (in elderly) netilmicin 1 mg/kg i.v. 8 hourly for 14 d + benzylpenicillin 60 mg/kg to 2.4 g i.v. 4 hourly for 6 w or 
amoxy/ampicillin 50 mg/kg to 2 g i.v. 4 hourly for 6 w 

Streptococci With Benzylpenicillin MIC > 4 mg/L, Penicillin Hypersensitive: vancomycin 
25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 1 g) i.v. 12 hourly slowly over 60 min (monitor blood levels and adjust dose 
to trough 10-20 mg/L) for 4-6 w + gentamicin 1 mg/kg i.v. 8 hourly (monitor blood levels and adjust dose to trough 
0.5-1 mg/L for 4-6 w or (for elderly) netilmicin 1 mg/kg i.v. 8 hourly 

Vancomycin Resistant Enterococci: linezolid, quinupristin-dalfopristin 

Neisseria, Haemophilus parainfluenzas, Haemophilus aprophilus, Rctinobacillus 
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Mngella kingae: cefotaxime 
50 mg/kg to 2 g i.v. 8 hourly for 4 w or ceftriaxone 50 mg/kg to 2 g i.v. daily for 4 w 

Fusobacterium, Prevotella: metronidazole, tetracycline + lincomycin 

Brucella: streptomycin 1 g twice a day i.m. for 30 d + doxycycline 100 mg twice a day orally for 90 d + 
rifampicin 900 mg/d orally for 90 d + cotrimoxazole 5/25 mg/kg/d in 4 equally divided doses for 90 d, or oxytetracycline 
500 mg orally 6 hourly for 12 w + gentamicin 120 mg i.m. 8 hourly for 4 w; + surgery (valvular replacement with 
biprosthetic valve) 

Salmonella: ampicillin 2 g i.v. 6 hourly for 6 w (child: 150-200 mg/kg i.v. daily in divided doses) + 
gentamicin 1.3 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 hourly (trough < 1.5 mg/L) for 6 w; ciprofloxacin, ceftriaxone, cefotaxime 

Streptobacillus moniliformis, Rctinomyces: benzylpenicillin 12-20 MU (neonates: 500,000-1 MU; child: 
200,000-400,000 U/kg) i.v. daily in divided doses for 30 d 

Legionella: erythromycin 4 g i.v. daily in divided doses for 2-6 mo (consider change to 2 g orally daily after 
2 mo) + rifampicin 600 mg orally for up to 14 mo; ciprofloxacin 600 mg i.v. daily in divided doses + rifampicin 1200 mg 
orally daily for 10 w 

Flavobacterium meningosepticum: sulphadiazine + rifampicin 

Pseudomonas aeruginosa: azlocillin 3 g i.v 4 hourly (child: 225 mg/kg i.v. daily in 3 divided doses) + 
amikacin 5 mg/kg i.v. 8 hourly 

Burkholderia cepacia: cotrimoxazole ± polymyxin B + valvectomy or valve replacement 

Stenotrophomonas maltophilia: cotrimoxazole + ticarcillin + rifampicin 

Escherichia coli: ceftriaxone + aminoglycoside 

Rcinetobacter: polymyxin, ampicillin-sulbactam, imipenem, cefperazone-sulbactam 

Rlcaligenes: imipenem 

Bartonella: doxycycline 2.5 mg/kg to 100 mg doxycycline 12 hourly for 6 w (not < 8 y) + gentamicin 
1 mg/kg i.v. 8 hourly for 14 d or rifampicin 7.5 mg/kg to 300 mg orally 12 hourly for 14 d 

Other Gram Negative Bacilli: gentamicin 5 mg/kg i.v. daily (trough < 1.5 mg/L) for 6 w or tobramycin 

5 mg/kg daily for 6 w + ticarcillin for 4-6 w; early consultation with cardiovascular surgeon and clinical microbiologist or 
infectious diseases physician 

Staphylococci: early surgery + 
Left-sided: 

Methicillin Snsceptible: di/flucloxacillin 50 mg/kg to 2 g i.v. 4 hourly for 4-6 w 
Methicillin Resistant: vancomycin 25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 1 g) i.v. 
12 hourly over 60 min for 4-6 w (monitor blood levels and adjust dose to trough 10-20 mg/L) 
Tricnspid Valve: di/flucloxacillin 50 mg/kg to 2 g i.v. 4 hourly for 4 w 
Bacillus: clindamycin 

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Infections of the Cardiovascular System 

Lactobacillus: benzylpenicillin 15-20 MU (neonates: 500,000-1 MU; older children: 200,000-400,000 U/kg) i.v. 
daily in divided doses for 2 w + gentamicin 1.3 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 hourly (trough <1.5 mg/L) 

Erysipelothrix rhusiopathiae: benzylpenicillin 12-20 MU/d i.v. for 4-6 w 

Corynebacterium jeikeium: vancomycin 

Other Corynebacterium: penicillin + aminoglycoside; vancomycin 

Listeria monocytogenes: ampicillin or penicillin, cotrimoxazole 

Mycobacterium chelonae, Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, ciprofloxacin, 
cotrimoxazole orally for 6-12 mo 

Coxiella burnetii: tetracycline 2 g orally daily in divided doses + clindamycin 600 mg i.v. 8 hourly; rifampicin 
10 mg/kg to 600 mg orally daily + cotrimoxazole 2/10 mg/kg to 160/800 mg orally twice daily; doxycycline + 
hydroxychloroquine for 2 y in chronic cases 

Pasteurella: penicillin, ampicillin, mezlocillin, piperacillin, cefuroxime, ceftriaxone, cefotaxime 

Fnngi: valve replacement essential to management; amphotericin B (increase to 1 mg/kg daily; total dose of 2 g 
or more) + ketoconazole; fluconazole 

Surgery where appropriate therapy fails to control infection or refractory congestive cardiac failure occurs. 
Test of Progress: fall in circulating immune complexes levels 

Prophylaxis: required with most congenital cardiac defects, previous endocarditis, hypertrophic cardiomyopathy, mitral 
valve prolapse with regurgitation, prosthetic valve, rheumatic and other acquired valvular dysfunction, surgically constructed 
systemic-pulmonary shunts or conduits 

Bronchoscopy with Rigid Bronchoscope, Dental Procednres (Dental Extractions, Snrgical 
Drainage of Dental Abscess, Maxillary or Mandibular Osteotomies, Snrgical Repair or Fixation of 
Fractnred Jaw, Periodontal Procednres (Including Probing, Scaling, Root Planing, Snrgery), Dental 
Implant Placement and Reimplantation of Avnlsed Teeth, Endodontic (Root Canal) Instrnmentation 
or Snrgery Only Beyond the Apex, Subgingival Placement of Antibiotic Fibres or Strips, Initial 
Placement of Orthodontic Bands (bnt not Brackets), Intraligamentary Local Anesthetic Injections, 
Prophylactic Cleaning of Teeth or Implants Where Bleeding is Anticipated), Snrgical Procednres 
Breaking Respiratory Mucosa, Tonsillectomy and/or Adenoidectomy: 0.5% chlorhexidine applied to gingival 
margin before local anasthesia for dental surgery; amoxycillin 50 mg/kg to 2 g orally as a single dose 1 h before procedure; 
amoxy(ampi)cillin 50 mg/kg to 2 g i.v. just before procedure or i.m. 30 min before procedure 

Penicillin Hypersensitive, On Long-term Penicillin or Having Taken p -lactam 
Antibiotic More Than Once in Previous Month: clindamycin 15 mg/kg to 600 mg orally single dose 1 h before 
procedure or i.v. over at least 20 min, ending just before procedure commences; lincomycin 15 mg/kg to 600 mg i.v. over at 
least 1 h, ending just before procedure commences; vancomycin 25 mg/kg to 1.5 g i.v. (child 30 mg/kg to 1.5 g) over at 
least 1 h, ending just before procedure commences; teicoplanin 10 mg/kg to 400 mg i.v. just before procedure or i.m. 30 min 
before procedue; cephalexin 50 mg/kg to 2 g orally 1 h before procedure (not those on long-term penicillin or having taken 
related beta-lactam > once in previous month or with immediate penicillin hyprsensitivity) 

Endoscopic Retrograde Cholangiography, Biliary Tract Surgery, Esophageal Dilatation, 
Sclerotherapy for Esophageal Varices, Surgical Procedures Breaking Intestinal Mucosa (Except 
Endoscopy, Biopsy, Percutaneous Endoscopic Gastrostomy), Prostatic Surgery, Transrectal Prostatic 
Biopsy, Cystoscopy, Urethral Catheterisation or Urinary Tract Surgery in Presence of Urinary Tract 
Infection, Urethral Dilatation and Curettage, Therapeutic Abortion, Sterilisation Procedures or 
Insertion or Removal of Intrauterine Contraceptive Device in the Presence of Infection, Vaginal 
Delivery in Presence of Infection or Prolonged Labour: (amoxy)ampicillin 50 mg/kg to 2 g i.v. just before 
procedure or i.m. 30 minutes before procedure then 25 mg/kg to 1 g i.v. i.m. or orally 6 h later + gentamicin 2 mg/kg 
(child: 2.5 mg/kg) i.v. just before procedure or i.m. 30 min before procedure 

Penicillin Hypersensitive: vancomycin 25 mg/kg (< 12 y: 30 mg/kg) to 1.5 g i.v. over at least 
1 h, ending just before procedure, teicoplanin 10 mg/kg to 400 mg i.v. just before procedure 

Patients With Prosthetic Valves Or Previous Endocarditis Undergoing Skin Biopsy: 
di(flu)cloxacillin 25 mg/kg to maximum 1 g i.v. just before procedure commences or i.m. 30 min before procedure + 
gentamicin 2 mg/kg (child: 2.5 mg/kg) i.v. just before procedure commences or i.m. 30 min before procedure 

If Parenteral Thrapy Impractical: di(flu)cloxacillin 25 mg/kg to maximum 1 g orally 1 h before 
procedure commences, then 25 mg/kg to maximum 1 g orally 6 h later 

Penicillin Hypersensitive: vancomycin 20 mg/kg to maximum 1 g i.v. slowly over 60 min + 
gentamicin as above 



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Infections of the Cardiovascular System 

Vascular Graft Infection 

Agents: 33% Staphylococcus aureus, 16% Escherichia coli, 12 % Staphylococcus epidermidis, 11% streptococci, 8% Proteus, 
7% other aerobic Gram negative bacilli, 6% other bacteria (including Listeria monocytogenes], 1% Candida, rarely Aspergillus 
Diagnosis: culture of surgical specimen, blood cultures 

Aspergillus: persistent back pain, fever, arterial embolusation 
Treatment: surgery + vancomycin 20 mg/kg to 1 g i.v. slowly 12 hourly (trough 10-20 mg/L) + cefotaxime 50 mg/kg 
to 2 g i.v. 8 hourly or ceftriaxone 50 mg/kg to 2 g i.v. daily 

Mycotic Aneurism: present in 2-11% of endocarditis cases, also due to direct arterial infection 
Agents: 18-66% Salmonella, 16-44% Staphylococcus aureus, Streptococcus pneumoniae, other streptococci, enterococci, 
Mycobacterium tuberculosis, Yersinia enterocolitica, Proteus, Klebsiella, Enterobacter, Campylobacter fetus subsp fetus, 
Pseudomonas aeruginosa, Neisseria gonorrhoeae, Listeria monocytogenes, Escherichia coli, Haemophilus influenzae, Aspergillus 
Diagnosis: CT scan; aortography; blood cultures; smears and cultures of sputum, urine, bone marrow, surgical specimens 
Treatment: surgery + vancomycin 25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 1 g) i.v. slowly 12 hourly (monitor 
blood levels and adjust dose to trough 10-20 mg/L) + cefotaxime 50 mg/kg to 2 g i.v. 8 hourly or ceftriaxone 50 mg/kg to 
2 g i.v. daily 

False Aneurism: common in i.v. drug addicts 

Agents: 83% Staphylococcus aureus, 39% polymicrobial, 22% streptococci, 20% anaerobes, 12% aerobic Gram negative 
bacilli 

Diagnosis: computed tomography (sensitivity 100%), arteriography (sensitivity 96%), digital subtraction angiography 
(sensitivity 92%); blood cultures, culture of surgical material 
Treatment: resection + appropriate antimicrobial 

Thrombophlebitis: rarely affects CNS; although 33% of intravenous catheters give positive cultures, only 3% are 
associated with sepsis; development of infection in intravenous catheters is related to patient being already septic, transient 
bacteremia from another source, irrigating or otherwise manipulating an occluded, leaking or infiltrated catheter, 
contaminated fluid being administered, total parenteral nutrition, burned patient, length of time catheter remains in place, 
cancer patient, corticosteroids and/or other immunosuppressive therapy, plastic cannulas (as opposed to steel), intravenous 
therapy in lower extremity 

Agents: 40% Klebsiella- Enterobacter, 20% Providencia, 20% Proteus, 12% Serratia marcescens, 12% Staphylococcus aureus 
(associated with local trauma), 8% Pseudomonas aeruginosa, 8% Escherichia coli, 8% Candida; Campylobacter fetus subsp 
fetus, halophile Vibrio, Aeromonas, Corynebacterium striatum (rare; associated with central venous catheters), Staphylococcus 
epidermidis 

Diagnosis: culture of infected material; blood cultures 
Treatment: dependent on agent 

Prevention: intravenous catheters should be used only when less dangerous methods are not possible; catheter must be 
inspected daily; three-way stopcocks should be avoided if possible or, if not, should at least be changed at least every 24 
hours, because they provide a portal of entry for bacteria or fungi; forced irrigation should be avoided because of possibility 
of thromboembolism; in placing an intravenous catheter, prepare area with antiseptic solution (chlorhexidine), use sterile 
drapes and gloves, apply 2% chlorhexidine ointment to the site after insertion, anchor catheter securely, apply sterile dry 
gauze (not transparent occlusive) dressing, 'date' catheter, use antiseptic/ antibiotic impregnated short-term central venous 
catheter if rate of infection is high despite adherence to other strategies 
Arteritis 

Agent: Pythium (in thalassemic farmers), Aspergillus 
Diagnosis: histology and culture of surgical material 
Treatment: 

Pythium: aggressive surgery + i.v. sodium iodide 

Aspergillus: surgery + amphotericin B 
Bacillary Angiomatosis: largely in immunocompromised patients, particularly AIDS 
Agent: Bartonella henselae, Bartonella quintana 
Diagnosis: Warthin-Starry stain of biopsy 

Treatment: doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 3-4 mo (not < 8 y), erythromycin 10 mg/kg to 500 mg 
orally 6 hourly for 3-4 mo, erythromycin ethyl succinate 20 mg/kg to 800 mg orally 6 hourly fo 3-4 mo 



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Chapter 10 

Infections of the Reticuloendothelial System 

Bone Marrow Infections 

Agents: Brucella, Salmonella typhi, Mycobacterium, Histoplasma capsulatum 

Diagnosis: hematological examination of bone marrow (infection causes an increased M/E ratio; in chronic infection, there 
is a myeloid hyperplasia and increased plasma cells; Mycobacterium kansasii causes a severe hypoplasia of hematopoietic 
cells); Gram stain, Ziehl-Neelsen stain, culture of bone marrow in biphasic medium for 3 w, aerobic and anaerobic bacterial 
cultures and fungal cultures at 25°C and 35°C on solid media, and culture for mycobacteria as indicated and quantity of 
specimen allows 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, profuse 
sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; isolation; Brucella tube 
agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, complement fixation test, Coombs, 
fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 
Treatment: 

Brucella: doxycycline 100 mg orally twice a day + rifampicin 600 mg orally 4 times a day or streptomycin l g 
i.m. 4 times a day fro 45 d, ciprofloxacin 500 mg orally twice a day + rifmapicin 600 mg orally twice a day for 30 d 

Salmonella typhi: chloramphenicol, cotrimoxazole 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Other Mycobacteria: ethionamide, cycloserine, viomycin, ethambutol 

Histoplasma capsulatum: amphotericin B, flucytosine, ketoconazole 
Ehrlichiosis 

Agent: Ehrlichia cam's, Ehrlichia chaffeensis and Ehrlichia sennetsu (monocytic; tick vector — Dermacentor variabilis and 
Mblyomma americanum in Southern and Eastern USA), Ehrlichia ewingii and Rnoplasma phagocytophilum (granulocytic; tick 
vector — Mblyoma americanum and Ixodes persulcatus) 

Diagnosis: incubation period < 3 w; fever, malaise, headache, nausea, vomiting, anorexia, myalgia, arthralgia, chills, 
sweating, cough, diarrhoea, abdominal pain, thrombocytopenia, leucocytopenia, increased liver enzyme levels; maculopapular 
rash (rare in granulocytic); encephalopathy, pulmonary complication (respiratory failure, acute respiratory distress, 
pharyngitis; pulmonary infiltrates, pulmonary edema on chest X-ray) may occur in monocytic (may evolve with severe 
multiorgan failure); disseminated intravascular coagulation, meningitis, gastrointestinal bleeding and renal failure also occur; 
immunohistologic examination of acute phase bone marrow and liver biopsy; PCR (positive in 71%); morulae in Wright-Giemsa 
stained peripheral or buffy coat smears (positive in 61%); thrombocytopenia and leucopenia in 49% 
Treatment: doxycycline 
Hepatitis 
Agents: 

Prenatal: human cytomegalovirus, rubella virus, simplexvirus, human coxsackievirus B, simplexvirus 3, Listeria 
monocytogenes (intrauterine infection with septicemia; mortality high), Treponema pallidum subsp pallidum 

Neonatal: simplexvirus, human cytomegalovirus, human echovirus, Reovirus, measles virus (fatal in children with 
leukemia), Listeria monocytogenes (acquired from environment; majority recover) 

Pediatric: simplexvirus 3, human parvovirus B19 

Adnlt: hepatitis A (infective hepatitis; acute viral disease of worldwide occurrence, particularly in Third World 
areas; global incidence 600,000 - 3M/y ; « 2000 notified cases/y in Australia (« 27% in NSW; causes 3% of fever in 
returned travellers); incidence 13/100,000 in USA but 33% serological evidence of prior infection; 0.02% of new episodes of 
illness in UK; 80% of hepatitis in travellers; global mortality 2400-12,000/y; case-fatality rate 0.1-0.3% overall, 1.8% in 
> 50 y.o.; antibody positivity varies from 30% in Switzerland to « 100% in Africa, Asia, Latin America, Mexico and South 
America; from shellfish from contaminated waters, raw produce, uncooked foods and cooked foods not reheated after contact 
with infected food handler; 50% no identified source, 12-26% household or sexual contact, 10% drug users and men who have 
sex with men; incubation period 15-50 d; duration of illness 2 w-3 mo), hepatitis B (serum hepatitis; « 8000 notified cases/y 

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Infections of the Reticuloendothelial System 

(52% in NSW) in Australia; global mortality rate l-2M/y (tenth leading cause of death); case-fatality rate generally 1% but 
up to 67% in some outbreaks; prevalence of HBsAg varies from 0.2-0.5% in Australia up to 80% in Taiwan; very common in 
China, SE Asia, Subsaharan Africa, Pacific Islands and the Amazon Basin; 181,000 new cases/y, 1.25 M with chronic 
infection, and 5000 deaths from related cirrhosis or hepatocellular carcinoma in USA; low incidence in W Europe and 
Australia (« 300 notified cases/y (« 35% in Queensland)); carrier rate from 0.5% in USA and Canada and 1% in Australia 
to 5-15% of adults in developing nations; 385 M chronic carriers worldwide; Australian Aborigines have a very high carrier 
rate; becomes chronic in 90% infected at birth, 25-50% at 1-5 y; transmission by sex (40% heterosexual, 15% men having sex 
with men), blood and blood products, secretions (eg., saliva, semen), body fluids, contaminated needles/sharp instruments, 
human bites and intimate contact); incubation period 3-20 w; > 90% of HbeAg-positive mothers transmit to newborns 
through blood exposure at time of birth), hepatitis C (20% of all cases of acute hepatitis; injecting drug users (80% of cases), 
those who received a blood transfusion prior to 1992 (5-10%), hemodialysis patients, health care workers (prevalence 1-2%), 
hemophiliacs, those with transplants before 1992, intranasal cocaine users, those with body piercing, sexual contacts of 
infected persons, persons with multiple sex partners, individuals with tattoos, those sharing household items with infected 
individuals, those indulging in fisticuffs, patients of infected healthcare workers; also transmitted from infected mother to 
newborn (3-5% risk if mother has chronic infection); 15-35% clear infection spontaneously within 2-6 mo, 65-85% develop 
chronic infection, 5-20% with chronic infection progress to cirrhosis after 20 y (20% after 40 y; increased risk with alcohol 
consumption, HIV or hepatitis B coinfection, older age at time of infection, male), 3-5% with cirrhosis develop liver failure or 
hepatocellular carcinoma after 30-40 y; 170 M carriers worldwide; infection rates vary from < 0.5% in Scandinavian 
countries to 8-14% in Egypt; « 200,000 infected in Australia with * 134,000 having developed chronic infection, and 
« 11,000 new infections/y); most common bloodborne infection and most common cause of liver transplant in USA (> 4 M 
infected; 30,000 new infections and 10,000 deaths annually; leading cause of death in HIV-infected patients in at least 1 US 
hospital), 8.9 M infected in Europe, 200 M worldwide), hepatitis D (delta hepatitis; superinfection of hepatitis B; transmitted 
in company with hepatitis B; 5% of HBsAg carriers infected worldwide; endemic in Russia, Romania, southern Italy, Africa 
and S America, rare in Australia (21 notified cases in 1999); associated with illicit drug usage and blood transfusions, less 
commonly sexually transmitted; chronic disease rare in acute cases but 70-80% chronic in HBsAg carriers; accelerates 
development of liver cancer; mortality 2-20%), hepatitis E (acute disease; enterically transmitted; water-borne epidemics in 
India, Nepal, Pakistan, Burma, former Soviet Union, Africa, Mexico, Middle East; 50% of non-A-C hepatitis in developing 
countries; endemic in Asia and South America; most common cause of acute sporadic hepatitis in Sudanese children; case- 
fatality rate up to 25% in pregnancy; 2 notified cases in Australia in 1999), hepatitis G (chronic; no known symptoms; 
prevalence 1-2% of blood donors, 30% of drug users, 10-30% of hepatitis C patients; transmitted by blood transfusion), 
simplexvirus 1 (associated with pregnancy, thymic dysplasia, celiac disease, corticosteroid therapy, leukemias and lymphomas, 
severe burns, renal transplantation, AIDS; death within 1 w), simplexvirus 3, human cytomegalovirus, Epstein-Barr virus, 
several viral hemorrhagic fevers including yellow fever virus and Lassa virus, adenovirus, human parvovirus B19, 
Staphylococcus aureus (in toxic shock syndrome), Listeria monocytogenes (associated with debilitating and neoplastic 
diseases, immunosuppressive therapy, renal transplantation, cardiac prosthetic devices), Escherichia coli, Salmonella typhi, 
Shigella, Pseudomonas pseudomallei, Brucella, Yersinia pseudotuberculosis, Campylobacter jejuni, Mycobacterium tuberculosis, 
Mycobacterium avium-intracellulare, Mycobacterium leprae (in 90% of lepromatous cases, 20% of tuberculoid), Treponema 
pallidum subsp pallidum, Leptospira, Rocky Mountain spotted fever, Boutonneuse fever, Q fever (abattoir and farm workers), 
Borrelia recurrentis, Actinomyces, Nocardia, Aspergillus, Mucor, Candida, Histoplasma, Leishmania, Plasmodium, Toxoplasma, 
Schistosoma, Echinococcus, Entamoeba histolytica (hepatic amoebiasis (amoebic hepatitis); early stage of invasion of liver via 
intrahepatic portal vessels; results from intestinal amoebiasis; may be self-limiting or progress to a liver abscess), Capillaria 
hepatica, Fasciola hepatica; also alcohol, phenothiazine (chlorpromazine), anesthetics (halothane), antituberculous drugs 
(rifampicin, isoniazid, pyrazinamide), methyldopa, contraceptive pills, organic solvents (eg., carbon tetrachloride, 'glue') 
Diagnosis: anorexia, malaise, extreme fatigue, right upper quadrant tenderness, nausea, vomiting, acute jaundice; 
epidemiological history; light-coloured stool, dark urine; computed tomography of abdomen (positive in 93% of cases of focal 
hepatic candidiasis), ultrasound; serology; Gram, Giemsa, Ziehl-Neelsen and silver-methenamine stains, bacterial, fungal and 
viral culture of biopsy; viral culture of throat swab, feces; increased urine urobilinogen, serum alanine aminotransferase 
> 2.5 times upper limit of normal; serum aldolase increased in viral hepatitis, less consistently in chronic hepatitis; serum 
(3-glucuronidase increased in viral hepatitis; serum isocitrate dehydrogenase increased in viral hepatitis; serum iron and total 
iron-binding capacity increased in infectious hepatitis; serum sorbitol dehydrogenase increased in acute hepatitis; rheumatoid 
factor may be present; 80% of cases of chronic active hepatitis have anti-nuclear antibodies titre > 320; anti-smooth muscle 
antibody test +++ in hepatitis A and B, ++ in chronic active hepatitis, cryptogenic cirrhosis and primary biliary 
cirrhosis; cytoplasmic mitochondrial smooth muscle fluorescence in chronic active hepatitis and other liver disease; white cell 
count decreased in simplexvirus hepatitis 

Hepatitis A: usually asymptomatic or unrecognised in children; in > 80% of adults, marked jaundice, diarrhoea, 
dark urine, flu-like symptoms (fever, headache, nausea, abdominal pain, fatigue, weakness, arthralgias, myalgias); may have 
clay coloured stools, skin rash and extreme aversion to tobacco smoke; ELISA tests for hepatitis A IgM antibody (persists 

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Infections of the Reticuloendothelial System 

3-6 mo post infection) and total hepatitis A antibody (also antigen; capture IgA in protracted cases); immune adherence 
hemagglutination test for hepatitis A IgM antibody (not always reliable), seroconversion of hepatitis A IgG antibody; 
counterimmunoelectrophoresis; immunoelectron microscopy of stool; increase in ALT and AST; bilirubin normal or elevated 

Hepatitis B: incubation period 4 w - 6 mo; may be asymptomatic, but usually fatigue, weakness, anorexia, 
nausea, fever, malaise and fullness or discomfort in right upper quadrant; jaundice in 20-50%; less frequently, hemorrhage 
due to diminished synthesis of prothrombin complex, altered mental status, Guillain-Barre syndrome, peripheral neuropathy, 
myokymia, neuropsychiatric dysfunction, red cell aplasia, thrombocytopenia, agranulocytosis, aplastic anemia, myocarditis, 
pericarditis, superficial/hemorrhagic gastritis, acute pancreatitis, renal failure, membranous glomerulonephritis, urticaria, 
papular acrodermatitis, arthralgia, vasculitis, pleural effusion; fatal fulminant hepatitis in 1% of acute infections; becomes 
chronic in 90% of infants, 60% of < 5 y.o. and 2-6% of adults; annual rate of development of cirrhosis 1-3% (5 y survival 
rate 30%); radioimmunoassay most sensitive; turkey erythrocyte passive haemagglutination test slightly less sensitive but 
simple, rapid and considerably less expensive; enzyme immunoassay (Auszyme I) 98% sensitivity and 99% specificity; 
hepatitis B surface antigen (HBsAg) indicates current infection but not necessarily infectivity; hepatitis B e antigen (HBeAg) 
indicates high infectivity in HBsAg + individual; anti-hepatitis B surface antibody (anti-HBs) indicates post-infection, 
immunity or (if IgM anti-HBc negative) chronic infection; anti-hepatitis B core antibody (anti-HBc; IgM diagnostic of acute 
infection); anti-hepatitis B e antibody (anti-HBe) indicates low infectivity in a HBsAg + individual 
IgM HbcAb +ve = acute infection 
HBsAb +ve HBcAb -ve HBV DNA -ve = hepatitis B immunisation 
HBsAb +ve HBcAb +ve HBV DNA -ve = recovered from HBV 
HBsAb +ve HBcAb ± HBV DNA < 10 3 copies = occult hepatitis B 
HBsAb -ve HBcAb +ve HBeAb -ve HBsAg +ve = acute HBV or chronic hepatitis B 
HbsAb -ve HbcAb +ve HbeAb -ve HbsAg -ve = occult hepatitis B 
HBsAb -ve HBcAb +ve HBeAb +ve HBsAg +ve = healthy or inactive carrier 
HbsAb -ve HbcAb +ve HbeAb +ve HbsAg -ve = occult hepatitis B 

serum alanine aminotransferase > 10-20X normal in acute cases, 2-10X normal in chronic cases, < 2X normal in "healthy' 
carrier state; total serum bilirubin 2.5-34.8 mg/dL; serum glutamic-oxaloacetic transaminase > 10X upper limit normal in all 
cases 

Hepatitis C: incubation period > 21 d; generally asymptomatic in acute phase; malaise, weakness and anorexia 
in 25-35%; fatigue and malaise with advanced liver disease; arthritis in 23%, paresthesia in 17%, myalgia in 15%, pruritus 
in 15%, sicca symptoms of mouth and/or eyes in 11%, mixed cryoglobulins in 40%, low thyroxine level in 10%, antinuclear 
antibodies in 10%, anti-smooth muscle antibodies in 7% of chronic infections; glomerulonephritis, lichen planus, porphyria 
cutanea tarda, Raynaud's syndrome, systemic vasculitis, lymphoma, diabetes mellitus, corneal ulceration, autoimmune 
phenomena, uveitis, sialadenitis and peripheral neuropathy also occur; 1 case of acute disseminated encephalomyelitis 
reported; infection becomes chronic in 75-85%, with 60-70% having evidence of active liver disease and cirrhosis occurring 
in 20% of total within 20 y; test for anti-HCV by ELISA (false positives and negatives) and recombinant immunoblot assay 
(expensive and number of samples give indeterminate results) if positive, reverse transcriptase PCR for hepatitis C virus 
RNA (negative result does not necessarily exclude infection); genotyping; serum alkaline phosphatase 310 IU/mL, total serum 
bilirubin 2.6 mg/dL, serum glutamic-oxaloacetic transaminase > 100 U/mL; serum ALT and AST may be elevated in acute 
cases 

Hepatitis D: incubation period 2-8 w; abrupt onset of signs and symptoms of hepatitis B; HbsAg +ve or IgM 
anti-HBc +ve + anti-HDV +ve 

Hepatitis E: incubation period 2-9 w; immunoelectron microscopy of stool during incubation and early infection; 
IgM anti-HEV +ve; enzyme immunoassay, Western blot assay (IgM elevated 1 mo after infection, IgG after 6-8 w); 

Q Fever: indirect fluorescent antibody titre, complement fixation test 

Focal Hepatic Candidiasis: serum alkaline phosphatase increased in 92% of cases; total serum bilirubin 
increased in 36% of cases, direct in 33% 

Parasites: complement fixation test, bentonite flocculation, indirect hemagglutination, latex agglutination, direct 
agglutination, indirect immunofluorescence, immunodiffusion, counterimmunoelectrophoresis 

Capillaria hepatica: acute or subacute hepatitis with high eosinophilia; may be splenomegaly, pneumonitis, 
fever, constipation and abdominal distension; case-fatality rate high; microscopy of biopsy or autopsy specimen for ova 

Fasciola hepatica: fever, pain in right hypochondrium, hepatomegaly, hypergammaglobulinemia, marked 
eosinophilia; ELISA 
Treatment: ursodeoxycholic acid in chronic 

Virnses: mainly non-specific; discontinue steroids 

Simplexvirus: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly for 
7-10 d, aciclovir 200 mg orally 5 times daily for 7-10 d 



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Infections of the Reticuloendothelial System 
Frequent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg orally 12 
hourly, aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Hepatitis B (e Antigen Positive, Chronic Active Disease for > 6 mo and on Liver 
Biopsy): lamivudine 100 mg orally daily until HbeAg is undetectable and replaced by anti-Hbe on 2 occasions at least 
3 mo apart (may cause severe and fatal infection if resistance develops), interferon a-2 4.5-10xl0 6 U s.c. 3 times a week for 
6 mo or 5x1 6 units s.c. daily for 6 mo 

Unresponsive: interferon a-2 9-10xl0 6 U s.c. 3 times a week for further 6 mo; famiclovir; 
lamivudine 

Renal Transplant Recipient: lamivudine, famciclovir 

Liver Transplant Recipient: lamivudine 12 mo + long term hepatitis B immunoglobulins 
Hepatitis C: pegylated interferon a-2b ± ribavirin (not if anemia, hemoglobinopathy, white blood cell 
count < 1500/mL, platelet count < 100,000/mL, pregnant or unable to practise contraception, decompensated cirrhosis, 
severe psychiatric illness, cardiovascular disease, seizure disorder or poorly controlled diabetes mellitus; low probability of 
effectiveness) ± amantadine for 6 mo if genotype 2 or 3, 1 y if genotype 1 or 4 

Staphylococcus aureus: cloxacillin, penicillin 

Listeria monocytogenes: penicillin, cotrimoxazole 

Escherichia colt gentamicin 

Salmonella typhi: chloramphenicol, cotrimoxazole 

Shigella: cotrimoxazole, ampicillin (not amoxycillin) 

Burkholderia pseudomallei: cotrimoxazole + ceftazidime or meropenem or imipenem 

Brucella: doxycycline + rifampicin or streptomycin, ciprofloxacin + rifampicin 

Yersinia pseudotuberculosis: gentamicin, cefotaxime, doxycycline, ciprofloxacin 

Campylobacter jejuni: erythromycin 

Coxiella burnetii: tetracycline 500 mg orally 6 hourly for 14 d, doxycycline 100 mg orally 12 hourly for 14 d, 
rifampicin 600 mg (child: 7.5 mg/kg) orally daily, erythromycin 500 mg orally 6 hourly (child: 30 mg/kg/d in 4 divided 
doses) for 14 d 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Mycobacterium avium-intracellulare: ethambutol 15 mg/kg orally daily (not < 6 y) + clarithromycin 
12.5 mg/g to 500 mg orally 12 hourly daily or azithromycin 10 mg/kg to 500 mg orally daily + rifampicin 10 mg/kg to 600 
mg orally daily or rifabutin 5 mg/kg to 300 mg orally daily 

Mycobacterium leprae: dapsone + isoniazid, sulphonamides 

Treponema pallidum subsp pallidum: penicillin 

Leptospira: oxytetracycline 

Rickettsia: tetracycline, chloramphenicol 

Borrelia recurrentis: penicillin, tetracycline, doxycycline (may be associated with Jarisch-Herxheimer reaction) 

Rctinomyces: penicillin + streptomycin, tetracycline, erythromycin, third generation cephalosporin 

Nocardia: sulphonamides, cotrimoxazole 

Fnngi: amphotericin B 

Leishmania, Plasmodium: chloroquine, hydroxychloroquine sulphate, amodiaquine, mepacrine, quinine, 
primaquine, proguanil, pyrimethamine 

Toxoplasma: sulphadiazine 1-1.5 g orally or i.v. 6 hourly for 3-6 w then 500 mg orally 6 hourly or 1 g orally 
12 hourly + pyrimethamine 50-100 mg orally loading dose then 25-50 mg daily for 3-6 w (continue if necessary) 

Sulphadiazine Hypersensitive: substitute clindamycin 600 mg orally or i.v. 6 hourly for 3-6 w 
(continue 8 hourly if necessary) 

Schistosoma: praziquantel, niridazole, sodium stibogluconate 

Echinococcus: thiabendazole 

Entamoeba histolytica: chloroquine + emetine hydrochloride 

Capillaria hepatica: no known treatment 

Fasciola hepatica: bithionol 



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Infections of the Reticuloendothelial System 
Prophylaxis: 

Hepatitis A: 

Postexposure: 0.02 mL/kg human immune globulin i.m. as a single dose within 2 w of exposure (close 
contact with persons having acute hepatitis A — household, sexual contacts, prisons, institutions for mentally retarded, day 
care centres; persons with repeated exposures within past 2 w to food prepared by IgM hepatitis A virus antibody positive 
handler handling high risk foods and with poor hygiene) 

Preexposure: Travellers to Endemic Regions, People Attending Day Care Centres or 
Institutions Where Hepatitis A is Prevalent, Sewerage Workers, HIV Negative Homosexual Men, Food 
Handlers, Recipients of Blood Products, People With Significant Chronic Liver Disease, Illegal Drug 
Users: 2 doses of inactivated virosome vaccine provides 20 y protection (combined hepatitis A and B vaccine also 
available); care in handling feces, blood, other secretions and possibly contaminated objects 

Hepatitis B: vaccine (low prevalence: health personnel, dialysis patients, institutionalised patients, drug addicts, 
male homosexuals, persons with history of sexually transmitted disease, persons who have had multiple sex partners, those 
who have had sex with injection drug user, household members, sex partners and drug-sharing partners of person with 
chronic infection, persons receiving clotting factor concentrates; high prevalence: all infants; months 0, 1, 2 and 12; 
inoculation in deltoid rather than buttock as gives better titres; 17% soreness at vaccination site, 15% fever, fatigue, 
headache, nausea; immunity 5 y but 30% require booster < 3 y after initial course; 2 types — plasma-derived and 
recombinant DNA; latter may require larger and repeated doses for hemodialysis patients and immunosuppressed patients; 
avoid in patients with risk of CNS disease) (combined hepatitis A and B vaccine also available), care in handling 
contaminated blood and secretions 

Perinatal Exposure (Infants Born to HBsAg Positive Mothers): hepatitis B immune globulin 
(HBIG) 0.5 mL i.m. within 12 h of birth, followed by vaccine 0.5 mL i.m. at same times as HBIG or within 7 d, repeated at 1 
and 6 mo 

Percutaneous Exposure (Acute Exposure to HBsAg by Accidental Needle Stick or 
Mucosal Exposure): 

Where Risk of Source of Infection Being Positive is High or Known to be 
HBsAg Positive: HBIG 0.06 mL/kg to maximum 5 mL i.m. as a single dose within 24 h, repeat at 1 mo or vaccine 
0.5-1 mL at same time as HBIG or within 7 d, repeated at 1 and 6 mo if unvaccinated or partially vaccinated 

Where Risk of Source of Infection Being Positive is Low or Source Unknown: 
vaccine only administered within 7 d of exposure; otherwise, no prophylaxis 

Sexual Exposure (Sexual Contact of Persons with Acute Hepatitis B during Previous 
Month): HBIG 0.06 mL/kg to 5 mL maximum i.m. + hepatitis B vaccine within 14 d 

Hepatitis C (Percutaneous Exposure): if source HCV antibody negative and unlikely to be in window 
period, none; otherwise, HCV RNA testing at 4-6 w and HCV antibodies and ALT at 4-6 mo; consider early therapy if 
seroconversion 

Mycobacterium avium Complex in HIV/AIDS, CD4 < 50/ uL: azithromycin 1.2 g orally weekly, 
clarithromycin 500 mg orally 12 hourly, rifabutin 300 mg orally daily 

Toxoplasma gondii in HIV/AIDS, CD4 < 200/ uL: cotrimoxazole 80/400 or 160/800 mg orally daily or 
160/800 mg orally 3 times daily 

Liver Carcinoma may be caused by hepatitis B virus transforming hepatic cell. Liver cancer is especially common in 
those with persistent hepatitis B infection. 

