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2018 Awesome rev > 2018 Infectious Disease 9% > Flashcards

2018 Infectious Disease 9% Flashcards

1
Q

MCC bacterial endocarditis

A

staph aureus

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2
Q

Native valve endocarditis

A

Staph aureus, strep bovix, strep gp D (enterococci) ->

Vanco/gentamycin empiric

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3
Q

Prosthetic valve

A

staph epi, streptococci, G neg fungi ->

vanco, rifampin (clears sticky bugs - staph epi), gentamycin

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4
Q

IVDU

A

staph aur, enteroccus, g neg strep viridans ->

vanco + gentamycin

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5
Q

Indications for endocarditis surgery

A
  1. Severe CHF
  2. bacteremia x 6 days (if repeat bcx 48 hrs +, cont abx, repeat ctx,
  3. recurrent emboli, valve abscess,
  4. large fungal vegetation
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6
Q

Rt sided endocarditis with septic emboli - abx?

A

Daptomycin

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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

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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

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9
Q

Pt fever, +BCtx for clostr sept/ Strep bovis - wtd

A

Colonoscopy r/o malignancy

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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

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11
Q

Vanc develops itching/redness

A

redman’s - slow IV infusion +- benadryl

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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

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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

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14
Q

Pt treated for endocardtisi defervesces and WBC dec but w/ 1st deg AVB - concerned?

A

yes - r/o valvular abscess - TEE

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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

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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

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17
Q

Endocarditis ppx

A

Amox 2g po 1 hr prior,
if no PO then amp IV,
PCN all - azithro,
post procedure - > NOTHING

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18
Q

Pt witih PDA going for cystoscopy

A

NO ppx

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19
Q

Pt with bacteremia s aur due to IV line - vanc started wtc

A

TEE if negative.

  1. BCx neg < 72 hrs on abx -> cont IV abx 2 wks
  2. BCx neg >72 hrs on abx -> cont IV abx 4 wks
  3. BCx pos in immun compromised -> cont IV abx 4 wks
  4. BCx pos in prost valve, cardiac device, arthroplasty -> IV abx for 4 wks

If TEE positive -> tx w/ abx 6-8 wks

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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

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21
Q

obesity with vanc

A

1.5g IV q12h (15-20mg/kg)

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22
Q

35yo IVDA fever/chills wit hmurmur, vegetation on TV bctx MRSA - tx?

A

Daptomycin

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23
Q

Empiric tx meningitis

A
  1. Head trauma/NSx - (staph aur MRSA, S pneumo, G neg bacilli) –> vanc + cefepime
  2. 50yo (Listeria, S pneumo, neisseria ) –> Ampicicillin (listeria), rocephin (S pneumo), Vanco (MRSA)
  3. 15yo (S.pneumo, n.mening, h.flu) –> Ceftriaxone
  4. 2 month (strep agalactiae, E. Coli, Listeria) –> Ceftx + ampilcillin (listeria)
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24
Q

Normal CSF

A

<5cells, lymph, Gluc 40-80, Protein 15-45

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25
Q

Bacteria CSF

A

10-100K cells, PMNs, dec gluc, inc protein, inc opening pressure

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26
Q

West nile CSF

A

10-1K cells, Lymph, dec gluc, inc protein, muscle wk, rash, dec DTR

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27
Q

TB CSF

A

10-1K, lymph, dec gluc, very inc protein,

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28
Q

Aseptic CSF

A

10-2K, lympoh normal gluc, inc to normal protein, enterovirus, OKT3, NSAIDS, bactrim

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29
Q

Early bacterial CSF

A

10-1K, lymphs > PMN, dec gluc, inc protein, CSDF to ser glu <0.4

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30
Q

Encephalitis CSDF

A

1-2K, lymph, normal gluc, normal to inc protein

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31
Q

HSV enceph CSF

A

1-2K, lymph, N gluc, n to inc protein, +RBC 1:1 ratio

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32
Q

70yo Pt with DM p.w mental status change spinal tap with many WBCs mainly PMN G stain neg ctx pending wtc

A

ceeftx + vanc cover resistant strep pneumo

+ ampicillin cover listeria

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33
Q

55yo post renal tx on steroids pw fever, neck stiffness with g po rods diphteroids in csf; PMN 65% and lymphs 35% - dx?

A

Listeria - tx

ampicillin + gentamycin (bactrim if PCN all)

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34
Q

24yo M neck pain, h/a, neck sign + spinal tap WBC 105, lymphs no RBC gluc 50 - cause?

A

entero/echo virus meningitis

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35
Q

Causes of aseptic meningitis

A

OKT3 ab, NSAID, bactrim, echo/enterovirus

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36
Q

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?

A

empiric thx –> ceftriaxone + vancomycin + dexamethasone

rifampin for pcn resistance

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37
Q

Pt with meningitis - LP WBC 75, gluc 28, elev protein - elev OP - crypt ag neg, g stain neg - tx for?

A

bacterial meningitis empirically

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38
Q

16yo MS change, fever BP 80/60 - exam midline scar abdomen - lab leukocytosis - h/o MVA 2ya splenectomy

A

organism - s pneumo (capsule)

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39
Q

Meningitis by h&p - wtd

A

IV abx - do not wait!

