Clinical Medicine Exam 2 ID Flashcards
1
Q
Endocarditis criteria for Dx
A
Accepted criteria for diagnosis
Modified Duke Criteria Definitive diagnosis: 80% accuracy IF 2 major criteria, or 1 major criterion + 3 minor criteria, or 5 minor criteria are fulfilled
2
Q
Chlamydia testing
“gold standard”
A
NAAT testing: urine or swabs
3
Q
Syphillis Tertiary
A
years later - effect neurological system
blindness, paralyzed, cognitive decline, meningitis, hearing loss, aphasia
4
Q
Which of the following is the most common risk factor associated with right-sided IE?
A. Left sided infective endocarditis
B. Intravenous drug use
C. History of alcohol abuse
D. Pulmonic stenosis
A
B. Intravenous drug use
5
Q
Tetanus vaccination types
A
Dtap (kids) = 2,4,6 mo / 15-18mo / 4-6 yrs
Tdap = 11-64 yrs
Td (booster) = Q 10 yrs, 5 if dirty wound
TIG human or equine
6
Q
Infectious Diarrhea Presentation
Noninflammatory
A
Noninflammatory
Non bloody or watery
=mild
giadia, noro, roto, crypto, ecoli, vibrio
7
Q
Sepsis Definition
A
A potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues.
When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally.
Sepsismay progress to septic shock.
8
Q
Pathogenicity
A
ability to cause disease
9
Q
Lyme Disease
A
Tick must be on for 24–36 hours
Erythema migrans: target rash
Headache or stiff neck.
Arthralgias, arthritis, and myalgias
no true test
doxy 100mg BID x 10-14d
Amox in Pregos
10
Q
MMR in pregnant women
A
Pregnant women without evidence of immunity:
It is recommended that they receive immune globulin.
Measles vaccination, in conjunction with mumps andrubella, is contraindicated.
11
Q
HSV-2 Genital Herpes in pregnancy
A
can be transmitted to the neonate during delivery
Risk is high enough that cesarean delivery is preferred
unless asymptomatic
Acyclovir(oral and topical) appears to be safe during pregnancy
Cultures
12
Q
Endocarditis Prophylaxis with dental
A
Prosthetic cardiac valve
Previous infective endocarditis
Congenital heart disease (CHD)
Amox 2G
13
Q
Diptheria Presentation
A
Classic physical exam finding – pseudomembrane covering tonsils and pharynx
mild sore throat, fever, malaise
Erythromycin
14
Q
Congenital Syphillis
A
skin lesions, lymphadenopathy, hepatosplenomegaly, failure to thrive, blood-stained nasal discharge, perioral fissures, meningitis, choroiditis, hydrocephalus, seizures, intellectual disability, osteochondritis, and pseudoparalysis (Parrot atrophy of newborn)
Diagnosis is clinical, confirmed by microscopy or serology
Treatment is penicillin
15
Q
Sepsis labs
A
Neutropenia
Neutrophilia (most common)
Thrombocytopenia (50% of patients)
DIC
Draw 3 cultures from seperate sites (95% discovery)
16
Q
Bacterial vs Viral STI’s
A
Bacterial
Chlamydia, LGV, gonorrhea & syphilis
Can be treated and cured with antibiotics
Untreated infection can cause PID, infertility, & epididymitis
Viral
Viral STI’s include HPV, HIV, Herpes, & Hepatitis A,B,C
Medication available to treat symptoms only
There is NO cure (C*)
Can pass onto others for the rest of your life
17
Q
Bacterial Meningitis CSF results
A
Elevated opening pressure >180
Low glucose <2.2
HIgh Protein >0.45
High WBC 10-10000 (mostly Neutrophils)
18
Q
GAS Strep Infection Misc.
A
Skin = Impetigo, cellulitis
Others = Arthritis, endocarditis, empyema, necrotizing fascitits
19
Q
Group D strep
A
Streptococcus gallolyticus (bovis)and the enterococci.S gallolyticus (bovis)is a cause of endocarditis in association with bowel neoplasia or cirrhosis and is treated like viridans streptococci
Tx: PCN G or Ceftriaxone or Vanc alone
20
Q
Which of the following is the drug of choice for MSSA bacteremia due to endocarditis?
Oxacillin
Ceftaroline
Doxycycline
Daptomycin
A
Oxacillin
21
Q
COVID-19
A
Supportive care, vaccine
80% asymptomatic or mild sx with low grade fever, mild cough, fatigue
22
Q
Infectious Diarrhea mild vs moderate vs severe
A
Mild less than 3
mod 4 or more with loal symptoms
severe 4 or more withsystemic symptoms
23
Q
A previously healthy 20-year-old college student presents to the office complaining of 2 days of sore throat, fevers, and myalgias. On physical exam, he has a fever (temperature of 101.3 °F), tonsillar enlargement with exudates, and freely moveable, tender anterior cervical lymphadenopathy. His exam is otherwise normal and he has no rashes. The patient’s rapid antigen detection test for group A Streptococcus (GAS) is negative, so he is sent home without antimicrobials. The serum monospot test for heterophile antibodies is also negative. However, 2 days later, the throat culture is growing group A, ß-hemolytic streptococci. The student is contacted and returns to clinic, but is reluctant to do anything further because he feels much better. He has no known drug allergies.
Which one of the following options would be most appropriate?
