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Module 12-Down & Dirty PPT
Terms in this set (29)
Fever of Unknown Origin (FUO):
Essentials of Diagnosis:
--Illness of at least 3 weeks duration
--Fever over 38.3 C on several occasions.
--Diagnosis has not been made after 3 outpatient visits or 3 days of hospitalization.
Fever of unknown origin (FUO):
Things to know:
--Most cases represent unusual manifestations of common diseases, such as TB, endocarditis, gallbladder disease, and HIV (primary infection or opportunistic infection).
--In addition to routine labs, blood cultures should always be obtained, preferably when the pt has not taken any antibiotics for several days, and should be held by the lab for 2 weeks to detect slow-growing organisms.
--All pt's with FUO should have a CXR.
--Although tempting to begin an empiric course of antibiotics for FUO, it's rarely helpful and may delay diagnosis if the etiology is infectious by reducing the sensitivity of the blood cultures.
--Empiric administration of corticosteroids should be discouraged because they can suppress fever and exacerbate many infections.
Epstein-Barr Virus & Infectious Mononucleosis:
Essentials of Diagnosis:
--Malaise, fever, & sore throat, sometimes with exudates. Palatal petechiae, lymphadenopathy, splenomegaly, and occasionally, a maculopapular rash.
--Positive heterophil aggulutination test (Monospot).
--Atypical large lymphocytes in blood smear; lymphocytosis.
--Complications: hepatitis, myocarditis, neuropathy, encephalitis, airway obstruction secondary to lymph node enlargement, hemolytic anemia, thrombocytopenia.
Epstein-Barr Virus & Infectious Mono:
Things to know:
--Over 95% of pt's with acute EBV-associated infectious mono recover without specific antiviral therapy. Treatment is symptomatic with acetominophen or other NSAIDs and warm saline throat irrigations or gargles 3-4 times a day.
--In uncomplicated cases, fever disappears in 10 days and lymphadenopathy and splenomegaly in 4 weeks. the debility sometimes lingers for 2-3 months.
--EBV is often implicated in the pathogenesis of a host of disorders from Hodgkin disease, multiple myeloma, breast & gastric carcinoma to CNS demyelination, multiple sclerosis, Graves disease, histiocytic necrotizing lymphadenitis (Kikuchi-Fugimoto disease), H.pylori-associated GI disease, COPD, rheumatic diseases, and dental disorders (pulpitis and apical periodontitis).
Cytomegalovirus Disease (CMV):
Essentials of Diagnosis:
--Frequent pathogen seen in transplant populations.
--Diverse clinical syndromes in HIV (retinitis, esophagitis, pneumonia, encephalitis).
--Major pathogen to consider in neonates in the differential of maternally transmitted agents.
Things to know:
--Most CMV infections are asymptomatic.
--CMV inclusion disease in infection newborns is characterized by jaundice, hepatosplenomegaly, thrombocytopenia, purpura, microcephaly, periventricular CNS calcifications, mental retardation, and motor disability.
--Acute acquired CMV infection in immunocompetent persons is characterized by fever, malaise, myalgias, arthralgias, and splenomegaly.
CMV--when to refer:
--Neonatal infections consistent with CMV inclusion disease.
--AIDS pt's with retinitis, esophagitis, colitis, hepatobiliary disease, or encephalitis.
--Organ and hematopoietic stem cell transplants with suspected reactivation CMV.
--Erythrovirus, formerly parvovirus B19, infects human erythroid precursor cells.
--Quite widespread (by age 15 about 50% of children have detectable IgG) & its transmittable through respiratory secretions and saliva, through the placenta (vertical transmission with 30-5% of pregnant women nonimmune), and through administration of blood products.
--Incubation period is 4-14 days. Chronic forms can occur.
--Symptoms of erythrovirus (parvovirus) infection can mimic those of autoimmune states such as lupus, systemic sclerosis, antiphospholipid syndrome, or vasculitis.
