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PGY1 - Fever Block > Fever > Flashcards

Fever Flashcards

1
Q

what conditions are classified as immunocompromised

A

cancer, organ transplantation, diabetes, renal failure, cirrhosis, asplenism, HIV, etc.

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2
Q

components of innate immunity

A

physical barriers: intact skin, GI and respiratory mucosa, cilia, biofilm, gastric acid, antibacterial substances in pancreatic and biliary secretions, antimicrobial peptides and proteins on skin and mucous membranes and resident microflora

initial inflammatory response: sentry cells detect pathogens and release cytokines

reticuloendothelial system: tissue macrophages and monocytes - encapsulated organisms

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3
Q

what type of bacteria does reticuloendothelial system target

A

encapsulated organisms- pneumococci, meningococci, and H. flu

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4
Q

components of adaptive immunity

A

humoral immuniry: antibodies, Igs, complement

cell mediated immunity: T lymphocytes, NK cells, and mononuclear phagocytes

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5
Q

what are the different subtypes of Ig

A

IgM- first to appear - acute
IgG- chronic, 75%of Ig mass, crosses placenta
IgA- Ig in GI fluids, nasal and oral secretions, tears and other mucous fluids
IgE- on mast cells/basophils, immediate type hypersensitivity reactions

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6
Q

what immune deficiency should be tested for in people with meningococcemia

A

complement deficiency - may benefit from immunization

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7
Q

what bacteria are people with complement deficiency susceptible to

A

S. pneumoniae, H. flu, Neisseria meningitidis and Neisseria gonorrhea

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8
Q

what medication condition is associated with complement defieciyn

A

SLE

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9
Q

what bacteria /viruses/funguses are people with cell mediated immunity deficiencies susceptible to

A

Mycobacterium tb, listeria, salmonella, MAC, legionella, nocardia
DNA viruses: CMV, HSV, and HZV, EBV, measles, adenovirus
fungus: Candida, Cryptococcus, Mucor, Aspergillus, and Pneumocystis, Histoplasmosis, Coccidiodies
protozoa: Toxoplasma gondii
parasites: cryptosporidium, strongyloides stercoralis

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10
Q

how to differentiate between margination of neutrophils during periods of stress or with increased catecholmaines/steroids with infection

A

infection has increased immature bands whereas margination is increase mature neutrophils only

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11
Q

bacteria people with splenectomy or asplenia susceptible to

A 
S. pneumo
H. flu
N. meningitidis
Capnocytophaga canimorsus
Bordetella holmesii

parasites: Babesia

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12
Q

bacteria people with neutropenia are susceptible to

A

GN bacilli: E. coli, Klebsiella, Pseudomonas, Enterobacter, Serratia, Citrobacter, Proteus, Acinetobacter, Stenotrophomonas
GP cocci: Staph epidermis, Staph aureus, Viridans streptococci, Strep pneumo, Strep pyogenes, Enterococcus
GP rods: corynebacteria, bacillus

fungi: candida, aspergillus, .. less common: mucor, rhizopus, trichosporon, fusarium, pseudallescheria

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13
Q

define neutropenia

A

neutrophil count less than 500 cells/mL or 0.5 x 10^6 cells

or less than 1.0 x 10^6 and expected to drop to 0.5 x 10^6

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14
Q

define febrile neutropenia

A

single T of 38.3 in neutropenic patient or T of 38.0C or higher during 1-2 hours

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15
Q

most common sites of infection in neutropenic patients

A 
lung  -25%
mouth and pharynx -25%
GItract - 15%
skin, soft tissue and intravascular catheters - 15%
perineum and anorectal area - 10%
UTI - 5%
nose/sinuses 5%
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16
Q

risk factors for serious viridans streptococcal infections

A

aggressive cytoreduction for acute leukaemia or allogeneic bone marrow transplantation, profound neutropenia, and severe oral mucositisi
prophylactic use of TMP-SMX or fluoroquinolone, used of antacids or H2 blockers and childhood

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17
Q

in patient with neutropenia, ulcerative lesions in the mouth suggestive of

A

viridans streptococci, HSV, Candida, anaerobes

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18
Q

in patient with neutropenia, necrotizing skin lesions

A

Pseudomonas aeruginosa, Aeromonas hydrophily, Aspergillus, Mucor

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19
Q

in patient with neutropenia, nontender, subcutaneous nodules

A

nocardia, cryptococcus

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20
Q

in patient with neutropenia, nontender pink skin papules

A

candida

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21
Q

in patient with neutropenia, black eschar of nose or palate

A

aspergillus, mucor

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22
Q

in patient with neutropenia, generalized macular red rash

A

viridans streptococci

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23
Q

in patient with neutropenia, RLQ abdo pain, tenderness, distension, bloody diarrhea

A

typhlitis (neutropenic enterocolitis) caused by pseudomonas, e coli, clostridium septicum

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24
Q

in patient with neutropenia, perineal pain and tenderness without inflammation or abscess

A

GN bacilli, anaerobes

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25
Q

in patient with neutropenia, redness or pain at vascular catheter sits

A

coagulase negative staphylococci, corynebacterium, bacillus species

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26
Q

what factors make pt with febrile neutropenia high risk for complications

A

patients with hypotension, pneumonia, new onset abdominal pain, neuro changes, other acute organ dysfunction (especially renal or hepatic disease, active COPD)

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27
Q

how to calculate MASCC score in febrile neutropenia (multinational association for supportive care in cancer)

A

burden of febrile neutropenia with mild or no sx.
no hypotension (SBP > 90)
no COPD
solid tumor or heme malignancy with no previous fungal infection
no dehydration requiring parenteral fluids
burden of febrile neutropenia with moderate symptoms
outpt. status
age younger than 60 years old

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28
Q

what empiric IV abx to use in febrile neutropenia

A

anti-pseudomonad beta-lactam (cefepime, meropenem, imipenem-cilastatin, or pip-tazo) ASAP after cultures obtained

add amino glycoside or Vanco for hypotension
may add azithro for pneumonia

if suspected polymicrobial/anaerobic ie. intraabdominal or perianal source - ad flagyl or clindamycin if cefepime is used as the beta-lactam agent

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29
Q

what abx to use for febrile neutropenic in pen-allergic patietns

A

minor allergy- cefepime, meropenem, or imipenem-cilastatin

severe allergy: consult ID, aztreonam and Vanco +/- clinda or flagyl

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30
Q

when to use vancomycin empirically in febrile neutropenia

A

suspicion of serious catheter-related infection, known colono=ization with MRSA or penicillin resistant pneumococci, known isolation of a GP organism before final identification and susceptibility known, presence of shock, severe mucositis, prior fluoroquinolone prophylaxis, and institutions in which MRSA, VRE and strep mitis are frequent pathogens

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31
Q

when to consider urgent CT scanning in febrile neutropenia

A

CXR normal or inconclusive in pt with acute respiratory symptoms/signs, HRCT chest without contrast
facial pain or swelling is present, consider CT scan of sinuses without contrast
in patients with abdominal pain and tenderness, CT abdominal pelvis with IV contrast

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32
Q

what patients make up high risk group of febrile neutropenia

A

inpatient when fever and neutropenia develop, presence of comorbid medical conditions, uncontrolled cancer, acute leukaemia, hemodynamic instability, evidence of organ failure, presence of pneumonia, severe soft tissue infection, infection of a central line, abdominal pain, or neuro or mental status abnormalities, neutropenia expected to last more than 10 days

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33
Q

considerations for outpatient management of febrile neutropenia

A

pt should have MASCC score > 21
pt medically stable without acute or chronic organ dysfunction or comorbid conditions, and no acute leukaemia
no focus of infection identified
pt has access to telephone and transportation to return to hospital 24 hours a day and has a caregiver at home
p that hx of compliance with f/u
pt not on fluoroquinolone prophylaxis
pt oncologist agrees to outpatient mgmt

should give IV dose in ED and watch for 4 hours before D/C

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34
Q

outpatient abx used in febrile neutropenia

A

cipro or levofloxacin PLUS clavulin or clinda (in pen allergy patients)

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35
Q

DDX of fever in non-neutropenic patents with solid organ cancer

A

wound infection, deep abscess, or perforated viscus
infections in central venous or urinary catheters, steps, and prosthetic devices
large tumor lesions can cause obstructive infections (of bronchus, bile duct, or ureter)

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36
Q

treatment of suspected meningitis in immunocompromised host - LIsteria

A

ampicillin and gentamicin

septra in pen allergic

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37
Q

hyponatremia + pneumonia symptoms in immunocompromised patient is

A

Legionella

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38
Q

treatment of legionella infection in immunocompromised patietns

A

reso fluoroquinolone or azithromycin

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39
Q

clinical manifestations of nocardia

A

subacute pneumonia with nodular infiltrates
cellulitis
subcutanoeus abscesses
meningitis brain abscess

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40
Q

treatment of nocardia

A

sulfonamides + other agents

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41
Q

presentation of Stronglyloides

A

intestinal nematode in patients with deficient CMI and usually on high dose steroids

disseminates from intestine to lung and other organs causing Strongyloides hyper infection syndrome with v. high mortality - wheezing, cough, SOB, hemoptysis sand hemorrhagic rash are common

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42
Q

treatment of sStronglyoides

A

oral ivermectin

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43
Q

DDX for pulmonary infiltrates - diffuse/ bilateral in immunocompromised patietn

A

viral: CMV, RSV, influenza, adenovirus, varicella
pneumocystis jiroveci
fluid overload/pulmonary edema
TRALI
radiation damage
chemotherapy-induced toxicity
ARDS due to viridans streptococcal bacteremia
bronchiolitis obliterates
pulmonary hemorrhage
progression of disease (lymphangitic spread, leukaemia infiltrates)

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44
Q

DDX for pulmonary infiltrates- focal or patchy in immunocompromised patients

A 
bacterial pneumonia including legionella
fungi: invasive pulmonary aspergillosis, zygomycosis, fusarium, pseudallsecheria
tb
non-tb mycoabcteria
nocardiosis
PE
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45
Q

factors contributing to diabetic increased risk of infection

A

defects in immune function
excess glucose for fungal/bacterial growth
vascular insufficiency related to microangiopathy and atherosclerosis
sensory neuropathy leads to wound neglect