A. He should be treated with oral penicillin to reduce the likelihood that rheumatic fever will develop
B. He should be treated with oral azithromycin due to increasing penicillin resistance against GAS
C. Hold antibiotics because it is too late to prevent non-suppurative complications of GAS infection
D. Hold antibiotics because he is colonized, no infected
A
A. He should be treated with oral penicillin to reduce the likelihood that rheumatic fever will develop
24
Q
Measles Immz
A
Routine Immunization (1st dose 12-15 mo, 2nd dose 4-6 y/o or 1 month after first dose if >12 mo)
(vaccine ↓ deaths by 75%),
25
Cytomegalovirus in pregnancy Tx
Treatment: Mainly supportive
Parenteral ganciclovir or oral valganciclovir may prevent hearing deterioration and improve developmental outcomes and is given to infants with symptomatic disease identified in the neonatal period
26
Malaria presentation
headache and fatigue, followed by fever
Then
chills, high fever, then sweats
Rash, lymphadenopathy are NOT typical in Malaria – if present – look for another reason for the fever
27
A 66-year-old diabetic man with past medical history significant for alcoholism and HIV presented to an outside ED for severe scrotal pain. He first noted a small “pimple” 2 days ago, and since noted increased rash, some drainage, and increasing pain. Exam revealed an area of erythema and copious, foul-smelling purulent discharge and crepitus in the soft tissue. The local ED did not have access to a surgeon and transferred the patient to the hospital for further care. No fluids, antibiotics, or other interventions were initiated there. On arrival, vitals show a heart rate of 123 bpm, blood pressure of 67/39 mmHg, respiratory rate of 22, and temperature of 38.9 °C.
Which one of the following steps is the most urgent next step in caring for this patient?
A. Start empiric antibiotics, such as Vancomycin and piperacillin/tazobactam
B. Obtain gram stain of pus to help select the most appropriate antibiotic
C. Obtain a CT scan of the pelvis and upper thighs
D. Fluid bolus, blood cultures and urgent surgical consultation
D. Fluid bolus, blood cultures and urgent surgical consultation
28
Trichomoniasis
protozoan parasite
Most common curable sexually transmitted parasitic infection
Strawberry Cervix
dysuria, urethral itching, urethral discomfort, painful intercourse, foul smelling frothy discharge
Metronidazole 2G
29
2nd most common bacterial STI worldwide and US
Gonorrhea
30
Syphillis Testing
Dark Field Microscopy
Neuro CSF evaluation
31
Helminth Testing
CBC will show eosinophilia, stool sample shows eggs under microscopy
32
Infectious Diarrhea acute vs chronic
under 2 weeks is acute
| over 2 weeks is chronic
33
Syphillis Treatment
Treatment depends on stage
1 or 2 = IM Bicillin 2.4 million units single dose or doxy
3rd or Latent = IM Bicillin 2.4 million units Qwk x 3
Neuro = Pen G qd x 14
34
Most common cause of STI in the world
Chlamydia Trachomatis
35
Bacterial meningitis
Fever, headache, stiff neck
bacterial and viral can be indisguinishable clinically
```
Group B strep (under 2 months), H flu, Listeria, N. meningitis,
s pneumo (most in adults and peds)
```
36
FUO Most common Autoimmune Disorders
Still Disease
Lupus
Cryoglobulinemia
Polyarteritis Nodosa
37
Endocarditis tx
MRSA, PCN Allergy = vanc/dapto
otherwise oxacillin or nafcillin (MSSA)
38
Pinworm tx
Treatment – Albendazole 400mg
or
Pyrantel pamoate 11mg/kg to max of 1 gram, mebendazole 100mg – all single doses
Repeat dose in two weeks due to frequent reinfection
Wash all cloths and bedding
Treatment of household members is advocated to eliminate potential reinfection
39
Left sided vs right sided endocarditis
```
Left =
valves = mitral, aortic
prior endocarditis
Cardiac murmurs (85%)
```
```
Right =
IVDA (90%)
10% of all endocarditis cases
Fever in 90% (most common)
S. aureus
```
40
Varicella -Zoster in pregnancy
Approximately 10-20% of those infected with varicella develop pneumonia
A pregnant mother can transmit varicella to her baby via the placenta
during the first 12 weeks of pregnancy, the baby has a 0.5-1% risk of developing a rare birth defect known as congenital varicella syndrome
May have underdeveloped arms and legs, eye inflammation, and incomplete brain development
Primary – anti-viral – Acylovir most common
41
Pinworm Testing
identification of eggs or adult worms on perianal skin
Scotch tape test
Albendazole 400mg or Pyrantel pamoate
42
Tetanus Presentation
Trismus (lockjaw), muscle pain and stiffness, back pain, and difficulty swallowing
muscle spasms and pain in trunk, jaw, and neck, respiratory distress or arrest
Metronidazole (Flagyl), Antitoxin Equine/Human
Vaccine, TIG Booster
43
Etiology of endocarditis
Valve disease (50%)
IV drug use
Protthetic valve
44
Endocarditis
Etiology
Underlying valve disease (~50% of cases)
IV Drug use
Prosthetic valve
Most common cause is S Aureus
Fever, murmur, cough, SOB
Classic sx:
Splinter hemorrhages, Petechiae,
Janeway Lesions = PainLESS lesions on soles, palms
Oslers nodes = PAINFUL lesions on fingers, toes, feet
Roth spots = lesions on retina
TEE = Trans esphogeal echo
Modified duke criteria
45
Pleuritis
infection of the pleura (pain on inspiration)
46
A 34-year-old man presents in the clinic today for a 2 to 3 day history of abdominal cramping and multiple frequent loose stools. His past medical history is significant for hypertension for which he has been on chlorthalidone. He has been hydrating himself well and, per physician’s advice, had stopped his chlorthalidone when his diarrhea persisted for more than 24 hours. He says that he recently ate at a new restaurant in his neighborhood and seems to think these symptoms began after that. He does not appear clinically ill and his physical examination is unremarkable except for hyperactive bowel sounds. Stool cultures are requested and results come back 2 days later with growth of Salmonella spp. (not Salmonella typhi) from the specimen.
