INFECTIOUS DISEASES 2

Dr Amro Adas
Internal Medicine Specialist
INFECTIVE ENDOCARDITIS
 Infection of heart valves causing a vegetation.

 Predisposing factors :

- Rheumatic heart disease- mainly in developing countries

- Intravenous drug use
- Degenerative valvular disease
- Prosthetic valve- mainly at the first 6-12 months after replacement
- Intra-cardiac devices
- Old age (higher incidence)
 Clinical Features:
-Fever, chills and sweats, weight

loss, myalgia and arthralgia.

-Heart murmur
-Arterial emboli
-Splenomegaly
-Clubbing
-Petechiae
-Neurologic manifestations, and back pain.
-peripheral manifestations (in 2-15% of

cases)- Osler’s nodes, Janeway

lesions, Roth’s spots, and subungual
hemorrhages.
 Infective endocarditis may be caused by many pathogens, usually bacterial:

- Native valve endocarditis which is community-acquired is most commonly caused

by Streptococci species, and second most common cause is Staphylococcus aureus.
- Native valve endocarditis which is health-care acquired is most commonly caused
by Staphylococcus aureus, followed by Enterococci (mainly E. faecalis), Streptococci and CoNS.
- Prosthetic valve endocarditis in the first year post surgery: Staph Epidermis.
and endocarditis in injection drug users: Staph auerues. .
 Tricuspid Valve Endocarditis:
-Associated with IV drug abuse.
-May cause septic emboli to lungs
-High rates of MRSA (resistant Staph aureus).

-Complications:
-Stroke, Cardiac Abscess, splenic infarction, spinal abscess, Glomerulonephritis.

-Streptococcus Bovis bacteremia (Streptococcus Gallolyticus) endocarditis:

should screen for colon cancer.
ENDOCARDITIS PROPHYLAXIS
Indications:
 A. Prosthetic heart valves or material
 B. Left ventricular assist devices or implantable heart
 C. Prior endocarditis
 D. Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits
 E. Completely repaired congenital heart defects during the 6 months after repair
 F. Repaired congenital heart disease with residual defects adjacent to prosthetic
material
 G. Surgical or transcatheter pulmonary artery valve or conduit placement
 H. Valvulopathy developing after cardiac transplantation
 The procedures that require prophylaxis are:
- Dental treatments with gingival involvement / Periapical tooth treatment /
Mucosa perforation
- Respiratory track surgery
- Invasive procedures in a contaminated urinary system or contaminated skin.

 The recommended prophylactic treatment is amoxicillin 2 grams an hour before

the procedure. In a patient who cannot swallow the treatment, ampicillin 2
grams (IV). For penicillin allergy the alternatives include
Clarithromycin/azithromycin, Cephalexin or Doxycycline.
 SURGERY IN INFECTIVE ENDOCARDITIS
Indications for an emergent surgery (within Indications for urgent surgery (within 48
24 hours): hours):

Cardiogenic shock or pulmonary edema due to Vegetation or blood clots blocking the valve
valvular dysfunction
Unstable prosthetic valve
Acute onset of aortic regurgitation causing
premature mitral valve closure Acute AR or MR with severe heart failure (NYHA 3-
4)
Sinus of Valsalva abscess ruptured into the right
heart Perforated septum

Ineffective antibiotic therapy

Rupture into the pericardial sac
 Indications for elective surgery in Infective Endocarditis:
• Infection persisting beyond 7 days despite appropriate treatment
accompanied by valve dysfunction
• Fungal endocarditis
• Progressive paravalvular prosthetic
regurgitation
LAST EXAM
A 32-year-old female is hospitalized for prolonged febrile illness. On the
physical examination, a systolic murmur is heard over the mitral valve. On the
blood cultures, growth of methicillin-sensitive Staphylococcus aureus (MSSA).
Echocardiography reveals a 5 mm vegetation on the mitral valve. Antibiotic
treatment was started according to sensitivity to the bacterium. After ten days
of treatment, the patient complained of shortness of breath and dizziness.
Which finding would necessitate surgical intervention in this patient?