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46
Q

infections more commonly seen in diabetics

A 
rhino cerebral zygomycosis
malignant otitis externa - Pseudomonas
pneumonia caused by S.aureus and GN bacilli
tb
emphysematous cholecystitis
UTI
Fournier's gangrene/ nec fasc of lower extremities
psoas abscess
spinal epidural abscess
foot infections with osteomyelitis
post op surgical site infections
vulvovaginal candidiasis
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47
Q

factors contributing to immunocompromised state in alcoholism and cirrhosis

A

alcohol suppresses the immune system, alters blood flow, depresses metal status and delays care-seeking
more likely to aspirate

alcoholic cirrhosis: deficient hepatic clearance and killing of bacteria by reticuloendothelial cells, and splenic hypo function; complement deficiency since liver makes C3, cellular immune deficiency occurs and is exacerbated by malnutrition, bactericidal activity of IgM decreased

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48
Q

what infections are cirrhosis patients more susceptible to

A

spontaneous bacteremia and sepsis caused by E.coli, Klebsiella, Salmonella, streptococci, Vibrio vulnificus, and Aeromonas

SBP caused by E.coli, K. pneumoniae, S.pneumo, or enterococci

pneumonia caused by pneumococci, GN bacilli (E. coli, klebsiella, H.flu) and anaerobes

tb
meningitis by S. pneumonia, listeria

skin/soft tissue with S.aureus, streptococci, and GN bacilli

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49
Q

factors contributing to immunocompromised state in renal failure

A

disruption of cutaneous barrier at vascular access sites, etc.
uremic prurituswith excoriatoin/skin breakdown
reduced renal clearance of toxins, nutritional deficiencies, and administration of immunosuppressive medications
CKD leads to generalized immune hyporesponsiveness

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50
Q

common infections seen in renal failure

A

vascular access site infection by S.aureus - may cause hematogenous spread - often osteomyelitis seeding ribs or thoracic vertebrae, endocarditis, meningitis, epidural abscess, septic arthritis
SBP

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51
Q

what conditions cause functional asplenism

A

sickle cell disease, ulcerative colitis, celiac disease, sarcoidosis, amyloidosis, RA and SLE

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52
Q

what can be seen on peripheral smear that may indicate functional hyposplenism

A

Howell-Joly bodies in RBCs

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53
Q

complications of prolonged steroid use

A

Cushing’s syndrome, PUD, pancreatitis, benign intracranial hypertension, psychosis, glaucoma, poster sub capsular cataract, poor wound healing, sodium retention, hypertension, vascular thrombosis, hyperglycaemia, DKA, HHS, AVN of bone, myopathy and osteoporosis, adrenocortical insufficiency

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54
Q

patients taking biologics at risk for what infections

A

reactivation of late tb, non-tb mycobacterial infection, histoplasmosis, and coccidiomycosis

cryptococcosis, listeriosis, legionellosis, salmonellosis, aspergillosis, candidiasis and pneumocystosis

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55
Q

DDX of fever -infectious

A

resp: bacterial pnuemonia, PTA, retropharyngeal abscess, epiglottiti, OM, sinusistis pharyngitis, bronchotiis, influenza, tuberculosis
CV: endocaditis, pericarditis
GI: peritonitis, appendicits, cholecystitis, diverts, colitiis or enteritis
GU: pyelonephritis, TOA, PID, cystitis, epidydimitis, porostatitis
skin: cellulitis, infectd deucubitus ulcer, soft tissue abscess
systemic: sepsis or septic shock, meningococcemia

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56
Q

DDX of fever- noninfectious

A

critical diagnoses: MI, PE, ICH, CVA, NMS, thyroid storm, acute adnreal insufficiency, transufion rxn,, plmonary edema
emergent: CHF, dehydration, recent seizure, sickle cell disease, transplant run, pancreatitis, DVT
nonemergent diagnoses: drug fever, malignancy, gout, sarcoidosis, crohn disease, postmyocardiotomy syndrome

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57
Q

considerations when fever associated wit bradycardia

A

pt on beta blockers etc.
factitious or drug related fevers
typhoid fever, brucellosis, leptospirosis

rheumatic fever, lyme disease, viral myocarditis, endocarditis

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58
Q

suspect case of diphtheria

A

pharyngitis, nasopharyngitis, tonsillitis, larnygitis, tracheaitis, absent or low grade fever
greyish adherent pseudo-membrane present
membrane bleeds, if manipulated or dislodged

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59
Q

probable case of diphtheria

A

suspect case plus one or more of following:
stridor
bull-neck (cervical edema)
toxic circulatory collapse
acute renal insuffieincy
submucosal or subq petechiae
myocarditis
death
recent return (<2 weeks) from travel to endemic area
recent contact (<2 weeks) with confirmed case or carrier, or visitor from area with endemic diphtheria
recent contact with dairy or farm animals or domestic pets
immunizaiton status

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60
Q

lab confirmed case of diphtheria needs

A

positive culture of Corynebacterium diphtheria or Corynebacterium ulcers AND
positive Elek test or PCR for tax gene (positive for subunit A and B)

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61
Q

DDX of respiratory diphtheria

A 
streptococcal pharyngitis
viral pharyngitis (EBC, adenovirus, HSV)
tonsillitis
vincent's angina (typically involve gingiva whereas dip doesn't)
acute epiglottitis
mononucleosis
laryngitis
bronchitis
tracheitis
Candida albicans
rhinitis
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62
Q

bacteria causing diphtheria

A

Corynebacterium diptheriae

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63
Q

what category of bacteria is diphtheria

A

gram positive bacillus

unencapsulated

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64
Q

pathophysiology of diptheria

A

toxin strains of C.diphtheria lysogenized and produce an exotoxin that inhibits cellular protein synthesis

diphtheria membrane composed of leuks, RBCs, fibrin, epithelial cells and bacteria results from necrosis caused by local effects of the exotoxin

exotoxin causes peripheral neuropathy manifested by muscle weakness - pharyngeal usually affected first, then proximal muscles

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65
Q

emergent complications of diphtheria

A

airway obstruction, CHF, cardiac conduction abnormalities and muscle paralysis

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66
Q

diagnostic w/u of suspected diphtheria

A

notify lab because routine cultures don’t ID organism
Elek test -tests for toxin A
PCR - used to detect toxin structural gene

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67
Q

mgmt of diphtheria

A

equine serum diphteria antitoxin

active immunization

erythromycin 40mg/kgk/day in divided doses
pen G 300,000U /day in those weighting 10kg or less, or 600,000U/day in divided doses

admit, isolate and monitor for detection of arrhythmias

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68
Q

how is diphteria transmitted

A

resp droplets or direct contact with secretions, skin lesions, fomites on food

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69
Q

how is pertussis transmitted

A

droplet

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70
Q

bacteria that causes pertussis

A

Bordetella pertussis

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71
Q

pathophysiology of pertussis

A

adheres to ciliated respiratory epithelial cells, releases several toxins
systemic effects of pertussis toxin = sensitization to lethal effects of histamine and increased excretion of insulin (hyperinuslin, therefore hypoglycaemia)

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72
Q

clinical case of pertussis defition

A

cough and illness for more than 2 weeks with no apparent other cause plus one of: paroxysms of coughing, inspiratory whoop, post-jussive emesis

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73
Q

probably case of pertussis

A

clinical case defn
not lab confirmed
not epidemiologically linked to a lab confirmed case

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74
Q

confirmed case of pertussis

A

acute cough illness of any duration with positive culture for B. pertussis
clinical case defn + confirmed by PCR
clinical case defn + epidemiologically linked to case confirmed by culture or PCR

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75
Q

clinical course of pertussis

A

incubation period: 7-10 days
catarrhal/prodromal phase: 1-2 weeks, rhinorrhea, low fever, malaise, conjunctival injection
paroxysmal phase: begins as fever subsides, cough worsens 1-10 weeks
convalescent phase: residual cough

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76
Q

complications of pertussis

A 
periorbital edema
subconjunctival hemorrhage
petechiae
epistaxis
hemoptysis
subcutaneous emphysema
pneumothorax
pneumomediastinum 
diaphragmatic rupture
umbilical and inguinal hernias
rectal prolapse
pneumonia
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77
Q

diagnostic w/u of pertussis

A

NP aspirate or swab for culture and PCR

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78
Q

DDX of pertussis

A

acute viral URTI, pneumonia, bronchiolitis, cystic fibrosis, tb, AECOPD, FB aspiration, leukemia (marked leukocytosis)

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79
Q

treatment of pertussis

A

O2, suctioning, hydration, nutrition, avoid respiratory irritants
admit if: associated pneumonia, hypoxia, CNS complication, or severe paroxysms, kids under age 1

abx to decrease infectivity and carriage
erythromycin, or azithromycin (day 1 -10mg/kg, then day 2-5 - 5mg/kg)

prophylaxis for household contacts

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80
Q

alternative to treat pertussis in macrolide allergic patietn

A

septra

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81
Q

what kind of bacteria is pertussis

A

gram negative coccobacilli - aerobic

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82
Q

what kind of bacteria is tetanus

A

spore-forming, motile, rod-shaped obligated gram positive anaerobic bacillus

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83
Q

what is the bacteria name for tetanus

A

Clostridium tetani

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84
Q

pathophysiology of tetanus

A

portal of entry required - tetanus prone wounds have damaged or devitalized tissue, foreign bodies or other bacteria - wound, OM, foreign bodies, corneal abrasions, childbirth, dental procedures
C. tetani produces neurotoxin that causes clinical illness
tetanospasmin binds motor nerve ending blocks presynaptic release of GABAergic and glycinergic neurons

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85
Q

what are the 4 types of clinical tetanus

A

generalized tetanus
localized tetanus
cephalic tetanus
neonatal tetanus

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86
Q

clinical manifestations of generalized tetanus

A

trismus, rictus sardonicus, irritability, weakness, myalgies, muscle cramps, dysphagia, hydrophobia, and drooling

autonomic dysfunction causes death - tachycardia, htn, hyperpyrexia, cardiac dysrhythmias, and diaphoresis

