Which hepatitis vaccine is generally administered to travelers? Those who are exposed to hepatitis _ will likely receive what?
HAV, passive immunization can be given to people exposed to the virus
Someone with acute hepatitis is is likely to present with which clinical features:
2. Dark-colored urine
3. RUQ pain
6. HSM may be present
How is rabies diagnosed?
1. Virus/viral antigen can be indentified in infected tissue and can be isolated to saliva as well
2. Four-fold increase in serum AB titers
3. Indentification of Negri bodies histologically
4. PCR detection of virus RNA
If a patients presents with inflammation, erythema, warmth, pain and swelling at an atraumatic site on skin - your clinical suspicion should lead to to dx?
Cellulitis secondary to a bacterial infection (GAS, S. Aureus)
Two primary clinical features associated with CRYPTOCOCCUS NEOFORMANS
1. CNS disease --> BIGTIME in patients with HIV
2. Isolated pulmonary infection
Clinical features of infectious mononucleosis:
1. LAD that is found in > 90% patients. Tonsillar or cervial (especially posterior cervical) lymph nodes that are enlarges, painful and tender
2. Pharyngeal erythema and/or exudate
4. Maculopapular rash (15% of patients but HIGHER if AMPICILLIN is administered)
5. Hepatomegaly (10%)
6. Palatal petechiae and eyelid (periorbital edema) may occur in a minority of cases
Complications that are commonly associated with gonorrheal infections?
3. Ectopic pregnancy
4. Fitz-Hugh-Curtis Syndrome (peri-hepatitis) with RUQ pain and elevated LFTs
5. Epididymitis, Prostatitis
6. Disseminated gonococcal infection
Which viral infection that can replicate in the dermis and epidermis, travel to the DRG via sensory nerves and reside as a latent infection, is associated with Bell's Palsy?
Treatment of ACUTE UNCOMPLICATED CYSTITIS
-empiric treatment with oral BACTRUM (TMP/SMX) for 3 days
-use of a CIPROFLOXACIN (FLUOROQUINOLONE) for 3 days is appropriate if resistance rate is high in community to BACTRUM
-amoxacillin not used as much due to high resistance
Hepatitis A serology: Acute versus chronic
Hepatitis A antibody (anti-HAV)
1. Anti-HAV is detectable during acute and chronic phase; cannot distinguish
2. IgM-specific anti-HAV denotes ACUTE
Therefore anti-HAV + means acute and/or chronic HAV infection
Therefore IgM anti-HAV + means acute and active HAV
Treatment of RMSF
Doxycycline - adminstered 7 days; given IV if the patient is vomiting
Chloramphenicol - CNS manifestations or pregnant patients
How does an HIV+ patient differ from a patient with full-blown AIDS?
AIDS criteria: marked immune suppression leads to disseminated opportunistic infections and malignancies;
1. CD4 count < 200
2. Pulmonary, GI, neuro, cutaneous, and systemic symptoms are common
What does the Hepatitis B core antibody indicate? (anti-HBc)
Assay of IgM and IgG combined
1. During "window' period of HBV infection, this is the only marker present
2. Doesnt distinguish between acute and chronic NOR immunity
Prophylaxis Rx for TB in patients with dx HIV
Screen annually with PPD test.
Prescribe INH and pyridoxine if patient has postitive PPD
Female risk factors versus male risk factors for UTI
Females: shorter urethra and gainal colonization of bacteria, sexual intercourse secondary to the use of diaphragms and spermicides increases rsk further and alters vaginal colonization, pregnancy
Males: uncircumcised males due to bacterial colonization of foreskin, anal intercourse, vaginal intercourse with a femal colonized with uropathogens, BPH, incomplete voiding, indwelling catheders
What indicates a "positive" PPD test?
1. >/= 15 mm if healthy individual
2. 10 mm --> High risk population (high prevalence, Homeless, prisonmates, HCW)
3. 5 mm --> HIV patients or those in close contact with active TB or evidence of primary TB on CXR
What are the most common risk factors for brain abscesses?
AIDS, immunosuppression, bone marrow transplant, bacterial meningitis
Which three areas of the united states are most commonly affected by lyme disease?
NE seaboard; Midwest; West coast (N. Cali)
How is necrotizing fasciitis treated?
Rapid surgical exploration and excision of devitalized tissue is necessary with BROAD SPEC AB parenterally.
A patient presents with lethargy, malaise for a period of 3 days to 2 weeks with other symptoms including: fever, sweats, headaches, arthralgias, diarrhea, sore throat, LAD, and a truncal maculopapular rash. The patient states that the majority of his symptoms have lessened to a minimum, and wants to know if his possible blood transfusion after he was diagnosed with SCA may have been what spawned it?
This is a typical presentation of someone with PRIMARY INFECTION of HIV. Currently, the patient had 3days-2 weeks of flu-like/mono-like symptoms. HIV has an incubation period of 2-4 weeks after its initial infection before its viral load is high enough to have an effect.
It is important BUT difficult to catch patients with primary HIV because of the benefits of early antiretrovirl therapy.
Treatment of chronic HBV:
treat with interferon (IFNalpha)
treat with lamivudine (nucleoside analog)
Risk factors for diffuse inflammation of the brain parenchyma (encephalitis) include:
1. AIDS: those with AIDS are at risk for toxo when count < 400
2. immunosuppression (chemo)
3. Travel in underdeveloped countries
4. Exposure to mosquitos (vectors) from endemic areas
5. Exposure to wild animals (BATS) in an endemic area for rabies
CLINICAL features of acute bacterial arthritis (SEPTIC arthritis)
1. Swollen, warm, painful
2. ROM active and passive is limited
3. Constitutional symptoms such as fever, chills, and malaise are common
Diagnosis of infectious mononucleosis is made by:
-Monospot test for detection of heterophile AB
-Heterophile antibodies are positive within 4 weeks of infection with EBV mononucleosis and are undetectable by 6 months. Thus a positive monospot test indicates acute infection with EBV mononucleosis.
-Heterophile antibodies are negative and do not form in CMV mononucleosis
EBV specific antibody testing is performed in cases inw hich diagnosis is not straightforward and dont by ELISA.
2. Peripheral blood smear: revelas lymphoctoc leukocytosis with large atypical lympocytes
3. Throat culture - perform if pharyngitis is present to rule out a secondary infection with B-hemolytic streptococciwith B-hemolytic stretococci
Primary syphilis includes
Painless chancre (indurated, hard with clean base)
-crater like lesion that appears on the genitalia 3-4 weeks post exposure
-heals in 14 weeks
Two recommendations for prevention of pneumonia
1. Influenza vaccination given annually to people at increased risk for complications and health care workers
2. Pneumococcal vaccine - for patients > 65YO and for younger people with SCA, heart disease, pulmonary disease (COPD), DM, alcoholics cirrhosis, asplenic individuals.
Treatment of acute prostatitis
1. If septic: hosptalize patient and start IV AB
2. If mild: treat on OUTPT basis with AB: BACTRUM, CIPRO, or DOXY for 4-6 wks
How is lymphadenitis treated for?
penicillin G, antistaph penicillin (naf or oxa), cephalosporin, warm compresses
Neutropenia is defined by absolute neutrophil count (ANC) < 1500/mm2. What does ANC represent?
Combination of bands and mature neutrophils
Women v. Men who are symptomatic for Chlamydia?
Females: purulent urethral discharge, intermenstral or post coital bleeding, dysuria
Males: dysuria, purulent uretral dischange, scrotal pain and swelling, fever
When should a CT scan of the head be ordered in patients with suspected acute bacterial meningitis?
Recommended before LP is there are focal neurological signs OR if there is evidence of a space-occurpying lesion with elevations in ICP (noted papilledema, ETC)
Major risk factors for developing OSTEOMYELITIS
1. Open fractures
3. Use of illicit drugs (IV)
How is disseminated/systemic candida treated?
ORAL AMP B
New agents include: voriconazole as CASPOFUNGIN
Most likely bacteria to result from aspirations pneumonia?
Oral anaerobes: Prevotella, Peptostreptococcus, Dusobacterium, Bacteroides
Others S. aureus, S pneumo, aerobic gram negative bacilli
In nursing home residents, the most common nosocomial pathogen with predilectation to the upper lobes?
DIAGNOSIS of pyelonephritis:
1. UA: pyuria, bacteriuria, WBC casts
2. Urine culture: get from all patients with pyelo
3. Blood culture: get from all ill appearing pts and hospitalized patients
4. CBC: left shift with leukocytosis
5. RFT: should be preserved; impairment can be reversible
6. Imaging studies: if Rx fails or if pt with complicated pyelo. Get renal US, then CT, IVP, or retrograde ureterogram.
What is Erysipelas? How does this differ from an uncomplicated cellulitis?
Erysipelas is a cellulitis that is usually confined to the dermis and lymphatics. This is caused by GAS with a presentation of well-demarcated, RED, PAINFUL lesion on the lower extremities and the face.
Unlike that of cellulitis, erysipelas often has predisposing factors of lympatic obstruction (pst radical mastectomy) local trauma or ascess, fungal infections, DM or alcoholism.
CHRONIC HEPATITIS is more likely to occur in acute hepatitis 1-10% of patients with Hepatitis __ virus versus patients diagnosed with Hepatitis __ virus whose chance is between 80-90%.