1. Systolic blood pressure of 100 mmHg.

2. Complete A-V Block on the ECG chart
3. Temperature of above 38°C with a finding of an abscess in the leg.
4. Increase in the level of creatinine.
A 54-year-old woman has a history of mitral prolapse and mild mitral
regurgitation.
She does not use any regular medications and has no additional medical
problems.
She consults you regarding prophylactic antibiotic use prior to tooth
extraction and
dental plaque cleaning. She states that 10 years ago she received antibiotic
prophylaxis
prior to dental therapy.
What would be the most appropriate recommendation for this patient?

1. Yes, you should take 2 gram of Amoxicillin PO, an hour before the dental
treatment
2. Yes, you should take 600 mg of Clindamycin PO, an hour before the dental
treatment
3. No, antibiotic therapy is not recommended prior to dental procedure
4. Yes, you should take Amoxicillin PO if bleeding is expected as a result of the
dental procedure
A 37-year-old woman is referred to the ER following a syncope event. The patient
complains
of tiredness and lack of appetite for the past two weeks. On examination:
temperature 38.2°C,
BP 112/58, regular pulse 49 per minute, poor oral and dental hygiene, an early
diastolic heart
murmur in the LSB and the base of the heart. Lungs are clear, abdomen is soft and
not tender.
ECG demonstrated sinus rhythm with 2:1 2nd Degree A-V Block. Blood count: white
blood cells 13800, hemoglobin 10.8, and platelets 410000 platelets/microliter.
Which of the following diagnoses is the most likely?

1. Acute pericarditis
2. Mitral leaflet perforation
3. Paravalvular abscess
4. Tricuspid valve endocarditis
A 73 year old man with diabetes and hypertension that underwent aortic surgical
valve
replacement 7 years prior, is now presenting with fever. A number of blood
cultures
returned positive for streptococcus, and the patient is started on penicillin. A
number of
days after the treatment is initiated, the patient's creatinine levels are found to be
elevated,
with red cell casts on urinalysis. What is the correct treatment?

1. Continue antibiotic treatment and monitor the patient.

2. Change antibiotic treatment
3. Dialysis
4. Steroids
5. Surgical valve replacement.
A 55-year-old man, generally healthy with no chronic medications, presents to
the ER
due to sudden difficulty moving his left hand. His vital signs are in normal range,
except
for a fever of 39.1. On imaging, a spinal epidural abscess was observed in the
cervical spine.
He was surgically treated and received treatment with empiric antibiotic
coverage.
After two days, blood culture results return positive for staph aureus.
Which of the following tests is the most appropriate next step?

1. Bone scan
2. Echocardiography
3. PET-CT
4. ESR levels
5. CT-Angio
CELLULITIS
 Acute skin infectious (symptoms).
 Common pathogens are staph aureus

and Group A streptococcus,

but may also include exogenous pathogens.
Strep groups B, C, and G.
 Pre-existing damage to the skin such

as an ulcer, fungal infection, a sting or bug bite,

furunculosis, an IV, and others.
 Recurring episodes of cellulitis are associated

with venous insufficiency and lymphedema.

Empirical therapy: oxacillin ,dicloxacillin, nafcillin,

cefazolin, clindamycin.
A 55 year old male presents to the ER with the rash appearing in the
photo below.
He has a history of venous insufficiency and chronic edema in his legs.
No known allergies.
What is the initial therapy of choice?

1. Erythromycin
2. Vancomycin
3. Ceftriaxone
4. Clindamycin
5. Oxacillin
A 30-year-old morbidly obese male with hypertension presents with fever, chills,
and right
calf edema. On examination temperature is 38.4oC, pulse 110/min, blood
pressure 130/80 mmHg, respiratory rate 20/min. There is local warmth,
erythema,
and tenderness of the right calf without fluctuation. He arrives to the ER due to
sore
throat and cervical lymphadenopathy. Pharyngeal smear is negative for
streptococcus.
Laboratory results include WBC 12,000 with 80% neutrophils.
Which of the following is the most appropriate treatment?