Hepatic Abscess: mortality 23%; pyogenic liver abscesses cause 0.007-0.03% of hospital admissions in temperate districts 
but * 0.09% in Thailand 

Agents: 50% mixed anaerobes (especially Gram positive cocci; also Odoribacter splanchnicus); Staphylococcus aureus, 
coliforms, Actinomyces, Burkholderia pseudomallei, Yersinia pseudotuberculosis, Chromobacterium violaceum (in 44% of 
infections), Listeria monocytogenes (in diabetes), Streptococcus milled, Edwardsiella tarda (rare), Haemophilus influenzae 
(adult), Haemophilus parainfluenzae, Klebsiella pneumoniae (in diabetics; especially serotype Kl), Entamoeba histolytica 
(resulting from hepatic amoebiasis; may rupture into peritoneum, pericardium, pleura or lung), Schistosoma, Toxocara 
Diagnosis: incubation period > 21 d in amoebic; night sweats in 75% of amoebic; liver enlargement in 69-76% of 
bacterial, 95-100% of amoebic (presenting complaint in 40%); fever in 63-100% of bacterial, 35-95% of amoebic (< 38°C in 
60%; presenting complaint in 40%); nausea/vomiting in 60-75% of amoebic; raised right diaphragm in 60% of amoebic; 
epigastric pain and tenderness in 48-52% of amoebic; right upper quadrant pain and tenderness in 47-69% of bacterial, 66- 
100% of amoebic (presenting complaint in 30%), 57% of actinomycotic; chills in 42-70% of amoebic; right shoulder pain in 
40% of amoebic (presenting complaint in 3%); anorexia/weight loss/fatigue in 33-100% of amoebic (presenting complaint in 
5%), 3% of actinomycotic; back pain in 30% of amoebic; diarrhoea in 25-66% of amoebic (50% bloody; presenting complaint 
in 15%); right chest pain in 6-50% of amoebic; hiccoughs occasionally in amoebic; right pleural effusion in 35% of amoebic; 
geographic history; epidemiological history; ultrasonography; radioactive isotope scan (positive in 89% of pyogenic; large, 

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Infections of the Reticuloendothelial System 

single defect in right lobe in amoebic); arteriogram (positive in 77% of pyogenic); upper gastrointestinal X-ray (positive in 
19% of pyogenic; elevated right hemidiaphragm in 60% of amoebic); micro and culture of biopsy, aspirated fluid (in amoebic, 
trophozoites found only at periphery of cavitary lesions and aspirates may be falsely negative; sensitivity is only 20-30%); 
serology (amoebic; complement fixation test (evaluated), bentonite flocculation (evaluated), indirect hemagglutination 
(commercially available; with counterimmunoelectrophoresis, most sensitive (70%) and specific (70-80% in acute, > 90% in 
convalescent)), latex agglutination (commercially available), indirect immunofluorescence (evaluated), immunodiffusion (agar 
gel diffusion; commercially available), immunoelectrophoresis, counterimmunoelectrophoresis (commercially available; with 
indirect haemagglutination, most sensitive and specific), ELISA (commercially available; dot ELISA for antibody as sensitive 
as indirect hemagglutination and better than plate ELISA and has 100% specificity); animal inoculation (monkey, ferret); 
trophozoites or cysts in stool (25% of amoebic); white cell count > 10,000/|.iL in 87% of pyogenic and 62-90% of amoebic 
(42-60% 10,000-20,000/VL); elevated prothrombin time in 80% of amoebic; anemia in 95% of actinomycotic, 31-70% of 
amoebic (haemoglobin 10-14 g/dL in 66-70%), also in pyogenic; hematocrit 80-100% of normal in 52% of amoebic, < 35% in 
50% of pyogenic; elevated ESR in 95% of actinomycotic; leucocytosis in 93% of actinomycotic; serum albumin decreased in 
23-60% of amoebic, 3 g/dL in 33% of pyogenic; serum alkaline phosphatase > 10 IU/mL in 55-60% of pyogenic, increased 
in 91% of actinomycotic and in 23-60% of amoebic (< 130 IU in 60% of acute cases but > 130 IU in 90% of chronic 
cases); serum bilirubin 2 mg/dL in 53% of pyogenic, increased in 13-26% of amoebic; serum glutamic-oxaloacetic acid 
transaminase > 40 U/mL in 51% of pyogenic, < 40 IU in 45-73% of amoebic; serum lactic dehydrogenase normal in 93% of 
amoebic; globulin elevated in 56% of amoebic 

Differential Diagnosis (Amoebic): pyogenic liver abscess, hepatic neoplasm, hydatid cysts; male gender, insidious 
onset, fever, history of chronic diarrhoea (only in 30-40% of patients), right pleuritic pain, single hepatic lesion of right lobe, 
liver enlargement, liver tenderness, liver filling defect favour diagnosis 
Treatment: aspiration +: 

Chromobactcrium violaceum: chloramphenicol 

Rctinomyces: penicillin, tetracycline 

Klebsiella pneumoniae: ceftriaxone 

Other Bacterial: ciprofloxacin + metronidazole 

Entamoeba histolytica: metronidazole 750 mg orally or i.v. 8 hourly (child: 35-50 mg/kg/d in 3 doses) for 
10 d or tinidazole 2 g orally daily for 3-5 d or 600 mg twice daily for 10 d (child: 50 mg/kg/d for 3-5 d); emetine 

1 mg/kg/d to 60 mg maximum in 2 divided doses for 5 d, followed by chloroquine phosphate 600 mg base orally daily for 

2 d, then 300 mg base orally daily for 2-3 w (child: 10 mg base/kg to 300 mg maximum daily for 2-3 w) if no response to 
metronidazole in 72 h; percutaneous or surgical drainage if no response to chemotherapy after 5 d, abscess > 10 cm, or 
suspected impending rupture; if concomitant cyst passing detected, presume cysts pathogenic and treat with diloxanide 
furoate 500 mg 3 times daily (child: 20 mg/kg/d in 3 divided doses) for 10 d or diodohydroxyquine to eliminate carrier 
state 

Hepatic Granuloma 

Agents: 20% Mycobacterium tuberculosis, 2% Brucella, 2% Schistosoma, 1% fungi (Histoplasma capsulatum, Cryptococcus 
neoformans, Coccidioides immitis, Ajellomyces dermatitidis, Candida, Torulopsis, Aspergillus), 1% viruses {human 
cytomegalovirus, Epstein-Barr virus, human hepatitis A virus, human hepatitis B virus, influenzavirus Bj; atypical 
mycobacteria, Mycobacterium bovis BCG, Mycobacterium leprae (in 90% of lepromatous cases, 20% of tuberculoid), Francisella 
tularensis, Klebsiella granulomatis, Burkholderia pseudomallei, Listeria monocytogenes, Nocardia, Actinomyces, Salmonella 
typhi, Salmonella paratyphi B, Coxiella burnetii, Treponema pallidum subsp pallidum, Chlamydia, Toxocara, Fasciola, Capillaria, 
Strongyloides, Ascaris, Ancyclostoma, Entamoeba histolytica, Toxoplasma, Plasmodium, Pentastomida; 35% sarcoidosis, 10% 
cirrhosis, 2% lymphomas, 1% drug-induced and toxic; others 

Diagnosis: histology, microscopy and culture of biopsy; serology; counterimmunoelectrophoresis; bromosulphophthalein 
retention increased in 80% of sarcoidosis, 73% of tuberculous and 56% of fungal; cholesterol abnormal in 33% of tuberculous, 
17% of fungal, normal in sarcoidosis; serum alanine aminotransferase decreased in 50% of sarcoidosis, 47% of tuberculous, 
25% of fungal; serum bilirubin increased in 37% of tuberculous, 18% of sarcoidosis, normal in fungal; serum gamma globulin 
increased in 86% of fungal, 83% of sarcoidosis, 68% of tuberculous 

Tnbercnlosis: fever of unknown origin, frequently with chills, anemia, meningeal involvement, loss of weight 
and asthenia, symptoms < 6-8 mo 
Treatment: 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 

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Infections of the Reticuloendothelial System 

regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Other Mycobacteria: 4-6 of ethionamide, cycloserine, viomycin, ethambutol, pyrazinamide, capreomycin 

Brucella, Francisella tularensis, Klebsiella granulomatis: streptomycin 

Burkholderia pseudomallei, Nocardia, Toxoplasma: cotrimoxazole + ceftazidime or meropenem or 
imipenem 

Listeria monocytogenes: ampicillin 

Salmonella: chloramphenicol 

Actinomyces: penicillin 

Fnngi: amphotericin B 0.75 mg/kg i.v. daily for 2-4 w + flucytosine 25 mg/kg i.v. or orally 6 hourly for 14 d 

Entamoeba histolytica: metronidazole, emetine + chloroquine 

Schistosoma: praziquantel, niridazole, sodium stibogluconate 

Plasmodium: chloroquine 

Fasciola: bithionol 

Capillaria: no known treatment 

Pentastomida: levamisole 

Other Parasites: thiabendazole 

Viral: mainly non-specific 

Unknown: isoniazid + steroids 
Bacillary Peliosis: blood-filled peliotic changes in hepatic or splenic parenchyma; especially in AIDS 
Agents: Bartonella henselae, Bartonella quintana 
Diagnosis: Warthin-Starry stain of biopsy 

Treatment: doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 3-4 mo (not < 8 y), erythromycin 10 mg/kg to 500 mg 
orally 6 hourly for 3-4 mo, erythromycin ethyl succinate 20 mg/kg to 800 mg orally 6 hourly fo 3-4 mo 
Malarial Splenomegaly: occurs in areas where malaria is endemic 
Agent: Plasmodium species 
Diagnosis: 

Hyperreactive Malarial Splenomegaly (Tropical Splenomegaly Syndrome): elevated serum IgM 
level, high malarial antibody titre, lymphocytic infiltration of hepatic sinusoids; parasitemia rare; decreases with long-term 
corticosteroid therapy 

Nonimmnne Malarial Splenomegaly: serum IgM and malarial antibody levels not elevated; occurs in the 
absence of immunity during acute malarial attacks, recrudescences or epidemics 
Treatment: 

Hyperreactive: corticosteroids 

Nonimmnne: antimalarials 
Splenic Abscess 

Agents: Staphylococcus aureus, Salmonella, Escherichia coli, Propionibacterium acnes, Propionibacterium avidum, Listeria 
monocytogenes, Clostridium difficile, Shigella flexneri (extremely rare), Streptococcus pneumoniae (rare), Streptococcus equinus 
(rare), Mycobacterium tuberculosis (in AIDS), Mlejomyces dermatitidis (rare), others 
Diagnosis: computed tomography, ultrasonography; culture of biopsy or surgical specimen 
Treatment: resection +: 

Staphylococcus aureus: cloxacillin 

Salmonella, Escherichia coli: chloramphenicol 

Propionibacterium: penicillin 

Listeria monocytogenes: ampicillin 

Clostridium difficile: vancomycin, metronidazole 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Streptococci: benzylpenicillin 18 MU/d i.v. + gentamicin 240 mg/d i.v. for 2 w, then amoxycillin 1.5 g/d oral 
+ clindamaycin 900 mg/d oral 

Rjellomyces dermatitidis: amphotericin B, ketoconazole 

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Infections of the Reticuloendothelial System 

Lymph Gland Infections 

Agents: 36% Mycobacterium (23% of cervical lymph node infections in children; 20% Mycobacterium tuberculosis (5% of 
tuberculosis cases; 5% of cervical lymph node infections in children), 12% Mycobacterium avium-intracellulare, 4% 
Mycobacterium kansasii; Mycobacterium scrofulaceum (frequent cervical in children); infrequent Mycobacterium chelonae, 
Mycobacterium fortuitum (cervical), Mycobacterium haemophilum, Mycobacterium maimoense), 35% fungal (27% Histoplasma 
capsuiatum, 3% Ajellomyces dermatitidis, 2% Coccidioides immitis, 2% Cryptococcus neoformans, 1% Sporothrix schenckii, rare 
Aspergillus], 3% Staphylococcus aureus (79% of cervical lymph node infections in children); Brucella (in 50% of infections), 
Corynebacterium pseudotuberculosis, Listeria monocytogenes, Yersinia pestis (pea-sized to orange-sized inguinal, axillary), 
Francisella tularensis (painful; neck, axillary, epitrochlear), Toxoplasma gondii (localised or general) 
Diagnosis: Gram stain, Ziehl-Neelsen stain, fluorescent antibody stain, direct immunofluorescence and culture of lymph 
node; histology; serology 

Cervical: mildly tender, small to moderate nodes usually secondary to viral upper respiratory tract infection; 
large, tender anterior nodes associated with phyaryngitis /tonsillitis; large tender nodes with skin erythema and fever occur 
in Kawasaki syndrome, Epstein-Barr virus infections and cat scratch disease; acute suppurative secondary to local 
staphylococcal skin infection, streptococcal tonsillopharyngitis or dental infection; chronic or subacute unilateral usually 
mycobacterial 

Tnbercnlosis: nodes usually in supraclavicular area or posterior cervical triangle, more commonly bilateral; 
pulmonary tuberculosis may be present; constitutional symptoms prominent 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, profuse 
sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; isolation; Brucella tube 
agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, complement fixation test, Coombs, 
fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 

Other Bacterial Infections: fever usually present; nodes may be warm and tender; pharyngitis may be 
present 

Toxoplasmosis: IgM-IFA, DS-IgM-ELISA, serial IgG tests; biopsy 
Differential Diagnosis: cat scratch disease (usually unilateral and suppurates — similar to nontuberculous mycobacterial 
infection; history of cat scratch; skin tests), infectious mononucleosis (blood picture, heterophil antibody test, specific tests 
for Epstein-Barr virus], lymphoma (involvement of other sites may be present), leukemia (blood picture, bone marrow 
examination) 
Treatment: 

Snppnrative: di/flucloxacillin 25 mg/kg to 500 mg orally 6 hourly for 7 d, cephalexin 12.5 mg/kg to 500 mg 
orally 6 hourly for 7 d 

Brucella: doxycycline 100 mg orally twice a day + rifampicin 600 mg orally 4 times a day or streptomycin 1 g 
i.m. 4 times a day for 45 d, ciprofloxacin 500 mg orally twice a day + rifmapicin 600 mg orally twice a day for 30 d 

Staphylococcus aureus: di/flucloxacillin 25 mg/kg to 500 mg orally 6 hourly for 7 d, cephalexin 12.5 mg/g 
to 500 mg orally 6 hourly for 7 d 

Corynebacterium pseudotuberculosis: erythromycin or penicillin + surgical drainage or excision 

Mycobacterium chelonae, Mycobacterium fortuitum: 2 of clarithromycin, doxycycline, ciprofloxacin, 
cotrimoxazole orally for 6-12 mo 

Listeria monocytogenes: erythromycin 500 mg orally 6 hourly (child: 30 mg/kg daily in 4 divided doses) for 
5d 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Other Mycobacteria: ethionamide, cycloserine, viomycin, ethambutol 

Francisella tularensis: streptomycin, tetracycline 

Yersinia pestis: streptomycin 

Fnngi: resection; amphotericin B, miconazole (not Aspergillus] 

Toxoplasma gondii: cotrimoxazole, sulphadiazine + pyrimethamine, spiramycin 
Lyihphadenopathy: 0.3% of new episodes of illness in UK 
Agents: in addition to the above specific infections, a number of agents cause more or less characteristic lymphadenopathy 

Preanricnlar: acute hemorrhagic conjunctivitis (in 77% of cases), epidemic keratoconjunctivitis (in 85% of cases) 

Postanricnlar: rubella (also suboccipital and postcervical) 

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Infections of the Reticuloendothelial System 

Cervical: 38% undiagnosed, 17% benign noninfectious causes, 13% cat scratch disease, 12% malignancy, 9% 
secondary to tonsillitis, sinusitis, parotitis, mastoiditis, otitis, 3% Toxoplasma gondii, 2% Streptococcus pyogenes,, 1% 
Staphylococcus aureus, 1% Mycobacterium tuberculosis, 1% anaerobes, 1% Epstein-Barr virus, 1% simplexvirus 3, mumps 
virus, tularemia, Lyme disease, Haemophilus parainfluenzas, Haemophilus aphrophilus, Streptococcus anginosus, Actinomyces 
israelii, Corynebacterium diphtheriae, human cytomegalovirus (rare), Kawasaki syndrome (68% of cases have an acute 
nonsuppurative cervical mass > 1.5 cm diameter) 

Axillary: anthrax, Pseudomonas aeruginosa whirlpool-associated dermatitis (painful; in 14% of cases), psittacosis 
(also enlarged red lymphoid follicles on posterior pharyngeal wall) 

Inguinal: anthrax, chancroid (in 32% of cases; tender, unilateral or bilateral), gonorrhoea, granuloma inguinale, 
herpes genitalis, lymphogranuloma venereum, Yersinia enterocolitica (bilateral) 

Near Primary Site of Infection: Chaga's disease, Pasteurella multocida, staphylococci, streptococci 

Generalised: human adenovirus 4 (in 7% of cases), human adenovirus 16 (in 58% of cases), AIDS (persisting 
3+ mo), algal infection, chromobacteriosis (in 11% of cases), cryptosporidiosis (in 14% of cases), Gambian trypanosomiasis, 
Rhodesian trypanosomiasis (fulminating), leprosy, protozoan infection, Rocky Mountain spotted fever (in 27% of cases; 13% in 
first 3 d), syphilis (primary and secondary) 

Diagnosis: clinical; ultrasound; serology; culture, histology and special staining of needle aspiration or extirpated node; PCR 
of biopsy for cat scratch disease 
Treatment: dependent on agent 

Lymphangitis occurs with Brugia malayi and Wuchereria bancrofti infections. Ascending lymphangitis is also seen (rarely) 
in tularemia. 

Mesenteric Lymphadenitis 

Agents: adenovirus (intussusception common), measles (in 15% of hospitalised cases), Yersinia pseudotuberculosis, Yersinia 
enterocolitica, Mycobacterium tuberculosis 

Diagnosis: viral and bacterial culture of biopsy; serology (monospecific saline agglutination titre > 1:128 in previously 
healthy individual; rise or fall in titre; indirect immunofluorescent antibody test) 

Yersinia pseudotuberculosis: ESR 10-105 mm/h, white cell count 5 500-18 500/j.iL 
Treatment: surgery if indicated 

Yersinia: gentamicin, cefotaxime, doxycycline, ciprofloxacin 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Cat Scratch Disease (Benign Inoculation Lymphoreticulosis, Benign Lymphoreticulosis, Benign 
Reticulosis, Cat Scratch Fever, Debrb-Mollaret Syndrome, Felinosis, Foshay-Mollaret Syndrome, 
Inoculation Adenitis, Lymphoreticulosis Benigna, Morbus Petzetakis, Nonbacterial Regional 
Lymphadenitis, Petzetakis Disease): usually benign; typical presentation (initial cutaneous lesion at site of 
inoculation, followed by regional lymphadenitis, which often leads to formation of fistulas through which enlarged 
suppurating lymph nodes drain) in 88% of cases, inoculation lesion (skin, eye, mucous membrane) in 59%, Parinaud's 
oculoglandular syndrome in 6%, encephalitis in 2%, severe or chronic systemic disease (including abdominal visceral 
granulomas) in 2%, erythema nodosum in 0.6%, pneumonitis in 0.2%, breast tumour in 0.2%, thrombocytopenia purpura in 
0.1%; also mesenteric adenopathy; fatigue, malaise, weight loss, progressively higher and longer recurring fevers, headache 
and hepatomegaly in HIV-infected patients; spread through cat flea feces 
Agent: Bartonella henselae 

Diagnosis: adenopathy only in 51%, fever in 31% (71% in AIDS), malaise/fatigue in 28% (36% in AIDS), headache in 13%, 
anorexia, emesis, weight loss in 13% (36% in AIDS), splenomegaly in 12%, sore throat in 9%, exanthem in 4%, conjunctivitis 
in 4%, swelling of parotid gland in 2%; severe systemic disease and multiple skin sites in 93% of AIDS patients infected; cat 
contact with presence of scratch or primary dermal or eye lesion; normal blood cells and differential count; Mantoux tests 
negative; serology for Epstein-Barr virus, human cytomegalovirus, Toxoplasma, fungal diseases, lymphogranuloma venereum, 
syphilis, human immunodeficiency virus, simplexvirus, tularemia, brucellosis and streptococci negative; skin test (cat scratch 
antigen; positive in 98-99% of cases; not in widespread use because antigen difficult to obtain and not standardised); 
characteristic histopathologic changes in lymph node or skin lesion; demonstration of small, pleomorphic bacilli in collagen 
fibres, in abscesses or in granulomas, stained by Warthin-Starry silver impregnation method, Brown-Hopps stain or 
immunoperoxidase stain; PCR; culture usually unsuccessful 

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Infections of the Reticuloendothelial System 

Treatment: spontaneous cure in 2-21 mo in normal patients; often severe in AIDS; azithromycin 10 mg/kg to 500 mg 

orally first day then 5 mg/kg to 250 mg orally once a day for 4 d; aspiration of abscesses or fluctuant nodes as necessary 

Prophylaxis: eradication of cat fleas 

Epstein-Barr virus Disease: widespread, particularly in young; « 14,000 cases/y (17 deaths/y) in USA; 0.01% of new 

episodes of illness in UK; transmitted by contact with external secretions (saliva); incubation period 7-14 d; inflammatory 

reaction in all reticuloendothelial organs 

Agent: Epstein-Ban virus; simplexvirus 6 primary infection in adults gives similar condition; human cytomegalovirus and 

Toxoplasma gondii give similar symptoms but without pharyngitis or heterophil agglutinins; lymphadenopathy and rash are 

rare with human cytomegalovirus 

Diagnosis: 

Children < 8 y: glandular fever: fever in 90%, splenomegaly in 60%, > 25% atypical lymphocytes in 55%, 
lymphadenopathy in 50%, hepatomegaly in 45%, abnormal liver function tests in 45%, lymphocytes > 50% of leucocytes in 
40%, exudative pharyngitis in 40%, heterophil antibody in 5%, autoantibodies absent 

Older Children, Yonng Adnlts, AIDS Cases and Organ Transplant Recipients: monocytic angina: 
sore throat + increased lymph glands 

Yonng Adnlts (15-30 y): infectious mononucleosis: lymphadenopathy in 95%, abnormal liver function tests in 
95%, lymphocytes > 50% of leucocytes in 90% (> 35% in all) and atypical lymphocytes in all cases (also present with 
adenovirus, human cytomegalovirus, simplexvirus, mumps virus, rubella virus, toxoplasmosis and viral hepatitis and as drug 
reaction to hydantoinates, paraaminosalicylic acid, phenylbutazone and sulphonamides) but with > 25% atypical lymphocytes 
in 45% (> 50% lymphocytes with > 10% atypical mononuclears sensitivity 39%, specificity 97%), continued fever in 85%, 
serum glutamic -pyruvic acid transaminase increased in 84%, serum glutamic-oxaloacetic acid transaminase increased in 83%, 
serum alkaline phosphatase increased in 81%, heterophil agglutinin antibody (Paul-Bunnell-Davidsohn test) positive (titre 
1:128 after absorption by guinea pig and ox cells) in 80-100%, exudative pharyngitis and sore throat (but without 
conjunctivitis or rhinitis) in 80%, serum gamma globulin increased in 72%, increased leucocytes but decreased neutrophils in 
60-80%, bone marrow granulomas in 50%, serum bilirubin increased in 43%, splenomegaly in 40-55%, serum albumin 
decreased in 36%, autoantibodies in 25%, platelet count slightly decreased in 25-50%, occult hemolysis in 20-40%, blood urea 
increased in 15-20%, rash in 10-20%, hepatomegaly in 10%, liver damage common; early antigen antibody > 1:20 (sensitivity 
90%, specificity 97%; indicates active infection; appears at 1-4 w, duration 6 mo); indirect fluorescent antibody titre or 
ELISA for IgG, IgA and IgM (viral capsid antigen antibody > 1:650 sensitivity 40%, specificity 100%; IgG appears rapidly 
after onset, peaks after 1-2 mo, slowly drops to « 1:320, maintained for life; IgM positive in acutely ill, peaks at 2-3 mo); 
EA:VCA > 0.031 (sensitivity 100%, specificity 97%); Epstein-Barr nuclear antigen antibody positive 2-52 w after onset, 
persists for life (Pasteur IgG ELISA kit 90% sensitivity, 95% specificity); (generally, VCA IgG negative, VCA IgM negative, 
EBNA IgG negative = negative; VCA IgG positive, VCA IgM positive, EBNA negative = recent infection; VCA IgG positive, 
VCA IgM negative, EBNA IgG positive = past infection); cold agglutinins in 10-50% of cases; mitochondrial cytoplasmic 
fluorescence may be seen in smooth muscle; serum leucine aminopeptidase inconsistently increased; rheumatoid factor may 
be present; possible complications include hemolytic anemia, aplastic anemia, thrombocytopenia, neutropenia, disseminated 
intravascular coagulation, airway obstruction, pneumonia, pleural effusion, myocarditis, pericarditis, aseptic meningitis, 
meningoencephalitis, encephalitis, transverse myelitis, peripheral neuritis, facial nerve palsy, optic neuritis, Guillain-Barre 
syndrome, hepatic necrosis, Reye's syndrome, splenic rupture 

Treatment: aspirin or paracetamol or nonsteroidal anti-iflammatory drug for pain (narcotic analgesics cotnraindicated); 
prednisolone 0.5 mg/kg for 1-2 w in patients with severe prostration, significant thrombocytopenia or hemolytic anemia; 
parenteral dexamethasone 0.5-1 mg/kg to 10 mg daily or hydrocortisone 100 mg 6 hourly in impending airway obstruction; 
famiclovir in severe cases; antimicrobials, especially ampicillin and amoxycillin, should be avoided unless there is concurrent 
infection with frank bacterial pathogens; drug reactions, especially skin reactions with ampicillin and amoxycillin 
(widespread maculopapular reaction), are common in this situation and occur also in other viral infections; if streptococcal 
pharyngitis is suspected, a 10 d course of penicillin or erythromycin should be given 

Nasopharyngeal Carcinoma: tumour of nasal passages and throat; affects up to 2% of people in Southern China; also in 
Southeast Asia, northern Africa and among Artie peoples; Epstein-Barr virus transforms epithelial cell (? + cocarcinogen in 
food) 

Burkitt's Lymphoma may be due to Epstein-Barr virus transforming B lymphocytes (evidence compelling but not 
conclusive; cofactor (? malaria) may be required 

Post-transplant Lymphoproliferative Disease: tumour often found in organ transplant patients 
Agent: ? Epstein-Ban virus 
Acute Infective Lymphocytosis: occurs in children 
Agent: ? enterovirus 

Diagnosis: absolute lymphocytosis persisting for 2-3 w, eosinophilia common; associated with abdominal pain, diarrhoea 
and vomiting 

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Infections of the Reticuloendothelial System 
Treatment: none 

Chronic Non-specific Infectious Lymphocytosis 
Agent: unknown 

Diagnosis: moderate leucocytosis with lymphocytosis lasting for months, low normal hemoglobin, normal platelet count and 
ESR; tests for infectious mononucleosis, human cytomegalovirus and toxoplasmosis negative 
Treatment: none 
Adult T Cell Leukemia 
Agent: human T-lymphotrophic virus 1 
Diagnosis: immunoprecipitation 
Treatment: as for other leukemias 

HUMRN IMMUNODEFICIENCY VIRUS (HIV) INFECTION/ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS): Worldwide; 

global prevalence (HIV infection) « 40 M (> 25 M in Subsaharan Africa; 36% of adult population in Botswana infected; 
malaria important cofactor); leading cause of death in Africa, causing 25% of deaths in South Africa, and fourth leading 
cause of death worldwide (« 20 M deaths to date); * 600 notified cases (« 500 deaths)/y in Australia; 0.1% of ambulatory 
care visits in USA; Pan troglodytes (chimpanzee) probable natural host and reservoir; majority of cases sexually transmitted 
by anal intercourse (risk 0.06-5% per contact), remainder by vaginal intercourse (risk 0.05-0.2% per contact male to female, 
0.03-6% female to male), shared use of needles (risk 0.7% per contact), transplantation, blood transfusion (risk 90% per 
contact), other exposure to contaminated blood (needle puncture risk 0.3% per contact), deep kissing infected individual with 
bleeding gums, oral sex (infection from fellatio very rare), congenital (« 750,000 HIV infected babies born/y globally; virus 
destroys T4 lymphocytes, weakening resistance to infection by a wide variety of bacteria, protozoa, fungi and viruses and 
causing an increased incidence of a number of carcinomas 
Agent: human immunodeficiency virus 

Diagnosis: patient history; fever in 87% of primary infections, skin rash in 50-68%; also night sweats, arthralgia, (40-80%) 
myalgia (40-80%), malaise, headache (40-80%), nausea (10-40%), vomiting (10-40%), diarrhoea (10-40%), anorexia, pharyngitis, 
weight loss (10-40% > 5 kg), lymphadenopathy (40-80%), sore throat (40-80%), fatigue (40-80%), retro-orbital pain, 
depression; on examination, 77% have abnormalities of oral cavity (10-40% ulcers), 73% of skin (10-40% genital ulcers) and 
57% of lymph nodes; 74% have thrombocytopenia (< 150X10 6 /mL); also leucopenia, meningitis, neuropathy, encephalopathy; 
in the absence of a known cause of immunosuppression (high dose or long term systemic corticosteroid therapy or other 
immunosuppressive/cytotoxic therapy, Hodgkin's disease, non-Hodgkin's lymphoma (other than primary brain lymphoma), 
lymphocytic leukemia, multiple myeloma, any other cause of lymphoreticular or histiocytic tumour, angioimmunoblastic 
lymphadenopathy, congenital immune deficiency syndrome or acquired immune deficiency syndrome (such as one involving 
hypogammaglobulinemia) atypical of human immunodeficiency virus infection, any disease that is indicative of a defect in 
cellular immune function (candidiasis of esophagus, trachea, bronchi or lungs; extrapulmonary cryptococcosis; human 
cytomegalovirus infection of organ other than liver, spleen or lymph node in patient > 1 mo; simplexvirus causing 
mucocutaneous ulcer persisting longer than 1 mo, or bronchitis, pneumonitis or esophagitis for any duration affecting patient 
> 1 mo; Kaposi's sarcoma or primary lymphoma in the CNS in patient < 60 y; meningitis, encephalitis, pneumonitis due to 
Pneumocystis jiroveci, Toxoplasma (patient > 1 mo), Aspergillus, Nocardia, Candida, Strongyloides, zygomycetes; lymphoid 
interstitial pneumonia and/or pulmonary lymphoid hyperplasia affecting a child < 13 y; progressive multifocal 
leucoencephalopathy; chronic cryptosporidial enterocolitis (diarrhoea persisting > 1 mo); disseminated (site other than or in 
addition to lungs, skin, cervical or hilar lymph nodes) atypical mycobateriosis (especially Mycobacterium avium-intracellulare 
complex or Mycobacterium kansasu), coccidioidomycosis, histoplasmosis, toxoplasmosis of the brain in > 1 mo, 2 or more 
bacterial infections (septicemia, pneumonia, meningitis, bone or joint infections) or abscess of internal organ or body cavity 
other than otitis media or superficial abscesses), or any patient with decreased T helper cells, decreased T helper/T 
suppressor ratio, increased serum globulins, decreased blastogenesis or anergy should be tested for possible AIDS 

Low Risk Individuals With No Known Exposnre: ELISA (false positives in multiparous women, those 
recently immunised against influenza or hepatitis B, those who have had multiple blood transfusions, and those with 
autoimmune disease, cirrhosis due to alcohol use, malaria, dengue or hepatitis B); confirmed with Western blot or 
immunofluorescence assay 

Low Risk Individuals With Possible Exposnre: ELISA + Western blot (frequent indeterminate reactions 
in absence of infection with some kits); repeated at 3, 6, 9 and 12 mo after possible exposure; p24 antigen capture if 
possible exposure within 6-12 w of evaluation or if patient has mononucleosis-like syndrome, followed by antibody test 4-6 
weeks later 

High Risk Individuals: ELISA and Western blot repeated at 6 w intervals; culture of peripheral blood 
lymphocytes or testing for proviral DNA in lymphocytes if negative 

AIDS (as opposed to human immunodeficiency virus infection) is diagnosed by laboratory evidence + presence of one or 
more of following diseases: multiple or recurrent septicemia, pneumonia, meningitis, bone or joint infection, or abscess of 
internal organ or body cavity (excluding otitis media or superficial mucosal abscesses) caused by Haemophilus, Streptococcus 

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Infections of the Reticuloendothelial System 

or other pyogenic bacteria in children < 13 y; disseminated or extrapulmonary coccidioidomycosis; human immunodeficiency 
rchtf-related encephalopathy; disseminated or extrapulmonary histoplasmosis; cryptosporidiosis or isosporidiosis with diarrhoea 
persisting > 1 mo; Kaposi's sarcoma; primary lymphoma of the brain; B cell non-Hodgkin's lymphoma; small noncleaved 
lymphoma or immunoblastic sarcoma of unknown immunologic phenotype; disseminated or extrapulmonary mycobacterial 
disease; pulmonary or extrapulmonary disease caused by Mycobacterium tuberculosis, recurrent nontyphoidal Salmonella 
septicemia; HIV wasting syndrome; candidiasis of esophagus, bronchi, trachea or lungs; human cytomegalovirus retinitis with 
loss of vision; human cytomegalovirus disease other than liver, spleen or nodes; lymphoid interstitial pneumonia and/or 
pulmonary lymphoid hyperplasia affecting a child < 13 y; Pneumocystis jiroveci pneumonia; toxoplasmosis of brain affecting 
patient > 1 mo; invasive cervical cancer; chronic ulcers (> 1 mo duration), bronchitis, pneumonitis or esophagitis due to 
simplexvirus, recurrent pneumonia; progressive multifocal leucoencephalopathy; in the absence of serological evidence, the 
diagnosis of AIDS will be accepted if all other indicators listed above are excluded and any of the indicator diseases listed 
above are present and the T helper/inducer (CD4 + ) lymphocyte count is < 200/VL; any patient with proven human 
immunodeficiency virus infection and with one or more of the indicator diseases listed above or with CD4 + T cell count < 
200/VL is to be considered as meeting the definition of AIDS; cases of human immunodeficiency virus infection with CD4 + 
counts > 200/|_lL are classified category B if they display any of the following symptoms: bacillary angiomatosis, 
oropharyngeal candidiasis, vulvovaginal thrush which is persistent or frequent or poorly responsive to therapy, moderate or 
severe cervical dysplasia/cervical carcinoma in situ, such constitutional symptoms as fever (38.5°C) or diarrhoea lasting > 
1 mo, oral hairy leucoplakia, shingles involving at least 2 distinct episodes or > 1 dermatome, idiopathic thrombocytopenic 
purpura, listeriosis, pelvic inflammatory disease (particularly if complicated by tubo-ovarian abscess), peripheral neuropathy; 
human immunodeficiency virus infections with CD4 + counts < 200/nL and any of the above conditions are grouped as 
category A 

Treatment: may be deferred until patient symptomatic or CD4 cell count < 350/ pL; [emtricitabine + tenofovir 200 + 
300 mg daily (not child) or lamivudine + zidovudine 150 + 300 mg 12 hourly (not child) or lamivudine 150 mg 12 hourly 
or 300 mg daily + tenofovir 300 mg daily (not child) or abacivir 300 mg 12 hourly or 600 mg daily + emtricitabine 200 
mg daily (not child) or abacivir + lamivudine 600 + 300 mg daily (not child) or didanosine (< 60 kg: 250 mg daily; 

> 60 kg: 400 mg daily) + emtricitabine 200 mg daily (not child) or didanosine (child: 120 mg/m 2 (150 mg/m 2 in 
neurological disease) 12 hourly; adult < 60 kg: 250 mg daily; > 60 kg: 400 mg daily) + lamivudine (child: 4 mg/kg to 
150 mg 12 hourly; adult: 150 mg 12 hourly or 300 mg daily)] + efavirenz (10-15 kg: 200 mg daily; 16-20 kg: 250 mg daily; 
20-25 kg: 300 mg daily; 25-32.5 kg: 350 mg daily; 32.5-40 kg: 400 mg daily; > 40 kg: 600 mg daily; not in pregnant or 
likely to become pregnant) or nevirapine 120 mg/m 2 to 200 mg daily for 2 w then 12 hourly (not in women with CD4 cell 
count > 250/ pL or men with CD4 cell count > 400/ pL) delavirdine 400 mg 8 hourly (not < 12 y) or lopinavir + 
ritonavir 400 + 100 mg 12 hourly (child > 2 y: 230 + 57.5 mg/m 2 12 hourly) or atazanavir 400 mg daily or 300 mg daily 
+ ritonavir 100 mg daily (not child) or fosamprenavir 700 mg + ritonavir 100 mg 12 hourly (not child) or fosampernavir 
1400 mg + ritonavir 200 mg daily (treatment naive only; not child) or indinavir 800 mg 8 hourly (not child) or 800 mg + 
100 mg ritonavir 12 hourly (not child) or nelfinavir 25-35 mg/kg to 750 mg 8 hourly or 45-55 mg/kg to 1250 mg 12 hourly 
or saquinavir 1200 mg 8 hourly (soft gel capsules only; not child) or 1000 mg + ritonavir 100 mg 12 hourly (not child) 

Treatment Failnre: enfuvirtide 2 mg/kg to 90 mg s.c. 12 hourly (not < 6 y) 
Prophylaxis: 

Low Risk Exposnre: lamivudine + zidovudine 4+10 mg/kg to 150 + 300 mg orally 12 hourly for 4 w, 
emtricitabine + tenofovir 200 + 300 mg orally daily for 4 w 

High Risk Exposnre: lopinavir + ritonavir 400 + 100 mg orally 12 hourly for 4 w, nelfinavir 25 mg/kg to 
1.25 g orally 12 hourly for 4 w 

Pregnancy: zidovudine + caesarean section (2% risk of vertical transmission) 
HIV Wasting Syndrome 
Agent: human immunodeficiency virus 

Diagnosis: human immunodeficiency virus infection + profound involuntary weight loss of > 10% of baseline body 
weight + either chronic diarrhoea (at least 2 loose stools/d for > 30 d) or chronic weakness and documented fever (for 

> 30 days; intermittent or constant) in absence of a concurrent illness or condition other than human immunodeficiency 
virus infection that could explain the findings (eg, cancer, tuberculosis, cryptosporidiosis or other specific enteritis) 
Treatment: as for AIDS + increased fluids, calories and protein, smoking cessation, regular exercise; recombinant growth 
hormone for muscle wasting 

Virus-associated Heihophagocytic Syndrome: fulminant disorder associated with systemic viral infection 
Agents: Epstein-Barr virus, human cytomegalovirus, adenovirus, simplexvirus 1 and 2 , human herpesvirus 6 
Diagnosis: multiple organ infiltration of hemophagocytic histiocytes into lymphoreticular tissues 
Treatment: supportive 



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Chapter 11 

Infections of the Skeletal System 

Joint Pain in Children 
Single Joint: 

Without Constitntional Symptoms: chondromalacia patellae, osteochondritis dissecans, other 
osteochrondritides, Osgood-Schlatter's disease, Sever's disease, Pertle's disease, slipped femoral epiphysis 

Signs of General Disease: leukemia, histiocystosis, sickle cell hemoglobin 

With Constitntional Upset: acute infections of joints and bones, juvenile rheumatoid arthritis, 
Henoch-Schonlein purpura, sickle cell hemoglobin, subacute bacterial endocarditis 

Multiple Joints: juvenile rheumatoid arthritis and other connective tissue disorders, multiple septic arthritis or 
osteomyelitis, rheumatic fever, anterior poliomyelitis, rickets, scurvy, purpura, non-accidental injury 
Arthritis 

Agents: Reiter syndrome (48% of inflammatory arthritis in young men; oligoarticular and asymmetrical, predominantly 
lower extremity), ankylosing spondylitis (18% of inflammatory arthritis in young men), rheumatoid arthritis (8% of 
inflammatory arthritis in young men), psoriatic arthritis (7% of inflammatory arthritis in young men), systemic lupus 
erythematosus (5% of inflammatory arthritis in young men), acute rheumatic fever (3% of inflammatory arthritis in young 
men), Behcet's disease (2% of inflammatory arthritis in young men), gouty arthritis (2% of inflammatory arthritis in young 
men), Henoch-Schonlein purpura (2% of inflammatory arthritis in young men; may be complication of Epstein-Ban virus 
infection), septic arthritis (1% of inflammatory arthritis in young men), Crohn's arthritis (1% of inflammatory arthritis in 
young men), sarcoid arthritis (1% of inflammatory arthritis in young men), Lyme arthritis (in 52% of cases; 29% knee, 14% 
shoulder, 12% hip, 11% ankle, 9% wrist, 8% hand, 6% foot, 3% toes), yersinosis (in 11% of Yersinia enterocolitica and 55% of 
Yersinia pseudotuberculosis cases), Kawasaki syndrome (in 29% of cases), dermatomyositis (in 25% of cases), acute viral 
hepatitis (in 15% of cases), scleroderma (localised form; in 10% of cases), brucellosis (arthritis in 9% of cases; arthralgia in 
55%), Ross River virus (poly, especially knees and wrists), rubella virus (transient poly), Mucha-Habermann disease, 
osteochondrosis (limited to maturing lower skeleton), Sweet's syndrome, Takayasu's arteritis 
Diagnosis: erythrocyte sedimentation rate 47 mm/h in ankylosing spondylitis, elevated in all cases of foreign body 
arthritis, 90% of discitis cases, 80% of cases of Kawasaki syndrome, also in Mucha-Habermann disease, multicentric 
osteomyelitis (mild to moderate), Sweet's syndrome and Takayasu's arteritis 
Synovial Fluid Examination: 

Normal: straw-coloured, clear, no fibrin clot, good mucin clot, < 200 leucocytes/ jliL, < 25% 
polymorphs, glucose « 100% blood level 

Reiter syndrome: turbid, large fibrin clot, fair to poor mucin clot, 5000-50,000 leucocytes/ jliL, 

> 50% polymorphs, glucose « 75% blood level 

Ankylosing Spondylitis: turbid, large fibrin clot, fair to poor mucin clot, 5000-50,000 leucocytes/ (.iL, 

> 50% polymorphs, glucose « 75% blood level 

Rheumatoid Arthritis: clear to turbid, large (2-4+) fibrin clot, fair to poor mucin clot, 
5000-50,000 leucocytes/^, > 66% polymorphs, glucose « 50-75% blood level 

Psoriatic Arthritis: turbid, large fibrin clot, fair to poor mucin clot, 5000-50,000 leucocytes/(.iL, 

