Fever Flashcards
1
Q
what conditions are classified as immunocompromised
A
cancer, organ transplantation, diabetes, renal failure, cirrhosis, asplenism, HIV, etc.
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
3
Q
what type of bacteria does reticuloendothelial system target
A
encapsulated organisms- pneumococci, meningococci, and H. flu
4
Q
components of adaptive immunity
A
humoral immuniry: antibodies, Igs, complement
cell mediated immunity: T lymphocytes, NK cells, and mononuclear phagocytes
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
6
Q
what immune deficiency should be tested for in people with meningococcemia
A
complement deficiency - may benefit from immunization
7
Q
what bacteria are people with complement deficiency susceptible to
A
S. pneumoniae, H. flu, Neisseria meningitidis and Neisseria gonorrhea
8
Q
what medication condition is associated with complement defieciyn
A
SLE
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
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
11
Q
bacteria people with splenectomy or asplenia susceptible to
A
S. pneumo H. flu N. meningitidis Capnocytophaga canimorsus Bordetella holmesii
parasites: Babesia
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
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
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
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%
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
17
Q
in patient with neutropenia, ulcerative lesions in the mouth suggestive of
A
viridans streptococci, HSV, Candida, anaerobes
18
Q
in patient with neutropenia, necrotizing skin lesions
A
Pseudomonas aeruginosa, Aeromonas hydrophily, Aspergillus, Mucor
19
Q
in patient with neutropenia, nontender, subcutaneous nodules
A
nocardia, cryptococcus
20
Q
in patient with neutropenia, nontender pink skin papules
A
candida
21
Q
in patient with neutropenia, black eschar of nose or palate
A
aspergillus, mucor
22
Q
in patient with neutropenia, generalized macular red rash
A
viridans streptococci
23
Q
in patient with neutropenia, RLQ abdo pain, tenderness, distension, bloody diarrhea
A
typhlitis (neutropenic enterocolitis) caused by pseudomonas, e coli, clostridium septicum
24
Q
in patient with neutropenia, perineal pain and tenderness without inflammation or abscess
A
GN bacilli, anaerobes
25
in patient with neutropenia, redness or pain at vascular catheter sits
coagulase negative staphylococci, corynebacterium, bacillus species
26
what factors make pt with febrile neutropenia high risk for complications
patients with hypotension, pneumonia, new onset abdominal pain, neuro changes, other acute organ dysfunction (especially renal or hepatic disease, active COPD)
27
how to calculate MASCC score in febrile neutropenia (multinational association for supportive care in cancer)
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
28
what empiric IV abx to use in febrile neutropenia
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
29
what abx to use for febrile neutropenic in pen-allergic patietns
minor allergy- cefepime, meropenem, or imipenem-cilastatin
| severe allergy: consult ID, aztreonam and Vanco +/- clinda or flagyl
30
when to use vancomycin empirically in febrile neutropenia
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
31
when to consider urgent CT scanning in febrile neutropenia
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
32
what patients make up high risk group of febrile neutropenia
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
33
considerations for outpatient management of febrile neutropenia
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
34
outpatient abx used in febrile neutropenia
cipro or levofloxacin PLUS clavulin or clinda (in pen allergy patients)
35
DDX of fever in non-neutropenic patents with solid organ cancer
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)
36
treatment of suspected meningitis in immunocompromised host - LIsteria
ampicillin and gentamicin
| septra in pen allergic
37
hyponatremia + pneumonia symptoms in immunocompromised patient is
Legionella
38
treatment of legionella infection in immunocompromised patietns
reso fluoroquinolone or azithromycin
39
clinical manifestations of nocardia
subacute pneumonia with nodular infiltrates
cellulitis
subcutanoeus abscesses
meningitis brain abscess
40
treatment of nocardia
sulfonamides + other agents
41
presentation of Stronglyloides
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
42
treatment of sStronglyoides
oral ivermectin
43
DDX for pulmonary infiltrates - diffuse/ bilateral in immunocompromised patietn
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)
44
DDX for pulmonary infiltrates- focal or patchy in immunocompromised patients