1. Vancomycin
2. Cefazolin
3. Imipenem
4. Fidaxomicin
NECROTIZING FASCIITIS
 (streptococcal gangrene), associated with group A

Streptococcus or mixed aerobic–anaerobic bacteria or

may occur as a component of gas gangrene caused by
Clostridium perfringens.

Gas gangrene follows severe penetrating injuries

that result in interruption of the blood supply and introduction
of soil into wounds. Such cases of traumatic gangrene are
usually caused by the clostridial species C. perfringens,
C. septicum, and C. histolyticum.
 Manifestations: fever and low blood pressure, with a CT scan
demonstrating gas in the soft tissue.
• Sepsis with limb pain with no visibly apparent cause, necrotizing
fasciitis should be suspected.

• Treatment:
- The most important treatment includes emergent fasciotomy
(previous question).
- The best drug treatment for those conditions is a combination of
Penicillin and clindamycin
 LAST EXAM
A 35-year-old male with a history of intravenous drug use presents with
swelling and pain in his left hand as of the day of admission, accompanied by a
fever and the chills. On admission: temperature 39.1°C, BP 110/60 mmHg,
pulse 105 bpm. On examination – evidence for skin erythema and edema, with
blue/purple bullae, and subcutaneous crepitus over the left arm. A CT was
performed that demonstrated gas in the deep tissues of the left arm. Urgent
surgical debridement was performed urgently in the OR, and he was
diagnosed with Necrotizing Fasciitis. Cultures were taken that came back
positive for Clostridium Perfringens. Which of the following treatments is the
most recommended for this patient?

1. Ceftazidime plus doxycycline

2. Ciprofloxacin plus doxycycline
3. Penicillin plus clindamycin
4. Piperacillin-tazobactam plus vancomycin
 OSTEOMYELITIS
 Infections of the bone.

 The Probe-to-bone test has a positive predictive value of 90% in patients with a
high pre-test probability.
 In patients with a low probability,

MRI is the imaging test with the highest

sensitivity and specificity.

ESR is high

Antibiotic treatment should depend on

cultures from the bone (taken during surgery).
 Staph Aureus is the most common pathogens, followed by anaerobes and gram-negative
bacilli.

 The treatment should cover gram-positive cocci (clindamycin, ampicillin/sulbactam) and

gram-negative bacilli if the patient has been treated with antibiotics in the last month (e.g.
quinolone).

 Further assessment of whether MRSA and Pseudomonas are suspected and appropriate
coverage should be given in these situations.

 Antibiotic treatment is given for 4-6 weeks which significantly reduces the need for
amputation in about two-thirds of the patients.
LAST EXAM
An 88-year-old male with uncontrolled diabetes. Was hospitalized in an
internal medicine department for fever of unknown origin. A total body CT
revealed inflammatory activity in the lumbar spine, suspected acute
osteomyelitis. Which pathogen is the most likely cause of the infection?

1. Escherichia coli
2. Pseudomonas aeruginosa
3. Brucella
4. Staphylococcus aureus
A 65-year-old male patient has type 2 diabetes and neuropathy. He was
admitted
to the ER due to a fever and an ulcer on his left foot. On examination, a deep
ulcer
is observed with a purulent discharge. In an orthopedic examination using a
metal
tool, the bone could be reached.
Which of the following is most likely correct regarding the infection in this
case?

1. The most likely diagnosis in this case is cellulitis with subcutaneous

involvement
2. The most likely diagnosis in this case is osteomyelitis
3. Candida Albicans will most likely grow in the bone culture
4. A gram-negative bacterium is the most common pathogen that causes
this infection
TUBERCULOSIS (TB)

 Causes by Mycobacterium tuberculosis (TB)

 Risk factors:
-Immigrants
-Alcoholics,
-Healthcare workers

- Prisoners, residents of homeless shelters and

nursing homes
- Immunocompromised
 TB occurs outside of the lungs in 15−20% of cases. The presentation is dependent
on the site involved.