HBV has 10% chance of becoming chronic
HCV has 80-90% chance of becoming chronic
Toxic-shock syndrome (TSS) is most commonly associated with?
Menstruating women and tampon use but can occur in both male and females secndary to surgical wounds, burnes, infected insect bites. This is due to an enterotoxin by S. Aureus or less frquently an exotoxin of GAS.
What are the clinical findings of patients with C. Trachomatis L1-L3 (lymphogranuloma venereum)?
PAINLESS ulcer at site of inoculation that can often go unnoticed. A few weeks post infection, it will have spread to inguinal lymph node and developed unilateral tenderness and can result in more severe issues that can resemble that of ulcerative colitis and/or orther IBDs. For example, PROCTOCOLITIS may develop with perianal fissures and rectal stricture resulting in the obstruction of lymphatics and elephantitis of the genitals.
Pathophysiology of HIV:
a. Most common virus assciated iwth HIV is the HIV type 1 human retrovirus
b. Attaches to surface of CD4+ T cells (target of HIV-1)-enters cell by binding to GP120 and entering GP40 the cell-uncoating-transcribing RNA into DNA using host machinery and OWN reverse transcriptase.
c. Particles are produced each day by activated CD4 cells. When the virus enters into the lytic phast of infection, the CD4+ cells are destroyed and its depletion of the bodys arsenal of CD4 cells weakens the cellular immunity of the host.
How should one approach a patient with recurrent UTI infections?
If relapse occurs within 2 weeks of cessation of treatment, continue treatment fr 2 more weeks then get a urine culture
Treatment for uncomplicated cystitis - if patient has more than two UTIs per year:
1. Give chemoprophylaxis (one dose of TMP/SMX after intercourse or at the first signs of symptoms)
2. Alternative lowdose prophylactic AB for 6 mo (TMP/SMX)
Empiric treatment for ACUTE BACTERIAL MENINGITIS for infants
Etiology: GBS, E. Coli, Klebsilla spp., Listeria monocytogenes
Empiric Treatment: Cefotaxime + amp + VANC
DO aminoglycoside < 4 weeks
Transmission of Hepatitis A, B, C, D, E?
HEP A: Fecal/oral
HEP B: Sexually or Parenterally
HEP C: Associated with cryoglobulinemia and IV drug abuse
HEP D: requires the outer envelope of HEP BsAg for replication or as a superinfection in a chronic HBV carrier
HEP E: Fecal/oral route and are more prevalent in developing countries
Atypical pneumonia syndrome is associated with which pathogens?
CAP can be either typical (S. Pneumo) or atypical in presentation. Those which are commonly associated with atypical include: Mycoplasma pneumonia, Chlyamydia pneumonia, Legionella, Coxiella Burnetti (Q Fever), and chlyamydia psittachi. Viruses are included in the atypical presentation
Most common areas affected by mucocutaneous growth of candida?
1. Oropharynx - ("thrush") with thick, white plaques that ahere to the oral mcosa, painless, unexplained thrush shuld rasie suspicion of HIV infection
2. Vagina-"yeast" infection
3. Cutaneous candidiasis-erythematous, eroded patches of satellite lesions
4. GI tract (esophagus) -esp in HIV; odynophagia can result
Second stage of syphilis
Develops 4-8 weeks post that of the primary infection that resples spontaneously. Maculopapular rash forms in this stage
What tests diagnose a lung abscess and how is this treated once tests confirm?
1. Order CXR: receals thick walled cavitation with air fluid levels
2. Order CT scan: differentiated between abscess and empyema
3. Sputum stain and culture low sensitivity so get bronchoscopy or transtracheal aspiration to avoid expetoration thats contaminated with oral flora.
Rx: Drainage if necessary should be performed first and foremost.
1. AB regimens:
-cover gram positive cocci = amp or amoxi/clav acid(zosyn), vanc for s. aureus
-cover anaerobes = clindamycin/metronidazole
-cover gram negatives = fluoroquinolones or ceftazidime
2. Duration: until cavity is gone or CXR improved significantly - can take months.
HIV + patients with contrast enhanced mass lesions in the BG and subcortical white matter (greater than three)?
Toxoplasmosis gondii (cause of noninfectious encephalopathy)
Complications for pneumonia
# 1 = pleural effusion ("parapneumonic effusion"
1. Seen in > 50% patients with CAP on routine CXR
2. Most uncomplicated courses and resolve with treatment of the pneumoia with AB however if it is complicated with an empyema - thoracentensis should be performed if LL decubitius film shows >1cm fluid. Get grain stain, culture, pH and cell count. Then determine amt of glucose, protein and LDH to differentiate between an exudative versus nonexudative
If patient is very ill, elderly, pregnany, or unable to tolerate oral medications for that of a pyelonephritis, how should patients be treated?
1. Hospitaliation with IV fluids
2. Administer AB first parenterally (broad spec) AMP-GENT or CIPRO
3. If blood cultures (-) --> not urosepsis --> Rx IV AB for 24 hours until patient is afebrile. Then give oral AB to complete 14-21 day regimen
4. If blood cultures (+) --> UROSEPSIS --> Rx: IV AB for 2-3 weeks.
Two forms of botulism
1. From ingestion of preformed toxin - adminster antitoxin if known
2. Wound contamination - clean and administer penicillin
Acute meningitis versus Chronic meningitis
Acute: onset within hours to days and are BACTERIAL (OFTEN)
Chronic: onset within weeks to months (commonly due to mycobacteria, fungi, parasites, Lyme disease)
What is more sensitive than the HCV antibody?
VIRAL LOAD: HCV RNA measured by PCR. Detectable 1-2 weeks after infection
Rabies is contracted from a bite or scratch of an infected animal and can result in a deadly viral _______ if not treated early.
Neurosyphilis is characterised by: ________, ___________, ________
Dementia, personality change, tabes dorsalis
Complications in males secondary to Chlamydia v. females?
Males: prostatitis, epididimitis
Females: Fits-Hugh-Curtis Syndrome (inflammation of liver with elevated LFTS), Pelvic inflammatory disease (PID), salpingitis, tubo-ovarian abscess, ectopic pregnancy
Three primary malignancies associated with HIV
1. Kaposis sarcoma (HHV8)
2. NHL -- rapidly growing lesion in CNS
3. Primary CNS lymphoma
Healthy patients who are positive for TB exposure and a positive PPD test without ACTIVE TB should be treated with which medications?
Diagnosis of UTI requires the use of which tests:
1. Urinary dipstick
-positive urine leukocyte esterase test-rapid screen for pyuria
-positive nitrite test for presense of bacteria (gram -)
-clean catch void; epithelial squamous cells indicates vulvular or urethral contamination
-Bacteriuria > 1 organism per oil-immersio
-pyuria: > 8 WBC/HPF
3. Urine gram stain
-count greater than 10^5 organisms/mL represents significant bacteriuria
4. Urine culture
-confirms diagnosis with high specificity: if >/= 10 CFU/mL or urine from clean-catch
5. Blood culture
6. IVP cytoscopy
What would an LP show to indicate encephalitis secondary to a viral infection?
1. Lymphocytosis: >5 WBC/uL with normal glucose is consistent with viral encephalitis (similar CSF as in viral meningitis)
2. Negative CSF cultures
3. CSF PCR: most specific and sensitive test for diagnosing many various viral encephalitis, including HSV-1, CMV, EBV, VZV
Medical treatment of acute bacterial arthritis in a relatively healthy adult: will be empircal treatment for:
1. Parenteral B-lactamase resistant penicillin (oxa/naf) or first gen ceph x 4 weeks
2. Parenteral VANC if MRSA suspected
What is the purpose of the CD4 count in patients with HIV?
Best indicator of the status of the immune system and of the risk for opportunistic infections and disease progression
In acute hepatitis, ALT is usually > _____, however drug induced hepatitis is much higher.
Acute hepatitis will normally have elevated ALT > 1000
Chronic hepatitis will normally have ALT < 1000
What makes FULMINANT hepatitis different from ACUTE hepatitis?
Fulminant hepatitis: where acute hepatitis turns into liver failure with complications (hepatic encephalopathy, hepatorenal syndrome, bleeding diathesis)
What is "cellulitis" and what are the two most common causes?
Cellulitis is an inflammation of skin and subcutaneous tissue that is caused bya wide vareity of bacteria - most common being that of:
2. S. Aureus
What is the treatment of RABIES postexposure?
1. CLEAN WOUND!
2. If wildlife bite (bat/raccoon) - capture animal if possible, destroy it, send to lab for immunofluorescence of brain tissue
3. If bitten by healthy dog/cat in endemic area, capture animal and observe for 10 days. If not change in animal condition then rabies is not present.
4. IF KNOWN rabies exposure then perform both of below:
-Passive immunization: admin human rabies Ig to patients into wound and into the gluteal region
-Administer the antirabies vaccine in 3 doses IM via the deltoid or thigh over a period of 28 days.
What diagnostic tests should be ordered to workup an ill neutropenic patient?
2. PAN culture (blood, urine, sputum, line tips, wound)
4. Complete metabolic panel
5. Place the patient on reverse isolation precautions (positive pressure rooms with masks and strict handwashing)
6. Give broad spectrum antibacterial agents immediately after cultures are drawn
7. If fever persists greater than 4-5 days despite broad spectrum antibacterial therapy, give antifungal agents like IV AMP B.
