2018 Infectious Disease 9% Flashcards
1
Q
MCC bacterial endocarditis
A
staph aureus
2
Q
Native valve endocarditis
A
Staph aureus, strep bovix, strep gp D (enterococci) ->
Vanco/gentamycin empiric
3
Q
Prosthetic valve
A
staph epi, streptococci, G neg fungi ->
vanco, rifampin (clears sticky bugs - staph epi), gentamycin
4
Q
IVDU
A
staph aur, enteroccus, g neg strep viridans ->
vanco + gentamycin
5
Q
Indications for endocarditis surgery
A
- Severe CHF
- bacteremia x 6 days (if repeat bcx 48 hrs +, cont abx, repeat ctx,
- recurrent emboli, valve abscess,
- large fungal vegetation
6
Q
Rt sided endocarditis with septic emboli - abx?
A
Daptomycin
7
Q
Pt with sympt endocarditis - bctx done, vanco/gent started - 72hrs later bctx + strept sens to PCN - abx changed to PCN - gnet d/c’d - reepat bctx still + 24hrs later wtd?
A
continue abx, repeat bctx in 48hrs
8
Q
IVDA rec with fever, cough hempotysis, pleuritis CP - II/VI SEM - 2-3 nodules on CXR - dx?
A
Rt sided endocarditis -> vanc/gent
9
Q
Pt fever, +BCtx for clostr sept/ Strep bovis - wtd
A
Colonoscopy r/o malignancy
10
Q
IVDA suspected for endocarditis vanc/gent started - ctx +PCN enterocci - vanc stopped - pcn started but then with prurtis swelling lip swelling - wtd?
A
D/C PCN start vanc
11
Q
Vanc develops itching/redness
A
redman’s - slow IV infusion +- benadryl
12
Q
Pt s/p TURP 2 wks later with fever growing enterococci
A
Tx: amp+gent, vanc+gent, zosyn, linezolid ( works for VRE faecium/faecalis, MRSA, VISA. SE: decr plts, neutropenia, serotonin synd, lactic acidosis, optic neuritis)
IE ENTEROCOCCAL:
- older men, AV>MV, more CHF less embolic events, more conduction defects - don’t use ceftriaxone (doesn’t kill)
AV endocards MC assoc w/ conduction defects
13
Q
Valve replacement
A
NOT in pt febrile on abx - mild AR EF 60% - BUN cr 25/2 -> immune complex phenomenon - see splinter hemorrhage, janeway lesion, roth spots
14
Q
Pt treated for endocardtisi defervesces and WBC dec but w/ 1st deg AVB - concerned?
A
yes - r/o valvular abscess - TEE
15
Q
Pt on imipenum/cilastatin for nosocomial infxn h/o seizure d/o - has dz - related to imipenum?
A
Yes - inc’d incidence of seizures at higher doses
16
Q
Endocarditis ppx only for high risk procedures in high risk conditions…
A
High risk condition -
- ALL prosthetic valve,
- prev h/o endocarditis,
- congential heart dz, unrepaired CHD, including shunts
- repaired CHD within 6 months,
- post tx heart WITH valvular dz,
- repaired CHD with prostesis or patch (forever)
High Risk procedure likely to cause bleeding->endocarditis -
- dental extraction, periodontal procedures, root canal, implants
NOT HIGH RISK - GI/GU (only if risk of mucosal damage
Low risk conidtions - ASD secundum, 6 months after repair of ASD/VSD/PDA, prev CABG/HOCM, PPM, MVP with murmur MS/AS, fxn murmur
Low risk procedures - cavity filling, endotrach intub, bronch all GI/GU, vaginal hyterectomy, D/C C section, IUD, cath, circumcision
17
Q
Endocarditis ppx
A
Amox 2g po 1 hr prior,
if no PO then amp IV,
PCN all - azithro,
post procedure - > NOTHING
18
Q
Pt witih PDA going for cystoscopy
A
NO ppx
19
Q
Pt with bacteremia s aur due to IV line - vanc started wtc
A
TEE if negative.
- BCx neg < 72 hrs on abx -> cont IV abx 2 wks
- BCx neg >72 hrs on abx -> cont IV abx 4 wks
- BCx pos in immun compromised -> cont IV abx 4 wks
- BCx pos in prost valve, cardiac device, arthroplasty -> IV abx for 4 wks
If TEE positive -> tx w/ abx 6-8 wks
20
Q
Pt with susp diverticulitis pw f/c/abd pain - 3 days later temp 101, catheter site clean wbc 17K - wtd
A
vanc + merrem
21
Q
obesity with vanc
A
1.5g IV q12h (15-20mg/kg)
22
Q
35yo IVDA fever/chills wit hmurmur, vegetation on TV bctx MRSA - tx?
A
Daptomycin
23
Q
Empiric tx meningitis
A
- Head trauma/NSx - (staph aur MRSA, S pneumo, G neg bacilli) –> vanc + cefepime
- 50yo (Listeria, S pneumo, neisseria ) –> Ampicicillin (listeria), rocephin (S pneumo), Vanco (MRSA)
- 15yo (S.pneumo, n.mening, h.flu) –> Ceftriaxone
- 2 month (strep agalactiae, E. Coli, Listeria) –> Ceftx + ampilcillin (listeria)
24
Q
Normal CSF
A
<5cells, lymph, Gluc 40-80, Protein 15-45
25
Bacteria CSF
10-100K cells, PMNs, dec gluc, inc protein, inc opening pressure
26
West nile CSF
10-1K cells, Lymph, dec gluc, inc protein, muscle wk, rash, dec DTR
27
TB CSF
10-1K, lymph, dec gluc, very inc protein,
28
Aseptic CSF
10-2K, lympoh normal gluc, inc to normal protein, enterovirus, OKT3, NSAIDS, bactrim
29
Early bacterial CSF
10-1K, lymphs > PMN, dec gluc, inc protein, CSDF to ser glu <0.4
30
Encephalitis CSDF
1-2K, lymph, normal gluc, normal to inc protein
31
HSV enceph CSF
1-2K, lymph, N gluc, n to inc protein, +RBC 1:1 ratio
32
70yo Pt with DM p.w mental status change spinal tap with many WBCs mainly PMN G stain neg ctx pending wtc
ceeftx + vanc cover resistant strep pneumo
+ ampicillin cover listeria
33
55yo post renal tx on steroids pw fever, neck stiffness with g po rods diphteroids in csf; PMN 65% and lymphs 35% - dx?
Listeria - tx
ampicillin + gentamycin (bactrim if PCN all)
34
24yo M neck pain, h/a, neck sign + spinal tap WBC 105, lymphs no RBC gluc 50 - cause?
entero/echo virus meningitis
35
Causes of aseptic meningitis
OKT3 ab, NSAID, bactrim, echo/enterovirus
36
70yo COPD PNA twice in 1 year p/w cough, fever, chills, MS change - WBC 17 PMN, LLL consolidation, CTH no bleed - spinal tap WBC >20K, PMN, dec gluc, inc protein, gram stain cocci in pairs - wtd?
empiric thx --> ceftriaxone + vancomycin + dexamethasone
rifampin for pcn resistance
37
Pt with meningitis - LP WBC 75, gluc 28, elev protein - elev OP - crypt ag neg, g stain neg - tx for?
bacterial meningitis empirically
38
16yo MS change, fever BP 80/60 - exam midline scar abdomen - lab leukocytosis - h/o MVA 2ya splenectomy
organism - s pneumo (capsule)
39
Meningitis by h&p - wtd
IV abx - do not wait!
