7. Clinical Considerations in Fever Flashcards
what causes coccidiocomycosis?
infxn from inhaling C. immitis or C. posadasii
=mold in SW US, Mexico, Central/S. America
exposure to anopheline mosquitoes in malaria-endemic areas will present as
intermittent chills, fever, sweating
HA, myalgia, vomiting, splenomegaly
anemia, thrombocytopenia
what are characterisitcs of MRSA
often hospital acquired
common in immunocompromised pt
wound = localized erythema w/ induration & purulent drainage (abscess common)
Gram (+) cocci on stain; culture = (+)
(+) s. aureus –> focus on endocarditis, osteomyelitis and deep seated systemic infxns
compare and contrast erysipela & cellulitis in MRSA skin infxn
erysipela: superficial & well-defined borders
cellulitis: deep (dermis & subQ fat); edema, & swelling common
both: painful, warm, indurated, erythematous, nonlocalized & may include lymphangitis
What are significant characteristics of primary coccidiodomycosis
arthralgia w/ periarticular swelling of knees & ankles
erythema nodosum 2-20 days after onset
also nasopharyngitis (flu-like sxs
How does multiple myeloma present?
what do you use to diagnose?
=infiltration of bone marrow, bone destruction & paraprotein elaboration ==> lytic bone lesions –> bone pain (spine, ribs, proximal long bones)
symptoms of - anemia, kidney failure
soft tissue masses
LAB : monoclonal Ig in serum/urine
Biopsy: clonal plasma cell in bone marrow/tissue
what is the difference btn CMV infection and disease
infection= acute = detect viral protein (Ag) or NA in body fluid/tissue, regardless sxs
disease: CMV infection w/ signs/sxs; viral syndrome or tissue-invasive dz
What are complications of progressive histoplasmosis
fever, wt loss, prostration
dyspnea, cough
ulcer of mucous mem of oropharynx
HSM
adrenal insufficiency
GI- mimic IBD
CNS probs
(progressive seen in pt w/ HIV (<100 CD4) or impaired cellular immunity)
What are clinical manifestations of SLE (besides malar rash)
systemic sxs
alopecia (common)
raynaud phenomenon (20%)
joint symptoms w/ or w/o synovitis (90%) –> can lead to reversible swan-neck defromity (changes NOT on radiograph)
pericarditis
what are risk factors for community acquired MRSA?
(aggresive!)
contact sports
military
incarceration
inject drugs
What are the 3 subtypes of influenza
A & B - same symptoms (A = pandemic)
C - milder
(difficult to diagnose in absence of epidemic bc looks like other viral illnesses)
What can increase the change of GAS pharyngitis in children
scarlatiniform rash (sandpaper-like -attached pic)
palatal petechiae
tonsillar enlargement w/ or w/o exudate
vomiting
tender cervical LN
(but is not enough to Dx)
What is the cause of bacteremia in pregnant women
& how does it present
Strep agalactiae (Group B)
UTI, chorioamnionitis, postpartum endometritis
what are HIV patients with disseminated coccidiodomycosis likely to show?
(& list other sxs of disseminated coccidiodomycosis)
*pulmonary miliary inflitrates
mediastinal LN - LAD
meningitis (may result in chronic basilar meningitis)
productive cough, lung abscess/empyema, skin/bone infxn, lymphadenitis –> suppuration
Multiple myeloma is more prone to infxn by….
encapsulated organisms
Strep pneumonia & H. influenzae
what population is disseminated histoplasmosis disease present? what is the prognosis in these pts?
how do you Dx?
common in AIDs/immunocompromised pts –> poor prognosis
= fulminant –> stimulate septic shock
Dx: blood/bone marrow culture & urine polysac Ag
What are clincal manifestations of multiple myeloma
anemia sxs
bone pain & tenderness (back, hip, ribs)
lytic bone lesion
sx of kidney failure
soft tissue masses
neuropathy or spinal cord compression
increased susceptibility to infxn
what are risk factors for TB REACTIVATION
gastrectomy
silicosis
DM
HIV
immunosuppressive drugs
how do you differentiate ACUTE acquired CMV from infxous mono?