**CONSIDER ADMIN OF G-CSF to stimulate growth factors to produce WBC
Unlike that of C. Trachomatis, how does N. Gonorrhea present in males versus females?
Males: SYMPTOMATIC - purulent d/c, dysuria, erythema, edema, erethral meatus, frequency of urination
Females: ASYMPTOMATIC - cervicitis, urethreitis
How is Herpes Simplex transmitted?
Contact with people who have the ACTIVE ULCERATIONS OR SHEDDING OF VIRUS from the mucous membrane. HSV-1 is usually nonsexually transmitted whereas HSV-2 is sexually transmitted nearly 100% of the time.
Duration of treatment for acute uncomplication cystitis?
Most cost-effective duration is 3 days;
1. Single-dose treatment has a higher recurrence rate
2. 7 day course has too many side effects.
diffuse inflammation of the brain parenchyma and is often seen SIMULTANEOUSLY with that of meningitis
Pathophysiology of RMSF:
Organisms enter host by tick bites --> multiply in the vascular endothelium, spread to different layers of vasculature, damage vascular endothelium and results in increased vascular permeability --> activation of compliment --> microhemorrhages --> microinfarcts
If a patient has a history of <3 doses, unknown status or > 10 YR sincle last "booster" of tetanus, what should be done for wound management in clean/minor wounds? Other wounds?
If clean, minor - administer active immunication with tetanus/dip toxoid (Td)
Do not provide TIG is clean, minor wound
If other wounds, administer both TIG and Td
Diagnosis of HIV requires which tests?
Two are required:
1. ELISA - screening test for detecting antibody to HIV; becomes positive 1-12 weeks after infection. These tests are 99% sensitive (and thus a negative ELISA excludes HIV as long as the patient hasnt had prior exposure before testing - hence seroconversion). A positive ELISA wins the patient another test...
2. Western blot - performed after a positive ELISA for confirmation. This is a highly specific test >99% thus will rule out if negative.
DDx for food-borne botulism includes:
Guillian Barre syndrome --> ASCENDING muscle paralysis
Myasthenia gravis-EM studies differentiate
Tick paralysis (RMSF)
What does the Hepatitis B e Antigen represent?
Infectivity of the virus. If HBeAg positive, then highly infectious and actively replicating. Will appear shortly after HBsAg
Fever pattern varies depending upon the cause:
1. P. falciparum --> A
2. P. ovale and P. vivax --> B
3. P. Malariae --> C
A. Fever is constant
B. Fever spikes every 48 hours
C. Fever spikes every 72 hours
How is menitigitis diagnosed?
CSF examination (LP) - must perform; also note the opening pressure
-Cloudy: pyogenic leukocytosis
-CSF sent for: cell count, chemistry (protein, glucose), gram stain, culture (AFB included), cryptococcal antigen OR india ink stain for cryptococcus sporidium
Most common bacteria associated with osteomyelitis?
S. Aureus and coag-negatice staphylococcus (epidermidis)
Cryptococcus neoformans is a budding, round yeast with a thick _ capsule. Cryptococcus is most commonly associated with ____ droppings and seen in patients with advanced HIV. Infection is often secondary to inhalation of fungus into lungs - hematogenous spread may involve the brain and meninges.
What is HAART?
Triple drug regimen used in patients with HIV
1. Regimen 1: two nucleoside reverse transcriptase inhibitors + NNRI or protease inhibitor
Treatment for Herpes Simplex?
NO CURE, this will forever ly dormant. Antiviral treatment provides relief from symptoms and reduces duration but doesnt inhibit flares.
-rx with acyclovir
What is the most common form of UTI?
UNCOMPLICATED acute cystitis which is more common in women than in men and are ASCENDING from the urethra.
What are the top three common agents for CAP?
Aerobic gram negative rods
Symptoms of progressive primary TB into secondary TB (active)
Initially asymptomatic with possible effusion. Then the pulmonary and consititutional symptoms of TB develop (fever, night sweats, weight loss, malaise) and the cough progresses from dry to purulent sputum Hemoptysis suggests advanced disease as well as apical RALES.
Which patients should be tested for HIV infection because they are considered to be "high risk"
1. Homosexual males/bisexual men
2. IV drug users
3. Blood transfusion receipients before 1985 (widespread donor screening)
4. Heterosexual contacts of HIV+ patients
5. Unborn/newborn babies of patients with HIV+ mothers
Fever of Unknown Origin (FUO) defined:
1. Fever >101.3F
2. Continuing "on several occasions" for at least 2 weeks
3. No diagnosis over this time period despite 1 week of inpatient workup
What is a common STD that results in "pubic lice"
Pediculosis pubis ("crabs") is a common STD caused by Phthirus pubis that is transmitted by sex, clothing, towels that are shared.
Patients with active TB should be treated in which order and with which medications?
1. ISOLATION! (Until sputum is negative for AFB
2. FIrst line therapy: the 4 drugger regimen RIPE
Ethambutol OR streptomycin
3. 4 drug regimen lasts 2 months then the last 4 months is INH and RIFAMPIN only
Differential diagnosis in patients with FEVER + ALTERED MENTAL STATUS (AMS)
--> Sepsis, UTI/urosepsis, Pneumonia, Bacterial Meningitis, intracranial abscess, subdural empyema
--> neuroleptic malignant syndrome (haloperidol, phenothiazines); DELIRIUM TREMENS
3. Metabolic --> thyroid storm
How is "septic joint" diagnosed?
Joint aspiration (tap it!)
1. WBC > 50,000 with 80% PMNs
2. Gram stain of fluid - positive in 75% gram (+) and 30-50% gram (-)
3. Culture - aerobic v. anaerobic
4. Crystal analysis - rule out acute gout
5. PCR of fluid - useful if gonococcal arthritis is sspected by gram stain/culture is neg
6. BLOOD culture - positive in > 50% of all cases
8. Elevated ESR (90%) and CRP
Best imaging: CT or MRI
What is herpetic whitlow?
HSV infection of the finger caused by inoculation into open skin suurface. Most common to health careworkers:
1. Painful vesucular lesions erupt at tip of finger
2. Fever, axillary LAD
3. TREAT WITH ACYCLOVIR but do not confuse paronychia with herpetic whitlow
Most common bacterial pathogen in CA-Pneumonia
Streptococcus pneumonia (occurs within the first 72 hours of hospitalization)
Treatment of CHRONIC prostatitis
CIPRO with prolonged course; difficult to treat because recurrence common
What are the CLASSIC findings of the flu? What are the two major types?
Rapid onset of fever
Antigenic type A and B which have many segments (H and N) and can thus undergo genetic drift and shift which is what causes both epidemic and pandemics. Annual epidemics are due to minor genetic changes of reassortment and are NOT life threatening. OH **** genetic drift incur with PANDEMICS and are secondary to genetic recombination and are fatal to even healthy hosts.
Which types of wounds are likely ro result in tetanus:
1. Wounds contaminated with dirt, feces, saliva
2. wounds with necrotic tissue
3. deep-puncture wounds
What is a neutropenic fever?
Common causes include:
1. BONE MARROW FAILURE (due to toxins, drugs)
2. BONE MARROW INVASION (due to hematologic malignancy, metastatic CA)
3. Peripheral causes (hypersplenism, SLE, AIDS)
4. Isolated neutropenia (agranulocytosis) is commonly caused by drug reactions.
How are chancroids transmitted and how do we diagnose it separate from HSV2?
Transmission by sexual contact with an incubation period of 2-10 days.
Diagnosis: PAINFUL genital ulcers that will never go systemic and will never disseminate. Tender LAD, ruled OUT syphilis via a negative VRDL and FTS-ABS and darkfield microscopy. HSV ruled out based on clinical presentation or negative culture for HSV (Tzank) negative.
How is chlamydia diagnosed? How long does it take post copulation for symptoms to present?
Diagnostic tests: Culture, enzyme immunoassay, PCR
Incubation period: 1-3 weeks
What should you expect to find in CSF that has been tested in suspician of an aseptic cause?
1. Nonpyogenic inflammatory response in CSF therefore there should be an increase in monoculear cells and a lymmphocytic pleocytosis present.
Protein: WNL or slightly elevated
CSF: may be completely normal
Which bones are most commonly involved in osteomyelitis?
1. Long bones *tibia, femur, humerus
2. Foot, ankle
3. Vertebral body (from Potts via TB)
Guidelines to AB therapy for brain abscess
1. Broad-spectrum AB if bacterial cause unknown
2. Parenteral AB for 4-6 weeks
3. Penicillin G + chloramphenicol/metronizdazole IF anaerobe suspected
4. Addition of nafacillin if S. aureus is suspected; VANC for MRSA
WHAT are the three forms as aspergillus
1. Allergic bronchopulmonary aspergillosis
2. Invasive aspergillosis
3. Pulmonary aspergilloma
As the episodes become more recurrent, how do the symptoms of HSV change?
Milder and shorter in duration, resolving within 10 days and there is a decrease in the number of recurrences.
Typical case of lung abscesses:
Occurs when infected lung tissue becomes necrotic and forms caitary lesions. Most commonly secondary to oropharyngral cotenst or food with resulting pneumonia and necrosis > 2cm in diameter
How might botulinum toxins be inactivated?
inactivated by cooking at high temperatures (100 deg C for 10 min)
How is cellulitis and its agent diagnosed?