40
Pt with h/a x 2 days - now dizzy, lethargic - meningieal + sign - 7th episode in 6 years dx - CSDF granular cells?
beningn recurrent lymphocytic meningitis - HSV-2 - supportive care only (antivirals no benefit) - Mollarett's meningitis
41
Fever, h/a, vom/seizure - smelling fishy odor/burning rubber, auditory hallucination - MR brian hyper intensity temporal lobe -> EEG sharp and slow waves temporal lobe - LP WBC 200 lymphs, gluc 45, protein 75 RBC 65! dx?
Herpes encelphalitis - IV acyclovir
confirmed by PCR assay of CSF
42
70yo h/a, fever x 5 days, confused, ocular pain, diplopia - hiking partner similar sx which resolved - mild neck signs + or focal wk one side body DTR absent - LP WBC 55, 100% lymph, protein 90 gluc 50 wtd
WNV IgM ab check - prognostic factor is age - >75 is bad
| Reservoir - birds, transmitting agent=mosquitos
43
Pt fever h/a x 2 days - neck stiffness WBC 8800 68% PMNs - 8% bands - spinal tap WBC 85 54% PMN 33 lymph RBC 0 - gluc 26, protein 68
early bacterial meningitis
44
20yo F college with tonic clonic sz - h/a and strange behavior x 1 week with anxiety/paranoid behavior, no psych/drug abuse hx - orthostatic hypotension, choreform movements difficulty choosing words - CSF 40WBC 96% lymph, 3 RBC, gluc 62, protein 30 CTH normal - tx'd for HSV enceph no improvement HSV PCR neg - dx?
NMDA rct encephalitis
then CT abdomen/pelvis --> ovarian teratoma
45
H/A confusion, petechial maculopapular rash - CT neg, LP WBC >2K - PMN and low gluc - G stain G neg diplococci - meningiococcal meningitis - tx with ceftx 3 days later hypotensive shock
b/l adrenal hemorrhage -> IV hydrocortisone
46
Who to PPX for meningitis
1. prophylax day care/nursery school contacts,
| 2. household contacts
47
How to PPX meningitis
1. rifampin 600po BID x 2 days, if CI cipro x 1 dose
2. If on OCP - change contraception while on rifampin
3. If preg - ceftx 250mg IM x 1
Droplet precautions (3-4 ft contact) (measles/TB = aireborne)
Meningococcemia also with Eculizumab use, men who have sex with men, college, middle east and africa) therefore should be vaccinated.
48
Pt tx'd for meningiococcal meningitis since yesterday - how long continue isolation
D/C isolation now.
24hour abx
49
52yo M p/w h/a - fever/neck signs - spinal tap elev open press, WBC 45 lymphs, protein 52, gluc 65, abx coverage for strep pneumo and hsv - 2 days later ctx neg, HSV pcr neg
d/c all meds and d/c home
50
HSV-2 causes...
aseptic meningitis - and can be accomopanied by gential ulcers
HSV-1 causes encephalitis
51
UTI cystitis etio?
1. cystitis -> mostly ecoli - young women, staph saprophyticus,
52
Uncomplicated cystitis
3 days nitrofurantoin/bactrim
recurrent cystitis in post menopausal women -> after tx w/ abx --> intravaginal estrogen for prevention of recurrent UTIs better than cranberry juice.
53
Cystitis in pregnancy
nitrofurantoin or amoxicillin x 7 days
54
Asx bacteruria in pregnancy
TREAT
55
Asx bacteriuria in DM
DO NOT TX
56
Asx bacteriuria post transplant
TREAT
57
Asx funguria with foley
DO NOT TREAT
58
asx bacteriria in foley
DO NOT TREAT
59
Recurrent cystitis
c/s and tx then suppressive regimen (bactrim/cipro)
60
Pyelonephritis
chills, fever, flank pain, tenderness, inc WBC urine
61
24yo F fever, chills, flank pain dysuria inc freq urin - +flank tenderness, +u/a 40WBC
tx cipro 7-10 days (quinolone like cipro)
bactrim if susceptible
if preg - admit and start ceftriaxone (NO bactrim/quinolone)
if pcn allegeric = aztreonam (azactam*)
62
32yo flnak pain, UA WBC >20 with many bacteria temp 102, HR 110 - started on amp-sulbactam - 3 days later pt eating/ambulating temp 99 HR 86 - grows ESBL E.coli and BCtx g neg rod -
still ok to d/c change to amox-clavulanate (augmentin*)
63
Elderly male dysuria inc freq, tender prostate
Acute prostatitis - common bacteria in elderly is E.Coli
| Tx: bactrim or quinalone (cipro) x 4-6 wks
64
NH pt with foley and recurrent UTI - ppx?
nothing effective
65
Pt with foley - urosepsis -
change foley, start abx
66
Nursing home pt with stroke and a chronic foley with urosepsis several times a year. best way to minimize risk of UTIs?
closed drainage catheter system.
67
STD - Gonnococcus, Chlamydia presentation?
no ulcer, no adenopathy, +discharge
presentations:
uretheritis, epididymitis(pain at posterior pole), mucopurulent cervicitis, dysuria, pyuria w/o bacteriuria, PID, dissem gonococcal infxn
68
Gonococcus tx
tx ceftriaxone 250mg IM
69
Chlamydia tx
Tx doxycycline or azithro 1gm
70
GC & Chlamydia tx
ceftriaxone + azithro 1gm or Azithro 2g one dose
71
Presentation GC/Chylamydia
urethritis, epidiymitis, mucopurulent cervicitis, dysuria, pyuria without bacteriuira, PID, diss gonococcal infxn (DIG)
72
24yo F college student sexually active with fever, chills.n,v x 3 days no vaginal d/c, tmep 102, HR 106, MM dry, left flank tenderness, mild suprapubic tenderness - no cervical motion tenderness - preg test neg
Admit - bctx, tx with IV cipro or bactrim
73
Vaginitis - Trichomonas
yellow d/c, strawberry cervix, pH>5
tx - metroniidazole 2g x 1 dose or tinidazole 2g x 1 dose -> TX PARTNER
repeat NAAT testing in 3 months
74
Bacterial vaginosis (gardnerella)
think d/c, clue cells, fishy odor pH>5
Tx Metronidazole 500mg BID x 7 days (whole garden - tx many days) - or metronid gel 0.75% qd x 5 days, or clinda cream 2% qd x 7 days - DO NOT TX PARTNER
75
Candidiasis
not foul smelling, #1 burning #2 itching #3thick white discharge
Tx - fluconazole 150mg x 1, topical clomazole x 3-7 days
(use in pregnancy 7 days)
tx partner only if balantitis present
76
pt with scanty foul smelling dc OTC vag azole for 3 days w/o improve and po fluconazole didnt work - wtd?
its NOT Candidasis - treat for gardenerella/trichomonas with flagyl or clinda
po or cream
- check vaginal pH (>5.5?) - if scraping bleeding - chlamydia
77
Pt with dysuria - discharge on exam - UA WBC and clue cells(epithelial cell with distinct margin) - tx?
metronidazole (bacterial vaginosis)
78
PID
lower abd pain, CMT, adnexal tenderness, mucopurulent d/c, uterine tenderness
Etiology - Neiseria gonorrhea, chlamydia, vaginal anaeroboes
79
Complications of PID
infertility, ectopic preg, perihepatitis, tuboovarian abscess
80
Tx of PID
Outpt - Ceftx 250 IM, dox 100 bid x 2 weeks (PCN ofloxacin +clinda/flagyl)
Inpt - vomiting/sev pain - cefoxitin/cefotetan + doxy 100mg bid x 2 weeks (PCN allergy - clinda/flagyl + genta + doxy)
81
25yo F p/w progressive lower abd pain for past 4 days with nausea, vomiting, fever - denies dysuria or flank pain - temp 101, HR 100 lower abd tenderness - cervical d/c and cervical discharge and motion tenderness - WBC 17, 70% pmn , pregn test neg, chlamydia, gonococcal, blood cx pending. you would...