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40
Q

Pt with h/a x 2 days - now dizzy, lethargic - meningieal + sign - 7th episode in 6 years dx - CSDF granular cells?

A

beningn recurrent lymphocytic meningitis - HSV-2 - supportive care only (antivirals no benefit) - Mollarett’s meningitis

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41
Q

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?

A

Herpes encelphalitis - IV acyclovir

confirmed by PCR assay of CSF

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42
Q

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

A

WNV IgM ab check - prognostic factor is age - >75 is bad

Reservoir - birds, transmitting agent=mosquitos

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43
Q

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

A

early bacterial meningitis

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44
Q

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?

A

NMDA rct encephalitis

then CT abdomen/pelvis –> ovarian teratoma

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45
Q

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

A

b/l adrenal hemorrhage -> IV hydrocortisone

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46
Q

Who to PPX for meningitis

A
  1. prophylax day care/nursery school contacts,

2. household contacts

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47
Q

How to PPX meningitis

A
  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.

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48
Q

Pt tx’d for meningiococcal meningitis since yesterday - how long continue isolation

A

D/C isolation now.

24hour abx

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49
Q

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

A

d/c all meds and d/c home

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50
Q

HSV-2 causes…

A

aseptic meningitis - and can be accomopanied by gential ulcers

HSV-1 causes encephalitis

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51
Q

UTI cystitis etio?

A
  1. cystitis -> mostly ecoli - young women, staph saprophyticus,
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52
Q

Uncomplicated cystitis

A

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.

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53
Q

Cystitis in pregnancy

A

nitrofurantoin or amoxicillin x 7 days

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54
Q

Asx bacteruria in pregnancy

A

TREAT

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55
Q

Asx bacteriuria in DM

A

DO NOT TX

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56
Q

Asx bacteriuria post transplant

A

TREAT

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57
Q

Asx funguria with foley

A

DO NOT TREAT

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58
Q

asx bacteriria in foley

A

DO NOT TREAT

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59
Q

Recurrent cystitis

A

c/s and tx then suppressive regimen (bactrim/cipro)

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60
Q

Pyelonephritis

A

chills, fever, flank pain, tenderness, inc WBC urine

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61
Q

24yo F fever, chills, flank pain dysuria inc freq urin - +flank tenderness, +u/a 40WBC

A

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*)

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62
Q

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 -

A

still ok to d/c change to amox-clavulanate (augmentin*)

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63
Q

Elderly male dysuria inc freq, tender prostate

A

Acute prostatitis - common bacteria in elderly is E.Coli

Tx: bactrim or quinalone (cipro) x 4-6 wks

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64
Q

NH pt with foley and recurrent UTI - ppx?

A

nothing effective

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65
Q

Pt with foley - urosepsis -

A

change foley, start abx

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66
Q

Nursing home pt with stroke and a chronic foley with urosepsis several times a year. best way to minimize risk of UTIs?

A

closed drainage catheter system.

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67
Q

STD - Gonnococcus, Chlamydia presentation?

A

no ulcer, no adenopathy, +discharge

presentations:
uretheritis, epididymitis(pain at posterior pole), mucopurulent cervicitis, dysuria, pyuria w/o bacteriuria, PID, dissem gonococcal infxn

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68
Q

Gonococcus tx

A

tx ceftriaxone 250mg IM

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69
Q

Chlamydia tx

A

Tx doxycycline or azithro 1gm

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70
Q

GC & Chlamydia tx

A

ceftriaxone + azithro 1gm or Azithro 2g one dose

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71
Q

Presentation GC/Chylamydia

A

urethritis, epidiymitis, mucopurulent cervicitis, dysuria, pyuria without bacteriuira, PID, diss gonococcal infxn (DIG)

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72
Q

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

A

Admit - bctx, tx with IV cipro or bactrim

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73
Q

Vaginitis - Trichomonas

A

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

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74
Q

Bacterial vaginosis (gardnerella)

A

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

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75
Q

Candidiasis

A

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

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76
Q

pt with scanty foul smelling dc OTC vag azole for 3 days w/o improve and po fluconazole didnt work - wtd?

A

its NOT Candidasis - treat for gardenerella/trichomonas with flagyl or clinda

po or cream

  • check vaginal pH (>5.5?) - if scraping bleeding - chlamydia
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77
Q

Pt with dysuria - discharge on exam - UA WBC and clue cells(epithelial cell with distinct margin) - tx?

A

metronidazole (bacterial vaginosis)

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78
Q

PID

A

lower abd pain, CMT, adnexal tenderness, mucopurulent d/c, uterine tenderness

Etiology - Neiseria gonorrhea, chlamydia, vaginal anaeroboes

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79
Q

Complications of PID

A

infertility, ectopic preg, perihepatitis, tuboovarian abscess

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80
Q

Tx of PID

A

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)

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81
Q

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…

A

Admit and tx with IV cefoxitin and iv doxy for PID (not tolerating PO)

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82
Q

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?

A

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
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83
Q

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?

A

Chlamydia

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84
Q

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?

A

dx chlamydia
- check urine nucleic acid (NAAT)
tx doxycycline or azithro

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85
Q

Pt w chlamydia treated w doxy, has f/u and is asymp, but repeat chlamydia test pos. wtd?

