clinical consdirations of fever- tyler's HY Flashcards
most common source of bacteremia
skin and soft tissue infection, central venous catheters + other intravascuar devices, bone and joint infections, pneumonia endocarditis
not obvious in 25% cases
lab changes seen with bacteremia and sepsis
leukocytosis and left shift of hemogram
what are SOFA and qSOFA
SOFA = organ dysfunction score, identify pts who potentially have a high risk of dying from infection
qSOFA= predicts chance of sepsis for patients admitted to medical foor
risk factors leading to sepsis
ICU admission bacteremia age >/= 65 immunosuppression DM and obesity CA community acquired pneumonia previous hospitalization in last 30 days, received abx
vital signs and clinical manifestations of sepsis
arterial hypotension SBP<90, MAP<70
Temp either >38.3 or <36 C
HR >90 bpm
tachypnea, RR >20 bpm
end organ manifestations in sepsis
warm flushed skin in early phases
progress to shock with cool skin, dec cap refill, cyanosis, or mottling
hypoperfusion= AMS, obtunded, restless, oliguria/anuria
end stage sign of end-organ hypoperfusion= ILEUS or ABSENT BOWEL SOUNDS –> indicates upcoming sepsis
labs in sepsis
signs and sx
increased: glucose, plasma CRP, Cr, coag time, total bilirubin, serum lactate
decreased: urine output, plts
sx: abdrupt onset hyperventilation with respiratory ALKALOSIS,
late finding= hypotension and shock, poor prognosis
staph bacteremia
-risk
-sx
-risk: breaks in skin (cellulits, folliculitis, trauma), intravac catheter, cardiac device, ortho hardware in joint ot spine
30% have systemic infection= bone/joint pain, fever+sweats (associated w endocarditis) abd pain (LUQ-splenic infarct) CVA tenderness (pyelonephritis, psoas abscess) HA (meningitis, intracranial infection, septic emboli)
most common hospital acquired infection that affects multiple systems
MRSA
MRSA
- traditional population
- presentation
- culture
- skin manifestations
- in hospitalized patients who are immunocompromised
- often at long term wounds: wound will have local erythemia w induration and purulent drainage, abscesses are common
pus = G+ cocci in clusters
-skin:
erysipelas (superficial red, well defined borders)
cellulits (deeper, edema and lymphangitis)
both (painful, nonlocal, warm)
if cultures of pus around a wound are positive for S. aureus, where should you focus your workup
endocarditis
osteomyelitis
deep seated systemic infections (epidural abscess, discitis, abscess)
risk factors for community acquired MRSA
how does prognosis fair compared to hospital acquired
community MRSA is more aggressive and invasive
risk: contact sports, military service, incarceration, injection drug use
MRSA infection may complicate ___ ____, and is commonly implicated in _______
osteomyelitis due to MRSA may be associated with (3)
surgical incisions
diabetic foot infection
(3) fixation device/prosthesis + hematogenous infection in children + nonhealing foot ulcers in DM or peripheral A ds
Group A strep bacteremia:
- most common bug
- presentation in neonates vs kids/teens vs adults
what sx in kids with a sore throat increase the likelihood of Group A Strep (tho not diagnostic)
strep pyogenes
neonates: maternal-fetal transmission
kids/teens: most common cause of tonsillopharyngitis, also impetigo or secondary infection of skin
adults: pharyngitis
sx: scarlatiniform rash (sandpaper like appearance), palatal petechiae, tonsillar enlargement , vomiting, tender cervical nodes
group B strep bacteremia
- bug
- -presentation in neonates vs pregnant Fs vs nonpregnant adults
strep agalactiae
neonates: acquired in utero or during passage- mostly present as sepsis, pneumonia, and/or meningitis
pregnant Fs= UTI, chorioamnionitis, postpartum endometritis
nonpregnant adults: MOST COMMON STREP PATHOGEN IN ADULTS, bacteremia, sepsis, soft tissue infections, endocarditis
sx , CXR, risk factors of TB
who is likely to present atypically
sx: productive cough most common, also blood streaked sputum, weight loss, fever+night sweats