Admit and tx with IV cefoxitin and iv doxy for PID (not tolerating PO)
82
24 yo sexually active man with uretheral d/c - given ceftx 250 x 1 and d/c 10 days later with uretheral d/c - wtc?
dx: chlamydia -->
wtd. : gonococcus ---> (2-6 day incubation)
Chlamydia (1-4 week incubation)
doxy 100mg PO bid x 7 days or aithro 1g x 1
- always tx for both gonorrhea and chylamydia
83
Young woman on OCP, sexually active with yellow mucoid dc - exam non-tender but bleeding and cervix erythematous swollen - smear with wbc bacteria no hypahe - organism?
Chlamydia
84
20 yo F dysuria x 1 week - no fever or flank pain - pelvic exam no cervical motion tenderness, no bacteriuria, wbc 20/hpf (pyuria) dx? test? tx?
dx chlamydia
- check urine nucleic acid (NAAT)
tx doxycycline or azithro
85
Pt w chlamydia treated w doxy, has f/u and is asymp, but repeat chlamydia test pos. wtd?
< 3 wks = false + (test neg after 3 weeks post tx)
>3 wks = true + test. -> retreat pt and partner
86
Student on spring break - p.w tenderness in posterior testes 1 week later - striping of urethra with d/c?
chlamydia epidiymitis
| - tx azithro
87
24yo F sexually active pain on movement of wrist joint - single pustular lesion on dorsum of hang, swollen right knee - greatest yield of culture from...
cervical culture or history****
| do not need parents permission to tx STD
88
Gay pt c/o constipation, severe pain on defecation and generlized wkness - ulcer in perineal area - ulcer in anal canal on anoscopy - dx?
HSV
89
Pt with acute testicular pain - h/o several sexual encounters - no trauma - US normal - dx of epididymitis - organism?
1. < 35 yrs = chlamydia, gonorrhea... tx azithro
2. >35 yrs = e.coli, enterobacter... levofloxacin
ALWAYS DO HIV TEST ON A PT WITH GENITAL ULCER
90
Uncircumcised pt wit pearly penile papules wtd?
do nothing
91
Genital ulcers
HSV, syphilis,
H ducreyi,
Lymphogranuloma venerium,
granuloma inguinale
92
Pt with PAINFUL ulcers - started as grouped vesicles - lymph nodes + --> fever, h/a, myalgias. dx? tx? multiple episodes?
HSV (DNA virus)
Tx - 1st episode = acyclovir x 10 days
2nd = acyclovir x 5 days
recurrent (>4episodes/yr) = cont acyclovir ppx indef.
severe dz - iv acyclovir
ACYCLOVIR reduces duration of sx and asympt viral shedding
93
Pt w/ PAINFUL genital ulcers, irreg borders initially started as tenderpapules painful adenopathy fluctulant -> rupture - "schools of fish" OR "boxcar" appearance - GRAM NEG Bacillus. dx ? tx?
H. ducreyi
tx - ceftrx 250 IM x1 or
azithro 1gm x1 or
erythro 500mg qidx 7 days
NO DOXY
94
Pt with PAINLESS gential ulcer - disappears in 1 week - 2-6 weeks later LAD - buboes, fistulae rectal scaring
```
Lymphogranulum venerum (LGV) - Chylymia trachomatis
tx - Doxy 100mg bid x 21 days
```
95
Pt with terrible looking PAINLESS ulcers on penis + LAD looks like penile CA. dx? micro? tx?
Granuluoma Infuinale - klebsiella granulomatis
Micro: Donovan bodies - bipolar safety pin intracytoplasmic inclusions
Tx - Doxy x 21 days or bactrim/erythro
96
Young woman 4 month ago with PAINLESS genital ulcer - dark field micro +, RPR neg at time - tx'd with PCN... now p/w severe small ulcer - tender. RPR 1:8 . wtd.
has herpes infxn - acyclovir
titers increase then decrease:
1: 256
1: 128
1: 66
1: 33
1: 16
1: 8 **
1: 6
1: 2
1: 1
RPR can disappear, FTA + is forever.
97
Asx pt RPR screening 1:8 postive FTA +
1. If pt RPR neg last year = early latent syphilis - tx benz PCN 2.4 mu x1
2. If Pt RPR neg >1 yr ago = late latent syphilis - tx 2.4 mill units wk x 3 (higher chance to go to the brain)
98
Pt with PAINLESS genital ulcer raised with indurated margin and clean base wtd?
Dark field microscopy
tx - benz PCN 2.4 units x1 or
doxy x 14 days
99
Pt with fever h/a generalized adenopathy, maculopap rash palms/soles, elev ast/alt/ alk phos, hereophile Ag neg, elisa neg, HIV PCR RNA <50cps. wtd
1. VDRL/RPR to r/o secondary syphilus
2. FTA+ for life
tx - Benz PCN 2.4 mu x 1
if repeat VDRL titer decr 4 fold, tx = success
If repeat VDRL inc/stay same -> LP to r/o neurosyphilis
100
40yo for regular checkup - pupils 4mm when finger to nose, eyes converge and pupils 3mm, (accomadation)
flashing light left pupil doesn't constrict - Arygl robertson pupil. Serum FTA +. wtd next.
Spinal tap VDRL r/o neuro syphilus
most sen but 30-50%
101
Spinal tap WBC 410 predom lymphocytes, VDRL -, protein 90, gluc 60 - best mngt?
PCN G 2m units Q4h x 2 weeks (till neurosyphilis, people miss this therfore Q)
If PCN allergic - desensitize in ICU
repeat spinal tap q6m till WBC normal
102
Pt dx with syphilis started on PCN couple hours later with HA/fever, myalgias - BP 90/70, HR 104. dx?
Jarisch Herxheimer rxn - wtd?
Bed rest, ASA, continue PCN (NOT ANAPHYLAXIS)
103
45yo M h/a, difficulty walking, imbalance, fever double vision - HIV CD4 395, VL<24 dx?
neurospyphilis - spinal tap VDRL
104
Tick borne
```
RMSF,
Lyme,
Erlichia (anaplasma),
babesia,
Tularemia,
STARI (southern tick associated rash illness)
```
ONLY ONE WITHOUT RASH COMMON IS ERLICHIA**
105
22yo N carolina camp c/o h/a, fever, myalgia, +/- abd pain. 3 days later macular rash extremities - next day petechial..... dx?
RMSF -
tx = doxycycline/tetracycline
increased creatinine = increased mortality
106
57yo M cramping p/w complaint of h/a, fever, myalgias can't recall tick bite (means nothing low sens) - exam low grade temp, mild confusion no rash - WBC 2500, Hg 13, plt 60,000, AST/ALT 150/120 - cause?
Erlichia aka anaplasma phagocytophilia
only one without common rash! inclusion bodies.
107
Pt vacationing nantucket/long island p.w fever, shaking chills*, drenching sweats* NO RASH* - blood smear ring forms, 'maltese cross', 'tetrads' - Hg decr, incr retic count(hemolysis) dx? tx?
Babesia
Tx - mild form = Azithro + atovaquone
Severe = Quinine + clindamycin
108
Pt presents to doc office in NJ with skin lesion on thigh, erythematous lesion about 6cms diameter, slightly raised with #1 partial central clearing, lesion smaller few days ago... dx?
```
#2 large lesion erythematous
#3 rash which is darker in the center
#4 rash 4cm, yesterday 1-2 cm
```
erythema chronicum migrans d/t secondary lyme's dz stage 1. .....
(serology not reliable - clinical dx)
Tx - doxy, if preg then amox
other feature of stage1 = (fever, h/a LAD, arthralgia)
109
Pt fishing on nantucket island - rash on leg which disappeared few days later - 2 wks later pt with dizziness - 2/3 deg heart block.... dx? tx?