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87
Q

clinical manifestations localized tetanus

A

persistent muscle spasms to site of injury

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88
Q

clinical manifestations of cephalic tetanus

A

rare variant of localized tetanus resulting in CN palsies and muscle spasms

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89
Q

clinical manifestations of neonatal tetanus

A

generalized tetanus in newborn due to inadequate maternal immunization and contaminated material used to cut/dress umbilical cord

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90
Q

complications of tetanus

A

acute respiratory failure form respiratory muscle spasms
autonomic dysfunction
forceful tetanic muscle spasms can cause vertebral subluxations and fractures, long bone fractures, joint dislocations
rhabdomylosis
secondary infection
DVT/PE - prolonged immobility
hyperthermia
GI: peptic ulcers, ileus, intestinal perforation, and constipation
SIADH

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91
Q

diagnostic w/u in tetatnus

A

cultures not helpful
check calcium to r/o hypocalcemia
spatula test: tough oropharynx with tongue blade- positive = reflex masseter muscle spasm

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92
Q

DDX for tetanus

A

strychnine poisoning - antagonizes glycine release, but doesn’t block GABA like tetanus does

acute abdomen
black widow spider bite
dental abscess/infection
dislocated mandible
dystonic reaction
encephalitis
head trauma
hyperventilation syndrome
hypocalcemia
meningitis
PTA
progressive fluctuating muscle rigidity (stiff-man syndrome)
psychogenic
rabies
sepsis
status epilepticus
SAH
TMJ syndrome
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93
Q

treatment of tetanus

A

aggressive supportive care: benzos, avoid unnecessary stimulation (causes more spasms), NM blockade and MV if cannot control
elimination of unbound tetanospasmin: HTIG
active immunization: Td
prevention of further toxin production: flagyl 500mg q6h

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94
Q

contraindication to Tdap vaccine

A

hx of neurologic or severe hypersensivity reaction to previous dose

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95
Q

what wounds need Tdap and TIG in ED

A

pt with unknown or less than 3 primary vaccine series- - clean wound: Tdap only, other wounds: Tdap + TIG

pt with 3 vaccine series previously: clean wound- if less than 10 years since previous give Tdap, other wounds- if less than 5 years since previous give Tdap

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96
Q

what types of wounds are high risk for tetanus

A

> 6 hours old, > 1cm deep, contaminated, stellate, denervated, ischemic, infection

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97
Q

what is the bacteria that causes botulism

A

Clostridium botulinum

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98
Q

what are the five types of botulism

A

food-borne botulism, infant botulism, wound botulism, unclassified botulism and inadvertent botulism

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99
Q

what kind of bacteria is C. botulinum

A

anaerobic, gram positive, rod-shaped organism

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100
Q

clinical manifestations of food-borne botulism

A

early symptoms: weakness, malaise, lightheadedness, N/V, and constipation
neuro sx: diplopia, blurred vision, dysphonia, dysphagia, dysarthria, and vertigo –> symmetric descending muscle weakness - neck muscles, UE > LE
-blocks cholinergic receptors so get dry mouth, ileum, urinary retention
-ocular: ptosis, EOM palsies

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101
Q

clinical presentation of infant botulism

A

constipation, poor feeding, weak cry, loss of head control, hypotonia, CN palsies, ocular invovlement

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102
Q

differences in wound botulism

A

GI symptoms absent
incubation period longer 4-14 days
toxin produced by spores in wound

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103
Q

diagnostic tests in botulism

A

diagnosis confirmed by detection of toxin in blood
notify public health
serial measurements of patients vital capacity

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104
Q

DDX botulism

A

pharyngitis/gastroenteritis initially

GBS (usually starts distal and ascends, paresthesias can be present)
tick paralysis (ascending, lack of bulbar involvement)
myasthenia gravis (eye signs also prominent, but pupil response preserved, no autonomic symptoms)
poliomyelitis- fever, asymmetrical neuro signs, CSF abnormalities
Eaton-Lambert- avoids bulbar muscles usually
brainstem CVA- acute onset, asymmetrical
anticholinergic toxins
organophoste insecticides
dystonic reactions
heavy metal poisoning
Mg toxicity
paralytic shellfish poisoning

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105
Q

DDX infant botulism

A 
sepsis
viral illness
dehydration
encephalitis
meningitis
failure to thrive
GBS, MG, polio
hypothyroid
hypoglycemia
diphtheria
toxin exposures
inborn errors of metabolism
congenital muscular dystrophy
cerebral degenerative diseases
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106
Q

treatment of botulism

A

supportive care, admit to ICU as respiratory failure may develop rapidly and insidiously
antitoxin
consider bowel decontamination

infant botulism with - BabyBIG - pooled plasma from immunized adults with high titters of antibodies to toxins

if using abx for secondary infection don’t use aminogylcosides or tetracyclines because they impair Ca entry to neuron and can worsen effects of the toxin

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107
Q

what infections does Strep pneumonia cause

A

OM, pneumonia, meningitis,

less common: endocarditis, septic arthritis, and peritonitis

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108
Q

what populations are at higher risk of pneumococcemia (Strep pneumoniae in the blood)

A

chronic resp or CV disease, chronic EtOH abusers, patients with cirrhosis, diabetes mellitus, or an absent or functionally impaired spleen, those receiving immunosuppression, those with CRF, nephrotic syndrome, organ transplant, lymphoma, Hodgkin’s disease, multiple myeloma, and AIDS

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109
Q

what kind of bacteria is Strep pneumo

A

encapsulated gram positive facilitate anaerobe

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110
Q

what lab findings correlate with more serious disease in pneumococcemia

A

normal or low WBC count

hypoxemia and hypercarbia

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111
Q

treatment of Strep pneumo positive blood cultures

A

penicillin G 2-4 million units IV q4h

ceftriaxone 2g IV daily

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112
Q

treatment of pneumococcemia in penicillin allergic or cephalosporin allergic patients

A

vancomycin, imipenem, chloramphenicol

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113
Q

what is the mortality rate of meningococcemia

A

40%

70% if septicemia without meningitis
less than 10% if only meningitis

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114
Q

bacteria that causes meningococcemia

A

Neisseria meningitidis

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115
Q

what kind of bacteria is N.meningitidis

A

aerobic gram negative diplococci

encapsulated

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116
Q

what are the 5 patterns of presentation of N.meningitidis infection

A 
occult bacteremia
meningococcal meningitis
meningococcal septicaemia
fever and non blanching rash
chronic meningococcemia
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117
Q

what is the rash seen in meningococcemia

A

purpura fulminans

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118
Q

complications of meningococcemia

A

acute respiratory failure
renal failure

meningitis- focal neuro deficits, seizures, hearing loss, visual deficits, neurodevelopment impairment, CN palsies, hemi and quadriparesis

purpura fulminans - loss of digits or limbs from gangrene
purulent or immune complex arthritis and pericarditis
herpes labialis

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119
Q

poor prognostic indicators in meningococcal disease

A

WBC less than 500, platelets less han 100, metabolic acidosis, purpura fulminans, onset of petechiae within 12 hours of admission, absence of meningitis, presence of shock, low sedimentation rate, and extremes of age

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120
Q

DDX of meningococcal disease

A 
viral exanthema
rocky mountain spotted fever
typhus/typhoid fever
endocarditis
vasculitis syndromes (PAN, HSP), toxic shock syndrome, acute rheumatic fever
dengue fever
drug reactions
ITP
TTP
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121
Q

empiric therapy for meningitis

A

corticosteroids prior to abx decreases long term neuro sequelae in adults and children (not true for neonates), dexamethasone 0.4-0.6mg/kg/day q6h for 4 days

ceftriaxone 100mg/kg IV followed by daily doses of 100mg/kg in divided doses q12h

+vanco

+/- ampicillin

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122
Q

clinical case definition of toxic shock syndrome

A

fever: t >38.9
rash: diffuse macular erythroderma
desquamation 1-2 weeks after onset of illness, particularly palms/soles
hypotension
multisystem involvement: 3 or more of the following:
GI: V/D
muscular: severe myalgia or CK level 2x ULN
mucous membrane: veginal, oropharygnal, or conjunctival hyperemia
renal: BUN or Cr at least twice ULN or urinary sediment with pyuria in the absence of UTI
hepatic: total bili, AST, and ALT at least 2x ULN
hematologic: platelets < 100
CNS: disorientation or alterations in consciousness without focal neuro signs when fever and hypotension are absent

lab criteria:
negative results:
on blood, throat, CSF cultures (blood culture may be positive for Staph aureus)
rise in titer to RMSF, leptospirosis or rubeola

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123
Q

probable vs confirmed case of toxic shock

A

probable: lab criteria met and 4/5 clinical findings present
confirmed: lab criteria met and 5/5 findings including desquamation unless pt dies before desquamation occurs

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124
Q

case definition of streptococcal toxic shock syndrome

A

hypotension
multisystem involvement: 2 or more of the following
-renal: Cr > 177 or 2 x ULN
-heme: platelets < 100 or DIC
-hepatic: total bili, AST and ALT 2x ULN
-ARDS
-generalized erythematous maculopapular rash that may desquamate
-soft tissue necrosis, including necrotizing fasciitis, myositis or gangrene

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125
Q

what bacteria can cause toxic shock

A

staph aureus

group A streptococcus

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126
Q

risk factors for toxic shock syndrome

A 
use of superabsorbent tampons
post-op wound infections
postpartum period
nasal packing
cancer
common bacterial infections
ethanol abuse
infection with influenza A
infection with varicella virus
diabetes mellitus
HIV
chronic cardiac disease
chronic pulmonary disease
NSAID use
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127
Q

what are some differences with staphylococcal and streptococcal toxic shock syndrome