> 50% polymorphs, glucose « 75% blood level 

Acute Gout or Pseudogout: turbid, large (2-4+) fibrin clot, fair to poor mucin clot, 
5000-50,000 leucocytes/^, > 70% polymorphs, glucose « 90% blood level 

Rheumatic Fever: slightly turbid, 1-2+ fibrin clot, good mucin clot, 18,000 leucocytes/jaL, 50% 
polymorphs, difference between blood and synovial fluid glucose = 10 

Tuberculous Arthritis: turbid, large (2-3+) fibrin clot, poor mucin clot, « 20,000-25,000 
leucocytes/ |.iL, polymorphs variable (usually 60%), glucose < 50% blood level; acid-fast stain positive in 20%, cultures 
positive in 80%, biopsy positive in 95% 

Other Bacterial Septic Arthritis: very turbid or purulent, large (2-4+) fibrin clot, poor mucin clot, 
10,000-100,000 leucocytes/nL, > 80% polymorphs, glucose < 50% blood level; Gram stain positive in 50-75%, culture 
positive 

Candida Septic Arthritis: 46,000-56,000 leucocytes/ (.iL, 79-97% polymorphs, glucose 
18-113 mg/dL, protein 2.8-3.7X serum 

Arthritis Associated With Intestinal Diseases: turbid, large fibrin clot, fair to poor mucin clot, 
5,000-50,000 leucocytes/|jIi, > 50% polymorphs, glucose « 75% blood level 

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Infections of the Skeletal System 

Degenerative Joint Disease: clear to slightly turbid, small (0-1+) fibrin clot, good mucin clot, 
« 700-2000 leucocytes/^, < 25% polymorphs, glucose « 100% blood level 

Foreign Body Arthritis: « 60% inflammatory 

Tranmatic Arthritis: straw-coloured, bloody or xanthochromic, small (0-1+) fibrin clot, good mucin 
clot, 50-1200 leucocytes/|jIi, < 25% polymorphs, glucose « 100% blood level, protein 2-3X normal 
Reactive Arthritis (Reiter Syndrome) 

Agents: Shigella, Salmonella, Yersinia enterocolitica, Yersinia pseudotuberculosis, Campylobacter (hips and lower back; 
uncommon), Vibrio parahaemolyticus, Clostridium difficile, Chlamydia, human immunodeficiency virus, Cyclospora, others 
Diagnosis: micro and culture of synovial fluid (very high cell count, glucose 80 mg/dL, culture negative), blood tests 
(moderate anemia, moderate neutrophilia, ESR raised; Rose-Waaler and latex negative; serology may be positive; specific 
organisms may be cultured); culture of feces (for enteric organisms listed); culture and immunofluorescence of any urethral 
discharge; HLA typing 

Shigella: typically sets in 10 d after enteritis; days 1-11 urethritis, days 3-7 conjunctivitis, day 4-month or more 
polyarthritis (may become permanent or recurrent, with erythrocyte sedimentation rate increased in each recrudescence) 
Yersinia: in adults, joint symptoms resembling rheumatoid arthritis; in children, polyarthritis and erythema 
nodosum resembling rheumatic fever; direct agglutination test, indirect immunofluorescence of intestinal biopsy 
Treatment: appropriate antimicrobial treatment of any relevant organisms isolated [Shigella, Salmonella, Yersinia: 
gentamicin, cefotaxime, doxycycline, ciprofloxacin; Campylobacter, erythromycin; Clostridium difficile: metronidazole, 
vancomycin; Chlamydia: tetracycline, doxycycline, erythromycin); bed rest and aspirin; phenylbutazone + indomethacin 
Ankylosing Spondylitis: chronic arthritis of spine; immune response to bacterial antigen cross-reacts with joint antigen, 
giving autoimmune damage; strong association with HLA B27 genotype 
Agent: Klebsiella 

Diagnosis: synovial fluid examination; HLA typing 
Treatment: phenylbutazone + indomethacin 

Rheumatic Fever: an acute febrile disease occurring as a sequela, nearly always after a latent period of 2 to several 
weeks, to an untreated or inadequately treated streptococcal respiratory tract disease (especially pharyngitis) 
Agent: Streptococcus pyogenes 

Diagnosis: manifestations and their severity vary widely, but usually (« 75% of cases) include polyarthritis with intense 
migrating arthralgia; there may be no objective features or clinically evident arthritis with heat, redness, swelling and 
tenderness; knees, ankles, elbows and wrists most affected joints; > 1 joint involved in « 50% of patients; with therapy, 
average duration of attacks is about 3 mo; carditis occurs in about 1/3 of cases; chorea is not common and erythema 
marginatum and subcutaneous nodules are now even less so, but these conditions are diagnostically important should they 
occur 

Prophylaxis: benzathine penicillin (< 20 kg: 450 mg; > 20 kg: 900 mg) i.m. at 3-4 weekly intervals or 
phenoxymethylpenicillin 250 mg orally 12 hourly or (if penicillin hypersensitive) erythromycin 250 mg orally 12 hourly or 
erythromycin ethyl succinate 400 mg orally 12 hourly; continue minimum 5 y (until at least 18 y) if without carditis or 
evident valve disease, minimum 10 y (until at least 25 years) if mild or moderate carditis or mild residual valve disease, for 
life if severe carditis or moderate to severe residual valve disease, or before surgery 
Septic Arthritis: can be life threatening and frequently associated with significant morbidity 
Agents: almost any organism may be introduced directly or hematogenously; Staphylococcus aureus (63% of hospital 
admissions; neonates, children over 2 y, 25% of total adult cases, usually chronic underlying disease, especially diabetes and 
rheumatoid arthritis; also Stage I and Stage III prosthetic infections; most common cause of chronic infective arthritis; 17% 
methicillin resistant), 20% streptococci (mainly Streptococcus pyogenes (15% of total adult cases; hematogenous spread from 
respiratory or skin infection; also Stage III prosthetic infections), Streptococcus agalactiae (Stage III prosthetic infections), 
Streptococcus pneumoniae (50% primary focus in lung, middle ear; associated meningitis, endocarditis; alcohol abusers; 6% of 
community acquired infections; mortality 19% in adults, <1% in children; 56% in knee in adults; bacteremia in 72% of adult 
cases), Group C streptococci), Enterococcus faecalis (seventh most common cause of chronic infective arthritis), 10% Gram 
negative bacilli (chronic debilitating diseases, such as diabetes, malignancy, immunosuppressive drugs; urinary tract infection 
may precede; neonates; alcoholics; also Stage III prosthetic infections; Proteus second and Klebsiella fifth most common cause 
of chronic infective arthritis; Haemophilus influenzae (infants 1-18 mo, young children, debilitated adults; preceding 
meningitis in 30%, osteomyelitis in 22%; 8% of all Haemophilus influenzae systemic disease in children), Haemophilus 
parainfluenzae, Brucella (in 9-37% of infections), Salmonella (< 20 y; related to sickle cell disease; Salmonella typhi (fourth 
most common cause of chronic infective arthritis), Salmonella paratyphi C, Salmonella choleraesuis, Salmonella typhimurium 
(in renal transplant recipients), Capnocytophaga, Mycoplasma hominis (associated with prostheses), Eikenella corrodens (in 
50% of infections related to human bites or fist fight injuries), Kingella kingae (mainly infants and young children; ~ '/a of 
cases in knee), Pseudomonas aeruginosa (complicating puncture wounds of foot in children; i.v. drug abusers; third most 
common cause of chronic infective arthritis), Burkholdeia cepacia, Serratia marcescens (i.v. drug abusers; may involve 

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sternoclavicular or sacroiliac joint), Moraxella catarrhalis (rare), Ureaplasma urealyticum (in hypogammaglobulinemia), 
Streptobacillus moniliformis (rare complication of rat-bite fever), Campylobacter fetus subsp fetus (uncommon), Moraxella 
osloensis (rare), Pasteurella multocida (polyarticular) and Pasteurella pneumotropica (dog and cat bite or exposure), 
Haemophilus paraprophilus, Legionella pneumophila (1 case reported in immunosuppressed patient)), 4% Mycobacterium 
tuberculosis (reactivation of latent disease; chronic, insidious, monoarticular; knee most common; most do not have 
concomitant active pulmonary tuberculosis; PPD almost always positive; differs from Poncet's disease, which is polyarthritis 
occurring during acute tuberculosis infection but in which no mycobacterial infection can be found), Neisseria gonorrhoeae 
(gonococcal arthritis (blenorrhagic arthritis, gonorrhoeal arthritis); 17% of community acquired infections; 50% of total adult 
cases; arises as a consequence of disseminated gonococcal disease; previously healthy adult, predominates in young women, 
often within 1 w of onset of menses or last trimester of pregnancy; initial migratory polyarthritis, synovitis or tenosynovitis 
(wrist, dorsum of hands or feet, Achilles' tendon), typical skin lesions during septicemic phase of disseminated gonococcal 
disease or localised arthritis, often with purulent joint fluid, in post-septicemic stage; knee or wrist most common), Neisseria 
meningitidis (2% of meningococcal infections; in 5% of children and 11% of adults with acute meningococccal disease 
(allergic, hemarthrosis and iatrogenic probably more common than septic); oligoarticular; appears as meningitis is resolving; 
also in chronic meningococcemia and primary infections), Staphylococcus epidermidis (catheter induced in neutropenics; Stage 
I and Stage III prosthetic infections; sixth most common cause of chronic infective arthritis), Listeria monocytogenes (rare), 
anaerobes (Stage II prosthetic infections), Rrcanobacterium haemolyticum (posttraumatic), Corynebacterium xerosis (following 
vascular surgery), kcanobacterium pyogenes, Corynebacterium diphtheriae, Corynebacterium kutscheri, Neisseria mucosa 
(rare), Erysipelothrix rhusiopathiae, Candida [Candida albicans and Candida tropicalis 17% of hospital acquired infections; 
especially in knee in cancer patients; insidious onset, indolent course; may occur in debilitated patient; males > females; 
usually 40s-50s; also Candida parapsilosis and Candida glabrata in prostheses), Scedosporium (penetrating trauma, surgery) 
Diagnosis: mono- or oligoarticular, lower > upper extremity, fever, local inflammation, pain with motion; micro 
(predominance of polymorphs), culture (mycobacteria and Legionella in Bactec 13A medium), counterimmunoelectrophoresis 
and latex agglutination of synovial fluid; blood cultures; white cell count 18,000-100,000/nL; increased erythrocyte 
sedimentation rate 

Brucella: acute or insidious onset with continued, intermittent or irregular fever of variable duration, profuse 
sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia, generalised aching; isolation; Brucella tube 
agglutination titre on serum > 160; ELISA (IgA, IgG, IgM), 2-mercaptoethanol test, complement fixation test, Coombs, 
fluorescent antibody test, antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 
Treatment: surgical drainage in all hip joint infections, inadequate closed drainage, persistent febrile course, inaccessible 
joint; needle drainage in other cases except prosthetic, where resection of prosthesis and all foreign bodies (including cement 
fragments) and debridement of involved tissues is required (especially in fungal infections) 

Organism Not Known: 

< 5 y Old: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly for 3-6 d + cefotaxime 50 mg/kg to 2 g 
i.v 8 hourly or ceftriaxone 50 mg/kg to 2 g i.v. once daily for 3-6 d, then di(flu)cloxacillin 12.5 mg/kg to 500 mg orally 6 
hourly or (if Haemophilus influenzae likely) amoxycillin-clavulanate 15 mg/kg to 500 mg orally 8 hourly for minimum 21 d 
total 

Sexually Active Yonng Adnlt: single dose ceftriaxone 125 mg i.m or single dose ciprofloxacin 
500 mg orally + doxycycline 100 mg twice a day for 7 d 

Adnlt: flucloxacillin + gentamicin or flucloxacillin + oral ciprofloxacin 
With Prosthesis: vancomycin + third generation cephalosporin 

Neisseria: benzylpenicillin 150 000 U/kg i.v. daily in divided doses for 7 d, ceftriaxone 50 mg/kg to maximum 
3 g i.v. daily for 7 d, cefoxitin 100 mg/kg i.v. daily in divided doses for 7 d, erythromycin 50 mg/kg daily orally in 4 
divided doses for 7 d 

Kingella kingae: benzylpenicillin 4 MU i.v. at once, then 2 MU i.v. 4 hourly (neonates: 100,000 U/kg daily in 
3 or 4 divided doses; < 45 kg: 250,000 U/kg daily in divided doses) for at least 10 d, followed by phenoxymethylpenicillin 
1 g orally 6 hourly for 3-7 w (< 12 y: 25-50 mg/kg orally daily in 4 divided doses) 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 



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Infections of the Skeletal System 

Staphylococcus aureus: di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly for 2-4 w, then di(flu)cloxacillin 
25 mg/kg to 1 g orally 6 hourly for at least 6 w total + probenecid 10 mg/kg to maximum 500 mg orally 6 hourly for 
minimum 6 w total; if methicillin resistant, vancomycin 20 mg/kg to 1 g i.v. slowly 12 hourly for 2-6 w, then rifampicin 
7.5 mg/kg to 300 mg orally 12 hourly + sodium fusidate 12 mg/kg to 500 mg orally 12 hourly 

Penicillin Hypersensitive: cephalothin 50 mg/kg to 2 g i.v. 6 hourly or cephazolin 25 mg/kg to 
1 g i.v. or i.m. 8 hourly, then cephalexin 25 mg/kg to 1 g orally 6 hourly; if severe, clindamycin 10 mg/kg to 450 mg i.v. 
slowly 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly, then clindamycin 300-450 mg orally 6-8 hourly (child: 
10 mg/kg to 450 mg orally 6 hourly) 

Streptococci, Capnocytophaga, Rrcanobacterium haemolyticum, Streptobacillus 
moniliformis: benzylpenicillin 100 000-150 000 U/kg/d i.v. for 10-14 d (4 w for Streptococcus pneumoniae) 

Brucella: streptomycin 1 g twice a day i.m. for 14-21 d + rifampicin 900 mg/d orally for 45 d + doxycycline 
100 mg orally twice daily for 45 d 

Haemophilus influenzae, Eikenella corrodens: cefotaxime 2 g i.v. 4 hourly (child: 200 mg/kg daily in 4 
divided doses) or ceftriaxone i.v. for 4-6 days, then amoxycillin-clavulanate for total period of 21 d; chloramphenicol 

Listeria monocytogenes: ampicillin 2 g i.v. 8 hourly for 10 d, then amoxycillin 500 mg orally 3 times daily 

Salmonella: joint aspiration, surgical drainage; chloramphenicol 500 mg orally 6 hourly (child > 2 w: 50 mg/kg 
orally daily in 4 divided doses; premature, newborn and those with immature metabolism: 25 mg/kg daily in 4 divided 
doses) for 15 d 

Coliforms, Pseudomonas aeruginosa, Serratia marcescens: gentamicin or tobramycin 5 mg/kg/d i.v. 
for 4-6 w (+ ticarcillin in immunocompromised host with Pseudomonas aeruginosa) 

Burkholderia cepacia: imipenem 

Corynebacterium: i.v. cefotaxime 2 g 3 times daily for 21 d, followed by oral erythromycin 500 mg 4 times 
daily for 14 w 

Campylobacter fetus snbsp fetus: gentamicin, erythromycin, amoxycillin-clavulanate 

Mycoplasma hominis: ciprofloxacin 750 mg twice daily, tetracycline, doxycycline 

Ureaplasma urealyticum: tetracycline, doxycycline 

Candida tropicalis, Candida glabrata: amphotericin B 

Other Candida: oral ketoconazole + i.v. miconazole, amphotericin B 

Scedosporium: debridement 
Test of Progress: complement fixation 
Viral Arthritis 

Agents: Ross River virus, Barmah Forest virus, hepatitis A virus, hepatitis B virus (in 10-42% of cases; usually preicteric), 
hepatitis C virus, mumps virus (polyarticular or monoarticular; mainly adult males; self-limited), infectious mononucleosis (in 
5-10% of cases), human cytomegalovirus, simplexvirus 1, human echovirus, simplexvirus 3, adenovirus (in 8% of human 
adenovirus E serotype 4 infections), group A arboviruses (rash, encephalitis, nephritis and hemorrhage), human rubella virus 
(usually adult women; fingers, wrists and knees; also vaccine), human parvovirus B19 

Diagnosis: arthralgias common; usually transient; fever; leucocytosis with neutrophilia, raised erythrocyte sedimentation 
rate, mild anemia; agglutinations (paired sera 2 w apart) 

Human parvovirus B19: PCR on synovial fluid or joint aspirate, dot hybridisation, capture ELISA (IgG) on 
serum 

Treatment: corticosteroids, non-steroidal anti-inflammatory drugs (not aspirin) 

Arthralgia also occurs in 77% of dengue cases (poly), 73% of acute schistosomiasis attacks, 73% of cases of 
Mediterranean spotted fever, 56% of influenza A cases, 50% of cases of Rocky Mountain spotted fever, 35% of human 
immunodeficiency virus infections, 25% of loiasis, in infections with Bacillus anthracis, Coxiella burnetii, Francisella 
tularensis, Listeria monocytogenes, Pasteurella multocida and Streptobacillus moniliformis, in malaria, Marburg virus disease, 
plague, psittacosis (generalised) and Rift Valley fever; also in arthromyalgia, leukemia (severe) and pigmented villonodular 
synovitis (+ swelling; knee, hip, ankle, tarsus, elbow) 

Osteomyelitis and Osteochondritis: secondary to an adjacent infection (overlying abscesses or burns, but usually 
from decubitus ulcers in patients without generalised vascular insufficiency and due to Staphylococcus, Gram negative bacilli 
(especially Pseudomonas aeruginosa) and anaerobes; in patients with generalised vascular insufficiency, such as with 
diabetes or peripheral vascular disease, the small bones of the feet are most commonly infected with Staphylococcus, 
Enterococcus, Gram negative bacilli and anaerobes), while necrotising/malignant otitis externa (usually due to Pseudomonas) 
also occurs; osteomyelitis of the fingers is a common complication of fingertip abscess); hematogenous (femur or tibia 
involved in most childhood cases; vertebrae next most common — 45% lumbar, 35% thoracic, 10% cervical, 10% 
thoracicolumbar, 10% lumbosacral, 20% due to Staphylococcus, 15% Gram negative rod, 3% Streptococcus, 30% from a 
genitourinary infection, 5% from skin, 5% from respiratory, less acute in adults and surgery is usually not necessary but 
10% suffer paraplegia and 5% die; long bone infection is commonly a reactivation and due to Staphylococcus, 

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Infections of the Skeletal System 

Peptostreptococcus, Pseudomonas aeruginosa); due to penetrating wounds (animal bites, iatrogenic heel puncture in children, 
other puncture wounds of the foot; Pseudomonas most common); due to compound fracture; due to infection of prosthesis; 
postoperative (postoperative pubic osteomyelitis may be misdiagnosed as osteitis pubis); multifocal (typical in neonates and 
drug addicts); 30% femur, 25% tibia, 15% vertebra, 10% humerus, 5% pelvis, 5% fibula, 5% tarsal, 2% radius, 2% rib 
Agents: 55% Staphylococcus aureus (60% in children; 30% of neonatal; most common cause of osteomyelitis secondary to 
contiguous focus), 22% Staphylococcus aureus + anaerobes, 5% anaerobes alone (Bacteroides fragilis, Peptostreptococcus, 
Propionibacterium, Actinomyces, rare Veillonella parvula), 5% Streptococcus pyogenes, 3% Pseudomonas aeruginosa (66% in 
drug abusers; spine, sacroiliac joint, sternoclavicular joint, symphysis pubis, as well as usual large joints, in these patients; 
second most common cause of osteomyelitis secondary to contiguous focus), 2% Streptococcus pneumoniae (< 1% in 
children), 1% Mycobacterium tuberculosis (lower thoracic, proximal femur, distal femur, proximal tibia, ankle); Streptococcus 
cam's (sacroiliitis), Streptococcus agalactiae (40% of neonatal), other p-hemolytic streptococci (including Group C), 
Streptococcus viridans, enterococci, Streptococcus milled, Streptococcus equinus (rare spondylodiskitis and vertebral 
osteomyelitis as complication of endocarditis), coagulase negative staphylococci, Escherichia coli, Klebsiella, Enterobacter, 
Proteus, Serratia (spine, sacroiliac joint, sternoclavicular joint, symphysis pubis as well as usual large joints, in drug 
addicts), Mycobacterium fortuitum (emerging pathogen in AIDS), Haemophilus influenzae (3% of non-bacteremic invasive 
Haemophilus influenzae infections in older children and adults), Brucella, Salmonella (associated with hemoglobinopathies, 
particularly sickle cell disease; more likely in patients with lymphoma or connective tissue disorders), Neisseria meningitidis, 
Neisseria sicca (following back injury), Aeromonas (post-traumatic), Clostridium botulinum (in wound botulism), Listeria 
monocytogenes, Capnocytophaga, Eikenella corrodens (in 50% of Eikenella corrodens infections related to human bites or fist 
fight injuries), Nocardia asteroides, Haemophilus aprophilus (rare vertebral), Haemophilus parainfluenzas (vertebral), Shigella 
kingae (mainly infants and young children), Actinobacillus actinomycetemcomitans (uncommon), Vibrio vulnificus (trauma in 
seawater), Burkholderia cepacia (cervical), Moraxella osloensis (rare), Acinetobacter calcoaceticus, Ochrobacterium antropi 
(puncture wound), Providencia, Plesiomonas shigelloides, Pasteurella multocida and Pasteurella pneumotropica (dog and cat 
bite or exposure), Haemophilus haemoglobinophilus, Haemophilus paraprophilus, Mycobacterium intracellulare, Mycobacterium 
simiae (infrequent), mixed aerobes and anaerobes (skull or facial bones secondary to ENT procedures; long bone compound 
fractures; pelvic bone secondary to intraabdominal sepsis; hand secondary to bites, especially human; foot associated with 
vascular insufficiency and/or diabetes; cervical spine secondary to retropharyngeal abscess), Bartonella henselae (vertebral), 
Candida (especially in drug abusers, also periprosthetic; vertebral in lengthy treatment with broad spectrum antibiotics, major 
surgery, hyperalimentation, neutropenia, sternal in coronary artery bypass grafting), Aspergillus (predisposing factors, liver 
transplantation), Drechslera (associated with prior surgery), Scedosporium (penetrating trauma, surgery), Cryptococcus 
neoformans 

Diagnosis: X-ray (82% of cases of vertebral osteomyelitis show intervertebral disc space narrowing); micro and culture of 
aspirate, swab or biopsy; blood cultures; counterimmunoelectrophoresis of serum; erythrocyte sedimentation rate usually 
elevated; white cell count (acute: 7400 - 73,000/nl (mean 21,100/nL); chronic traumatic: 8300 - 12,700/nl (mean 
9800/jliL); chronic prosthetic: 8300/|.iL); fluorodeoxyglucose-positron emission tomography 96% accurate for hip prothesis, 
81% for knee prosthesis, 91% for other osteomyelitis 

Neonatal: 40% multiple bone involvement (never with Streptococcus agalactiae); increasing incidence of 
Escherichia coir, often secondary to complications during pregnancy or delivery (preeclampsia, premature rupture of 
membranes, etc); also iatrogenic — heel or scalp resulting from infected heel-stick or phlebitis; septic arthritis in 70% of 
staphylococcal and 35% of Streptococcus agalactiae cases; fever in 66% of total cases, 40% of staphylococcal infections, 
never in Streptococcus agalactiae cases; white cell count > 210,000/nL in 40% of staphylococcal and 10% of Streptococcus 
agalactiae infections; swelling in 75% of patients, decreased movement in 55%, erythema in 30%, tenderness in 15% 

Children: bone pain, limp or disuse in all, fever in 85%, joint pain in 66%, history of injury in 45%; 30% femur 
(60% proximal, 30% distal, 10% middle), 30% tibia (50% distal, 45% proximal, 5% middle), 10% pelvis, 10% humerus, 10% 
fibula, 3% radius; 20% complicating septic arthritis, 20% growth disturbance, 15% restricted motion, 15% deformity, 15% 
draining sinus, 10% recurrence, 5% chronicity, 5% pathologic fracture, 1% death 

Aspergillus: 1,3-p-D-glucan levels increased 
Differential Diagnosis: cellulitis, bone infarction, subperiosteal hematoma, traumatic periostitis, bone cyst, eosinophilic 
granuloma, osteitis deformans, neurofibromatosis, monoarticular rheumatoid arthritis, osteodystrophy in patient on long term 
dialysis, recurrent multifocal osteomyelitis with pustularis palmoplantaris (very rare, apparently noninfectious), multiple 
myeloma, primary or metastatic malignancy, congenital syphilis, pyomyositis, wound infection, soft tissue abscess, acute 
rheumatic fever, septic arthritis 

Treatment: debridement of necrotic bone and loculated purulence, reestablishment of vascularity, grafting bony defects, 
removal of prostheses; surgery if development of neurological abnormalities in vertebral or cranial osteomyelitis or if spread 
to hip joint in child; nonsteroidal antiinflammatory drugs +: 

General Empirical: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly 

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Infections of the Skeletal System 
Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 hourly; 
cephazolin 50 mg/kg to 2 g i.v. 8 hourly 

Immediate Penicillin Hypersensitive: vancomycin 25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 
1 g) i.v. 12 hourly by slow infusion (monitor blood levels and adjust dose accordingly) 

Acnte Neonatal: gentamicin 5-7.5 mg/kg i.v. daily in 2 or 3 divided doses + cloxacillin/flucloxacillin 
200 mg/kg daily i.v. in 3 divided doses for 14 d + fusidic acid 20 mg/kg 12 hourly by i.v. infusion over 2 h for 14 d, 
followed by cloxacillin/flucloxacillin orally for 6 mo 

Gram Negative Infection Snspected, Child < 5 y Not Immnnised Against Haemophilus 
influenzae type b: cefotaxime 50 mg/kg to 2 g i.v. 8 hourly; ceftriaxone 50 mg/kg to 2 g i.v. daily + di/flucloxacillin 
50 mg/kg to 2 g i.v. 6 hourly 

Diabetic Foot or Contignons Ulcer: debridement or surgery, biomechanical offloading of mechanical 
impediments to wound healing; ciprofloxacin or clindamycin or piperacillin-tazobactam or ampicillin-sulbactam + 
aminoglycoside for 4-6 w; rifampicin 600 mg twice daily + ofloxacin 200 mg 3 times daily for 6 mo 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Mycobacterium fortuitum, Nocardia asteroides: 2 of clarithromycin, doxycycline, ciprofloxacin, 
cotrimoxazole orally for 6-12 mo 

Streptococci: benzylpenicillin 4 MU i.v. once then 2 MU i.v. 4 hourly (child: 150 000-250 000 U/kg daily in 4 
divided doses), followed by phenoxymethylpenicillin 1 g orally 6 hourly for 3-7 w (< 12 y: 25-50 mg/kg orally daily in 4 
divided doses); drainage at operation and removal of any prosthesis 

Methicillin Snsceptible Staphylococcus aureus: di/flucloxacillin 50 mg/kg to 2 g i.v. 6 hourly, then 
di/flucloxacillin 25 mg/kg to 1 g orally 6 hourly 

Penicillin Hypersensitive (Not Immediate): cephalothin 50 mg/kg to 2 g i.v. 6 hourly or 
cephalozin 50 mg/kg to 2 g i.v. 8 hourly, then cephalexin 25 mg/kg to 1 g orally 6 hourly 
Immediate Penicillin Hypersensitive: 

Macrolide Snsceptible: clindamyicn 10 mg/kg to 450 mg i.v. 8 hourly or lincomycin 
15 mg/kg to 600 mg i.v. 8 hourly, then clindamycin 10 mg/kg to 450 mg orally 8 hourly 

Macrolide Resistant: vancomycin 25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 1 g) i.v. 
12 hourly by slow infusion (monitor blood levels and adjust dose accordingly), then cotrimoxazole 8/40 mg/kg to 
320/1600 mg orally 12 hourly or doxycycline 2.5 mg/kg to 100 mg orally 12 hourly (not in child < 8 y) 

Methicillin Resistant Staphylococcus aureus: vancomycin 25 mg/kg to 1 g (child < 12 y: 30 mg/kg to 

1 g) i.v. 12 hourly by slow infusion (monitor blood levels and adjust dose accordingly, then rifampicin 7.5 mg/kg to 300 mg 
orally 12 hourly + sodium fusidate tablets 12 mg/kg to 500 mg orally 12 hourly or fusidic acid 18 mg/kg to 750 mg orally 

2 hourly or clindamycin 10 mg/kg to 450 mg orally 8 hourly or cotrimoxazole 8/40 mg/kg to 320/1600 mg orally 12 
hourly 

Listeria monocytogenes, Eikenella corrodens: ampicillin 

Kingella kingae: benzylpenicillin 4 MU i.v. once, then 2 MU i.v. 4 hourly (neonate: 100 000 U/kg daily in 3 or 
4 doses; < 45 kg: 250 000 U/kg daily in 6 divided doses) for at least 10 d, followed by phenoxymethylpenicillin 1 g orally 
6 hourly for 3-7 w (< 12 y: 25-50 mg/kg orally daily in 4 divided doses) 

Brucella: streptomycin 1 g twice a day i.m. for 14-21 d + rifampicin 900 mg/d orally for 45 d + doxycycline 
100 mg orally twice daily for 45 d 

Burkholderia cepacia: imipenem 

Pseudomonas: ofloxacin 200 mg/kg orally 3 times daily for 2-4 w (not child), i.v. tobramycin for 7 d 

Vibrio vulnificus: doxycycline 100 mg orally or i.v. twice daily + ceftazidime 2 g i.v. 3 times a day or 
ciprofloxacin 400 mg twice a day for 3 d or gentamicin 

Reromonas: gentamicin 

Anaerobes: chloramphenicol, clindamycin 

Other Bacteria: ceftriaxone 

Fnngi: amphotericin B + flucytosine, itraconazole, fluconazole (all ineffective for Scedosporium); debridement with 
immediate bone grafting desirable if appropriate 



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Infections of the Skeletal System 

Prophylaxis Before Joint Snrgery: cloxacillin/flucloxacillin 500 mg i.v. or i.m. immediately specimens taken during 

surgery + amoxycillin 500 mg i.v. or i.m. at same time and 6 hourly for 48 h + gentamicin on polymethylmethacrylate 

beads put into joint and left in situ % 19 d 

Granulomatous Synovitis 

Agents: Mycobacterium tuberculosis, Mycobacterium kansasii, Mycobacterium marinum, Mycobacterium gordonae, 

Mycobacterium avium, Mycobacterium chelonae 

Diagnosis: Ziehl-Neelsen stain, culture and histology of surgical specimen 

Treatment: surgery +: 

Mycobacterium avium: ethambutol 15 mg/kg (not < 6 y) orally daily + clarithromycin 12.5 mg/kg to 
500 mg orally 12 hourly or azithromycin 10 mg/kg to 500 mg orally daily + rifampicin 10 mg/kg to 600 mg orally daily or 
rifabutin 5 mg/kg to 300 mg orally daily till culture negative 12 mo 

Mycobacterium chelonae: 2 of clarithromycin, doxycycline, ciprofloxacin, cotrimoxazole for 6-12 mo 

Mycobacterium kansasii: isoniazid 10 mg/kg to 300 mg orally daily [+ pyridoxine 25 mg (breastfed baby 
5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg orally daily + ethambutol 15 mg/kg (not < 6 y) orally 
daily for 18 mo and 12 months negative cultures 

Mycobacterium marinum: clarithromycin 12.5 mg/kg to 500 mg orally 12 hourly, cotrimoxazole 4/20 mg/kg 
to 160/800 mg orally 12 hourly, doxycycline 2.5 mg/kg to 100 mg orally (not < 8 y) 12 hourly for 3-4 mo 

Others: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 times weekly for 6 mo 
[+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg orally once daily 1 h 
before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once 
daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) 
+ ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 
30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo) 
Tenosynovitis 

Agent: Mycobacterium nonchromogenicum (chronic of knee) 
Diagnosis: culture of biopsy 

Treatment: ethambutol, sulphonamides, cotrimoxazole, erythromycin, streptomycin + surgical debridement 
Bursitis 

Agents: Staphylococcus aureus, coagulase negative staphylococci, p-haemolytic streptococci, Mycobacterium marinum, 
Mycobacterium kansasii, Mycobacterium szulgai, Brucella abortus, Haemophilus influenzae, Serratia marcescens, Pseudomonas 
fluoresces, Enterobacter cloacae, Escherichia coli, Prototheca (olecranon) 
Diagnosis: culture of aspirate 

Treatment: repeated aspiration + appropriate antimicrobials; surgical drainage if necessary 
Carpal Tunnel Syndrome 

Agents: 21% Mycobacterium tuberculosis, 19% Mycobacterium other than Mycobacterium tuberculosis, 14% rubella vaccine, 
11% Borrelia burgdorferi, 11% rubella virus, 5% Histoplasma capsulatum, 5% Sporothrix schenckii, 3% Neisseria gonorrhoeae, 
3% toxic shock syndrome, 1% Staphylococcus aureus, 2% p-haemolytic streptococci, 0.8% coagulase negative staphylococci, 
0.8% Enterococcus faecalis, 0.8% Clostridium histolyticum, 0.8% guinea worm 
Diagnosis: smear and culture of biopsy 
Treatment: surgery + appropriate antimicrobial 
Compound Fractures 

Agents: Staphylococcus aureus, Gram negative bacilli, Clostridium perfringens 

Diagnosis: if infection is evident before treatment or develops despite treatment, Gram stain and culture of tissue or swab 
Treatment: treatment should be prophylactic; di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly, or cephalothin 50 mg/kg to 

2 g i.v. 6 hourly or cephazolin 25 mg/kg to 1 g i.v. 8 hourly if penicillin hypersensitive (not immediate), or clindamycin 

10 mg/kg to 450 mg i.v. 8 hourly or lincomycin 15 mg/kg to 600 mg 8 hourly if immediate penicillin hypersensitvity for 1- 

3 d + (if wound soiling or tissue damage severe and/or devitalised tissue present) piperacillin + tazobactam 

100 + 12.5 mg/kg to 4 + 0.5 g i.v. 8 hourly or ticarcillin + clavulanate 50 + 1.7 mg/kg to 3 + 0.1 g i.v. 6 hourly then 
amoxycillin + clavulanate 22.5 + 3.2 mg/kg to 875 + 125 mg orally 12 hourly or (penicillin hypersensitive) gentamicin 
(< 10 y: 7.5 mg/kg; child > 10 y: 6 mg/kg; adult 4-6 mg/kg) i.v. as single daily dose (adjust dose for renal function) or 
ciprofloxacin 10 mg/kg to 400 mg i.v. or 15 mg/kg to 750 mg orally 12 hourly + clindamycin 10 mg/kg to 450 mg i.v. or 
orally 8 hourly or lincomycin 15 mg/kg to 600 mg i.v. 8 hourly then clindamycin 10 mg/kg to 450 mg orally 8 hourly; 
review patient's immune status to tetanus 
Paget's Disease: localised deformation of bone 
Agent: ? measles virus persistent infection of osteoclasts 



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Chapter 12 



Eye Infections 

Eye Infections: A large number of local and systemic conditions of non-infectious origin are reflected in the eye and may 
mimic eye infections. However, the most common cause of failure to isolate organisms from an apparent infection is prior 
use of local antimicrobial preparations. 