Which one of the following steps is the next best step in management of this patient?
A. Inform the patient about the results and start intravenous ceftriaxone
B. Inform the patient about the results and encourage good supportive care with fluid and food intake
C. Inform the patient about the results and start trimethoprim/sulfamethoxazole
D. Inform the patient about the results and start ampicillin
B. Inform the patient about the results and encourage good supportive care with fluid and food intake
47
Syphillis Testing
Dark field microscopy- allows direct examination of spirochetes
Serological testing: Treponemal/Nontreponemal
Neuro patients: CSF fluid evaluation
Imaging studies depend on organ involved
CXR – aortic aneurysm -> CT confirmation
Echo rule out aortic regurgitation
Tx: Depends on stage
48
Noscomial pneumonia bacteria
more likely to be caused by a resistant bacteria
MRSA or pseudomonas
49
Shigellosis Presentation
stool with mucus and blood,
abdominal cramps, tenesmus, diarrhea, fever, chills, anorexia, malaise, headache
Rehydrate
Empiric Azithromycin, Ciprofloxacin or Ceftriaxone
50
GAS Strep Infection
| Pharyngitis
group a beta-hemolytic strep (Gram Pos)
Pharyngitis
Sudden fever, sore throat, odynophagia, tender cervical adenopathy, malaise, nausea
51
GAS Strep Infection types
group a beta-hemolytic strep (Gram Pos)
Pharyngitis
Sudden fever, sore throat, odynophagia, tender cervical adenopathy, malaise, nausea
Scarlet Fever
Diffuse fine red papules, sand paper-like; resembles sunburn-> Groin, axilla. Blanches. “Strawberry tongue”
GAS pharyngitis, wound infections and burns
Rheumatic fever
(Jones Criteria)
arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum
52
FUO Most Common Neoplasms
Lymphoma
Leukemia
**there are many types of cancer that may manifest fever
53
Cryptococcosis Presentation
Most common cause of fungal meningitis
presents clinically as chronic meningoencephalitis
CNS disease predominates
Nuchal rigidity and meningeal signs present ~ 50%,
54
Sepsis Presentation
```
Fever, chills (often abrupt onset)
Hypothermia (15%)
Tachycardia
Hyperventilation
Hypotension and shock
```
55
Malaria General
Most important protozoan parasitic disease of humans
Hundreds of millions of illnesses and hundreds of thousands of deaths each year
Plasmodium falciparum is responsible for nearly all severe disease (4 types of plasmodium)
All travelers to endemic areas who present with fever and similar symptom complex must be evaluated for Malaria
Severe disease has a very high morbidity and mortality
It may take up to 2 months for symptoms to begin
56
Tetanus TIG indications
```
Administer Antitoxin (early)
Human tetanus immune globulin (TIG)-PREFERRED OR equine antitoxin
```
TIG is the preparation of choice, A single IM dose (3000–5000 IU) is given, with a portion injected around the wound.
57
Infectious diarrhea
| secretory (watery)
```
Bacteria = ie vibrio cholera
Virus = Rotavirus, norovirus
protozoa = giargdia, cryptosporidium
```
```
copious diarrhea (rice water stools)
can lead to dehydration and vascular collapse
```
58
Rocky Mountain SPotted Fever Presentation
Acute onset of high fever, chills, headache, nausea, and vomiting, myalgias, restlessness, insomnia, irritability
Rash days 2-6
Doxycycline 100 mg BID – continue treatment at least 3 days after fever is gone
59
Jones criteria
Jones criteria -
1 required,
2 major or 1 required,
1 major and 2 minor criteria must be present for diagnosis.
1 required – evidence of antecedent strep infection
Major (JONES)– polyarthritis, Carditis, subcutaneous nodules, erythema marginatum, chorea
Minor – fever, arthralgias, previous rheumatic fever or rheumatic heart disease, acute phase reactions – ESR, CRP, leukocytosis, prolonged PR interval
60
Infectious Diarrhea Etiology
```
Emotional stress
Food intolerance
Inorganic agents
Organic substances
Medications
Infectious Agents
```
61
Bacterial Meningitis etiology
Strep Pneumo (50%) adults
N. meningitis (25%)
Group B strep (15%)
62
Varicella -Zoster in pregnancy treatment
Primary – anti-viral – Acylovir most common
63
Influenza
2 types, A & B
Inflammation of the upper respiratory tree and trachea w/i 2 days of transmission
aerosolized respiratory droplets via coughing, sneezing, talking, or touching inanimate objects
Self limiting, supportive, flu vaccine, tamiflu
64
Helminth Presentation
(Round worms most common)
cough, blood tinged sputum, wheezing, late – anorexia, abdominal pain, nausea, vomiting, diarrhea
65
Syphillis treatment
Treatment depends on stage
1 or 2 = IM Bicillin 2.4 million units single dose or doxy
3rd or Latent = IM Bicillin 2.4 million units Qwk x 3
Neuro = Pen G qd x 14
66
Erythema Infectiosum
Fifth disease (Parvo virus)
targets red blood cells and marrow
1 of 6 of the most common viral rashes in children
respiratory droplets
Fever, HA, sore throat
