Infectious Diseases in Critical Care Medicine

System PE ID findings Noninfectious mimics Diagnostic features

Right parasternal
or suprasternal
pulsation

1. Mycotic or luetic
   ascending aortic
   aneurysm

l Noninfectious ascending

aortic aneurysm

l Tortuous carotid artery

l Dissecting aneurysm of the

ascending aorta

l Right-sided aortic arch

Fever, positive blood cultures

in mycotic aneurysm. RPR in

luetic aneurysm.

Echocardiography in other

diagnoses.

Pericardial friction
rub

1. Acute viral or
   bacterial
   pericarditis

l Collagen vascular diseases

(esp. SLE)

l Postpericardiotomy/MI

syndrome

l Uremia

l Pericardial metastases

Clinical context for post-

pericardiotomy syndrome.

Serologic testing, BUN/

creatinine,

echocardiography.

Apical pan-systolic
murmur

1. Mitral regurgitation
   in acute rheumatic
   fever


2. Mitral regurgitation
   in bacterial
   endocarditis

l Mitral regurgitation due to

other causes—mitral valve

prolapse, papillary muscle

dysfunction/rupture,

endocarditis, severe

LV dilation.

Jones criteria in ARF.

Echocardiography in other

diagnoses.

Apical diastolic
rumbling murmur

1. Relative mitral
   stenosis in acute
   rheumatic fever
   (Carey Coombs
   murmur)

l Mitral stenosis—late effect

of rheumatic fever or

degenerative valvular disease

l Austin Flint murmur

Jones criteria in ARF.

Echocardiography in other

diagnoses.

Basilar diastolic
blowing murmur
(LSB)

1. Aortic regurgitation
   in endocarditis

l Aortic regurgitation due to

hypertension, rheumatic heart

disease, aortoannular ectasia,

aortic dissection

l Pulmonic insufficiency

Blood cultures and IE stigmata

for IE. Echocardiography for

other diagnoses.

Pan-systolic
murmur LLSB

1. Tricuspid
   regurgitation in
   endocarditis


2. Tricuspid
   regurgitation in
   rheumatic fever

l Tricuspid regurgitation in

Ebstein anomaly, prolapse,

carcinoid, papillary muscle

dysfunction, connective

tissue disorders (Marfan),

RA, radiation injury

Blood cultures and IE stigmata

for IE. Jones criteria for ARF.

Echocardiography for other

diagnoses.

Jaundice 1. Viral hepatitides
(A, B, E, EBV,
CMV)

2. Ascending
   cholangitis


3. Sepsis-associated
   cholestasis


4. Leptospirosis


5. Malaria


6. Hemorrhagic
   fevers


7. Relapsing fever

l Alcoholic liver disease

l Biliary tract obstruction

(stone, tumor, stricture)

l Drug induced

l Hemolytic anemia

l Cancer (primary or metastatic

to liver)

l Hepatic vein thrombosis

l Ischemic hepatitis

Clinical context. Serologic

testing. Culture. Peripheral

smear (hemolytic anemia,

malaria). US for CBD

obstruction, tumors/hepatic

vein thrombosis.

Doughy abdomen 1. Tubercular
peritonitis

l Peritoneal metastases

l Recent significant weight loss

l Peritoneal mesothelioma

Imaging (CT, US). Peritoneal/

ascites culture or biopsy.

Right lower
quadrant
tenderness

1. Acute salpingitis
   with a tuboovarian
   abscess


2. Bacterial ileocecitis
   (Yersinia
   enterocolitica,
   Campylobacter
   jejuni,Salmonella
   enteritidis)

l Acute appendicitis

l Cecitis/typhlitis

l Regional enteritis

l Diverticulitis

l Epiploic appendagitis

l Impaction of a stone in the right

ureter

l Meckel’s diverticulitis

l Ovarian cyst

Stool culture, specific serology

in enteric infections. CT

scanning/US for

noninfectious etiologies.

58 Mishriki