A

sex: staph more common in women, strep equal
severe pain at site of infection: common in strep, rare in staph
erythroderma rash: more common in staph\
bacteremia: low in staph, 60% in strep
tissue necrosis: rare in staph, common in strep
predisposing factors: tampons, packing, NSAID use in staph; cuts, burns, bruises, varicella, NSAID use in strep
mortality rate: <3% in staph, 30-70% in strep

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128
Q

clinical manifestations that prompt consideration of toxic shock syndrome

A

patients with fever, rash, hypotension, evidence of end-organ function such as respiratory failure or AMS
prodromal illness of fever, chills, N/V, watery diarrhea, h/a, myalgia and pharyngitis can last 2-3 days before frank sepsis
rash- nonpruritic, diffuse, blanching, macular erythroderma
-strep TSS may have scarlet-fever like rash- petechiae, maculopapular lesions, mucosal- strawberry tongue, mucosal ulceration; conjunctival/scleral hemorrhages
-mental status abnormal out of proportion to degree of hypotension

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129
Q

complications of TSS

A

ARDS, shock, gangrene, DIC, neuropsych problems, renal failure irreversible in 10%

rhabdo, seizures, pancreatitis, pericarditis, cardiomyopathy

menstrual form may reoccur

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130
Q

lab abnormalities in TSS

A 
leukocytosis or leukopenia
elevated Cr
hypoalbuminemia and life threatening hypocalcemia
anemia, thrombocytopenia
prolonged INR and PTT
increase bill
elevated transaminases
metabolic acidosis
pyuria
elevated CK
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131
Q

DDX for toxic shock syndrome

A

any septic illness with exanthema, heat stroke, cellulitis, Kawasaki disease, staphylococcal scalded skin syndrome, scarlet fever, drug reactions -SJS, TEN, RMSF, clostridia gas gangrene, leptospirosis, meningoceoccemia, gram negative sepsis, atypical measles, and viral illnesses

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132
Q

treatment of toxic shock syndrome

A 
fluid resus - may need 10-15L/day
supplemental O2 
monitored setting
remove source- tampon, nasal packing etc.
surgical consult to debride wounds
vasopressors pre
abx: clindamycin 1st line 600-900mg IV q8h
IVIG if suspected strep
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133
Q

4 categories of transplant organ complications

A

anatomy
rejection
infection
drug toxicity

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134
Q

what are the subtypes of anatomic complications of organ transplant

A 
vascular: thrombosis, stenosis, AV fistula, pseudo aneurysm formation
nonvascular anastomosis (ie. bile ducts, bronchi, ureters): leaks, obstructions from scarring, migration of stent, stone development 
complications related to surgery
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135
Q

three phases of organ rejection / what occurs at each

A

hyperacute: preformed antibodies against MHC or ABO blood type antigens
acute: days to weeks after transplant, constitutional symptoms and signs of transplant organ insufficiency (or anytime later if immunosuppression is stopped)
chronic: months to years, gradual failure of transplanted organ over time, ie. interstitial fibrosis/tubular atrophy in kidneys, inflammation causing airway obstruction in lungs, fibrosis of bile ducts, veins and arteries in liver, CAV - chronic allograft vasculopathy

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136
Q

infectious pathogens in transplant patients 0-1 months post-transplantation (early)

A

pre-existing in transplant patient: bacterial colonization (Pseudomonas aeruginosa, M. tb), viral (HIV, HBV, HCV, CMV, HSC, VZV), fungal (Candida, Cryptococcus neoformans, Aspergillus, Histoplasma capsulatum, Blastomyces dermatidis, Coccidiodes immitis)
donor-derived: bacteria from transplant bacteremia, fungal (Candida species), rarely Trypanosma cruz, HCV, HIV, West Nile virus, lymphocytic choriomeningitis virus, Legionella, H. capsulate, Strongyloides stercoralis, C. neoformans, Schistosoma species, Toxoplasma gondii, and M. tb
nosocomial: bacteremia, surgical site infection, VAP, UTI, C.diff, MRSA, VRE, resp viruses, Legionella

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137
Q

infectious pathogens in transplant patients 1-6 months post-transplant (intermediate)

A

viral infections: CMV, EBV, HBV, HCV, BK virus, respiratory viruses, HSV, VZV
opportunistic infections: Listeria monocytogenes, Nocardia, C.neoformans, Mycobacterium species, Candida species, Aspergillus, H. capsulatum, B. dermatitis, C.immitis, Pneumocystis jiroveci, T.gondii, S. stercoralis

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138
Q

infectious pathogens in transplant patients more than 6 months post-transplant (late)

A

community acquired pathogens: respiratory viruses, community-acquired pneumonia, UTI
chronic viral infection: CMV, EBV, HBV, HCV, BK virus
opportunistic infections: in patients remaining on high dose immunosuppression

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139
Q

presentation of CMV infection in transplant patients

A

may be asymptomatic
fever, malaise, and leukopenia or symptoms specific to invasive disease of lungs, liver or GI tract
lungs: fever, hypoxia, diffuse infiltrates on CXR
liver: microabscesses in liver
GI: abdo pain, diarrhea, bleeding, perforation

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140
Q

effects of CMV on transplant patients unrelated to infection

A

immune-modulating properties, increased risk of bacterial and fungal infections, opportunistic infection, acute or chronic organ rejection, increased mortality

linked with glomerulopathy and graft dysfunction in renal allograft recipients, recurrent HCV in liver transplant, acute cardiac dysfunction and accelerated atherosclerosis in heart transplants

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141
Q

how to treat CMV

A

IV ganciclovir

often patients are on prophylaxis of valganciclovir for 3-6 months

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142
Q

effects of EBV infection on transplant patients

A

mononucleosis like syndrome: fever, malaise, pharyngitis, lymphadenopathy or hepatitis, pneumonitis, and GI complaints
post-transplant lymphoproliferative disorder: viral mononucleosis syndrome, plasmacytic hyperplasia, B-cell infiltration of organs, or lymphoma

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143
Q

treatment of post-transplant lymphproliferative disorder

A

reduction in immunosuppression, monoclonal B-cell antibody therapy (rituximab), cytotoxic chemotherapy

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144
Q

how does BK virus present in post-transplant patients

A

resides in kidneys, can progress from viruria to viremia to nephropathy, graft dysfunction and graft loss in renal transplants

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145
Q

how does Listeria infection present

A

immunocompetent: fever, abode pain, diarrhea
immunocompromised: bacteremia, meningoencephalitis

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146
Q

treatment of Listeria in solid organ transplant patients

A

high dose pen or amp + aminoglycoside

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147
Q

which organ transplant patients have highest incidence of Nocardia

A

heart/lung

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148
Q

presentaiton of Nocardia

A

fever, cough, SOB, hemoptysis, but can progress to disseminated infection with CNS abscess, skin and soft tissue abscess

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149
Q

what does Nocardia look like on culture

A

classic beading and branching gram positive bacilli

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150
Q

what is first line treatment for Nocardia

A

septra

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151
Q

what are secondline/other optinos to treat Nocardia

A

minocycline, amikacin, imipenem, cefotaxime, ceftriaxone

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152
Q

how does invasive candidemia in transplant patients present

A

fungemia, UTI, peritonitis, pleural empyema, IAI

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153
Q

how does aspergillosis present in transplant patients

A

pulmonary nodules w/ or w/o cavitation, may disseminate to any organ system including CNS

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154
Q

treatment for aspergillosis

A

amphotericin B, azoles or echinocandins

155
Q

what are examples of endemic mycoses

A

histoplasmosis, blastomycosis, and coccidiomycosis

156
Q

how to treat endemic mycoses in organ transplant pt

A

amphotericin B

157
Q

treatment of Pneumocystis jiroveci

A

septra + steroids depending on degree of hypoxia

158
Q

presentation of toxoplasmosis

A

usually reactivation of latent infection - causes pneumonia, HSM, myocarditis, brain abscess, or diffuse encephalitis

159
Q

treatment of toxoplasmosis

A

IV sulfdiazine and pyrimethamine

septra has been used to treat toxo in AIDS pts successfully

160
Q

what is the presentatino of cryptococcus neoformans in solid organ transplant patients

A

meningoencephaltiis

1/3 have lesions on imaging

161
Q

how to diagnose cryptococcus neoformans

A

LP or serum cryptococcal antigen

amphotericin B and flucytosine

162
Q

what happens when transplant patients develop primary varicella

A

life threatening with pneumonia, pancreatitis, hepatitis, encephalitis, and DIC

163
Q

treatment of primary varicella in transplant pt

A

varicella zoster Ig

IV acyclovir

164
Q

presentation of Stronglyoides stercoralis in transplant patients

A

intestinal nematode causing hyperinfeciton syndrome causing necrotizing hemorrhagic enterocolitis and hemorrhagic pneumonia

disseminated Stronglyoides causes severe abdominal pain, obstructive symptoms, hemorrhage, and secondary peritonitis, sepsis, meningitis, and pneumonia

165
Q

treatment of disseminated Strongyloides

A

thiabendazole

166
Q

what are typical prophylaxis abx. post transplant

A

septra (for pneumocystis, but also covers Nocardia, Listeria, and UTIs)
fungal prophylaxis with fluconazole
CMV prophylaxis with ganciclovir

167
Q

3 categories of patients with infections from 1-6 months post transplant

A

healthy transplant: no chronic immunomodulating viral infections and a functioning allograft- mild increased susceptibility to normal community acquired infections, such as flu, UTI, pneumococcal pneumonia

chronic viral infection: progressive disease- HBV, HCV cause liver dz, HCC; EBV -> PTLD; CMV after prophylaxis stopped; HSV reactivation

chronic rejection: require ongoing high dose immunosuppression, highest risk for life-threatening opportunistic infections, and standard nosocomial infection

168
Q

toxicity associated with cyclosporine

A

nephrotoxicity, hypertension

tremor, hyperkalemia, hyperuricemia, glucose intolerance, hyperlipidemia, hirsutism, GI upset, gingival hyperplasia

169
Q

toxicity associated with tacrolimus

A

nephrotoxicity, neurotoxicity (tremor, h/a)

hypertension, hyperlipidemida, glucose intolerance, GI upset, hypokalemia, alopecia