A

< 3 wks = false + (test neg after 3 weeks post tx)

> 3 wks = true + test. -> retreat pt and partner

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86
Q

Student on spring break - p.w tenderness in posterior testes 1 week later - striping of urethra with d/c?

A

chlamydia epidiymitis

- tx azithro

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87
Q

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…

A

cervical culture or history**

do not need parents permission to tx STD

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88
Q

Gay pt c/o constipation, severe pain on defecation and generlized wkness - ulcer in perineal area - ulcer in anal canal on anoscopy - dx?

A

HSV

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89
Q

Pt with acute testicular pain - h/o several sexual encounters - no trauma - US normal - dx of epididymitis - organism?

A
  1. < 35 yrs = chlamydia, gonorrhea… tx azithro
  2. > 35 yrs = e.coli, enterobacter… levofloxacin

ALWAYS DO HIV TEST ON A PT WITH GENITAL ULCER

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90
Q

Uncircumcised pt wit pearly penile papules wtd?

A

do nothing

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91
Q

Genital ulcers

A

HSV, syphilis,
H ducreyi,
Lymphogranuloma venerium,
granuloma inguinale

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92
Q

Pt with PAINFUL ulcers - started as grouped vesicles - lymph nodes + –> fever, h/a, myalgias. dx? tx? multiple episodes?

A

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

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93
Q

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?

A

H. ducreyi

tx - ceftrx 250 IM x1 or
azithro 1gm x1 or
erythro 500mg qidx 7 days

NO DOXY

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94
Q

Pt with PAINLESS gential ulcer - disappears in 1 week - 2-6 weeks later LAD - buboes, fistulae rectal scaring

A 
Lymphogranulum venerum (LGV) - Chylymia trachomatis
tx - Doxy 100mg bid x 21 days
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95
Q

Pt with terrible looking PAINLESS ulcers on penis + LAD looks like penile CA. dx? micro? tx?

A

Granuluoma Infuinale - klebsiella granulomatis

Micro: Donovan bodies - bipolar safety pin intracytoplasmic inclusions

Tx - Doxy x 21 days or bactrim/erythro

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96
Q

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.

A

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.

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97
Q

Asx pt RPR screening 1:8 postive FTA +

A
  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)
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98
Q

Pt with PAINLESS genital ulcer raised with indurated margin and clean base wtd?

A

Dark field microscopy

tx - benz PCN 2.4 units x1 or
doxy x 14 days

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99
Q

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

A
  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

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100
Q

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.

A

Spinal tap VDRL r/o neuro syphilus

most sen but 30-50%

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101
Q

Spinal tap WBC 410 predom lymphocytes, VDRL -, protein 90, gluc 60 - best mngt?

A

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

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102
Q

Pt dx with syphilis started on PCN couple hours later with HA/fever, myalgias - BP 90/70, HR 104. dx?

A

Jarisch Herxheimer rxn - wtd?

Bed rest, ASA, continue PCN (NOT ANAPHYLAXIS)

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103
Q

45yo M h/a, difficulty walking, imbalance, fever double vision - HIV CD4 395, VL<24 dx?

A

neurospyphilis - spinal tap VDRL

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104
Q

Tick borne

A 
RMSF, 
Lyme, 
Erlichia (anaplasma),
 babesia, 
Tularemia, 
STARI (southern tick associated rash illness)

ONLY ONE WITHOUT RASH COMMON IS ERLICHIA**

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105
Q

22yo N carolina camp c/o h/a, fever, myalgia, +/- abd pain. 3 days later macular rash extremities - next day petechial….. dx?

A

RMSF -
tx = doxycycline/tetracycline

increased creatinine = increased mortality

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106
Q

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?

A

Erlichia aka anaplasma phagocytophilia

only one without common rash! inclusion bodies.

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107
Q

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?

A

Babesia

Tx - mild form = Azithro + atovaquone
Severe = Quinine + clindamycin

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108
Q

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
A

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)

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109
Q

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?

A

Lyme dz stage 2

Tx: PCN/Ceftx –> Doxy

Cardiac I/II/III deg heart block
Neuro: aseptic meningitis, bell’s palsy, foot drop

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110
Q

Pt with disseminated or late stage lyme usually has…

A

positive western blot IgG, > 5 bands positive

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111
Q

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?

A

Foot drop 2/2 lyme dz stage II

Stage III months to years later - presents as monoarticular arthritis or chronic neuro sx

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112
Q

Pt hiking in NE on friday for bird watching, found tick monday - no rash no sx. wtd?

A

doxycycline

> 36 hr with tick = increased risk -> doxycycline even if asx
< 36 hrs with tick = can observe if asx

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113
Q

Pt hiking NE for bird watching - p/w facial palsy - cluster of vesicular eruption over auditory canal - dx?

A

Herpes zoster - DNA virus (multinucleated giant cells)

tx - acyclovir

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114
Q

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?

A

systemic exertion intolerance disease (new name for chronic fatigue syndrome)

wtd.. reassure that she has received enough tx for lyme

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115
Q

Pt p/w tick attached - wtd?

A

place forceps at base of tick and lift gently

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116
Q

22yo Pt hiking in wisconsin - to ED with new onset weakness, DTR absent, denies tick bite - wtd?