Slapped cheek: bright red, raised erythema over cheeks
Red lacelike reticular pattern
Papular Purpuric Gloves and Socks
caused by Parvo B19
Self limiting, supportive
67
Cryptococcosis Testing
Respiratory disease is diagnosed by culture of secretions
Meningeal disease – lumbar puncture
Gram stain of CSF usually reveals budding yeast
68
Infectious Diarrhea Tx
usually self limiting, supportive
mild = replace fluids, avoid dehydration
Severe=rehydration, ORS
Bloody = Flouroquinolone or azithro
Avoid lopermide in shigella or toxic megacolon
69
Tetanus Vaccination times
Receive a series of 3 vaccinations
Tdap initially
Td at least 4 weeks later
TD again between 6-12 months
Then every 10 years
In pregnancy, best to wait until 2nd trimester unless tetanus prone wound
70
Tetanus prone wounds
Greater than 6 hours old
Stellate, avulsion
Greater than 1cm deep
Missile, crush, burn, frostbite
Devitalized tissue
Contaminants
71
EBV
Epstein Barr Virus (Herpes Family)
95% of people will get it in their lives
direct contact saliva, bodily fluid
Might be asymptomatic, mononucleosis, fever, malaise, spleenomegaly
supportive, avoid contact sports
72
Pneumonia
Typical ”Classic” Presentation:
Chills, followed by fever, pleuritic pain and productive cough
Atypical = MAC , legionella, chlamydia
73
Acute Rheumatic fever Presentation
Migratory joint pain, fatigue, fever, heart murmur, flat rash, chorea (Sydenham) and unusual behavior
```
JONES
Joints
Carditis
Nodules
Erythema
Chorea
```
PCN-G x 1
74
Zika
Serum or urine Zika virus IgM, screen pregnant women with reverse-transcriptase PCR, NAAT
during pregnancy can cause microcephaly
Supportive
75
Syphillis Secondary
2-24 weeks
morbilliform rash on the body, dark spots on palms and soles, hair loss, feeling ill, condyloma lata
HA, myalgia, arthralgia, hepatosplenomegaly, alopecia, malaise
76
HPV Testing
Clinically based on visible lesions
Pap smear, anal pap, colposcopy, anoscopy
77
Histoplasmosis Presentation
Most are asymptomatic, go unrecognized
Past infection leaves pulmonary and splenic calcification
May have a mild flu like illness
Moderate = clinical picture of pneumonia with fever, cough and mild central chest pain
78
Infectious diarrhea
loss of intravascular volume
loss of electrolytes
can result in cardiovascular failure
Common bugs =
cholera, a aureus, salmonella, shigella, rotavirus
norovirus,campylobacter, e. coli, c dif,
3 types
secretory (watery)
inflammatory
Hemorrhagic
79
Empiric skin treatment
Cephalosporin 500 QID
80
Sepsis Tx
Removal predisposing factors i.e. immunosuppresants
Identifying the Source of Bacteremia
ie venous catheter, abcess etc.
Supportive = fluid, pressors etc
Antibiotics = IV ABX for both gram pos/neg bugs
3rd 4th gen ceph if CNS involve
81
Syphillis Primary
3 days- 3 months
smal chancres
goes away on it’s own
82
Viral meningitis Etiology
Enteroviruses-MOst common cause
| coxsackieviruses, echoviruses, and human enteroviruses 68–71
83
Fifth Disease during Pregnancy
There is no single recommended way to monitor pregnant women with parvovirus B19 infection
low-grade fever, malaise, slapped cheek
84
TB Presentation
Primary infection = Rarely causes acute illness, 95% asymptomatic. cough, fever, night sweats, or weight loss
Latent infection = The Tb skin test becomes positive during the latent phase
Active infection = low grade fever, night sweats, dyspnea, pneumothorax or pleural effusion.
85
TORCH infections
```
Toxoplasmosis
Other (syphillis, varicella-zoster, parovirus b19)
Rubella
Cytomeglovirus
Herpes
```
86
Scabies
microscopic mites
prolonged skin to skin contact
(rarely off bedding, clothing, towels)
Pimple-like rash with burrows, blisters, scales, excoriations, intense pruritis
Permethrin cream
87
Pregnancy pearls
Maternal infections that can damage the fetus include
```
cytomegalovirus infection,
herpes simplex virus infection,
rubella,
toxoplasmosis,
hepatitis B,
syphilis
```
88
TB Testing
Cultrue first
Chest x-ray
Acid-fast stain and culture
Tuberculin skin test
89
Syphillis
```
treponema pallidum (spirochete)
Primary, secondary, latent, tertiary
```
3 phase infection that progresses in stages with periods of asymptomatic latency, without treatment invades CNS
Treatment depends on stage
1 or 2 = IM Bicillin 2.4 million units single dose or doxy
3rd or Latent = IM Bicillin 2.4 million units Qwk x 3
Neuro = Pen G qd x 14
90
Cholera Presentation
Acute diarrheal disease that can lead to death within hours, primary from dehydration.
Clinical appearance – sudden onset of severe, frequent watery diarrhea (up to a L/hr), dehydration, hypotension
”rice water stool” – grey, turbid without fecal odor, pus or blood
Erythromycin, Azithromycin, cipro (fluids)
91
TB General
The most common mycobacterial infection
One of the most widespread and deadly illnesses globally
– M tuberculosis, a small, slow growing aerobic bacilli
Rarely causes acute illness, 95% asymptomatic.