CXR: non-specific, post-tussive apical rales are classis
risk: household exposure, incarceration, recreational drugs, travel to an endemic area
atypical ~ elderly, HIV+
TB: primary infections vs latent vs reactivation
primary: airborn droplets, person to person transmission
latent: bacilli are contained within granulomas, become active ds if the person’s immune function becomes impaired
reactivation= immune system because weak and no longer able to contain the latent bacteria so they become active and active infection ensues
-associated with gastrectomy, silicosis, DM, HIV, immunosuppressive drugs
what are the risk factors for drug resistance to T
immigration from regions with drug-resistant TB,
close contact with patients infected w drug-resistant TB
unsuccessful prior anti-TB therapy
pt noncompliance
influenza
- virus type, transmission
- pandemics are usually associated with which antigenc subtye
- common sx
orthomyxovirus, respiratory droplets
pandemics= type A with major antigenic shift
resemble other viral illnesses,
GI sx common in young children with Flu B infection
fever lasts 3-5 days typically
leukocytosis may be marker of SECONDARY complications
HIV
associated CA
neuro manifestations
mean time btwn HIV infection and AIDS
NHL
3- dementia, aseptic meningitis, neuropathy
10 yrs
- conditions highly suggestive of HIV infection
2. AIDS defining illness
- hairy leukoplakia of tongue, disseminated kaposi sarcoma, CUTANEOUS BACILLARY ANGIOMATOSIS, gen lymphadenopathy early on
- PNEUMOCYSTIS JIROVECI pneumonia, LYMPHOMA, CMV, HISTOPLASMOSIS (w dec CD4), COCCIDIOMYCOSIS
also recurrent bac infecitons, kaposi sarcoma, crypto, M. tuberculosis
CMV
- most infections present how
- seroprevalence increases w:
- how is it different infectious mono (EBV)
- serious ds occurs primary in who?
complications of CMV
- most= asx
- seroprevalence increases w: age, low SES, # sexual partners, hx of STI, employement in child day care centers
- vs EBV= CMV DOESN’T have pharyngeal sx
- serious ds is in immuncompromised pts
- complications: mucosal GI damage, encephalitis, severe hepatitis, thrombocytopenia, guillan barre, peri/myo-carditis
CMV infections vs CMV ds
CMV infections: virus isolations or detection of viral proteins
CMV ds: evidence of CMV is signs and sx, = fever, malaise, leukopenia, neutropenia, atypical lymphocytosis, thrombocytopenia
perinatal CMV inclusion ds
acquisition
sx:
most infected neonates are:
prognosis
acquired thru breastfeeding or blood products
jaunndice, hepatosplenomegaly, purpura, microcephaly, preventricular CNS calcification, motor disability, >50% infants symptomatic at birth have hearing loss
most infected neonates are ASX, but neurologic deficits may ensue later in life
typically benign
sx of..
1. CMV in immunoCOMPETENT patients
- CMV in immunoCOMPROMISED patients
- mono-like w negative heterophil Abs, can occur post-splenectomy years after infection
fever, malaise, myalgias+arthralgias, splenomegaly, a
abn liver tests, atypical lymphocytes, leukopenia followed by leukocytosis - CMV retinitis (mostly advanced AIDS),
esophagitis, small bowel inflammation, colitis, or cholangiopathy (AIDS, or high dose chemo)
pneumonitis (2-6 months post transplant, AIDS)
neuro: polyneuropathy, transverse myelitis, encephalitis
histoplasmosis
- hx : exposure to what and where
- most patients are ___ : ____ is the mst common clin problem
- presentation common in AIDS or other immunosuppressed states, prognosis
- presentations in older paients with COPD
- exposure to bird/bat droppings, Ohio River or Mississippi River valleys
- most patients are asx : respiratory illness is the most common clin problem (atypical pneumonia, mild CP ) + PE is usually norm
- disseminated ds in immunosupp+AIDS= poor prognosis
- CHRONIC PROGRESSIVE PULMONARY HISTOPLASMOSIS in old COPD pts
complications of histoplasmosis in immunocompromised patients
disseminated histoplasmosis
fever and multiple organ system involvement
presentations may be fulminant, simulating septic shock
coccidioidomycosis