170
Q

toxicity associated with sirolimus

A

nephrotoxicity, impaired wound healing, pneumonitis

hyperlipidemia, edema, GI upset, anemia, stomatitis

171
Q

toxicity associated with azathioprine and mycophenolate mofetil

A

hepatotoxicity, bone marrow depression, GI upset

172
Q

toxicity associated with prednisone

A

glucose intolerance, osteoporosis, GI bleeding, myopathy, cataracts

173
Q

adverse effects on induction agents- monoclonal antibodies ie. basiliximab, muromonab-CD3 (OKT3)

A

increased risk opportunistic infections, PTLD
pulmonary edema in overhydrated oliguric patients
aseptic meningitis

174
Q

which drugs interact with cyclosporine, tacroliums and sirloumus by decreasing half-life and immunosuppressive effect, and cause potential for acute rejection

A

carbamazepine, nafcillin, phenobarbital, phenytoin, rifampin

175
Q

which drugs interact with cyclosporine, tacroliums and sirloumus by increasing the half-life and potential drug toxicity or immunosuppression

A

colchicine, diltiazem, fluconazole, fluorquinolones, ketoconazole, macrolides, oral contraceptives, verapamil

176
Q

which drugs interact with cyclosporine, tacroliums and sirloumus to cause increased nephrotoxicty

A

aminoglycosides, amphotericin B, cimetidine, NSAIDs, sulfur

177
Q

differences in cardiac physiology post heart transplant

A

resting heart rate 95-110 - loss of PNS tone
meds affected autonomic NS- ie. atropine have no effect ton heart
pressers work by increasing catecholamines
no classic anginal symptoms due to lack of innervation
heart sensitive to adenosine, half dose

178
Q

ECG changes after heart transplant

A

incomplete RBBB and depolarization abnormalities most common

bi-atrial technique: may demonstrate two P waves (one from native recipient sinus nose and one from donor sinus node)

179
Q

what to do with pt with heart transplant with symptomatic bradycarda

A

admit, may need pacemaker

180
Q

what to do with pt with heart transplant with new tachyarrhythmias

A

concerning for rejection or CAV ( cardiac allograft vasculopathy)

181
Q

how does acute rejection present in cardiac transplan tpatients

A

fatigue, fever, dyspnea (most sens), signs of HF, hypotension
pericardial effusions, atrial arrhythmias.

182
Q

w/u of heart transplant pt when considering rejection

A

ECG, CBC, lytes, Cr, troponin, cultures, CXR, echo

183
Q

what is the gold standard for diagnosing acute rejection in heart transplant

A

endomyocaridla biopsy

184
Q

treatment of acute rejection in heart transplants

A

IV corticosteroids with or without OKT3 or ATG

if Ab mediated rejection, plasmapheresis, IVIG with rituximab

185
Q

how to diagnose chronic allograft vasculopahty )CAV)

A

angio - diffuse concentric narrowing coronary arteries (vs. eccentric focal narrowing in classic cardiac atherosclerosis)

186
Q

most common in diction for liver transplant

A

HCV infection

187
Q

what is the most common vascular complication of liver transplant

A

hepatic artery thrombosis

188
Q

presentation of hepatic artery thrombosis

A

in 1st month post liver transplant- jaundice, RUQ pain, fever, elevated liver enzymes and bili

189
Q

how to diagnosis hepatic artery thrombosi

A

Doppler ultrasound, helical CT scan or arteriography

190
Q

anatomic complications of liver transplant

A

hepatic artery thrombosis
hepatic artery rupture: usually caused by bacterial arteritis
biliary complicatiosn: leask, obstruction, stricture

191
Q

how to diagnose rejection of liver transplant

192
Q

what infections are common in liver transplant patients

A

adominal/biliary infections ie. cholangitis, peritonitis, liver abscess, and abdominal abscesses
most common- GN bacilli, enterococci, anaerobes

staph, candida can also occur
invasive aspergillosis

HBV, HCV

193
Q

what is anatomic location of transplanted kidney usually

A

iliac fossa

194
Q

clinical manifestations of kidney graft rejection

A

fever, hypertension, edema, tenderness over the allograft, and decreased urine output, subtle rise in Cr

195
Q

anatomic complications in lung transplant

A

PTX, hemothorax, pleural effusion, empyema, persist air leak

196
Q

clinical manifestations of acute rejection in lung transplant

A

fews days to several years after transplnt
cough, dyspnea, fatigue, fever
rales and rhonchi heard with deterioration in oxygenation and pulmonary function

197
Q

what is the most common opportunistic infection in lung transplant and when is highest risk

A

3 weeks to 4 months

CMV pneumonia

198
Q

howt o differentiate between rejection and CMV infection in lung transplant

A

transbronchial biopsy and culture

199
Q

difference n organ transplant patients in trauma

A

give leukorediced and CMV negative blood
heart transplant patients may have clinical tamponade from scarring and adhesions even without a pericardium

lung patient have pleural adhesions, complication chest tube placement

200
Q

questions included in comprehensive travel history

A

dates of travel
what countries/how long in each
activities/where they stayed
tourist, adventure traveler or worker
cities vs. rural villages
sleeping in hotels or tents
sex?
eat/drink?
activities, ie. swimming in fresh water (schistosomiasis)
prophylactic immunizations prior to leaving?
malaria chemoprophylaxis and compliance?
mosquito repellent/netting use?
underlying chronic medical problems, medications
chronology of symptoms, particularly fever and diarrhea

201
Q

what are the species responsible for causing human malaria

A

Plasmodium falciparum, Plasmodium vivax, Plasmodiumovale, Plasmodium malariae, Plasmodium knowlesi

202
Q

clinical manifestations of malaria

A

cyclic or irregular fevers

anemia, h/a, nausea, chills, lethargy, abdo pain, upper resp complaints

203
Q

what is the difference between P. falciparum aand other malari

A

falciparum causes severe organ system damage and death due to infected RBCs making sludge in arterioles and capillaries causing ischemia - manifested by cerebral malaria with cerebral deem and encephalopathy, hypoglycaemia, metabolic acidosis, severe anemia which may cause high output cardiac failure, renal failure, pulmonary edema, DIC

204
Q

what is the gold standard for diagnosis of malaria

A

light microscopic examination of thick and thin blood films

205
Q

treatment of malaria

A

in chloroquine-resistant regions: doxycycline or clindamycin, proguanil-atovaquone

for complicated falciparum infection: IV quinine or quinidine used

206
Q

side effects of rapid infusion of quinine

A

profound hypoglycaemia, hyponatremia and coma vigil (neuroimpairment due to high rates of parasite destruction)

207
Q

malaria treatment to prevent recrudescent disease in ovale, vivax

A

primaquine

208
Q

who is primaquine contraindicated in

A

G6PD deficiency

209
Q

what are the clinical manifestations of babesiosis

A

fatigue, anorexia, malaise, emotional lability, with myalgia, chills, high spiking fevers, sweats, h/a and dark urine

HSM, anemia, thrombocytopenia, leukopenia, elevated liver enzymes /hemolysis

210
Q

what organism causes babesiosis

A

Babesia microti, gibsoni, and divergens

malaria-like illness due to protozoan similar in structure and life cycle to plasmodia

211
Q

what areas of travel are at risk for babesiosis

A

NE US, NW US, Europe

endemic to Long Island, Cape Cod, Block Island

212
Q

how to diagnosis babesiosis

A

multiple thick and thin smears

213
Q

treatment of babesiosis

A

atovaquone plus azithromycin or for severe illness quinine plus clindamycin

214
Q

how is babesiosis transmitted

A

deer tick Ixodes dammini

215
Q

parasitic illnesses that cause significant fever

A 
malaria
babesiosis
schistosomiasis
leishmaniasis
toxoplasmosis
amebic liver abscess
African and American trypanosomiasis
fascioliasis
216
Q

what is katayama fever

A

initial phase of schistosomiasis
spiking fevers, diaphoresis, wheezing and cough - eosinophilia common
exposure to fresh water in endemic areas

217
Q

what is fascioliasis

A

liver fluke Fasciola hepatica - sheep/cattle exposure- metacercariae ingested in watercress
within 6 weeks, its get RUQ pain, fever, eosinophilia

218
Q

what is American trypanosomiasis (Chagas disease)

A

endemic to Central/South America
reduviid bug sheds trypomastigotes proximal to bite site, host scratches skin - disease begins with chagoma at site often periorbital - progresses to fever, facial swelling, and pedal deem- parasitization of cardiac muscle leads to dysrhythmias and ventricular dysfunction

219
Q

what is leishmaniasis

A

spread by sandflies and found in Middle East, India, East Africa, Brazil and along Mediterranean coast - can involve skin / mucosa, fever only seen with visceral involvement in immunocompetent persons
massive HSM, neutropenia, wt loss

220
Q

how does Entamoeba histolytic present

A

amebic liver abscess

high fevers, RUQ pain, elevated WBC count

221
Q

what parasitic infections are neurotrophic and cause neurologic symptoms

A

malaria
cysticercosis
echinococcosis
trypanosomiasis

222
Q

examples of anthelmintic drugs

A

thiabendazole
mebendazole
albendazole
ivermectin

223
Q

examples of trematodicide drugs

A

praziquantel use for flukes/schistosomes

224
Q

example of antiprotozoal drugs

A

metronidazole
tinidazole
niridazole

225
Q

example of antimalarial drug

A

chloroquine
mefloquine
proguanil-atovaquone
doxycycline

226
Q

what bug causes cysticercosis and where do you get it

A

Taenia sodium - tropical areas - undercooked pork contains larval cysts

227
Q

parasitemias that present with anemia

A

malaria
whipworm and hookworm
tapeworm

228
Q

parasxitemias that present with peripheral edema

A

filarial infection or parasite-induced malnutrition and hypoproteinemia

elephantiasis or filariasis - Wuchereria bancrofti or Brugia malayi

229
Q

parasites that present with derm symptoms

A

cutaneous leishmaniasis
dracunculiasis
cutaneous larva migrant (Anclyobranziliense larva) from dog/cat hookworm
swimmer’s itch - schistosome of avians/mammals
Strongyloides can cause transient pruritic rash
Taenia sodium cysts in soft tissue/muscle
onchocerciasis severe prurutius and nodules over bony proturuberances