 Lymph node, meningeal, GI, and genitourinary

are the most frequent sites involved in

extrapulmonary TB.

 Lymph node involvement (adenitis) shows

caseating granuloma.
SCREENING FOR LATENT TB

 PPD skin Test

 Gold QuantiFERON Test.

Diagnosis of active pulmonary TB:

 Acid fast test - an examination of sputum under microscopy with Ziehl-Neelsen

staining to assess whether acid fast bacteria, such as TB, are seen. The sensitivity
and specificity are not high, with around 40-60% sensitivity.
 Sputum cultures - growth of TB in culture is the gold standard for the diagnosis,
however it takes around 4-8 weeks for such growth to occur. This method allows
a complete sensitivity test.
 Nucleic Acid Amplification test - also known as Xpert MTB/RI, is a kind of PCR,
which has a a high sensitivity and specificity. It also can give information about
sensitivity to rifampin.
 TREATMENT
 Treatment of active TB consists

of a combination of several drugs.

The regimen that is the first line
treatment is isoniazid, rifampin,
pyrazinamide and ethambutol.
(RIPE)
A 72-year-old female patient, a refugee from Ukraine, arrived a year and a half
ago.
She was hospitalized due to a fever that lasted for two months, night sweats,
and
a productive cough. Which of the following statements is most correct
regarding the
possibility that the patient has tuberculosis?

1. Using sputum smear with staining for acid-fast bacilli has a sensitivity of
about
50% for active tuberculosis
2. Tuberculosis is unlikely in this case since more than a year passed between
leaving the endemic area and the onset of symptoms
3. Tuberculosis diagnosis using molecular methods (Nucleic Acid Amplification
- Xpert MTBF/RIF) has a low sensitivity and specificity (about 40%)
4. In pleural tuberculosis, the sensitivity of a direct pleural fluid smear is about
80%
A 28-year-old woman, usually healthy with no known medical history,
arrived at
the emergency room due to the lesion in the attached picture. She says
that the
lesion appeared gradually in the last few days, and is not particularly
painful. She
rules out any exposure to animals, and adds that recent laboratory tests
are
negative for HIV. She is hospitalized for further investigation and a biopsy
was
taken from the lesion to culture and pathology. The pathology result found
multiple
caseating granulomas. What is the most appropriate treatment?

1. Isoniazid, rifampin, ethambutol and pyrazinamide

2. Surgical drainage and leaving a drain
3. Steroids
4. Doxycycline
5. Clofazimine and bedaquiline
ACQUIRED IMMUNE DEFICIENCY
SYNDROME (AIDS)
 AIDS is caused by the human immunodeficiency virus (HIV).

 The primary mechanism of HIV is infection of a particular subset of T lymphocytes

called CD4 cells, often just referred to as T cells.

 Over time, HIV decreases the number of CD4 cells. As CD4 count drops, he becomes
at increasing risk of developing opportunistic infections and certain malignancies.

 Risk factors: unprotected sexual intercourse, exposure to contaminated blood,

IV drug abusers.
 HIV DIAGNOSIS
 ELISA test: Anti-HIV antibodies are detected in blood 3-12 weeks following
infection. (If negative after 3 months it rules out infection).
 The ELISA test is very sensitive but is not specific, therefore following a positive
result, another test, the Western Blot or PCR, is done in order to identify false
positive results.

 When suspecting HIV infection, An ELISA test is performed :

-If negative and in the absence of suspicion of early infection (within the last 3
months), a diagnosis can be ruled out.
-If positive\inconclusive, the test must be repeated. If it is positive again, a
western blot or PCR is done which enables to confirm\rule out the diagnosis.
TREATMENT
 Antiretroviral therapy should be initiated as soon as possible in all HIV
patients once the diagnosis is made (regardless of CD4 count).