Lyme dz stage 2
Tx: PCN/Ceftx --> Doxy
Cardiac I/II/III deg heart block
Neuro: aseptic meningitis, bell's palsy, foot drop
110
Pt with disseminated or late stage lyme usually has...
positive western blot IgG, > 5 bands positive
111
22yo c/o left foot weakness, no trauma - hiking several weeks ago with as rash cleared in few days doesn't recall tick bite - dec power L foot, dec reflexes L foot dx?
Foot drop 2/2 lyme dz stage II
Stage III months to years later - presents as monoarticular arthritis or chronic neuro sx
112
Pt hiking in NE on friday for bird watching, found tick monday - no rash no sx. wtd?
doxycycline
>36 hr with tick = increased risk -> doxycycline even if asx
< 36 hrs with tick = can observe if asx
113
Pt hiking NE for bird watching - p/w facial palsy - cluster of vesicular eruption over auditory canal - dx?
Herpes zoster - DNA virus (multinucleated giant cells)
| tx - acyclovir
114
40yo F referred with rash, central clearing - tx'd with doxy x 3 weeks, f/u at doc office, who ordered serologic testing... 7/10 IgG bands positive.. and all bands + for IgM. Patient referred to you again and she is tired and has unrefreshing sleep. most likely dx?
systemic exertion intolerance disease (new name for chronic fatigue syndrome)
wtd.. reassure that she has received enough tx for lyme
115
Pt p/w tick attached - wtd?
place forceps at base of tick and lift gently
116
22yo Pt hiking in wisconsin - to ED with new onset weakness, DTR absent, denies tick bite - wtd?
search scalp for tick - tick paralysis better in hours once tick removed
117
Elderly pt with fiery red, well demarcated cellulits on face... dx... etio.. tx... compl?
cocci in chains
dx: Erysipelas -
etio: strep - cocci in chains
Tx: PCN
Complication: endocarditis
118
Female honey crusted lesions around mouth and chin - dx?
Staph infxn - impetigo
bactrim
119
Strep throat complication
Acute glomerular nephritis
120
Pt with cellulits of leg, started on IV cephalosporin 1st gen - 72hr later cellulitis worse w/ small punctate abscess points. no brawny edema or bullous lesions, no DM.... wtd?
D/C cephaloporin and start bactrim, vanc or clinda
121
32yo cellulits on left leg... what would you start?
bactrim and cephalexin (cover MRSA and strep)
122
Invasive MRSA commonly presents as ?
Bacteremia
123
Daptomycin used for G pos organisms including MRSA (not for PNA) - what to follow in pt on dapto?
CPK weekly.
also dapto inactivated by surfactant so do not use in pneumonia
124
Pt with venacaval filter placed - 48hrs later p/w erythema at incision site diffuse rash hypocalcemia, hyponatremia, inc Cr dec BP, fever - wound gram stain neg... dx?
dx: Toxic shock syndrome
etio: Strep - early onset < 24hrs - cx usually (+) OR
Staph - late onset > 24hrs - cx usually (-)
Tx - surgical debridement > PCN+clindamycin
125
Pt slipped and hit leg on bed railing in hospital, OR Pt fishing and scraped arm 2 days later BRAWNY edema and severe tenderness with erythema - next day BULLOUS lesions - aspiration of bullae -> G+ cocci - started on IV abx - Pt hypotensive - on clinda and 1st gen cephalosporin..... dx?
dx: Group A strep necrotizing fascitis
WTD?
Surgical consult!
best imaging study = MRI scan to confirm diagnosis in earliest manifestations (best for soft tissues)
126
causes of toxic shock syndrome ....
- menstruating women wearing tampons,
- post op wound,
- breast implants,
- prolongednasal packing
LEAST LIKELY: nursing home pt wearing diapers
127
Pt Gulf coast/florida (warm waters) p.w cellulitis with hemorrhagic bullae and necrosis +LN dx?
Vibrio vulnificurous (loves iron) -
also:: liver tx patients at inc risk with raw shell fish
tx - aggressive debridement
IV 3rd gen ceph or tetracyclin/gentamycin
128
Pt (fish tank clenaer/swimming instructor) - p.w non-healing skin ulceration - started as single lesion on hand now multiple lesions forearm - bx = AFB + ..... dx?
Mycobacterium Marinum
Tx - Clarithromycin+ethambutol +/- rifabutin
129
Pt with cut while in fresh water now leg swollen, septic and has h/o ETOH LIVER DZ - what is bacteria?
Aeropronas hyophillia
130
Florist/gardener p/w multiple nodules on hand and formarm - lymphatic channels - dx?
Sporotrichosis - sporothrix schenkii
Tx: local dz = itraconazole
Disseminated dz = amphotericin B (DM, transplant pts)
131
Pt p/w folliculitic rash - h/o Jacuzzi/bath tub - dx?
dx: hot tub rash -
etio: pseudomonas - improperly chlorinated hot tub
Tx: self limited (ONLY TIME YOU DONT TX, THERFORE HY)
132
Pt with cough, CXR infiltrated with thin walled cavity - indoor hot tub 3 days/wk... dx?
MAI
| - Hot tub lung - avoid hot tubs
133
Pt on chemo becomes neutropnic - develops cellulitis w/ black lesion with central ulceration - dx?
dx: Ecythema gangrenosum 2/2 pseudomonas
Tx: meropenem + cefepime ... until sensitivities are back
134
pseudomonas can cause.....
can cause....
1. malig otitis externa in DM,
2. osteomyelitis in nail puncture wounds
3. endocarditis in IVDUs
4. sepsis in neutropenic,
5. ecthema gangrenosum,
6. hot tub folliculitis
CANNOT BE TREATED WITH AMP-sulbactam
135
50yo HIV p/w vesicular lesions on one side of face including ext aud canal, c/o severe burning pain - scrapings from vesicles ==> with multinucleate giant cells... wtd?
IV Acyclovir
136
Pt p/w burning sensation over R forehead x 36hr - hyperesthesia over R forehead and single vesicular lesion on erythematous base on tip of R nose - what is WORST complication
Zoster ophtalmicus
wtd.. Optho referral, topical trifluridine
pt started on valacyclovir 1000mg TID, slit lamp no corneal invovlment, continues to have pain, cant sleep... wtd -> add prednisone
137
pt w/ Post herpetic neuralgia.. best tx?
Desipramine > gabapentin
138
what kind of - Isolation for herpes zoster?
- Single dermatome = contact isolation
| - 2 or > = contact and airborne
139
Herpes zoster with single rash. symptoms.....
< 72 hrs = supportive care
> 72 hrs = treat w/ valacyclovir, acyclovir, famciclovir
> 72 hrs + HIV = treat
> 72 hrs on steroids OR anti-TNF = treat
> 72 hrs + Age>50, if new lesions appearing ONLY then tx
140
65yo M herpes zoster vaccine - precautions for caregivers that never had chicken pox?
None
141
Non-Tb mycobacteria .... (HY d/t increasing freq)
1. MAC/Kansasii --> commonest lung infx, hot tub lung
2. Abscessus/chelonae/fortuitum --> water use, cutaneous, or implant infxns. osteomylelits can also occur
3. Marinum - fresh and salt water
142
Non-healing cellulitis or infxn post breast implant/liposuction (dom. repub.) =
M. Absessum... do bx and cx
143
Non-healing cellulitis in pt with pedicure
Marinum OR Fortuitum
144
Small Pox... location? rash?
1. Pharynx/face -> extremities and trunk
2. Rash -> Vesicles-> pustules evolve CONcurrently
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available
145
Chicken pox.. location? rash?