Fifths disease--things to know:
Erythrovirus (parvovirus B19) causes several syndromes:
--In children, an exanthematous illness ("fifth disease," erythema infectiosum) is characterized by a fiery red "slapped cheek" appearance, circumoral pallor, and a susequent lacy, maculopapular, evanescent rash on the trunk and limbs. Malaise, headache, and pruritius (especially on the palms and soles) occur.
--In immunosuppressed pt's, including those with HIV or transplants, or with hematologic conditions such as sickle cell, transient aplastic crisis and pure red blood cell aplasia may occur.
--A limited nonerosive symmetric polyarthritis that mimics lupus erythematosus and rheumatoid arthritis, which may in some cases be a type II mixed cryogalobulinemia, can develop in middle aged persons (especially in women) but can also occur in children.
--Rashes, especially facial, are less common in adults.
Kawasaki Disease--Essentials of Diagnosis:
--Fever, conjunctivitis, oral mucosal changes, rash, cervical lymphadenopathy, and peripheral extremity changes.
--Elevated erythrocyte sedimentation rate and C-reactive protein levels.
--Occurs mainly in children ages 3 months to 5 years but can occur occasionally in adults.
--Occurs significantly more often in Asians or native Pacific Islanders than in whites.
Kawasaki Disease--Things to know:
--Clinical diagnosis of "complete" Kawasaki disease requires, in the absence of other processes, explaining the current illness of fever and 4 of the following criteria for at least 5 days:
*Bilateral nonexudative conjunctivitis
*Mucous membrane changes of at least one type (injected pharynx, erythema, swelling and fissuring of the lips, strawberry tongue)
*Peripheral extremity changes of at least one type (edema, desquamation, erythema of the palms and soles, induration of the hands and feet, Beau lines [transverse grooves of the nails]
*A polymorphous rash, and
* cervical lymphadenopathy > 1.5 cm (most worrisome when retropharyngeal with edema is present).
--"Incomplete" form is diagnosed when only 2 criteria are met.
--Classic syndrome: often preceded by nonspecific symptoms including irritability, vomiting, anorexia, cough, and diarrhea for up to 10 days.
Rocky Mountain Spotted Fever--Essentials of Diagnosis:
--Exposure to tick bite in an endemic area.
--A flu-like prodrome followed by chills, fever, severe headache, and myalgias; occasionally, delirium, and coma.
--Red macular rash appears between the 2nd and 6th days of fever, first on the wrists and ankles then spreading centrally; it may become petechial.
--Serial serologic examinations by indirect fluoroscent antibody confirm the diagnosis retrospectively.
Rocky Mountain Spotted Fever--Things to know:
--Can cause severe multiorgan dysfunction and fatality rates of up to 73% if left untreated, making it one of the most serious rickettsial diseases.
--Two to 14 days (mean, 7 days) after the bite of an infectious tick, symptoms begin with an abrupt onset of high fevers, chills, headache, n/v, myalgias, restlessness, insomnia, and irritability.
--The characteristic rash (faint macules that progress to maculopapules then petechiae) appears between days 2 and 6 of fever.
--Thrombocytopenia, hyponatremia, elevated aminotransferases, and hyperbilirubinemia are common.
--Treatment with doxycycline at similar doses and duration (100 mg po BID for 4-10 days) is recommended, including for children.
Rubella--Essentials of Diagnosis:
--Exposure 14-21 days prior to onset.
--Arthralgia, particularly in young women.
--No prodrome in children, mild prodrome in adults; mild symptoms (fever, malaise, coryza) coinciding with eruption.
--Posterior cervical and postaurical lymphadenopathy 5-10 days before rash.
--Fine maculopapular rash of 3 days duration; fact to trunk to extremities.
Rubella--Things to know:
--A fine, pink maculopapular rash appears on the face, trunk, and extremities in rapid progression (2-3 days) and fades quickly, usually lasting 1 day in each area.
--Definitive diagnosis of acute rubella infection is based on elevated IgM antibody, fourfold or greater rise in IgG antibody titers, or isolation of the virus.