 Antiretroviral therapy slows down disease progression at all stages of HIV

infection and significantly reduces the transmission of the infection.

 Administration of antiretroviral therapy for 6 weeks is recommended for

uninfected individuals following high-risk HIV exposure.
 PNEUMOCYSTIS JIROVECI
 Acute/subacute onset of dyspnea, fever, and nonproductive cough which may
progress to respiratory failure and death.
 Chest x-ray: diffuse bilateral symmetrical,

perihilar, interstitial infiltrates.

High-resolution chest CT shows diffuse ground glass
opacities in all patients with PCP

 TMP-SMX should be added as prophylaxis in

HIV patients with a CD4 count under 250,

 The treatment of choice for PCP is

trimethoprim-sulfamethoxazole
(TMP-SMX),
given either IV or PO.
Other options: IV pentamidine,
clindamycin+primaquine or Atovaquone.

 Indications for glucocorticoids (steroids):

-moderate to severe disease

(room air PO2, <70 mmHg;

or A-agradient, ≥35 mmHg).
A 50-year-old generally healthy female presents to the clinic due to difficulty in
swallowing.
Vitals include a temperature of 36.6 C, a pulse of 71/min, blood pressure of
118/67, and
O2 saturation of 96% at room air. Upon examination, the finding in the attached
photo is
seen while the rest of the exam is normal.
Labs are significant for a total lymphocyte count of 100 cells/mm3.
Which of the following is the best next step?

1. Test for HIV

2. Test for Varicella
3. Chlorhexidine mouthwash
4. Gastroscopy
5. X-Ray
A patient was diagnosed with M. tuberculosis. After his diagnosis, he was also
found to
be HIV positive with CD4 + <25. Treated to TB. After two weeks, HIV treatment
began
with Truvada and Isentress (Raltegravir). After about a month, he came to the
ER due to
fever, cough, low saturation and shortness of breath.
Which of the following can explain his condition?

1. IRIS
2. Resistance to rifampin and isoniazid
3. Infection with Mycobacterium avium
4. Isentress side effect
5. Pyrazinamide side effect
A 26-year-old man is admitted to the hospital with a flu-like illness and
generalized
lymphadenopathy. He had unprotected sexual intercourse two weeks
ago.
Which of the following is the most appropriate diagnostic test in this
patient?

1. PCR HIV
2. ELISA HIV
3. VDRL\RPR
4. Sputum culture for Tuberculosis
5. Antibody testing for Cryptococcus
A 32-year-old male was recently diagnosed with HIV infection. CBC
demonstrated a CD4
level of 198 cell/microliter.
Which of the following is the recommended treatment?

1. Trimethoprim-sulfamethoxazole (resprim)
2. Azithromycin
3. Rifampicin
4. Fluconazole
 CEREBRAL TOXOPLASMOSIS
 Common infection in patients with HIV and low CD4 counts

(below 200).
 Infection through consumption of undercooked meat or

contact with cat feces.

 Manifestations of cerebral toxoplasmosis include fever,

headaches, neurological deficiencies, and seizures.

 Patients with HIV should be screened for toxoplasmosis,

patients with CD4 below 100 and positive IgG antibody to

toxoplasmosis should receive prophylactic treatment.
- A diagnosis is made by MRI, showing multiple lesions, typically
in a ring enhancement appearance.

Treatment is up to 6 weeks of sulfadiazine and pyrimethamine.

A 30-year-old man, a refugee from Africa, has been here for one week.
He was
admitted to the emergency room due to seizures. During his
hospitalization in an
internal medicine department, a diagnosis of AIDS was determined with
a CD4 of 100.
What is the pathogen that most likely causes seizures in his condition?