1. Chest and back
2. Rash -> vesicles -> pustules evolve in crops, diff stages
contagious, until all scabs formed and fall off, direct contacts with fever need quarantine, vaccine available
146
24yo brings 5yo daughter with small pox - she is worried about her 10 yo son who is scheduled for chemo for a leukemia - new PA can't remember if he had small pox as child - wtd?
- Child with immune def -> VZIG (highest risk)
- Pregnant mother -> check titer.... if VZIG low - tx for symptoms
- PA -> check titer ... if neg.. give vaccine
147
Pt with lesions on extremities in diff stages (vesicle -> pustule -> escar) MC complication??
PNA
148
Nurse/resp therapist with vesicular lesions on finger with erythema and tenderness - pet kitten at home... dx? etio? tx?
dx: Herpetic whitlow
etio: HSV (DNA virus)
tx: acyclovir
149
Young pt p/w fever, malise sore throat followed by vesicular lesion on tongue, buccal mucosa -> later with painful vesicle lesions on dorsum of hand and feet... dx?
hand foot mouth dz.. 2/2 coxackie virus
150
Pustules on palms after petting at a fair or petting a wild dog - dx?
Monkey pox
151
pt from southwest OR after visiting yosemite natio park p/w sudden resp failure, pulm edema and inc'd HCT........
HANTA virus
152
Pt bit by cat - wtd?
Augmentin (Amox/clav)
- to cover pasterella multiloci + anaerobies
(also for human and dog bites)
153
Pt w/ h/o splenectomy for ITP plays with pet dog and sustains scratch/lac. next morning hypotensive. dx?
Septic shock 2/2 CAPNOCYTOPHAGA CANIMORSUS
154
Pt with tooth ache, + submandibular LN. PCN allergic. wtd?
Clindamycin
155
Pt with cat p/w pustular lesion on hand and tender LN in axilla ... dx? etio? tx?
dx: Cat scratch dz
etio: Bartonella Hansleae
Tx: Doxy/erythro
156
HIV pt with multiple nodular lesions on extremities - AST , inc ALT inc
bx -> modifed silver stain +/ warthin starry organisms+
liver -> peliosis hepatis (cystic spaces with blood)
dx? etio? tx?
Dx bacillary angiomatosis
etio: bartonella henslae
Tx - doxy/erythro
157
Pt with HIV, T cells 150/cmm, homeless, lives in shelters and streets, p/w itching and excoriations of skin. pt disheveled. AST/ALT ELEVATED. spiking temp. holosystolic murmur at apex. Blood c/s neg. dx?
dx: Bartonellosis endocarditis 2/2 bartonalla quintana (trench fever)
158
Rabies vaccine/immune globulin for exposure to ...
```
dog bite
bat bite/scratch
fox bite
racoon bite (major in US)
rural cat yes, house cat NO
```
NOT rat bite
159
Pt with dog bite in mexico - rabies vaccine 1 year ago. wtd
Vaccine x 2 doses (no HRIG)
160
Malaria - P. Falciparum .... where?
resistant almost everywhere
161
Malaria P. falciparum sensitive and others.. where?
parts of Caribbean, central america, near east
162
Malaria ppx
P. falciparum resistant = start Mefloquine 1 wk prior and 4 weeks after return arrival OR
start atovaquone/proguanil (Malarone) 1day prior to departure and up to 1 week after arrival into US
P. falciparum sensitive = chloroquine
163
Malaria tx
P. falciparum resistant = Quinine sulfate + doxy OR
Atovaquone/proguanil (Malarone) OR
Quinidine gluconate + clinda OR
Artemisinin-Amodiaquine (only CDC has it, but its the best)
P. falciparum sensitive = Chloroquine + Primaquine
164
Look at book #1 pg 220
Malaria endemic areas and other endemic dz
165
PT returns from nigeria trip - 2 wks later c/o shaking chills/fever, drenchign sweats then becomes comatose
Hb 11g. retic 4%.
smear = gametocytes.
Pt dx'd w/ cerebral malaria. Tx?
Quinidine gluconate + doxy
166
Pt fever chills after nigeria 4 weeks ago - most sensitive test for malaria. More sen test for malaria? blood smear or antigen based rapid?
Antigen based malaria rapid dx test
Best tx - artemether-lumefantrine (less s/e)
167
Pt did not take mefloquine for ppx now with malaria - wtd?
malarone (atovaquone/Proguanil)
| mefloquone can't be used with cardiac conduction dz
168
Pt ER in NY with fever, rash mylagias retro orbital HA last few days. recent vacation in florida keys and miami, temp 101, HR 95 - faint MORBILLIFORM rash on trunk, few petechiea on arms- plt 55K, WBC 4.5 - dx?
Dengue
| (bone breaking fever - hemorrhagic fever, mosquito borne, low plts, plasma leakage, low BP - n/v/f/diarrhea/GIB
169
Pt with lower abd pain, pelvic exam adnexal tenderness, cervical motion tenderness and a retained IUD wtd?
remove IUD and start ampilcillin/PCN
170
Actinomyces
delicate sulfur granules, branching filaments
171
Pt with extensive dental caries p/w tenderness over mandible - c/o difficulty opening mouth. o/e: brawny edema over upper neck with tenderness dx? etio? tx?
Ludwigs angina
etio - peptostreptococcus, mixed anaerobes
Tx - Amoxicillin-clavulante/amp-sulbactam
172
Pt with absolute PMN<500 s/p chemo p/w fever...
| DON'T start on routine G-CSF ... wtd?
neutropenic fever = cover gram neg (pseudomonas) with a cefepime** or meropenem.
If IV line present.. add vanco (for MRSA)
If no IV line and fever > 3 days, add vanco
If continues to spike 7th day, add Voriconazole to cover fungal infections
Neutropenia: S. Aureus, Pseudomonas**, Aspergillus**
173
Which antifungal improve mortality for ppx post chemo neutropenia
Posaconazole (noxafil)
174
```
Transplant infectious ...
< 1 month?
2 month?
3 month?
4 month?
6 month?
```
Transplant infectious ...
< 1 month? nosocomial: MRSA/line sepsis/PNA
--------------6 wks--------- herpes reactivates----
2 month? CMV (large intranuc, inclusion bodies), EBV, Aspergillosis** (halo sign)
3 month? MTB, Listeria, Nocardia**, BK virus (tacrolimus)
4 month? Candida
6 month? Cryptococcus
175
complication of BK virus
BK virus nephropathy
176
Pt s/p chemo - neutropenia and fever - pt started on vanc, primaxin 5 days later still high fever
CR/CT= LLL infiltrate w/ dense core and rim of ground glass appearance (halo sign) - dx?
Aspergilllosis
- amphotericin B
if Cr elev - voriconazole
177
what is positive most likely in aspergillosis infxn pt
Serum galactomannan (aspergillous antigen - can be tested for as screen)
serum beta-D-glucan is in PJP PNA.
178
55yo renal tx - rejection 2 weeks later on immunosupp drugs - tacrolimus added - several months after - ground glass intranuclear inclusions in urine.. most likely dx?
BK virus (human polyoma virus nephropathy) - ground glass intranuclear inclusions urine
179
2 months post transplant ... pt with fever, cough not responding to levofloxacin x 1 week
ABG = PO2 65,
CXR = b/l infiltrates. CMV+ b4 tx
Lung bx = intracytoplasmic inlusion bodies - dx/tx?
CMV
| tx: Ganciclovir and CMV immune globulin
180
Norcardia ...... .....tx?