230
Q

parasites that present with visual symtpoms

A

onchocerciasis - major cause of blindness - microfiliaria migrates to eye , foreign tissue deposited in iris musculature incites immune sclerosis keratitis
loiasis - both in Africa
toxocariasis
toxoplasma gondii

231
Q

parasites that present with pulmonary symptoms

A 
P. falciparum
E. histolytica
Pneumocystis penumonia 
Strongyloides
W. bancrofti, B.malayi
E. granulosus - pulmonary hydatid cyst disease
232
Q

parasites with CV symptoms

A

Chagas’ disease- Trypanosoma cruzi - in reduviid bug - usually bites near eye and forms chagoma - can lead to CHF

233
Q

parasites that cause diarrha

A 
Cryptosporidium pavum
Cyclospora cayetanensis
Entamoeba histolytica
Balantidium coli
Giardia lamblia
S. stercoralis
Capillaria philipinensis
T. trichura
Schistosome
234
Q

which micro-organisms cause infective endocarditis

A 
Staph aureus
Viridans group streptococci
Enterococci
Coagulase-negative staphylococci
Streptococcus bovid
other streptococci
non-HACEK, gram negative bacteria
fungi
HACEK
polymicrobial
culture negative 
other organisms
235
Q

what are HACEK organisms

A 
Haemophilus spp.
Aggregatibacter actinomycetemcomitans 
Cardiobacterium hominis
Eikenella corrodes
Kingella kingae
236
Q

symptoms associated with infective endocarditis

A

intermittent fever
malaise

weakness
myalgia
back pain
dyspnea
CP
cough
headaches
anorexia

“classic” triad: fever, anemia, heart murmur

237
Q

what diagnosis to think about stroke like symptoms and fever

A

endocarditis with septic emboli causing stroke like symptoms

238
Q

physical exam findings in endocarditis

A

murmur
vasculitic lesions: petechia, splinter hemorrhages, Osler’s nodes, Janeway lesions
splenomegaly (30%)
ocular: conjunctival/retinal hemorrhages (pale center/surrounding red halo- Roth’s spot)

239
Q

what are the major clinical criteria in Duke criteria

A

positive blood cultures (of typical pathogens) from at least 2 seperate cultures

evidence of endocardial involvement by echo: endocardial vegetation, paravalvular abscess, new partial dehiscence of prosthetic valve, new valvular regurgitation

240
Q

what are the minor clinical criteria in Duke criteria

A

predisposition: heart condition or IVDU
fever: T > 38.0C
vascular phenomena: arteiral emobli, septic pulmonary infarcts, mycotic aneurysm, conjunctival hemorrhages or Janeway lesions
immunologic phenomena: Osler’s nodes, Roth’s spots and rheumatoid factor
microbio: single positive blood culture (except coag neg staph or organism that does NOT cause endocarditis)
echo findings: consistent with endocarditis but does not meet major criteria

241
Q

how does duke criteria classify definite endocarditsi

A

2 major
1 major + 3 minor
5 minor

242
Q

how does duke criteria classify possible endocarditis

A

1 major and 1-2 minor

3 minor

243
Q

how does duke criteria classify rejected endocarditis

A

firm alternate diagnosis made
resolution of clinical manifestations occurs after 4 days or less of abx.
clinical criteria for possible or definite endocarditis not met

244
Q

empiric abx for endocarditis in the ED

A

ceftriaxone 2g + 15mg/kg vancomycin

245
Q

which endocarditis patients are appropriate for outpatient mgmt

A

HD stable, compliant, and capable of managing technical aspects of IV therpay

246
Q

conditions requiring surgical therapy for infective endocarditis

A 
infective endocarditis with acute heart failure
fungal endocarditis
periannular extension of infection
recurrent emboli
large mobile vegetations
persistent bacteremia
247
Q

which conditions are high risk for bacterial endocarditis and should have prophylaxis prior to certain procedures

A

prosthetic heart valve
hx. of endocarditis
unrepaired cyanotic CHD, including palliative shunts and conduits
completely repaired CHD with prosthetics during first 6 months after procedure
repaired CHD with residual defect at or adjacent to site of prosthetic
cardiac valvulopathy in a transplanted heart

248
Q

jones criteria for diagnosis of acute rheumatic fever

A

major: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules
(JONES, joints, <3, nodules, erythema marginatum, sydenham’s chorea)

minor: arthralgia, fever, increased ESR/CRP, prolonged PR interval

evidence of preceding strep infection:
positive throat culture for group A beta-hemolytic strep or positive rapid antigen test
elevated or rising strep antibody tiger, usually anti-streptolysin O

249
Q

what valve is most commonly affected in rheumatic fever

A

mitral - causing MR

250
Q

treatment of acute rheumatic fever

A

penicillin 250mg kids or 500mg adults B-TID x 10 days

asa for arthritis

251
Q

when should you culture an asbcess

A

complicated purulent infections, like surgical wound infections and abscesses in immunocompromised patientss

252
Q

when to get blood cultures in skin infections

A

deep tissue infection or systemic infection likely ie. septic shock, necrotizing infections, immunocompromised, multifocal infections suggesting ghemoatogenous seeding and infections complicating lymphedema

253
Q

likely bacterial cause and 1st line therapy for uncomplicated cutaneous abscess

A

CA-MRSA, others

I/D without abx.

254
Q

likely bacterial cause and 1st line therapy for non purulent bacterial skin infections

A

various strep, staph aureus

keflex or clindamycin

255
Q

likely bacterial cause and 1st line therapy for purulent cellulitis and wound infections

A

CA-MRSA, others

keflex + septra or clinda monotherpay

256
Q

likely bacterial cause and 1st line therapy for diabetic foot infection

A

mixed gram-positive, gram negative and anaerobes

amox-clav + septra - avoid abx for uninfected ulcers

257
Q

likely bacterial cause and 1st line therapy for any cat bite or infected dog bite

A

Pasteurella multiocida, others

amox-clav

258
Q

likely bacterial cause and 1st line therapy for human bite

A

oral anaerobes, orhters

amox-clav

259
Q

likely bacterial cause and 1st line therapy for erythema migrans

A 
Borrelia burgdoferi (lyme)
doxycycline
260
Q

likely bacterial cause and 1st line therapy for puncture wound through sole of shoe

A

Pseudomonas aeruginosa

cipro

261
Q

likely bacterial cause and 1st line therapy for buccal cellulitis

A

H. flu type b

ceftriaxone or amp-sulbactam

262
Q

likely bacterial cause and 1st line therapy for balanitis

A

Candidia albicans or group A strep

fluconazole plus pen/amox; consider diabetes

263
Q

likely bacterial cause and 1st line therapy for skin infection after liposuction

A

Peptostreptococcus (anaerobe), group A strep

amp-clav +/- septra

264
Q

likely bacterial cause and 1st line therapy after skin infection with saltwater exposure

A

Vibrio vulnificus

doxycycline

265
Q

likely bacterial cause and 1st line therapy for skin infection after freshwater exposure

A

Aeromonas species

cipro

266
Q

likely bacterial cause and 1st line therapy for skin infection if pt is butcher, clam handler or veterinarian

A

Erysipelothrix rhusiopathiae

amoxicillin

267
Q

likely bacterial cause and 1st line therapy for skin infection with black necrotic eschar with raised border and severe surrounding edema

A 
Bacillus anthracis (anthrax)
cipro
268
Q

risk factor for Vibrio vulnificus infection

A

patients with liver disease/ cirrhosis

269
Q

what is inducible resistance and when does it occur

A

CA-MRSA can be become resistant to clindamycin in single course of torment - about 2%

270
Q

abx effective against MRSA

A 
vancomycin
septra
clindamycin
doxycycline
linezolid
daptomycin
tigecycline
telavancin
271
Q

adjunctive measure to treat cellulitis

A

compression, elevation of extremity

NSAIDs

272
Q

when do abscesses need abx after I/D

A

severe or extensive disease, severe associated cellulitis, signs and symptoms of systemic illness, associated comorbidities or immunosuppression, extremes of age,, abscess in an area difficult to drain, septic phlebitis, poor response to I/D

273
Q

cause of impetigo

A

most S.aureus

some strep pyogenes

274
Q

tx impetigo

A

nonbullous -topical mupirocin

extensive dz. or bullous- clinda or keflex+septra

275
Q

mgmt of Bartholin cyst abscess

A

I/D, place Word catheter, test for GC/chlaydia

276
Q

tx hot tub folliculutis

A

antihistamines, cipro

277
Q

what causes hot tub folliculitis

A

Pseudomonas

278
Q

treatment of folliculitis

A

hot compresses, mupirocin

279
Q

AIDS-associated folliclutls - fungal or eosinophilic

A

isotretinoin topical or systemic antifungal

280
Q

tx of fungal folliculitis

A

topical anitfungal

281
Q

what is the distribution of hidradenitis supparativa

A

apocrine gland bearing skin - perineum, breasts, inner thighs, axilla

282
Q

clinical manifestations of skin infection associated with necrotizing infection

A

signs of systemic toxicity, abnormal vitals, severe pain or pain out of proportion to physical exam findings, altered mental status, rapidly advancing infection, crepitus, hemorrhage sloughing and blistering

283
Q

risk factors /inciting events for necrotizing skin/soft tissue infections

A

diabetes, vascular insufficiency, immunosuppression

inciting events: pentrating trauma, recent surgery, varicella infection, injection drug use, burns and childbirth

284
Q

what are the two types of necrotizing fasciitis

A

Type I - polymicrobial with aerobes and anaerobes

Type II- single organism, usually GAS

285
Q

tretment of suspected nec fasc

A

clindamycin, piptazo, Vanco

refer to surg ASAP

286
Q

how to differentiate staphylococcal scalded skin syndrome from staphylococcal toxic shock syndrome

A

mucosa spared in SSSS,

287
Q

components in MEDS (mortality in ED sepsis) score

A 
terminal illness (death within 30 days)
tachypnea/hypoxia
septic shock
platelet < 150
bands >5%
age > 65
pneumonia
NH resident
AMS
288
Q

DDX for sepsis

A 
dehydration
ARDS
anemia
ischemia
hypoxia
CHF
vasculitis
tox: poisoing, overdose, drug-induced
pancreatitis
hypothalamic injury
DIC
anaphylaxis
metabolic
hyperthyroidism
DKA
adrenal dysfunction: environment, burn, heat exhaustion/stroke
trauma: blood loss, cardiac contusion
NMS
289
Q

hows does lactate correlate with mortality in sepsis

A

0-2.5 - 5% mortality
2.5-4 - 9% mortality
> 4 - 28% mortality

290
Q

blood cultures in endocarditis ?