Purulent Conjunctivitis: 2% of new episodes of illness in UK; 0.5% of ambulatory care visits in USA 
Agents: Haemophilus (mainly nontypeable Haemophilus influenzae (especially young children; 62% of cases bilateral; 
conjunctival injection in 86% of cases, purulent discharge in 77%), also Haemophilus aegyptius], Streptococcus pneumoniae 
(occasional ophthalmia neonatorum, outbreaks in students and military recruits, sporadic), Streptococcus pyogenes, other 
streptococci (a, p, microaerophilic), Staphylococcus aureus (ophthalmia neonatorum), Moraxella lacunata (Axenfeld 
conjunctivitis (diplobacillary conjunctivitis, Morax-Axenfeld conjunctivitis, subacute conjunctivitis); not significant cause in 
certain areas), Moraxella catarrhalis, Escherichia coli, Neisseria gonorrhoeae (gonococcal conjunctivitis (gonococcal ophthalmia, 
gonorrhoeal conjunctivitis, gonorrhoeal ophthalmia); acute purulent conjunctivitis usually unilateral in adults (blennorrhoea 
adultorum) and bilateral in newborn infants (blennorrhoea neonatorum); may lead to corneal ulceration and, if untreated, to 
impairment or loss of vision), Neisseria meningitidis (rare except in central and northern Australia; corneal ulcers in 16%; 
systemic disease in 18%, with 13% case-fatality rate in those cases), Neisseria mucosa (rare neonatal), Mnetobacter 
calcoaceticus, Corynebacterium diphtheriae (uncommon; resulting from inoculation into eye), Mycobacterium tuberculosis, 
Corynebacterium striatum (rare), Vibrio parahaemolyticus, Vibrio alginolyticus, Capnocytophaga, Pseudomonas aeruginosa 
(antecedent corneal trauma, contact lens wear, concurrent serious systemic disease), Stenotrophomonas maltophilia 
(occasional), Kingella indologenes (rare), Listeria monocytogenes, Erysipelothrix rhusiopathiae, Bacillus subtilis, Candida 
{Candida albicans common; Candida tropicalis, Candida stellatoidea, Candida parapsilosis, Candida glabrata infrequent to rare); 
any organism other than a light growth of coagulase negative staphylococcus, Corynebacterium species other than 
Corynebacterium diphtheriae or Corynebacterium striatum, or Streptococcus viridans, should be considered possibly significant 
Diagnosis: moderate injection, moderate to profuse exudate, follicles absent, no preauricular node enlargement; Moraxella 
lacunata mainly affects area of the canthi; Gram stain and culture of swab of pus or conjunctiva 

Gonococcal in Neonate: age 2-4 d at onset, bilateral, marked edema, copious purulent discharge; polymorphs 
and Gram negative diplococci in smear 
Treatment: 

Neisseria meningitidis: ceftriaxone 25 mg/kg to 1 g i.m. daily for 3-5 d 

Neisseria gonorrheae: 
Neonates: 

Penicillinase Negative: benzylpenicillin 15 mg/kg i.v. 12 hourly during first week of life 
and 7.5 mg/kg thereafter for total of 7 d 

Penicillin Resistant or Susceptibility Not Known: cefotaxime 50 mg/kg i.v. 8 hourly 
for 7 d or ceftriaxone 50 mg/kg i.v. daily for 7 d 

Others: procaine penicillin 50 mg/kg to 1.5 g i.m. daily for 1-3 d, amoxycillin 75 mg/kg to 3g + 
probenecid 25 mg/kg to 1 g (not < 2 y) orally daily for 1-3 d 

Penicillinase-Prodncing, Penicillin Hypersensitive: ceftriaxone 25 mg/kg to 1 g 
i.m. or i.v. as single dose or cefotaxime 25 mg/kg to 1 g i.m. or i.v. as single dose 

Mycobacterium tuberculosis requires specialised attention; corticosteroids must not be used 

Staphylococcus aureus (Serions Ophthalmia Neonatornm): i.v. cloxacillin for 7 d 

Listeria monocytogenes: ampicillin 2 g i.v. 4 hourly (< 1 w: 100 mg/kg daily in 2 divided doses; 1-4 w: 
200 mg/kg daily in 3 divided doses; older children: 200-400 mg/kg daily in 4 divided doses) for 2 w + gentamicin 
1.3 mg/kg (child: 1.5-2.5 mg/kg) 8 hourly; benzylpenicillin 15-20 MU (neonates: 500 000-1 MU; older children: 
200,000-400,000 U/kg) daily in divided doses for 2 w + gentamicin 1.3 mg/kg (child: 1.5-2.5 mg/kg) i.v. 8 hourly; 
cotrimoxazole 320/1600 mg (child: 8/40 mg/kg) i.v. daily in divided doses 

Pseudomonas aeruginosa: topical tobramycin + parenteral aminoglycoside + ticarcillin or piperacillin 

Stenotrophomonas maltophilia: cotrimoxazole + rifampicin 

Haemophilus aegyptius (BPF Clone): oral rifampicin 20 mg/kg/d for 4 d 

Other Bacteria: 

Mild: propamidine isethionate 0.1% 1-2 drops 3-4 times daily for 5-7 d 



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Eye Infections 

More Severe: chloramphenicol 0.5% eye drops topically 1-2 drops every 2 h, decreasing to 4 times 
daily as infection improves + chloramphenicol 1% eye ointment topically at night for 3-5 d or framycetin 0.5% eye drops 1- 
2 drops every 1-2 h, decreasing to 8 hourly as infection improves 

Candida: amphotericin B + flucytosine 
Prophylaxis: 

Neisseria gonorrhoeae in Neonates: single application of 0.5% erythromycin ointment, 1% tetracycline 
ointment or 1% silver nitrate 

Neisseria meningitidis: ceftriaxone 250 mg (child 125 mg) i.m. as single dose (preferred if pregnant), 
ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), rifampicin 10 mg/kg 
to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver disease; preferred for children) 
Chlamydial Conjunctivitis (Endemic Paratrachoma, Inclusion Blennorrhoea, Inclusion Conjunctivitis, 
Occidental Paratrachoma, Oculogenital Inclusion Conjunctivitis, Paratrachoma): transmitted to eye from 
infected genital secretions, also via secretions and fomites in endemic areas; acute or chronic, with conjunctival follicles and 
mucopurulent discharge 
Agent: Chlamydia trachomatis 
Diagnosis: 

Neonatal (Inclusion Conjunctivitis of Newborn, Ophthalmia Neonatornm): age 7-10 d at onset, 
unilateral or bilateral, redness and moderate edema of lids, copious purulent or mucopurulent discharge, diffuse conjunctival 
injection; culture, cytology (polymorphs and intracytoplasmic inclusions on Giemsa stain) and immunofluorescence of scrapings 
from conjunctiva 

Older Patients: acute or chronic; conjunctival follicles and mucopurulent discharge; culture, cytology and 
immunofluorescence of scrapings from lower fornix 
Treatment: 

Adnlts, Children > 6 kg: azithromycin 20 mg/kg to 1 g orally as single dose to clinical case, care-givers 
and close children 

Children < 6 kg: erythromycin base 10 mg/kg or erythromycin ethyl succinate 20 mg/kg orally 6 hourly for 
21 d 

Prophylaxis: 0.5% erythromycin ophthalmic ointment, 1% tetracycline ophthalmic ointment 
Trachoma (Arlt Disease, Arlt Trachoma, Egyptian Ophthalmia, Military Ophthalmia): affects 15% of 
world's population; very common in developing countries, especially N Africa and Arab countries; in Australia, mainly in 
Aborigines; « 10 cases/y in USA; usually chronic immunopathologic disease in which more severe progressive trachoma 
infections (active trachoma characterised by follicle formation and papillary hypertrophy in conjunctiva, vascularisation and 
corneal infiltration (pannus), followed by healed trachoma in which there is scarring of eyelids and cornea, sometimes 
leading to partial or total loss of sight) occur only after reinfection; transmission by contact with infectious discharge 
Agent: Chlamydia trachomatis 

Diagnosis: follicle formation and papillary hypertrophy in conjunctiva, infiltration of cornea, scarring of lids and cornea; 
cytology (Giemsa stain sensitivity 29%, specificity 100%) and immunofluorescence (Microtrak-methanol fix sensitivity 78%, 
specificity 100%), culture (sensitivity 76%, specificity 100%), DNA probe (sensitivity 84%, specificity 96%) of scrapings from 
upper tarsus; serology 

Treatment: as for Chlamydial Conjunctivitis 

Prophylaxis (5-14 y): oily tetracycline drops, 1 drop once daily for 5 consecutive days in each school month 
Prevention and Control: hygiene; treatment of cases; fly control 
Nonpurulent Conjunctivitis ('Pink Eye'): common in children 

Agents: simplexvirus /(uncommon; may involve cornea; occasional ophthalmia neonatorum), simplexvirus 3, measles virus 
(46% of hospitalised measles cases also develop bacterial conjunctivitis), human rubella virus, dengue, sandfly fever, human 
echovirus 17 and IS, coxsackievirus A9, Newcastle disease virus, adenovirus (common cause of swimming pool conjunctivitis; 
human adenovirus C serotypes 1, 2, 5, 6, human adenovirus B serotypes 3, 7, human adenovirus E serotype 4, human 
adenovirus D serotypes 8, 9, 10, 17, 19, 37, human adenovirus B serotype 16 (in 50% of infections)), human enterovirus 70, 
influenza A virus, influenza B virus (eye discharge and discomfort in 8% of cases), human cytomegalovirus in AIDS, Rocky 
Mountain spotted fever (in 30% of cases; 13% in first 3 d), Crimean-Congo hemorrhagic fever, Mediterranean spotted fever 
(in 32% of cases), infectious mononucleosis, Chlamydia, Acanthamoeba, Acinetobacter (contact lenses); also toxic shock 
syndrome, allergic, caused by silver nitrate prophylaxis, caused by unshielded mercury vapour lamps, sensitivity reaction, 
chemical irritants 

Diagnosis: intact vision, mild pain, mild diffuse injection, minimal exudate present, photophobia absent, lacrimation and 
pupil normal, follicles present, preauricular node enlargement; cytology, immunofluorescence and viral culture of swab of 
mucus or corneal or conjunctival scraping; serology 

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Eye Infections 

Rcanthamoeba: Giemsa-Wright, Wheatley trichrome, calcfluor white /methylene blue, fluorescein conjugated 
lectin, Gomori methenamine silver, PAS or immunofluoresecent stain and culture of scraping from corneal ulcer; electron 
microscopy of biopsy 
Treatment: 

Chlamydia: erythromycin 

Rcinetobactet: 

Mild: propamidine isethionate 0.1% 1-2 drops 6-8 hourly for 5-7 days 

More Severe: (polymyxyin B sulphate 5000 U/mL + chloramphenicol 0.5% or neomycin 2.5 mg/mL) 1- 
2 drops hourly, decreasing to 6 hourly as infection improves + eye ointment as above at bedtime for 3-5 d; chloramphenicol 
0.5% eye drops topically 1-2 drops at least 4 times daily to both eyes for 3-5 d + chloramphenicol 1% eye ointment 
topically at night for 3-5 d; chloramphenicol eye ointment topically 6 hourly for 3-5 d; oily tetracycline eye drops 1-2 drops 
at least 4 times daily to both eyes for 3-5 d 

Rcanthamoeba: propamidine isethionate, dibromopropamidine isethionate, clotrimazole + neomycin or 
gentamicin, Baquacil (10 3 dilution) 

Human herpesvirus 1: 

Mild: aciclovir 3% eye ointment 1 cm 3 hourly, idoxuridine 0.1% eye drops 1 drop in each eye every h 
during day and every 2 h at night till improvement, idoxuridine 0.5% eye ointment 1 cm 4 times daily and at night, 
vidarabine 3% eye ointment 1.5 cm 5 times daily at 3 hourly intervals, reducing to twice daily for 7 d after 
reepithelialisation has occurred 

Severe: aciclovir 5 mg/kg (< 12 y: 250 mg/m 2 ) 8 hourly i.v. as 1 h infusion for 5 d 

Human herpesvirus 3: cool compresses, topical lubrication, topical broad spectrum antibiotic 

Allergy: sodium cromoglycate drops 

Others: cold compresses, artificial tears, phenylephrine 0.12%, avoidance of bright light, systemic analgesics 
Acute Hemorrhagic Conjunctivitis: highly contagious; due to poor hygiene 

Agents: human adenovirus B serotype 11, human coxsackievirus S24, human enterovirus JO; conjunctival hemorrhages and 
injection also occur in 57% of cases of hemorrhagic fever with renal syndrome 

Diagnosis: conjunctival congestion, bilateral conjunctival injection and irritation in 93% of cases, conjunctival watering, 
scanty white to profuse watery discharge; viral culture of conjunctival swab; hemagglutination inhibition test 
Treatment: betamethasone drops 

Conjunctival Congestion and Injection also occur in 88% of cases of Kawasaki syndrome 
Conjunctival Hyperemia is present in 80% of toxic shock syndrome cases 
Conjunctival Suffusion is common in psittacosis 
Conjunctivitis and Keratitis (Keratoconjunctivitis) 

Agents: human adenovirus D serotypes 7, 8, 19, 37, human adenovirus A serotype 18 (in developed countries, epidemic and 
primarily iatrogenic and affecting mainly adults; in developing countries, endemic and primarily disease of children), 
simplexvirus 1, simplexvirus 3, AIDS, Listeria monocytogenes, Acinetobacter (contact lens), Rcanthamoeba (contact lens) 
Diagnosis: eye redness in 98% of cases, eye discharge in 95%; fluorescein staining of cornea; culture of nasopharyngeal 
swab, swab or scraping of conjunctiva and cornea, feces; cytology, immunofluorescence and culture of corneal or 
conjunctival scraping; serology 

Rcanthamoeba: Giemsa-Wright, Wheatley trichrome, calcfluor white/methylene blue, fluorescein conjugated 
lectin, Gomori methenamine silver, PAS or immunofluoresecent stain and culture of scraping from corneal ulcer; electron 
microscopy of biopsy 
Treatment: 

Adenovirns: non-specific 

Simplexvirus 1: aciclovir 3% ophthalmic ointment 5 times daily for 14 days or for at least 3 d after healing + 
atropine 1% 1 drop 12 hourly for duration of treatment 

Simplexvirus 3: famciclovir 250 mg orally 8 hourly for 7 d (500 mg orally 8 hourly for 10 d in 
immunocompromised), valaciclovir 1 g orally 8 hourly for 7 d, aciclovir 20 mg/kg to 800 mg orally 5 times daily for 7 d 
(preferred in children and in pregnancy); if sight is threatened, aciclovir 10 mg/kg i.v. 8 hourly, each infusion administered 
over a period of 1 h, for 7 days (adjust dose for renal function); aciclovir 3% eye ointment 5 times daily may be added 
Epithelial Keratitis: debridement or none 
Stromal Keratitis: topical steroids 

Nenrotropic Keratitis: topical lubrication, topical antibiotics for secondary infections, tissue 
adhesives and protective contact lenses to prevent corneal perforation 

Listeria monocytogenes: ampicillin or benzylpenicillin + gentamicin, cotrimoxazole 

Rcinetobactet: topical tobramycin, polymyxyin B 



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Eye Infections 

Keratitis and Iritis: 0.01% of new episodes of illness in UK 

Agents: simplexvirus 1, simplexvirus 3, human immunodeficiency virus, Staphylococcus aureus, Pseudomonas aeruginosa, 

Streptococcus pneumoniae, Moraxelia iacunata, a-haemolytic streptococci, Gram negative bacilli (associated with soft contact 

lenses), Mycobacterium chelonae, Mycobacterium fortuitum (emerging pathogen in AIDS), Mycobacterium tuberculosis, 

Aspergillus, Fusarium, Curvularia, Drechslera, Alternaria; Mnetobacter, Acanthamoeba castellanii, Acanthamoeba culbertsoni, 

Acanthamoeba hatched, Acanthamoeba polyphaga and Acanthamoeba rhysoides (associated with soft contact lenses, hot tubs, 

unsterile water); also interstitial keratitis due to congenital syphilis or complication of tuberculosis or leprosy, Sarcopodium 

oculorum 

Diagnosis: vision may be compromised, severe pain, injection localised to iris ('ciliary flush'), exudate absent, photophobia 

present, lacrimation increased, pupil contracted; cytology and culture of swabs, scrapings of cornea, corneal biopsy; 

immunodiffusion, immunofluorescence 

Acanthamoeba: Giemsa-Wright, Wheatley trichrome, calcfluor white/methylene blue, fluorescein conjugated 
lectin, Gomori methenamine silver, PAS or immunofluoresecent stain and culture of scraping from corneal ulcer; electron 
microscopy of biopsy 
Treatment: 

Simplexvirus 1, simplexvirus 3: see Conjunctivitis and Keratitis 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Other Mycobacterium: sulphacetamide drops 

Other Gram Positive Bacteria: povidone iodine + topical prednisolone 

Gram Negative Bacilli: topical tobramycin, polymyxyin B 

Fnngi: topical pimafucin ± ketoconazole; keratoplasty 

Acanthamoeba: propamidine isethionate, dibromopropamidine isethionate, clotrimazole + neomycin or 
gentamicin, Baquacil (10 3 dilution) 
Penetrating Eye Injuries 

Treatment: specialised management required; urgent advice from ophthalmologist mandatory; if significant delay before 
specialised treatment, vancomycin 20 mg/kg to 1 g i.v. slowly single dose + ciprofloxacin 15 mg/kg to 750 mg orally 
single dose; gentamicin 5 mg/kg single dose + cefotaxime 50 mg/kg to 1 g i.v. single dose or ceftriaxone 50 mg/kg to 1 g 
i.v. single dose 

Onchocerciasis (River Blindness): Sub-Saharan Africa, Latin America; incidence 18 ffl/y; no deaths reported but 
270,000 reported cases of blindness annually; transmitted by blackflies, Simulium 
Agent: Onchocerca volvulus, recent report that real culprit is Wolbachia carried by the worms 
Diagnosis: sclerosing keratitis, chronic iridocyclitis, chorioretinitis, optic atrophy; biopsy of nodule will disclose adult 
worm, while skin shavings may show microfilariae; slit-lamp eye examination (punctate keratitis, microfilariae in cornea); 
nodules can be detected by ultrasound; a patch test in which blot of 10% diethylcarbamazine in anhydrous lanolin fixed to 
skin produces pruritus, edema and papule formation within 72 h is positive in up to 92% of cases; eosinophilia 
Treatment: ivermectin 20 jag/kg orally once as a single dose, diethylcarbamazine under expert supervision, suramin (if 
ocular microfilariae present after diethylcarbamazine and nodulectomy) 50 mg test dose i.v. then 10-15 mg/kg to maximum 
dose 1 g orally for 5 w, flubendazole 750 mg i.m. once a week for 5 doses; tetracycline to kill WolbachicP. 
Chronic Eye Infections 

Agents: Pseudomonas, Proteus, Escherichia coli, Klebsiella, anaerobes, fungi (Fusarium, Alternaria, Pseudallescheria boydii, 
Candida albicans, others) 

Diagnosis: culture of corneal, conjunctival scrapings 
Treatment: dependent on findings 
Iridocyclitis (Cyclitis + Iritis) 

Agents: human herpesvirus 3, human immunodeficiency virus, Bacillus, Pseudomonas aeruginosa 
Diagnosis: cytology, Gram stain and culture of swabs, scrapings 
Treatment: 

Human herpesvirus 3: as for Conjunctivitis and Keratitis 

Bacillus: clindamycin 

Pseudomonas aeruginosa: topical tobramycin, polymyxin B 

Diagnosis and Management of Infectious Diseases Page 173 



Eye Infections 

Anterior Uveitis (Choroiditis + Iridocyclitis) 

Agents: simplexvirus 1, mumps virus, simplexvirus 3, measles virus, human immunodeficiency virus, Mycobacterium 
tuberculosis, Treponema pallidum subsp pallidum (secondary syphilis), Neisseria gonorrhoeae, Brucella, Rocky Mountain 
spotted fever, Leptospira, Listeria monocytogenes, Histoplasma capsulatum, Toxoplasma gondii, Toxocara cam's, Acanthamoeba; 
also rheumatoid arthritis, sarcoidosis, Reiter syndrome, Behcet's disease, inflammatory bowel disease 
Diagnosis: smear and culture of aspirate; serology 
Treatment: prompt referral to ophthalmologist 

Human herpesvirus 1, Human herpesvirus £ see Conjunctivitis and Keratitis 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Syphilis: aqueous crystalline penicillin G 3-4 MU i.v. every 4 h or 18-24 MU/d as continuous infusion for 
10-14 d, procaine penicillin 2.4 MU i.m. once daily + probenecid 500 mg orally 4 times a day for 10-14 d 

Histoplasma capsulatum: amphotericin B, flucytosine, ketoconazole + steroids 

Toxoplasma: corticosteroids + sulphadiazine 1-1.5 g orally or i.v. 6 hourly for 3-6 w then 500 mg orally 6 
hourly or 1 g orally 12 hourly + pyrimethamine 50-100 mg orally loading dose then 25-50 mg daily for 3-6 w (continue if 
necessary) 

Sulphadiazine Hypersensitive: substitute clindamycin 600 mg orally or i.v. 6 hourly for 3-6 w 

Toxocara canis: thiabendazole 

Rcanthamoeba: propamidine isethionate, dibromopropamidine isethionate, clotrimazole + neomycin or 
gentamicin, Baquacil (10 3 dilution) 
Chorioretinitis (Choroiditis + Retinitis) 

Agents: Mycobacterium tuberculosis, Nocardia, Candida, Aspergillus, Cryptococcus neoformans (associated with meningitis), 
Histoplasma capsulatum; also sarcoidosis 

Diagnosis: clinical; serology; culture of anterior chamber and vitreous aspirates 
Treatment: 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Nocardia: cotrimoxazole 

Fnngi: amphotericin B + steroids 
Retinochoroiditis (Retinitis + Choroiditis) 

Agents: human cytomegalovirus (in renal transplantation, AIDS), simplexvirus I, simplexvirus 3, Toxoplasma gondii (20% of 
cases of posterior uveitisO, Toxocara canis 
Diagnosis: clinical; serology; culture of anterior chamber and vitreous aspirates 

Human cytomegalovirus: characteristic appearance on serial ophthalmoscopic examinations (eg., discrete 
patches of retinal whitening with distinct borders, spreading in a centrifugal manner along the paths of blood vessels, 
progressing over several months, and frequently associated with retinal vasculitis, hemorrhage and necrosis); resolution of 
active disease leaves retinal scarring and atrophy with retinal pigment epithelial mottling 

Toxoplasma: intense white focal area of retinal necrosis with substantial inflammation 

Simplexvirus 3 : rapid spread; 67% completely blind within 1 mo 
Treatment: 

Simplexvirus 1: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly for 7-10 
d, aciclovir 200 mg orally 5 times daily for 7-10 d 

Simplexvirus 3: as for Conjunctivitis and Keratitis 

Human cytomegalovirus: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally daily, 
ganciclovir 



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Eye Infections 

5 mg/kg i.v. twice a day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 times a week during continued 
immunosuppression, foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg 
i.v. weekly for 2 w (+ probenecid if proteinuria < 2+ and creatinine clearance > 55 mL/min) then as above every 2 w 

Other Viral: reduction of immunosuppressive therapy 

Toxoplasma: pyrimethamine 25 mg 3 times first day then orally daily for 4 w (child: 2 mg/kg to 25 mg 
maximum daily for 3 d, then 1 mg/kg daily (infant: every second or third d) for 4 w + trisulphapyrimidine or sulphadiazine 
2 g then 1 g (child: 50 mg/kg) orally 4 times daily for 4 w + folinic acid 3-9 mg orally daily; clindamycin 300 mg orally 6 
hourly (child: 16 mg/kg daily in 3 or 4 doses) for 3-4 w then 150 mg 4 times daily (child: 8 mg/kg daily in 3 or 4 doses) 
for 3-4 w; spiramycin 1 g twice daily (recommended in pregnancy); azithromycin 500 mg loading dose then 250 mg daily; 
atovaquone; + corticosteroids; surgery as needed for complications 

Toxocara canis: thiabendazole 
Endophthalmitis: surgery, trauma, penetrating corneal ulcer, systemic infection 

Agents: Staphylococcus aureus (postoperative, posttraumatic, septicemia), coagulase negative staphylococci (postoperative, 
posttraumatic), Propionibacterium acnes (postoperative), Corynebacterium (postoperative), Streptococcus pneumoniae 
(septicemia), Streptococcus viridans (conjunctival filtering-bleb associated, bloodborne), Streptococcus pyogenes (septicemia, 
posttraumatic), Listeria monocytogenes (oculoglandular listeriosis (angioso-septic listeriosis); uncommon; caused by accidental 
inoculation into eye), Bacillus cereus (posttraumatic, bloodborne), aerobic Gram negative bacilli (< 20% of cases; especially 
Proteus mirabilis, Klebsiella pneumoniae (especially in diabetics), Escherichia coli (bloodborne), Enterobacter and Pseudomonas 
aeruginosa (postoperative, antecedent corneal ulcers, penetrating trauma, metastatic seeding from bacteremia), Burkholderia 
cepacia, Aeromonas (foreign body trauma), Actinobacillus actinomycetemcomitans and Haemophilus paraprophilus (in 
association with endocarditis), Pasteurella multocida and Neisseria sp R-24681 (cat scratch), Moraxella (postoperative), 
Achromobacter (postoperative), Flavobacterium meningosepticum (postoperative), Haemophilus influenzae (postoperative and 
conjunctival filtering-bleb associated), Butyrivibrio fibrisolvens (single case following penetrating injury), Nocardia asteroides, 
Mycobacterium tuberculosis, Actinomyces (postoperative), Candida albicans and other Candida species (associated with 
parenteral hyperalimentation and in immunocompromised, postoperative, i.v. drug abuse), Aspergillus (rare; bloodborne), 
Cryptococcus neoformans (rare; bloodborne), Scedosporium and Pseudallescheria boydii (in immunocompromised), Coccidioides 
immitis (bloodborne), Sporothrix schenckii (bloodborne), Ajellomyces dermatitidis (bloodborne), Histoplasma capsulatum 
(bloodborne), other fungi (i.v. narcotic abuse) 

Diagnosis: intense pain, decreased visual acuity, marked corneal swelling, lid edema, intense hyperemia of globe, 
conjunctival chemosis, hypopyon, anterior uveitis, opacity of cornea and vitreous, occasional rupture of globe; Gram stain and 
Giemsa, methenamine silver or PAS stain, culture (including in blood culture bottle) of aspirate of anterior chamber or 
vitreous cavity or fine needle retinal biopsy; blood cultures; culture of wound abscess, fistula, conjunctiva 
Treatment: vitrectomy or vitreous aspiration if loculated infection or necrotic tissue +: 

Empirical Where Delay In Diagnosis: ciprofloxacin 15 mg/kg to 750 mg orally as a single dose + 
vancomycin 25 mg/kg to 1.5 g (child < 12 y: 30 mg/kg to 1.5 g i.v. as single dose by slow infusion; gentamicin 5 mg/kg 
i.v. as single dose + cefotaxime 50 mg/kg to 2 g i.v. as single dose or ceftriaxone 50 mg/kg to 2 g i.v. as single dose 

Nocardia: cotrimoxazole 20/100 mg/kg/d i.v. for 5 d, then 320/1600 mg orally 4 times a day 

Pseudomonas aeruginosa: parenteral, topical, subconjunctival and intraocular antipseudomonal antibiotics 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 

Other Bacteria: guided by culture and susceptibility 

Pseudallescheria boydii, Scedosporium: azole 

Other Fnngi: 

Severe: intravitreal amphotericin B + dexamethasone 
Less Severe: i.v. fluconazole (not Aspergillus] or itraconazole 
Panophthalmitis 

Agents: Bacillus cereus (in drug abusers), Pseudomonas aeruginosa, Vibrio parahaemolyticus, Mycobacterium tuberculosis 
Diagnosis: Gram stain and culture of tissue aspirate, Ziehl-Neelsen stain and culture of tissue 
Treatment: 

Bacillus cereus: clindamycin 

Pseudomonas aeruginosa, Vibrio parahaemolyticus: gentamicin or neomycin topically and injected 
beneath Tenon's capsule 

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Eye Infections 

Mycobacterium tuberculosis: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg 
orally 3 times weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg 
to 600 mg orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) 
Parasitic Eye Infections 

Agents: Taenia solium, Gnathostoma spinigerum, Gnathostoma hispidum, Rngiostrongylus cantonesis, Loa Loa (in 5% of 
infections), Multiceps (cysts usually beneath conjunctiva), Thelazia caliipaeda, Baylisascaris (from raccoons) 
Diagnosis: direct visualisation 

Taenia solium: pain on ocular movement, afferent pupillary defect, optic disc edema; combined vector 
ultrasonography and magnetic resonance imaging; serum ELISA 

Multiceps: poor vision and pain in eye 

Thelazia: lacrimation, severe pain, scarring, opacities of conjunctiva; may be nervous symptoms and paralysis of 
ocular muscles 
Treatment 

Taenia solium: dexamethasone sodium phosphate 100 mg i.v. daily then oral steroids 

Others: surgical removal 
Blepharitis: 0.3% of new episodes of illness in UK 

Agents: commonly seborrhoeic; also viruses (including simplexvirus 3\, Staphylococcus aureus, coagulase negative 
staphylococci, Gram negative bacilli, fungi, Demodex kerns, Demodex folliculorum, Pediculus humanus, Phthirus pubis 
Diagnosis: culture of swab from lid margin, microscopy of epilated eyelashes collected into oil 

Demodex folliculorum: usually mild pruritus and fibrous tissue response; rarely, dry chronic erythema with 
burning irritation and scaling of epidermis 
Treatment: 

Seborrhoeic: removal of scales from lid margins with 'baby' shampoo or sodium bicarbonate solution; selenium 
sulphide shampoo of scalp 

Simplexvirus 3: cool compresses, topical lubrication, broad spectrum antibiotic 

Demodex: occlusive ophthalmic ointment to eyelids and eyelashes 

Staphylococcus aureus: as for Seborrhoeic + tetracycline hydrochloride 1% ointment, chloramphenicol 1% 
ointment, or framycetin 0.5% ointment to lid margins once or twice daily until clinically resolved 
Associated with Lid Abscess: flucloxacillin 500 mg orally 6 hourly 

Other Bacterial: chloramphenicol 1% + polymyxyin B sulphate 5000 U/g ointment to lid margins 3-6 hourly or 
tetracycline HC1 1% ointment to lid margins 3-6 hourly 

Associated with Rosacea: doxycycline 100 mg orally 12 hourly for 2 w, then 100 mg orally daily for 1-2 mo 
Stye (External Hordeolum): 0.3% of new episodes of illness in UK 
Agent: Staphylococcus aureus 
Diagnosis: pus culture 

Treatment: warm compresses, removal of the involved eyelash 
Meibomianitis (Internal Hordeolum) 
Agents: Staphylococcus aureus 

Treatment: warm compresses; surgical incision and curettage when necessary; di(flu)cloxacillin 12.5 mg/kg to 500 mg 
orally 6 hourly for at least 5 d 

Penicillin Hypersensitive: cephalexin 12.5 mg/kg to 500 mg orally 6 hourly for at least 5 d 
Dacrocystitis, Adenitis and Canaliculitis: 0.04% of new episodes of illness in UK; usually infants or adults > 40 y; 
unilateral, secondary to blockage of nasolacrimal duct 
Agents: 

Acnte: viruses, Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Chlamydia, 
Propionibacterium propionicum (particularly older males), Actinomyces 

Chronic: many different bacteria and fungi (especially Candida albicans] 
Diagnosis: culture and immunofluorescence of canalicular material, conjunctiva 
Treatment: 

Mild: relief of obstruction, warm compresses; zinc sulphate 0.25% + phenylephrine HC1 0.12% 2 drops 4-8 hourly, 
with massaging over tear sac before and after instilling drops 

Acnte and More Severe: di(flu)cloxacillin 12.5 mg/kg to 500 mg orally 6 hourly 

Penicillin Hypersensitive: cephalexin 12.5 mg/kg to 500 mg orally 6 hourly 

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Eye Infections 

Preseptal (periorbital) and Postseptal (Orbital) Cellulitis 

Agents: Haemophilus influenzae (< 5 y of age; following URTI; previously usually type b, now more commonly non-type b; 
preseptal and postseptal), Staphylococcus aureus (postseptal), Streptococcus pyogenes (secondary to puncture wounds or 
lacerations), Streptococcus pneumoniae (preseptal and postseptal), aerobic Gram negative bacilli (postseptal), anaerobes (due 
to trauma, especially human or animal bites; also dental procedures; postseptal), Pseudomonas aeruginosa, Mucor and 
Aspergillus (postseptal; immunosuppressed; sinusitis spreading to orbit) 

Diagnosis: cultures of swabs of conjunctivae and nearby skin lesions, sinus drainage, abscess drainage or biopsy; blood 
cultures; sinus and orbital X-rays; CT scanning and ultrasound; lumbar puncture to exclude meningitis 

Preseptal: pain, redness, edema of eyelid, low grade fever, inflamed and purulent conjunctiva 

Postseptal: fever, headache, swelling of globe, proptosis, marked chemosis, pain on eye movement and 
compromised eye movement 
Treatment: 

Bacterial: 

Preseptal: 

< 5 y: 

Child Well: amoxycillin/clavulanate 22.5/3.2 mg/kg to 875/125 mg orally 
12 hourly for 7 d or cehpalexin 12.5 mg/kg to 500 mg orally 6 hourly for 7 d 

Severely 111 Child: cefotaxime 50 mg/kg to 2 g i.v. 8 hourly or ceftriaxone 
50 mg/kg to 2 g i.v. once daily or cefuroxime or ampicillin-sulbactam until response, then amoxycillin-clavulanate 
22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for total duration of 7 d; if stye, dacrocystitis, impetigo or wound present, 
add di/flucloxacillin as below 

> 5 y: di(flu)cloxacillin 12.5 mg/kg to 500 mg orally 6 hourly for 7 d or 50 mg/kg to 2 g 
i.v. 6 hourly for at least 14 d if severe 

Postseptal: drainage of abscesses/sinuses; di(flu)cloxacillin 50 mg/kg to 2 g i.v. 6 hourly + 
ceftriaxone 50 mg/kg to 2 g i.v. once daily or cefotaxime 50 mg/kg to 2 g i.v. 8 hourly, then amxycillin/clavulanate 
22.5/3.2 mg/kg to 875/125 mg orally 12 hourly for further 10 d; + 2 antipseudomonal antibiotics in neutropenics 

Fnngi: amphotericin B + flucytosine 
Ocular Myiasis (Ophthalmomyiasis, Ophthalmomyiasis Externa, Ophthalmomyiasis Interna Anterior, 
Ophthalmomyiasis Interna Posterior): infestation of eye or surrounding tissues by larvae of certain flies 
Agents: Cochliomyia hominivorax, Cochliomyia macellaria, Chrysomya bezziana, Chrysomya megacephala, Gasterophilus 
intestinalis, Hypoderma boms, Hypoderma lineatum, Oestrus ovis, Rhinoestrus, Wohlfahrtia 
Diagnosis: usually painful conjunctivitis but larvae may also penetrate cornea or reach into tissues of eye, producing 
serious damage; direct visualisation 
Treatment: removal or destruction of larvae if alive; appropriate management of any sequelae 



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Chapter 13 

Thyroiditis 

Thyroiditis 

Agents: Mycobacterium tuberculosis, Mycobacterium intracellular, Mycobacterium chelonae, Staphylococcus aureus, other 
Staphylococcus, Streptococcus pyogenes, Streptococcus pneumoniae, other streptococci, Enterobacteriaceae, Haemophilus 
influenzae, Pseudomonas aeruginosa, Actinobacillus actinomycetemcomitans, anaerobes, Aspergillus fumigatus, Aspergillus 
flaws, Coccidioides immitis, Candida, Pseudallescheria boydii, Echinococcus, Taenia solium 
Diagnosis: histology and culture of biopsy or surgical specimen 
Treatment: 

Mycobacterium: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 times 
weekly for 6 mo [+ pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg 
orally once daily 1 h before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 
25-35 mg/kg to 2 g orally once daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be 
susceptible to isoniazid and rifampicin) + ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; 
regular ocular monitoring) or 30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and 
rifampicin (to 6 mo) + drainage 

Other Bacteria: drainage + antimicrobial agents depending on organism 
Fnngi: incision or excision + amphotericin B (not Pseudallescheria boydu) or flucytosine 
Parasites: excision 



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Chapter 14 
Multi-System, Generalised and Disseminated Infections 



Adenovirus infections: acute respiratory disease (bronchitis, croup, febrile catarrh, rhinitis, sinusitis, laryngotracheitis, 
tracheobronchitis, pertussis-like syndrome in children < 36 mo, 'influenza-like illness', pharyngitis/sore throat, acute 
exudative tonsillitis, acute laryngitis, pneumonia, pneumonitis, otitis media, pharyngoconjunctival fever), acute diarrhoea 
and/or vomiting, intussusception in children, pancreatitis, acute hemorrhagic cystitis in immunosuppressed, non-pyogenic 
meningitis and meningoencephalitis, maculopapular rash, roseola-like illness, rhabdomyolysis, carditis, myocarditis and 
pericarditis, mesenteric lymphadenitis, hepatitis, arthritis, follicular conjunctivitis, keratoconjunctivitis, acute hemorrhagic 
conjunctivitis; disseminated with hepatic necrosis in AIDS, severe combined immunodeficiency, other immunodeficiency; 
important pathogen in adult bone marrow transplant patients (respiratory infection, urinary tract infection, disseminated 
disease with hepatitis or conjunctivitis); transmission by droplets, contact; incubation period 2-10 d 
Diagnosis: complement fixation test, hemagglutination inhibition antibody technique, neutralisation antibody titre; mild 
increase in white cell count in 60% of cases; virus isolation in tissue culture from throat and/or conjunctival swabs or 
pharyngeal washing, feces, CSF (lung tissue post mortem) 
Treatment: i.v. ribavirin 

Prophylaxis: live, attenuated oral vaccine (experimental) 

Cytomegalic Inclusion Disease: worldwide; occurs in noncompromised older children and adults as mononucleosis 
syndrome (fever, malaise, sore throat, headache, increased levels on liver function tests, atypical lymphocytosis, antibiotic 
rash common; exudative pharyngitis, splenomegaly, cervical lymphadenopathy, nonspecific rash, anemia less common; icteric 
hepatitis rare; antinuclear antibodies, rheumatoid factor, cold agglutinins) and in immunocompromised patients (AIDS and 
after suppressive therapy preceding organ transplantation and after treatment with chemotherapy, steroids or other 
immunosuppressive agents in other conditions) and as bloodborne disease; encephalitis, myelitis, peripheral neuropathy, 
polyradiculopathy, chorioretinitis, Guillain-Barre syndrome, intestinal ulceration, pancreatitis, myocarditis, pneumonia, 
thrombocytopenia purpura, gastrointestinal bleed (particularly in bone marrow transplant recipients 1-3 mo post 
transplantation); transmission respiratory, blood transfusions (especially cardiac surgery and neonates who require several 
units of blood); incubation period 1-3 mo 
Agent: human cytomegalovirus 

Diagnosis: fever, leucopoenia, hepatomegaly, splenomegaly, arthralgia; 'glandular fever type atypical mononuclears' in 
peripheral blood smear; culture of 5 mL of first morning's sample of urine (most dependable source), heparinised blood during 
acute phase, throat swabs (may be successful weeks or months after acute illness has subsided) using human diploid cell 
culture; serology by complement fixation test, IgM indirect fluorescent antibody titre test, ELISA (IgG, IgM and Igffl capture) 

Nonimmnnocompromised: IgG seroconversion, presence of IgM antibody specific for human cytomegalovirus, 
urine culture (may reflect remote infection), blood culture 

Immnnocompromised: demonstration of viral antigen or DNA/RNA in diseased tissue (lung, esophagus, 
colon), IgG seroconversion (rarely occurs) 

Kidney and Liver Transplant Recipients: viral culture by shell vial procedure 
Treatment: valganciclovir 900 mg orally 12 hourly for 14-21 d then 900 mg orally daily, ganciclovir 5 mg/kg i.v. twice a 
day for 2-3 w then 10 mg/kg i.v. 3 times a week or 5 mg/kg i.v. 5 times a week during continued immunosuppression, 
foscarnet 90 mg/kg i.v. 12 hourly for 2-3 w then 90-120 mg/kg i.v. 5 times weekly, cidofovir 5 mg/kg i.v. weekly for 2 w 
(+ probenecid if proteinuria < 2+ and creatinine clearance > 55 mL/min) then as above every 2 w 
Prophylaxis 

Hematopoietic Stem Cell Transplantation: use of blood products from seronegative donors; ganciclovir 
5 mg/kg i.v. every 12 h for 5-7 d, then 5-6 mg/kg i.v. daily for 5 d/w from engraftment until day 100 

Human cytomegalovirus Seropositive HIV Patient with CD4 Cell Connt < 50/ uL: valganciclovir 
900 mg orally daily 

Seovirus Infections: epidemic viral diarrhoea, non-pyogenic meningitis, acute respiratory illness (pharyngitis, rhinitis), 
neonatal hepatitis, maculopapular rash 

Diagnosis: tissue culture and inoculation of suckling mouse with material from feces and throat swab 
Treatment: non-specific 

Hvmrn herpesvirus 3 Infections: varicella (chickenpox; vesicular rash; case-fatality rate 9/100,000, with 80% in 
adults), zoster (shingles), abortion, encephalitis, Guillain-Barre syndrome, non-pyogenic meningitis, pneumonia (including 

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Multi-system, Generalised and Systemic Infections 

diffuse interstitial) with exanthem, pneumonitis, retinochoroiditis, anterior uveitis, nonpurulent conjunctivitis, iridocyclitis, 
iritis, keratoconjunctivitis, arthritis, hepatitis (adult, perinatal and prenatal), mouth lesions, myocarditis and pericarditis, 
oophoritis, prenatal generalised disease, 1/3 of ischemic strokes in children, Ramsay Hunt syndrome (reactivation of latent 
virus in geniculate ganglion in immunocompromised patients, causing vesicles over pinna and external auditory meatus, 
facial nerve palsy, tinnitus, vertigo and deafness); uncommonly, gastrointestinal visceral motor manifestations; transmission 
by respiratory droplets, crusts from lesions; chickenpox 0.4% of new episodes of illness in UK, herpes zoster 0.4%; herpes 
zoster affects 10-20% of general population throughout lifetime; chickenpox latent period 8-12 d, incubation period 13-17 d, 
infectious period 10-11 d, interepidemic period 2-4 y 

Diagnosis: Tzanck smear; complement fixation test, ELISA, fluorescent antibody staining, radioimmunoassay; tissue culture 
of scrapings from skin lesions, vesicle fluid, sputum (lung, liver, spleen post mortem) 
Test for Susceptibility: fluorescent antibody to membrane antigen test 
Treatment: 

Varicella (Chicken Pox): 

Immnnocompromised, Normal Patient with Pnenmonitis or Encephalitis: aciclovir 
10 mg/kg i.v. every 8 h for 7-10 d 

Immnnocompetent Children (< 12 y): 

Primary Cases: symptomatic treatment with acetaminophen and antiprurutics 
Secondary Cases: aciclovir 20 mg/kg orally 4 times a day for 5 d, starting within 24 h of 
rash onset 

Adolescents and Yonng Adnlts: aciclovir 800 mg orally 4-5 times daily for 5-10 d, starting 
therapy within 24 h of rash onset 

Pregnant Women: aciclovir 10 mg/kg i.v. every 8 h 

AIDS: famciclovir 500 mg orally 8 hourly for 7-14 d, valaciclovir 1 g orally 8 hourly for 7-14 d, 
aciclovir 800 mg orally 5 times daily or 10 mg/kg i.v. 8 hourly for 1-2 w (adjust dose for renal function) 

Zoster (Shingles; Ophthalmic Zoster, Immnnocompromised Patient, Any Patient Seen Within 
72 h of Onset of Vesicles): famciclovir 250 mg orally 8 hourly for 7 d (500 mg orally 8 hourly for 10 d in 
immunocompromised), valaciclovir 1 g orally 8 hourly for 7 d, aciclovir 20 mg/kg to 800 mg orally 5 times daily for 7 d 
(preferred in children and pregnancy) 

Prophylaxis: varicella-zoster immune globulin; supplies limited; administration limited to patient with leukemia, lymphoma, 
congenital or acquired immunodeficiency, < 24 mo after hematopoietic stem cell transplant or on immunosuppressive therapy 
or with chronic graft-versus-host disease, with exposure to chickenpox or herpes zoster patient who was household contact, 
playmate contact of a fairly close nature or hospital contact in adjacent bed, with negative or unknown prior history of 
chickenpox (except patients who have bone marrow transplantation), and aged < 15 y or adult with good evidence of not 
having been infected previously, or neonate whose mother had onset of chickenpox within a period of 5 d before and 2 d 
after delivery; in either case, must be < 96 h after exposure; dose 1 vial/10 kg body weight up to maximum 5 vials; no 
evidence of beneficial effect against established infection or fetal infection (ie., exposure of women in early pregnancy); 
immunodeficient patients, especially children, with a negative or unknown history of chickenpox, should be tested for serum 
antibody to simplexvirus 3, thus avoiding unnecessary varicella-zoster immunoglobulin in the future; isolation of cases; live 
attenuated varicella vaccine gives protection rate of 44-100% and should be given to all susceptible health care workers, 
household contacts and family members > 12 mo and not pregnant or immunocompromised 
Simplexvirus Infections: non-purulent conjunctivitis, iritis, keratoconjunctivitis, anterior uveitis, retinochoroiditis, 
encephalitis, non-pyogenic meningitis, meningoencephalitis, hepatitis (adult, neonatal and prenatal), localised skin lesions, 
papulovesicular rash (neonatal), acute herpetic gingivostomatitis, esophagitis, genital herpes, balanitis, nonpurulent cervicitis, 
urethritis, proctitis, vaginitis, dysuria without frequency, urinary infection, perinatal and prenatal genital disease, arthritis, 
rhabdomyolysis, acute exudative tonsillitis, pneumonia (neonatal and diffuse interstitial in T cell deficiency) with exanthem, 
disseminated infection associated with atopic eczema in children 

Diagnosis: culture by MRC-5 shell vial centrifugation enhancement and direct immunoperoxidase staining of material from 
vesicle fluid, throat swab, CSF, corneal scraping, brain post mortem; electron microscopy; indirect fluorescent antibody test 
for Igffl; ELISA (types 1 and 2); complement fixation test, neutralisation antibody titre 