= lung skin, brain lesions. branching/filamentous, gram +, weakly acid fast
tx: sulfonamides
TMP-SMZ - if Cr increases this is NOT RENAL COMPROMISE, continue bactrim. if BUN/Cr increases this is intersititial nephritis (positive eos).. d/c bactrim
181
40 yo HIV (+) pt .. T cells 25 and viral load 225,000 cps/ml.. p/w c/o fever and cough. CXR --> thin walled cavity in RLL - BAL grows CMW, candida, HSV, norcardia.
You would tx the pt with...
TMP-SMX (Bactrim) for norcardia
182
Pt with liver transplant on high dose steroids and immunosuppressives OR SLE pt on steroids w/ cough, fever, n/v - skin with nodular lesion - CXR nodular lesion - CT brain ring enhancing lesion. most likely dx?
Nocardia
skin,lung,brain
183
MCC osteomyelitis in US
Staph aureus
184
Older adult with bacteremia p/w fever, lower back ache, point tenderness on spine dx? tx?
verebral osteomyelitis
| tx - bctx, imagaing ct/mri, abx for 4-6 weeks
185
How to dx infection prosthetic hip 3 months post op
CT guided asp and culture
186
Pt with UTI, BCtx pos - Tx with IV abx, on TLC, 3 days later spiking temp, confused - hyper-reflexia in lower extrem and hyporeflexia in UE -
CSF gluc 80, protein 295, WBC 75 w/ 60% pmn - dx?
Spinal epidural abscess
DO MRI NOT XRAY
187
pt s/p chemo, no hx mets, recovering from neurtropenia with high fever - nodules on liver in CT abd... dx?
hepatosphere candidiasis.
micafungin -> sensitive -> fluconazole
188
Pt poorly controlled DM with bloodly nasal d/c - BLACK NECROTIC SPOT near nostril - redness one eye - bx of lesion = FILAMENTS BRANCHING right angles/ dx? tx?
Murcormycosis
| Tx: surgical debridement > amphotericin B
189
Pt with CRF on HD with recurrent staph aureus infxn - MRSA infxn from infected catheters - sucessfully treated with vancomycin IV in past - recent infection with staph not responding to vanc x 3 days
do epsilon e test measure MIC - if >2 then GISA or Vanc insensitive staph ->
tx Linezolid or quinupristin/dalfoprisitn
190
Pt started on abx for pos blood cx enterobacter - pt defervesces, feels better on 6th day. starts spiking fever - pt blood cx positive again for enterobacter now resistant to abx. what abx was pt receiving?
cephalosporin
191
Pt with enterobacter infxn sensitive to cephalosporins - few days later enterobacter now resistant - what happened?
Plasma mediated resistance -aka- ESBL, mutants
| tx - meropenum
192
Pt growing ESBL klebsiella resitant to impipenum - wtd
ceftazidime (avibactam)
193
Pt with UTI with ESBL sensitive only to colistin and tigecycline wtd?
Colistin only - tigecycline does NOT penetrate GU tract (only goes to bile)
194
Best management for stenotrophonas (xanthomonas) maltophilia
bactrim
195
What organism can be treated with abx without d/c central line?
staph epi
GNR/s.aureus dc CVC
196
Best way to do BCx on pt with triple lumen catheter
timed pair BCtx from both peripheral blood and catheter
197
Pt in ICU starts spiking temp of 102F, abx started, triple lumen cath changed over guide wire and tip sent for ctx - next day tip ctx grows GNR sensitive to Abx - pt better temp 100.5 wtd
REPLACE CVC with fresh needle stick and continue abx
most prone to infections TLC: femoral > IJ > SC
most complications = SC
198
Best way to prevent central line infection
maximum barrier protection while insertion
199
Best way to prevent nosocomial infection outbreaks
hand washing
200
best way to prevent vent associated PNA
elevation of bed 45 deg,
chlorhexidine mouth wash,
handwashing,
ET suctioning
201
15yo p/w low fever, sore throat, fatigue, myalgia and cervical lympahdenopathy - petetchiae over palate. no posterior phalangial lesions - monospot neg for heterphile abs - wtd
do more sensitive test
| check EBV viral caspid antigen (VCA IgM)
202
Pt receives Ampicillin -> gets morbilliform rash - organism?
EBV - hypersensitivity rxn to abx - only occurs in presense of EBV infxn though...false neg monospot
203
Pt w/ +LN, monospot +, inc SOB, large tonsils - wtd
steroids... no abx
204
Pt with infectious mono and LUQ pain wtd?
CT scan stat - splentic rupture complication
| tx: splenectomy
205
Pt in MICU on IV TPN x days with fever, chills and growing yeast with blurry vision - etiology?
candida opthalmitis- chromium deficiency
206
Candida in BAL. tx?
DO NOT TX
207
Asymptomatic Candiduria.. tx?
DO NOT TX
208
Asymptomatic candida in blood.. tx?
TREAT THIS!!
209
Pt grows candida in blood, fluconazole d/c'd 2 weeks ago wtd?
start caspofungin, then downgrade when sensitivities arrive
210
Anthrax
- Skin form - necrotizing form rare - animal hides
- GI - ingestion with sever diarrhea
- Inhalational - non-sp sx, h/a, chills vomitting..
sob, hemorrhagic meningitis,CXR with widened mediastinum (spores taken up by lymphocytes) - preterminal events
211
Anthrax tx
Flouroquiniolone or PCN
212
Anthrax other characteristics
```
NO person to person transfer
Isolation NOT required
BCtx = gram + bacilli
PPX effective only one day after exposure
Vaccine available for military
```
213
Farmer goes hunting and gets sick rabbits.p/w #1: ulcers, #2: fever, chills, myalgias and PNA. #3: tender inguinal and femoral LN and conjuncitvitis. gram stain = g neg pleomorphic organisms - dx? tx?
dx: Tularemia .... ulcers+glands=ulceroglandular fever
lab test = serology*
tx - streptomycin x 7 to 10 days**
214
Good samaritan removes dead deer from highway in Arkansas/Oklahoma - couple days later with tender erythemaous papule that became ulcerated with black eschar - organism?
Francisella Turarensis (tularemia)
215
45yo h/a, cough, myalgias - temp 101.5 - cxr with RL infiltrate - watching US open in NYC - two other ppl had similar sx. One of them dies after admission. dx?
Tularemia (infiltrate) anthrax does not have inflitrates.
216
2 days after superbowl - inc'd pts p/w to ERs w/ fever, cough, chest pain, hemosptysis and prostration - several of them die 24hrs after admission - dx?
Plague
Yersenia Persisitis
Bubonic (LN), Septicemic(causes DIC), Pneumonic (lungs)
Speads by droplets, close contact (also sexual)
Droplet isolation... doxy for pt... doxy for exposed contacts
217
Which most commonly aeorsolized
Coxiella burnetii (Q fever)
218
Rancher with fever, culture neg endocarditis - cryoglobulins pos and HCV neg - dx?
Brucella - musc pain, sweating, fever, cryoglob +, endocarditis (neg ctx)
brucellosis - from unpaturized mild - ranchers infected animals
Tx tetracyclines, rifampin, streptomycin, aminoglycosides
219
Q fever infected most likely by...
Vets, Abattoir workers, farmers handling infected goat, sheep, cattle
Q fever - coxiella burnetti (ricksettia)
URI, fever, myalgias, headache
Tx - doxycycline, tetracycline, cipro
220
Young male with fever, myalgias, petechial rash after rafting trip PR or costa rica - icteric, mildly elev LFT with high T bili dx?
Leptospirosis - mildly elev transaminases and D bili 5-10x normal
221
Most likely inhaled with atypical PNA/h/a, fever
Q fever
222
MC with contaminated soil and animal products
Q fever
223
Caused by rikettsia
Q-fever
224
Skin contact or aerosolized -> RE system - splenomegaly, hepatitis, LN+ fever and drnching sweat - dx?