- bugs, US location
- primary acute infection vs dissemination
C. immitis or C. posadasii (US, mexico, central and south america)
-primary acute infection: flu like= usually respiratory w constitutional
dissemination: productive cough, mediastinal LN enlarged,
CXR: lung abscess, epyema
meningitis (30-50%), arthralgias, bone lesions, or skin/ST abscess
TEST Q:
disseminated coccidioidomycosis in HIV ps
miliary infiltrates, lymphadenopathy, meningitis
skin lesions UNCOMMON
malaria
sx and labs
bug responsible for nearly all severe ds
-seizures may represent ___ or ___
constitutional (HA and fatigue, followed by irregular fever), thrombocytopenia, intrerythrocytic parasites (on blood smears)
P falcuparum: responsible for nearly all severe ds
seizures are either SIMPLE FEBRILE CONVULSIONS or EVIDENCE OF SEVERE NEUROLOGIC DS
multiple myeloma vs waldenstrom’s macroglobulinemia
multiple myeloma: sx of anemia, bone tenderness (back, hips, ribs), LYTIC BONE lesions, sx of kidney failure (~amyloid), neuropathy/SC compression, ST masses, increased susc to infections
Waldenstrom’s macroglobulinemia= NO lytic bone lesions, rest same
multiple myeloma pts are especially prone to infections with …
encapsulated organisms = Strep pneumoniae , H. influenzae
most common HIV-related malignancy
kaposi sarcoma = HHV8/KSHV
presentation of kaposi sarcoma
pulmonary kaposi sarcoma
chronic kaposi sarcoma
- purple/dark plaques and nodules on cutaneous or mucosal surfaces
- pulmonary kaposi sarcoma: SOB, sough, hemoptysis, CP, OR asx, show on CXR only
- chronic KS: in high CD4 count and low viral load,looks like a melanoma (need rule out)
clinical manifestations of SLE
systemic alopecia mucus memebrane lesions raynauds joints (arthritis, no erosion)
leuko/thrombocyto -penia, AI hemolytic anemia, TTP
conjunctivitis, cotton-wool spots on retina
abn pericardium, arrhythmia, HF
pleural effusion, bronchopnuemonia
lupus cerebritis
what conditions are associated with sjogren’s
RA SLE PBC scleroderma polymyositis polyarteritis interstitial pulmonary fibrosis
sjogren’s is associated with increased incidence of ___
lymphoma
serology associated with sjogren
sjogren sx
rheumatoid factor and antinuclear auto-Ab
sicca, xerostomia, loss of taste and smell, dysphagia, pancreatitis, obstructive airway ds and interstitial lung ds,
Type 1 RTA (distal)
chronic interstitial nephritis
labs for acute HIV infection
negative HIV ELISA resut but + viral load
heterophile Ab test ~
infectious mono (EBV)
most febrile illness are caused by _____, are __-lived, and are relatively ____ to diagnose
common infections
short
easy
infections to consider in a returned traveler with fever
malaria
dysentery
hepatitis
dengue fever
key components of management of septic shock?
restore perfuion
adequate O2
early goal directed therapy protocol
use broad spectrum abx and then narrow down with culture results
what end organ effects of poor perfusion can one monitor
mental status urine output lactic acidemia cardiac ischemia or arrhythmia peripheral perfusion
line placement at _____ has a higher infection risk than one at a subclavian or internal jugular site
femoral
when should a central line be removed?
if there is purulence at the exist ste if organism found is S aureus or Candida persistent bacteremia septic thombophlebitis endocarditis metastatic abscesses occur
common causes of healthcare-associated infections
often multidrug resistant
MRSA
S. epidermidis
Enterococcus faecium resistant to ampicillin and vancomycin
resistant G(-) infections= Pseudomonas, Citrobacter, Acinebacter, Stenotrophomonas, Enterobacter
carbapenem-resistant enterobacteriaceae
CXR with diffuse interstitial infiltrate in a “bat’s wing” or “butterfly” pattern
pneumocystis jiroveci pnuemonia
test to diagnose HIV vs test to confirm the diagnosis
when after exposure is HIV anitbody detectable
HIV Ab by ELISA
Western Blott
95% detectable within 6 wks
kid with fever, diffuse maculopapular rash that is erythemic and oral lesions on tongue
measles