Treatment: famciclovir 500 mg orally 12 hourly for 7-10 d, valaciclovir 500 mg orally 12 hourly for 7-10 d, aciclovir 200 
mg orally 5 times daily for 7-10 d 

Freqnent, Severe Recurrences: famiclovir 500 mg orally 12 hourly, valaciclovir 500 mg orally 12 hourly, 
aciclovir 200 mg orally 8 hourly or 400 mg orally 12 hourly 

Prophylaxis (Bone Marrow Transplantation): aciclovir 200 mg 6 hourly from 8 d before to 35 d after bone marrow 
transplantation 

Rubella (German Measles): 376 notified cases in Australia in 1999 (steady decrease from 4590 cases in 1995), 271 in 
USA (58,000 in 1969; 86% in adults in 1999); 0.1% of new episodes of illness in UK; epidemic, worldwide; attack rate 5%; 

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Multi-system, Generalised and Systemic Infections 

respiratory transmission; incubation period 2-3 w, latent period 7-14 d, infectious period 11-12 d, interepidemic period 2-7 y; 

up to 90% of infants born to mothers infected during first 11 w of gestation develop congenital rubella syndrome but the 

risk falls rapidly from this point 

Agent: human rubella virus 

Diagnosis: 20-50% asymptomatic; incubation period 12-23 d; infectious period 7 d before to 5-7 d after rash onset; infants 

infected in utero can shed for 1 y or more; conjunctivitis +, pharyngitis +, rhinitis +, exanthem (generalised maculopapular 

or erythematous rash) +, postauricular, suboccipital and cervical lymphadenopathy, low grade fever (> 37.2°); arthralgia and 

polyarthritis in < 70% of adults and adolescent females; thrombocytopenia feature in children; thrombocytopenic purpura, 

encephalitis, neuritis and orchitis; EIA capture for IgM (false positives with acute Epstein-Barr virus infection, recent human 

cytomegalovirus infection, Parvovirus infection), significant rise in serum rubella IgG, tissue culture of throat swab, nasal 

swab, urine, blood, cerebrospinal fluid (lung, kidney, bone marrow, spleen, brain, lymph node post mortem), reverse 

transcriptase PCR 

Treatment: non-specific 

Prophylaxis: highly effective live vaccine (95% efficacy), encephalitis 0.04/M doses, lifetime immunity, highly cost 

effective; contraindicated in < 12 mo old, pregnant, patients with neomycin allergy and immunocompromised 

Mumps: acute viral disease of childhood; worldwide; endemic in urban areas; « 180 notified cases/y in Australia (« 40% 

in Victoria); case-fatality rate 2/10,000; encephalitis (1:6000 cases; 0.5-2.3% death rate), non-pyogenic meningitis, 

meningoencephalitis, hydrocephalus, deafness (may be sudden, unilateral and permanent), demyelating disorders, transverse 

myelitis, Guillain-Barre syndrome, cerebellar ataxia, pancreatitis, mastitis, myocarditis, oophoritis, orchitis, parotitis, salivary 

adenitis, neuroretinitis, arthritis; 70% salivary gland (60% parotid, 10% submandibular, 5% submaxillary), 10% CNS (5% 

symptomatic, 0.02% encephalitis), 1% gonadal in prepubertal, 25% epididymoorchitis and 5% oophoritis in postpubertal; 

respiratory transmission; incubation period 12-26 d, latent period 12-18 d, infectious period 4-8 d, interepidemic period 

2-6 y 

Agent: mumps virus 

Diagnosis: complement fixation test, immunofluorescent antibody test for IgG and IgM, ELISA (IgM), hemadsorption, passive 

hemagglutination, hemagglutination inhibition antibody technique, neutralisation antibody titre (not routine); culture of blood, 

saliva, throat swab, secretions from Hansen's duct, CSF, urine (brain, salivary glands post mortem) in monkey or human 

kidney, chick embryo amnion 

Treatment: none effective 

Prophylaxis: highly effective (83%) live vaccine; all persons > 12 mo not pregnant or immunocompromised 

Monkeypox: tropical rainforests of West and Central Africa; sporadic zoonosis in man, occasionally fatal, especially in 

children; secondary attack rate < 4% 

Agent: monkeypox virus 

Diagnosis: electron microscopy 

Treatment: non-specific 

Prophylaxis: vaccination with smallpox vaccine for laboratory workers involved with virus 

Hemorrhagic Fevers 

Agents: black measles, hemorrhagic smallpox, hepatitis A, hepatitis B, hepatitis C, chikungunya fever, Sindbis fever, yellow 

fever, dengue, Crimean-Congo fever, Omsk fever, Kyanasur Forest disease, West Nile fever, Rift Valley fever, Lassa fever, 

Argentinian hemorrhagic fever (Junin arenavirus), Bolivian hemorrhagic fever (Machupo virus), Venezuelan haemorrhagic 

fever {guanarito virus), hemorrhagic fever with renal syndrome, Marburgvirus, Ebola-like viruses, Russian spring-summer 

encephalitis virus, epidemic typhus fever, tick-bite fever, Rocky Mountain spotted fever, Q fever, Neisseria meningitidis 

septicemia, streptococcal septicemia, staphylococcal septicemia, septicemic plague, Plasmodium falciparum (haemoglobinuric 

falciparum malaria, blackwater fever, bilious haematuric fever, haematuric bilious fever, haematuric fever, haemoglobinuric 

bilious fever, haemoglobinuric fever, haemoglobinuric malaria, haemoglobinuric malarial fever, melanuric fever, malarial 

haematuria, malarial haemoglobinuria, West African fever), Tyrpanosoma brucei rhodesiense; specific agent not demonstrated 

in large series of cases 

Diagnosis: incubation period < 21 d; fever, myalgia and malaise progressing to multiple organ involvement with evidence 

of vascular damage and hemorrhage; progressive renal failure, rising blood urea, proteinuria, fluid and electrolyte imbalance, 

sometimes thrombocytopenia (all viral hemorrhagic fevers); specific clinical presentation and epidemiological features may 

provide clues; repeated blood films for malaria parasites, trypanosomes and spirochaetes; PCR; ELISA for viral antigen; 

culture of blood, urine and throat swab; fluorescent antibody; serology 

Arenaviral Haemorrhagic Fevers: S America, principally Argentina and Bolivia; acute febrile illness with 
petechiae on skin and palate (Junin arenavirus, vesicles on palate); isolation of virus from throat washings or from blood; 
also serology 

Arthropod-Borne Viral Haemorrhagic Fevers: mainly tropical (not found in Australia); usually serology 

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Multi-system, Generalised and Systemic Infections 

Haemoglobinmic Falciparum Malaria: sudden onset of chills and irregular fever, nausea, hemoglobinuria, 
tender and enlarged liver, jaundice, palpable spleen, very dark urine, kidney failure, severe anemia; death in severe cases; 
due to combination of low level parasitemia, high antibody level and idiosyncratic, probably drug induced, intravascular 
hemolysis after exposure to amino-alcohol quinolones 
Treatment: supportive +: 

Argentinian Fever: postconvalescent plasma 

Rickettsia: tetracycline, chloramphenicol 

Neisseria meningitidis, Streptococci: penicillin 

Plagne: gentamicin 4-7.5 mg/kg/d i.v., doxycycline 4 mg/kg to 200 mg i.v. then 2 mg/kg to 100 mg i.v. twice 
daily (not < 8 y), ciprofloxacin 15 mg/kg to 400 mg i.v. twice daily, chloramphenicol 25 mg/kg i.v. 4 times a day 

Malaria: sulphadoxine-pyrimethamine, artemisinin, atovaquone-proguanil 

Tyrpanosoma brucei rhodesiense: i.v. suramin 1 w, then i.v. melarsopol 
Prophylaxis: 

Plagne Postexposnre: doxycycline 2 mg/kg to 100 mg orally 12 hourly (not < 8 y), ciprofloxacin 15 mg/kg 
to 500 mg orally 12 hourly 

Neisseria meningitidis: ceftriaxone 250 mg (child 125 mg) i.m. as single dose (preferred if pregnant), 
ciprofloxacin 500 mg orally as single dose (not < 12 y; preferred for women taking oral contraceptive), rifampicin 10 mg/kg 
to 600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver disease; preferred for children) 
Measles (Morbilli): of worldwide occurrence but coming rapidly under control in temperate countries; virtually 
eliminated in USA; * 230 notified cases/y in Australia (steady decrease from 4825 cases in 1994); incidence 256/100,000 in 
Africa; 0.3% of new episodes of illness in UK; global case-fatality rate 2% (67% pneumonia, 33% encephalitis); > 1.5 M 
deaths/y worldwide; cross-sex transmission gives increased mortality; latent period 6-9 d, incubation period 11-14 d, 
infectious period 6-7 d, interepidemic period 2-4 y 
Agentmeasles virus 

Diagnosis: initially malaise, fever, conjunctival injection ++, photophobia, hacking cough without pharyngitis, rhinitis 
with nasal discharge; enanthem (Koplik's spots) has characteristic appearance of tiny white dots, like grains of salt, and are 
best seen on the cheek near the second upper molar; the exanthem (cutaneous rash) appears 2 d after the Koplik's spots, is 
initially macular, becomes maculopapular and multiform and may become confluent over face and trunk; complications 
include bronchopneumonia, otitis media, encephalitis (1 in 2000), subacute sclerosing panencephalitis, hepatitis; 
epidemiological; culture of throat swab or washings collected soon after rash appears (brain, lung post mortem); serology 
(capillary blood filter paper specimens suitable (sensitivity 100%, specificity 96%); hemagglutination inhibition (4-fold rise), 
complement fixation test (titre = 8 at 9 d after onset), staphylococcal protein A adsorption (specific IgM; sensitivity 71%, 
specificity 81%, predictive value of positive 94%; detected shortly after appearance of rash, peaks within 10 d, usually 
undetectable by 30 d), sucrose gradient ultracentrifugation, ELISA (IgG, IgM), fluorescent antibody staining (not routine; 
serum: IgG 96-97% correlation with complement fixation test or hemagglutination inhibition, IgM detected in only « 30%; 
CSF), neutralisation antibody titre (not routine); confirmatory rather than ruling out); histology (giant multinuclear cells of 
Warthin-Finkedy type in submucous lymphoid tissue of appendix); neutrophilia with thrombocytopenia, panyctopenia; serum 
creatinine 6.8 mg/dL; white cell count 14,500 in atypical measles 
Treatment: supportive; antimicrobial treatment of secondary infection 

Prophylaxis: highly effective live vaccine (95-98% efficacy when given during second year of life; * 100% if second dose 
at primary or secondary school entrance), encephalitis and encephalopathy 1/M doses, subacute sclerosing panencephalitis 
0.5-1.1/M doses, lifetime immunity, highly cost effective, contraindicated in < 12 mo old, pregnant, immunocompromised, 
severe febrile illness (postponed), tuberculosis, caution (facilities for resuscitation) if history of marked reactions to hen's egg 
(generalised urticaria, swelling of mouth and throat, difficulty in breathing, hypotension, shock) or hypersensitivity to 
neomycin or polymyxin (vaccine is produced in chick embryo cell culture and contains trace amounts of neomycin and 
polymyxin), human globulin injections or other antibody-containing blood products within preceding 3 mo (deferred); passive 
immunity (patients with severe malnutrition in contact with measles patients): immunoglobulin 0.02 mL/kg i.m. within 5 d of 
contact 

Smallpox: with measles, killed 90% of New World population 1518-1837; eliminated as natural infection by use of highly 
effective live vaccine; potential biowarfare agent; transmission respiratory, contact with lesions; incubation period 7-19 d 
(average 12 d); fatality rate variola major 5-40%, variola minor 0.1-2% 
Agent: variola major virus, variola minor virus 

Diagnosis: sudden onset of influenza-like symptoms (fever, malaise, headache, chills), prostration, severe back pain, 
anorexia and vomiting, less often abdominal pain, diarrhoea, delirium and convulsions; 2-3 d later, temperature falls and 
maculopapular rash appears centrifugally on face, neck and distal extremities including palms and soles and then, after a 
few days, on trunk and sometimes on more proximal extremities; ulcerating lesions also appear in mucous membranes of nose 
and mouth; skin lesions progress from macules to papules to vesicles to pustules, which, on the eighth or ninth day, form 

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scabs which leave depressed, depigmented scabs on healing; rarely, rash accompanied by hemorrhage into mucous 

membranes and skin (hemorrhagic smallpox; invariably fatal) or lesions fail to form pustules but remain soft and flat 

(malignant smallpox; almost invariably fatal); complement fixation test, fluorescent antibody staining (not routine), 

hemagglutination antibody technique; tissue culture of scrapings from skin lesions, vesicle fluid, pus, blood, crust (liver, 

spleen, blood post mortem) 

Treatment: cidofovir 5 mg/kg i.v. weekly for 2 w 

Prophylaxis: vaccine up to 4 d (possibly 7 d) after exposure can prevent infection or ameliorate severity (+ vaccine 

immune globulin in pregnant women and patients with eczema); vaccine containing live vaccinia virus protects for at least 

10 y; contraindicated for pregnant, persons with diseases or conditions or treatments which cause immunodeficiency or 

immunosuppression, with a history of eczema, atopic dermatitis or other acute, chronic or exfoliative skin conditions, with 

previous allergic reaction to smallpox vaccine or life-threatening allergy to polymyxin B sulphate, streptomycin sulphate, 

tetracycline hydrochloride or neomycin sulphate, with moderate or severe acute illness, < 12 mo old or > 18 y except in 

emergency, breastfeeding; complications include postvaccinial encephalitis, progressive vaccinia, eczema vaccinatum and 

generalised vaccinia; vaccinia immune globulin may be given with vaccine to reduce complications or as therapy for 

complications but is in short supply and should be reserved for most serious cases; cidofovir may be used when vaccinia 

immune globulin is not efficacious 

Yellow Fever: transmitted by bite of infected mosquito; incubation period 3-6 d; sylvatic fever in tropical areas of S 

America (Bolivia, Brazil, Colombia, Ecuador, Peru), sylvatic and urban forms in Africa (endemic in Burkina Faso, Gambia, 

Ghana, Nigeria, Sudan, Zaire); 5000 cases/y worldwide; no notifications in Australia in past decade 

Agent: yellow fever virus 

Diagnosis: clinically inapparent infections common; overt attacks most common in aged; incubation period 3-6 d; acute 

onset and constitutional symptoms, followed by brief remission and recurrence of fever, hepatitis, albuminuria and symptoms 

and, in some instances, renal failure, shock and generalised hemorrhages; severe jaundice in 100%, abrupt onset of chills and 

fever in 96%, headache in 90%, myalgias in 75%, vomiting in 70%, palatal petechiae in 70%, black vomit in 20%, abdominal 

pain; raised bilirubin, proteinuria, neutropenia, anemia, thrombocytopenia, reduced levels of coagulation factors; geographic 

history; vaccination none or > 10 y; exposure to mosquitos; serology (specific IgM or fourfold or greater rise in titre by 

complement fixation test, hemagglutination inhibition antibody technique, neutralisation antibody titre); demonstration of 

virus, antigen or genome in tissue, blood or other body fluid; histology of liver (early ballooning and fatty infiltration of 

hepatocytes, followed by midzonal acidophil necrosis and 'Councilman' bodies within hepatocytes) 

Treatment: tiazofurin 825 mg/m 2 for 10 d 

Prophylaxis: immunisation administration limited to designated national centres and designated medical practitioners, 

contraindicated in children < 6 mo, pregnant women (may be reviewed), patients with altered immune status, patients 

allergic to eggs, should not be administered within 3 w of cholera vaccine 

Prevention and Control: mosquito control 

Dengue: transmitted by Redes aegypti mosquito bite; incubation period 3-15 d; all tropical environments, with concentration 

in Asia, Central and South America; « 60 notified cases/y in Australia (« 50% in Queensland; all imported; 43% from Papua 

New Guinea; causes 8% of fever in returned travellers); global incidence dengue 50-100 ffl/y, dengue hemorrhagic fever 

250,000-500,000/y (24,000 deaths/y); case-fatality rate 3-20% 

Agent: dengue virus group 

Diagnosis: severe myalgia in 100%, arthralgia in 90%, retroocular pain in 75%, nausea in 75%, maculopapular rash in 

30%, headache; viral culture of serum or autopsy samples (sensitivity 30-80%), ELISA (IgM positive in 80% by fifth day) on 

tissue, serum or CSF, immunochromatographic card test (sensitivity 99% in primary cases, 94% in secondary, specificity 

93%), reverse transcription-polymerase chain reaction, hybridisation assay (in evaluation), fourfold or greater increase in 

serum IgG by hemagglutination inhibition test or increase in specific IgM antibody; neutropenia and thrombocytopenia, 

anemia, hemoglobin 16.6 g/dL, platelet dysfunction, reduced levels of coagulation factors, disseminated intravascular 

coagulation, vascular injury 

Dengne Hemorrhagic Fever 

Grade I: fever, constitutional symptoms, positive tourniquet test (> 20 petechiae/cm 2 ), 
hemoconcentration (rise in hematocrit of > 20%), thrombocytopenia (platelet count < 100,000/VL) 

Grade II: Grade I + spontaneous bleeding (eg, skin, gums, gastrointestinal tract) 

Grade III (Dengne Shock Syndrome): Grade II + circulatory failure, agitation, hypotension 
(systolic pressure < 80 mm Hg for those < 5 y or <90 mm Hg for those > 5 y) or narrowing of pulse pressure to 
< 20 mmHg 

Grade IV (Dengne Shock Syndrome): profound shock (blood pressure = 0) 
Differential Diagnosis: Chikungunya virus, Hantavirus, measles, rubella, enteroviruses, influenza, hepatitis A, 
meningococcemia, scarlet fever, typhoid, leptospirosis, rickettsioses, malaria 

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Treatment: rapid volume replacement through intravenous electrolyte solutions, plasma or plasma expanders (lowers 

mortality from 10-20% to « 3%) 

Prevention and Control: vector control; live vaccine in development 

Crimean-Congo hemorrhagic Fever (Central Asian Hemorrhagic Fever): case-fatality rate 10-50%; Europe, 

Africa, Asia; source tick, nosocomial (person-to-person aerosol), during slaughter of domestic animals; incubation period 2-9 d 

Agent: Nairovirus 

Diagnosis: hemorrhage predominant; non-purulent conjunctivitis, hemoptysis, meningoencephalitis; disseminated 

intravascular coagulation in fatal cases; isolation of virus from blood; fourfold rise in antibody titre, presence and decline of 

Igffl antibody; fibrin degradation products > 40 mg/L, platelet count < 10,000/jLtL, white cell count 4000-7000/nL, reduced 

levels of coagulation factors, disseminated intravascular coagulation, vascular injury 

Treatment: ribavirin 

Omsk Hemorrhagic Fever: former Soviet Union, Romania; tick source 

Agent: Omsk haemorrhagic fever virus 

Diagnosis: clinical; thrombocytopenia 

Treatment: non-specific 

Kyasanur Forest Disease: India; tick source 

Agent: Kyasanur Forest disease virus 

Diagnosis: clinical; thrombocytopenia 

Treatment: non-specific 

Rift Valley Fever: usually complete recovery in 2 w but retinitis in 10%, hemorrhagic fever in 1% and encephalitis in 

1%; case-fatality rate among severely ill > 50% (1% overall); Sub-Saharan Africa, Saudi Arabia, Yemen; sources several 

Aedes and Culex mosquitoes, slaughter of domestic animals (camels, cattle, goats, sheep) 

Agent: Rift Valley fever virus 

Diagnosis: anorexia, 'saddle back' fever, headache, myalgia, retroorbital pain, retinitis with characteristic cotton-wool 

exudates on macula in 10%, hemorrhage and jaundice (often with death from hepatic failure shock), meningoencephalitis (high 

death rate); thrombocytopenia, reduced levels of coagulation factors, severe liver dysfunction; serology; isolation by tissue 

culture or inoculation of suckling mice during acute febrile stage 

Treatment: supportive; ribavirin 

Prophylaxis: limiting contact with infected mosquitoes, livestock and freshly slaughtered meat 

Lassa Fever: widely distributed over W and Central Africa in Guinea, Liberia, Mali, Senegal, Sierra Leone; case-fatality 

rate 10%; rodent source, nosocomial transmission (person-to-person aerosol) 

Agent: Lassa virus 

Diagnosis: usually clinical (fever, pharyngitis, retrosternal pain, proteinuria; incubation period 6-21 d) and excluding 

malaria and diabetic coma, as laboratory tests dangerous; thrombocytopenia, platelet dysfunction, reduced levels of 

coagulation factors; isolation from blood, throat or urine; serology (fluorescent antibody staining of conjunctival scrapings) 

Treatment: ribavirin 30 mg/kg i.v. loading dose, followed by 15 mg/kg i.v. 6 hourly for 4 d, then 8 mg/kg 8 hourly for 

6d 

Prophylaxis: ribavirin 500 mg orally every 6 h for 7 d; experimental vaccine 

Argentinian Hemorrhagic Fever: Argentina; rodent source, nosocomial transmission 

Agent: Junin arenavirus 

Diagnosis: incubation period 7-16 d; thrombocytopenia, reduced levels of coagulation factors, vascular injury, disseminated 

intravascular coagulation in terminal shock; serology 

Treatment: convalescent antisera; ribavirin 

Bolivian Haemorrhagic Fever: Bolivia; rodent source, nosocomial transmission 

Agent: Machupo virus 

Diagnosis: incubation period 7-16 d; thrombocytopenia; serology 

Treatment: supportive 

Hemorrhagic Fever With Renal Syndrome (Korean Hemorrhagic Fever): Europe, Asia, Americas, Africa; 

rodents, bats, birds reservoir; transmission via aerosol; person-person transmission reported; * 150,000 hospitalised cases/y 

worldwide; fatality rate 3-15% 

Agent: Hantavirus 

Diagnosis: incubation period 5-42 d; fever in 94-99%, thirst in 89%, chills in 77-92%, anorexia in 66-96%, nausea in 61- 

84%, pharyngeal or palatal injection in 55-70%, backache in 53-95%, insomnia in 51%, headache in 42-86%, myalgia in 38- 

78%, vomiting in 33-70%, epistaxis in 28%, hemorrhages in 26-72%, abdominal pain in 21-66%, constipation in 19-60%, 

conjunctival injection in 16-79%, dizziness and vertigo in 7-100%, petechiae in 1-99% (mainly in febrile phase); Hantavirus 

pulmonary infection rare but deadly infection with predominance in the Southwest of USA; creatinine increased in 96%, 

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C-reactive protein increased in 96%, proteinuria in 94-96%, lactate dehydrogenase increased in 88%, fibrinogen increased in 
85%, erythrocyte sedimentation rate increased in 84% (> 20 mm/h in 7-72%), hematuria in 73-86%, albumin decreased in 
66%, polyuria in 63-97%, alanine aminotransferase increased in 60%, thrombocytopenia in 52-78%, ASAT increased in 52%, 
blood urea nitrogen > 20 or serum creatinine level > 2 mg/dL in 50-100%, leucocytosis in 41-92%, oliguria in 37-83%, 
hypotension in 22-80%, disseminated intravascular coagulation in 5%, platelet dysfunction, reduced levels of coagulation 
factors, prolonged prothrombin time, vascular injury; immunofluorescent antibody test, ELISA 
Treatment: ribavirin 30 mg/kg i.v. then 15 mg/kg i.v. 6 hourly; fluids, vasopressors, dialysis, plasma and platelet 
transfusions 

Prophylaxis: combined Hantavirus/Puumula virus vaccine 

Nephropathica Epideihica: mild form of hemorrhagic fever with renal syndrome occurring in Scandinavia 
Agent: Puumala virus 

Diagnosis: acute onset of symptoms in all cases, fever in 99-100%, thirst in 89%, headache in 85-90%, backache in 82- 
84%, nausea in 78-84%, vomiting in 70%, myalgia in 69%, abdominal pain in 67%, anorexia in 66-70%, chills in 60%, 
insomnia in 51%, petechiae in throat and soft palate in 36%, conjunctival injection in 18%, petechial rash in 12%, epistaxis 
in 10%; proteinuria in all cases, C-reactive protein raised in 96%, lactate dehydrogenase raised in 88%, bleeding time normal 
in 86%, erythrocyte sedimentation rate raised (> 20 mm/h) in 84-90%, thrombocytopenia in 80%, whole blood coagulation 
time normal in 77%, Rumpel-Leede tourniquet test normal in 77%, hematuria in 74%, blood urea nitrogen > 20 or serum 
creatinine level > 2 mg/dL in 70-96%, serum albumin decreased in 66%, alanine aminotransferase increased in 52%, 
prothrombin ratio normal in 50-60%, leucocytosis in 37%; serology; histology (hemorrhages in renal medullary interstitium in 
all cases, hemorrhages in renal cortex in 53%) 
Treatment: as for Hemorrhagic Fever with Renal Syndrome 

Marburg Hemorrhagic Fever: Kenya and Republic of South Africa; source unknown, nosocomial transmission (person-to- 
person aerosol); high mortality 
Agent: Marburgvirus 

Diagnosis: incubation period 3-9 d; disseminated intravascular coagulation in fatal cases; virus specific 
immunofluorescence or electron microscopy of isolate (grows readily in Vero cells) from blood or serum or suspensions of 
heart, kidney, liver or spleen, histology and electron microscopy of autopsy specimens (liver and kidney tissue); complement 
fixation test less sensitive than indirect fluorescent antibody titre; IgM peaks 2-3 w after onset; IgG rises more slowly and 
may be found in low titres years later; leucopoenia (1400/ i_lL), relative lymphocytosis, atypical monocytes, thrombocytopenia, 
reduced levels of coagulation factors, disseminated intravascular coagulation; occult blood in stool, elevated serum 
transaminases, alkaline phosphatase, amylase and bilirubin 
Treatment: supportive 

Ebola Hemorrhagic Fever (African Hemorrhagic Fever): case-fatality rate 50-90%; Central and E Africa, Sudan; 
source unknown, nosocomial transmission (person-to-person aerosol); acute febrile systemic infection 
Agent: Ebola-like viruses 

Diagnosis: incubation period 2-21 d; fever, extreme asthenia, gastroenteritis with diarrhoea, nausea and vomiting, 
headache, arthralgias, back pain, myalgias; bilateral conjunctival injection, maculopapular rash and pharyngitis with severe 
odynophagia in patients prone to hemorrhagic manifestations; antibody ELISA (IgG and/or IgM), virus isolation, 
immunohistochemistry of skin biopsy, reverse transcriptase polymerase chain reaction; thrombocytopenia, reduced levels of 
coagulation factors 
Treatment: supportive 

Ross River Fever (Epidemic Polyarthritis): endemic in Australia (* 4000 notified cases/y (« 52% in Queensland)), 
New Guinea, Solomon Islands; mosquito vector 
Agent: Ross River virus 

Diagnosis: polyarthralgia, rash, malaise, myalgia, fever; culture of serum; ELISA (IgG and IgM) 
Treatment: non-specific 

Barmah Forest Virus Infection: widespread in Eastern states of Australia (« 600 cases/y, « 50% in Queensland) 
Agent: Barmah Forest virus 

Diagnosis: rash in 80-90%, fever in 60-80%, arthritis or arthralgia in 50%, headache in 40-50%, respiratory symptoms in 
20%, gastrointestinal symptoms in 15%; serology 
Treatment: non-specific 
Phlebotomus Fever (Sandfly Fever) 
Agent: Phlebovirus 
Diagnosis: serology 
Treatment: supportive 
Prophylaxis: ribavirin 

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Mucocutaneous Lymph Node Syndrome (Kawasaki Disease, Kawasaki Syndrome): acute, febrile, exanthematous 
infectious disease (mucocutaneous, lymph node inflammation and systemic vascular disease); worldwide but unusual, affecting 
mainly children; attack rate 7/100,000 in children < 5 y, 0.4/100,000 in Caucasian, and 2.7/100,000 in Oriental, children 
< 8 y; case-fatality rate 1-2% (cardiac involvement); several cases found in Australia; vector ? house mites and cat fleas 
Agent: ? Ehrlichia, ? retrovirus 

Diagnosis: rash (macular, papular, polymorphous, scarlatiniform, urticarial, vesicular, erythema multiforme) in 100% of 
cases (erythema multiforme rash without vesicles or crusts in 90%), > 5 d of fever in 95%, desquamation of fingertips in 
85-95%, bilateral conjunctival injection in 81-90%, dryness of lips in 80%, non-suppurative lymphadenopathy in 75-85%, 
indurative edema of hands or feet in 75%, desquamation of palms and soles in 73%, red oropharynx in 73%, carditis in 70%, 
periungual desquamation in 69%, other desquamation in 58%, redness and fissuring of lips in 66-90%, coronary artery 
abnormalities in 23% (cardiac arteries may be affected by widespread endarteritis, resulting in aneurism formation, 
thrombosis or rupture, causing death in third or fourth week; even those apparently not affected may develop highly 
premature coronary artery disease in later life), diarrhoea, arthralgias/arthritis, aseptic meningitis, mild jaundice, transient 
nail furrow 1-2 mo post-onset; electrocardiogram (transient changes associated with diffuse ischemia or myocarditis in 11% 
of cases, myocardial infarction in 4-8%, increased PR interval, increased ST interval, decreased R waves, flat T waves); 
raised erythrocyte sedimentation rate, platelet count increased days 10-25; white cell count increased in 68% (shift to left), 
proteinuria and increased urinary leucocytes in 46%, slight anemia in 44%, slight elevation in serum transaminases in 19% 
Differential Diagnosis: infectious mononucleosis, leptospirosis, scarlet fever, serum sickness, systemic lupus 
erythematosus, rubella, measles, Rocky Mountain spotted fever, scalded skin syndrome, juvenile rheumatoid arthritis, 
staphylococcal toxic shock 

Treatment: aspirin 60-100 mg/kg daily in divided doses, then 10-30 mg/kg daily for 6-8 w (reduces incidence of 
aneurisms) + y-globulin 400 mg/kg/d i.v.; PGEi or sympathetic block + thrombolytic and anticoagulant therapies in 
peripheral ischemia 

Reye Syndrome: case-fatality rate 23-30%; age of onset 4 d-29 y (usually 6 mo-15 y; 95% age < 14 y), 94% Caucasian, 
55% antecedent respiratory illness, 25% varicella, 10% diarrhoea; permanent neurological or psychiatric disorders in 34-61% 
of survivors 

Agents: interaction of aspirin and other salicylates with influenza A virus, influenza B virus, simplexvirus 3 (5-30%) and 
other viruses 

Diagnosis: history of viral infection; encephalopathy, varying from drowsiness to deep coma (also combativeness, 
confusion), associated with vomiting and hepatic enlargement; no evidence of drug intoxication; no jaundice (slightly elevated 
or normal serum bilirubin), but > 3 fold rise in serum transaminases and serum ammonia levels, and there may be 
hypoglycemia (only in children < 5 y) and disturbances of acid-base balance and of blood clotting (prolonged prothrombin 
time); CSF < 8 leucocytes/jaL; cerebral edema without perivascular or meningeal irritation; histologically (biopsy or 
autopsy), liver shows microvesicular fatty metamorphosis, with fine droplets of fat scattered through cytoplasm of 
hepatocytes; electron microscopy shows specific mitochondrial damage which is self-limiting 
Treatment: supportive 

Multisystem Streptococcus pyogenes Disease: in children; preexisting varicella in 47%; also associated with use of 
nonsteroidal antiinflammatory drugs 
Agent: Streptococcus pyogenes 

Diagnosis: confusion in 62% of cases, abdominal pain in 62%, headache/irritability in 50%, vomiting in 50%, anorexia in 
50%, local extremity swelling/pain in 50%, hyperesthesia in 50%; hypoalbuminemia in 100%, renal sediment abnormalities in 
100%, elevated immature polymorphonuclears in 87%, hyponatremia in 87%, lymphopenia in 75%, elevated AST in 67%, 
thrombocytopenia in 62%, prothrombin time > 14 s in 60%, fibrin split products or fibrinogen < 500 in 60%, elevated 
creatinine in 50%, direct hyperbilirubinemia in 50%; blood cultures 
Treatment: benzylpenicillin 150,000-200,000 U/kg i.v. daily in divided doses 

Listeriosis (Listerellosis, Listerosis): « 50 notified cases/y in Australia; « 30 cases/y in USA (50% nosocomial), 
56% of isolates from blood, 16% blood and CSF; bacteremia without known focus (43% of infections), cutaneous listeriosis, 
disseminated (typhoidal) listeriosis, food poisoning (from unpasteurised or inadequately pasteurised milk, fresh soft cheeses, 
ready to eat deli meats and hot dogs), genital tract listeriosis, listerial endocarditis (endocardial listeriosis), listerial 
meningoencephalitis (meningitis/meningoencephalitis 43% of infections; associated with malignancy; also, neonatal and 
postneonatal pyogenic meningitis), listerial septicemia, lymph gland infections, neonatal disseminated listeriosis, 
oculoglandular listeriosis, prenatal generalised disease; case-fatality rate from 0% in previously healthy patients to 80% in 
disseminated infection; fatal neonatal listeriosis 0.1-0.3% of births, 1-7% of perinatal deaths; risk factors pregnancy, neonatal 
status, hematological, gastrointestinal or pulmonary malignancy, organ transplantation, oncologic chemotherapy, steroid 
therapy, systemic lupus erythematosus, alcoholism, renal failure, hepatic failure, portal hypertension and ascites, increased 
age, splenectomy, human immunodeficiency virus infection 
Agent: Listeria monocytogenes 

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Diagnosis: incubation period 9-48 h for gastrointestinal symptoms, 2-6 w for invasive disease; fever, muscle aches and 
nausea or diarrhoea; pregnant women may have mild flu-like illness (fever in 82%, chills in 82%, headache in 82%, 
abdominal cramps in 45%, stiff neck in 45%, vomiting in 27%, photophobia in 18%) and infection can lead to premature 
delivery or stillbirth 

Disseminated: granulomatous lesions and focal necroses; elderly or immunocompromised may have bacteremia or 
meningitis 

for other forms, see appropriate sections 
culture of appropriate specimen on blood agar; cold enrichment at 4°C may be useful in some circumstances; blood or CSF 
cultures; antibody to listerolysin may be helpful to identify outbreak retrospectively 
Treatment: supportive care + i.v. ampicillin, penicillin or cotrimoxazole 

Actinomycosis: cervicofacial (lumpy jaw; most common form; usually arising as result of infection following extraction of 
tooth or injury to jaw), pulmonary (arises from inhalation or aspiration of infective material (eg., from cervicofacial lesions), 
by extension of abdominal disease or, more rarely, by metastasis of disseminated disease), abdominal (gastrointestinal 
actinomycosis; most common in ileorectal region but sometimes in anorectal or gastric areas; arises from intestinal flora and 
intestinal perforation), septicemia (usually from pulmonary), brain, bone, liver, kidney, genital (uterus, associated with 
intrauterine devices), disseminated; « 6 cases/y in USA; endogenous (oral) 

Agents: Actinomyces israelii, Actinomyces naeslundii, Actinomyces odontolyticus, Actinomyces meyeti, Actinomyces boms, 
Propionibacterium propionicum, Bifidobacterium 

Diagnosis: visualisation of macroscopic sulphur-coloured colonies in pus; Gram stain, direct immunofluorescent stain and 
anerobic culture of pus, curettings, biopsy from wall of abscess; neutrophilia and raised erythrocyte sedimentation rate usual 

Cervicofacial: painful swelling on jaw that enlarges and eventually forms sinuses that open onto cheek or 
submandibular region 

Abdominal: abdominal discomfort, fever, palpable mass, production of external sinus 

Pnlmonary: severe pneumonia, lung abscess or empyema, with characteristic production of small, multiple 
abscesses and sinuses in chest wall; on occasion, actinomycotic pneumonia may simulate a pulmonary neoplasm or 
tuberculosis 

Treatment: penicillin (mild disease: phenoxymethylpenicillin 500 mg 6 hourly (< 12 y: 25-50 mg/kg daily orally in 4 
divided doses); severe disease: benzylpenicillin 10M units (children: 100 000-250 000 U/kg) daily i.v. in 4 divided doses for 
6 w, then phenoxymethylpenicillin as above), tetracycline 500 mg 6 hourly orally for 6 weeks, erythromycin 500 mg 4 times 
daily (children: 30 mg/kg daily in 4 divided doses) orally for 6 w 
Prophylaxis: good dental hygiene 

Anthrax (Contagious anthrax, Fellihonger's Disease, Tanner's Disease): an acute disease of herbivorous 
animals readily transmitted to man; worldwide; rare in Australia 
Agent: Bacillus antkacis 

Diagnosis: Gam positive bacilli seen on microscopy; confirmed by culture; ELISA, Western blot, toxin detection, 
chromatographic assay, fluorescent antibody test 

Treatment: see Cutaneous Anthrax, Pulmonary Anthrax, Gastrointestinal Anthrax, Meningitis, 
Bacteremia 

Prophylaxis: vaccine 93% effective against cutaneous form, effectiveness against other forms not known 
Prevention and Control: sterilisation of infected tissue, hides, etc 

Nocardiosis: worldwide; 70 cases (« 20 deaths)/y in USA; associated with Hodgkin's disease, connective tissue disorders, 
diseases treated by organ transplantation and corticosteroid administration; 75% lungs (33% only; may simulate pulmonary 
tuberculosis; subacute chronic pneumonia, occasionally with extension to pleura, resulting in empyema (pulmonary mycetoma) 
and dissemination), 23% brain, meninges and spinal cord; skin and subcutaneous tissue lesions + osteomyelitis, kidneys, 
adrenals, eye, liver, lymph nodes, pericardium, myocardium (disseminated disease); lymphocutaneous (may present similarly to 
sporotrichosis, most commonly Nocardia brasiliensis); actinomycetoma (usually lower extremity secondary to trauma); septic 
arthritis; disseminated; epididymoorchitis (extremely rare) 

Agents: Nocardia asteroides, Nocardia brasiliensis, Nocardia brevicatena, Nocardia ototididiscaviarum, Nocardia farcinica, 
Nocardia nova 

Diagnosis: Gram (Brown-Breen or Hueker modification) and Ziehl-Neelsen (Kinyoun or Putt modification) stains and culture 
of sputum, thoracentesis specimen, transtracheal aspirate, bronchial brushings, lung biopsy, pus from abscess or draining 
sinus, biopsy from other affected sites; serology (immunodiffusion) 

Treatment: cotrimoxazole 320/1600 mg orally 12 hourly (child: 6/30 mg/kg daily in 2 divided doses) for 6-12 mo; 
sulphadiazine 100 mg/kg orally daily in 4 divided doses (child: 75 mg/kg initially, then 160 mg/kg daily in 4-6 divided 
doses to 6 g daily) + sodium bicarbonate 50 mg/kg orally daily in 4 divided doses for 4-6 w, then sulphisoxazole 
60 mg/kg 6 g orally daily in divided doses for 12-18 mo; minocycline 300 mg orally 12 hourly; ciprofloxacin, cefotaxime, 
amikacin, imipenem, linezolid; surgical excision or drainage of abscesses, empyema and other necrotic tissue 

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Tuberculosis: progressive or chronic disease; usually begins in lung but may affect any other organ or system, eg., 
lymphatic, osseous, urogenital, nervous and gastrointestinal systems and skin; conditions caused include tuberculous laryngitis 
(laryngeal tuberculosis), lymphadenitis (tuberculosis of intrathoracic lymph nodes, tuberculous peripheral lymphangitis), 
meningitis, leptomeningitis, meningoencephalitis, brain abscess, myelitis, ascites, peritonitis (peritoneal tuberculosis, 
tuberculosis of the peritoneum), arthritis, osteitis, osteomyelitis, synovitis, tenosynovitis, kyphosis (Pott curvature), spondylitis, 
dactylitis, mastoiditis, pyelitis, pyelonephritis, epididymitis, oophoritis, salpingitis, erythema nodosum, adenitis, episcleritis, 
interstitial keratitis, keratoconjunctivitis, otitis media, Addison disease, mediastinal tuberculosis (tuberculosis of the 
mediastinum), nasal tuberculosis, nasopharyngeal tuberculosis (tuberculosis of the nasopharynx), pharyngeal tuberculosis, 
cerebral tuberculosis (tuberculosis of the brain), intestinal tuberculosis (tuberculosis of the intestine, tuberculous enteritis), 
rectal tuberculosis, anorectal tuberculosis, anal tuberculosis, spinal tuberculosis (David disease, Pott caries, tuberculosis of the 
vertebral column, tuberculous spondylitis), tuberculosis of the hilar and other lymph nodes, sinuses, ear, mouth, esophagus, 
liver, genitourinary system, kidney, bladder, ureter, prostate, seminal vesicle, testis, endometrium (tuberculous endometritis), 
skin and subcutaneous tissues, thyroid gland, adrenal glands, spleen, endocardium, myocardium, pericardium, hip and knee, 
meningeal tuberculoma; miliary tuberculosis is a disseminated tuberculosis that spreads via lymphatic vessels and 
bloodstream from any active tuberculous lesion; massive hematogenous spread of bacilli results in tubercles scattered 
throughout pulmonary tissue and other body tissues (rarely, skin tissue); occurs mainly in elderly and immunocompromised; 
old foci may be reactivated by alcoholism, anthracosis, corticosteroid therapy, cytotoxic therapy, diabetes mellitus, gastric 
resection, malignancy, malnutrition, old age, pulmonary infections, radiation, sarcoidosis, severe viral infections, silicosis, 
thoracic surgery, thoracic trauma; abscesses in liver, abdominal wall, psoas muscle, mediastinum and peripancreatic area 
common in AIDS (12% of cases of tuberculosis); leading cause of death due to infectious organism worldwide (2 M deaths/y, 
with 8-10 M new active cases (20% in India); 1.9 billion infected worldwide; * 1000 notified cases/y in Australia (« 26% 
in Victoria; most new cases in migrants from Indochina and South East Asia); 69% pulmonary, 9% lymphatic, 5% pleural, 3% 
multiple, 2% bone/joint, 1% meningeal, 6% other; « 20,000 cases/y in USA; transmission from elephants to humans recently 
reported 

