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Infectious Disease

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What are the classical symptoms of pneumonia?

What are the atypical symptoms of pneumonia?
Classic:
sudden onset, fever, productive (yellow-green purulent sputum/hemoptysis), dyspnea, night sweats, pleuritic chest pain

Atypical:
gradual onset, dry cough, headache, myalgias, sore throat, GI symptoms
How do you dx pneumonia?
2 or more symptoms of acute respiratory illness
+
new infiltrate on CXR or CT

w/u: CXR, CBC, sputum gram stain, sputum/blood cultures
Which patients with pneumonia can be treated as outpatient and which patients should be hospitalized?
Outpatient (oral antibiotics):
uncomplicated pneumonia

Inpatient (iv antibiotics):
>65 yo
comorbidities (EtOH, COPD, DM, malnutrition)
respiratory failure
AMS
multilobar involvement
What are some potential complications of pneumonia?
Pleural effusion
Empyema
Lung abscess
Necrotizing pneumonia
Bacteremia/Septicemia
What organism is responsive for TB?
Mycobacterium tuberculosis
What are some risk factors for TB exposure in the US?
Homelessness
Crowded living conditions (prisons)
Emigration/Travel from developing nations
Health professionals
Contact with TB pts
What are some risk factors for active/reactivation TB?
Immunosuppression (HIV)
EtOH
Preexisting lung dz
DM
Advancing age
What is the presentation of TB?
Cough/Hemoptysis
Dyspnea
Weight loss/Cachexia
Fatigue
Night sweats
Fever (fever of unknown origin)
Lymphadenopathy
Prolonged symptoms > 3 weeks
Extrapulmonary involvement
How do you dx active TB?

How do you dx latent TB (LTBI)?
Active:
Sputum/blood/tissue culture (gold std but takes weeks)
Sputum acid fast stain (rapid but lacks sensitivity)
CXR w cavitary infiltrate in upper lobe (HIV pt may have lower lobe infiltrates +/- cavitation)
Multiple fine nodular densities suggests Miliary TB

Latent:
PPD (all +PPDs -> f/u CXR)
What is the relationship between the BCG vaccine and PPD?
BCG vaccination -> +PPD but does not preclude prophylaxis as recommended for unvaccinated pts (possible false positive PPD)
How do you read a PPD?
PPD injected intradermally on volar surface of forearm and then the diameter of the induration is measured at 48-72 hours. PPD is positive if:

> 5 mm: HIV, risk factors, TB contacts, CXR e/o TB
> 10 mm: health care workers, homeless, IVDU, prison, resident of developing nation
> 15 mm: no risk factors + everyone not above

Anergy = Immunosuppression, elderly, malnutrition may give false -PPD thus TB not ruled out
What type of hypersensitivity reaction is a PPD test?
Type IV Hypersentivity Reaction

Delayed (cell-mediated) type
Sensitized T lymphocytes encounter antigen -> release lymphokines
What is the tx for TB?
All cases (active/latent) must be reported to health department.

Respiratory isolation if active TB suspected.

Active:
Directly observed 4-drug therapy
RIPE (Rifampin, INH, Pyrazinamide, Ethambutol) + vitamin B6 (pyridoxine) x 2 mo -> INH, Rifampin + vitamin B6 (pyridoxine) x 4 mo

Latent (+PPD w/o e/o active dz):
INH + vitamin B6 (pyridoxine) x 6-9 mo
or Rifampin x 4 mo
What are the major s/e of the tx for TB?
RIPE Vit B6

Rifampin -> orange bodily fluids
INH -> peripheral neuropathy + hepatitis (tx w vitamin B6)
Pyrazinamide -> ?
Ethambutol -> optic neuritis
What is the most common cause of acute pharyngitis?
Viral (>90% in adults)

rhinovirus, coronavirus, adenovirus, HSV, EBC, CM, influenza, coxsackievirus, acute HIV
What are some bacterial causes of acute pharyngitis?
Group A beta-hemolytic Streptococcus pyogenes
N.gonorrhoeae, C.diphtheriae, M.pneumoniae
Early antibiotic tx of streptococcal pharyngitis can prevent which complication while having no affect on which other?
Early antibiotic tx of streptococcal pharyngitis can prevent rheumatic fever but not post-strept glomerulonephritis