5-57
Assessment:
Differential Diagnosis
Lymphadenitis - cat scratch disease (kitten exposure, pain), lymphoma, tuberculous lymphadenitis (also called
scrofula; positive PPD or TB exposure)
Skin and soft tissue infection - nocardiosis (no water exposure), sporotrichosis (exposure to soil, organic
gardening materials), leishmaniasis (endemic area, sandfly exposure)
Pulmonary disease - see ID: TB; see Respiratory: Pneumonia, COPD
Plan:
Treatment
Primary: Lymphadenitis (due to MAC or M. scrofulaceum) - excisional surgery without antimicrobial drugs.
Cutaneous lesions (due to M. marinum) - doxycycline 100 mg bid or trimethoprim/sulfamethoxazole,
160/800 mg bid for 3 months. Excisional therapy is also an option.
Other Syndromes: Therapy based on site of disease, organism and susceptibility testing results.
Alternative: A multitude of regimens exist for most of these infections. Consult an expert for guidance.
Patient Education
General: NTM infections are not contagious to others.
Activity: As tolerated.
Diet: No limitations.
Medications: Based on selected regimen.
Prevention and Hygiene: Avoid swimming with unhealed wounds.
No Improvement/Deterioration: Reevaluation and repeat culture and susceptibility testing.
Follow-up Actions
Wound Care: Local care (clean, dry, protect, topical antibiotics) to prevent secondary bacterial infection.
Return evaluation: Routine follow-up required for pulmonary infections.
Consultation Criteria: Management of chronic pulmonary infection usually requires specialty consultation.
Although the acid-fast bacilli can be detected in lesional or sputum smears or biopsy material, culture is
required to confirm diagnosis.
NOTES: Disseminated M. avium complex (DMAC) is another NTM disease that is virtually restricted to
persons with late stage AIDS. This infection presents as a chronic febrile wasting syndrome with associated
anemia and MAC bacteremia.
ID: Introduction to Fungal Infections (Mycoses)
LTC Duane Hospenthal, MC, USAThe fungal infections discussed in this subchapter, with the exception of the superficial presentations of
candidiasis, are diseases that can rarely be diagnosed or treated in the field. Cryptococcosis is found
worldwide but symptoms are most common in the immunosuppressed and are not acutely life-threatening.
Blastomycosis, coccidioidomycosis, histoplasmosis, and paracoccidioidomycosis are endemic fungal infec-
tions that should be included in a differential diagnosis so individuals with potential infections may be removed
or referred to higher echelons of care.
ID: Candidiasis (Thrush)
LTC Duane Hospenthal, MC, USA & MAJ Daniel Schissel, MC, USAIntroduction: Candida albicans is a yeast normally found in the mouth, intestines, and vagina. Overgrowth of
this yeast can cause skin or mucosal diseases including oropharyngeal candidiasis (thrush), intertrigo (disease