A

search scalp for tick - tick paralysis better in hours once tick removed

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117
Q

Elderly pt with fiery red, well demarcated cellulits on face… dx… etio.. tx… compl?

cocci in chains

A

dx: Erysipelas -
etio: strep - cocci in chains
Tx: PCN
Complication: endocarditis

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118
Q

Female honey crusted lesions around mouth and chin - dx?

A

Staph infxn - impetigo

bactrim

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119
Q

Strep throat complication

A

Acute glomerular nephritis

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120
Q

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?

A

D/C cephaloporin and start bactrim, vanc or clinda

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121
Q

32yo cellulits on left leg… what would you start?

A

bactrim and cephalexin (cover MRSA and strep)

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122
Q

Invasive MRSA commonly presents as ?

A

Bacteremia

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123
Q

Daptomycin used for G pos organisms including MRSA (not for PNA) - what to follow in pt on dapto?

A

CPK weekly.

also dapto inactivated by surfactant so do not use in pneumonia

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124
Q

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?

A

dx: Toxic shock syndrome

etio: Strep - early onset < 24hrs - cx usually (+) OR
Staph - late onset > 24hrs - cx usually (-)

Tx - surgical debridement > PCN+clindamycin

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125
Q

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?

A

dx: Group A strep necrotizing fascitis
WTD?
Surgical consult!

best imaging study = MRI scan to confirm diagnosis in earliest manifestations (best for soft tissues)

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126
Q

causes of toxic shock syndrome ….

A
  • menstruating women wearing tampons,
  • post op wound,
  • breast implants,
  • prolongednasal packing

LEAST LIKELY: nursing home pt wearing diapers

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127
Q

Pt Gulf coast/florida (warm waters) p.w cellulitis with hemorrhagic bullae and necrosis +LN dx?

A

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

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128
Q

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?

A

Mycobacterium Marinum

Tx - Clarithromycin+ethambutol +/- rifabutin

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129
Q

Pt with cut while in fresh water now leg swollen, septic and has h/o ETOH LIVER DZ - what is bacteria?

A

Aeropronas hyophillia

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130
Q

Florist/gardener p/w multiple nodules on hand and formarm - lymphatic channels - dx?

A

Sporotrichosis - sporothrix schenkii

Tx: local dz = itraconazole
Disseminated dz = amphotericin B (DM, transplant pts)

131
Q

Pt p/w folliculitic rash - h/o Jacuzzi/bath tub - dx?

A

dx: hot tub rash -
etio: pseudomonas - improperly chlorinated hot tub
Tx: self limited (ONLY TIME YOU DONT TX, THERFORE HY)

132
Q

Pt with cough, CXR infiltrated with thin walled cavity - indoor hot tub 3 days/wk… dx?

A

MAI

- Hot tub lung - avoid hot tubs

133
Q

Pt on chemo becomes neutropnic - develops cellulitis w/ black lesion with central ulceration - dx?

A

dx: Ecythema gangrenosum 2/2 pseudomonas

Tx: meropenem + cefepime … until sensitivities are back

134
Q

pseudomonas can cause…..

A

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
Q

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?

A

IV Acyclovir

136
Q

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

A

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
Q

pt w/ Post herpetic neuralgia.. best tx?

A

Desipramine > gabapentin

138
Q

what kind of - Isolation for herpes zoster?

A
  • Single dermatome = contact isolation

- 2 or > = contact and airborne

139
Q

Herpes zoster with single rash. symptoms…..

A

< 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
Q

65yo M herpes zoster vaccine - precautions for caregivers that never had chicken pox?

A

None

141
Q

Non-Tb mycobacteria …. (HY d/t increasing freq)

A
  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
Q

Non-healing cellulitis or infxn post breast implant/liposuction (dom. repub.) =

A

M. Absessum… do bx and cx

143
Q

Non-healing cellulitis in pt with pedicure

A

Marinum OR Fortuitum

144
Q

Small Pox… location? rash?

A
  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
Q

Chicken pox.. location? rash?

A
  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
Q

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?

A
  • 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
Q

Pt with lesions on extremities in diff stages (vesicle -> pustule -> escar) MC complication??

A

PNA

148
Q

Nurse/resp therapist with vesicular lesions on finger with erythema and tenderness - pet kitten at home… dx? etio? tx?

A

dx: Herpetic whitlow
etio: HSV (DNA virus)
tx: acyclovir

149
Q

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?

A

hand foot mouth dz.. 2/2 coxackie virus

150
Q

Pustules on palms after petting at a fair or petting a wild dog - dx?

A

Monkey pox

151
Q

pt from southwest OR after visiting yosemite natio park p/w sudden resp failure, pulm edema and inc’d HCT……..

A

HANTA virus

152
Q

Pt bit by cat - wtd?

A

Augmentin (Amox/clav)
- to cover pasterella multiloci + anaerobies
(also for human and dog bites)

153
Q

Pt w/ h/o splenectomy for ITP plays with pet dog and sustains scratch/lac. next morning hypotensive. dx?

A

Septic shock 2/2 CAPNOCYTOPHAGA CANIMORSUS

154
Q

Pt with tooth ache, + submandibular LN. PCN allergic. wtd?