1. Blood cultures if patient has a fever (r/o sepsis)
2. Tissue culture if there is an obvious wound, ulcer, site of infection
3. Imaging (plain film, MRI) or suspicion of a deeper infection
Approach to diagnosing CAP
Step 1: Diffferentiate lower RTI versus other causes of cough and from upper RTI
Step 2: if nasal discharge, sore throat, ear pain predominates, upper RTI is likely
Step 3: once lower tract infection is suspected, the next task is to differentiate between penumonia and acute bronchitis. Clinical features including cough, sputum fever and SOB are not reliable in differentiating betwen lower RTI and bronchitis
Step 4: CXR is the ONLY reasonable method of differentiating between pneumonia and acute bronchitis
Course of hepatitis C post subclinical infection?
1. Resolution (10-15%)
2. Chronic hepatitis (85-80%)
-Cirrhosis (10-20% of all patients with chronic hepatitis C)
-Develops 20-30 years after onset
3. Fulminant (<1%)
Q fever is secondary to infection of _____ ____ which is a gram _____ organism in the family of ______. Transmission is by ____ and not tick, its reservoir is in farm animals, and clinically there is a fever but no rash. Acutely, will have constitutional symptoms; Chronically will have endocarditis.
blood and fluids
Diagnosis: CXR: multiple opacities inacute illness
Treatment: IM streptomycin (AG) or streptomycin
Causes of FEVER of UNKNOWN ORIGIN (FUO)
1. Infection is the most common cause
2. Occult neoplasms are the second most common cause (lymphoma)
3. Collagen vascular disease (SLE, Stills dz, PAN, Temporal Arteriosis)
4. Granulomatous disease (Sarcoid, Syphilis, Crohns)
6. Pulm Embolism
8. Familial Mediterranean Fever
10. Subacute thyroiditis
11. Facitious illnesses
How are chancroid's treated?
AZITHROMYCIN (Macrolide) po ONE DOSE, OR CEFTRIAXONE (Cephalosporin, 3rd gen) IM one dose; Or an ORAL course of AZITHRO, ERYTHRO, CIPROFLOXACIN works.
Chancroid will resolve within 1-2 weeks with Rx.
Transmission is usually sexual or parenteral for HIV, thus which avenue of bodily fluids might HIV be contracted?
3. Vaginal discharge
4. Breast milk
Which viral infection is associated with oropharyngeal lesions and if symptomatic, can be associated with systemic manifestations (fevers, malaise)?
What drug can exacerbate the results of ASP galactomannon elevation?
ZOSYN can result in false positive ASP galactomannan
How are pregnant women treated with UTI?
1. Treat with AMPICILLIN, AMOXACILLIN, oral CEPHALOSPORINS for 7-10 days
2. Avoid use of FLUOROQUINOLONES - results in fetal arthropathy
Noninfectious causes of hepatitis
1. Alcoholic hepatitis
2. Drug-induced hepatitis
3. Auto-immune hepatitis
4. Hereditary diseases
How is Lyme Disease diagnosed?
In early: localized disease with documented erythema migrans in a patient with a history of tick eposure in an endemic are obviates the need for lab confirmation thus TREAT EMPIRICALLY
Serological studies: MOST IMPORTANT TESTS TO CONFIRM A CLINICAL SUSPICION OF LYME DISEASE
-ELISA is used to detect IgM and IgG AN during first month
-Western blot is used to confirm
Leading cause of death in patients with AIDS with a CD4 count <200
PCP: fever, nonproductive cough, SOB (with exertion first, then at rest); CXR will show diffuse interstitial infiltrates, negative radiographs in 10-15%
RX: TMP-SMX (BACTRUM) po or IV for 2 weeks; steroid therapy if patients is hypoxic or has an elevated A-a gradient
Prophylaxis: Oral BACTRUM, ONE dose PO daily
Can the annual "flu" be treated with AB?
No, treatement for VIRUSES do not include AB which is for BACTERIA. Treatment is largely supportive with some antivirals capable for use if given within the first 24 hours of illness.
Both decrease the duration of symptoms. AB are ONLY INDICATED if secondary bacterial infections occur (number one cause of death in the elderly from influenza virus is the secondary bacterial infection) - this is why vaccinations are critical.
Treatment for C. Trachomatis D-K (STD)
1. Azithromycin (oral one dose) or doxycycline (oral for 7 days)
2. Treat all sexual partners
CANDIDIASIS is the most common cause of esophageal dysphagia in patients with HIV once CD4 counts have reached:
What should be ordered to diagnose pneumonia?
PA and later CXR required to confirm the diagnosis
1. Considered sensitive - if CXR no suggestive of penumonia, do not treate the patient with AB. After treatment changes evident in CXR usually lag behind the clinical response for 6 weeks maximum.
Pretretaement expectorated spupm for gram stain and culture - low sensitivity and specificity but still wothwhile tests because antimicrobial resistance is an increasing problem.
1. Sputum gram stain - obatin in all patients. Commonly contaminated with oral secretions. 60% speificity of 85% for identifying gra positive cocci in chains (S pneumonia)
2. Sputum culture should ALWAYS be obtained in patients req hospitalization.
Special stains of the sputum in selected cases:
1. AFB - acid fast stain if TB is suspected
2. Silver stain - fungi, PCP for HIV/immunocompromised patients
Urinary antigen assay for legionella in selevted patients
1. Sensitive test, persists in urine for weeks post treatment
When are blood cultures indicated in patients with suspected UTI?
If a patient is ill and urosepsis is suspected
Treatment of VIRAL ENCEPHALITIS
1. SUPPORTIVE - no antibiotics
2. Mechanical ventilation if ARF becomes an issue secondary to medulla/pons
3. Anti-viral therapy: no specific antiviral therapy for most causes of viral enceph
a. IF HSV encephalitis - acyclovir for 2-3 weeks
b. IF CMV encephalitis - ganciclovir or foscarnet
4. Management of complications: Seizures requires phenytoin (anticonvulsants); and cerebral edema may require that of hyperventilation, osmotic diuresis, steroids.
Medical treatment of acute bacterial arthritis is patient is immunocompromised of has significant risk factors for gram-negative arthritis:
1. Parenteral BROAD spectrum AB with gram negative coverrage (3rd generatiion ceph or aan AG) x 3-4 weeks
In patients with CD4 count between 200-500 and diagnosed with HIV, what is the most worrisome?
Herper zoster, TB, lymphoma, bacterial pneumonia, Kaposi Sarcoma (HHV8)
What is the standard of care for patients diagnosed with both hepatitis A and B?
Both HAV and HBV have an active and passive immunoglobulin available
Is there a vaccination for RABIES?
Yes, pre-exposure prophylaxis for individuals who are at risk
2. Wildlife officials
3. Laboratory workers
Noninfectious causes of encephalitis:
#1 Metabolic encephalopathies (hyperuremia secondary to liver cirrhosis)
#2 T-cell lymphoma
Chronic osteomyelitis differs from acute in which way?
Bone necrosis and soft tissue compromise or to a relapse of previously treated OM. It is challenging to treat and impossible to eradicate
How do bacterias gain access into the skin to cause cellulitis?
1. IV catheders
3. Immersion in water
4. Bites or wounds
5. Venous stasis diseases
7. Diabetic ulcers
*If untreated, can lead to potentially life-threatening bacteremia
Infectious mononucleosis is generally caused by:
caused by: EBV; in HIV patients its secondary to CMV
most commonly seen in adolescents and young adults
Transmission: Infected saliva
Incubation period: 2-5 weeks
Immunity: One infection will likely provide lifelong immunity
How does tertiary syphilis differ from primary, secondary, and latent?
33% of untreated syphilis patients in the latent phase enter this phase (tertiary)
-occurs after the development of primary infection - up to 40 years later
-Manifestations include: CV syphilis (vasovasorum of aorta), or neurosyphilis, or subcutaneous granulomas called "gummas"
Empiric treatment for acute bacterial meningitis in the elderly?
Etiology: Listeria, Gram (-) bacilli, S pneumo
Empiric therapy: Ceftriaxone + VANC + Ampicillin
Sympathetic hyperactivity, lockjaw, risus sardonicus (grin due to contraction of facial muscles), opisthotonos (arched back due to contrations of back muscles) are all symptoms/signs of?
T or F: Patients with HIV should stop retroviral treatment once viral loads become minimal or undetectable.
FALSE. Latency infected cells can lead to reappearance of viral RNA once therapy is stopped.
What is INVASIVE aspergillosis and who is MOST likely to get this?
When hyphae invades lung vasculature resulting in thrombosis and infarction - hosts are usually at risk patients with acute leukemia, transplant or patients wth advance AIDS and a CD4 count < 200.
Fever, cough, respiratory distress, and diffuse, bilateral pulmonary infiltrates present that has spread via hematogenous dissemination and may invade the sinuses, orbits and BRAIN
Neonatal HSV is associated with which congenital abnormalities?
Uncomplicated v. Complicated pyelonephritis?
1. Uncomplicated pyelonephritis is limited to renal pyelocalceal-medullary region.
2. Complicated pyelonephritis is caused by functional or structural abnormalities of the UT. Vesicoureteral reflux facilitates this spread upward.
Diagnosis of TB requires which tests to be completed?