```
bacterial pneumonia including legionella
fungi: invasive pulmonary aspergillosis, zygomycosis, fusarium, pseudallsecheria
tb
non-tb mycoabcteria
nocardiosis
PE
```
45
factors contributing to diabetic increased risk of infection
defects in immune function
excess glucose for fungal/bacterial growth
vascular insufficiency related to microangiopathy and atherosclerosis
sensory neuropathy leads to wound neglect
46
infections more commonly seen in diabetics
```
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
```
47
factors contributing to immunocompromised state in alcoholism and cirrhosis
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
48
what infections are cirrhosis patients more susceptible to
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
49
factors contributing to immunocompromised state in renal failure
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
50
common infections seen in renal failure
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
51
what conditions cause functional asplenism
sickle cell disease, ulcerative colitis, celiac disease, sarcoidosis, amyloidosis, RA and SLE
52
what can be seen on peripheral smear that may indicate functional hyposplenism
Howell-Joly bodies in RBCs
53
complications of prolonged steroid use
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
54
patients taking biologics at risk for what infections
reactivation of late tb, non-tb mycobacterial infection, histoplasmosis, and coccidiomycosis
cryptococcosis, listeriosis, legionellosis, salmonellosis, aspergillosis, candidiasis and pneumocystosis
55
DDX of fever -infectious
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
56
DDX of fever- noninfectious
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
57
considerations when fever associated wit bradycardia
pt on beta blockers etc.
factitious or drug related fevers
typhoid fever, brucellosis, leptospirosis
rheumatic fever, lyme disease, viral myocarditis, endocarditis
58
suspect case of diphtheria
pharyngitis, nasopharyngitis, tonsillitis, larnygitis, tracheaitis, absent or low grade fever
greyish adherent pseudo-membrane present
membrane bleeds, if manipulated or dislodged
59
probable case of diphtheria
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
60
lab confirmed case of diphtheria needs
positive culture of Corynebacterium diphtheria or Corynebacterium ulcers AND
positive Elek test or PCR for tax gene (positive for subunit A and B)
61
DDX of respiratory diphtheria
```
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
```
62
bacteria causing diphtheria
Corynebacterium diptheriae
63
what category of bacteria is diphtheria
gram positive bacillus
| unencapsulated
64
pathophysiology of diptheria
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
65
emergent complications of diphtheria
airway obstruction, CHF, cardiac conduction abnormalities and muscle paralysis
66
diagnostic w/u of suspected diphtheria
notify lab because routine cultures don't ID organism
Elek test -tests for toxin A
PCR - used to detect toxin structural gene
67
mgmt of diphtheria
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
68
how is diphteria transmitted
resp droplets or direct contact with secretions, skin lesions, fomites on food
69
how is pertussis transmitted
droplet
70
bacteria that causes pertussis
Bordetella pertussis
71
pathophysiology of pertussis
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)
72
clinical case of pertussis defition
cough and illness for more than 2 weeks with no apparent other cause plus one of: paroxysms of coughing, inspiratory whoop, post-jussive emesis
73
probably case of pertussis
clinical case defn
not lab confirmed
not epidemiologically linked to a lab confirmed case
74
confirmed case of pertussis
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
75
clinical course of pertussis
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
76
complications of pertussis
```
periorbital edema
subconjunctival hemorrhage
petechiae
epistaxis
hemoptysis
subcutaneous emphysema
pneumothorax
pneumomediastinum
diaphragmatic rupture
umbilical and inguinal hernias
rectal prolapse
pneumonia
```
77
diagnostic w/u of pertussis
NP aspirate or swab for culture and PCR
78
DDX of pertussis
acute viral URTI, pneumonia, bronchiolitis, cystic fibrosis, tb, AECOPD, FB aspiration, leukemia (marked leukocytosis)
79
treatment of pertussis
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
80
alternative to treat pertussis in macrolide allergic patietn
septra
81
what kind of bacteria is pertussis
gram negative coccobacilli - aerobic
82
what kind of bacteria is tetanus
spore-forming, motile, rod-shaped obligated gram positive anaerobic bacillus
83
what is the bacteria name for tetanus