Agents: Mycobacterium tuberculosis (usually acquired by inhalation), Mycobacterium bovis (usually acquired by ingestion; 
30-40% respiratory; also genitourinary, lymphatic, skeletal and disseminated), Mycobacterium africanum 
Diagnosis: persistent productive cough, hemoptysis, unexplained fever and night sweats, unexplained weight loss; 
auramine-rhodamine, Kinyoun or Ziehl-Neelsen stain and Bactec 12B (97% MJubercuiosis (mean 14 d) and 94% 
nontuberculous mycobacteria (mean 13 d) positive; 3% contamination rate), Mycobacterial Growth Indicator Tube (92% 
MAuberculosis (mean 19 d) and 94% nontuberculous mycobacteria (mean 14 d) positive; 4% contamination) or Septichek AFB 
biphasic system or routine culture (Middlebrook 7H9, 7H10, 7H11 or selective 7H11 or Lowenstein-Jensen; 95% MJubercuiosis 
(mean 29 d) and 77% nontuberculous mycobacteria (25 d) positive; 4% contamination) of appropriate specimen; tuberculin 
test (PPD; zone of induration read at 72 h; > 5 mm positive in patients with HIV, close contacts of active TB cases, 
patients with chest X-ray findings of inactive tuberculosis or fibrosis, patients with organ transplants or other 
immunosuppression; > 10 mm positive in patients with medical risk factors for TB (silicosis, diabetes mellitus, chronic renal 
failure, leukemia, lymphoma, carcinoma of head, neck or lung, weight loss of > 10% of ideal body weight, gastrectomy, 
jejunoileal bypass), injection drug users, immigrants within last 5 y from high prevalence countries, residents and employees 
of prisons, nursing homes and other long term facilities for elderly, hospitals and other health care facilities, residential 
facilities for patients with AIDS and homeless shelters, mycobacteriology laboratory personnel, children < 4 y or infants, 
children and adolescents exposed to adults at high risk; > 15 mm positive in persons with no risk factors for TB; 'true' 
negative if patient never infected with Mycobacterium tuberculosis or if isoniazid prophylaxis begun within 3 mo of skin 
test conversion; can be 'false' negative (10-25% of active tuberculosis) in small children, early in infection, in acute miliary 
tuberculosis, tuberculous pleurisy and tuberculous meningitis, if the patient also has human immunodeficiency virus infection, 
measles, mumps, chickenpox, scarlet fever, influenza, typhoid fever, brucellosis, typhus, leprosy, pertussis, South American 
blastomycosis, chronic lymphocytic leukemia, lymphoma, Hodgkin's disease, sarcoidosis, amyloidosis, uremia, chronic renal 
failure, severe protein depletion or has received live virus vaccine (measles, mumps, polio) or is on immunosuppressive 
therapy, in late pregnancy and puerperium, old age and occasionally middle age, if patient has been receiving UV light 
therapy or sunbathing, in stress states such as surgery, burns, mental illness, graft versus host reactions, and in individuals 
of low sensitivity or if infected with atypical mycobacteria, also if incorrect dilution of tuberculin, incorrect diluent, 
improper storage (inactivated by sunlight, heat), adsorbed to container (partially controlled by addition of Tween 80), 
chemical denaturation, bacterial contamination, injection of too little antigen, delay in administration after drawing of 
preparation into syringe, injection too deep, incorrect route, improper reading (unsupervised reader, conscious or unconscious 
bias, error in reading); interferon gamma test; PCR (sensitivity 90%, specificity 99.6%); DNA probe identification; gene 
amplification and hybridisation or RFLP; ELISPOT; serum angiotensin converting enzyme decrease; rheumatoid factor may be 
present; 4% of cases diagnosed postmortem 



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Miliary Tuberculosis: fever in 89-90%, anemia in 78%, sweats in 86%, weight loss in 66%, cough in 55%, 
weakness in 53%, dyspnoea in 50%, tachypnoea in 47-50%; reticulonodular miliary chest radiograph in 68%; sputum culture 
positive in 76%, gastric aspirate in 75%, urine in 59%, bronchial washings in 54% 

Treatment: isoniazid 10 mg/kg to 300 mg orally once daily or 15 mg/kg to 600 mg orally 3 times weekly for 6 mo [+ 
pyridoxine 25 mg (breastfed baby 5 mg) orally with each dose] + rifampicin 10 mg/kg to 600 mg orally once daily 1 h 
before breakfast or 15 mg/kg to 600 mg orally 3 times a week for 6 mo + pyrazinamide 25-35 mg/kg to 2 g orally once 
daily or 50 mg/kg to 3 g orally 3 times weekly for 2 mo (6 mo if not known to be susceptible to isoniazid and rifampicin) 
+ ethambutol 15 mg/kg orally daily (not < 6 y or plasma creatinine > 160 pM/L; regular ocular monitoring) or 
30 mg/kg orally 3 times weekly for 2 mo or until known to be susceptible to isonazid and rifampicin (to 6 mo); vitamin A 
and zinc may augment efficacy 

Latent Infection (Prophylaxis): rule out active tuberculosis and do not give if previous treatment for TB or 
previous isoniazid, previous isoniazid adverse reaction or acute or unstable liver disease; otherwise, should be given to 
recent tuberculin converters; children and adolescents with strongly positive tuberculin reactions; tuberculin positive juvenile 
close contact; old untreated tuberculosis or radiologically healed pulmonary lesion, tuberculin positive or anergy in patients 
about to be treated with steroid drugs or by immunosuppressive or chemotoxic therapy or radiotherapy; patients with chronic 
lung disease such as silicosis; patients with tuberculin skin test > 5 mm who have not had BCG or with positive TB-specific 
interferon gamma release assay and with cancer or other debilitating disease or with diabetes or chronic renal failure 
(especially if < 35 y) or who have had a gastrectomy, having long-term corticosteroid therapy or other immunosuppressive 
therapy (prior to commencement), with history of tuberculosis and with leukemia, Hodgkin's disease or other chronic 
malignancies, with silicosis and with human immunodeficiency virus infection; isoniazid 10 mg/kg to 300 mg orally daily 
[+ pyridoxine 25 mg (breastfed baby: 5 mg) orally with each dose] for 6-9 mo; vitamin D 2.5 mg single oral dose 

Contacts of Isoniazid Resistant, Rifampicin Snsceptible TB: rifampicin 10 mg/kg to 
600 mg orally daily + pyrazinamide 15-20 mg/kg to 2 g daily for 2 mo 

Patients Who Cannot Tolerate Pyrazinamide: rifampicin 10 mg/kg to 600 mg daily for 4 mo 
Prophylaxis: 

Vaccination: live vaccine (BCG) efficacy 50% total, 66% meningitis, 71% death from TB; ulceration and 
lymphadenitis in 1-10%, osteomyelitis 1/M vaccinees; duration of immunity unknown, cost effective; recommended for 
Aboriginal and Torres Strait Islander neonates in regions of high incidence, neonates born to patients with leprosy (cross- 
protection), children under 5 y who will be travelling to live in countries of high TB prevalence for long periods, neonates 
who will be living in a household which includes immigrants or visitors recently arrived from countries of high prevalence 
or who have returned to visit homes of relatives in countries of high prevalence, children and adolescents aged < 16 y who 
continue to be exposed to a patient with TB and child or adolescent cannot be given isoniazid or where the person with 
active disease has organisms resistant to both rifampicin and isoniazid; may also be given to healthcare workers in frequent 
contact with patients with tuberculosis, especially multi-drug resistant tuberculosis; should not be given to patients with 
current or previous tuberculosis, with a current febrile illness, with skin conditions such as eczema or dermatitis, who have 
had a previous live vaccination within the past 4 w, with a history of a positive reaction to a Mantoux test, who are HIV 
positive or are in a high risk group for HIV and have not been tested, or receiving immunosuppressive medication such as 
corticosteroids or cancer chemotherapy or with other conditions likely to suppress immunity 

Infants of Mothers with Active Pnlmonary Tnbercnlosis: isolation for 7-10 d and treatment of cases 
Mycobacteriosis Due to Mycobacterium krnsrsii: uncommon; clinically indistinguishable from pulmonary 
tuberculosis (great majority of patients underlying pulmonary factors, 70% nonpulmonary disposing factors), cervical adenitis 
in children, arthritic and renal lesions reported, disseminated infection (lung, reticuloendothelial system, bone, joint, skin) in 
severely immunocompromised patients, frequently with pulmonary predispositions 

Diagnosis: Ziehl-Neelsen stain and culture of sputum, lymph gland, bone marrow, spleen biopsy; severe anemia, gross 
leucopoenia (to 500/(.iL), gross thromobocytopenia; bone marrow severe hypoplasia of hematopoietic cells 
Differential Diagnosis: lymphoma, leukemia (blood smear, bone marrow examination) 
Treatment: isoniazid 10 mg/kg to 300 mg orally daily + rifampicin 10 mg/kg to 600 mg orally twice daily + 
ethambutol 15 mg/kg orally (not < 6 y) daily for 18 mo and 12 mo negative cultures 
Disseminated Mycobacteriosis in AIDS 

Agents: Mycobacterium avium-intracelluiare; also Mycobacterium tuberculosis, Mycobacterium kansasii, Mycobacterium 
gordonae, Mycobacterium fortuitum, Mycobacterium chelonae, Mycobacterium xenopi, Mycobacterium szulgai, Mycobacterium 
smegmatis, Mycobacterium scrofulaceum, Mycobacterium maimoense, Mycobacterium fiavescens, Mycobacterium asiaticum, 
Mycobacterium boms, Mycobacterium haemophilum, Mycobacterium genavense 

Diagnosis: fever in 87% of cases, night sweats in 78%; anemia (< 8.5 g hemoglobin/dL) in 85%, elevated serum alkaline 
phosphatase in 53%; Ziehl-Neelsen stain and culture of lung biopsy (100% positive), spleen biopsy (100% positive), brain 
biopsy (100% positive), duodenal contents (100% positive), blood (63-86% positive; use Isolator lysis centrifugation 
concentrate inoculated into a Bactec 7H12 culture vial and onto Wallenstein medium or Bactec 13A broth system), sputum 

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(56% positive), bronchial washing (50% positive), liver biopsy (43-67% positive), stool (42-100% positive); postmortem 
histology of lung, lymph node, spleen, bone marrow, brain, adrenals, liver, intestine (all 100% positive) 
Treatment (Mycobacterium avium): 

Initial Regimen: ethambutol 15 mg/kg orally daily (not < 6 y) + clarithromycin 12.5 mg/g to 500 mg orally 
12 hourly daily or azithromycin 10 mg/kg to 500 mg orally daily + rifampicin 10 mg/kg to 600 mg orally daily or rifabutin 
5 mg/kg to 300 mg orally daily 

Salvage Regimen: amikacin 10 mg/kg daily + ciprofloxacin 750 mg bid 
Prophylaxis (CD4 < 50/ nL): azithromycin 1.2 g orally weekly, clarithromycin 500 mg twice a day, rifabutin 300 mg 
orally daily 

Disseminated Mycobacteriosis in Non-AIDS Patients: skin involvement in patients with no immune defect, kidney 
transplant recipients, collagen disease, chronic renal failure, 90% survival rate; widespread, multiorgan involvement, severe 
illness in cell-mediated immunity deficiency, lymphoma, leukemia, survival rate 10%; intermediately severe illness and 
response to therapy in patients with other underlying diseases 

Agents: Mycobacterium fortuitum, Mycobacterium chelonae; also Mycobacterium gordonae, Mycobacterium malmoense 
Diagnosis: histology (dimorphic (acute and granulomatous) inflammation) and culture of skin lesions; blood cultures 
Treatment: 

Mycobacterium fortuitum, Mycobacterium chelonae: 2 of clarithromycin, doxycycline, ciprofloxacin, 
cotrimoxazole orally for 6-12 mo 

Mycobacterium gordonae: isoniazid + rifampicin + pyrazinamide 

Mycobacterium malmoense: rifabutin + clofazimine + isoniazid 
Leprosy (Hansen Disease, Hanseniasis, Lepra, Lepra Arabuih, St Lazarus' Disease): usually chronic infectious 
disease mainly affecting skin, peripheral nerves and mucosa of upper respiratory tract; formerly worldwide, now largely 
confined to tropics; 600,000 cases worldwide (mainly in Brazil, India, Madagascar, Mozambique, Myanmar, Nepal); 150 
cases/y in USA; 6 notified cases in Australia in 1999 (50% in Western Australia); transmission by personal contact; 
incubation period years 

Agent: Mycobacterium leprae (? + cooperation of corynebacteria) 

Diagnosis: combination of skin lesions and thickening of peripheral nerves very suggestive; leprosy is characterised by a 
wide variety of lesions; intradermal lepronin aids in assessing type; indeterminate leprosy (indeterminate Hansen disease, 
indeterminate hanseniasis, lepra incaracteristica, uncharacteristic leprosy, undifferentiated leprosy), the earliest form, is 
characterised by 1 or more ill-defined and asymptomatic hypopigmented or erythematous lesions with ill-defined borders 
appearing on face, scapular region, buttocks or extremities; there may be minimal sensory loss in lesions; lesions may be 
transient and self-healing but may evolve to lepromatous or tuberculoid type; nerve damage does not occur; in tuberculoid 
leprosy (paucibacillary leprosy, TT leprosy, tuberculoid Hansen disease, tuberculoid hanseniasis), there may be 1 or several 
well-defined erythematous or brownish red anesthetic or hypesthesic skin lesions appearing on the extremities, trunk, 
buttocks or face; damage to peripheral nerves is usually severe but limited to the skin lesions and the main nerve trunk 
related to the main skin lesions; borderline leprosy (B leprosy, BB leprosy, bi-polar leprosy, borderline group, dimorphic 
leprosy, dimorphous Hansen disease, dimorphous hanseniasis, dimorphous leprosy, intermediate leprosy, mixed leprosy) 
occupies most of the spectrum between tuberculoid leprosy and lepromatous leprosy; it is unstable and may include a wide 
range of manifestations of either of the 2 polar forms; nerve damage may be severe, rapidly advancing and unpredictable; it 
may precede cutaneous manifestations of the disease; borderline leprosy with tuberculoid features (borderline tuberculoid 
leprosy, BT leprosy) and borderline leprosy with lepromatous features (borderline lepromatous leprosy, BL leprosy) may be 
distinguished; lepromatous leprosy (diffuse leprosy, elephantiasis graccorum, hanseniasis virchowiana, lepra tuberosa, 
lepromatous Hansen disease, LL leprosy, multibacillary leprosy, nodular Hansen disease, nodular hanseniasis, nodular leprosy, 
virchowian hanseniasis) is a progressive form in which skin lesions are bilateral symmetrical, numerous, diffuse, 
erythematous and ill-defined macules; later, papules, nodules and diffuse infiltrations appear; at a later stage, eyebrows and 
eyelashes may be lost; involvement of nasal mucosa may lead to crusting, obstructed breathing and epistaxis; collapse of the 
nose is characteristic of advanced cases; ocular involvement leads to iritis and keratitis; diffuse lepromatous leprosy (diffuse 
lepromatosis, diffuse leprosy, Lucio leprosy) is a variety in which there is diffuse infiltration of skin but no macules or 
nodules; eyebrows may be lost and generalised paresthesiae may occur, with bouts of pyrexia; polygonal ulceration of skin 
occurs, especially near elbows and knees; if reactions develop, patients exhibit necrotising vasculitis (Lucio phenomenon; 
erythema necroticans, necrotising vasculitis of leprosy) rather than erythema nodosum leprosum; essentially limited to Central 
America and, especially, certain States in Mexico; neural leprosy = involvement of peripheral nerves in the absence of 
detectable skin lesions; reactions are acute inflammatory states occurring in any type of leprosy except early or 
indeterminate and precipitated by a change in the hormonal state (eg., during pregnancy or parturition), pyrexia (however 
caused), viral infection and smallpox vaccination; reversal reaction (upgrading reaction), occurs in borderline leprosy; 
preexisting lesions in skin and peripheral nerves become acutely painful, erythematous and inflamed; new lesions may occur; 
fever usually absent; increase in cell-mediated immunity; erythema nodosum leprosum (ENL, type 2 reaction) occurs in 

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multibacillary (especially lepromatous) leprosy; crops of red, tender nodules and 'pink patches' appear on trunk, face and 
exterior surfaces of limbs; usually accompanied by fever and systemic signs, eg., general malaise and pains in large muscle 
masses, arthralgia (perhaps with effusion into joints), lymphadenopathy, iridocyclitis, neuropathy, orchitis and nephritis; 
modified Ziehl-Neelsen stain of scrapings from mucosal ulcers or fluid from nodules obtained by scrape-incision method, 
biopsy of macule, muscle or nerve (bacilli are not found, or are extremely scanty, in indeterminate leprosy, usually very 
scanty in tuberculoid, easily found in borderline, rather low in borderline tuberculoid, numerous in lesions but absent from 
apparently normal skin and usually absent from nasal mucosa in borderline lepromatous, and found in large numbers in 
lesions, apparently normal skin, peripheral nerves, mucosa of the upper respiratory tract, reticuloendothelial system, eyes, 
testes and bone marrow in lepromatous); histological examination of a lesion; ELISA (antibody); causes moderate anemia, 
increased serum globulins, reduced serum albumin, raised erythrocyte sedimentation rate, increased serum angiotensin 
converting enzyme 

Nemal Leprosy: histopathology usually consistent with tuberculoid or borderline tuberculoid disease 

Lncio Phenomenon: histopathologically a necrotising vasculitis with extravasation of erythrocytes and fibroid 
degeneration of blood vessel walls 

Differential Diagnosis: fungal infections, yaws, vitiligo, leishmaniasis, mycoides fungoides, lupus, syphilis, disseminated 
tuberculosis; tuberculoid leprosy may be histologically indistinguishable from sarcoidosis unless there are changes 
(lymphocytic and histocytic infiltration) in the cutaneous nerve fibrils 
Treatment: zinc in all cases 

Pancibacillary Leprosy: dapsone 1-2 mg/kg to maximum 100 mg self-administered once daily for 6 mo + 
rifampicin supervised 600 mg orally once a month for 6 mo; follow closely for relapse and restart if necessary 

Multibacillary Leprosy: as above + clofazimine supervised 300 mg orally once monthly + 50 mg orally self- 
administered daily; continue complete regimen for at least 2 y and until negative for organisms; if clofazimine totally 
unacceptable due to skin discolouration, substitute ethionamide/prothionamide 250-375 mg orally daily self-administered 
Prevention and Control: treatment of active cases 

Brucellosis (Febris Undulhns, Mimic Disease, Undulant Fever): usually a generalised disease but may give rise 
to numerous localised complications; occasionally, some of these localised conditions may arise independently of systemic 
disease (eg., pneumonia resulting from inhalation of infected aerosols); these local conditions include bronchitis, pneumonia, 
meningitis, encephalitis, arthritis, osteomyelitis, osteochondritis, orchitis, cholecystitis and endocarditis; worldwide; 
transmission by contact with infected animals, ingestion of raw milk, goat cheese made from unpasteurised milk, 
contaminated meats; natural reservoir in domestic animals such as cattle, goats, sheep and swine; in Australia, cattle herds 
are free of Brucella abortus, Brucella cam's and Brucella melitensis are not found, and Brucella suis is found only in wild 
pigs; « 50 notified cases/y in Australia (« 94% in Queensland); incubation period 1 w to several mo; duration of illness: 
acute < 60 d, subacute 60 d-1 y, chronic, > 1 y; fatality rate <1% but can cause significant illness for months to years 
Agents: Brucella abortus, Brucella cam's, Brucella melitensis, Brucella suis 

Diagnosis: incubation period 5-60 d (usually 1-2 mo); 2/3 of cases chronic or undulating disease with wavelike relapses 
of weakness, headache, constipation, insomnia, generalised aches and fever; 1/3 of cases acute symptomatic illness with 
severe malaise in 92%, moderate or high fever (38.3-40°C) in 91-96%, fatigue and weakness in 88%, myalgia in 69%, weight 
loss in 63%, chills in 40-82%, drenching sweats in 39-99%, osteoarticular complications in 37%, headache (usually severe) in 
23-79%, musculoskeletal symptoms (especially tenderness over spine) in 22-66%, arthralgia in 19%, gastrointestinal symptoms 
(diarrhoea, bloody stools, vomiting during acute phase) in 17-30%, hepatosplenomegaly in 17-47%, cough in 17%, sacroiliitis 
in 8-15%, pneumonia in 8%, lymphadenopathy in 7-21%, rash in 4%, malodorous perspiration and dysgeusia common; may 
present with localised symptoms such as ischemic limb, mediastinal mass, dementia; 5% of cases have microscopic 
hematuria; prostration, delirium, coma and death can occur within days or weeks; in recovering patients, relapses (anorexia, 
diarrhoea, constipation, colitis in 75%, weight loss, myalgias and arthralgias in 25-50%, bone and joint disease involving 
weight-bearing and sacroiliac joints in 20-60%, papular, maculopapular, erythema nodosum-like or purpuric eruptions in 
< 5%, endocarditis (rare but most common cause of death) can occur for weeks and gradually diminish in severity until 
patient recovers; generalised lymphadenopathy and hepatosplenomegaly; granulomas in liver, spleen, bone marrow, lymph 
nodes, brain, skin and kidneys; mild leucopoenia, thrombocytopenia 

Acnte and Snbacnte: bone marrow culture (positive in 92%), blood cultures (positive in 54-90%), serology, 
direct immunofluorescence after incubation in nutrient broth; standard tube agglutination (labour intensive; agglutinins to 
Brucella abortus antigen detect all cases due to Brucella abortus, as well as 2/3 of infections with Brucella melitensis and 
Brucella suis, significant titres (> 160) appear late in second week; cross-reactions occur with Proteus OX-19 antigen, 
Yersinia, Vibrio, Francisella; measures IgM mainly but also IgG; becomes low or negative later) 

Chronic: 2-mercaptoethanol test (measures IgG), antihuman globulin (Coomb's) test (measures non-agglutinating 
IgG and some IgA), complement fixation test (measures IgG), ELISA (IgA, IgG, IgM), fluorescent antibody test, 
antipolysaccharide antibody radioimmunoassay, counterimmunoelectrophoresis 

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Treatment: 

< 8 y: cotrimoxazole 4/20-6/30 mg/kg orally 12 hourly for 6 w + rifampicin 15 mg/kg orally once daily for 
6 w (relapse rate 2%) or gentamicin 7.5 mg/kg i.v. daily for 2 w (adjust dose for renal function) 

> 8 y: doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 6 w (not pregnant or breastfeeding) + rifampicin 
15 mg/kg to 600 mg orally once daily for 6 w (relapse rate 8%) or gentamicin (< 10 y: 7.5 mg/kg; child > 10 y: 
6 mg/kg; adult: 4-6 mg/kg) i.v. as single daily dose for 2 w (adjust dose for renal function); ciprofloxacin 500 mg orally 
twice a day + rifampicin 600 mg orally 4 times a day for 30 d 

Prophylaxis: live vaccine (veterinary use); pasteurisation of milk products 
Glanders: an uncommon disease of horses and other equines, on rare occasions transmitted to man; may be acute, 
affecting mainly the nose, or chronic, causing cutaneous, pulmonary or gastrointestinal nodular lesions 
Agent: Burkholderia mallei 

Diagnosis: incubation period 1-21 d; Gram stain and culture of swab of discharge from necrotic foci in skin or from 
enlarged regional lymph nodes (also blood, sputum, nasopharyngeal discharge); complement fixation test, agglutinations; 
contact with horses or mules 
Treatment and Prophylaxis: as for Melioidosis 

Melioidosis (Pseudocholera, Stanton Disease, Whitihore Disease, Whitihore Fever): SE Asia and Northern 
Australia, also Africa, N America; acute septicemic (57% of cases; 45% disseminated, 12% nondisseminated; associated with 
diabetes mellitus and hematological diseases; often associated with patchy pneumonitis), acute localised and suppurative (42% 
of cases; cellulitis, subcutaneous abscess, infected wound, septic arthritis of knee, ankle and elbow joints, osteomyelitis, liver 
abscess, splenic abscess, pyelonephritis, prostatitis or prostatic abscess, lymphadenitis or lymphatic abscess, pericarditis, 
pericardial effusion common; erythema gangrenosum, hemorrhagic bleb, cutaneous pustules, pyomyositis, urticaria, mastitis, 
subperiosteal abscess, cholangitis, pancreatic abscess, epididymoorchitis, perinephric abscess, scrotal abscess, endocarditis, 
endarteritis, meningitis, encephalitis, intracisternal abscess, ophthalmitis (corneal ulcer), parotid abscess rare), acute or 
chronic pulmonary (pneumonitis, lung abscess, pleural effusion, empyema common; miliary, granuloma rare; chronic resembles 
tuberculosis and is marked by granulomatous abscess formation), chronic suppurative (chronic granuloma) 
Agent: Burkholderia pseudomallei 

Diagnosis: incubation period 1-21 d; manifestations vary from asymptomatic to rapidly overwhelming septicemia (case- 
fatality rate 85-95%), prolonged fever without localising signs, localised infections (either acutely suppurative or chronic and 
granulomatous), septicemia of abrupt onset with metastatic lesions in skin, muscle, bone and joints; culture of pus swab from 
ulcers and abscesses, sputum, urine, blood; indirect hemagglutination antibody titre (< 1:80, unlikely; 1:80-1:320, suggestive; 
> 1:320, very likely) 

Treatment: ceftazidime 50 mg/kg to 2 g i.v. 6 hourly or meropenem 25 mg/kg to 1 g i.v. 8 hourly or imipenem 
25 mg/kg to 1 g i.v. 6 hourly for at least 14 d (4-8 w in deep-seated infections, osteomyelitis, septic arthritis), then 
cotrimoxazole 8 + 40 mg/kg to 320 + 1600 mg orally 12 hourly + folic acid 0.1 mg/kg to 5 mg orally daily ± 
doxycycline 2.5 mg/kg to 100 mg orally 12 hourly (not < 8 y) for at least further 3 mo 

Prophylaxis (Postexposnre): cotrimoxazole 8 + 40 mg/kg to 320 + 1600 mg orally 12 hourly, doxycycline 100 mg 
orally 12 hourly (adults only) 

Non-Pneumonic Legionnaire's Disease (Form Characterised by Malaise, Myalgia and Headache Known as 
Pontiac Fever): a self-limited febrile disease 
Agents: species of genera Fluoribacter, Legionella and Tatlockia 

Diagnosis: malaise, myalgia, headache, encephalopathy (and possibly other neurological syndromes) and gastrointestinal 
upset, mainly diarrhoea; serology 
Treatment: erythromycin 

Plague (Black Death, Great Mortality, Oriental Plague, Pest, Pestis): « 1800 cases/y (240 deaths) 
worldwide; great deal of central and eastern Africa — Tanzania « 900 cases (70 deaths), Zaire « 320 cases (85 deaths)/y, 
Madagascar « 260 cases (60 deaths)/y, Asia total « 960 cases (50 deaths)/y, Vietnam « 600 cases (25 deaths)/y, Burma 
« 280 cases (4 deaths)/y, recent outbreak in India, Americas total « 520 cases (30 deaths)/y, Western USA, « 40 cases 
(7 deaths)/y, Peru « 260 cases (20 deaths)/y; last notification in Australia in 1923; killed 40% of population of 
Constaninople in 541 and 542, 44 ffl in Europe in latter half of fourteenth century, 12 ffl in India 1896-1936; bubonic plague 
(glandular plague, malignant polyadenitis, pestis bubonica, pestis fulminans, pestis major, polyadenitis maligna, St Roch 
disease, Tarabagan disease; most frequent form; characterised by inflammation and enlargement of lymphatic glands, 
especially in groin (pestis inguinaria) and axilla; hemorrhage may occur (black plague, hemorrhagic plague); cervical form 
associated with meningitis and pneumonia; mortality in untreated 50-60%), primary pneumonic plague (pulmonary plague; 
arises from inhalation, usually rapidly fatal; secondary plague pneumonia is complication of plague elsewhere in body 
through hematogenous spread, variable in severity), pharyngeal plague (anginal plague, tonsillar plague; result of exposure to 
larger infectious droplets or ingestion of infected tissues), septicemic plague (pesticemia, pestis siderans; primary septicemic 

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plague; relatively infrequent, no involvement of lymphatics and no buboes); bubosepticamic plague (secondary septicemic 

plague; more frequent, result of delay in treatment of bubonic plague); transmission by infected rodents and fleas (Xenopsylla 

cheopis], pus from lesions, sputum; zootic plague resulting from transmission from an animal; may be sylvatic (rodents living 

in wooded areas), campestral (rodents living in plains) or domestic (peridomestic, agrestial; in 'domestic' rodents and 

domestic cats), demic (mostly from transmission from other humans) 

Agent: Yersinia pestis 

Diagnosis: incubation period 1-6 d; prostration in 75% of cases, chills in 40-61%, headache in 40-55%, abdominal pain in 

39% of septicemic and 8% of bubonic, malaise in 38-44%, vomiting in 33-50%, confusion in 30%, nausea in 29-44%, cough in 

25%, diarrhoea in 23-39%, chest pain in 15%, fever, lymphadenitis (bubo), meningitis; geographic history; contact with 

rodents; Gram stain, fluorescent antibody stain and culture of lymph node and bubo aspirates, sputum; blood cultures; also 

sputum, CSF and urine; identify isolates by fluorescent antibody and bacteriophage; fourfold or greater change in serum 

antibody titre to Yersinia pestis Fl antigen (serum passive hemagglutination; ELISA (sensitivity 100%)); rapid monoclonal 

antibody test (sensitivity 100%, specificity 100%, positive predictive value 91%, negative predictive value 87%) white cell 

count 9000-17,400/|j,L with marked shift to left, 79% neutrophils, 13% bands, 5% monocytes, 3% lymphocytes; gross 

haematuria, 4+ proteinuria, many granular and red blood cell casts, pyuria, bacteriuria 

Treatment: gentamicin 4-7.5 mg/kg/d i.v., doxycycline 4 mg/kg to 200 mg i.v. then 2 mg/kg to 100 mg i.v. twice daily 

(not < 8 y), ciprofloxacin 15 mg/kg to 400 mg i.v. twice daily, chloramphenicol 25 mg/kg i.v. 4 times a day 

Prophylaxis (Postexposnre): doxycycline 2 mg/kg to 100 mg orally 12 hourly (not < 8 y), ciprofloxacin 15 mg/kg to 

500 mg orally 12 hourly 

Pseudotuberculosis (Rodent Pseudotuberculosis): 3 forms: systemic pseudotuberculosis, pseudotuberculous 

enterocolitis, pseudotuberculous mesenteric lymphadenitis 

Agent: Yersinia pseudotuberculosis 

Diagnosis: culture of appropriate specimen 

Treatment: gentamicin, cefotaxime, doxycycline, ciprofloxacin 

Tularemia (Alkali Disease, Deer-Fly Disease, Francis Disease, Ohara Disease, Pahvant Valley Fever, 

Pahvant Valley Plague, Rabbit Fever, Yato-bigo, Yato-byo): Europe, Japan, USA, former Soviet Union; incidence 

0.1/100,000 in USA; 75-85% ulceroglandular (fever, development of a cutaneous ulcer at the site of infection, with regional, 

and sometimes general, lymphadenopathy), 5-15% typhoidal (generalised tularemia; severe systemic form with septicemia, 

arising by dissemination via bloodstream from a primary lesion; fever, prostration, weight loss), 1-2% oculoglandular 

(ophthalmic tularemia; portal of entry is the eye; fever, regional lymphadenopathy, purulent conjunctivitis, swollen eyelids), 

< 1% oropharyngeal (fever, adenopathy, inflammation of the mouth or pharynx, sometimes resembling tonsillitis), 

tracheobroncitis (primary from inhalation of contaminated material or secondary from dissemination via bloodstream), 

bronchopneumonia and lobar pneumonia, gastrointestinal (abdominal tularemia, ingestion tularemia; gastrointestinal lesions, 

often severe); death in 18%; transmission by contact with infected animal (eg., rabbit), ticks (Dermacentor variabilis and 

Mbylomma americanum in southern and eastern USA, Dermacentor andersoni in southern and western USA), deerfly, rarely 

cat bite 

Agent: Francisella tularensis 

Diagnosis: residence in, or visit to, endemic area; exposure to ticks, rabbits or other animals; incubation period 1-57 d 

(average 4 d); fever in all, cutaneous ulcer in 64%, painful adenopathy in 55%, cough in 45%, diarrhoea in 18%, headache, 

malaise, pneumonia, pleural effusion and patchy infiltrates on chest X-ray; culture of nodules, pustules, ulcers, lymph node 

aspirate, blood, pleural exudate or sputum on glucose-cysteine agar; fluorescent antigen staining of exudates; 

microagglutination, tube agglutination, ELISA (sensitivity 96%, specificity 98%); animal inoculation; erythrocyte sedimentation 

rate 40 mm/h; white cell count 1 1,400/jLtL, 60% segmented neutrophils, 16% band forms, 13% lymphocytes, 2% atypical 

lymphocytes, 5% monocytes 

Treatment: gentamicin 4-7.5 mg/kg i.v. daily for 10 d, doxycycline (< 45 kg, 2.2 mg/kg i.v. twice daily for 14-21 d; 

> 45 kg, 100 mg i.v. twice a day), chloramphenicol 15 mg/kg i.v. 4 times a day for 14-21 d, ciprofloxacin 15 mg/kg i.v. 

twice a day for 10 d 

Prophylaxis (Postexposnre): doxycycline 2.5 mg/kg to 100 mg orally 12 hourly (not < 8 y), ciprofloxacin 15 mg/kg to 

500 mg orally 12 hourly 

Prevention and Control: avoid contact; regularly detick dogs with 6% malathion powder 

Rat Bite Fever: usually transmitted by bite of rats and certain other animals but, in the case of streptobacillosis, 

transmission via contaminated milk has occurred and the disease has been reported in the absence of bites following contact 

with live or dead rats or dogs 

Agents: Streptobacillus moniliformis (epidemic arthritis erythema, Haverhill fever, streptobacillary fever; distinctly 

uncommon disease of N and S America; single case reported from Australia; complications uncommon but severe; case-fatality 

rate « 13%), 'Spirillum minus' (Sodoka; complications very rare; case-fatality rate « 6%) 

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Diagnosis: dark ground, Gram stain, culture and guinea pig inoculation of pus from bite site, metastatic abscess or 
infected joint, lymph gland aspirate, blood; serology; marked neutrophilia 

'Spirillum minus': Gram negative, spiral; incubation period > 10 d; local skin reaction at site of bite; regional 
lymphadenopathy; chills; arthritis and leucocytosis rare; isolation of organism by animal inoculation; no specific serology; 
false positive serologic test for syphilis in > 50% of cases 

Streptobacillus moniliformis: microaerophilic, Gram negative, pleomorphic; incubation period < 10 d; no 
local skin reaction at site of bite; lymphadenopathy and chills rare; polyarthritis and leucocytosis present; palmar and plantar 
rash; isolation of organism in artificial medium; serology; false positive test for syphilis in < 25% of cases 
Treatment: aqueous procaine penicillin 600,000 U i.m. twice daily (child: 25,000-50,000 U/kg daily in 2 divided doses) for 
7-10 d; phenoxymethylpenicillin 500 mg orally 6 hourly (< 12 y: 25-50 mg/kg orally daily in 4 divided doses) for 7-10 d, 
tetracycline 500 mg orally 6 hourly for 7-10 d, erythromycin 500 mg orally 6 hourly (child: 30-50 mg/kg daily in 4 divided 
doses) for 7-10 d 

Differential Diagnosis: acute viral exanthems, rickettsial infections, drug reactions, septic arthritis, leptospirosis, 
collagen-vascular diseases, secondary syphilis, neisserial infections, influenza, infective endocarditis, acute rheumatic fever, 
malaria, relapsing fever, lymphoma/leukemia 

Disseminated Gonococcal Disease: a generalised gonococcal disease arising as a result of hematogenous spread, 
usually from a urogenital tract or pharyngeal disease; during septicemic phase, manifested by cutaneous (especially palmar 
and plantar) lesions that develop necrotic centres (gonococcal keratosis, gonococcal dermatitis, gonococcal dermatosis, 
keratoderma blenorrhagica, keratosis blennorrhagia); occurs most frequently in women; may be manifested by any of 
numerous clinical conditions, including gonococcal endocarditis, gonococcal myocarditis, gonococcal pericarditis, gonococcal 
meningitis, gonococcal brain abscess, gonococcal peritonitis and gonococcal pneumonia; frequently gives rise to arthritis and 
occasionally to septicemic adrenal hemorrhage syndrome 
Agent: Neisseria gonorrhoeae 

Diagnosis: blood cultures; culture of other specimens as appropriate 

Treatment: benzylpenicillin 10 MU i.v. daily until patient improves, followed by 500 mg 6 hourly to complete at least 7 d 
of treatment; amoxycillin 3 g orally once as a single dose + probenecid 1 g orally once as a single dose, followed by 
amoxycillin 500 mg orally 6 hourly for at least 7 d; ceftriaxone 1 g i.v. daily for 7 days; tetracycline 500 mg orally 6 hourly 
for at least 7 d; cefoxitin 1 g i.v. 6 hourly for at least 7 d; cefotaxime 500 mg i.v. 6 hourly for at least 7 d; erythromycin 
500 mg orally 6 hourly for a minimum of 7 d; ceftriaxone 1 g for 24 - 48 h, then ciprofloxacin for 7 d 
Disseminated Meningococcal Disease: generalised disease arising as a result of hematogenous spread of Neisseria 
meningitidis, manifested by severe toxemia and intravascular coagulation, usually with hemorrhagic signs varying from small 
petechiae to widespread extravasation of blood; meningitis usually absent; occasionally gives rise to numerous clinical 
conditions, including meningococcal carditis, meningococcal endocarditis, meningococcal myocarditis, meningococcal 
pericarditis, meningococcal arthritis and meningococcal conjunctivitis; most common cause of septicemic adrenal hemorrhage 
syndrome 

Agent: Neisseria meningitidis 
Diagnosis: incubation period < 21 d; blood cultures 
Treatment: as for Disseminated Gonococcal Disease; activated protein C 

Prophylaxis: ceftriaxone 250 mg (< 15 y: 125 mg) i.m. as single dose (preferred if pregnant), ciprofloxacin 500 mg orally 
as single dose (not < 12 y; preferred for women taking oral contraceptive), rifampicin 10 mg/kg (< 1 mo: 5 mg/kg) to 
600 mg orally 12 hourly for 2 d (not pregnant, alcoholic, severe liver disease; preferred for children); vaccines (quadrivalent 
polysaccharide, quadrivalent conjugate, and serogroup conjugate) available 
Rickettsioses: cause 2% of fever in returned travellers to Australia 

Agents: Rickettsia rickettsii (spotted fever, American spotted fever, black fever, Brazilian spotted fever, Bullis fever, Choix 
fever, Colombian tick fever, eastern-type Rocky Mountain spotted fever, exanthematous typhus of Sao Paulo, Lone Star fever, 
Mexican spotted fever, New World spotted fever, pinta fever, Rocky Mountain spotted fever, Sao Paulo fever, Sao Paulo 
typhus, Texas tick fever, Tobia fever (Colombia), western-type Rocky Mountain spotted fever; Western Hemisphere; 3 
cases/million in USA (23/million in North Carolina); wood tick (Dermacentor andersom) vector in northeastern USA, dog tick 
(Dermacentor variabilis) in eastern and southern USA, and lone Star' tick [Mblyoma americana) in southeastern USA; 
vertebrate host rodents, dogs, rabbits, opossum), Rickettsia conorii (spotted fever, African tick fever, Boutonneuse fever, 
Conor and Bruch disease, eruptive Mediterranean fever, fievre boutonneuse, India tick typhus, Kenya tick typhus, Marseilles 
fever, Mediterranean exanthematous fever, Mediterranean tick fever, Olner disease, South African tick bite fever; 
Mediterranean, Black Sea and Caspian Sea littorals, Middle East, India, Africa; tick (Rhicephaius sanguineus) vector; 
vertebrate host rodents, dogs), Rickettsia akari (rickettsialpox, Kew Garden fever, Kew Garden spotted fever, vesicular 
rickettsialpox; N America, former Soviet Union, Southern Africa, Korea, Mediterranean; mites vector; vertebrate host mice, 
rat), Rickettsia sibirica (spotted fever, North Asian tick fever, Siberian tick typhus; Armenia, Central Asia, Siberia, Mongolia, 
Central Europe; tick vector; vertebrate host rodents), Rickettsia australis (North Queensland tick typhus, Queensland coastal 

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Multi-system, Generalised and Systemic Infections 

fever, Queensland fever, Queensland tick typhus; eastern coast of Australia east of the Great Dividing Range; tick {Ixodes 
hokcyclus) vector; vertebrate host marsupials), Rickettsia honei (Flinders Island spotted fever; Flinders Island (Bass Strait) 
and Schuten Island (east coast of Tasmania); Rponomma hydrosauri (reptile tick) vector), 'Rickettsia pijperf (tick bite fever; 
S Africa), Rickettsia prowazekii (typhus fever (blasting typhus, camp fever, classical endemic typhus, classic typhus, 
epidemic typhus, European typhus, exanthematous typhus, famine fever, Fleckfieber, flecktyphus, gaol fever, Hildebrand 
disease, hospital fever, jail fever, louse-borne typhus, louse typhus, primary epidemic typhus, ship fever, typhus, typhus 
exanthematicus, war fever) and benign typhus (Brill disease, Brill-Zinsser disease, recrudescence fever, recrudescent fever, 
recrudescent louse-borne typhus, recrudescent typhus, sporadic typhus, typhus sidera) for form appearing years after 
complete recovery; human body louse (Pediculus humanus corporis) vector; vertebrate host man, squirrels; epidemic disease, 
late recrudescence; 'sylvatic typhus' in eastern USA probably transmitted by squirrel fleas; not seen in Australia since gold 
rush and convict times), Rickettsia typhi (typhus fever, benign typhus, Congolian red fever, endemic typhus, fievre nautique, 
flea-borne tarbardillo, flea-borne typhus, latent typhus, Manchurian fever, Manchurian typhus, Mexican typhus, Moscow 
typhus, murine typhus fever, rat-borne typhus, rat typhus, red fever of the Congo, ship typhus, shop typhus (Malaysia), 
Toulon typhus, typhus marinus, urban tropical typhus; worldwide, with outbreaks reported from Australia, China, Greece, 
Israel, Kuwait, Thailand; < 100 cases/y in USA; vector flea (classically, rat flea Xanopsylla cheopsis, but free-ranging cats, 
dogs, opossums and their fleas assuming increasing importance) and rat louse; vertebrate host wild rats, field mice), 
Rickettsia africae (African tick bite fever; main cause of rickettsiosis in travellers to sub-Saharan Africa; transmitted by 
Mbylomma tick), Orientia tsutsugamushi (typhus fever, akamushi disease, akamushi fever, Burma eruptive fever, chigger- 
borne rickettsiosis, China fever, flood fever, inundation fever, island disease, island fever, island typhus, Japanese flood fever, 
Japanese river fever, kedani disease, kedani fever, Malayan fever, mite-borne typhus, mite typhus, rural typhus, scrub fever, 
scrub typhus, shashitsu, shima-mushi disease, shimu-mushi, Shishito, Sumatran typhus, tsutsugamushi, tsutsugamushi disease, 
tsutsugamushi fever, yochubyo; Asia, Indian subcontinent, tropical northern Australia, Pacific Islands, Indonesia; trombiculid 
mites (Leptotrombidium deliense in Australia) vector; vertebrate host native rodents, bandicoots), Rickettsia sibirica (Siberian 
tick typhus; central Asia; tick vector; rodents, dog reservoir), Coxiella burnetii (Q fever, Australian Q fever, Australian typhus, 
Balkan grippe, Derrick-Burnet disease, Nine Mile fever, quadrilateral fever; worldwide; vector tick (unnecessary); vertebrate 
host sheep, cattle, goats; respiratory pathogen, infection by aerosol from vertebrate carrier; * 700 notified cases/y in 
Australia (« 40% in Queensland)), Ehrlichia sennetsu (Hyuga fever), Rickettsia Mis (transmitted by cat fleas; causes murine 
typhus-like syndrome); Ehrlichiosis see Chapter 10. 