A

Clindamycin

155
Q

Pt with cat p/w pustular lesion on hand and tender LN in axilla … dx? etio? tx?

A

dx: Cat scratch dz
etio: Bartonella Hansleae
Tx: Doxy/erythro

156
Q

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?

A

Dx bacillary angiomatosis
etio: bartonella henslae
Tx - doxy/erythro

157
Q

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?

A

dx: Bartonellosis endocarditis 2/2 bartonalla quintana (trench fever)

158
Q

Rabies vaccine/immune globulin for exposure to …

A 
dog bite
bat bite/scratch
fox bite
racoon bite (major in US)
rural cat yes, house cat NO

NOT rat bite

159
Q

Pt with dog bite in mexico - rabies vaccine 1 year ago. wtd

A

Vaccine x 2 doses (no HRIG)

160
Q

Malaria - P. Falciparum …. where?

A

resistant almost everywhere

161
Q

Malaria P. falciparum sensitive and others.. where?

A

parts of Caribbean, central america, near east

162
Q

Malaria ppx

A

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
Q

Malaria tx

A

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
Q

Look at book #1 pg 220

A

Malaria endemic areas and other endemic dz

165
Q

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?

A

Quinidine gluconate + doxy

166
Q

Pt fever chills after nigeria 4 weeks ago - most sensitive test for malaria. More sen test for malaria? blood smear or antigen based rapid?

A

Antigen based malaria rapid dx test

Best tx - artemether-lumefantrine (less s/e)

167
Q

Pt did not take mefloquine for ppx now with malaria - wtd?

A

malarone (atovaquone/Proguanil)

mefloquone can’t be used with cardiac conduction dz

168
Q

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?

A

Dengue

(bone breaking fever - hemorrhagic fever, mosquito borne, low plts, plasma leakage, low BP - n/v/f/diarrhea/GIB

169
Q

Pt with lower abd pain, pelvic exam adnexal tenderness, cervical motion tenderness and a retained IUD wtd?

A

remove IUD and start ampilcillin/PCN

170
Q

Actinomyces

A

delicate sulfur granules, branching filaments

171
Q

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?

A

Ludwigs angina
etio - peptostreptococcus, mixed anaerobes
Tx - Amoxicillin-clavulante/amp-sulbactam

172
Q

Pt with absolute PMN<500 s/p chemo p/w fever…

DON’T start on routine G-CSF … wtd?

A

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
Q

Which antifungal improve mortality for ppx post chemo neutropenia

A

Posaconazole (noxafil)

174
Q 
Transplant infectious ...
< 1 month?
2 month?
3 month?
4 month?
6 month?
A

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
Q

complication of BK virus

A

BK virus nephropathy

176
Q

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?

A

Aspergilllosis

  • amphotericin B
    if Cr elev - voriconazole
177
Q

what is positive most likely in aspergillosis infxn pt

A

Serum galactomannan (aspergillous antigen - can be tested for as screen)

serum beta-D-glucan is in PJP PNA.

178
Q

55yo renal tx - rejection 2 weeks later on immunosupp drugs - tacrolimus added - several months after - ground glass intranuclear inclusions in urine.. most likely dx?

A

BK virus (human polyoma virus nephropathy) - ground glass intranuclear inclusions urine

179
Q

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?

A

CMV

tx: Ganciclovir and CMV immune globulin

180
Q

Norcardia …… …..tx?

A

= 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
Q

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…

A

TMP-SMX (Bactrim) for norcardia

182
Q

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?

A

Nocardia

skin,lung,brain

183
Q

MCC osteomyelitis in US

A

Staph aureus

184
Q

Older adult with bacteremia p/w fever, lower back ache, point tenderness on spine dx? tx?

A

verebral osteomyelitis

tx - bctx, imagaing ct/mri, abx for 4-6 weeks

185
Q

How to dx infection prosthetic hip 3 months post op

A

CT guided asp and culture

186
Q

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?

A

Spinal epidural abscess

DO MRI NOT XRAY

187
Q

pt s/p chemo, no hx mets, recovering from neurtropenia with high fever - nodules on liver in CT abd… dx?

A

hepatosphere candidiasis.

micafungin -> sensitive -> fluconazole

188
Q

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?

A

Murcormycosis

Tx: surgical debridement > amphotericin B

189
Q

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

A

do epsilon e test measure MIC - if >2 then GISA or Vanc insensitive staph ->
tx Linezolid or quinupristin/dalfoprisitn

190
Q

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?

A

cephalosporin

191
Q

Pt with enterobacter infxn sensitive to cephalosporins - few days later enterobacter now resistant - what happened?

A

Plasma mediated resistance -aka- ESBL, mutants

tx - meropenum

192
Q

Pt growing ESBL klebsiella resitant to impipenum - wtd

A

ceftazidime (avibactam)

193
Q

Pt with UTI with ESBL sensitive only to colistin and tigecycline wtd?

A

Colistin only - tigecycline does NOT penetrate GU tract (only goes to bile)

194
Q

Best management for stenotrophonas (xanthomonas) maltophilia

A

bactrim

195
Q

What organism can be treated with abx without d/c central line?

