Conrad Fischer 3 Flashcards
What is the first step in management in an IV drug user with suspected acute endocarditis?
Blood cultures and IV antibiotics. Antibiotics BEFORE waiting for results of culture or getting echo
Which antibiotics should be used in suspected acute endocarditis?
Empiric therapy should be vancomycin and gentamicin due to synergistic effect
What is “red man syndrome?”
Possible histamine mediated response to rapid infusion of vancomycin
What is the best next step if a patient on vancomycin develops “red man syndrome?”
Decrease rate of infusion. Total dose need not be decreased. Antihistamines and corticosteroids are not necessary.
Which type of anemia can be present in infectious endocarditis?
Anemia of chronic disease
What happens to complement levels in endocarditis?
Low complement levels are associated with endocarditis. There are circulating immune complexes and activation of the immune system
What is the next step when a patient’s blood culture is positive for Streptococcus bovis?
Colonoscopy. Strep bovis is HIGHLY associated with colonic pathology (cancer, polyps, and diverticulosis)
What should be added to therapy of endocarditis in individuals with prosthetic valves?
Rifampin. Helps with tissue penetration
What is the best next study in suspected endocarditis if a transthoracic echo is negative?
Transesophageal echo
Under what conditions would a transesophageal echo be indicated first (instead of transthoracic)?
In patients with prosthetic valves
What organism is associated with endocarditis in homeless, flea bitten, patients?
Bartonella
Which organism is associated with drinking unpasteurized milk?
Brucella
What type of prophylaxis is necessary prior to colonoscopy?
None
What are the indications for endocarditis prophylaxis?
Patients with prosthetic valves, uncorrected cyanotic heart disease, previous endocarditis, or heart transplantation who are going to undergo dental procedures with bleeding or oral surgery
What type of endocarditis prophylaxis is necessary in a patient with aortic stenosis undergoing dental work?
None. ONLY if they have one of the criteria (prosthetic valves, uncorrected cyanotic heart disease, previous endocarditis, or heart transplant)
What antibiotic(s) should be used when prophylaxis for endocarditis is indicated?
Oral amoxicillin. If allergic, use clindamycin
What is the typical presentation of giardiasis?
Flatus/bloating in patient with history of camping/hiking
Which skin lesions are associated with IBD?
Erythema nodosum and pyoderma gangrenosum
What skin condition is associated with celiac disease?
10% of patients will have dermatitis herpetiformis
What is erythema nodosum?
Idiopathic inflammation of the subcutaneous tissue resulting in tender, reddish brown lesions of the legs
What is erysipelas?
Acute streptococcal infection of the deep epidermis with lymphatic . Usually Group A Strep
Which skin lesion in IBD corresponds to the level of disease activity?
Erythema nodosum. Pyoderma gangrenosum does NOT correspond to disease activity
What is pterygium?
Outgrowing from the conjunctiva due to irritation. Can be replaced with amniotic transplant
Which ophthalmological findings are seen in IBD?
Iritis and uveitis. Debris from inflammation of the iris floats up and gets stuck on the back of the cornea
How is iritis/uvetis in IBD detected?
Slit lamp exam
What is the clinical presentation of uveitis/iritis?
Redness and photophobia
How is uveitis/iritis treated?
Steroids
What pathology of the biliary system is associated with IBD?
Sclerosing cholangitis and cholangiocarcinoma
Why does IBD cause sclerosing cholangitis?
Inflammatory mediators from the colon bathing the liver through the portal circulation
What is the treatment for sclerosing cholangitis?
Ursodeoxycholic acid and cholestyramine
Which kind of kidney stones are associated with IBD?
Oxalate stones (increased absorption in GI in IBD)
What is the cure for sclerosing cholangitis?
Only cure is liver transplantation. Treating the IBD or colectomy doesnt cure the cholangitis.
What is the most accurate test for sclerosing cholangitis?
ERCP - will show beading and narrowing of the biliary system
What is the best test for primary biliary cirrhosis?
Anti-mitochondrial antibody
What antibodies are present in autoimmune hepatitis?
Anti-smooth muscle antibody and liver-kidney microsomal antibody
Is UC ANCA positive or negative? Crohns?
UC is ANCA positve; Crohn’s is ANCA negative
Is UC anti-saccharomyces cervevisiae positive or negative? Crohns?
