Exam 2 - ID (need to know) Flashcards
Indications for emergent admission to the hospital and GI/hepatology referral
- Patients with increasing signs of liver failure
- Decompensation of cirrhosis
- Newly diagnosed hepatitis
Which three hepatitis viruses cause chronic hepatitis?
B, C, and D
Others are just acute (A, E, G)
High risk groups for hepatitis screening
- Household or sexual contact
- IV drug use
- Multiple sexual partners, MSM
- Inmates in correctional facilities
- Chronically elevated ALT/AST
- HIV or hep C infection
- Hemodialysis
- Pregnancy
- Occupation (healthcare workers)
Hep A mode of transmission
- Fecal-oral
- Blood
- Person to person contact
- Ingestion of contaminated foods (e.g. shellfish) or water
Hep B mode of transmission
Blood, tears, CSF, breastmilk, saliva, vaginal secretions, seminal fluid
- Sexual contact
- IV drug use
- Vertical transmission (pregnancy)
Hep C mode of transmission
Blood borne disease
- IV drug use
- Blood transfusions before 1992 or receipt of clotting factors before 1987
- Chronic hemodialysis
- Intranasal drug use (sharing needles or straws)
- Sexual contact
- Tattoos, manicures, pedicures, body piercings
What are the phases of hepatitis A?
Pre-icteric: lasts 5-7 days
Icteric phase: lasts 4-30 days
What are the symptoms associated with the pre-icteric phase of hepatitis A?
- Fever
- Malaise
- N/V
- Abdominal pain
- Anorexia
What are the symptoms associated with the icteric phase of hepatitis A?
- Dark urine (before jaundice, 1-5 days)
- Pale, clay colored stool
- Jaundice
- Hepatomegaly, splenomegaly
Testing for hepatitis (lab results)
- Positive IgM anti-HAV, negative IgG anti-HAV → early infection
- Elevated AST and ALT (LFTs)
- Elevated lymphocytes
What does HBsAg mean?
Hepatitis B surface antigen
- Positive indicates patient is infected with hep B (active illness)
What does anti-HBs mean?
Hepatitis B surface antibody
- Positive indicates patient is protected and has immunity (via vaccine or successfully recovering from previous infection)
What does anti-HBc mean?
Hepatitis B core antibody
- Positive indicates patient had previous or current hep B infection
- Provides no protection against hep B virus
- Need more information from HBsAg and anti-HBs
What does IgM anti-HBc mean?
Patient is actively ill since IgM is present
HBsAg → negative
anti-HBs → negative
anti-HBc → negative
NOT immune - not protected
- Needs hep B vaccine
HBsAg → negative
anti-HBs → positive
anti-HBc → positive
Immune controlled (protected)
- Surface antibodies present d/t natural infection
- Has recovered from prior hep B infection
- Cannot infect others
- NO vaccine needed
HBsAg → negative
anti-HBs → positive
anti-HBc → negative
Immune (protected)
- Has been vaccinated
- Does not have the virus and has never been infected
- NO vaccine needed
HBsAg → positive
anti-HBs → negative
anti-HBc → positive
Infected
- Positive HBsAg indicated hep B virus is present
- Virus can spread to others
- More testing needed
HBsAg → negative
anti-HBs → negative
anti-HBc → positive
Could be infected
- Results unclear (possible past or current hep B infection)
- More testing needed
What is the role of the primary care NP in managing patients with acute hepatitis?
- Treating acute symptoms
- Supportive care
- LFTs every 2 weeks until normalization
- Monitoring
What patient population will it be important to screen for hep C?
Baby boomers (1945-1965)
Hepatitis patient education
- Avoidance of hepatotoxic substances (alcohol, medications)
- Avoid contaminated foods and should not handle/prepare food if hep A +
- Wear gloves when handling fluids or blood (healthcare workers)
- Travelers should avoid consuming uncooked shellfish, fruits, vegetables, drinking tap water
- Don’t share razors, toothbrushes, nail clippers
What is hepatitis C antibody is negative but RNA is positive?