Clostridium tetani
84
pathophysiology of tetanus
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
85
what are the 4 types of clinical tetanus
generalized tetanus
localized tetanus
cephalic tetanus
neonatal tetanus
86
clinical manifestations of generalized tetanus
trismus, rictus sardonicus, irritability, weakness, myalgies, muscle cramps, dysphagia, hydrophobia, and drooling
autonomic dysfunction causes death - tachycardia, htn, hyperpyrexia, cardiac dysrhythmias, and diaphoresis
87
clinical manifestations localized tetanus
persistent muscle spasms to site of injury
88
clinical manifestations of cephalic tetanus
rare variant of localized tetanus resulting in CN palsies and muscle spasms
89
clinical manifestations of neonatal tetanus
generalized tetanus in newborn due to inadequate maternal immunization and contaminated material used to cut/dress umbilical cord
90
complications of tetanus
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
91
diagnostic w/u in tetatnus
cultures not helpful
check calcium to r/o hypocalcemia
spatula test: tough oropharynx with tongue blade- positive = reflex masseter muscle spasm
92
DDX for tetanus
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
```
93
treatment of tetanus
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
94
contraindication to Tdap vaccine
hx of neurologic or severe hypersensivity reaction to previous dose
95
what wounds need Tdap and TIG in ED
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
96
what types of wounds are high risk for tetanus
> 6 hours old, > 1cm deep, contaminated, stellate, denervated, ischemic, infection
97
what is the bacteria that causes botulism
Clostridium botulinum
98
what are the five types of botulism
food-borne botulism, infant botulism, wound botulism, unclassified botulism and inadvertent botulism
99
what kind of bacteria is C. botulinum
anaerobic, gram positive, rod-shaped organism
100
clinical manifestations of food-borne botulism
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
101
clinical presentation of infant botulism
constipation, poor feeding, weak cry, loss of head control, hypotonia, CN palsies, ocular invovlement
102
differences in wound botulism
GI symptoms absent
incubation period longer 4-14 days
toxin produced by spores in wound
103
diagnostic tests in botulism
diagnosis confirmed by detection of toxin in blood
notify public health
serial measurements of patients vital capacity
104
DDX botulism
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
105
DDX infant botulism
```
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
```
106
treatment of botulism
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
107
what infections does Strep pneumonia cause
OM, pneumonia, meningitis,
less common: endocarditis, septic arthritis, and peritonitis
108
what populations are at higher risk of pneumococcemia (Strep pneumoniae in the blood)
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
109
what kind of bacteria is Strep pneumo
encapsulated gram positive facilitate anaerobe
110
what lab findings correlate with more serious disease in pneumococcemia
normal or low WBC count
| hypoxemia and hypercarbia
111
treatment of Strep pneumo positive blood cultures
penicillin G 2-4 million units IV q4h
| ceftriaxone 2g IV daily
112
treatment of pneumococcemia in penicillin allergic or cephalosporin allergic patients
vancomycin, imipenem, chloramphenicol
113
what is the mortality rate of meningococcemia
40%
70% if septicemia without meningitis
less than 10% if only meningitis
114
bacteria that causes meningococcemia
Neisseria meningitidis
115
what kind of bacteria is N.meningitidis
aerobic gram negative diplococci
| encapsulated
116
what are the 5 patterns of presentation of N.meningitidis infection
```
occult bacteremia
meningococcal meningitis
meningococcal septicaemia
fever and non blanching rash
chronic meningococcemia
```
117
what is the rash seen in meningococcemia
purpura fulminans
118
complications of meningococcemia
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
119
poor prognostic indicators in meningococcal disease
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
120
DDX of meningococcal disease
```
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
```
121
empiric therapy for meningitis
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
122
clinical case definition of toxic shock syndrome
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
123
probable vs confirmed case of toxic shock
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
124
case definition of streptococcal toxic shock syndrome
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
125
what bacteria can cause toxic shock
staph aureus
| group A streptococcus
126