1. CXR: classic findings of UPPER LOBE INFILTRATES WITH CAVITATIONS
a. Pleural effusions
b. Ghon's complex or Ranke's complex (hilar LAD)
c. Atypical findings in immunocompromised patients
2. Sputum studies
a. Definitive diagnosis by sputum culture: growth of Mtb
b. Get 3 morning sputum specimens because 4-8 weeks req to culture
c. Dignosis is made by finding AFB on the microscopic examinaton
3. Tuberculin skin test
a. TB test is a screening test to detect those ho have been exposed to TB. Its not for diagnosis of active TB but rather of latent (primary TB)
Life-threateneing deep soft tissue infection that rapidly tracks along the fascial plane post surgery, DM, trauma, and IV drug use. If not treated, this dx can leavd to thrombosis of microcirculatipon resulting in tissue necrosis - discoloration - crepitus and cutaneous anesthesia.
Primary TB v. Secondary TB
Primary: Bacilli are inhaled and depositied into lung and ingested by alveolar macrophages. THose that survive disseminate by lymph and blood. Granulomas form and wall off the MB to immune defense. This occurs in O2 rich areas like the lungs and are therefore aerobes. After resolution of primary infection, the organism remains dormant within granuloma.
Secondary: Occurs when the hosts immunity is weakened (HIV, immunosuppressants like anti-TNF AB, chemotherapy, substance abuse and poor nutrition. Manifests in the most oxygenated aspect of the lungs (apical/posterior segments).
Diagnosis of CRYPTOCOCCUS NEOFORMANS
1. LP is absolutely esential if meningitis is suspected
-(latex agglutination detects cryptococcal antien in CSF)
-(india ink smear shows encapsulated yeasts)
2. Tissue biopsy is characterised by lack of an inflammatory response
How is the diagnosis of N. Gonorrhea different from that of C. Trachomatis?
1. Gram stain of urethral discharge showing organisms within leukocytes
2. Obtain cultures in all cases - in men from the urethra; in women from endocervix
3. Consider testing for syphilis and HIV
4. Obtain blood cultures if disease has disseminated and patient becomes septic. (Gram negative cocci)
For C. Trachomatis, diagnosis is done via urine culture, PCR
What is a NORMAL CSF finding (WBC count, differential, glucose, protein)?
WBC: < 5 normal
WBC differential: ALl lymphocytes or monocytes; no PMNs
Protein < 60
If bacterial meningitis, WBC 1000-20,000; differential are PMNs; HI protein; LO glu
If aseptic meningitis, WBC <1,000; all lympho monocytes with diff; WNL glu, HI protein
Acute bacterial arthritis can be caused by:
1. S. Aureus is the most common in adults and children
2. An important gram-negative agent in N. Gonorrhea that is common in YOUNG, SEXUALLY ACTIVE ADULTS
3. Pseudomonas or Salmonella if history of sickle cell disease, immunodeficiency, or IV drug abuse.
What does the Hepatits B surface antigen represent (HbsAg)?
Present in acute or chronic infection that can be detected within 1-2 weeks of infection. Persists through chronic hepatitis regardless of whether symptoms are present - if virus is cleared then HbsAg is NOT detectable.
Malaria can be caused by one of 4 different organisms:
1. Plasmodium falciparum
2. Plasmodium ovale
3. Plasmodium vivax
4. Plasmodium malariae
VECTOR: mosquito (PROTOZOAL INFECTION)
What is the treatment regimen for oropharyngeal candidiasis?
1. Clotrimazole troches (dissolves in mouth) five times per day
2. Nystatin ("swish and swallow") 3-5 times per day; only for oral candida
3. Oral ketoconazole or fluconazole for esophagitis
Syphilis is caused by _____ _________ and is transmitted by DIRECT ______ ________
Treponema pallidum spirochetes, transmitted by sexually contact with INFECTIOUS lesions
Most common bacterial pathogen for Nosocomia pneumonia
Gram-negative rods (GNR) and Staphylococcus Aureus (occurs after the first 72 hours of hospitalization)
Diagnosis of prostatitis:
1. DRE: boggy tender prostate in acute disease; will be enlarged but not tender in chronic disease.
2. UA: numerous sheets of WBC in acute bacterial prostaturia
3. Urine cultures: always positive in acute
4. Chronic prostatitis: UA cultures may be positive (chronic bacterial prostatitis) or negative (chronic, non-bacterial prostatitis)
5. Get blood cultures if patient appears to become septic.
Treatment of intra-abdominal abscess usually involves two things:
2. Antibiotic regimen inclusive of broad coverage against gram negative rods, entercocci and anaerobes
How can primary TB (latent) be differentiated from secondary TB (active)?
Primary TB (latent): negative CXR, sputum culture, or BOTH
What is lymphadenitis?
Inflammation of a lymph node (1 or >) caused by local skin or soft tissue bacterial infections (GAS/Staph). Likely, will have fever, tender LAD or regional lymph nodes, red streadking of skin from wound or area of cellulitis.
Complications include: thrombodid of adjacent veins sepsis, and even death if untreated.
Helpful diagnostic studies include BLOOD and WOUND cultures
How is the VIRAL LOAD determined in patients with HBV?
HBV DNA measured by PCR; if > 6 weeks, patient likely to develop chronic disease
TREATMENT for MALARIA
1. Use chloraquine phosphate unless resistance suspected
2. Use quinine sulfate and tertracycline or atovaquone-proguanil and mefloquine if RESISTANT to chloroquine
3. Use chloraquine and IV quinidine and doxycyline for P. Falciparum
4. Use chloraquine and PRIMAQUINE in patients with P vivax or P ovale due to latency/dormancy found in hepatocytes due to dormant hypnozoites. Must add a 2 week regimen to it.
Treatment of pateints with early syphilis versus later?
Early, AB are effective.
-Benzathine benicillin (G) one dose IM is preferred treatment
-If patients cannot take penicillins, start with PO doxy or tetra for 2 weeks
-If patient has LATE syphilis
-give penicilin in 3 doses IM / week
-recheck RPR or VRDL every 3 mo to ensure adequate response to treatment. Titers shoud decrease fourfold within 6 mo time.
MAC prophylaxis in patients with HIV
Start once CD4 count < 100
Use: CLARITHROMYCIN (Macrolide) and AZITHROMYCIN
What is the most common bacterial STD?
Chlamydia: intracellular pathogen; often will be coinfected with N. Gono
Incubation period: 1-3 weeks
*risk factor for cervical cancer especially if a history of multiple infections has occured
Host-dependent factors that increase risk for recurrent or COMPLICATED UTI
Diabetes- risk for upper UTI
Spinal cord lesion
Structural abnormality to properly and FULLY void.
How might the symptoms of a brain abscess differ from someone with acute bacterial meningitis?
DUE to mass effect rather than systemic infection:
1. headache (most common symptom)
2. change in mental status
4. nausea, vomiting
5. nuchal rigidity may be seen.
Note --> **fever and chills are not present.
Does contracting HSV-2 decrease the severity of HSV-1 if the same person becomes infected with the virus at a later time?
YES. Cross-immunity is prevalent in herpes, therefore the primary infection with the other form of herpes is indeed less severe
Describe the clinical picture of an asymptomatic HIV infected individual:
1. CD4 counts normal (> 500)
2. Longest phase (4-7 years, but varies widely, especially with treatment)
Patients most likely to develop lung abscesses?
Those with predisposition to aspiration: alcoholics drug addiction, CVA, seizure disorder, general anesthesia, or an NG/ET tube. Poor dental hygiene increases the content or oral anaerobes. Edentulous patients less liekly to aspirate.
Treatment for chronic HCV?
Chronic HCV must first be genotyped 1, 2, 3, 4
-once genotyped, then progression to the treatment options/regimen results
-treat with IFNalpha and ribavirin
If transaminanses are markedly elevated (>500) think of:
Acute viral hepatitis, shock liver, or DI hepatitis
Bartonella henselae is a gram-negative bacillus which is transmitted by a scratch from a flea-infested cat with reservoirs in ___ and ____. Clinical findings include LAD, lymphadenitis.
Serology and clinically
Usually is self-limited and thus doesnt require treatment. If severe, administer oral doxycycline or CIPRO for good gram negative coverage
What complications are commonly found in patients with infectious mononucleosis?
2. Hepatitis (inflammation of the liver)
3. Neurologic complications (rare):
4. splenic rupture
5. thrombocytopenia, hemolytic anemia
6. Upper airway obstruction due to LAD
Treatment for gonorrhea
Ceftriaxone (IM one dose) is preferred because it is also effective against syphilis
-CIPROFLOXACIN or OFLOXACIN good also
Also administer azithromycin to cover for C. Trachomatis D-K (one dose) or doxycycline (for 7 days) for complete coverage.
If disseminated: hospitalize patient and initiate ceftriaxone (IV ROCEPHIN) 7 days
Which vaccinations are HIV patients able to and SHOULD receive?
1. Pneumococcal vaccination (pneumovax) 5-6 years
2. Influenza virus annually
3. HEP B Vaccination
DO NOT GIVE LIVE VIRUSES
Treatment of UTI in males
1. Treat with BACTRUM (TMP/SMX) but for 7 days
2. Use CIPROFLOXACIN (FLUOROQUINOLONE) for 7 days if resistant
Perform a urologic workup if there are complicatins of recurrences or if initial Rx fails
Causes of VIRAL hepatitis
Five well-known categories of hepatitis secondary to a viral infection:
Hepatitis A Virus
Hepatitis B Virus (DNA)
Hepatitis C Virus
Hepatitis D Virus
Hepatitis E Virus
Other forms that can induce hepatitis includes: EBV, CMV, HSV
What is the treatment for early lyme disease?