Primary, latent & active infections
92
Hepatitis B
Direct contact through blood or bodily fluids
95% with acute Hep B may naturally produce antibodies and is self-cleared; Asymptomatic
Chronic HBV presents with serum sickness-like syndrome w/ fever, rash, arthralgia, cirrhosis
etc
Liver Cancer/Cirrhosis/Liver Failure/Death
Supportive during acute phase; Antivirals treatment with acute or severe disease; NO Cure
Prevention through vaccination
93
2 types of pneumonia
community aquired
noscomial pneumonia (hospital)
94
FUO
The term FUO should be reserved for prolonged febrile illnesses without an established etiology despite intensive evaluation and diagnostic testing
Minimum of 3 weeks duration of illness
Fever greater than 38.3C on several occasions
No know immunocompromised state
Diagnosis has not been made post 3 outpatient visits or 3 days of hospitalization
Arbitrary
travel, diet, known exposure, history and family history
95
Chlamydia Trachoma
Chlamydia of the eyes
96
TB Tx
Isoniazid INH +Rifampin +Pyrazinamide +Ethambutol
Daily dosing for the first 2 months (intensive phase)
Daily dosing or three times per week (continuation phase)
97
Chlamydia
Chlamydia Trachomatis, (gram neg)
Most common bacterial STI in US
females twice as often
Direct contact with infected tissue/fluid
70% have NO symptoms
Scant yellow d/c, dysuria, posytcoital bleeding
Untreated can lead to ectopic pregnancy and infertility, reactive arthritis
Azithromycin (preferred): Single dose therapy, 1G
98
Candidiasis Testing
Can be cultured from the mouth, vagina, and feces of most people
wet prep koh
99
Histoplasmosis Testing
Pancytopenia on CBC
Increased alkaline phosphatase and LDH
Antigen test – sputum or urine
Cultures
CXR – pulmonary infiltrates, hilar or mediastinal lymphadenopathy
100
Infectious Diarrhea Presentation
| inflammatory
```
inflammatory / Bloody (bloody think bacteria)
Colonic involvement (bacteria, parasites, toxins)
```
frequency, small stools, bloody, fever, cramps
Shigella, salmonella, campy, yersinia, ecoli, cdiff
Fecal leukocytes are often positive
101
Viral meningitis Presentation
Headache
Fever
Nuchal rigidity
Constitutional signs: malaise, anorexia, nausea/vomiting, abd pain, diarrhea
102
Virulence
the degree or extent of pathogenicity of a microorganism
103
Epidemiology
how often disease occurs in population and why
104
Roseola
(Herpes family)
Self limiting, supportive,
10-45% 9-12 mo old infant; 77% by 24 months with febrile illness
saliva via respiratory droplets.
```
High fever (104F+) 3-5 days, seizures, malaise,
after fever dissapates, rash develops
```
2-5mm rose-pink/red maculopapular appearance with halos, starting on trunk spreading to neck, face, and extremities.
105
Most common curable sexually transmitted parasitic infection
Trichomoniasis
106
Most common laboratory abnormality in septic patients
Neutrophilia, often with increased numbers of immature forms of polymorphonuclear leukocytes, is the most common laboratory abnormality in septic patients
107
GAS Strep Infection
| Scarlet Fever
group a beta-hemolytic strep (Gram Pos)
Scarlet Fever
Diffuse fine red papules, sand paper-like; resembles sunburn-> Groin, axilla. Blanches. “Strawberry tongue”
GAS pharyngitis, wound infections and burns
108
Bacterial vs Viral Meningitis CSF results
```
Bacterial
Elevated opening pressure >180
Low glucose <2.2
HIgh Protein >0.45
High WBC 10-10000 (mostly Neutrophils)
```
```
Viral
normal glucose,
normal or mildly elevated opening pressure
normal or mildly elevated protein
neg gram stain
```
109
Methicillin-resistant Staphylococcus aureus (MRSA)
| Presentation
Abscess formation common and typically more purulent
Folliculitis, Furuncles
Rarely a cause of necrotizing fasciitis
Treatment – Incision and drainage, refer to local advisements as to antibiotic choice.
110
FUO Imaging Workup
Chest X-ray – all patients with FUO
CT scan of body part that is symptomatic (above & below for some)
MRI reserved for suspected CNS or vascular disease
Ultrasound – kidney, pancreas, biliary tree
Echo – suspected endocarditis or atrial myxoma
111
GAS Strep Infection
| Rheumatic fever
group a beta-hemolytic strep (Gram Pos)
Rheumatic fever
(Jones Criteria)
arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum
112
Most common bacterial STI in US
Chlamydia Trachomatis
113
C diff risk factors
7-10 days of anitbiotics but can occur after single dose
mostly with clindamycin and b lactams
can be due to flouroquinolones as well
114
HACEK organisms
Gram negative
ampicillin resistant
penicillin and ampicillin should not be used
highly susceptible to 3rd gen cephs (ceftriaxone)
```
Haemophilus aphrophilus
Acintobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
```
115
Trichomoniasis Testing
Microscopic evaluation using vaginal discharge with saline and observing motile protozoa
NAAT – vaginal swab or urine
Rapid Ag and DNA hybridization test – POC 1hr
116
Congenital Toxoplasmosis Risks
Prematurity, intrauterine growth restriction,
jaundice, hepatosplenomegaly,
myocarditis, pneumonitis,
rash, chorioretinitis,
hydrocephalus, intracranial calcifications,
microcephaly, and seizures
117
HIV Testing
p24Antigen testing
2 weeks after infection
118
Bacterial endocarditis
Bacteria infect the leaflets of the valves
Most common factor is structurally abnormal cardiac valve
Almost always left side = mitral and aortic valves
Rheumatic / congenital heart disease
Prior heart valve, prior endocarditis
IV drug users
Usually gram postive Streptococci, S. aureus, enterococci
119
MAC
M. avium Complex
Elderly and immunocompromised primary
No known person to person transmission
Typically present as lung disease
macrolides
120
CMV
Cytomegalovirus (Herpes Family)
```
Intial asymptomatic, mild symptoms
2nd rx (immuno comp) = fever, night sweats, myalgia...
```
```
Self limiting (supportive)
Immunocomp = antiviral ganciclovir
```
121
Pubic Lice
Crabs (Crab louse)
Can live off human host x24-48h
Wash all clothing, towels, bedding
Permethrin cream
Ivermectin topical
122
Most common newly diagnosed STI in US
HPV
123
Herpes Simplex Virus
Oral or Genital Herpes/ HSV1 and 2
30% of the world has symptomatic HSV
90% worlwide asymptomatic w/ ~65% in US
Direct contact withsaliva or bodily secretions
Acyclovir
124
Campylobacter jejuni Presentation
watery diarrhea, +/-bloody, fever, cramps, weight loss lasting ~ 6 days.