Current HCV infection
What is hepatitis C antibody and RNA are positive?
Current HCV infection
What is hepatitis C antibody positive and RNA negative?
No current HCV infection
CBC recommendations for routing HIV testing
- All pregnant patients
- Patients 15-65 years old at least once; can screen more often depending on increased risk
Chronic HIV infection screening and diagnostic tests
Screening test → ELISA
- If negative, no further testing needed
- If positive, order Western blot or IFA (performed automatically in U.S. if ELISA is positive)
What additional testing can be done to confirm HIV infection?
- CD4 count
- Viral load
- STIs
- Toxoplasma gondi
- CMV
- Hep A, B, C
- TB
- Routine CBC, CMP, lipid panel, UA
New CDC recommendations for HIV screening - what test? What does it detect?
4th generation antigen/antibody combination immunoassay
- Detects both HIV1 and HIV2 antibodies
What should be done if the fourth generation test for HIV is reactive?
Retest with HIV1/HIV2 antibody differentiation immunoassay
What is the next step if HIV1 and HIV2 are negative after antibody differentiation immunoassay?
Reflex testing with HIV1 NAT
What are the stages of HIV?
- Acute HIV infection
- Clinical latency or chronic infection
- AIDS
What symptoms are associated with the acute phase of HIV?
Before seroconversion (can take up to 3 months) → seroconversion illness
- Flu-like (fever, myalgia, headache, pleomorphic rash)
- Lasts 2-4 weeks s/p infection
What symptoms are associated with the clinical latency or chronic HIV phase?
Often asymptomatic, but monitor for OIs (TB, shingles, severe psoriasis, leukoplakia, idiopathic thrombocytopenia, pneumococcal disease)
- Slow viral replication → can go 10-15 years without treatment
What symptoms are associated with AIDS?
- Fatigue
- Malaise
- Anorexia
- Night sweats
- OIs and malignancies
HIV management - role of NP in primary care?
- ART - long life expectancy r/t to patient’s ability to tolerate it and adherence (a lot of side effects)
- Prevention of OIs
- Immunizations
- Screening: latent TB, HPV, STIs, risk for cardiovascular disease
- Management of hep B and C infections
- Treat comorbidities
What are the stages of Lyme disease?
- Early localized
- Early disseminated
- Late persistent
What symptoms/manifestations are seen during the first stage (early localized) of Lyme disease?
- Enlarging erythematous circular rash (erythema migrans) → bulls eye appearance
- Flu-like illness → fatigue, malaise, lethargy, fever, headache, arthralgia, myalgia, regional lymphadenopathy
What symptoms/manifestations are associated with the second stage (early disseminated) of Lyme disease?
- Multiple EM lesions
- Neurologic complications → meningitis, cranial nerve palsy, motor/sensory neuritis, carditis
- Cardiac complications → heart block, bradycardia
What symptoms/manifestations are associated with the third stage (late persistent) of Lyme disease?
- Arthritis with swelling and pain
How would the provider diagnose Lyme disease?
- Visual inspection of skin for EM → should be >5cm in diameter, circular, expanding
Lyme disease treatment for early localized infection
Doxycyline x10 days
- Or amoxicillin or cefuroxime for 14 days
Lyme disease treatment for patients with early or late neurologic signs
Ceftriaxone IV once daily
- Or PCN G or oral doxycycline x14 days
Lyme disease treatment for patients with Lyme carditis
Ceftriaxone IV
- Hospitalized if evidence of symptomatic myopericarditis (syncope, dyspnea, chest pain) or heart block
- Can be discharged on oral doxycycline x14 days
Lyme disease treatment for Lyme arthritis
Same antibiotic as early localized
- Doxycycline, amoxicillin, or cefuroxime x28 days
Is a second round of antibiotics indicated if a patient is reinfected with Lyme?
No because patient did not respond to previously given antibiotic (but can retreat Lyme arthritis)
- Treat the symptoms → NSAIDs, corticosteroid injections, temporary pacemaker (with heart block)
Is prophylaxis available for patients who have been bitten by ticks?