risk factors for toxic shock syndrome
```
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
```
127
what are some differences with staphylococcal and streptococcal toxic shock syndrome
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
128
clinical manifestations that prompt consideration of toxic shock syndrome
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
129
complications of TSS
ARDS, shock, gangrene, DIC, neuropsych problems, renal failure irreversible in 10%
rhabdo, seizures, pancreatitis, pericarditis, cardiomyopathy
menstrual form may reoccur
130
lab abnormalities in TSS
```
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
```
131
DDX for toxic shock syndrome
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
132
treatment of toxic shock syndrome
```
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
```
133
4 categories of transplant organ complications
anatomy
rejection
infection
drug toxicity
134
what are the subtypes of anatomic complications of organ transplant
```
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
```
135
three phases of organ rejection / what occurs at each
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
136
infectious pathogens in transplant patients 0-1 months post-transplantation (early)
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
137
infectious pathogens in transplant patients 1-6 months post-transplant (intermediate)
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
138
infectious pathogens in transplant patients more than 6 months post-transplant (late)
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
139
presentation of CMV infection in transplant patients
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
140
effects of CMV on transplant patients unrelated to infection
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
141
how to treat CMV
IV ganciclovir
often patients are on prophylaxis of valganciclovir for 3-6 months
142
effects of EBV infection on transplant patients
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
143
treatment of post-transplant lymphproliferative disorder
reduction in immunosuppression, monoclonal B-cell antibody therapy (rituximab), cytotoxic chemotherapy
144
how does BK virus present in post-transplant patients
resides in kidneys, can progress from viruria to viremia to nephropathy, graft dysfunction and graft loss in renal transplants
145
how does Listeria infection present
immunocompetent: fever, abode pain, diarrhea
immunocompromised: bacteremia, meningoencephalitis
146
treatment of Listeria in solid organ transplant patients
high dose pen or amp + aminoglycoside
147
which organ transplant patients have highest incidence of Nocardia
heart/lung
148
presentaiton of Nocardia
fever, cough, SOB, hemoptysis, but can progress to disseminated infection with CNS abscess, skin and soft tissue abscess
149
what does Nocardia look like on culture
classic beading and branching gram positive bacilli
150
what is first line treatment for Nocardia
septra
151
what are secondline/other optinos to treat Nocardia
minocycline, amikacin, imipenem, cefotaxime, ceftriaxone
152
how does invasive candidemia in transplant patients present
fungemia, UTI, peritonitis, pleural empyema, IAI
153
how does aspergillosis present in transplant patients
pulmonary nodules w/ or w/o cavitation, may disseminate to any organ system including CNS
154
treatment for aspergillosis
amphotericin B, azoles or echinocandins
155
what are examples of endemic mycoses
histoplasmosis, blastomycosis, and coccidiomycosis
156
how to treat endemic mycoses in organ transplant pt
amphotericin B
157
treatment of Pneumocystis jiroveci
septra + steroids depending on degree of hypoxia
158
presentation of toxoplasmosis
usually reactivation of latent infection - causes pneumonia, HSM, myocarditis, brain abscess, or diffuse encephalitis
159
treatment of toxoplasmosis
IV sulfdiazine and pyrimethamine
septra has been used to treat toxo in AIDS pts successfully
160
what is the presentatino of cryptococcus neoformans in solid organ transplant patients
meningoencephaltiis
| 1/3 have lesions on imaging
161
how to diagnose cryptococcus neoformans
LP or serum cryptococcal antigen
| amphotericin B and flucytosine
162
what happens when transplant patients develop primary varicella
life threatening with pneumonia, pancreatitis, hepatitis, encephalitis, and DIC
163
treatment of primary varicella in transplant pt
varicella zoster Ig
| IV acyclovir
164
presentation of Stronglyoides stercoralis in transplant patients
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
treatment of disseminated Strongyloides
thiabendazole
166
what are typical prophylaxis abx. post transplant
septra (for pneumocystis, but also covers Nocardia, Listeria, and UTIs)