1. Toxoplasma
2. Cryptococcus
3. Pneumocystis Jirovecii
4. Mycobacterium Tuberculosis
 SYPHILIS
 Caused by Treponema pallidum

subspecies pallidum
- Sexually transmitted
After an incubation period averaging 2–6
weeks, a primary lesion appears
—a chancre—
resolves without treatment.

-The classical manifestations of the

secondary stage include

mucocutaneous or cutaneous
lesions and generalized nontender
lymphadenopathy.
 There are two types of serologic tests for syphilis:
-Nontreponemal antibodies tests for syphilis are the RPR and VDRL tests. They
offer a quantitative measurement and help assess the degree of syphilis activity and
monitor response to therapy. Due to the high rate of false positives in these tests, a
confirmation test is required by
-treponemal antibodies (FTA-ABS and TPPA).

-Treatment:

- Penicillin G is the drug of choice for all stages of syphilis. Penicillin G benzathine
cures>95% of cases of early syphilis.
- Syphilis treatment (in high prevalence- secondary syphilis) might initially cause the
Jarisch herxheimer reaction, characterized by fever, chills, low blood pressure,
tachycardia, ect. This is mostly a mild and transient reaction necessitating
symptomatic treatment only.
A male patient with secondary syphilis is receiving treatment with penicillin
for the first
time.
Following the first dose he develops fever, chills and low blood pressure of
100\60.
What is the best treatment plan for this patient?

1. Lower the penicillin dose

2. Stop penicillin treatment and follow up
3. Continue antibiotic treatment and administer steroids and fluids
4. Broaden antibiotic treatment regimen and obtain blood cultures
5. Continue antibiotic treatment and administer fluids, antipyretics and
monitor
the patient.
 LIVER ABSCESSES
 Causes:
-Hematogenous spread of bacteria
-contiguous sites of infection within the peritoneal

cavity.
-The most common reason for liver abscess formation

is a disease in the biliary tract.

 Clinical Picture: fever, RUQ pain, chills, and vomiting.

 Labs: leukocytosis, normocytic anemia,

hypoalbuminemia, and elevated liver enzymes.

Diagnosis is conducted with CT scan.

 The most common bacteria to form liver abscess is Klebsiella pneumoniae,
and is typically accompanied by bacteremia.

 The cornerstone of treatment for a liver abscess is percutaneous drainage.

Imaging-guided percutaneous drainage is associated with a shorter hospital stay
in comparison with surgical treatment. Prompt empiric antibiotic
treatment should be initiated with the diagnosis, with coverage being similar to
other intraabdominal infections (coverage of anerobic and gram-negative rods).
A 45-year-old man is suffering from fever and right upper quadrant pain for the last two
weeks. He was treated with Ampicillin for a few days without improvement.
In the laboratory - leukocytosis, hypoalbuminemia, and elevated aminotransferase
and bilirubin levels. Blood cultures grew ESBL Klebsiella pneumoniae. An abdominal CT scan
was performed and showed the attached finding.
What is the most appropriate treatment?

1. CT-guided percutaneous drainage + Ceftriaxone + Metronidazole

2. CT-guided percutaneous drainage + Ertapenem
3. Surgical drainage + Ceftriaxone + Metronidazole
4. Surgical drainage + Ertapenem
5. Continuing ampicillin
 BOTULISM
 Caused by clostridium botulinum.
 Most commonly it occurs after eating home-canned food.
 Clinical manifestation includes paralysis of cranial nerves that may cause diplopia,
dysarthria, ptosis, ophthalmoplegia, depressed pupil reflex, dilated pupils,
respiratory depression, dizziness, dry mouth and sore throat, flaccid paralysis of
voluntary muscles and even death.
 Patients are usually fully conscious.

 The cornerstone of botulism treatment is ICU and the botulinum anti toxin should be
given as early as possible empirically once suspected of the disease before
completing a clarification.
A 50-year-old man presents with dry mouth, pupil dilation, dyspnea,
dysarthria.
He says that he ate a vegetarian meal with canned vegetables and
home-made
cheese. What will prevent paralysis later?