A

staph epi

GNR/s.aureus dc CVC

196
Q

Best way to do BCx on pt with triple lumen catheter

A

timed pair BCtx from both peripheral blood and catheter

197
Q

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

A

REPLACE CVC with fresh needle stick and continue abx

most prone to infections TLC: femoral > IJ > SC
most complications = SC

198
Q

Best way to prevent central line infection

A

maximum barrier protection while insertion

199
Q

Best way to prevent nosocomial infection outbreaks

A

hand washing

200
Q

best way to prevent vent associated PNA

A

elevation of bed 45 deg,
chlorhexidine mouth wash,
handwashing,
ET suctioning

201
Q

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

A

do more sensitive test

check EBV viral caspid antigen (VCA IgM)

202
Q

Pt receives Ampicillin -> gets morbilliform rash - organism?

A

EBV - hypersensitivity rxn to abx - only occurs in presense of EBV infxn though…false neg monospot

203
Q

Pt w/ +LN, monospot +, inc SOB, large tonsils - wtd

A

steroids… no abx

204
Q

Pt with infectious mono and LUQ pain wtd?

A

CT scan stat - splentic rupture complication

tx: splenectomy

205
Q

Pt in MICU on IV TPN x days with fever, chills and growing yeast with blurry vision - etiology?

A

candida opthalmitis- chromium deficiency

206
Q

Candida in BAL. tx?

A

DO NOT TX

207
Q

Asymptomatic Candiduria.. tx?

A

DO NOT TX

208
Q

Asymptomatic candida in blood.. tx?

A

TREAT THIS!!

209
Q

Pt grows candida in blood, fluconazole d/c’d 2 weeks ago wtd?

A

start caspofungin, then downgrade when sensitivities arrive

210
Q

Anthrax

A
  • 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
Q

Anthrax tx

A

Flouroquiniolone or PCN

212
Q

Anthrax other characteristics

A 
NO person to person transfer
Isolation NOT required
BCtx = gram + bacilli
PPX effective only one day after exposure
Vaccine available for military
213
Q

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?

A

dx: Tularemia …. ulcers+glands=ulceroglandular fever
lab test = serology*
tx - streptomycin x 7 to 10 days**

214
Q

Good samaritan removes dead deer from highway in Arkansas/Oklahoma - couple days later with tender erythemaous papule that became ulcerated with black eschar - organism?

A

Francisella Turarensis (tularemia)

215
Q

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?

A

Tularemia (infiltrate) anthrax does not have inflitrates.

216
Q

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?

A

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
Q

Which most commonly aeorsolized

A

Coxiella burnetii (Q fever)

218
Q

Rancher with fever, culture neg endocarditis - cryoglobulins pos and HCV neg - dx?

A

Brucella - musc pain, sweating, fever, cryoglob +, endocarditis (neg ctx)
brucellosis - from unpaturized mild - ranchers infected animals
Tx tetracyclines, rifampin, streptomycin, aminoglycosides

219
Q

Q fever infected most likely by…

A

Vets, Abattoir workers, farmers handling infected goat, sheep, cattle

Q fever - coxiella burnetti (ricksettia)
URI, fever, myalgias, headache
Tx - doxycycline, tetracycline, cipro

220
Q

Young male with fever, myalgias, petechial rash after rafting trip PR or costa rica - icteric, mildly elev LFT with high T bili dx?

A

Leptospirosis - mildly elev transaminases and D bili 5-10x normal

221
Q

Most likely inhaled with atypical PNA/h/a, fever

A

Q fever

222
Q

MC with contaminated soil and animal products

A

Q fever

223
Q

Caused by rikettsia

A

Q-fever

224
Q

Skin contact or aerosolized -> RE system - splenomegaly, hepatitis, LN+ fever and drnching sweat - dx?

A

Brucellosis

225
Q

Gram neg coccobacilli

A

Brucellosis

226
Q

Sewage worker contact - fever hep, jaundice, liver hemorrhage, CONJUNCTIVAL SUFFUSION

A

Leptospirosis

227
Q

Vet with fever - mental status change, jaunce renal failure, ecchymosis

A

Leptospirosis

228
Q

Doxycycline

A

Q fever, burcellosis, leptospriosis, erysipelothrix

229
Q

Buchter with fever, palpable spleen tip

A

brucellosis

230
Q

Fisherman or fish handler with burnign or throbbing pain with erythematous lesion on finger

A

erysipelothrix

231
Q

Pt walks on beach in west florida p/w red eyes, SOB, no wheeze or rhonchi - dead fish on beach - dx?

A

Redtide bloom caused by Karenia brevis (algae)

232
Q

Pt p/w diarrhea, fever, non-productive cough with HYPONATREMIA - drinks from TAP water. most consistent with ….

A

Legioniella -

tx quinolones - levoflox, azithro

233
Q 
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?
A

Dx? Leptospirosis

Tx: Doxycycline

234
Q

21yo Iraq or afghan vet p/w 3cm lesion on arm, ulcerated with irrreg margins, eschar w/ surrounding erythema.. dx? tx?

A

Cutaneous Leishmaniasis

Tx: self-limited

235
Q

40yo immigrant rural turkey/middle east with enlarged liver - dx?

A

Hydratid cyst (echinnococcus)

236
Q

CMV colits isolation?

A

none

237
Q

MRSA isolation?