Oral doxycycline for 21 days - contraindicated in pregnant women and in children < 12YO.
Amoxicillin and cefuroxime can be used.
Erythromycin can be admin to pregnant patients with penicillin allergies
**IF patients have bells palsy or other complications involving cardiac disease, PROLONG admin of AB for 30-60 days. or meningitis or other CNS complications, treat with IV AB for 4 weeks.
Diagnosis: Foul-smelling sputum consistent with anaerobic infecton with blood tinged exudate. Dyspnea, fever, chils, fatigue, malaise and possible weight loss
Lung abscess +/- aspiration pneumonia (secondary)
Treatment of botulism?
Admit patients and observe respiratory status. Gstric lavage helpful within hours after ingestion of suspected foot.
If suspicion is high, administer ANTITOXIN (TOXOID) as soon as lab specimans are obtained
If wound contamination - clean wound and adminster penicillin
What is the key marker for hepatitis C infection?
Hepatitis C antibody that is sometimes not detectable until months after infection so its absense does not rule out infection
What is the prophylaxis for people wanting to travel to areas endemic for MALARIA?
MEFLOQUINE is the agent of choice in chloroquine R areas. Chloroquine can be used in areas where chloroquine resistance has not been reported.
Rx of Bacterial Meningitis?
1. IV AB immediately after specimans taken via the LP. DO NOT DELAY even in case of CT scan. If cloudy, begin immediately according to the patients age and modify treatment as appropriate based on the gram stain, culture and sensitivity findings.
3. Steroids - if cerebral edema is present
4. Vaccination - all adults > 65YO for S. Pneumococcus
5. Vaccination - all adults with aslpenia for S. pneumo, N. Meningitidis, H. Influ
6. Prophylaxis - RIFAMPIN or CEFTRIAXONE for all close contacts with NM,
-1 dose of IM ceftriaxone
Pain over the involved area of the bone with erythema, warmth, swelling. Systemic features including that of fever, headache, fatigue can be present.
What is the HIV-1 wasting syndrome?
Profound involuntary loss of > 10-15% of body weight in conjuntion with either:
1. chronic diarrhea
2. fever and persistent weakness for a similar period in the absense of another cause
Steps are appropriate in patiets admitted to the hospital with suspected pneumonia:
1. CXR - PA and lateral
2. Lab tests - CBC with diff, BUN, creatinine, lucose, electrolytes
3. O2 saturations
4. Pretreatment blood cultures
5. Gram stain and culture of sputum
6. Antibiotic therapy
Clinical features noted with common UTI
Dysuria (with burning sensation on voiding)
Lower UTI have no fever associated with it
Most common pathogen causing pneumonia in organ transplant recipients, patents with renal failure, and paitenst with CLD and smokers? This type is RARELY found in young and healthy individuals.
How might encephalitis be diagnosed in relation to meningitis?
Encephalitis must have routine lab tests to rule out nonviral causes:
1. CXR, UA, blood cultures, urina toxicology screen, serum chemistries
2. Perform an LP to examine CSF unless the patient has signs of significantly increased ICP then a LP is contraindicated.
3. MRI of brain GOLDEN STD
4. EEG to diagnose HSV encephalitis to show unilateral or bilateral temporal lobe discharges
4. Brain biopsy ONLY if ill patient with focal, enhaving lesion on MRI without a clear dx
Complications of septic joint
1. Destruction of join and surrounding structures (ligaments, tendons) leading to stiffness, pain, and loss of function
2. Avascular necrosis if hip involved
Treatment of/for uncomplicated pyelonephritis patients capable of swallowing:
Depends upon gram stain:
1. TMP/SMX or CIPRO 10-14 days for gram negatives
2. AMOXACILLIN for 10-14 days for gram positives
3. Single dose ceftriaxone or gentamicin administered initially before rx
ONCE COMPLETE: recheck urine culture 2-3 days post therapy; if symptoms fail to resolve within 48 hours readjust treatment. If FTR to antimicrobial therapy, then perform urologic investigation
What are major complications noted with that of erysipelas?
1. Necrotizing fasciitis
2. Local spread to subcutaneous tissues
Symptoms of TSS:
2. Diffuse macular, erythematous rash
3. hyperemic mucus membranes, "strawberry tongue"
4. Warm skin due to peripheral vasodilation
By definition TSS must include at least 3 organ systems
SYMPTOMATIC HIV infection (pre-AIDS) represents which stage of HIV?
FIrst evidence of immune system dysfunction: without treatment, this phase lasts 1-3 years
Diagnosis of C. trachomatic L1-L3 is made via?
Course of treatment:
Serological testing (complement and immunofluorescence) followed by treatment with DOXYCYCLINE for a total of 21 days.
Elevated LFTs are likely to be AST > ALT in patients with?
Alcohol-induced hepatitis. ALT is typically elevated more than AST for all forms of viral hepatitis (ALT > AST).
Diagnosis and treatment of Pediculosis PUBIS/CAPITIS/CORPORA
Diagnosis: severe pruritis, examination of hair undr microscope or with naked eye to idetify adult lice.
Treatment: Permethrin (1%) shampoo *Elimite - appe to all hairy regions from neck down and wash off after several hours.
How to dx osteomyelitis:
1. WBC count
2. ESR and CRP: nonspecific but are markers of inflammation that will b elevated in the appropriate clinical setting. GOOD FOR TRACKING RESPONSE TO THERAPY
3. NEEDLE aspiration of infected bone or bone ciopsy obtained in the OR is the most direct and accurate means of diagnosis.
4. Plain radiography (no soooo good because takes 10 days to show
5. Radionucleotide bone scan (OK to use 2-3 days post infection but is nonspecific)
6. MRI IS THE MOST EFFECTIVE IMAGING STUDY FOR DIAGNOSING OSTEOMYELITIS AND ASSESSING THE EXTENT OF DISEASE PROCESS - take time for results is issue
Empiric treatment for ACUTE BACTERIAL MENINGITIS 3 mo - 50 YR
Etiology: Neisseria meningtidis, Streptococcus pneumonia, H. influenza
Empiric Treatment: Ceftriaxone + VANC
What are the most common infections in neutropenic patients?
2. Cellulitis (often due to GAS or S. Aureus)
Disseminated or invasive disease of candida is common in patients who are immunosuppressed. What manifestations can result from systemic candida?
4. Multiple abscesses in various organs
What percent of patients with secondary syphilis will continue to latent syphilis rather than teriary syphilis?
30% go to latent phase if left untreated in secondary. This includes (+) serologic tests resulting in the ABSENSE of clinical symptoms or signs. 66% of pateints remain asymptomatic whereas 33% continue to tertiary syphilis
Empirical therapy for acute bacterial meningitis in immunocompromised patients?
Etiology: S. Pneumo, N meningitis, L monocytogenes, aerobic gram negative bacilli (including pseudomonas)
Empiric therapy: Ceftazidime + ampicillin + VANC
Acute versus chronic PROSTATITIS
Acute: less common, fever, tender prostate, appears toxic, younger males, ascending infection; organisms include E COLI, KLEBSIELLA, PROTEUS, PSEUDOMONAS, ENTEROBACTER, SERRATIA
Chronic: more common, asymptomatic, ages 40-70YO
Bacterial versus Aseptic Meningitis
Bacterial causes vary depending upon age (neonates - GBS, E coli, Listeria; children - n meningitis, s pneumo, h influ; adult - s pneumo, n meningitis, h influ; elderly - listeria, gram neg, then s pneumo.
-Complications of Acute Bacterial Meningitis: come, brain abscess, seizures, DIC, subdural empyema, respiratory arrest.
-Permanent sequele: deafness, brain damage, hydrocephalus
Aseptic causes occurs secondary to nonbacterial pathogens (virus, parasites and fungus), Often difficult to distinguish from acute so if ANY uncertainty, treat for acter bacterial menigitis. Much better prognosis than acute bacterial
Patient has >/= 3 Td doses with a clean/minor wound. How should this patient be managed? What if this same patient had other wounds?
No Td (active immunization)
No TIG (immune globulin for tetanus)
No for other wounds
Diagnosis of syphilis
1. DEFINITIVE TEST: Darkfield microscopy examines specifmen of chancre
3. Serologic tests (most commonly used)
a. Nontreponemal RPR, VDRL-high sensitivity specificity is 70%, thus if positive must confirm with specific treponemal tests
b. Treponemal test FTA-ABS, MHA-TP - more specific thus not for screening but for confirmation of a positive nontreponemal test
If a 17 YO sexually active female presents to the clinic with symptoms including urethral discharge that is purulent, intermenstral and postcoidal bleeding and dysuria with pharyngitis and conjunctivitis, what should your differential dx include?
N. Gonorrhea (infection of pharynx, conjunctiva, and rectum can occur)
What two signs can be tested for acute bacterial meningitis in 50% of patients?
Kernings sign: unable to fully exted knees when patient is supine with hips flexed
Brudzinskis sign: unable to flex legs and thighs secondary to passive flexion
What are the 2 main categories of osteomyelitis?