Brucellosis
225
Gram neg coccobacilli
Brucellosis
226
Sewage worker contact - fever hep, jaundice, liver hemorrhage, CONJUNCTIVAL SUFFUSION
Leptospirosis
227
Vet with fever - mental status change, jaunce renal failure, ecchymosis
Leptospirosis
228
Doxycycline
Q fever, burcellosis, leptospriosis, erysipelothrix
229
Buchter with fever, palpable spleen tip
brucellosis
230
Fisherman or fish handler with burnign or throbbing pain with erythematous lesion on finger
erysipelothrix
231
Pt walks on beach in west florida p/w red eyes, SOB, no wheeze or rhonchi - dead fish on beach - dx?
Redtide bloom caused by Karenia brevis (algae)
232
Pt p/w diarrhea, fever, non-productive cough with HYPONATREMIA - drinks from TAP water. most consistent with ....
Legioniella -
| tx quinolones - levoflox, azithro
233
```
sewage worker who hunts deer and squirrel.. p/w fever, fatigue, abd pain and gen aches - CONJUNCTIVAL SUFFUSION - scrapes on hands but no ulcers
- CPK 765,
mild ast alt elev,
Bili 6.8 (elev),
BUN/Cr 110/8
dx? best management?
```
Dx? Leptospirosis
| Tx: Doxycycline
234
21yo Iraq or afghan vet p/w 3cm lesion on arm, ulcerated with irrreg margins, eschar w/ surrounding erythema.. dx? tx?
Cutaneous Leishmaniasis
| Tx: self-limited
235
40yo immigrant rural turkey/middle east with enlarged liver - dx?
Hydratid cyst (echinnococcus)
236
CMV colits isolation?
none
237
MRSA isolation?
contact
238
VRSA,VRE isolation?
contact
239
HZV 1 dermatome isolation?
contact
240
HZV >2 derm isolation?
contact AND airborne
241
C diff isolation?
contact
242
scabies isolation?
contact
243
Measles isolation?
airborne
244
Varicella isolation?
contact AND airborne
245
MTB isolation?
airborne
246
Neisseria isolation?
dropelt
247
Influenza isolation?
droplet
248
Plague isolation?
droplet
249
HIV highest risk?
contaminated blood products?
increased w/ men who have sex with men: anal receptive intercourse with highest risk
contaminated blood products 1 in 500,000 to 3,000,000 screenings. nucleic acid testing used to confirm.
250
Occupation risk exposure - high risk
```
for high risk exposure, recommend:
1 INSTI (Raltegravir or Dolutegravir) +
2 NRTIs (Tenofovir + Emcitrabine)
```
251
Pt with HIV on ART undetctable VL now preg - WTD
continue ART to term
252
If HIV pt wants to breast feed
continue ART maintain undetect VL to prevent baby transission
253
A preg pt has HIV test which shows antibodies are indeterminate and NAAT negative. What is the best management.?
Tell the patient is HIV negative.
254
Nurse with needle stick exposure to a pt with HIV or high risk for HIV.. wtd
baseline HIV ELISA test for documentation
- start 1 INSTI (Raltegravir or Dolutegravir) +
2 NRTIs (Tenofovir+Emcitrabine)
x 4 weeks. Repeat HIV test if neg... d/c meds
cont. checking up to 6 months tho.
255
Sexual assult victim by IVDA unknown HIV status. < 72hrs ago. wtd
```
Offer 1 INSTI (Dolutegravir) +
2 NRTIs (Tenofovir+Emcitrabine)
```
after 3 days no.
256
Opp infxn >200 T cells
1. CAP : S pneumon
2. PP(+): Tx PPD > 5mm with INH x 9 months
3. Kaposi's sarcoma: dark bronish plaues on legs, pulm inviltrate - pulm nodules - purple red on bronch HHSV8
4. Lymphoma
T cells 600 MTB > Cryptosporidium
257
Opp Infxn < 200 T cells
1. Pneumocystis Jirovechi PNA - dry cough > 1 wk, grad onset progresssive - ABG with hypoxiemia
ele LDH, CXR b/l intersitial infiltrate or PTX
Dx - sputum silver methanamine + (sen 55-92%)
BAL with stain (sen 97-100%), transbronch bx (100%)
Tx - Bactrim **
(allergy ? clinda + primaquine)
If PaO2<70 add STEROIDS
258
Best test for suspected mild to mod dz where BAL is not planned in the diagnosis of PJP?
check serum Beta-D-glucan
259
HIV pt with PJP on bactrim for a couple of days... creatinine goes up from 0.8 to 1.7mg/dl.. urine output ok. wtd?
continue bactrim.
goes up, does not dec renal clearance - continue bactrim if Cr increases (dec'd tubular clearance of Cr by trimethopram) cobicistat does the same thing
260
Pt on bactrim ppx with rxn.. wtd
change to dapsone OR atovaquone
261
Which drug covers both PJP ppx and secondary ppx for toxo?
dapsone + pyrimethamine
262
Candidasis...
oropharyngeal white patches adherent to oral mucosa
Tx Fluconazole
recurrent on fluconazole - use Echinocandins
263
HIV with T cell 55 - severe heart burn wtd
- empiric fluconazole for susp esoph candidasis
| - if no response upper endscopy - r/o CV or HSV or candidial esophagitsi
264
<100 t cells
| pt w/ CD4 45 p/w HA x wks, not relieved with analgesics. CT head neg - wtd
spinal tap to r/o cryptococal meningitis
- HA may be the only presentation without meningeal signs
- spinal tap: india ink + in 75% and crypt Ag + in 90%, in blood and CSF
Tx: Amphotericin B and 5FC induction and then change to long term fluconazole
dont start HAART until tx is completed (5wks) then start.... immune reconstitution syndrome.. incr cerebral edema, dyspnea.
265
< 50 t cells - you can get ...
MAI: fevers, hepatomeg, LAD - elev alk phos (vit D def), bctx + AFB
Tx: clarithro + ethambutol +/- rifabutin
266
<25 tcells
CMV retinitis - blurring vision (cheese and ketchup appearance)... Tx Gancyclovir, cidofovir, foscarnet
Progressive multifocal leukoencephalopathy: white matter lesions caused by JC virus.
ALSO seen with use of natalizumab (for MS) or efalizumab(for psoriasis), rituximab, infliximab
267
Prophylaxis against opportunistic infxns...
<200 T cells: PJP = Bactrim, Dapsone, atovaquone
<50 T cells: MAI = Azithro 1200mg/wk or clarithro 500mg BID
268
Pt with T cells 25 started on HAART, bactrim and azithro. 6 months later T cells 150. wtd
d/c azithro for MAI ppx
| not < 50
269
Pt 4 months later t cells increased to 250 wtd
d/c bactrim for PJP ppx
270
Which finding r/o crypto meningitis
neg crypt antigen in serum or CSF
271
Ring enhancing lesions
Toxo
brain abscess
lymphoma
272
Pt with HIV T cells 25 w/ headache and one sided weakness - CT scan ring enhancing lesion wtd?
tx for presumptive TOXO w/ sulfadiazine and pyrimethamine and
repeat CT brain in 2-3 weeks
- if no change in size of lesion, then do biopsy of lesion for definitive dx and tx
273
CNS lymphoma seen in patients w/..
T cells < 50. EBV ag + in almost all of them
274
HIV pt w/ T-cell < 45 - VL 150K p/w weakness of left leg - CT scan ring enhancing lesion, CMV +. most likely causes...
Toxo, lymphoma, or brain abscess
NOT CMV (biventricular enhancement should be there)
275
Middle aged latin american immigrant living in US recent onset Seizures - CT multiple cystic lesions with calcification mild hydroceph.. dx? tx?