Yes, single dose doxycycline given with 72 hours of tick bite
What conditions must be met before chemoprophylaxis with doxycycline is considered for patients with known tick bite exposure?
- Attached tick can be reliably identified as scapularis tick and has been attached for >36 hours
- Prophylaxis can be started within 72 hours of tick removal
- Local rate of infection is at least 20%
- No contraindication to the use of doxycycline (pregnant, lactating, children under 8 years old)
How is babesiosis different from other tick borne vectors?
It is protozoan (e.g. can be transferred through blood transfusions)
What clinical manifestation sets babesiosis apart from other tick borne illnesses?
May show proteinuria or hematuria
Besides a PCR and blood smear, what other diagnostic testing is needed for babesiosis?
- CBC w/ diff
- LFTs
Is treatment indicated for patients who are asymptomatic with babesiosis?
Antimicrobial therapy not recommended (unless present for >3 months upon analysis)
Babesiosis treatment for mild to moderate disease
Oral atovaquone + azithromycin
Babesiosis treatment for severe disease
- Hospitalization w/ IV clindamycin + oral quinine
- RBC exchange transfusion (high grade parasitemia)
What diagnostic tests would the provider order to rule out anaplasmosis or ehrlichiosis infection?
- PCR
- Blood smear
Anaplasmosis and ehrlichiosis present similarly. What symptoms sets anaplasmosis apart?
- GI symptoms
- Mild anemia
What symptoms do anaplasmosis and ehrlichiosis have in common?
- Fever, chills, HA, myalgias
- Leukopenia
- Thrombocytopenia
- Elevated liver transaminase
Does anaplasmosis present with a rash?
No, but ehrlichiosis does 33% of the time
Treatment for anaplasmosis and ehrlichiosis
Doxycycline x10 days
What is the most lethal tick borne illness in the U.S.?
RMSF
RMSF clinical presentation
- Fever, malaise, HA, myalgia, GI symptoms
- Rash (becomes petechial)
RMSF lab results
- Thrombocytopenia
- Elevated liver transaminase
- Hyponatremia
Diagnostic testing for RMSF
- Indirect immunofluorescence antibody (IFA) assay to Rickettssia → not accurate since antibodies still developing in first week of infection
- Confirmed with IgG titers, 2-4 weeks apart
RMSF treatment
Empiric doxycycline while waiting for lab results
Are patients with latent TB symptomatic?
Asymptomatic - cannot spread disease
- But will show up positive on TST and IGRA tests
Symptoms of pulmonary TB (most common)
- Fatigue
- Anorexia
- Weight loss
- Night sweats
- Cough
- Chest pain
- Hemoptysis
- Irregular menses
- Low grade fever
High risk groups for TB
- Foreign born persons from areas where TB is common (Asia, Africa, Latin America)
- Low income
- Migrant farm workers
- Homeless
- Residents of long term care facilities
What happens if a patient does not return within 72 hours to have their TST read?
Positive reaction can still be measurable up to 1 week later
True/false: Once a patient has a positive TST reading, no further skin testing is indicated
True
Criteria for positive TST reaction → induration >5mm
- HIV infection
- Close contact of person with TB
- Persons with fibrotic lesions or evidence of old, healed TB on chest x-rays
- Organ transplant recipient
- Immunosuppressed (e.g. prednisone or TNF alpha)
Criteria for positive TST reaction → induration > 10 mm
- Recent immigrant from high risk country
- Resident or employees of high risk settings
- Medically underserved, low income
- Children < 4 years
- Children with chronic disease
- IV drug abuse
Criteria for positive TST reaction → induration > 15 mm
Over age 4 years with no risk factors
LTBI treatment (preferred) for all patients >2 and/or HIV positive
3 months of weekly isoniazid + rifapentine
LTBI treatment (preferred) for all patients and/or HIV negative
4 months of daily rifampin
LTBI treatment (preferred) for all patients and/or HIV positive
3 months daily isoniazid + rifampin