V similar!
but NO pharyngeal symps in ACUTE CMV
& (-) heterophile Ab
how does CMV infxn present in immunoCOMPROMISED pts
CMV retinitis w/ neovascular & prolif retinal lesions- cottage cheese & ketchup infiltrates upon fundoscopic exam
GI & hepatobiliary CMV w/ esophagitis, small bowl inflam
colitis
pneumonitis (transplant & AIDs pts)
neuro sxs: polyneuropahty, transverse myelitis, encephalitis
How can Staphylococcal infxns cause MSSA and MRSA or any infxn?
skin/soft tissue infxn
break in skin (erysipelas, folliculitis, cellulitis, trauma)
IV cath
cardiac devices
orthopedic hardware
describe latent TB and reactivation of TB
latent: bacilli contained w/i granulomata - NON-transmittable
reactivation when infected person’s immune fxn is compromised
= now active!
why do you have kidney failure in multiple myeloma
light chain component deposited in tissues as amyloid
how does the primary infection occur in TB
inhale droplet w/ tubercle bacilli
& subsequent lymphangitic & hematogenous spread before immunity develops
What are clinical manifestations of Sjorgren’s syndrome
sicca sxs: dry eyes, mouth due to immune-mediated dysfxn of lacrimal and salivary glands
w/ or w/o RA
enlarged parotid gland
increased incidence of lympoma (NHL-maltoma)
List Clinical Manifestations of Sepsis
arterial HYPOtenstion (sBP < 90; MAP <70)
Temp >38.3C or <36C ( >100.94F or <96.8F )
HR >90
tachypnea- RR >=20
what is the bacteremia?
causes of bacteremia?
=abnormal presence of bacteria in blood stream
MOST COMMON causes:
- skin/soft tissue infxn
- central venous cath & other IV devices
- bone/joint infxn
- pneumonia
- endocarditis
list the clinical manifestations of bacteremia
fever, fatigue, malaise
nausea/vomitting
loss of appetite, dehydration
myalgia/arthralgia
Lab : leukocytosis & left shift
Staph infections are typically localized but how do you know it has become systemic?
bone/joint pain
what is qSOFA?
(vs SOFA?)
predicts chance of sepsis -bedside scoring system based on:
resp rate >=22, altered mentation & sBP =< 100
(vs SOFA - organ dysfxn score - not diagnostic, time consuming)
what are symptoms of systemic staph infections and what do they suggest
bone/joint pain (osteomyelitis, discitis, epidural abscess)
protracted fever/sweats - (endocarditis)
abd pain - (esp LUQ - splenic infxn)
costovertebral angle tenderness - (pyelonephritis, renal infarction or psoas abscess)
HA (meningitis, intracranial infxn, septic emboli)
what are outside risk factors for TB
household exposure
incarceration
recreational/illicit drugs
travel to endemic areas
if a pt presents w/ end-organ perfusion, what is going on?
what are these manifestations?
=Septic Shock
- warm, flushed skin (early) –> cool (w/ progression of shock bc redirect blood flow to core)
- decreased cap refill, cyanosis, mottling (red-purple blotching of skin)
- altered mental status, obtundation, restless
- oliguria/anuria
- ileus/absent bowel sounds
- How does SLE present?*
- what are serologic finding to Dx*
female, malar rash
anemia, leukopenia, thrombocytopenia
serology: (+) ANA, (+) anti-ds DNA & low complement (and (+) Smith)
What is the significance of strep agalactiae (group B) in neonates & nonpregnant adults
neonates: most common manifestation of neonatal dz = bacteremia w/o focus, sepsis, pneumonia &/or meningitis
nonpregnant: MCC strep in adults; sepsis, soft tissue infxn, endocarditis and other focal infxn can manifest too
What are lab findings in sepsis
(one is V important!)
HYPERLACTATEMIA -bc organ hypoperfusion in presence/absence of hypotension –> POOR PROGNOSIS
(lot of others..)
- leukocytosis or -penia!/ thrombocytopenia
- normal WBC (W/ DIFF will give more info!)
- hyperglycemia (w/o diabetes)/hyperbilirubin
- Increase plasma-CRP
- arterial hypoxemia (<300)
- acute oliguria
- increase creatinine
what are risk factors for sepsis?