Diagnosis: incubation period 7-14 d; acute onset, fever, true rigours, rash (except in Q fever; macular, maculopapular or 
petechial, starting on extremities and extending to trunk, with regular occurrence on palms and soles in Rocky Mountain 
spotted fever; vesicular or vesiculopapular (may be sparse or diffuse) in rickettsialpox; macular or maculopapular, starting on 
trunk and extending to extremities in typhus fever), headache, arthralgias, myalgias, conjunctivitis; primary lesion in 
Boutonneuse fever, Siberian tick typhus, Queensland tick fever, scrub typhus; adenopathy in scrub typhus; murine typhus 
mild disease; tachypnoea in 97% of cases of typhus fever, fever in 85%, conjunctival suffusion in 53%, raised erythrocyte 
sedimentation rate in 57%, increased lactate dehydrogenase in 82%, aspartate aminotransferase increased in 63%, severe 
involvement of CNS, myocardium and kidneys not unusual; spotted fever due to Rickettsia sibirica resembles that due to 
Rickettsia rickettsii but is less severe; usually leucopenia with rickettsialpox; often pneumonitis in tsutsugamushi (relapses 
and second attacks common); on rare occasions, Q fever may become latent and reappear as chronic condition, usually 
complicated by chronic hepatitis, thrombocytopenia and endocarditis (latter invariably fatal if untreated); manifestations of 
Ehrlichia sennetsu infection vary from low grade fever with mild headache and slight back pain to persistent high fever, 
anorexia, lethargy, lymphadenopathy and prominent hematological abnormalities; geographic, epidemiological; indirect 
microimmunofluorescence; ELISA (antibody); growth in tissue culture (VERO or L929); Weil-Felix (Boutonneuse fever, Rocky 
Mountain spotted fever, tick bite fever, tick typhus: OX19 + , OX2 + , tenth to fourteenth day; epidemic typhus, murine typhus: 
OX1 9 + , OX2 1 ; scrub typhus: OXK + ; Brill's disease: usually negative; Q fever, rickettsialpox: negative; specificity not absolute; 
many false positive and false negative reactions occur; cross-reactions with typhoid, Proteus urinary tract infection, 
leptospirosis, severe liver disease), complement fixation test (tenth to fourteenth day), microscopic agglutination; animal 
inoculation; lysis-centrifugation blood cultures 

Boutonneuse Fever: microimmunofluoresecence, latex agglutination of serum; immunofluorescence of skin lesion 
biopsy; Western blot; isolation of Rickettsia conorii from blood culture with shell vial cell culture; abnormal serum /-glutamyl 
transferase in 60% of cases, abnormal SGOT in 55%, abnormal SGPT in 54% 

Q Fever: incubation period < 21 d; farm worker, slaughtering or dressing animals, exposure to parturient cats; 
histology of liver (multiple non-caseating granulomas); complement fixation test (phase 1 negative in first 3-4 w, phase 2 
> 4X increased in acute; phases 1 and 2 titre > 160 in chronic), immunofluorescent antibody and ELISA tests (IgG 
significantly increased in acute, titre > 1280 in chronic; IgA titre > 1280 in chronic; IgM positive in acute, negative or low 
in chronic) 



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Rocky Mountain Spotted Fever: incubation period 2 w; fever, spotted rash, headache, myalgia, abdominal 
pain; pulmonary complication (pharyngitis, pleural effusion, pleurisy; pleural effusion, diffuse infiltrates and pulmonary edema 
on chest X-ray) occurs; IgM, IgG, serology 

'Rickettsia africae': 95% inoculation eschar (54% multiple), 88% fever, 63% influenza-like syndrome, 63% 
myalgias, 46% rash (usually maculopapular or vesicular, rarely purpuric), 43% regional lymphadenopathy; 
microimmunofluorescence assay + Western blot + cross-adsorption assay (sensitivity 56%; each test positive predictive 
value and specificity 100%) 
Treatment: 

Q Fever: 

Acnte: doxycycline 2 mg/kg to 100 mg orally 12 hourly for 14 d (not < 8 y, pregnant or 
breastfeeding), chloramphenicol 12.5 mg/kg to 500 mg i.v. 6 hourly for 14 d 

Chronic: doxycycline or chloramphenicol + rifampicin or hydroxychloroquine for 2 y 
Endocarditis: see Endocarditis 

Anstralian Spotted Fever, Tick Typhus, Scrnb Typhns, Rocky Mountain Spotted Fever, 
Epidemic Typhus, Endemic Typhus: doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 7-10 d (not < 8 y), 
chloramphenicol 12.5 mg/kg to 500 mg i.v. 6 hourly for 7-10 d (until afebrile for 2-3 d) 

Others: tetracycline or doxycycline as above 
Prophylaxis: doxycycline 200 mg orally weekly; use of protective clothing and tick repellent containing N,N-diethyl-m- 
toluamide in tick areas 

Rocky Mountain Spotted Fever: incomplete natural immunity; vaccine available (yearly booster, exposed 
persons) 

Rickettsialpox: complete natural immunity; no vaccine available 

Epidemic Typhus: natural immunity gives complete protection against infection but recrudescent illness in 
some individuals common; vaccine available (epidemics) 

Endemic Typhus: natural immunity gives protection against both endemic and epidemic typhus; vaccine 
available but not recommended 

Scrub Typhus: natural immunity gives complete protection for strain of organism but second infection with 
another strain occurs; no vaccine available 

Q Fever: complete natural immunity; vaccine available for laboratory workers, animal processors 
Trench Fever (Febris Quintans, 5-day Fever, His-Werner Disease, Ikawa Fever, Meuse Fever, Quintan 
Fever, Salonica Fever, Saloniki Fever, Shank Fever, Shin-bone Fever, Tibialgic Fever, van der Sheer 
Fever, Volhynia Fever, Werner-His Disease, Wolhynian Fever): Europe, Africa, S and Central America, Russia; 
louse vector; vertebrate host man; extracellular growth 
Agent: Bartonella quintana 

Diagnosis: primary inoculation site, discrete macular rash, sweating and splenomegaly common; serology; smear and 
culture; PCR 

Treatment: erythromycin, doxycycline, tetracycline, minocycline, rifampicin, ciprofloxacin 
Prophylaxis: doxycycline 200 mg orally weekly; use of protective clothing and tick repellent containing N,N-diethyl-m- 
toluamide in tick areas; incomplete natural immunity; no vaccine available 

Yaws (Boba, Boubi, Breda Disease, Buba, Charlouis Disease, Coko (Fiji), Dube, Framboesia Tropica, 
Parangi (Sri Lanka), Purru (Malaysia), Tonga, Tropical Yaws): acute and chronic; transmission by indirect or 
direct nonvenereal contact 
Agent: Treponema pallidum subsp pertenue 

Diagnosis: preclinical incubation period of 3-5 w; initial yaws (initial framboesia, primary framboesia, primary yaws) 
begins as a papule and becomes either papillomatous (chancre of yaws, chancre pianique, mother yaw, primary 
framboesioma) or ulceropapillomatous (initial framboesial ulcer, ulcere post-chancreux); cutaneous involvement in early yaws 
is manifested by a wide variety of lesions — plaques (yaws patches), erythematous macular yaws (erythematous macular 
framboesia, rosele pianique), squamous macular early yaws (depigmented framboeside, furfuraceous macular framboeside, 
yaws trash), macular early yaws, papillomatous early yaws (butter yaws, framboesia secundaria papillomatosa, 
framboesioma, pianoma, papilloma tropicum, tropical papilloma; includes palmar and plantar papillomatous early yaws (crab 
yaws, framboesia papillomatous palmaris/plantaris, pian guigne, wet crabs, web crab yaws)), palmar and plantar squamous 
macular early yaws (erythematous squamous psorariform plaque of yaws, papulosquamous palmar/plantar pianides, squamous 
plaques of yaws, yaws of the first type of Baerman), palmar and plantar hyperkeratotic macular early yaws (hyperkeratosis 
and trichophytoid pianides, keratomas of yaws, keratoderma punctata of yaws, polymorphic hyperkeratosis of yaws, punctate 
keratosis of palms/soles, worm-eaten soles), squamous maculopapular early yaws (lichenoid pianide, pityriasiform pianide), 
simple papular early yaws, umbilicate papular early yaws (hyperkeratotic papules), acuminate micropapular early yaws 
(follicular framboeside, folliculopapular framboeside; desquamation may case apparent depigmentation), squamous micropapular 

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early yaws (corymbiform framboeside, furfuraceous framboeside, keratitis-pilaris-like framboeside, lichenoid macular 
framboeside, papulosquamous framboeside, pityriasiform framboeside, pain dartre); mucosal early yaws may be either 
maculopapular or papillomatous; osteoarthropathy (osteitis, periostitis, osteoperiostitis (frequently polydactylitis (spina ventosa 
pianides)), osteomyelitis, hydrarthrosis (synovitis), ganglion) in early yaws is usually nondestructive and most frequently 
affects shafts of long bones; latent yaws with no symptoms; late yaws characterised by destructive lesions of skin — plaques 
(papulo-erythematous framboeside; squamous, well demarcated lesions), nodular late yaws (gummatous framboesides, gomme 
pianique; cutaneous or subcutaneous nodular lesions), ulcerated nodular late yaws (tuberculo -crusted circinate ulcers of yaws, 
yaws ulcers; ulcerated nodular lesions which may result in keloid scarring, contractures and pigmentary changes), palmar 
and plantar hyperkeratotic late yaws (ghoul hand, keratosis palmaris/plantaris of yaws, pintoid lesions of yaws, yaws 
hyperkeratosis with trichophytoid characteristics, yaws keratodermia; polymorphic, ill-defined hyperkeratotic lesions of palms 
or soles, with tendency to leave scars and pigmentary changes (leukomelanoderma)), mucous membrane and bone — osteitis, 
periostitis, osteoperiostitis, arthritis, hydrarthrosis (synovitis), ganglion, juxta-articular nodules of late yaws (Lutz-Jeanselme 
nodules; fibromatous tumour like masses arising beneath skin in vicinity of joints), goundou (hyperkeratotic osteitis of nasal 
processes of maxilla, frequent in Africa, not seen in some areas), gangosa (ogo, rhinopharyngitis mutilans; ulcerative 
destructive lesion of nose and hard palate which may cause severe disfiguration); serology 
Treatment: penicillin 

Leptospirosis (Akiyami B, Autumnal Fever, Autumn Fever, Cane-cutter's Disease, Cane-field Fever, 
Feldfieber B, Field Fever, Hasaihi Fever, Japanese Seven-day Fever, Leptospirosis Febrilis, Mud 
Fever, Nanukayami, Pea-picker's Disease, Schlammfieber, Slime Fever, Spirochaetasis, Swamp Fever, 
Swineherd's Fever, Water Fever): « 300 notified cases/y in Australia (« 70% in Queensland; incidence 1.9/100,000; 
11% prevalence in banana growers); wherever domestic animals are kept, particularly pigs; survival enhanced by alkaline pH 
of animal urine, ground water and soil (days to weeks under optimal conditions); concentrated in summer and early autumn; 
most cases during childhood through middle age because of increased hazards resulting from recreational and occupational 
activities; transmission by food or water contaminated with animal (eg., rat) urine; incubation period 4-19 d 
Agent: Leptospira interrogans 

Diagnosis: incubation period < 21 d; asymptomatic to severe (with jaundice, anemia, hemorrhage and renal failure; 
epidemic spirochaetal jaundice, hemorrhagic jaundice, icterogenic spirochaetosis, icterohemorrhagic jaundice, Indonesian Weil 
disease, infectious spirochaetal jaundice, Landouzy disease, leptospiral hemorrhagic icterus, leptospiral jaundice, leptospirosis 
icterohemorrhagica, Mathieu disease, ricefield fever, spirochaetosis icterohemorrhagica, spirohematosis icterohemorrhagica, 
Vasilev disease, Weil icterus, Weil syndrome); typically a biphasic disease, the first phase being an acute febrile illness with 
leptospiremia and a wide variety of manifestations and the second (urine) phase being less febrile with different 
manifestations; fever in 75-90% of cases, headache in 66%, severe myalgias in 40-55% (pain on raising extended leg positive 
predictive value of 67%), stiff neck in 40%, arthralgia in 38%, CSF pleocytosis in 35%, jaundice in 35%, CSF protein 
increased in 30%, nausea and/or vomiting in 30%, rigours in 19%, rash in 15%, chills in 10%, conjunctivitis or conjunctival 
hemorrhage in 9%; pulmonary hemorrhage may occur; sudden onset; phase examination and culture of blood (first week of 
infection), urine (second and third weeks of infection); serology (complement fixation test detects antibodies to group antigen, 
4-fold rise in titre diagnostic, titres > 160 in abattoir workers and veterinarians, negative result does not exclude infection; 
microscopic agglutination test distinguishes antibody to range of serovars; ELISA sensitivity 100%, specificity 93-100%; Lepto 
dri-dot test for IgM gives comparable results to ELISA and is faster, more economical and does not require sophisticated 
equipment or skilled personnel); culture and inoculation of young hamster or guinea-pig with CSF or blood; normochromic 
anemia with marked neutrophilia; raised erythrocyte sedimentation rate; hematuria in 25%, protein + casts in urine in 20%, 
oliguria in 15%; history of exposure to animals (30% dogs, 10% cattle/swine, 8% rodent, 5% wildlife (skunks, raccoons, foxes, 
opossums, armadillos; horses), occupational (construction, farm, veterinary, abattoir) or recreational (swimming in 
contaminated water, hunting) exposure (incubation period usually 7-14 d) 

Serovar canicola: influenza-like illness followed by meningitis 

Serovar hardjo: usually a less severe disease with influenza-like symptoms, slight meningitis, slight renal 
failure 

Serovar icterohaemorrhagiae: jaundice, renal failure, meningitis 
Differential Diagnosis: meningitis (initial diagnosis in 30% of cases), hepatitis (initial diagnosis in 15%), encephalitis 
(initial diagnosis in 10%), fever of unknown origin (initial diagnosis in 9%), pneumonia (initial diagnosis in 2%), influenza 
(initial diagnosis in 2%) 

Treatment: administer within first 4 d of illness; doxycycline 2.5 mg/kg to 100 mg orally 12 hourly for 5-7 d (not < 8 y, 
pregnant or breastfeeding), benzylpenicillin 30 mg/kg to 1.2 g i.v. 6 hourly for 5-7 d, ceftriaxone 25 mg/kg to 1 g i.v. daily 
for 5-7 d, cefotaxime 25 mg/kg to 1 g 6 hourly for 5-7 d 
Prevention and Control: good sanitation 



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Relapsing Fever (Bilious Typhoid Fever, Febris Recurrentis, Polyleptic Fever, Recurrent Fever, 
Spirillum Fever, Typhus Recurrens): general term for a systemic borreliosis in man, characterised by alternating 
febrile and nonfebrile periods, each of the febrile periods ending in crisis 

Agents: louse-borne: Borrelia recurrentis (carapata, carapata disease, epidemic relapsing fever, European relapsing fever, 
famine fever, louse-borne relapsing fever, Obermeier relapsing fever, vagabond fever); tick-borne: Borrelia crocidurae, Borrelia 
duttonii (D fever, Dutton fever, Dutton relapsing fever, Novy relapsing fever), Borrelia hermsii, Borrelia hispanica, Borrelia 
parked, Borrelia persica (miameh disease, miameh relapsing fever, miana disease), Borrelia turicatae, several other species 
Diagnosis: disease usually begins with rigours and fever, nausea, vomiting, photophobia, arthralgia and myalgia, followed 
by marked pulmonary signs, hepatosplenomegaly, jaundice and hemorrhagic diathesis; organisms seen in Giemsa or Wright- 
stained peripheral blood smears or in dark ground microscopy of blood at time of rising temperature in 70% of cases; 
urinalysis normal to trace of protein, red blood cells, casts; hematocrit 40%, hemoglobin decreased, white cell count 
10,000/(.iL, 71% neutrophils (6% bands), 22% lymphocytes, 8% monocytes; ESR 67 mm/h; serum creatinine and alkaline 
phosphatase normal, serum bilirubin 3.1 mg/dL, SGOT 55 U/mL, SGPT 67 U/mL; CSF protein 95 mg/dL, glucose 75 mg/dL, 
950 cells/VL, organism seen in 10%; Weil-Felix: OX-19 negative, OX-2 negative, OX-K > 1:40 in 90% of louse-borne and 30% 
of tick-borne; complement fixation test for Borrelia positive in 50%; positive animal inoculation in 85% of cases 

Lonse-borne: splenomegaly in 75% of cases, hepatomegaly in 66%, jaundice in 35%, respiratory symptoms in 
35%, CNS involvement in 30%, rash in 9% 

Tick-borne: splenomegaly in 40%, rash in 25%, hepatomegaly in 15%, respiratory symptoms in 15%, CNS 
involvement in 9%, jaundice in 7% 

Differential Diagnosis: malaria and dengue (febrile periods shorter), leptospirosis (conjunctival suffusion), rat-bite fever 
(bite history, inflammatory reaction at site of bite), Rocky Mountain spotted fever (rash typically different — first on limbs, 
involves palms and soles) 
Treatment: 

Lonse-borne: aqueous procaine penicillin 600,000 U (child: 25,000-50,000 U/kg) i.m. at once and repeated after 
12-24 h, tetracycline 500 mg orally as a single dose, erythromycin 500 mg orally as a single dose (infants and young 
children: 25-50 mg/kg daily in divided doses for 4-5 d), chloramphenicol 500 mg orally 6 hourly for 5 d (child > 2 w: 
50 mg/kg daily orally in 4 divided doses; premature, newborn and those with immature metabolism: 25 mg/kg daily in 4 
divided doses), doxycycline 

Tick-borne: tetracycline 500 mg orally 6 hourly for 5-10 d, doxycycline 100 mg orally 12 hourly for 5-10 d 
Treatment may be complicated by a severe Herxheimer reaction. 
Prophylaxis (Within 48 h of Tick Bite): tetracycline 1 g/d for 3-5 d 
Prevention and Control: lice and tick control 

Lyme Disease (Lyme Arthritis): multi-system, immune-mediated, inflammatory disorder that may last several years; 
erythema chronicum migrans (exanthema; in 26%), followed (in 10%) by disease of central and peripheral nervous system 
(aseptic meningitis, encephalitis, cranial and spinal neuropathies, especially unilateral or bilateral Bell's palsy, Garin- 
Bujadoux-Bunwarti syndrome of meningoencephalitis, cranial neuritis and radiculoneuritis) and (in 6-8%) of heart 
(atrioventricular conduction defects, myocarditis, pericarditis), by acromodermatitis chronica atrophicans and by solitary or 
diffuse lymphadenosis benigna cutis, followed (in 50%) by arthritis; hepatitis, nephritis, uveitis, myositis, pulmonary 
complication (cough, acute respiratory distress, respiratory failure) also occur; recorded from Algeria, Belgium, England, 
Federal Republic of Germany, France, Italy, Northern Ireland, Scotland, Sweden, USA (95% of vector borne illness; « 16,000 
cases/y), few cases in Australia; vector Ixodes minus in Europe, Ixodes scapularis in NE, E and midwest USA and Ixodes 
pacificus in western USA, also Mblyoma americana and Dermacentor variabilis, ? Ixodes holocyclus in Australia; principal 
mammalian host deer; 24-53% of healthy dogs from enzootic areas show serological evidence of infection; ticks acquire 
infection from rodents (white-footed mice and eastern chipmunks); transplancental transmission documented in child with 
congenital heart defect; incubation period 1 w stage 1, 5-6 w stage 2 

Agent: Borrelia burgdorferi group [Borrelia afzellii associated with erythema migrans and acrodermatitis chronica 
atrophicans, Borrelia burgdorferi and genospecies Borrelia garinii associated with extracutaneous symptoms) 
Diagnosis: single erythema migrans 3-30 d after tick bite, with myalgia, arthralgia, fever, headache, fatigue, regional 
lymphadenopathy; at 1-12 w after tick bite, erythema migrans may become multiple, with neck pain, meningitis, cranial 
neuritis (facial palsy), radiculoneuritis, carditis (variable hearth block), eye involvement; arthritis and/or chronic CNS 
involvement may develop after « 2 mo; may have pulmonary edema, cardiomegaly on chest X-ray; quantitative PCR using 
skin biopsy (sensitivity 81%), borreliacidal antibody test (sensitivity 79%, specificity 100%), acute + convalescent phase 
serology (sensitivity 68%), nested PCR (sensitivity 64%); circulating immune complexes during erythema chronicum migrans; 
patients with increased IgM and cryoglobulins containing IgM at risk of developing arthritis; cryoglobulins and immune 
complexes found in synovial fluid, but not serum, during arthritis 
Treatment: 

Erythema Chronicnm Migrans: tetracycline 250 mg orally 6 hourly (child after completion of dentition: 

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Multi-system, Generalised and Systemic Infections 

40 mg/kg to 1 g orally daily) for 10-20 d; phenoxymethylpenicillin 500 mg orally 6 hourly (< 12 y: 25-50 mg/kg orally 
daily in 4 divided doses) for 10-20 d, erythromycin 250 mg orally 6 hourly (younger children: 30 mg/kg to 1 g orally daily 
in divided doses) for 10-20 d, doxycycline 1-2 mg/kg to 100 mg twice a day, amoxycillin 50 mg/kg/d to 1500 mg/d in 3 
divided doses, cefuroxime axetil 10-15 mg/kg to 500 mg twice a day, clarithromycin 500 mg twice a day, azithromycin 
500 mg on dayl and then 250 mg 4 times a day 

Arthritis: doxycycline 100 mg orally 12 hourly for 3-4 w, amoxycillin 500 mg orally 8 hourly (child: 40 mg/kg 
orally daily in 3 divided doses) for 4 w, ceftriaxone 2 g (child: 50-80 mg/kg) i.v. daily for 14-21 d, benzylpenicillin 
20-24 MU (child: 250,000-400,000 U/kg) i.v. daily in divided doses for 21 d, benzathine penicillin 2.4 MU l.m. weekly for 
3 w 

Bell's Palsy, Mild Cardiac Disease: doxycycline 100 mg orally 12 hourly for 4 w, amoxycillin 250-500 mg 
orally 8 hourly (child: 20-40 mg/kg orally daily in 3 divided doses) for 4 w, cefuroxime axetil 10-15 mg/kg to maximum 
500 mg twice a day, macrolides 

Meningoencephalitis, Heart Block: oral prednisone + ceftriaxone 2 g (child: 50-80 mg/kg) i.v. daily for 
14 d or benzylpenicillin 20-24 MU (child: 250,000-400,000 U/kg) i.v. daily in divided doses or oral or i.v. doxycycline 
Prophylaxis: vaccine 79-92% efficacy (not cost effective unless prevalence > 2% per season) 
Reiter Syndrome (Arthritic Spirochetosis, Blenorrhagic Arthritis, Conjunctivourethral-synovial 
Syndrome, Enteroarticular Syndrome, Fiessinger-Leroy-Reiter Syndrome, Infectious Uroarthritis, 
Nongonococcal Urethritis with Conjunctivitis and Arthritis, Oculourethroarticular Syndrome, 
Postdysenteric Rheumatoid, Postdysenteric Syndrome, Postenteric Rheumatoid, Reiter Disease, Reiter 
Triad, Reiter Rheumatism, Spirochaetosis Arthritica, Urethral Arthritis, Urethral Rheumatism, 
Urethroarthritis, Urethrooculoarticular Syndrome, Urethrooculosynovial Syndrome, Waelsch 
Urethritis) 

Agents: unknown; has followed epidemics of diarrhoea due to Shigella, Salmonella, Yersinia and Cyclospora; gonococcal and 
nongonococcal urethritis (especially that due to Chlamydia trachomatis) is also a common antecedent, particularly in young 
males having HLA B27 histocompatibility antigen 

Diagnosis: triad of inflammatory oligoarthritis, ocular inflammation and sterile urethritis; may be fever, ulceration of glans 
penis (balanitis circinata) and oral mucosa, palmar and plantar lesions (keratodermia blenorrhagica), nausea, anorexia, 
erythema, myocarditis, pericarditis, neuritis 
Treatment: symptomatic 

Whipple's Disease: rare (< 1000 cases worldwide reported to date) systemic infectious disease; 97% Caucasian 
Agent: Tropheryma whippelii 

Diagnosis: arthralgia (initial presentation in 67%), epigastric pain (initial presentation in 15%), lethargy, anemia and low 
grade fever (initial presentation in 14%), neurological symptoms (initial presentation in 4%); later, diarrhoea with fetid, 
watery, steatorrhoeic stools, malabsorption of fat, protein, carbohydrate, vitamins and minerals, and weight loss in 85%; 
hyperpigmentation; progresses to cardiac and neurological deficits (headaches, lethargy, visual disturbances, auditory 
disturbances, gait disturbances, disturbed sleep, impotence, convulsions) and occasionally eye problems (edema in papilla, 
retinal bleeding, uveitis, corneoretinitis, keratitis); immunohistochemical analysis or PCR of tissue; PCR of CSF, peripheral 
blood; multiple rounded or sickle-shaped PAS diastase resistant inclusions in lamina propria macrophages in small bowel 
biopsy 

Differential Diagnosis: AIDS, Crohn's disease, disseminated histoplasmosis, immunocomplex disease, immunodeficiency 
disease, infectious arthritis (shigellosis, salmonellosis, yersinosis, Campylobacter infection, amoebiasis), macroglobulinemia 
Waldenstrom, Mycobacterium avium-intracellulare infection, neoplasia (especially non-Hodgkin's lymphoma), rheumatoid 
arthritis, Corynebacterium equi infection, sarcoidosis, ulcerative colitis, prodromal stage of measles (Warthin-Finkeldey giant 
cells), malakoplakia (Michaelis-Gutmann bodies staining for calcium and iron in macrophages) 
Treatment: parenteral cotrimoxazole or streptomycin 1 g/d + benzylpenicillin 1.2 MU/d for 2 w, then cotrimoxazole 
160/800mg for 1-2 y 

Sarcoidosis (Benign Lymphogranulomatosis, Besnier-Boeck-Schaumann Disease, Besnier-Boeck-Schaumann 
Syndrome, Boeck Disease, Boeck Lupoid): generalised granulomatous disease; may affect any part of body but, most 
frequently, lesions are found in lymph nodes, liver, spleen, lungs, skin (Besnier-Boeck disease, Boeck sarcoid, Hutchinson- 
Boeck disease), eyes, tonsils and bone marrow; causes defects in cell-mediated immunity, with increased susceptibility to 
Mycobacterium tuberculosis, Nocardia and fungi 
Agent: ? Mycobacterium species 
Diagnosis: clinical; histology and immunohistology 
Treatment: steroids 

Candidiasis (Moniliasis): « 240 deaths/y in USA; bronchopulmonary, cutaneous, genital, oral, urinary, endocarditis, 
chronic and sub-acute fever 



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Chronic Mucocutaneous Candidiasis: T-cell immunodeficiency (fairly specific — Candida and some antigenically close 
fungal genera; thus different from other known immunodeficiencies; since other host defences are normal, systemic candidal 
infection is not a problem); candidal infection of mucous membranes, skin, hair and nails; endocrinopathy in « 50% (usually 
several years after candidiasis; most common hypoparathyroidism, Addison's disease; cause autoantibodies); familial in 
* 20%; other manifestations autoimmunity (eg., pernicious anemia, alopecia, depigmentation, iron-deficiency anemia); early 
onset chronic mucocutaneous candidiasis most severe form, hypoparathyroidism and Addison's disease very rare; late onset 
chronic mucocutaneous candidiasis mild, in older individuals, no endocrinopathies; familial chronic mucocutaneous candidiasis 
autosomal recessive, mild to moderate, endocrinopathies uncommon; juvenile familial endocrinopathy with candidiasis mild to 
moderate, hypoparthyroidism and/or Addison's disease usually present; other predisposing conditions diabetes mellitus, oral 
contraceptives, broad spectrum antimicrobials, treatment with immunosuppressive drugs, ? gastrointestinal reservoir 
Agent: Candida 

Diagnosis: micro (wet film, Gram stained film) and culture of appropriate specimen 
Treatment: ketoconazole 200-400 mg orally daily, fluconazole 50-100 mg orally daily 
Systemic Candidiasis: associated with antibiotic administration, intravenous or intraarterial catheters or needles, 
corticosteroid administration (infection in brain and kidneys), use of immunosuppressive agents, neutropenia (disseminated 
infection), parenteral nutrition (eye may be affected), ambulatory peritoneal dialysis (peritonitis reported), heroin addiction 
(septicemia followed by folliculitis, bone and joint lesions, ocular abnormalities such as abscess or hypopyon), AIDS 
Agent: Candida 
Diagnosis: 

Acnte: cutaneous lesions, myositis, myocarditis, acute renal failure, pulmonary infiltration (often multiple), 
hypotension, fungemia, granulocytopenia, high mortality despite therapy 

Chronic: calcified hepatic and splenic abscesses, lesions usually detectable on computerised axial tomography and 
magnetic resonance imaging during granulocytopenia, elevated level of serum alkaline phosphatase, low mortality 
urine micro (blastospores and hyphae in * 1/3) and culture (« 80% positive), arterial blood culture (biphasic medium), 
sterile site culture or smear; precipitin test; agglutination titre (commercially available antigen), counterimmunoelectrophoresis 
(sensitivity 58%, specificity 96%), immunodiffusion (restricted availability; detects antigen and antibody) — all highly 
controversial tests with many false positive and negative results; antigen in urine or serum experimental; ELISA (antigen, 
antibody), latex agglutination, radioimmunoassay (sensitivity 71%, specificity 66%), indirect hemagglutination (sensitivity 
97%, specificity 60%), indirect immunofluorescence (sensitivity 91%, specificity 50%); increased arabinitol/creatinine ratio 
experimental 

Treatment: ketoconazole 200-400 mg orally (< 20 kg: 50 mg; 20-40 kg: 100 mg) once daily, fluconazole 200-400 mg (child: 
1-4 mg/kg) orally daily, amphotericin B under expert supervision + flucytosine (not Clavispora lusitaniae); removal of 
catheters, needles, prostheses, valves and vegetations 

Secondary Prophylaxis and Maintenance: fluconazole 50-200 mg orally daily, ketoconazole 200 mg orally daily 
Disseminated Trichosporon Infection: nonspecific febrile illness or pneumonia in immunosuppressed (especially 
neutropenic) patients (especially with acute myelogenous leukemia); lungs, liver, spleen, blood, urine, bone marrow, kidney, 
skin, heart, trachea, esophagus, adrenal; case-fatality rate 74% 
Agent: Trichosporon beigelii, Trichosporon asahii 
Diagnosis: blood cultures, culture and histology of specimens 

Treatment: amphotericin B 1-1.5 mg/kg/d + flucytosine 800 mg/d; fluconazole; itraconazole for 20 mo in chronic cases 
Disseminated Coccidioidomycosis: rare (7% of total); more common in infants, elderly, male, Filipino, African-American, 
native American, Hispanic, Oriental, and patients with impaired immunity (second '/a of pregnancy and postpartum, 
malignancy, chemotherapy, steroid use, seropositive for human immunodeficiency virus); skin (most common), meninges (most 
serious, 40% case-fatality rate), viscera (liver, spleen, prostate, adrenals), bones and joints, lymph nodes, serous membranes 
(peritoneum, pericardium) 
Agent: Coccidioides immitis 

Diagnosis: fever in 95%, pulmonary disease in 90%, weight loss in 60%, anemia in 50%, hepatosplenomegaly in 10-20%, 
meningitis in 10%, skin lesions in 5%; antibody detection often unreliable in immunocompromised host; EIA using a 
combination of antigens method of choice; latex agglutination (IgM) detects early acute disease, false positive results occur, 
positive results must be confirmed with immunodiffusion tube precipitin or immunodiffusion complement fixation test; 
immunodiffusion tube precipitin test (IgM) useful for diagnosis of early acute illness; immunodiffusion complement fixation 
test (IgG) useful for diagnosis of localised and disseminated disease, qualitative screen, may be quantitative; complement 
fixation test (IgG) diagnostically and prognostically valuable, titres of 1:8 diagnostic, changes in titres diagnostic, when titres 
of 1:2-1:8 are revealed confirmation by immunodiffusion complement fixation test necessary; coccidioidin skin test; negative 
skin test and serum complement fixation test titre > 1:66 indicate large likelihood; micro (30-80 |.im round spherules 
containing 2-5 |.im endospores reproducing by fission) and culture of appropriate specimen obtained directly from tissues 
affected or fluid from these tissues 

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Treatment: 

Meningitis: 

Indnction: 

Severe: i.v. amphotericin B up to 1.5 mg/kg/dose + amphotericin B + hydrocortisone 
intrathecal^ 

Mild: fluconazole 
Maintenance: fluconazole 

Skin, Lymph Nodes: amphotericin B 1-1.5 mg/kg/d to total 1.5-2 g i.v. + local irrigation with 10% solution 
or local paste and/or excision 

Bones, Viscera, Genitonrinary Tract, Peritonitis: 

Severe or Potentially Severe Disease: amphotericin B (1-1.5 mg/kg (initial up to 50 mg) i.v. to 
total 1-3 g + local irrigation and/or surgery 

Mild to Moderate Stable Disease: ketoconazole 400 mg orally for 3 mo to several years, 
fluconazole 400 mg orally initial then 400-800 mg for 3 mo to several years, itraconazole 400 mg orally 

Nondisseminated Extracntaneons Disease in Immnnocompetent Host: ketoconazole 
Cryptococcosis (European Blastomycosis, Torulosis): sporadic, worldwide; incidence 8/ffl/y in Australia (from 
2/ffl/y in Tasmania to 44/M/y in Northern Territory); associated with HIV (50%) and other immunodeficiency (21%; 
Hodgkin's disease, sarcoidosis, collagen disease, carcinoma, treatment with corticosteroids and immunosuppressive agents, 
adrenal hyperplasia, renal transplantation under treatment with azathioprine and corticosteroids); meningitis, pneumonia, 
pericarditis, hepatic failure, osteomyelitis, arthritis, subcutaneous and cutaneous lesions, paravertebral abscesses and cord 
compression, muscle weakness 

Agent: 84% Cryptococcus neoformans var neoformans, 12% Cryptococcus gattii, 5% unknown biotype, rarely Cryptococcus 
albidus, Cryptococcus laurentii 

Diagnosis: India ink micro preparation (positive in 33-60%), culture (usually growth in 4-7 d, may take 4-6 w or require 
hypertonic medium) of spinal fluid (46-100% positive), blood (lysis-centrifugation blood culture; 48-89% positive), 
bronchoalveolar lavage (75-100% positive), pus, sputum (50% positive), pleural fluid (50% positive), urine (17% positive), 
peritoneal dialysate (100% positive), bone marrow (100% positive); latex slide agglutination test (commercially available) for 
antigen in CSF, blood, urine (positive in 86-90%; may be positive when India ink test is negative; highly sensitive and 
specific for diagnosis of meningeal and disseminated forms; prozone-like effect controlled by dilution of specimen or 
treatment with pronase; rare false negatives with capsule-deficient Cryptococcus neoformans in patients with AIDS; rare 
false positives with Capnocytophaga canimorsus septicemia, patients with malignancy, Trichosporon beigelii disseminated 
infection); tube agglutination, charcoal particle agglutination, indirect fluorescent tests for antibody in serum (positive in 
28%); complement fixation test; meningitis: CSF cells usually < 800/|.iL, either neutrophils or lymphocytes predominating, 
protein increased (rarely > 800 mg/dL), glucose decreased, chloride < 105 mEq/L 
Treatment: 

Mild: fluconazole 800 mg orally or i.v. initially, then 400 mg daily for 10 w 

More Severe: amphotericin B desoxycholate 0.7 mg/kg i.v. daily for 2-4 w + flucytosine 25 mg/kg i.v. or orally 
6 hourly for 2-4 w; if clinical improvement after 2 w, change to fluconazole 800 mg orally initially then 400 mg daily for 
8 w 

Secondary Prophylaxis in HIV Infection: fluconazole 200 mg orally daily or itraconazole 200 mg orally 
daily 

Torulopsosis: superinfection during treatment with cytotoxic and/or immunosuppressive drugs + corticosteroids (similar 
to systemic candidiasis) and in diabetes mellitus, particularly with acidosis (pyelonephritis; occasionally pneumonia and/or 
empyema) 

Agent: Candida glabrata 

Diagnosis: direct mount and culture of urine, sputum 
Treatment: amphotericin B + flucytosine 

Geotrichosis: neutropenic leukemics; blood, urine, skin, lungs, heart, liver, spleen, lymph nodes, bone marrow, kidney 
Agent: Geotrichum candidum 