1. Hematogenous osteomyelitis (most common to children) - secondary to sepsis
2. Direct spread of bacteria from an adjacent infection, trauma (OPEN FRACTURES), vascular insufficiency (PVD)
Treatment of aspergillus:
1. Allergic bronchopulmonary aspergillosis:
2. Pulmonary aspergilloma:
3. Invasive aspergillosis:
1. Should avoid exposure to aspergillus, corticosteroids may be beneficial
2. If massive hemoptysis may require a lung lobectomy
3. Invasive aspergillosis, treat with IV amp B, coriconazole, or caspofungin
**if suspect possible brain involvement, perform imaging studies. (because can disseminate to sinuses, orbits and BRAIN)
How is HSV diagnosed?
1. If lesions are recognized, then dx clinically
2. If uncertain, CONFIRM with Tzank test (quickest)
a. Swabbing base of ulcer and staining with Wrights stain
b. POSITIVE test if multinucleated giant cells are visible.
i. This means either HSV or VZV infection
3. GOLD STANDARD: CULTURE
a. Swab base, get results in 2-3 days
4 DIrect fluorescent assay and ELISA
a. 80% sensitive, get results within the hr
Organisms most frequently causing pyelonephritis?
#1 E. Coli
2. Other gram negatives: Proteus, Klebsiella, Enterobacter, Pseudomonas
3. Some gram positives: S. aureus, enterococcus faecalis
What are the classic signs of meningitis?
CHARACTERISTIC TRIAD: fever, nuchal rigidity, change in mental status
#1 most common: Nuchal rigidity: stiff neck, resistance to flexion of spine (may be absent
2. Rashes: maculopapular rash with petechiae - purpura is classic N. meningitis; vesicular lesions in varicella or HSV
3. Increased ICP and its manifestations - papilledema, seizures
4. Cranial nerve palsies
5. Kerning's sign: inablilty to pully extend knees when patient is suprine with hips flexed (cause by irritation ofthe meninges) only present in haf of patients with abcterial meningitis
6. Brudzinskis sign: flexision of legs and thighs that is brought on by passive flexion of neck
When to hospitalize and when to administer AB therapy with PNEUMONIA
1. Pnuemonia severity index > 71 with risk of mortality >2.8%
2. If comorbidities includ that of neoplastic disease, liver disease, CHF; if altered ental status, tachypnea, hypotension, hypothermia or hyperthermia; if acidotic, elevated BUN, hyponatremia, hyperglycemia.
1. Outpatients <60YO: S pneumonia, mycoplasma, chylamidia, legionella = Macrolides (azithro, erythro, clarithromycin), doxycycline are all first line. Second line try fluoroquinolones (cipro, moxifloxacin). Do not use 3rd generation ceph or penicillins because not good coverage for atypicals.
2. Outpatents >60YO: more likely to have typicals (S pneumo, H influ, Klebsiella) so 2nd or 3rd generation cephalosportin is the first line treatment. Alternatives include that of zosyn (amoxicillin/clavulanic acid, macrolides, and fluoroquinolones (levo and moxifloxacin - these are two with good pneumonoccal coverage too).
Course of acute HBV be can be one of 4 different things:
1. Resolution - 90%
2. Chronic hepatitis - 5-10%
-Cirrhosis deveops in 25% of all patients with chronic HBV
3. Fulminant - (<1%) hepatic encephalopathy, Hepatorenal syndrome, Bleeding diathesis.
4. Chronic carrier (<5%)
Leptospirosis is transmitted by contaminated ______ and have reservoirs in _____. Clinical findings are anicteric (rash, LAN, inc LFTs) or icteric (renal and or liver failure with vasculitis, vascular collapse.
dx: isolation of organism in blood or urine culture
-oral AB: tetracycline/doxycycline;
-IV penicillin G if severe
(LOOKS LIKE QUESTION MARK!)
Extrapulmonary TB versus Miliary TB
Extrapulmonary TB: indivudals with impaired imunity may not be bale to contain bacteria at primary or secondary stage of infection ang therefore the disease will spread to other locations throughout the body (Pott's disease - vertebral body)
Miliary TB: hematogenous/lymphatic spread of secondary TB
Treatment for patients diagnosed with Cryptococcus neoformans?
AMP B + FLUCYTOSINE for 2 weeks followed by po FLUCONAZOLE
Common pathogens in cellulitis:
1. If local trauma, breaks in skin --> A
2. Wounds, abscesses --> B
3. Immersion in H2O --> C
4. Acute sinusitis --> D
B. S Aureus
D. H. Influ
What are the three forms of "pediculosis"
1. Pediculosis pubis -- genital lice, "crabs"
2. Pediculosis capitis -- head lice
3. Pediculosis corpora -- body lice
What is a disseminated gonococcal infection (1-2%) of cases?
1. Fever, arthralgias, tenosynovitis of hands and feet
2. Migratory polyarthritis/septic arthritis, endocarditis, or even meningitis
3. Skin rash (usually on distal extremities)
What is often lacking in patients who are HIV and TB positive?
1. PPD skin test result is negative
2. "Atypical" chest x ray (diffuse)
3. Sputum smears are likely to be negative for AFB
4. Granuloma formation not present until later stages of TB
Hospitalized patients should receive which two AB for coverage of pneumonia causing agents?
2. 2rd generation cephalosporin (IV rocephin) plus macrolide (azithro, erythro)
A patient was recently treated with acute uncomplicated cystitis using a 3 day course of BACTRUM (TMP/SMX) and reports no change in pain and urination and also reports new onset of fever. What is your next step?
Treat presumptively for pyelonephritis if the condition fails to respond to a short course of AB for what was thought to be an acute uncomplicated cystitis.
After having been bite by a tick infected with rickettsia rickettsii, how long until symptoms will present?
1 week post tick bite. Will have fever, chills, malaise, nausea, vomiting, myalgias, photophobia, headache. A papular rash will appear 4-5 days after fever which starts at the wRRRist, forearms, palms, ankles, solesm and spreads centrally.
The rash will be maculopapular and then become petechial leading to interstitial pneumonitis.
How can mucocutaneous lesions be treated for in patients diagnosed with (HSV-1/HSV-2)
1. Po and/or topical acyclovir 7-10 days
2. Famcyclovir and valacyclovir have better BIOAVAILABILITY
3. Oral acyclovir may be administered for patients with recurrents
4. FOSCARENT administered in immunocompromised patients.
5. Disseminated HS: hospital ADMIT and put on IV FOSCARNET or PARENTERAL
Diagnosis of AIDS requires which tests?
1. HIV-1 positive patient with a CD4 count lower than 200
2. Indicator conditions that are AIDS defining
Intraabdominal abscesses are often _______ in origin and can be caused by?
Polymicrobial. CAuses include:
1. Peritonitis, pelvic infection, pancreatitis perforation of the GI tract, osteomyelitis of the vertebral bodies with extension into retroperitoneal cavity (seen in Potts disease with TB)
What does the present of Anti-HBsAg indicate?
Immunization to HBV or after clearance of HBsAg - can be detected 2-3 months after infection. Indicative of immunity to HBV
Radiographic findings in primary TB
Ghon's complex: calcified primary focus
Ranke's complex: calficied primary focus and calcified hilar lymph node
PCP prophylaxis in patients with HIV
IF < 200 (CD4) then prophylaxisly treat with BACTRUM (TMP-SMX) daily
Most common organisms responsible for UTI
#1 by far is E. COLI (80%)
2. S. saprophyticus (females dom), enterococcus, klebsiella, proteus, pseudomonas, enterbacter and yeast (candida)
How might a brain abscess be approached for diagnosis differently than someone with meningitis?
1. Get a CT SCAN - shows any focal lesions at low density mass with peripheral enhancement - is done quickly
2. MRI - takes longer to get results back BUT results in earlier diagnosis and overrall a better iaging study
3. Aspiration or surgical excision - diagnositc (obtaining cultures and therapeutic)
IV AB or surgical drainage or glucocorticoids depending on size of abscess and presense of mass effect
What is the transmission cycle for lyme disease?
1. Caused by spirochete BORRELIA BURGDORFERI
2. Transmitted by ticks - commonly the deer tick IXODIDAE SCAPULARIS
3. The host is the wfite-footed mice (immature ticks), white-tailed deer (mature ticks) and brief encounters with humans
How might someone with HIV initially present post infection of HIV?
1. Primary infection
2. Asymptomatic infection
3. Symptomatic HIV infection (pre AIDS)
Botulism generally results from:
1. Preformed toxins produced by spores of Clostridium botulinum. Improperly stored foods (home canned goods) that are contaminated; honey; wound contamination
ACUTE HBV may also present with a ____-________ like illness
HEPATITIS C may not present with an _______ illness.
Chronic hepatitis patients can be asymptomatic for years and may present with late comlications of hepatitis such as either ______ or _________
HBV: serum-sickness like syndrome
cirrhosis or HCC
Ehrlichiosis is an intracellular gram negative bacteria that is transmitted by ___ in the family of ____ and has reservoir in ____. Fever, chills, malaise, rash, renal failure and GI bleeding can occur.
Clinical diagnosis confirmed by serology
Treatment: oral tetracycline/doxycyline +/- 1 week
HEADACHE, Malaise, myalgia that occurs in conjunction with a worsening illness over hours to days. Patients have signs of meningitis in addition to altered sensorium including confusion, delirium, disorientation and behavior abnormalities. Focal neurologic findings may include that of hemiparesis, aphasia, CN lesions and seizures.