A

contact

238
Q

VRSA,VRE isolation?

A

contact

239
Q

HZV 1 dermatome isolation?

A

contact

240
Q

HZV >2 derm isolation?

A

contact AND airborne

241
Q

C diff isolation?

A

contact

242
Q

scabies isolation?

A

contact

243
Q

Measles isolation?

A

airborne

244
Q

Varicella isolation?

A

contact AND airborne

245
Q

MTB isolation?

A

airborne

246
Q

Neisseria isolation?

A

dropelt

247
Q

Influenza isolation?

A

droplet

248
Q

Plague isolation?

A

droplet

249
Q

HIV highest risk?

contaminated blood products?

A

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
Q

Occupation risk exposure - high risk

A 
for high risk exposure, recommend:
1 INSTI (Raltegravir or Dolutegravir) + 
2 NRTIs (Tenofovir + Emcitrabine)
251
Q

Pt with HIV on ART undetctable VL now preg - WTD

A

continue ART to term

252
Q

If HIV pt wants to breast feed

A

continue ART maintain undetect VL to prevent baby transission

253
Q

A preg pt has HIV test which shows antibodies are indeterminate and NAAT negative. What is the best management.?

A

Tell the patient is HIV negative.

254
Q

Nurse with needle stick exposure to a pt with HIV or high risk for HIV.. wtd

A

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
Q

Sexual assult victim by IVDA unknown HIV status. < 72hrs ago. wtd

A 
Offer 1 INSTI (Dolutegravir) + 
2 NRTIs (Tenofovir+Emcitrabine)

after 3 days no.

256
Q

Opp infxn >200 T cells

A
  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
Q

Opp Infxn < 200 T cells

A
  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
Q

Best test for suspected mild to mod dz where BAL is not planned in the diagnosis of PJP?

A

check serum Beta-D-glucan

259
Q

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?

A

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
Q

Pt on bactrim ppx with rxn.. wtd

A

change to dapsone OR atovaquone

261
Q

Which drug covers both PJP ppx and secondary ppx for toxo?

A

dapsone + pyrimethamine

262
Q

Candidasis…

A

oropharyngeal white patches adherent to oral mucosa

Tx Fluconazole
recurrent on fluconazole - use Echinocandins

263
Q

HIV with T cell 55 - severe heart burn wtd

A
  • empiric fluconazole for susp esoph candidasis

- if no response upper endscopy - r/o CV or HSV or candidial esophagitsi

264
Q

<100 t cells

pt w/ CD4 45 p/w HA x wks, not relieved with analgesics. CT head neg - wtd

A

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
Q

< 50 t cells - you can get …

A

MAI: fevers, hepatomeg, LAD - elev alk phos (vit D def), bctx + AFB
Tx: clarithro + ethambutol +/- rifabutin

266
Q

<25 tcells

A

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
Q

Prophylaxis against opportunistic infxns…

A

<200 T cells: PJP = Bactrim, Dapsone, atovaquone

<50 T cells: MAI = Azithro 1200mg/wk or clarithro 500mg BID

268
Q

Pt with T cells 25 started on HAART, bactrim and azithro. 6 months later T cells 150. wtd

A

d/c azithro for MAI ppx

not < 50

269
Q

Pt 4 months later t cells increased to 250 wtd

A

d/c bactrim for PJP ppx

270
Q

Which finding r/o crypto meningitis

A

neg crypt antigen in serum or CSF

271
Q

Ring enhancing lesions

A

Toxo
brain abscess
lymphoma

272
Q

Pt with HIV T cells 25 w/ headache and one sided weakness - CT scan ring enhancing lesion wtd?

A

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
Q

CNS lymphoma seen in patients w/..

A

T cells < 50. EBV ag + in almost all of them

274
Q

HIV pt w/ T-cell < 45 - VL 150K p/w weakness of left leg - CT scan ring enhancing lesion, CMV +. most likely causes…

A

Toxo, lymphoma, or brain abscess

NOT CMV (biventricular enhancement should be there)

275
Q

Middle aged latin american immigrant living in US recent onset Seizures - CT multiple cystic lesions with calcification mild hydroceph.. dx? tx?

A

Neurocystercircosis 2/2 Taenea soliens

Tx: Phenytoin (cyerco serology)

276
Q

Hog farmer with fever, myalgia - periorobital edema, spinter/conjuntival hemorrhages - muslce tenderness no murmur - EOS 8%, LDH 400, CPK 700. what will establish dx?

A

trichinella antibodies.

277
Q

MCC PNA in pt w/ HIV CD4 150 is

A

Strep Pneumo

278
Q

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.?