1. Steroids
2. Plasmapheresis
3. Tdap vaccination
4. Anti-toxin
5. Aminoglycosides
 BRUCELLA
 Diagnostic clues in the patient’s history may include consumption of unpasteurized milk products
(including soft cheeses), contact with animals, or accidental inoculation with veterinary Brucella
vaccines.

 Symptoms: fever, which may be associated with profuse night sweats, fatigue, myalgia, headache,
weight loss, and chills. The fever of brucellosis is associated with back pain. One-quarter of patients
have hepatosplenomegaly, and 10–20% have significant lymphadenopathy. Furthermore, Neurologic
involvement is common, especially depression and lethargy.

 Brucellosis osteomyelitis more commonly involves the lumbar and low thoracic vertebrae than the
cervical and high thoracic spine.

 In acute infection, IgM antibodies appear early and are followed by IgG and IgA.

 Treatment: streptomycin and tetracyclines (doxycycline).

 LAST EXAM
A 40-year-old male shepherd presents with lower back pain, high fever, and
night sweats for about one month. Upon admission, a temperature of 38.3°C.
On examination, hepatomegaly palpated. Serology and blood cultures confirm
Brucella infection. Echocardiography completed - no abnormal findings.
What is the most appropriate antibiotic treatment at this stage?

1. Streptomycin + Doxycycline
2. Amoxicillin
3. Ceftriaxone + Azithromycin
4. Doxycycline + Azithromycin
MUCORMYCOSIS
 It affects patients with impaired immune function, especially patients with poorly
controlled diabetes.
 Eye and facial pain
 Ophthalmoplegia, proptosis and chemosis.
-Hematogenous spread or direct dissemination result in
-cavernous sinus thrombosis
-A black, necrotic tissue becomes evident.
 Diagnosis is made by biopsy, (nonseptate hyphae).
 Imaging studies (e.g. CT)
 Treatment: intravenous Amphotericin B +

surgical debridement and tight

glycemic control in diabetics.
A 41 year old female arrives at the ER due to sight loss of the left eye. She reports
pain above
the sinuses and rhinorrhea for the past two weeks. She has type 1 diabetes for 20
years
which is not well-controlled. On examination – fever 37.2, blood pressure 130/70
mmHg,
pulse regular 110 beats/min. Left eye proptosis and unresponsive left pupil. On
neurological
examination – palsy of III, IV, V, VI cranial nerves. Head CT demonstrates left
maxillary sinus
mass that protrudes to the left frontal lobe with surrounding edema.
Which of the following is the most likely diagnosis?

1. Anthrax
2. Aspergillosis
3. Pseudomonas
4. Mucormycosis
5. Diphtheria
 SERUM SICKNESS
- A reaction that occurs when the body's immune system reacts to
proteins in certain medications or antisera, often from animal sources.

- Symptoms typically appear 5-10 days after exposure and include fever,
rash, joint pain, and swollen lymph nodes.
- Causes:
Serum sickness can be triggered by - medications containing animal-
derived proteins, such as antivenoms, antitoxins, or medications used to
treat immune conditions. It can also be caused by other injected proteins
like antithymocyte globulin and rituximab.

- Complications:
While typically mild and self-resolving, in rare cases, complications can
include vasculitis, neuropathy, acute kidney injury, or glomerulonephritis.
 LAST EXAM
A 54-year-old male is hospitalized due to fever, a generalized rash, and joint pain.
He reports being bitten by a snake a week ago and was treated with antivenom at
that time. He was discharged home the following day. Currently stable, with a
temperature of 38.6°C. Upon physical examination, there is generalized
lymphadenopathy, a rash, and diffuse joint tenderness.
What is the most likely diagnosis for this patient?

1. Vasculitis
2. Serum Sickness
3. Systemic Lupus Erythematosus
4. Catastrophic APLA Syndrome