Treatment of septic joint
1. Prompt therapy with AB. If gram stain is negative but still suspect acute bacterial arthritis - treat empiracally baced upon the clinical scenario
2. Drainage: daily aspiration of affected joint as long as effusion persists
What is the treatment for infectious mononucleosis (HHV-4, EBV)
Generally, no specific treatment is indicated (or available) as most people recover completely within 3-4 months. Supportive care includes:
1. Rest, fluids
2. Avoidance of strenuous activities until splenomegaly resolves to prevent splenic rupture
3. Analgesics to reduce temperature and pharyngeal pain
Give a short course of glucorticoids if there is airway compromise. Glucocorticoids have een effective in patients with thrombocytopenua or HA
What are the two types of Herpes Simplex Virus (HSV) that are prevalent in the general population?
What is the purpose of administering PHENAZOPRIDINE (pyridium) in patients with acute uncomplicated UTI?
Urinary analgesic given for 1-2 days for dysuria
What are the stages of Lyme Disease?
Stage 1: ERYTHEMA MIGRANS (hallmark lesion at site of bite) - large and painless, target shaped and seen on thigh groin or axilla. Multiple lesions signify that hemtogenous spread has occurred
Stage 2: Early disseminated infection - spreads by lymphatics and bloodsteam and within days to weeks post erythema migrans. FLU-LIKE symptoms, headaches, neck stiffness, fever/chills, malaise, MUS pain. Weeks following: meningitis, encephalitis, cranial neuritis (bilateral bells palsy) and peripheral radiculoneuropathy.
*Weeks-mo post symps will have AV heart block, pericarditis, carditis that lasts several weeks.
Stage 3: late, persistent infection (mo-years post initial infection)
-Arthritis-60% of untreated patients which will typically affect the large joints (predomnantly the knee).
-Chronic CNS disease - subacute, mild encephalitis, transverse myelitis, or axonal polyneuropathy
-Acrodermatitis chronica atrophicans - reddish purple plaques and nodules on extensor surface of legs.
NEUROTOXINs produced by spores of ______ _________ that is a GRAM POSITIVE ANAEROBIC BACILLUS. This proliferates and produced an exotoxin in contaminated wounds and can thus inhibit transmitters at the NMJ
What is the only manifestation of a raging infection in patients who are severely neutropenic with an ANC < 500/mm3?
Because neutropenia severely compromises the patients ability to mount an inflammatory response, FEVERRR may be the only manifestaton of a raging infection.
Anti-retroviral treatment in initiated in patients with HIV when?
Administered to patients + symptoms regardless of CD4 count OR asymptomatic patients with CD4 count <200
Dry mouth, diplopia, aysarthria, paralysis of limb muscles that is symmetric descending and flaccid.
What should you expect to find in bacterial meningitis regarding testing of the CSF fluid subsequent to a suspicious CSF and opening pressure?
1. Pyogenic inflammatory response in CSF
WBC count: HI (PMNS dominant)
Gram stain: positive in 75%-80% cases
GI COMPLAINTS COLLOWED BY PERIORDBITAL EDEMA, MYOSITIS, SPLINTER HEMORRHAGES AND EOSINOPHILIA
parasitic ifnection with larvae
ABPG (allergic bronchopulmonary aspergillosis) occurs in patients who a type ___ hypersentitivity reaction to inhaled spores of aspergillus. This will present with both _____ and _____ and recurrency of such exacerbations are common
Organism diagnosed by india ink staining, antigen, or culture of the CSF in patients with HIV.
1. AMPHOTERACIN B for 10-14 days then oral FLUCONAZOLE for 8-10 weeks or LIFELONG
HSV2 will often present with which clinical findings?
1. Painful genital vesicles
3. Tender inguinal LAD
4. Vaginal and/or urethral discharge
Most common cause of CVA (costovertebral tenderness)?
Unilateral or bilaterally due to that of PYELONEPHRITIS
Treatment of cellulitis:
1. Parenteral AB THERAPY
-TREAT with a staphylococcal penicillin (oxacillin, nafcillin) or a cephalosporin
2. Continue IV AB until signs of infection improve and f/u with oral AB for 2 weeks
CXR in a typcial presentation of CAP versus an atypical presentation of CAP
CXR typical pneumonia: Lobar consolidation (if multilobal, indication of serious illness)
CXR atypical pneumonia: diffuse reticulonodular infiltrates with absent or minimal consolidation
Treatment of Fever of UNKNOWN origin
1. AB and coticosteroids may mask patterns of fever response. Empiric AB should be based on severity of illness.
2. If patient not actuely ill, observation along
3. If FUO, some patients resolve spontaneoulsy without every being dx
What is lymphogranuloma venereum?
STD via that of C. trachomatis with serological types L1, L2, L3 and thus differes from D-K which is the most common.
Treatment of OM:
Give IV AB for extended periods of time 4-6 weeks. Initiate AB therapy only after microbial etrioloy is narrowed based on data from cultures.
1. Empiric therapy requires penicilinase-R penicillin (oxacilin) OR a first generation cephalosporin (CEFAZOLIN)
2. Addition of an aminoglycoside or a b-lactam AB if pssibility of GRAM-NEG
3 Surgical debridement of infected necrotic bone is important
Classic CAP presentation includes that of
Sudden chill --> fever --> pleuritic pain --> productive cough
What are the risk factors for candidiasis?
1. Antibiotic therapy
3. Immunosuppressive therapy
4. Immunocompromised hosts (increased risk for both mucocutaneous and systemic candidiasis)
Late latent syphilis versus early latent syphilis?
Late latent = serology positive >1 year and not contagious during this time nor have symptoms
Early latent = serology postive < 1 year and not contagious during this time, the patient may relapse back to secondary phase with maculopapular rash...
What should be avoided in patients with acute bacterial prostatitis?
Prostatic massage: could lead to bacteremia
What are infectious causes of meningitis?
Neonates (GBS, E. coli, Listeria);
Children (N. Meningitis, S pneumo, H influ);
Adults (S. pneumo, N. meningitis, H. influ);
Elderly (S. pneumo, N. Meningitidis, L. Monocytogenes);
Immunocompromised (L monocytogenes, gram -, S. pneumo)
2. Viral: Enterovirus; HSV
Incubation period of tetanus ranges from ___ - ___. Onset of symptoms is gradual from 1-7 days.
2 days - 2 weeks
Unique symptoms of RABIES
1. Pain at site of bite
2. Sore throat, fatigue, headache, nausea, and/or vomiting
3. Encephalitis - confusion, altered mental status, headache, hyperactivity, fever
4. Hydrophobia - inability to drink, largneal spasm with drinking, hypersalivation
5. Ascending paralysis
Main route of HCV is ______ and is therefore more prevalent in IV drug users. Both sexual and perinatal transmission are not common in HCV but are in ___.
HIV/immunocompromised patients are at risk for which two pathogens capable of causing pneumonia?
Pneumocystis carinii and Myco TB
Common origin of encephalitis:
VIRAL IN ETIOLOGY
HSV-1 ("herpes encephalitis")
Arbovirus - eastern equine encephalitis, West Nile Virus
Enterovirus- poliovirus (also causes aseptic meningitis)
Less common causes: Measles, mumps, EBV, CMV, VZV, rabies, and PRION diseases like Creutzfeldt-Jakob disease
What is a complicated UTI?
(1) Any UTI that spreads beyond the bladder (pyelonephritis, prostatitis, urosepsis)
-risk factors for upper UTI: pregnancy, DM, vesicoureteral reflux
(2) Any UTI cause by structural abnormalities, metabolic disorder, neurologic dysfcn
If a patient presents to the ED suspected of tetanus, what should be done?
1. Admit to ICU and provide respiratory support
2. Give diazepam for tetany (NonDHP CCB)
3. Neutralize unbound toxin with passive immunity TIG
4. Provide active immunity with Td
5. Thoroughly clean and debride any wounds with tissue necrosis
6. Give AB (metronidazole or penicillin G), although efficacy isn't well known
What is the most common vector born illness in the US?
Lyme disease via tick bites. Peak incidence is during the summer months
How might a brain abscess manifest?
Focal lesion that involves the brain parenchyma secondary to:
1. Ear, nose, throat infection (sinusitis, otitis media)
2. Cranial trauma, brain surgery
3. Pyogenic lung infection (with hematogenous spread)
4. Dental Infection
Common microbial etiologies:
1. S. Intermedius (sinusitis)
2. S. Aureus (post-trauma; post-operative)
3. Anaerobes: chronic otitis media and chronic pulmonary disease; polymicrobial
Patients with sarcoidosis, histoplasmosis, tuberculosis and bronchiectasis are at severe risk of developing which forms of aspergillus?
Pulmonary aspergillus - may see fungus ball on CXR with dense pulmonary cavitation and consolidation of an entire lung lobe
How does disseminated HSV differ from HSV1 and HSV2?
-Common to immunocompromised patients
-Encephalitis (viral in origin); meningitis, kertitis, chorioretinitis, pneumoia, esophagitis
-pregnant women can develop disseminated HSV that can be fatal
Viral load of HIV-1 RNA levels facilitate the anti-viral treatment in which way?
1. Assess response to and adequacy of antiretroviral therapy, provides complementary prognostic information to the CD4 count.
2. If viral load is >50 after 4 mo treatment, modification to regimen may be necessary.
3. Measured at TIME of diagnosis and every 3-4 months thereafter. (both viral load and CD4)