A

Azithro 1200mg qwk OR
clarithro 500mg BID
for MAI ppx

279
Q

Indications for ART therapy for HIV

A 
VL>100K
T Cell <500
Acute retroviral syndrome
Opportunistic Infections
Pregnancy
280
Q

Protease Inhib - main SE Lipodystrophy

A

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
Q

NRTI - lactic acidosis, CAD, hypersensitiv rxn, neuropathy

A 
Tenofovir (Viread)- renal insuffiency, fanconi
Emtricitabine (Emtriva)
Zidovudine (Retrovir) 
Abacavir (Ziagen)
Lamivudine (Epivir)

tenofovir + emtricitabine = truvada

282
Q

NNRTI

A

Efavirenz (sustiva) weird dreams
Entravirine (intelence) CNS effuects, conf, abn dreams, agitiation
Rilpivirine(edurant)

283
Q

Integrase Inhibitors

A

Dolutegravir (tivicay)
Raltegravir (Isentress)
Elvitegravir (Viteka)

284
Q

Combinations of HIV drugs

A

2 NRTI + PI/Integ Inhib

2 NRTI + NNRTI

285
Q

protease inhibitors S/E

A

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
Q

What drug causes bone marrow suppression?

A

Zidovudine (AZT)

287
Q

Best statin for HLD with HIV

A

Pravastatin, or atorvastatin

288
Q

What statin to NEVER use

A

Simvastatin (inc levels HIV drugs)

289
Q

Best drug for insulin resistance/ hyperglyc

A

metformin

290
Q

Best inh steroid for HIV asthma

A

Beclamethasone

291
Q

Best HIV med with HCV therapy

A

Dolutegravir (Tivicay)

292
Q

What drug causes renal insuff (HIV drug)

A

Tenofovir

293
Q

HIV pt started on stribild (elvitegravir + cobicistat + emtricitabine + tenofovir) 2 weeks ago. creatinine goese up from 0.8 to 1.3. Most likely etiology?

A

cobicistat

294
Q

HIV pt with anorexia, wt loss, lethargy dizziness - hyperpig of skin, BP low, HR orthostatic, Na 135, K 5 dx?

A

Addison’s dz (Ag/ab HIV) autoimmune adrenalitis

295
Q

Immune reconstitution syndrome -

A

pt with adv HIV low t cells high VL - start on ART - react to latent pathogens - inflamation - continue ART

296
Q

Pt with T cells 25, VL 250K, start ed on ART - 3 weeks later with cervical lymphadenopathy

A

immune reconstitution to MAI/TB

297
Q

HIV survelilence

A
  • 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
Q

HIV VL note dropping but t-cell count the same

A

VL should be undetectable by 6months.
Reason?
Non-adherence OR Resistant virus - check HIV genotyping and change tx accordingly

299
Q

Earliest change to see in HIV therapy failure

A

rise in VL

300
Q

Earliest OI in AIDS (not aids def lesion)

A

Oral thrush

301
Q

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?

A
  • 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
Q

Pt dx with TB start on 4 anti TB - found to be HIV (+) - T-cells 25. when to start ART?

A

within 2 weeks

303
Q

Labs/monitorsing

A

HIV VL, T cells, RPR, Hep panel, PPD, Tox, LFTs

Vacc : HAV, HBV, flu, pneumovax, inactiv poli, Tdt
NO LIVE VACCines

304
Q

Live vaccines

A

Oral polio
MMR
Varicella
Yellow fever

305
Q

complicated UTI with ESBL

A

Fosfomycin

306
Q

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?

A

Mycoplasma genitalium

tx: moxifloxacin

307
Q

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

A

neurosyphilis. wtd. spinal tap

a. neurosyphilis
b. cryptococcal meningitis … Tcells <100
c. PML …. Tcells < 25

308
Q

Patient with an abscess with surrounding erythema. I%D is done. wtd?

A

prescribe bactrim

309
Q

Pt traveling to brazil for olympics or visiting latin america or south america.. wtd.?

A

DEET at least 30%

310
Q

Preggo asks how to prevent infectious diseas on her visit to a destination wedding in the DR?

A

cancel trip

311
Q

30 yr old man visits caribbean island for a week on business and comes back w fever, HA, rash, conjunctivitis. You suspect zika.. wtd?

A

RNA PCR of serum and urine, if expos < 2 weeks ago

serum ELISA IgM, if expos > 2 weeks ago

312
Q

Osteomyeltitis. prosthetic implants …. etio, tx?

A

staph epi

tx: vanc + gent + rifampin

313
Q

osteomyelitis. necrotic bone (sequestrum) –> chronic osteo –> tx?

A

debridement

314
Q

sickle cell with osteo ….

A

salmonella incidence increased > staph

315
Q

Husband w/ HIV positive Tcells 450 and VL 900… /hiv negative wife asks you how to prevent HIV in addition to condoms?

A

Emcitrabine-Tenofovir daily (Truvada)

316
Q

What is atripla

A

efavirenz + emtricitabine + tenofovir

317
Q

what is complera

A

emtricitabine + rilpivirine + tenofovir

318
Q

what is stribild

A

elvitegravir + cobicistat + emtricitabine + tenofovir

319
Q

what is triumeq

A

dolutegravir + abacavir + lamuvidine

320
Q

what is odefsey

A

emtricitabine + rilpivirine + tenofovir

321
Q

NNRTIs SE

A

rash, steven johnsons

nevirapine = rash steven johnson, liver tox
efavirenz = CNS effects; confusion, abnormal dreams, agitation
322
Q

NRTIs SE

A

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
Q

cobicistat boosts levels of what other meds

A

CCB, BB, statins

324
Q

Pt with T-cells of 30 w/ cryptococcal meningitis, newly diagnosed HIV. when to start ART?

A

After treating crypotococcal mening .. 5 wks.

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