A

3 from 3 separate sites, 1 hour apart if possible

pt doesn’t have to be febrile, always bactermeic in IE

291
Q

recommendedventilation in ARDS

A

plateau pressures below 35

TV 6ml/kg

292
Q

dose of dobutamine infusion

A

5-15ug/kg/min

293
Q

dose of dopamine infusion

A

2-20ug/kg/min

294
Q

dose of epinephrine as vasopressor infusion

A

5-20ug/kg/min

295
Q

dose of NE as infusion

A

5-20ug/kg/min

296
Q

dose of phenylephrine infusion

A

2-20ug/kg/min

297
Q

how does NE work

A

mixed alpha and beta agonist, minimal B2 activity

increases CO and SVR

298
Q

how does dopamine work

A

precursor of epi and NE, acts on alpha, B1 and dopamine

side effects: persistent tachycardia, decreased PaO2, increased PA occlusion pressure

299
Q

how does phenylephrine work

A

pure alpha1 agonist, increases SVR
can cause reflex bradycardia/suppress CO

may be useful when significant tachycardia limits use of another agent

300
Q

how does epi work

A

mixed alpha and beta agonist
also associated with increased O2 consumption, increased splanchnic lactate concentrations, decreased splanchnic blood flow

301
Q

how does vasopressin work

A

naturally occurring peptide in hypothalamus - initially early surge followed by profound drop in sepsis, which is the though behind using it

302
Q

how does dobutamine work

A

mixed alpha and beta agonist, cardiac index is increased at expense of HR, decreased splanchnic blood flow
use in pt with depressed cardiac index and persistent hypo perfusion

303
Q

initial abx management in patient with sepsis unknown source - immunocompetent

A

ceftazidime + aminoglycoside or fluroquinolone

piptazo + aminogylcoside or fluoroquinolone

carbapenem + amino glycoside or fluoroquinolone

304
Q

initial abx management in patient with sepsis unknown source - suspected anaerobic infection

A

add metronidazole or clindamycin to piptazo + aminogylcoside or fluoroquinolone

305
Q

initial abx management in patient with sepsis unknown source - MRSA

A

add vancomycin to piptazo + aminogylcoside or fluoroquinolone

306
Q

initial abx management in patient with sepsis unknown source - splenectomy

A

ceftriaxone

307
Q

initial abx management in patient with sepsis unknown source - HIV infection

A

ticarcillin-clavulanature + tobramycin

308
Q

initial abx management in patient with sepsis - source pneumonia - immunocompetent

A

ceftriaxone + azithro or levo

309
Q

initial abx management in patient with sepsis- source pneumonia - Legionella suspected

A

azithromycin or fluoroquinolone

310
Q

initial abx management in patient with sepsis- source abdominal infection - immunocompetent

A

ampicillin + amino glycoside + metronidazole

311
Q

initial abx management in patient with sepsis- source -MDRO suspected

A

ticarcilin-clavulanate or carbapenem or piptazo+aminoglyocside

312
Q

initial abx management in patient with sepsis- source abdominal infection - urinary tract source

A

fluoroquinolone or ceftriaxone or ampicillin + aminogylcoside

313
Q

initial abx management in patient with sepsis- source nonnecrotizing fasciits

A

cefazolin or nafcillin

314
Q

initial abx management in patient with sepsis- source skin MRSA possible

A

vancomycin

315
Q

initial abx management in patient with sepsis- source necrotizing fasciitis

A

piptazo + aminoglycoside + clinda
or ticarcillin-clav
or carbapenem

316
Q

initial abx management in patient with sepsis- source IV catheter infection (remove cath) - outpatient acquired

A

ceftriaxone

317
Q

initial abx management in patient with sepsis- source IV catheter infection (remove cath) - MRSA suspected

A

ceftriaxone + vancomycin

318
Q

initial abx management in patient with sepsis- source IV catheter infection (remove cath) - fungal infection

A

amphotericin B

319
Q

initial abx management in patient with sepsis- source CSF - immunocompetent

A

ceftriaxone + vanco

320
Q

initial abx management in patient with sepsis- source CSF - older adult or immunocompromised

A

ceftriaxone + vancomycin + ampicillin

321
Q

initial abx management in patient with sepsis- IVDU - MRSA not suspected

A

nafcillin + aminoglycoside

322
Q

initial abx management in patient with sepsis- IVDU - MRSA suspected

A

vancomycin +aminoglycoside

323
Q

antibiotics that cover pseudomonas

A
  • Antipseudomonal cephalosporin (eg, ceftazidime, cefepime), or
  • Antipseudomonal carbapenem (eg, imipenem, meropenem), or
  • Antipseudomonal beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam, ticarcillin-clavulanate), or
  • Fluoroquinolone with good anti-pseudomonal activity (eg, ciprofloxacin)
  • Aminoglycoside (eg, gentamicin, amikacin), or
  • Monobactam (eg, aztreonam)
324
Q

what are the serious bacterial infections in paediatric fever referring to

A

UTI, bacteremia, meningitis, osteomyelitis, bacterial gastro, bacterial pneumonia, cellulitis, and septic arthritis

325
Q

causes of fever in 0-28 day old

A

bacterial: GBS, E.coli, Listeria, Chlamydia trachomatis, Neissseira gonorrhea, Strep pneumo
viral: HSV, varicella, enteroviruses, RSV, influenza
other: bundling, environmental

326
Q

cause of fever in 1-3 month old

A

bacterial: H. flu, Strep pneumo, Neisseria meningitis, E.coli
viral: varicella, enteroviruses, RSV, influenza
other: environmental

327
Q

cause of fever in 3-36months

A

bacterial: Strep pneumo, N. meningitidis, E.coli
viral: varicella, enteroviruses,RSV, influenza, mononucleosis, roseola, adenovirus, norwalk virus, coxsackievirus
other: leukemia, lymphoma, neuroblastoma, wilms tumor

328
Q

cause of fever in 3 years to adulthood

A

bacterial: Strep pneumo, N. meningitidis, E.coli, GAS
viral: varicella, enteroviruses, RSV, influenza, mononucleosis, roseola, adenovirus, norwalk virus
other: leukemia, lymphoma, neuroblastoma, Wilms’ tumor, juvenile rheumatoid arthritis

329
Q

what workup is needed after UTI is diagnosed in infant

A

ultrasound to look for hydronephrosis or renal/perirenal abscesses
VCUG only needed if abnormal US

330
Q

what peds groups are high risk for UTI

A

febrile girls under 24 months
uncircumcised boys under 12 months
circumcised boys under 6 months

331
Q

contraindications for lumbar puncture in peds

A

cellulitis over proposed site of puncture, CP instability, bleeding diathesis, or platelet count below 50, focal neuro deficits, signs of increased ICP including papilledema

332
Q

how to differentiate children with bacterial vs. aseptic meningitis

A

kids without any of hte following have less than 0.1% risk of bacterial meningitis: positive CSF gram stain, CSF ANC of 1000 cells/ml or more, CSF protein of at least 80mg/dL, peripheral blood ANC of 10,000 mL or more, and history of seizure before or at time of presentation

333
Q

when to get CXR in febrile child

A

hypoxemia, resp distress, tachypnea, or focal findings on lung exam

in high febrile kids with no source of infection - occult pnuemonia risk 9% - get CXR

334
Q

RSV with other SBI - what workup needed

A

in kids UTI risk 7% still with RSV positive - so get urine/culture

335
Q

amount of fluids to give kid with signs of shock (poor perfusion, hypotension, altered)

A

20cc/kg bolus of crystalloid, repeat up to 60cc/kg in 60 mins then think about pressors

336
Q

when to consider neonatal HSV

A

febrile neonate with maternal hx of genital herpes, or who appears ill with fever/seizure, has cutaneous vesicles on physical exam or evidence of transminitis or coagulopathy

337
Q

non infectious causes of septic appearing neonate

A

acute salt wasting crisis in CAH, undiagnosed ductal dependent CHD

338
Q

workup required for infant 0-28 days with fever

A

CBC, blood cultures, UA + culture, and lumbar puncture

CXR, stool prn

339
Q

treatment of neonate 0-28 days with fever

A

ampicillin (100mg/kg/day in q6h doses) plus gentamicin (5mg/kg/day in q8-12h doses) or ampicillin plus cefotaxime (150mg/kg/day in q8h doses)

add acyclovir (60mg/kg/day in q8h doses) if any one of following: ill-appearing, skin or mucosal lesions consistent with HSV, CSF pleocytosis, seizure, focal neuro sign, abnormal neuroimaging, respiratory distress, apnea or progressive pneumonitis, thrombocytopenia, elevated transaminases viral hpeattis or acute lvier fialure, coonjunctivitis, excessive tearing, orpainful eye symptoms

340
Q

treatment of infant 29-90 days old with fever

A

ampicillin 50-100mg/kg q6h plus cefotaxime 50mg/kg q8h

add vanco 10-20mg/kg IV q6-8h if concerned about Strep pneumonia resistant to pen/cephalosporins

341
Q

what is Rochester criteria

A

history: term infant, no perinatal abx, no underlying disease, not hospitalized longer than mother
physical: well-appearing, no ear/soft tissue/bone infection
labs: WBC 5-15, absolute bands < 1.5, urine <10 WBC/hpf, stool <5 WBC/hpf