Azithromycin, cipro (fluids)
125
Mumps immz
Endemic worldwide with epidemic outbreaks, due to insufficient vaccination
Vaccine ↓ 99.8% of cases in US in the late 60’s
126
Measles (rubeola)
Kids 4-5 y/o; Extremely contagious (vaccine ↓ deaths by 75%),
countries with poor health system and/or whose children at risk for malnutrition(Vitamin A def);
pregnant women, immunosuppressed individuals.
Person to person droplets in the air (2 hours)
Immune response is suppressed by the virus and thus promoting replication.
Can be transmitted 4 days before and after the appearance of the rash
Fever and rash 1-2 weeks after infection
3 C’s = Cough, coryza, conjunctivitis; depletes vitamin A
127
FUO Most common Infections
```
TB
Q Fever
Brucellosis
HIV
Abdominal/Pelvic Abscess
Cytomegalovirus
Cat Scratch Disease
Typhoid
Toxoplasmosis
```
128
Syphillis in pregnancy
risk of transplacental fetal infection is about 60 to 80%
Likelihood is increased during the 2nd half of the pregnancy
Untreated primary or secondary syphilis in the mother usually is transmitted, but latent or tertiary syphilis is transmitted in only about 20% of cases
Untreated syphilis in pregnancy is also associated with a significant risk of stillbirth and neonatal death.
Many patients are asymptomatic, and the infection may remain clinically silent throughout their life.
129
Bacterial Meningitis Presentation
classic triad
Fever, Headache, Nuchal rigidity
positive Kernig and Brudzinski signs
Decreased LOC (75%)
NV
photophobia
Seizures 20-40%
130
Toxoplasmosis Presentation
Most acute infections are asymptomatic
Nontender cervical or diffuse lymphadenopathy may last for months
Malaise, headache, sore throat, rash, myalgias, hepatosplenomegaly
Severe – pneumonitis, meningoencephalitis, hepatitis, myocarditis, polymyositis and retinochoroiditis
Can be congenital
131
A 27-year-old woman presents in the hospital setting. She was initially admitted to the ICU with respiratory failure due to pulmonary edema. The cardiac evaluation revealed moderately severe mitral stenosis on echocardiogram with no vegetations. Throughout the hospitalization, she has had no fevers, rash, pharyngitis, or arthritis. Blood cultures have remained negative. The patient has undergone successful diuresis with resolution of shortness of breath and dyspnea. She is on room air with a normal physical exam other than an opening snap and low-pitched diastolic murmur on cardiac auscultation, consistent with mitral stenosis. The patient is ready for discharge. Upon taking a more in depth history, the patient is from Turkey and emigrated to the U.S. about 3 years ago. She has been working in daycare centers for several years, and continues to do so. She has been well since arriving in the U.S., but had several episodes of chest pain or joint swelling, arthralgias, and fevers between the ages of 5 and 16 years while living in Turkey, which was diagnosed as rheumatic fever.
For long-term outpatient management, which one of the following recommendations would be best for rheumatic fever prophylaxis?
A. IM benzathine penicillin monthly for 5 years
B. Oral penicillin for 12 months
C. IM benzathine penicillin until the patient is at least 40 years of age
D. IM benzathine penicillin monthly until anti-streptolysin O (ASO) titers are normal for 12 months
C. IM benzathine penicillin until the patient is at least 40 years of age
132
Sepsis complications
Septic shock = vasodilatory or distributive shock
133
Most common empiric treatment for bacterial meningitis
```
MC Empiric=
Dexamethasone
+ 3rd or 4th cephalosporin (Ceftriaxone, Cefotaxime)
And Vancomycin PLUS
Acyclovir
```
Tx Course: Until pt is afebrile for 5 days
134
Hepatitis C
Multiple genotypes 1-6
~178 million living with HCV worldwide; ~2 million in US
Direct contact with bodily fluid, specifically blood (IVDU, sex)
Acute -usually asymptomatic or slight fever, malaise, nausea, RUQ pain, dark urine jaundice
Liver Cancer/Cirrhosis/Liver Failure/Death
Chronic(10-20yr after infection
Direct acting antiviral
2nd generation protease inhibitors
135
Salmonellosis Presentation
3 distinct clinical syndromes
– fever (Typhoid),
Gradual onset of malaise, headache, cough, sore throat, abdominal pain and constipation
- bacteremia (immunocompromised)
Recurrent fevers, arthralgias, local infection in bone, joints, pleura, pericardium, lungs, other sites
- Gastroenteritis (most common form of salmonellosis)
Fever, chills, cramping, nausea/vomiting, diarrhea (may be grossly bloody) – lasts for 3-5 days
ciprofloxacin for all
136
Hepatitis Testing
Serologic antibody and antigen (blood)
137
Rabies
30-70k deaths/year worldwide from rabid animals, 10% domestic animals; 2 deaths/yr in US
Targets CNS by means of peripheral nervous system
Tingling at bite site w/i days-fever, malaise, myalgia
Neuro sx of anxiety, agitation, delirium
Rabies Immune globulin ASAP along with rabies vaccine (4 in 14 d)
138
Gonorrhea testing
| "gold standard"
NAAT testing: urine or swabs
139
Gonorrhea
Neisseria gonorrhoeae (Clap) (Gram Neg)
2nd most common bacterial STI worldwide and US
Direct contact with infected tissue/fluid
often asymptomatic
Copious mucopurulent green, yellow, white d/c
Azithromycin - Single dose therapy, 1G PLUS Rocephin 250mg IM
140
Rubella vaccine in pregnant women
Pregnant women should NOT get
MMR vaccine
until after they hav given birth
avoid getting pregnant for at least four weeks after receiving MMR vaccine.