--False positive IgM antibodies, however, are associated with Epstein-Barr virus, CMV, erythrovirus (parvovirus), and rheumatoid factor.
Measles--Essentials of Diagnosis:
--Exposure 10-14 days before onset in an unvaccinated pt.
--Prodrome of fever, coryza (stuffy nose), cough, conjunctivitis, malaise, irritability, photophobia, Koplik spots.
--Rash: brick red, irregular, maculopapular; onset 3-4 days after onset of prodrome; begins on the face and proceeds "downward and outward," affecting the palms and soles last.
Measles--Things to know:
--Koplik spots (small, irregular, and red with whitish center on the mucous membranes) are pathogenic of measles. They appear about 2 days before the rash adn last 1-4 days as tiny "table salt crystals" in the buccal mucosa opposite the molars and vaginal membranes.
--Immediately following measles, secondary bacterial infection, particularly cervical adenitis, otitis media (most common complication), and pneumonia, occurs in about 15% of pt's.
--Repeated studies show no link between vaccination and autism.
--Prevalence of asthma-like diseases in childhood appears to be reduced among vaccinated children.
--Some data implicate the measles virus in the pathogenesis of rheumatoid arthritis.
--Pt should be isolated for the week following onset of rash and kept on bed rest until afebrile. Treatment is symptomatic including antipyretics and fluids as needed.
--Vitamin A 200,000 units/d po x 2 days (the benefit being maintenance of GI and respiratory epithelial mucosa) reduces pediatric morbidity (diarrhea, night blindness, xerophthalmia) and measles-associated mortality for infants between 6 months and 5 years of age.
Varicella (Chickenpox) & Herpes Zoster (Shingles)--Essentials of Diagnosis:
--Varicella rash: pruritic, centrifugal, papular, changing to vesicular ("dewdrops on a rose petal"), pustular, and finally crusting.
--Zoster rash: tingling, pain, eruption of vesicles in a dermatomal distribution, evolving to pustules and then crusting.
Varicella (Chickenpox) & Herpes Zoster (Shingles)--Things to know:
*Fever and malaise are common in children and more marked in adults.
*The pruritic rash begins prominently on the face, scalp, and trunk, and later involves the extremities.
*Acyclovir, 20 mg/kg (up to 800 mg/dose) po QID x 5 days, should be given within the first 24 hours after onset of varicella rash and should be considered for pt's older than 12.
*Herpes zoster ("shingles") usually occurs among adults.
*Pain is often severe and commonly precedes the appearance of rash.
*For uncomplicated herpes zoster, valacyclovir or famciclovir is preferable to acyclovir due to dosing convenience and higher drug levels in the body. Therapy should start within the first 72 hours of the onset of the lesions and be continued for 7 days or until the lesions crust over. There is no role for corticosteroids.
--Secondary bacterial skin superinfections, particularly with group A streptococcus and Staph aureus, are the most common complications.
--Acute infection of children and young adults caused by Bartonella henselae.
--Transmitted from cats to humans as the result of a bite or scratch. Within a few days, a papule or ulcer will develop at the site of innoculation in 1/3rd of pt's.
--1-3 weeks later, fever, HA, and malaise occur.
--Regional lymph nodes become enlarged, often tender, and may suppurate.
Cat-scratch fever--Things to know:
--Cat-scratch disease is usually self-limited, requiring no specific therapy. Encephalitis rarely occurs.
--A variety of atypical infections, including retinitis, encephalitis, osteomylitis, and persistent bacteremia and endocarditis have been described.
--Disseminated forms of the disease--bacillary angiomatosis, peliosis hepatitis, and retinitis--occur most commonly in immunocompromised pt's such as persons with late states of HIV or solid organ transplant recipients.
Pneumococcal pneumonia--Essentials of diagnosis:
--Productive cough, fever, rigors, dyspnea, early pleuritic chest pain.
--Consolidating lobar pneumonia on CXR.
--Gram+ diplococci on gram stain of sputum.