342
Q

what workup needed according to Rochester criteria

A

minimum: CBC, cath UA and urine culture, then

blood culture if WBC abnormal
CXR if respiratory symptoms
LP if WBC abnormal

343
Q

what are the disposition options for infant 29-90 days old with fever

A

low risk infant- must have reliable caregiver

  • option 1: no abx and close f/u in 24 hours
  • option 2: ceftriaxone IV/IM after LP with close f/u in 24 hours

high risk infant: admit to hospital for ceftriaxone IV/IM

344
Q

what workup needed for Boston criteria

A

CBC, blood culture, LP, urine + culture, +/- CXR, ABX prior to D/C

345
Q

what workup needed for Philadelphia critera

A

CBC, blood culture, urine+ culture, LP, CXR, no ABX prior o DC`

346
Q

what work up needed for kids3 month - 3 years with fever

A

fever defined as above 39 in this age group
clinical judgment - toxic vs. nontoxic

nontoxic kids-
CBC, blood culture
urine /culture for girls under 24 mo, circumcised boys under6 mo, uncircumcised boys under 12 mo

+/- CXR, stool

abx if WBC above 15k

347
Q

what is rate of epilepsy after febrile seizure

A

gen pop epilepsy - 0.5-1%

after febrile seizure - 1-2%

348
Q

what is rate of recurrence after febrile seizure

A

33% will have another one, 75% of which in one year of time

if kid is under age 1, and temp of 38.5C - 35% chance of recurrent vs. 13% if temp 40C

349
Q

what classifies a simple febrile seizure

A

brief < 15 mins
non focal
single occurrenceli

350
Q

what kids need LP after febrile seizure

A

workup for source of fever
kid with signs of meningeal irritation after first febrile seizure
symptomatic kids that are incompletely immunized or have recevied prior abx therapy

351
Q

differential diagnosis for fever + petechiae

A 
meningococcemia
RMSF
DIC
pneumococcal bacteremia
Strep pyogenes infection
viral infections
ITP
HSP
leukemia

petechiae can be caused by vomitting or cough but are typically confined above the nipple line vs. SBI petechiae have any distribution

352
Q

what tests to order for kid with fever + petechiae

A

CBC, CRP, blood cultures -if abnormal admit and treat until blood cultures negative

if normal blood work and well appearing cacn send home without abx as long as close outpatient followup

353
Q

what abx are used in sickle cell kids

A

penicillin 125mg PO BID until 3 years old, then 250g BID until age 5 - can be DC in kids if not prior severe pneumococal infection or surgical splenectomy

354
Q

what bug often causes infection in Sickle cell kids

A

Salmonella - osteomyelitis, gastroenteritis

355
Q

what workup needed for Sickel cell kids with fever

A

CBC, reticulocyte count, ESR, blood culture,

356
Q

acute HIV infection clinical manifestatiosn

A

fever, pharyngitis, LAD 2-6 weeks after transmission

neuro: cases of GBS, encephalitis, and mono neuritis have occurred

357
Q

AIDS defining conditions

A

bacterial infections - multiple or recurrent
candidiasis of broncho, trachea, lungs, or esophagus
cervical cancer- invasive
coccidioidomycosis - disseminated or extrapulmonary
cryptococcus, extra pulmonary
cryptosporidiosis, chronic intestinal (>1mo duration)
CMV disease (other than liver, spleen or nodes), onset at age >1mo
CMV retinitis (w loss of vision)
HIV encephalopathy
HSV - chronic ulcers (>1 mo duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1mo)
histoplasmosis - disseminated or extrapulmonary
isosporiasis, chronic intestinal > 1mo duration
Burkitt’s lymphoma
Kaposi’s sarcoma
immunoblastic lymphoma
CNS lymphoma
MAC or mycobacterium kansasii, disseminated or extra pulmonary
TB
other mycobacterium
PCP
pneumonia, recurrent
progressive multifocal leukoencephalopathy
Salmonella septicemia
toxoplasmosis of brain
wasting syndrome attributed to HIV

358
Q

what abx prophylaxis regimens are usedin HIV

A

Pneumocystis jiroveci pneumonia (PCP) prophylaxis when CD4 < 200 with septra
toxoplasma gondii encephalitis prophylaxis if CD4 < 100, and IgG positive - with septra
MAC prophylaxis when CD4 under 50 with azithromycin

359
Q

common clinical presenation of Toxoplasma encephalitis in HIV pt

A

fever, h/a, AMS, focal neuro findings, seizure, evolves during days to weeks

360
Q

imaging/diagnostic test findings in Toxoplasma encephalitis in HIV

A 
ring enhancing CNS lesions
frequent edema nd mass effect
toxoplasma antibodies (reflects past exposure)
CD4 often <100cells/uL
PCR detection of Toxoplasma gondii
361
Q

common clinical presentation of primary CNS lymphoma (PCNSL) in HIV pt

A

confusion, lethargy, memory loss, hemiparesis, aphasia, seizure, fever, night sweats, weight loss, evolves during months

362
Q

imaging/diagnostic test findings in primary CNS lymphoma

A

CNS lesion or lesions (may have mass effect)
solitary lesions are often large (>4cm)
some ring enhancement may occur but less regular
PCR assay for EBV associated with PCNSL

363
Q

common clinical presentation of progressive multifocal leukoencephalopathy

A

progressive focal neuro deficits (during months), hemiparesis, visual field defects, ataxia, aphasia, cognitive impairment

364
Q

imaging/diagnostic test findings in PML

A

multifocal areas of demyelination primarily involving white matter
less frequent mass effect or ring-enhancing
PCR assay for DNA of JC virus

365
Q

common clinical presentation of HIV encephalopathy

A

memory and psychomotor speed impairment, depressive symptoms, movement disorders

366
Q

imaging/diagnostic test findings in HIV encephalopathy

A

multiple hyperintesine signals in T2-weighted images

often symmetric, not well demarcated

367
Q

common clinical presentation in CMV encephalitis

A

delirium, confusion, focal neuro abnormalities

368
Q

imaging/diagnostic tests in CMV encephalitis

A

MRI shows multifocal scattered micro nodules and ventriculoencephalitis
CD4 < 50 cells/uL

369
Q

common clinical presentation of brain abscess

A

focal neuro deficit, h/a, bacteremia or craniofacial infection

370
Q

imaging and diagnostic tests in brain abscess

A

often concomitant evidence of disseminated infection

focal ring-enhancing lesion

371
Q

common clinical manifestation of tuberculoma

A

focal neuro deficit, h/a, tuberculous infection

372
Q

imaging/diagnostic tests in tuberculoma

A

single or multiple mass lesions

can be manifested as focal lesion or meningeal infection

373
Q

dermatologic and mucocutaneous manifestations of WHO Stage 4 HIV disease

A 
chronic HSV ulcers
extrapulmonary tuberculosis
Kaposi's sarcoma
extrapulmonary cryptococcosis
disseminated mycosis
atypical disseminated leishmaniasis
disseminated nontuberculous mycobacterial infection
extra pulmonary cryptococcosis including meningitis
374
Q

what renal manifestations of HIV occur

A

HIVAN -HIV associated nephropathy - FSGS

vs. HIV immune complex kidney disease

375
Q

DDX of respiratory infections in HIV patients by CD4 counts

A

any CD4- acute bronchitis, bacterial pneumonia, tb

> 500 CD4 - bacterial pneumonia
early HIV infection- PCP, HHV-8 related Kaposi’s sarcoma
200-500- bacterila pneumonia, PCP

< 200, bacterial pneumonia
AIDS - PCP, histoplasma capsulation or Coccidiodes immitis pneumonia, Cryptococcus neoformans pneumonia, extra pulmonary or disseminated tb

<50 CD4- bacterial pneumonia

advanced HIV infection - PCP, toxoplasma gondii pneumonia, pulmonary Kaposi’s sarcoma, histoplasma / Coccidiodes, MAC

376
Q

clinical manifestations/diagnostic labs of bacterial pneumonia in HIV

A

acute onset, <1 week, cough, purulent sputum ,fevers, chills, rigors
elevated WBC, CXR- focal consolidation, CD4 variable

377
Q

treatment of bacterial pneumonia in HIV

A

abx against Strep pneumo and H. flu, also cover atypical pathogens
ie. ceftriaxone, azitho.

378
Q

clinical manifestations/diagnostic labs in PCP

A

gradual onset > 2 week, non productive cough, dyspnea, fever

exercise-induced hypoxia, elevated LDH, CXR- bilateral reticular or interstitial pattern, CT -ground glass opacity 56%, CD4 < 200

379
Q

treatment of PCP

A

septra x 21 days, if PaO2 < 70 on r/a, or A-a gradient > 35, give prednisone, taper over 21 days

380
Q

clinical manifestations/diagnostic labs in TB in HIV pt

A

gradual onset > 2 weeks, cough, fever, night sweats, weight loss, LAD

CXR- alveolar pattern +/- cavitation, military pattern, nodules, adenopathy, effusions

CD4 variable

381
Q

clinical manifestations/diagnostic labs of Kaposi’s sarcoma

A

gradual onset >2-4 weeks, cough, dyspnea, fever

CXR- bilateral perihilar nodules, opacities, effusions, adenopathy

CD4 <200

382
Q

treatment of Kaposi’s sarcoma

A

cryotherapy, radiation therapy
infrared coagulation
sclerosing agents, intralesional vinblastine
systemic chemo

383
Q

treatment of esophageal candidiasis

A

fluconazole po - should have clinical response in 5-7 days

if no response - endoscopy for biopsy as ddx includes candidiasis, HSV, CMV, deep apthous ulcers

384
Q

cutaneous findings highly suggestive of HIV disease

A 
any WHO criteria for stage 4 disease
facial molluscum in an adult
proximal subungal onychomycosis
herpes zoster scarring
oral hairy leukoplakia
bacillary angiomatosis
widespread dermatophytosis
severe seborrheic dermatitis

PGY1 - Fever Block (1 decks)

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