141
Hepatitis A
Direct contact, most commonly fecal-oral route, contaminated food and water sources,
Nausea, vomiting, RUQ pain/discomfort, malaise, anorexia, myalgia, fatigue, fever, Jaundice, icteric sclera
Supportive, prevent trhough vaccine
liver transplant
142
Infectious diarrhea
| Hemorrhagic
Primarily caused by E.coli
deaths are caused by hemolytic uremic syndrome
related to contaminated foods
leads to vascular damage and in some patients a prothrombolitic state that procedes hemolytic uremic syndrome.
143
Syphillis Latent
asymptomatic stage, tests positive
lesions or rashes can recur- but not present on exam
144
3 most common etiologies of noscomial pneumonia
E. Coli
S. Aureus
Pseudomonas
145
parainfluenza
Community acquired for children < 5years old
immunocompromised, elderly
Malnutrition, overcrowding, Vitamin A def, environmental smoke or toxin
Primarily through direct person to person contact
More likely with Asthma, COPD, CHF
Can cause common cold, croup, bronchilitis, pneumonia, tracheobronchilitis
Supportive, could be steroids, nebulizer etc.
146
When is HIV Detectable
HIV not detectable <21 days
147
Direct transmission
touching, biting, licking, kissing, sex
direct projection (droplet) via coughing or sneezing within 3f
148
Herpes testing
| "gold standard"
Viral Culture
PCR if in CSF
149
HIV/ AIDS
HIV is a virus that destroys the immune system over time, robbing the body of its ability to fight other infections and illnesses
Once the immune system is weakened, other infections occur and AIDS develops (the fatal stage of HIV infection)
The virus is present in blood, semen, vaginal secretions & breast milk
enters the body by infecting CD4 cells
CD4 cell produces about 300 new virions
Anti-Retroviral Therapy (ART), HAART, ARV
150
Congenital Syphilis
stillbirth, bulging fontanelles, seizures, saddle nose
151
Treatment for Streps
Penicillins
Strep throat = Pen G 1.2u
152
MRSA or PCN allergy
Vancomycin or Daptomycin
153
FUO Lab Workup
CBC with differential
Metabolic profile with liver function tests
Liver Function
Blood Cultures (no abx 3 days prior if possible)
Cultures of urine, sputum, stool, cerebrospinal fluid
Sed rate, ANA, RA, Cytomegalovirus IgM, Tb test,
heterophile antibody, HIV
154
Malaria Testing
Blood smears (Giemsa-stained) mainstay of diagnosis
Repeat smears in 8-24 hour intervals if diagnosis suspected
Severe Malaria is a medical emergency
Standard of care is IV Artesunate
Old standard – quinine – still used when/where Artesunate not available
155
Cytomegalovirus in pregnancy Dx
Diagnosis of neonatal infection is best made by viral detection via culture or PCR testing
156
Most common Sepsis etiology
MC etiology – bacterial pathogen (gram + in U.S.)
Sepsis is ALWAYS caused by infection
157
Sepsis pearls
Mortality higher for Noscomial than CAD
lactate over 4 = poor prognosis
Risk factors for sepsis:
ICU admission, a nosocomial infection, bacteremia, advanced age, immunosuppression, previous hospitalization & CAP
cant always get the right abx as treatment starts before cultures
158
Infectious diarrhea
| inflammatory
bacterial invasion of mucosal lining resulting in cell death
febrile, cramp lower abdominalpain, diarrhea which may contain mucous
shigella ,salmonella, campylobacter
Shigella is cause of bacillary dysentery
person to person or food/water contamination
159
Indirect transmission
airborne, vehicle borne(fomite), vector borne does not require physical contact ( sneezing, coughing, talking)
160
6 main types (or classes) of drugs that work
| against parts of HIV
```
NRTI
NNRTI
PI
INI
CCR5
Fusion inhibs
mAbs
```
161
Pinworms presentation
Enterobius vermicularis
Cardinal sign – perianal pruritis, typically nocturnal
162
Parvovirus B19 (5th)
About half of pregnant women are immune to parvovirus B19, so they and their babies are usually protected from getting the virus and fifth disease
Those that arent ususally have mild symptoms
Risk of fetal death is 2 to 6% after maternal infection
Rarely (<5%), a baby will develop anemia from mother’s fifth disease, resluting in miscarriage
More common in 1st half of pregnancy
low-grade fever, malaise, slapped cheek
Treatment is supportive
163
Varicella -Zoster
Chicken pox / Herpes zoster
person to person contact
Self limiting, supportive, isolation, vaccination
164
C diff Tx
Vanc 15mg PO Q4
or
fidaxomicin 200mg BiD x 10 days
165
S. aureus
folliculitis, carbuncle, furuncle, necrotizing fasciitis (rare)
Nafcillin or Cefazolin
166
Who gets Varicella-Zoster IG
```
Varicella = Chicken pox
Zoster = shingles
```
Varicella-zoster immune globulin for postexposure prophylaxis in
Those with no known immunity and....
Pregnant women
Immunocompromised
Hospitalized premature infants who were born at ≥ 28 weeks gestation
Hospitalized premature infants who were born at < 28 weeks gestation or who weigh ≤ 1000 g at birth
167
Etiology
cause or origin, source
168
Which one of the following regimens is recommended for prophylaxis of mycobacterium avium complex (MAC) infections in a 22-year-old HIV infected male patient with CD4 count of 40 and viral load of 65,426 copies/ml?