Pneumococcal pneumonia--Things to know:
--Pneumococcus is the most common cause of community-acquired pyogenic bacterial pneumonia.
--Pneumococcal pneumonia classically is lobar pneumonia with radiographic findings of consolidation and occasionally effusion.
--Differentiating it from other pneumonia's radiographically or clinically is not possible because of significant overlap in presentations.
--Once S. pneumoniae is identified as the infecting pathogen, any of several antimicrobial agents may be used depending on the clinical setting, community patterns of penicillin resistance, and susceptibility of the particular isolate.
--Uncomplicated pneumococcal pneumonia may be treated on an outpatient basis with amoxicillin.
--PCN allergic pt's, alternatives are azithromycin, clarithromycin, doxycycline, levofloxacin, and moxifloxacin.
Bordetella pertussis (whooping cough)--Essentials of Diagnosis:
--Predominantly in infants under age 2.
--Adolescents and adults are an important reservoir of infection.
--2 week prodromal catarrhal stage of malaise, cough, coryza, and anorexia.
--Paroxysmal cough ending in a high-pitched inspiratory "whoop"
--Absolute lymphocytosis, often striking; culture confirms diagnosis.
Bordetella pertusis (whooping cough)--Things to know:
--Pertussis is an acute infection of the respiratory tract caused by B pertusis that is transmitted by respiratory droplets.
--Incubation period is 7-17 days.
--Half of all cases occur before 2 years of age.
--Symptoms of classic pertussis lasts about 6 weeks and are divided into 3 consecutive stages.
--Acellular pertussis vaccine is recommended for all infants, combined with diphtheria and tetanus toxoids (DTaP).
--Antibiotic treatment should be initiated in all suspected cases. Treatment options include erythromycin, azithromycin, clarithromycin, or trimethorpim-sulfamethoxazole.
--Treatment shortens the duration of carriage and may diminish the severity of coughing paroxysms.
--Complex infectious disease caused by Treponema pallidum, a spirochete capable of infecting almost any organ or tissue in the body and causing protean clinical manifestations.
--Most commonly used nontreponemal antigen tests are the Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests, which measure the ability of heated serum to flocculate a suspension of cardiolipin-cholesterol-lecithin.
Syphilis--Things to know:
--Natural history of acquired syphilis is generally divided into 2 major clinical stages: early (infectious) syphilis and late syphilis.
--Most cases of syphilis in the US continue to occur in men who have sex with men (MSM).
--Lesions associated with primary and secondary syphilis are self-limiting, even without treatment, and resolve with few or no resdiua.
--Late syphilis may be highly destructive and permanently disabling and may lead to death.
--PCN remains the preferred treatment for syphilis, since there have been no documented cases of PCN resistant T pallidum.
--Pt's with infectious syphilis must abstain from sex for 7-10 days after treatment.
--All cases of syphilis must be reported to the appropriate local public health agencies in order to identify and treat sexual contacts.
--In addition, pt's with syphilis should have an HIV test at the time of diagnosis.
Lyme Disease--Essentials of Diagnosis:
--Erythema migrans, a flat or slightly raised lesion that expands with central clearing.
--Headache or stiff neck.
--Arthralgias, arthritis, and myalgias; arthritis is often chronic and recurrent.
--Wide geographic distribution, with most US cases in the Northeast, mid-Atlantic, upper Midwest, and Pacific coastal regions.
Lyme Disease--Things to know:
--Under experimental conditions, ticks must feed for 24-36 hours or longer to transmit infection.
--Nonspecific lab abnormalities can be seen, particularly in early disease. Most common: an elevated sed rate of > 20 mm/h seen in 50% of cases and mildly abnormal liver function tests are present in 30%.
--Tetracycline is effective against spirochete, but PCN is only moderately so.
--Erythromycin is effective in vitro but has been disappointing in clinical trials.
--Ampicillin, ceftriaxone, azithromycin, cefuroxime, and imipenem are also effective in vitro, but aminoglycosides, ciprofloxacin, and rifampin are not.
--Doxycycline is most commonly used.
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