UC is anti-saccharomyces cerevisiae negative. Crohn’s is positive
Which type of IBD tends to spare the rectum?
Crohn’s spares the rectum. UC always involves the rectum
Which type of IBD is transmural?
Crohn’s is transmural, UC is not
What is the drug of choice for maintenance in IBD?
Mesalamine (5-ASA derivative)
Which type of IBD can result in rectovesicular or rectocutaneous fistulas?
Crohn’s due to transmural granulomas
What should be done prior to treatment with infliximab for fistulas in Crohn’s?
PPD placement. Infliximab dissolves granulomas. Granulomas are trapping the TB and infliximab can reactivate the TB.
What is the mechanism of infliximab?
anti-TNF. TNF is necessary for granuloma formation so infliximab “unlocks” granulomas
What is budesonide?
Oral corticosteroid used for IBD treatment. Low systemic effects because high first pass effect so therapy is targeted to GI
What is the best treatment for IBD that is poorly controlled with mesalamine?
Azathioprine
What are the drugs of choice for diverticulitis?
Ciprofloxacin and metronidazole
What is the typical presentation of hemochromatosis?
Patient with fatigue, joint pain, and erectile dysfunction along with skin darkening.
What is the best initial diagnostic method for Wilson’s disease?
Slit lamp exam for Kayser-Fleischer rings
What is the difference in presentation between Wilson’s disease and hemochromatosis?
Both have fatigue and liver disease but Wilson’s has neuropsychiatric disturbances (tremor, psychosis, paranoia) whereas hemochromatosis doesn’t
Where in the GI is iron primarily absorbed?
Duodenum
What is the genetic transmission of hemochromatosis?
AR
What is the difference in neutrophil count between gout and septic arthritis?
Septic arthritis will have joint aspiration with >50,000 neutrophils. Gout will stay ~20,000
What is the pathology in the joints of hemochromatosis?
Deposition of calcium pyrophosphate (pseudogout).
Which endocrine disease is strongly associated with hemochromatosis?
Diabetes mellitus (iron deposition in pancreas). If a patient has “bronze diabetes” think hemochromatosis
What will be seen on echocardiogram in hemochromatosis?
Restrictive cardiomyopathy
What is the most likely cause of death in hemochromatosis?
Cirrhosis
What type of stain is used in hemochromatosis biopsies?
Prussian Blue
When is a Sudan Black stain used?
Stain for fat in stools to detect malabsorption
What is the best initial test for hemochromatosis?
Iron studies. The most accurate test, however, is a liver biopsy
What is the most accurate test for hemochromatosis?
Liver biopsy (or HFE gene test and MRI)
Infection by which organism is most likely in hemochromatosis patients?
Vibrio vulnificus
What is the treatment of choice for hemochromatosis?
Phlebotomy
What medicine is used for patients with Wilson’s disease?
Penicillamine (removes copper)
What is the typical presentation of SLE?
Rash, fever, and fatigue with joint pain w/ swelling
What is the best initial diagnostic test for SLE?
ANA? (95-99% sensitivity, poor specificity)
What is the most specific test for SLE?
Anti-dsDNA
What is CREST?
Calcinosis, Raynauds, esophageal dysmotility, sclerodactyly, telangiectasia
What is anti-centromere antibody associated with?
CREST syndrome
What is anti-histone antibody associated with?
Drug induced lupus
What organs does drug induced lupus spare?
Brain and kidneys
What condition is associated with anti-Ro and anti-La?
Sjogren’s syndrome
What are the skin manifestations of SLE?
Malar rash, discoid lupus, photosensitivity, and oral ulcers
What is the treatment for Raynaud’s?
Calcium channel blockers
What can be seen on X-ray of joints in SLE?
Nothing, normal X-rays (vs RA which has abnormal X-rays)
Which form of joint disease has osteophytes?
OA
Which disease presents with X-rays showing elevation of the periosteum?
Osteomyelitis
What is likely seen on a CBC of a patient with SLE?
Coomb’s positive hemolytic anemia or pancytopenia
What are Howell Jolly bodies?
Nuclear remnants in RBCs seen in pt’s who have splenectomies. Small basophilic dot in RBCs
Which RBC abnormality can be seen in SLE?
Spherocytosis (antibody attack tears off a piece of RBC membrane and makes it smaller, rounder, and tighter)