A. Rifampin 300mg orally daily
B. Ethambutol 800mg orally daily
C. Isoniazid 300mg orally daily
D. Azithromycin 1,200mg weekly
D. Azithromycin 1,200mg weekly
169
Botulism Presentation
12-36 hours after ingestion – visual disturbance, diplopia, loss of accommodation, ptosis, CN palsies, EOM impairment, fixed dilated pupils.
Dysphagia, dysphonia, dry mouth, nausea and vomiting.
Paralysis progressing to respiratory failure and death
Botulinum antitoxin– cornerstone of tx
equine = adults , Human = under 1
170
A 68-year-old man is being evaluated for measures to decrease his risk of acquiring a surgical site infection; he is scheduled for coronary artery bypass graft surgery in 5 weeks for limiting chronic angina despite maximal medical therapy. Medical history includes chronic stable angina, hyperlipidemia, hypertension, and diabetes. Medications are low-dose aspirin, propranolol, isosorbide dinitrate, ranolazine, chlorthalidone, lisinopril, and atorvastatin.
On physical examination, blood pressure is 126/72 mm Hg; all other vital signs are normal. On cardiac examination, an S4 is present. The remainder of the examination is noncontributory.
Which of the following is the most appropriate measure to prevent surgical site infection?
Evaluate for Staphylococcus aureus nasal carriage
Provide postoperative vancomycin prophylaxis for 7 days
Provide preoperative vancomycin prophylaxis
Shave patient’s chest hair the morning of surgery
Evaluate for Staphylococcus aureus nasal carriage
171
Candidiasis Presentation
Normal flora becomes an opportunistic pathogen
Can be cultured from the mouth, vagina, and feces of most people
most common in esophagus
GERD, dysphagia, nausea (no substernal pain)
Risk factors – neutropenia, recent abd sx, broad spectrum abx, renal disease, IV catheters, cellular immunodeficiency
172
Modified Duke Criteria
Endocarditis
2 major / 1 major-3 minor / 5 minor
Major Criteria
(1) Two positive blood cultures of typical microorganism or One positive cx of Coxiella burnetii
(2) Documented ECHO showing vegetation, myocardial abscess, dehiscence of a prosthetic valve or NEW valvular regurgitation
Minor criteria
1. Predisposing factors (IV Drug use or Heart condition)
2. Temp over 38C
3. Vascular phenomena (emboli, infarcts, hemorrhages)
4. Immunilogic phenomena (RF factor +, nephritis etc)
5. Microbiologic evidence (other positive cultures)
173
Meningitis types
Bacterial = Acute infection in the subarachnoid space
Viral = An infection of the meninges (lining of the brain and spinal cord) by any number of viruses
Fungal = fungus spreads from elsewhere in the body to the brain or spinal cord.
174
Incubation
period of time between exposure and onset of symptoms
175
Rheumatic fever complications
heart valve disease
176
Cytomegalovirus in pregnancy
Most common congenital viral infection
may be acquired prenatally or perinatally
Intrauterine growth restriction, prematurity, microcephaly, jaundice, petechiae, hepatosplenomegaly, periventricular calcifications, chorioretinitis, pneumonitis, hepatitis, and sensorineural hearing loss
177
Most common community aquired pneumonia pathogen
Streptococcus pneumoniae
178
HPV
Human Papilloma Virus
Low risk HPV - cause of warts
High risk HPV (16 and 18)- cause cervical or anal CA
Most common newly diagnosed STI in US
Direct skin to skin sexual contact
Genital warts flat or raised
NO CURE
vaccination is available to prevent certain types of HPV
179
Empyema
Bacterial infection is present in the pleura
180
Mumps
respiratory droplets, saliva and in household fomites
Highly infectious
1/3 can be asymptomatic, but contagious
Fatigue, fever, malaise
parotitis, orchitis
Self limiting, supportive, isolation
181
Non-group a strep infections
Group B Strep
GBS-sepsis, bacteremia, meningitis
182
Acute Viral Infection S/S
```
Fever
Night sweats
Chills
Lack of Appetite
Rash
Fatigue
Diarrhea
Body Aches
Lymphadenopathy
STIs
Sore throat
Ulcers
```
183
Sepsis
Dysfunction caused by dysregulated immune response to infection
SIRS -- Sepsis -- Severe Sepsis -- Septic Shock
Most patients who die have multi organ failure or refractory hypotension
184
Viral Meningitis CSF results
normal glucose,
normal or mildly elevated opening pressure
normal or mildly elevated protein
185
Pneumonia
Bcteria, virus, fungi
inflammation of the lung parenchyma causes accumulation of exudate in the airway
Infection typically begins in the alveoli
Can be aquired 3 ways = inhalation, aspiration hematogenous (blood borne)
186
Toxoplasmosis Tx
Medications do not eradicate disease and immunocompetent persons infected do not typically require tx
If severe sxs: Generally treat for 1 month with pyrimethamine plus either sulfadiazine or clindamycin and sometimes with prednisone
Treatment required in Pregnancy
Prevention – avoid cats, avoid undercooked meat
Most experts use spiramycin to treat pregnant women (controversial)
187
Gonorrhea Tx
Gonorrhea is becoming resistant – treat with IM ceftriaxone in combination with azithromycin or doxycycline
Disseminated – Ceftriaxone 1 gm plus azithromycin 1000mg (1gm) PO, single dose until 48 hrs after improvement begins.
188
parapneumonic effusion
The exudative inflammatory response of the pleura to pneumonia
189
Toxoplasmosis Testing
Confirmed by isolation of Toxoplasma gondii or identification of tachyzoites in tissue or body fluids
Multiple serologic methods
190
Viral Meningitis Tx
Supportive=
Symptomatic-analgesics, antipyretics, and antiemetics
Dispo: Home or hospital
Prognosis: Excellent
191
Pneumonia 2 types
Noscomial (after 72 hours hospitalized)
Community acquired (before 72 hours hospitalized)
