Step Up to Medicine: Chapter 10 Infectious Disease

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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:

1. Jaundice
2. Dark-colored urine
3. RUQ pain
4. N/v
5. Fever/malaise
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

Most common cause of death due to infection worldwide


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
3. Splenomegaly
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?

1. PID
2. Salpingitis
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?



-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 is the diagnostic tool for intra-abdominal absesses using IMAGING:

CT scan or ultrasound

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

How is malaria diagnosed?

peripheral blood smear, must have GIEMSA STAINS

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:

1. Serology
-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

Toxoplasmosis prophylaxis in HIV patient:

If CD4 < 100 administer BACTRUM (tmp-smx)

How might vaginal candidiasis be treated?

1. Miconazole
2. Clotrimazole cream

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
-highly infectious

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

What causes a CHANCROID?

Haemophlius ducreyi, a gram-negative ROD

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
2. DM
3. Use of illicit drugs (IV)
4. Sepsis

How is disseminated/systemic candida treated?

ORAL fluconazole

New agents include: voriconazole as CASPOFUNGIN

How long does genital herpes last for (symptoms)?

3 weeks

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?

Pseudomonas Aeruginosa

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

Oval budding yeasts known for their formation of hyphae and long pseudohyphae.

Candida species

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

OM of the vertebral bodydue to M. TB is called _____ ______.

Potts Disease

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

RMSF is characterized by the intracellular bacteria

Rickettsia rickettsii
Vector: ticks

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.


Diagnosis of TSS

High index of clinical suspicion, blood cultures are usually negative

Neurosyphilis is characterised by: ________, ___________, ________


Dementia, personality change, tabes dorsalis

Rx. penicillin

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?

Isonizid only

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 -)
2. UA
-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:

S. aureus

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

Headache that worsens when lying down; fevers; n/v; stiff, painful neck, malaise


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:

1. GAS
2. S. Aureus

What is the treatment of RABIES postexposure?

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?

1. CXR
2. PAN culture (blood, urine, sputum, line tips, wound)
3. CBC
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.

Define encephalitis:

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

Which countries have an elevated prevalence of HEV?

India, Pakistan, SE Asia, parts of Africa

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
Eaton-Lambert syndrome
Myasthenia gravis-EM studies differentiate
Diptheria toxin
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.

polysaccharide, pigeons

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.

Chronic pyelonephritis can result in ______ of the kidneys long-term


Necrotizing fasciitis is common two which two bacterial causes?

1. C. Perfringens
2. S. Pyogenes

What are the top three common agents for CAP?

S. Pneumonia
H Influenza
Aerobic gram negative rods
S. Aureus

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)

1. Infection
--> Sepsis, UTI/urosepsis, Pneumonia, Bacterial Meningitis, intracranial abscess, subdural empyema
2. Medication/Drugs
--> 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
7. Leukocytosis
8. Elevated ESR (90%) and CRP

Best imaging: CT or MRI

How is disseminated candida diagnosed?

BLOOD or TISSUE culture

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?

Clinical symptoms:
Rapid onset of fever
NONproductive cough
Sore throat

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
Glucose: WNL
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

The majority of tick bites do not result in infection, T or F


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.

In alcoholics, most common agent causing pneumonia?

klebsiella pneumonia

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

Fever/chills + flank pain + suprapubic pain + urinary frequency/urgency


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.


Coxiella burnetti
blood and fluids
Diagnosis: CXR: multiple opacities inacute illness
Treatment: IM streptomycin (AG) or streptomycin


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)
5. Drugs
6. Pulm Embolism
7. HA
8. Familial Mediterranean Fever
9. Gout
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?

1. Blood
2. Semen
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


-ELISA is used to detect IgM and IgG AN during first month
-Western blot is used to confirm

Most common cause of candidiasis

Candida albicans

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

How is botulism diagnosed?

Toxin identification in serum, stool, gastric contents via bioassay

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.

What is the incubation period for rhabdovirus (RABIES)?

30-90 days but can vary

Hepatitis D antibody (HDV) presense indicates ___________.

Superinfection (usually) with HBV

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:

< 100

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


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.

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