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==Cryptococcus neoformans==
 
  
Keywords (immunodeficiency): HIV, antiretroviral therapy, oropharyngeal thrush, hepatosplenomegaly, central umbilication, central necrosis, hemorrhagic crust.
 
 
*Cryptococcus neoformans is an encapsulated yeast
 
*Occurs in patients with advanced HIV (CD4<100/mm3)
 
*The most common manifestation is meningoencephalitis
 
*Pulmonary and/or disseminated disease may occur
 
*Cutaneous cryptococcosis considered as a marker of disseminated disease
 
*Rapid onset (2 weeks) of multiple widespread papular lesions with central umbilication
 
*Diagnostic clue is the presence of a small area of central hemorrhage or necrosis
 
*Resembles molluscum contagiosum
 
*Most common areas affected are head and neck
 
*Disseminated infections can affect liver, lymph nodes, peritoneum, adrenal gland, and eyes
 
*Diagnosis
 
**Biopsy of the lesion
 
**Histopathological examination after staining (periodic acid-Schiff, Gomori methenamine silver nitrate)
 
**Hyperplasia of the overlying dermis with underlying granulomas surrounding encapsulated yeasts
 
**Fungal blood culture is often positive in severe disseminated cryptococcal disease but a biopsy is more sensitive and specific than blood culture (because untreated HIV patients have multiple ongoing opportunistic infections)
 
**Serum antigen testing can be useful for the diagnosis
 
**The most common wrong answer is skin scrapings with a microscopic evaluation which is used for the diagnosis of fungal infections as tinea or candidiasis.
 
 
 
*Treatment:
 
**>/= 2 weeks of IV amphotericin B plus oral flucytosine
 
**Followed by a year of oral fluconazole (higher dose for 8 weeks, then maintenance)
 
 
 
 
DD:
 
 
*Kaposi Sarcoma:
 
**Primarily presents in homosexual men(men with HIV who are sexually active with other men)
 
**Red or purple papules with no necrosis
 
 
*Disseminated Mycobacterium avium complex:
 
**Common opportunistic infection
 
**Affects patients with advanced AIDS
 
**Presents as fever, night sweats, abdominal pain, diarrhea, weight loss
 
**Cutaneous lesions are uncommon and are usually nodular and ulcerating
 
 
*Pyoderma gangrenosum:
 
**Rare neutrophilic dermatitis
 
**Associated with inflammatory bowel disease and inflammatory arthritides
 
**Presents as a tender papule that degrades into a bluish, violaceous ulcer
 
 
*Basal cell carcinoma
 
**Single, pink, flesh-colored papules
 
**Arise slowly
 
 
 
 
==Tuberculosis==
 
*Active pulmonary tuberculosis
 
**Due to reactivation of the latent disease
 
**Epidemiologic risk factors
 
***Substance abuse
 
***Homelessness
 
***Birth in a TB-endemic region
 
**Clinical manifestations
 
***Fever, cough >2 weeks, weight loss
 
 
 
Diagnosis:
 
*Chest x-ray
 
**signs of active disease (upper lobe cavitation 970-80%), hilar lymphadenopathy, or pleural effusion.
 
*Definitive diagnosis of suspicious x-ray finding by isolation of Mycobacterium tuberculosis in body fluid or tissues (lung, pleura)
 
*Sputum sampling (acid-fast bacilli smear and culture)
 
**Least invasive and costly route for microbial confirmation
 
**Three single sputum samples (spontaneous or induced) are submitted in 8- to 24-hour intervals with at least 1 early-morning sample
 
**Sputum should be sent for acid-fast bacillus smear, mycobacterial culture, and nucleic acid amplification testing.
 
*Tuberculin skin test and interferon-gamma release assay
 
**both can only support the diagnosis and if positive suggest exposure
 
**Can't distinguish between active and latent disease
 
*Bronchoscopy with bronchoalveolar lavage
 
**More invasive and expensive than sputum sampling
 
**Reserved for patients who are
 
***Unable to produce adequate expectorated or induced sputum
 
***Have negative sputum studies with a high suspicion for active TB
 
***Have possible alternate diagnosis that requires bronchoscopy for evaluation
 
*Transthoracic needle aspiration
 
**Invasive and associated with greater risk of complications
 
**Typically reserved for patients who remain undiagnosed after less invasive tests (sputum, bronchoscopy with bronchoalveolar lavage)
 
 
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF| Diagnosis}}
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF|Sensitivity}}
 
! style="background: #4479BA; padding: 5px 5px;" colspan=1 | {{fontcolor|#FFFFFF|Specificity}}
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF|BCG vaccine}}
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF|Cost effective}}
 
! style="background: #4479BA; padding: 5px 5px;" colspan=1 | {{fontcolor|#FFFFFF|Latent vs active TB}}
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF| TB vs non-TB mycobacteria}}
 
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 | {{fontcolor|#FFFFFF| Result}}
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tuberculin skin test|Tuberculin skin test]]'''
 
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| style="padding: 5px 5px; background: #F5F5F5;" |
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Interferon gamma release essay|Interferon gamma release essay]]'''
 
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| style="padding: 5px 5px; background: #F5F5F5;" |
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Smear microscopy|Smear microscopy]]'''
 
| style="padding: 5px 5px; background: #F5F5F5;" |
 
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| style="padding: 5px 5px; background: #F5F5F5;" |
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Sputum culture|Sputum culture]]'''
 
| style="padding: 5px 5px; background: #F5F5F5;" |
 
| style="padding: 5px 5px; background: #F5F5F5;" |
 
| style="padding: 5px 5px; background: #F5F5F5;" |
 
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| style="padding: 5px 5px; background: #F5F5F5;" |
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Nuclic acid amplification|Nuclic acid amplification]]'''
 
| style="padding: 5px 5px; background: #F5F5F5;" |
 
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Latest revision as of 16:27, 15 October 2019