- ICU admission
- bacteremia
- >= 65 yo
- immunosuppression
- diabetes & obesity
- CA
- community acquired pneumonia
- previous hospitalization (esp w/i 90 days)
MRSA pearls
may complicate surgical incision
-diabetic foot infxn
joint (unusual) but if so = bacteremia, instrumentation or prosthetic joint
osteomyelitis - fixation device/prosthetic; hematogenous infxn (kids); nonhealing foot ulcer
What are risk factors for drug resistance in TB
immigration from regions w/ drug-resisitant TB
close contant w/ person infected w/ drug-resisitant TB
unsuccessful prior anti-TB therapy
noncompliance
what are the clinical manifestations of histoplasmosis
(most ppl asymptomatic!)
mild sxs: flu-like 1-4 days
severe: like atypical pneumonia w/ fever, cough and mild chest pain for 5-15 days
elderly w/ COPD: chronic progressive histoplasmosis
PE = normal
What is the most common cause of tonsilopharyngitis in kids/teens
strep pyogenese
Describe the clinical manifestation of acute malaria
prodrome - HA & fatigue –> irregular fever
w/o therapy fever becomes regular - (vivax & ovale = 48 hr cycles & malariae = 72 hr)
HA, malaise, myalgia, arthralgia, cough, chest pain, abd pain
anorexia, NVD
PE = anemia, jaundiace HSM, HYPOtension, seizures
What are the 4 species of the genus repsonible for human malaria?
what is the severity of each
Plasmodium
- vivax- rarely severe
- malariae -not severe
- ovale- not severe
nearly all severe dz = 4. falciparum
What is CMV infxn in immunoCOMPETENT pts characterized as
mononucleosis-like syndrome w/ NEG heterophil Ab
(can also occur post-splenectomy yrs later)
cutaneous rash common (compared to mono)
what is the most common HIV-related malignancy?
& how does it present
= HHV-8 - Kaposi sarcoma
= red/purple/dark plaques/nodules on cutaneous/mucosal surface often on LE, face (noses), oral mucousa & genitalia
chronic kaposi: HIV infxn, high CD4 & low viral load
pul kaposi: SOB, cough, hemoptysis/chest pain ; could be asymptomatic and only show on radiograph!
What are symptoms of monocleosis-like syndrome (CMV infxn) in immunoCOMPETANT pts
fever, malaise, myalgia, arthralgia
persistent splenomegaly, atypical lymphocytes,
abnormal liver fxn test
leukocytosis –> leukopenia
Histoplasmosis is related to what region/animal
exposure to bird & bat droppings
river valley, esp Ohio river and Mississippi river valley
[. boards fav :).]
what are characteristics of CMV
most - asymptomatic
increase prevalence w/ age, low SES, # sexual partners, Hx prior STI, employment in daycare
serious dz in immunocompromised pts
What are the main symptoms & clinical manifestations of TB
most common: productive COUGH
hemoptysis
slowly progressive: malaise, anorexia, fatigue, wt loss, fever, night sweats
looks chronically ill
chest exam - nonspecific post-tussive apical rales
(be aware of atypical presentation in elderly and HIV pts)
Differentiate multiple myeloma w/ waldenstrom macroglobulinemia
Waldenstrom - no lytic bone lesions!
*clinical pearl
What are respiratory and systemic symptoms of the flu
resp: rhinorrhea, congestion, pharyngitis, hoarseness, nonproductive cough, substernal soreness
systemic: fever (3-5 days), chills, HA, malaise, myalgia
*may see GI symps in kids w/ flu-B
how can CMV inclusion disease present in neonates
- jaundice, HSM, thrombocytopenia, purpura,
- microcephaly, periventricular CNS calcifications,
- mental retardation & motor disability
*hearing loss - 50% symptomatic infants at birth
*most = asymptomatic BUT may get neurological deficits later in life (hearing loss/mental retardation)
how/why does strep pyogenes present in neonates, kids/teens/ adults
neonates - maternal/fetal transmission
kids/teens - tonsilopharyngitis, impetigo; secondary bacterial skin infxn
adults - pharyngitis