Neurocystercircosis 2/2 Taenea soliens
| Tx: Phenytoin (cyerco serology)
276
Hog farmer with fever, myalgia - periorobital edema, spinter/conjuntival hemorrhages - muslce tenderness no murmur - EOS 8%, LDH 400, CPK 700. what will establish dx?
trichinella antibodies.
277
MCC PNA in pt w/ HIV CD4 150 is
Strep Pneumo
278
Pt dx HIV...T-cells 45 and VL 105K. asx started on darunavir (prezista), emtricitabine (emtriva), tenofovir (viread) and bactrim. What else would you start at this time.?
Azithro 1200mg qwk OR
clarithro 500mg BID
for MAI ppx
279
Indications for ART therapy for HIV
```
VL>100K
T Cell <500
Acute retroviral syndrome
Opportunistic Infections
Pregnancy
```
280
Protease Inhib - main SE Lipodystrophy
Darunavir (prezista)
Lopinavir/Rit. (kaletera)
Atazanavir (Reyetaz)- incr bili, kidney stones
Fosamprenavir (Lexiva)
Indinavir(Crixivan)- kidney stones incr bili
Ritonavir (Norvir)- boosting agent, inc TGA, chol
281
NRTI - lactic acidosis, CAD, hypersensitiv rxn, neuropathy
```
Tenofovir (Viread)- renal insuffiency, fanconi
Emtricitabine (Emtriva)
Zidovudine (Retrovir)
Abacavir (Ziagen)
Lamivudine (Epivir)
```
tenofovir + emtricitabine = truvada
282
NNRTI
Efavirenz (sustiva) weird dreams
Entravirine (intelence) CNS effuects, conf, abn dreams, agitiation
Rilpivirine(edurant)
283
Integrase Inhibitors
Dolutegravir (tivicay)
Raltegravir (Isentress)
Elvitegravir (Viteka)
284
Combinations of HIV drugs
2 NRTI + PI/Integ Inhib
| 2 NRTI + NNRTI
285
protease inhibitors S/E
HLD, insulin resistance, lipodystrophy, liver tox
(fat accumulation behind nexk, abdomen, and fat wasting in legs thighs)
```
indinavir = nephrolithiasis
atazanavir = indirect bilirubin, renal stones
ritonavir = incr TG, incr Chol
```
286
What drug causes bone marrow suppression?
Zidovudine (AZT)
287
Best statin for HLD with HIV
Pravastatin, or atorvastatin
288
What statin to NEVER use
Simvastatin (inc levels HIV drugs)
289
Best drug for insulin resistance/ hyperglyc
metformin
290
Best inh steroid for HIV asthma
Beclamethasone
291
Best HIV med with HCV therapy
Dolutegravir (Tivicay)
292
What drug causes renal insuff (HIV drug)
Tenofovir
293
HIV pt started on stribild (elvitegravir + cobicistat + emtricitabine + tenofovir) 2 weeks ago. creatinine goese up from 0.8 to 1.3. Most likely etiology?
cobicistat
294
HIV pt with anorexia, wt loss, lethargy dizziness - hyperpig of skin, BP low, HR orthostatic, Na 135, K 5 dx?
Addison's dz (Ag/ab HIV) autoimmune adrenalitis
295
Immune reconstitution syndrome -
pt with adv HIV low t cells high VL - start on ART - react to latent pathogens - inflamation - continue ART
296
Pt with T cells 25, VL 250K, start ed on ART - 3 weeks later with cervical lymphadenopathy
immune reconstitution to MAI/TB
297
HIV survelilence
- VL and Tcell should be q 3-6 months for 2 yrs and then Tcells yearly
- If T-cells > 500, then repeat checking is optional **
298
HIV VL note dropping but t-cell count the same
VL should be undetectable by 6months.
Reason?
Non-adherence OR Resistant virus - check HIV genotyping and change tx accordingly
299
Earliest change to see in HIV therapy failure
rise in VL
300
Earliest OI in AIDS (not aids def lesion)
Oral thrush
301
Pt dx with HIV started on Norvir, Indinavir, AZT, epivir
4 months later VL <25, T cell 500
pt develops pulm TB dv and started on rifampin, ethambutol and PZA
- VL 2 months later 15K - pt claims to be adherent explanation?
- rifampin dec level of PI
- change rifampin to rifabutin (causes less decrease of PIs) or change PI to NNRTI (efavirenz) or INSTI (raltegravir or dolutegravir)
302
Pt dx with TB start on 4 anti TB - found to be HIV (+) - T-cells 25. when to start ART?
within 2 weeks
303
Labs/monitorsing
HIV VL, T cells, RPR, Hep panel, PPD, Tox, LFTs
Vacc : HAV, HBV, flu, pneumovax, inactiv poli, Tdt
NO LIVE VACCines
304
Live vaccines
Oral polio
MMR
Varicella
Yellow fever
305
complicated UTI with ESBL
Fosfomycin
306
Pt presents with some uretheral discharge after sex >1 wk ago, tx w/ ceftriaxone 250mg x1 and azithro 1g PO x1. Couple of days later, still with some discharge on stripping the urethra. most likely dx?? tx?
Mycoplasma genitalium
tx: moxifloxacin
307
A 45 yo M p/w HA, difficulty walking with imbalance(ataxia) and fever. Double vision. PMHx: HIV Tcells 395 and VL <25 copies last month. dx? wtd?
a. neurosyphilis
b. cryptococcal meningitis
c. PML
neurosyphilis. wtd. spinal tap
a. neurosyphilis
b. cryptococcal meningitis ... Tcells <100
c. PML .... Tcells < 25
308
Patient with an abscess with surrounding erythema. I%D is done. wtd?
prescribe bactrim
309
Pt traveling to brazil for olympics or visiting latin america or south america.. wtd.?
DEET at least 30%
310
Preggo asks how to prevent infectious diseas on her visit to a destination wedding in the DR?
cancel trip
311
30 yr old man visits caribbean island for a week on business and comes back w fever, HA, rash, conjunctivitis. You suspect zika.. wtd?
RNA PCR of serum and urine, if expos < 2 weeks ago
| serum ELISA IgM, if expos > 2 weeks ago
312
Osteomyeltitis. prosthetic implants .... etio, tx?
staph epi
| tx: vanc + gent + rifampin
313
osteomyelitis. necrotic bone (sequestrum) --> chronic osteo --> tx?
debridement
314
sickle cell with osteo ....
salmonella incidence increased > staph
315
Husband w/ HIV positive Tcells 450 and VL 900... /hiv negative wife asks you how to prevent HIV in addition to condoms?
Emcitrabine-Tenofovir daily (Truvada)
316
What is atripla
efavirenz + emtricitabine + tenofovir
317
what is complera
emtricitabine + rilpivirine + tenofovir
318
what is stribild
elvitegravir + cobicistat + emtricitabine + tenofovir
319
what is triumeq
dolutegravir + abacavir + lamuvidine
320
what is odefsey
emtricitabine + rilpivirine + tenofovir
321
NNRTIs SE
rash, steven johnsons
```
nevirapine = rash steven johnson, liver tox
efavirenz = CNS effects; confusion, abnormal dreams, agitation
```
322
NRTIs SE
lactic acidosis, hypersensitivity rxns, neuropathy
abacavir = life threatening hypersen, fever, rash, emesis, malaise, lactic acidosis
stavudine = neuropathy, lactic acidosis
zalcitabine = neuropathy, pancreatitis
zidovidine (AZT) = anemia (incr MCV), neuropenia, bone marrow suppression
tenofovir = renal insufficiency, fanconi
323
cobicistat boosts levels of what other meds
CCB, BB, statins
324
Pt with T-cells of 30 w/ cryptococcal meningitis, newly diagnosed HIV. when to start ART?
After treating crypotococcal mening .. 5 wks.