Diagnosis: micro and culture of sputum, pus from oral lesions, feces 
Treatment: amphotericin B 

Blastomycosis (Gilchrist's Disease, North American Blastomycosis): uncommon, sporadic in N and Central 
America, recently recorded in Spain; transmission by inhalation; 75% of patients not immunocompromised 
Agent: Ajellomyces dermatitidis 

Diagnosis: microscopy (visualisation of buds in wet preparation) and culture of scrapings from cutaneous lesions and pus 
from abscesses on periphery of lesion, sputum, urine, CSF; complement fixation test (usually positive only in systemic 
disease; sensitivity 40%, specificity 100%; predictive value positive 100%, predictive value negative 81%), immunodiffusion 

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Multi-system, Generalised and Systemic Infections 

(sensitivity 66%, specificity 100%, predictive value positive 100%, predictive value negative 88%) and skin tests (frequently 
unhelpful), ELISA using purified antigen A (sandwich sensitivity 88%, specificity 100%, predictive value positive 100%, 
predictive value negative 98%; indirect sensitivity 80%, specificity 94%, predictive value positive 94%, predictive value 
negative 93%; false positives in some cases of histoplasmosis and sporotrichosis), radioimmunoassay (sensitivity 85%, 
specificity 100%, predictive value positive 100%, predictive value negative 92%); hypochromic anemia with neutrophilia, 
raised erythrocyte sedimentation rate 
Treatment: 

Mild Cases: itraconazole, ketoconazole 200-800 mg orally daily for up to 1 y, amphotericin B to total dose of 
2g 

Severe Cases: amphotericin B under expert guidance, hydroxystilbamidine if amphotericin B fails 
Histoplasmosis: reported from 130 widely scattered countries; endemic in Ohio Valley, Mississippi Valley and Appalachian 
Mountains; in Australia, patients infected from a chicken coop and associated with a cave in NSW; 'cave disease' contracted 
by visitors to caves inhabited by bats; African form in endemic belt through central Africa; « 300 cases (« 60 deaths)/y in 
USA; 50-99% asymptomatic, 1-50% self-limited; pulmonary infections (tuberculosis-like disease of lungs; acute 60% of 
symptomatic, chronic 10%), pericarditis (10% of symptomatic), disseminated (immune defect, leukemia, Hodgkin's disease; in 
75% of symptomatic patients on immunosuppression (especially steroids); < 0.5% of AIDS patients; 10% of symptomatic 
patients overall), arthritis and erythema nodosum (5% of symptomatic), bone marrow infections, endocarditis, 
oronasopharyngeal lesions, lymph gland infections, mediastinal granulomas, meningitis (8% of cases in AIDS and !4 of those 
with disseminated disease) 

Agent: Histoplasma capsulation var capsulation, Histoplasma capsulatum var duboisi (tropical Africa; predilection for 
visceral involvement, higher case-fatality rate) 

Diagnosis: incubation period > 21 d; fever in 95%, weight loss in 90%, anemia in 70%, pulmonary disease in 50%, 
hepatosplenomegaly in 25%, lymphadenopathy in 20%, skin lesions in 5-10%, meningitis in < 1%; microscopy (1-5 |.im round 
to oval budding cells; rapid but low sensitivity and identification errors) and culture (insensitive in cases of self-limited 
disease, may require 2-4 w of incubation to produce growth, may require invasive procedure for obtaining specimen) of 
material from cutaneous and mucosal lesions, sputum, gastric washings, biopsy of oronasopharyngeal lesions, lymph glands, 
bone marrow; serological tests for antibody sensitive in chronic and self-limited disease, falsely negative early in infection, 
falsely positive in cases of other fungal disease, may remain positive for years; HP antigen detection sensitive (80-92%) in 
cases of disseminated disease but poor sensitivity in chronic and self-limited disease, rapid turnaround time, level of HP 
antigen decreases after treatment, increases with relapse); immunodiffusion (active cases 2% H positive, 10% H and M 
positive; 70% of all cases M positive; detection of M precipitin may be influenced by skin test), complement fixation test 
(commercially available; yeast antibody 90% sensitivity, nonspecific at low titres; histoplasmin antibody 80% sensitivity, 
more specific; skin test may interfere), latex agglutination (detects early acute disease, most chronic cases negative), 
radioimmunoassay detection of antigen in serum and in urine (disseminated cases 90% urine and 50% serum positive, 
valuable for immunodeficient patients; nondisseminated cases urine 50-75% negative, some cross-reactivity); skin test not 
useful diagnostically, useful epidemiologically, may confuse interpretation of serological tests by presence of booster effect; 
hypochromic anemia with leucopenia; in children, lymphocytosis with atypical mononuclears 

Disseminated: fever in 70% of cases, weight loss in 66%, pulmonary symptoms in 50%, thrombocytopenia in 
50%, anemia in 45%, splenomegaly in 40%, oral lesions in 25%, leucopenia in 25%, neurologic symptoms in 20%, leucocytosis 
in 10%; positive cultures from 90% of oral lesions, 70% of lymph nodes, 70% of bone marrows, 60% of sputum specimens, 
55% of liver biopsies (granulomas in 70%, organism seen microscopically in 40%), 55% of blood cultures, 45% of CSF 
specimens and 45% of urine specimens; 1/3 of patients with negative blood cultures have positive bone marrow; none with 
negative bone marrow have positive blood culture; 40% of patients with positive urine culture have normal renal function 
Treatment: not indicated in acute pulmonary, pericardial, rheumatologic, coin lesions, fibrous mediastinitis; indicated in 
disseminated, chronic pulmonary, acute respiratory distress syndrome, symptomatic mediastinal granuloma, persistent 
(> 1 mo) acute pulmonary 

Indnction: 

Mild: itraconazole 400 mg/d for 3 mo, fluconazole 800 mg/d for 3 mo 

Severe: amphotericin B 0.7 mg/kg/d to 50 mg/d + prednisone 60 mg daily for 2 w 

Maintenance: itraconazole 200-400 mg/d for 12 w (acute pulmonary), 12-24 mo (chronic pulmonary), 6-18 mo 
(disseminated in non-AIDS), life (disseminated in AIDS), 6-12 mo (granulomatous mediastinitis); fluconazole 400 mg/d for life 

Nondisseminated Extracntaneons Disease in Immnncompetent Host: ketoconazole 400 mg orally 
(child < 20 kg: 50 mg; 20-40 kg: 100 mg, > 40 kg: 200 mg) daily for 6-12 mo, cotrimoxazole 160/800 mg orally 12 hourly 
for 4-5 w 

Paracoccidioidomycosis (Kutz-Splexdore-De Almeida's Disease, South American Blastomycosis): restricted 
to S America and Central America, including Mexico; may not appear till long after acquisition; mucous membrane of mouth 
most frequently affected area; lymph nodes affected in almost all cases; lungs affected in high proportion of cases 

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Multi-system, Generalised and Systemic Infections 

Agent: Paracoccidioides kasiliensis 

Diagnosis: microscopy and culture of scrapings from affected skin (paracoccidioidal granuloma) and mucous membranes, 

pus from fluctuant nodules, sputum; complement fixation test (usually positive only in systemic cases); iron deficiency 

anemia with neutrophila and raised erythrocyte sedimentation rate; eosinophlia sometimes 

Treatment: ketoconazole 400 mg (child < 20 kg: 50 mg; 20-40 kg: 100 mg; > 40 kg: 200 mg) orally daily for 3 mo then 

200 mg daily for 9-12 mo, sulphonamides, amphotericin B under expert supervision then maintenance ketoconazole as above, 

miconazole 

Sporotrichosis: worldwide; up to 1/1000 in rural areas of Central and S America; cutaneous lymphatic (most common 

form; firm subcutaneous nodules), fixed cutaneous (no lymphatic involvement), localised extracutaneous (skeletal most 

common; pulmonary can mimic tuberculosis), disseminated (rare; immunosuppressed patients) 

Agent: Sporotkix schenckii 

Diagnosis: wet preparation micro, Gram stain (note that cigar-shaped yeast phase cells may resemble diphtheroids), 

methenamine silver stain, fungal culture of aspirate or purulent exudate or biopsy of cutaneous or mucosal lesion, sputum, 

bronchial aspirate, lung biopsy, synovium, synovial fluid; blood cultures; serology (latex agglutination, tube agglutination) 

Treatment: 

Cutaneous-lymphatic Form: surgery; potassium iodide up to 3-4 g 8 hourly as a saturated (1 g/mL) solution 
continuing for 1 mo after clinical cure, ketoconazole 200-400 mg orally (< 20 kg: 50 mg; 20-40 kg: 100 mg) daily for 3-6 
months, itraconazole 100 mg orally daily with meals for 120 d (not in pregnancy) 

Pnlmonary and Disseminated Forms: amphotericin B to total dose 2-3 g, ketoconazole 400-500 mg daily 

Maintenance: itraconazole 
Aspergillosis: in farmers, poultry workers and immunocompromised; 151% increase in annual incidence (1.91 to 4.8/ffl) 
between 1970 and 1976 in USA; associated with use of corticosteroids and/or antimicrobials, immunosuppressive agents, 
leucopoenia; acute lymphocytic leukemia in 40% of patients, acute myelogenous leukemia in 20%, chronic myelogenous 
leukemia in 10%, Hodgkin's disease in 5%, lymphoma in 5%, other diseases of lymphoreticular system (aplastic anemia, 
chronic lymphocytic leukemia, mycoides fungoides, multiple myeloma) in 10%, 'autoimmune' disease (systemic lupus 
erythematosus, polyarteritis nodosa) in 5%; 95% lung, 20-70% gastrointestinal tract, 15-50% brain, 10-40% liver, 10-40% 
kidney, 10-30% thyroid; also heart, sinus, eye, spleen, diaphragm, tongue, testis, rare meningitis in AIDS 
Agents: Aspergillus fumigatus (75%), Aspergillus flavus, Aspergillus glaucus, Aspergillus terreus, Aspergillus ustus 
Diagnosis: visualisation of hyphae; confirmed by culture 

Aspergilloma: hyphae in mass in bloody sputum from lung; sputum and biopsy culture 

Invasive Aspergillosis: 60% of isolates in allogeneic bone marrow transplant recipient, 60% in neutropenics, 
50% in persons with hematological cancer, 30% in malnutrition, 20% in HIV infection, 20% in solid organ transplantation, 
20% in corticosteroid users, 10% in those with underlying pulmonary disease; only 38% alive 3 mo after diagnosis; sputum 
culture in neutropenic patient; KOH preparation and culture of biopsy of sterile site; sandwich ELISA for galactomannan on 
serum (sensitivity 94%, specificity 85%), counterimmunoelectrophoresis (precipitating antibodies), radioimmunoassay (usually 
positive), immunodiffusion (restricted availability; positive result suggests diagnosis if serial specimens are obtained), 
complement fixation test, precipitins; serial quantitative assay for antibodies may be better than culture (recovered from 
blood in < 5%, cutaneous lesions in < 10%), or attempts to detect antigen in immunocompromised patients; halo sign on CT 
inidcative of invasive pulmonary aspergillosis 
Treatment: 

Severe: amphotericin B under expert supervision (rate of response 55%) + flucytosine or rifampicin; reduce 
immune suppression 

Mild or Moderate: itraconazole 
Neosmtorya Infections: occasional opportunistic infections 

Agents: Neosartorya fischeri systemic infection in transplant recipients, mixed pulmonary infection in patient with multiple 
myeloma; Neosartorya pseudofischeri localised and invasive infections; Neosartorya hiratsukae cerebral infection 
Diagnosis: visualisation of hyphae; confirmed by culture 
Treatment: itraconazole 400 mg daily 

Zygoihycosis: lung, spleen, kidney, CNS, gastrointestinal tract, heart, sinus, eye, liver, pancreas; rhinocerebral associated 
with diabetes mellitus (with or without associated acidosis or hyperglycemia; 75% of cases), hematological neoplasia, 
malnutrition, severe (third degree) burns, immunosuppression, following homotransplantation, uremia; cerebral associated with 
pulmonary or disseminated fungal infection, hematolgic malignancy; pulmonary associated with leukemia, lymphoma and 
leucopenia (75% of cases), diabetes mellitus (with or without associated acidosis or hyperglycemia), renal failure, third 
degree burns, corticosteroid therapy, cytotoxic therapy; gastrointestinal rare, associated with protein-calorie malnutrition 
(especially children in tropical and subtropical countries with kwashiorkor), diabetes mellitus, hematological malignancy, 
uremia, acidosis due to diarrhoea, amoebic colitis, therapy with corticosteroids, ulcerative colitis, abdominal surgery; 
disseminated associated with leukemia, lymphomas, anmias, multiple myeloma, solid tumours, agranulocytosis, uremia, third 

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Multi-system, Generalised and Systemic Infections 

degree burns, intravenous narcotic abuse, hemodialysis and deferroxamine, organ transplantation, wounds, neonatal state, lung 

disease; cutaneous associated with diabetes mellitus, burns, under Elastoplast dressings, AIDS; localised following surgery 

rare — brain abscess following neurosurgery, prosthetic valve, vascular graft; renal associated with chronic or acute renal 

failure 

Agents: Rhizopus, Mbsidia, Mucor, rarely Cunninghamella elegans, Cunninghamella bertholetiae, Basidiobolus haptosporus 

Diagnosis: temperature > 38.3°C in 61% of cases; histology and culture of infected tissue (necrotic lesion or sterile site) 

Treatment: aggressive surgical debridement; amphotericin B 1 mg/kg/d i.v. for 2-3 mo; control of underlying predisposing 

conditions (diabetes, immunosuppression, immunodeficiency); hyperbaric oxygen 

Penicilliosis: in acute lymphoblastic leukemia; focal infections and fatal, progressive disseminated infection (lungs, heart, 

blood, mediastinum, superior vena cava) 

Agent: Penicillium, including Penicillium marneffei in AIDS (geographic distribution limited to SE Asia) 

Diagnosis: fever in 99%, weight loss in 75%, anemia in 75%, skin lesions in 70%, pulmonary disease in 50%, 

hepatosplenomegaly in 50%, lymphadenopathy in 40-50%, meningitis very rare; Grocott methenamine silver, periodic acid 

Schiff and Wright's staining (1-8 (.im pleomorphic elongated cells reproducing by fission) and culture at 25°C and 37°C of 

biopsies, bone marrow aspirate, touch smears of skin specimens 

Penicillium marneffei: fever, marked weight loss, anemia, generalised papular skin lesions, lymphadenopathy, 
hepatomegaly 
Treatment: 

Severe: amphotericin B 

Mild: itraconazole; flucytosine 150 mg/kg/d + ketoconazole 400 mg/d for 90 d 

Maintenance: itraconazole 
Fushriosis: in immunocompromised, especially acute leukemia; skin, lung, blood, kidney, sinus, eye, gastrointestinal tract, 
heart, spleen, CNS, liver, pancreas, urine, i.v. line tip, bone marrow, testis; death rate approaching 100% 
Agents: Fusarium solani, Fusarium oxysporum, Fusarium chlamydosporum, Gibberella fujikuroi, Fusarium anthophilum, 
Gibbeiella intermedia 

Diagnosis: persistent fever, skin lesions (ecthyma-like lesions, target lesions, multiple subcutaneous nodules; 60% of 
patients), orbofacial involvement, fungemia, myalgias; blood cultures positive in 60%; histology and culture of skin biopsies 
Treatment: control of underlying disease and recovery from neutropenia (granulocyte infusions + GM-CSF); surgical 
resection; voriconazole; amphotericin B 1.0-1.5 mg/kg daily, liposomal amphotericin B 5-15 mg/kg daily 
Trichothecene Mycotoxins: used as biowarfare agents 
Agent: Fusarium 

Diagnosis: cutaneous exposure causes rapid erythema, blistering and necrosis of skin; eye exposure causes tearing, 
conjunctivitis and blurred vision; respiratory exposure causes nasal burning and epistaxis, sore throat, cough, dyspnoea and 
chest pain; high doses cause nausea, burning skin, lethargy and incoordination within minutes, bleeding, cough, dyspnoea, 
chest and abdominal pain, diarrhoea and blistering of skin within hours; severe poisoning causes extensive mucosal bleeding, 
hypothermia and shock; gas chromatography, mass spectrometry, ELISA or radioimmunoassay on urine 
Treatment: none proven; gastric infusion of activated charcoal and high doses of corticosteroids beneficial in mice 
Prevention: protective clothing and face masks 

Systemic Hrnsenulr Infections: immunosuppression, use of intravenous device, previous treatment with antibacterial 
drugs; 59% from blood, 18% from CSF, 6% from mediastinal lymph nodes, 6% from endocardium, 6% from kidney, 6% from 
spleen 

Agents: 92% Hansenula anomala, 8% Pichia angusta 
Diagnosis: blood cultures, histology and culture of biopsy specimens 
Treatment: amphotericin B 

Systemic Bipolrris Infections: in multiple myeloma; sinus, lungs 
Agent: Bipolaris 

Diagnosis: histology and culture of biopsy specimens 
Treatment: amphotericin B (usually not successful), itraconazole 

Systemic Pseudrllescherir boydii Infections: cancer patients on steroids, chronic pulmonary disease, hematological 
malignancy during therapy, neutrophil dysfunction, near-drowning; heart, blood, brain, lungs, kidney 
Agent: Pseudailescheria boydii 
Diagnosis: culture of blood, sputum and urine 
Treatment: ketoconazole, fluconazole, flucytosine 

Srcchrromyces cerevisire Invasive Infections: severe immunosuppression, prolonged hospitalisation, prior 
antibacterial therapy, prosthetic cardiac valves; pneumonia, liver abscess, sepsis, disseminated infection with cardiac 
tamponade 
Agent: Saccharomyces cerevisiae 

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Multi-system, Generalised and Systemic Infections 

Diagnosis: smear and culture of biopsy 

Treatment: amphotericin B to total dose 300-1400 mg 

Systemic Dipodascus capitatus Infections: leukemia; pneumonia, focal infection of liver, spleen, kidney, brain, skin, 

oesophagus, stomach, bacteremia, myocarditis, endocarditis 

Agent: Dipodascus capitatus 

Diagnosis: blood cultures; smear and culture of sputum, sinus, biopsy 

Treatment: prolonged amphotericin B + flucytosine 

Systemic Exophirla dermatatidis Infection: pneumonia, brain abscess; chronic granulomatous disease 

Agent: Exophiala dermatitidis 

Diagnosis: micro and culture of biopsy 

Treatment: surgical resection of pulmonary lesion; amphotericin B, flucytosine, ketoconazole + transfused white cells, 

followed by prolonged course of fluconazole 

Scedosporiosis: posttraumatic cellulitis, septic arthritis and osteomyelitis, oncychomycosis, otomycosis, fungal balls in 

paranasal sinuses, lungs and bronchi in immunocompetent; endophthalmitis in i.v. drug use; systemic infection 

(endophthalmitis, endocarditis, metastatic abscesses) in immunocompromised 

Agents: Scedosporium apiospermum, Scedosporium prolificans 

Diagnosis: micro and culture of appropriate specimen 

Treatment: surgery; itraconazole; amphotericin B in lipid 5-15 mg/kg/d 

Systemic Protothecosis: gallbladder, liver, duodenum 

Agents: Prototheca wickerhamii, Prototheca zop&i 

Diagnosis: elevated IgG, elevated erythrocyte sedimentation rate, eosinophilia, raised liver enzymes; microscopy and 

culture of biopsy, stool 

Treatment: short course of amphotericin B followed by oral ketoconazole for 3 mo 

Disseminated Pneumocystis /mojtc/ Infection: AIDS, hematolgic malignancy, lymphoreticular malignancy, 

immunosuppressive therapy; 46% lymph nodes, 36% bone marrow, 36% spleen, 32% liver, 18% gastrointestinal tract, 18% 

retina, 16% adrenal, 16% thyroid, 14% kidneys, 12% vessels, 10% heart, 8% pancreas, 6% external auditory canal, 4% brain, 

4% thymus, 4% pleura, 2% middle ear/mastoid, 2% hard palate, 2% ureters, 2% Virchow-Robin spaces, 2% diaphragm, 2% 

pericardium, 2% retroperitoneal tissue 

Agent: Pneumocystis jiroveci 

Diagnosis: Wright-Giemsa, Papanicolau, Gomori methenamine silver stain, direct immunofluorescence of appropriate 

specimen 

Treatment: cotrimoxazole 5/25 mg/kg oral or i.v. 6-8 hourly for 3 w then 80/400-160/800 mg orally daily or 

160/800 mg orally 3 or 4 d/w or 12 hourly 2 d/w; pentamidine isethionate 4 mg/kg to 300 mg i.v. daily for 3 w then 

300 mg i.v. or aerosolised every 2-4 w 

Maintenance Therapy in HIV/AIDS: cotrimoxazole 80/400-160/800 mg orally daily or 160/800 mg orally 
3 times weekly, dapsone 100 mg orally 3 times weekly, pentamidine 300 mg i.v. or aerosolised every 2-4 w 
Prophylaxis (CD4 Cell Connt < 200/ |aL): cotrimoxazole 80/400-160/800 mg orally daily or 160/800 mg orally 3-4 
times a week or 12 hourly twice a week, pentamidine 300 mg i.v. or aerosolised every 2-4 w, dapsone 100 mg orally 3 
times a week 

Visceral Leishmaniasis (Assam Fever, Bundwan Fever, Cachectic Fever, Cachexial Fever, Death Fever, 
Dum-dum Fever, Infantile Leishmaniasis, Kala-azar, Nonmalaria Remittent Fever, Ponos, Sahib 
Disease): endemic in 62 countries including India, Mediterranean, East Africa, Middle East, S Africa, China, Latin America; 
500,000 new cases/y worldwide, with 41, 000 recorded deaths; human (only reservoir for Lesihmania donovani donovam), 
dog, fox, rodent, jackal reservoirs; transmission by sandfly (Phiebotomus and Lutzomyia) bite; incubation period weeks to 
months; untreated cases usually fatal 

Agents: Leishmania donovani (India and East Africa), Leishmania chagasi (New World), Leishmania nfantum 
(Mediterranean); rarely, Leishmania tropica 

Diagnosis: incubation period > 21 d; prolonged or intermittent fever, marked splenomegaly, hepatomegaly, intermittent 
cough, diarrhoea, malaise, poor weight gain, wasting; if cell-mediated immunity isufficient, disease may be mild or 
asymptomatic, with limited pathology; geographic history; history of sandfly bites; fever, splenomegaly; anti-K39 IgG strip 
test on fingerstick blood (sensitivity 100%, specificity 98%), ELISA (sensitivity 98%, specificity 100%), PCR, examination of 
splenic pulp smears (positive in 98%), bone marrow smears (positive in 90%), liver biopsy (positive in 70%), thin smears of 
buffy coat of blood (positive in 60%), lymph node aspirate or biopsy; histological appearances of chronic infection of 
reticuloendothelial system with presence of parasites in bone marrow, liver, lymph nodes and spleen; culture of tissue or 
blood; indirect hemagglutination titre, direct agglutination titre, complement fixation test, latex agglutination, Montenegro skin 
test; progressive anemia with leucopenia and thrombocytopenia, falling serum albumin, greatly increased y-globulin, raised 
erythrocyte sedimentation rate and serum viscosity and, later, serum bilirubin 

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Multi-system, Generalised and Systemic Infections 

Treatment: meglumine antimonate 20 mg antimony/kg/d for 20-40 d, amphotericin B 7-20 mg/kg total dose i.v. for up to 
20 d, liposomal amphotericin B 10-20 mg/kg total dose i.v. in 5-10 doses over 10 d, amphotericin B colloidal suspension 10- 
15 mg/kg total dose over 5 d, pentamidine 15-30 doses over 3-4 w, miltefosine, metronidazole 25 mg/kg daily i.v. for 5 d, 
followed by 40 mg/kg orally daily in divided doses for 7 d, sodium stibogluconate 10 mg/kg i.m. or i.v. 8 hourly for 10 d, 
paromomycin 11 mg/kg i.m. daily for 21 d 

Visceral Larva Migrans (Larva Migrans Visceralis, Parasitic Larval Granulomata, VLM Syndrome) 
Agents: Toxocara (toxocariasis, Toxocara infection, Toxocara infestation; principally Toxocara cam's, less frequently Toxocara 
cati), occasionally Ascaris lumbricoides, Baylisascaris procyonis (from raccoons), Capillaria hepatica, Diro&laria, Gnathostoma, 
Toxascaris leonina 

Diagnosis: symptoms depend on number of larvae and on tissues invaded; may be no localised reaction or may be 
hepatomegaly or hepatosplenomegaly, pneumonitis (tropical eosinophilic pneumonia) or pulmonary infiltrates, allergic 
phenomena and neural and ocular lesions of varying severity; granulomatous lesions characteristic; fever, rigours, pruritic 
rash, abnormal behaviour 

Toxocara: ELISA, bentonite flocculation (needs evaluation; 1:5 titre may be diagnostic if indirect 
hemagglutination also positive), indirect hemagglutination (generally reliable although status of disease activity may be 
uncertain; diagnostic titre 1:400) 

Visceral Form: usually benign, but rare deaths due to severe neurologic or myocardial involvement; 
exposure to dogs and cats or eating raw chicken; 1-5 y old with history of pica; malaise, weight loss, wheezing, cough; 
surgical liver biopsy; marked eosinophilia (usually > 30%), anemia, neutrophilia in children, increased serum y-globulin 
(including increased IgE), raised isohemagglutinin titres 

Ocnlar Form: 5-20 y old; history of pain unusual; failing vision, strabismus, whitish retinal 
granuloma, endophthalmitis, uveitis; hematological tests usually normal; unnecessary enucleation because of misdiagnosis of 
retinoblastoma 

Rscaris: acute localised manifestations (hepatic, pancreatic, bile duct, intestinal obstruction, peritonitis, 
appendicitis) and allergic reactions (bronchospasm, pulmonary infiltration, urticaria) 

Treatment: corticosteroids in severe cases; thiabendazole 25 mg/kg 12 hourly orally daily for 5 d, diethylcarbamazine 
2 mg/kg 8 hourly orally for 7-10 d 

Visceral Gnathostoihiasis: SE Asia and S America; large range of freshwater fish, amphibians, reptiles, crustaceans, 
birds and mammals act as second intermediate hosts; pulmonary, gastrointestinal, genitourinary, opthamologic, ear, nose, 
throat 

Agent: Gnathostoma spinigerum 

Diagnosis: isolation of parasites when possible; eosinophilia; history of travel to SE Asia or S America and ingestion of 
raw or undercooked fish, poultry or pork 
Treatment: removal of worm where appropriate 
Trypanosomiasis 

Agents: Tyrpanosoma kucei gambiense (Gambian fever, Gambian sleeping sickness, Gambian trypanosomiasis, Mid-African 
sleeping sickness, West African trypanosomiasis), Trypanosoma kucei rhodesiense (East African trypanosomiasis, Rhodesian 
sleeping sickness, Rhodesian trypanosmiasis; prevalence 12 M), Trypanosoma cruzi (American trypanosomiasis, barbeiro fever, 
Brazilian trypanosomiasis, careotrypanosis, Chagas-Cruz disease, Chagas disease, Chagas-Mazza disease, Cruz trypanosomiasis, 
South American trypanosomiasis; Central and S America; transmission mostly indoors) 

Diagnosis: skin nodule, fever, lymphadenopathy, circinate rash, mental changes; geographic history; insect vector bite 
(Glossina in African trypanosmiasis, reduviid bugs (triatomine (cone nose) bugs of genera Triatoma, Rhodnius and 
Panstrongylus) in trypanosomiasis due to Trypanosoma cruzi); electrocardiogram (myocarditis); thick and thin blood films and 
buffy coat examination (febrile stage) 

American Trypanosomiasis: incubation period 1-3 w; children 1-5 y old; chagoma (erythematous, warm mass 
at site of and within few h of bite) persists for 2-3 mo, becomes fibrotic and encapsulated, most commonly on cheek or 
around eye 

Acnte: fever, toxic anemia, rash, edema of eyelids with unilateral conjunctivitis, regional adenitis, 
moderate hepatomegaly or splenomegaly, epistaxis, convulsions, acute myocarditis, cardiac arrhythmias and congestive heart 
failure, meningoencephalitis 

Chronic: fever, adenitis, anemia, monocytosis, weight loss, autonomic neuropathy causing 
gastrointestinal lesions (megaesophagus, megacolon), myocardial degeneration, biventricular cardiac failure (greater on right 
than left), meningoencephalitis, pulmonary or systemic embolism 

serology (Machado-Geurrein test, indirect fluorescent antibody titre, hemagglutination inhibition test); culture of 
blood and bone marrow aspirate on biphasic blood agar (NNN) medium; xenodiagnosis (6 clean, uninfected, laboratory-bred 
reduvid bugs allowed to feed on patient and hindgut examined for epimastigotes after 2 w) 

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Multi-system, Generalised and Systemic Infections 

African Trypanosomiasis: incubation period < 21 d; skin nodule (trypanosomal chancre) at site of bite firm, 
tender, indurated, inflamed, may ulcerate, persists 2-3 w, precedes other manifestations of illness by weeks to years; chills, 
intermittent fever 2-3 w duration, accompanied by erythematous skin eruption; debilitation, anemia, dyspnoea, edema, 
headache weeks to months; lymphadenopathy symmetric, predominantly cervical, persists for several months; CNS 
involvement, muscular pain and spasms, emaciation; hepatosplenomegaly; parasitemia frequently visible on blood smear; early 
sleeping stage lassitude, apathy, fatigue, later asleep most of time, terminal coma; Kerandel's sign (severe pain over area of 
nerve distribution following light tap on nerve); Giemsa stained smears of fluid aspirated from an enlarged lymph gland, 
bone marrow aspirate, CSF; serology (ELISA most sensitive, may give false positives if CSF used; IgM increase in blood and 
in CSF when nervous system involvement 

Tyrpanosoma brucci gambiense: subacute or chronic with mild onset; more severe encephalitis; 
less visceral involvement; more lymphadenopathy; death in untreated cases usually after several years as result of severe 
malnutrition and/or intercurrent infections 

Trypanosoma biucei rbodesiense: acute with sudden onset and much more acute rapid course; 
less severe encephalitis; more visceral involvement, including heart; less lymphadenopathy; death in untreated cases usually 
within weeks or months 
Treatment: 

Trypanosoma brucei: 

Hemolymphatic Stage: suramin 100-200 mg test dose then 1 g (child: 20 mg/kg) i.v. on days 1, 3, 
7, 14, 21; Tyrpanosoma brucei gambiense only: pentamidine isethionate 4 mg/kg i.m. daily for 10 d 

Organisms in CSF: suramin 200 mg test dose i.v. followed by 20 mg/kg to 1 g on days 1, 3 and 8, 
followed by melarsopol (commencing on day 12) 2-3.6 mg/kg daily for 3 d, course repeated after 1 w at 3.6 mg/kg daily at 
intervals of 1-5 d for total of 10 doses and 25 mg/kg over 1 mo; nitrofurazone 1-2 g daily in 3 or 4 divided doses for 5-7 
days; difluoromethylornithine hydrochloride monohydrate 100 mg/kg 6 hourly infused over 1 h for up to 14 d, followed by 
75 mg/kg orally 6 hourly for 30 d 

Trypanosoma cruzi: nifurtimox 8-10 mg/kg orally daily in 4 divided doses for 120 d (1-10 y: 15-20 mg/kg 
daily for 90 d; 10-16 y: 12.5-25 mg/kg daily for 90 d; 50% cure rate), lampit, benzimidazole 
Prophylaxis (Tyrpanosoma brucei gambiense): pentamidine isethionate 250 mg i.m. given as a single dose 
FiLflRiflSis: 120 M infected worldwide; no deaths reported; Africa, Eastern Mediterranean, Asia, South America; transmission 
by mosquitoes, infected arthropods; incubation period weeks to years 

Agents: Wuchereria bancrofti, Brugia malayi, Brugia timori, Loa loa, Onchocerca volvulus, Mansonella ozzardi, Mansonella 
perstans, 'Mansonella streptocerca', 'Meningonema peruzzii', Dirofilaria 

Diagnosis: clinical; bentonite flocculation test (1:5 titre diagnostic if indirect hemagglutination assay also positive), 
indirect haemagglutination assay (1:400 titre diagnostic if bentonite flocculation test also positive), ELISA (sensitive but non- 
specific), indirect immunofluorescence; eosinophilia sometimes 

Wuchereria bancrofti, Brugia malayi, Brugia timori: demonstration of microfilariae in peripheral thick 
blood films taken at night and by histological examination of biopsy material 

Acnte: recurrent lymphangitis (with Brugia, not severe and usually affecting lower limbs with 
enlargement of femoral and popliteal lymph nodes); may be fever, headache and urticarial rash ('filarial fever') 

Chronic: fibrosis and lymphatic obstruction, leading to hydrocele and/or elephantiasis (enlargement of 
legs, arms, breast and genitals) 

Loa loa: adult worms migrate through subcutaneous tissues producing painful transient erythematous 
inflammation ('fugitive swelling', 'Calabar swelling'), migratory angiedema, urticarial vasculitis, and occasionally across eye 
beneath conjunctiva; microfilariae in films of peripheral blood collected repeatedly at midday and midnight and concentrated 
by Knott's technique; occasionally, adult filariae under conjunctiva or in biopsy material of swelling; white cell count 
9900/|A 31% eosinophils 

Onchocerca volvulus: chronic; dermatitis (irritating pruritic rash) and sometimes hyperkeratosis, 
depigmentation; subcutaneous encapsulated tumours (onchocercomata containing adult worm) with muscular pain, sclerosing 
lymphadenitis, eye disease (conjunctival hyperemia, iritis, corneal opacities, chorioretinitis, optic nerve disease leading to 
blindness (river blindness)); in Africa, loss of skin elasticity causing hanging groin syndrome; in S America, pouches under 
eyes causing 'leonine fades'; adult filaria in excised nodules, microfilaria in shavings of skin; histology of lymph nodes; 
radioimmunoassay; Mazzotti test; patch test 

Mansonella: eosinophilia; recovery of microfilariae from blood by Knott's concentration 

Mansonella ozzardi: asymptomatic or urticaria, lymphadenopathy, articular pains, pruritic skin 
eruptions, headaches, hydrocele 

Mansonella perstans: usually mild or asymptomatic but can cause arthropathy, Calabar swellings 
and pyrexia 

Mansonella streptocerca: rare; cutaneous edema, rash, red macules 

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Multi-system, Generalised and Systemic Infections 

Meningonema peruzzii: acute encephalomyelitis or mild illness with headache, fatigue and drowsiness 

Dirofilatia: often asymptomatic; abscesses or nodules ('coin lesions') in heart, lungs, subcutaneous tissue, eye 
Treatment: ivermectin 200 jug/kg single oral dose, flubendazole 750 mg i.m. weekly for 5 w, albendazole, 
diethylcarbamazine 

Prevention and Control: control of vectors, treatment of cases 

Schistosomiasis (Bilharziasis, Haeihic Distomiasis, Snail Fever): worldwide incidence 200 ffl/y (Africa, Near 
East, rain forest belt in Central Africa, Western Pacific, Kampuchea, Laos; absent from Australia and Papua New Guinea); 
dermatitis (within 1-2 d of cercarial penetration), enteritis (Schistosoma mansoni, Schistosoma japonicum, Schistosoma 
mekongi, Schistosoma intercaiatum, Schistosoma mattheei), Katayama syndrome (4-8 w after primary infection), urinary 
infection (chronic Schistosoma haematobium infection), intestinal polyps, hepatosplenic schistosomiasis (hepatosplenic 
bilharziasis; caused by tissue reaction to trapped eggs; varies from formation of a few hepatic granulomas to occurrence of 
severe hepatosplenic fibrosis, hepatosplenomegaly and portal hypertension), pulmonary schistosomiasis (lung schistosomiasis, 
pulmonary bilharziasis; caused by a reaction of lung tissues to eggs of Schistosoma mansoni and, very rarely, Schistosoma 
haematobium and Schistosoma japonicum), CNS schistosomiasis (Schistosoma mansoni, Schistosoma haematobium, Schistosoma 
japonicum, localisation of granulomata leading to paresis of different types; reported in both acute and chronic stages) 
Agents: Schistosoma mansoni (Africa, Middle East, S America, Caribbean; mature adults in mesenteric vessels; eggs in liver 
or feces), Schistosoma japonicum (Japan, China, Philippines; 600,000 sufferers; 25% of transmission due to animal reservoirs; 
mature adults in intestine or mesentery; eggs in spleen or liver), Schistosoma haematobium (Africa, Middle East; mature 
adults in bladder or mesentery; eggs in urine or liver), Schistosoma mekongi (only in Mekong River basin), Schistosoma 
intercaiatum (worms and eggs in mesenteric portal system, vesical system not involved; mainly colonic and rectal 
involvement), Schistosoma mattheei 

Diagnosis: bentonite flocculation test (1:5 titre diagnostic if cholesterol lecithin flocculation test also positive), complement 
fixation test, counterimmunoelectrophoresis, fluorescent antibody staining of serum, indirect hemagglutination titre, FAST- 
ELISA; light microscopy of stool (acid-ether concentrate), urine (concentrate; midday for Schistosoma haematobium), aspirate, 
puncture, unstained biopsy of rectum; anemia (erythrocyte count and hemoglobin decreased) 

Schistosoma japonicum and Schistosoma mekongi: urticarial rash and fever followed by dysentery, 
bloody and mucoid stools, epigastric pain, acute hepatitis, high eosinophilia, weight loss and hyperemia; may be liver 
cirrhosis, splenomegaly and ascites in late stage 

Schistosoma mansoni: pruritic papular rash followed by dysentery, bloody and mucoid stools, abdominal pain, 
nausea, vomiting, eosinophilia, hepatosplenomegaly or liver cirrhosis 

Schistosoma intercaiatum: similar to, but milder than, Schistosoma mansoni 

Schistosoma haematobium: microscopic and macroscopic hematuria, painful and frequent micturition; chronic 
sequelae hydronephrosis, renal failure and squamous cell carcinoma of bladder 
Treatment: 

Schistosoma haematobium, Schistosoma mansoni: praziquantel 20 mg/kg orally for 2 doses after food 
4 h apart 

Schistosoma japonicum, Schistosoma mekongi: praziquantel 20 mg/kg orally for 3 doses after food at 
4 hourly intervals 

Prevention and Control: mass chemotherapy; control of snails Bulanus (Schistosoma haematobium), Biomphalaria and 
Oncomeiicera (Schistosoma mansoni, Schistosoma japonicum); controlled sanitation 
Katayama Syndrome (Acute Schistosomiasis 

Agents: Schistosoma mansoni (primary and secondary), Schistosoma japonicum (primary and secondary), Schistosoma 
haematobium (primary; rare) 

Diagnosis: fever, cough, hepatosplenomegaly, myalgias, urticaria, eosinophilia; pulmonary infiltration visible radiologically; 
at least 3Xlg stool samples concentrated by modified Ritchie technique and examined for ova; ova in urine; 
immunofluorescent antibody tests on serum 
Treatment: praziquantel as above + dexamethasone 

Cysticercosis (Cysticercal Disease, Cysticerciasis, Cysticercous Disease, Taenia solium Cysticersosis): 
eggs in food contaminated by infected person or autoinfection; areas of low socioeconomic development in Central and S 
Africa, Mexico (causes 1.9% of all human deaths), Central and S America, Southern Asia; subcutaneous tissues, skeletal 
muscles, brain, eye, heart, lungs, liver; presentation time may be delayed for up to 30 y, with mean presentation time being 
5y 

Agent: Taenia solium, one case due to Taenia crassiceps reported 

Diagnosis: subcutaneous or muscular disease often asymptomatic but subcutaneous nodules or intramuscular swellings 
occur; if larvae become lodged in vital organs, differing manifestations, according to site of disease and number of larvae, 
may result; cerebral cysticercosis frequently causes epileptiform fits; death may ensue; computed tomography of brain; X-ray 
of large muscle; hemagglutination of serum (> 1:128) and CSF (> 1:8), ELISA, enzyme-linked immunoelectrotransfer blot assay 

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Multi-system, Generalised and Systemic Infections 

(sensitivity 98%, specificity 100%), indirect fluorescent antibody titre; histology of biopsied nodules; 53% of patients have 
intestinal taeniasis 

Posterior Fossa Syndrome: lymphocytosis, elevated protein level and diminished glucose level of CSF 

Meningoencephalitis: eosinophilia of CSF 
Treatment: praziquantel 50 mg/kg orally daily in 3 divided doses for 15 d + dexamethasone 12-16 mg orally daily or 
prednisone 30-40 mg orally daily in neurocysticercosis; albendazole; surgery for ventricular involvement and in cases of 
raised intracranial pressure 

Trichinellosis (Trichina Worm Infection, Trichinelliasis, Trichiniasis, Trichurosis, Trichinous 
Myositis, Trichinous Polymyositis) 
Agents: Trkhinella spiralis 

Diagnosis: often asymptomatic; f