fungal prophylaxis with fluconazole
CMV prophylaxis with ganciclovir
167
3 categories of patients with infections from 1-6 months post transplant
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
toxicity associated with cyclosporine
nephrotoxicity, hypertension
tremor, hyperkalemia, hyperuricemia, glucose intolerance, hyperlipidemia, hirsutism, GI upset, gingival hyperplasia
169
toxicity associated with tacrolimus
nephrotoxicity, neurotoxicity (tremor, h/a)
hypertension, hyperlipidemida, glucose intolerance, GI upset, hypokalemia, alopecia
170
toxicity associated with sirolimus
nephrotoxicity, impaired wound healing, pneumonitis
hyperlipidemia, edema, GI upset, anemia, stomatitis
171
toxicity associated with azathioprine and mycophenolate mofetil
hepatotoxicity, bone marrow depression, GI upset
172
toxicity associated with prednisone
glucose intolerance, osteoporosis, GI bleeding, myopathy, cataracts
173
adverse effects on induction agents- monoclonal antibodies ie. basiliximab, muromonab-CD3 (OKT3)
increased risk opportunistic infections, PTLD
pulmonary edema in overhydrated oliguric patients
aseptic meningitis
174
which drugs interact with cyclosporine, tacroliums and sirloumus by decreasing half-life and immunosuppressive effect, and cause potential for acute rejection
carbamazepine, nafcillin, phenobarbital, phenytoin, rifampin
175
which drugs interact with cyclosporine, tacroliums and sirloumus by increasing the half-life and potential drug toxicity or immunosuppression
colchicine, diltiazem, fluconazole, fluorquinolones, ketoconazole, macrolides, oral contraceptives, verapamil
176
which drugs interact with cyclosporine, tacroliums and sirloumus to cause increased nephrotoxicty
aminoglycosides, amphotericin B, cimetidine, NSAIDs, sulfur
177
differences in cardiac physiology post heart transplant
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
ECG changes after heart transplant
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
what to do with pt with heart transplant with symptomatic bradycarda
admit, may need pacemaker
180
what to do with pt with heart transplant with new tachyarrhythmias
concerning for rejection or CAV ( cardiac allograft vasculopathy)
181
how does acute rejection present in cardiac transplan tpatients
fatigue, fever, dyspnea (most sens), signs of HF, hypotension
pericardial effusions, atrial arrhythmias.
182
w/u of heart transplant pt when considering rejection
ECG, CBC, lytes, Cr, troponin, cultures, CXR, echo
183
what is the gold standard for diagnosing acute rejection in heart transplant
endomyocaridla biopsy
184
treatment of acute rejection in heart transplants
IV corticosteroids with or without OKT3 or ATG
| if Ab mediated rejection, plasmapheresis, IVIG with rituximab
185
how to diagnose chronic allograft vasculopahty )CAV)
angio - diffuse concentric narrowing coronary arteries (vs. eccentric focal narrowing in classic cardiac atherosclerosis)
186
most common in diction for liver transplant
HCV infection
187
what is the most common vascular complication of liver transplant
hepatic artery thrombosis
188
presentation of hepatic artery thrombosis
in 1st month post liver transplant- jaundice, RUQ pain, fever, elevated liver enzymes and bili
189
how to diagnosis hepatic artery thrombosi
Doppler ultrasound, helical CT scan or arteriography
190
anatomic complications of liver transplant
hepatic artery thrombosis
hepatic artery rupture: usually caused by bacterial arteritis
biliary complicatiosn: leask, obstruction, stricture
191
how to diagnose rejection of liver transplant
biopsy
192
what infections are common in liver transplant patients
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
what is anatomic location of transplanted kidney usually
iliac fossa
194
clinical manifestations of kidney graft rejection
fever, hypertension, edema, tenderness over the allograft, and decreased urine output, subtle rise in Cr
195
anatomic complications in lung transplant
PTX, hemothorax, pleural effusion, empyema, persist air leak
196
clinical manifestations of acute rejection in lung transplant
fews days to several years after transplnt
cough, dyspnea, fatigue, fever
rales and rhonchi heard with deterioration in oxygenation and pulmonary function
197
what is the most common opportunistic infection in lung transplant and when is highest risk
3 weeks to 4 months
| CMV pneumonia
198
howt o differentiate between rejection and CMV infection in lung transplant
transbronchial biopsy and culture
199
difference n organ transplant patients in trauma
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
questions included in comprehensive travel history
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
what are the species responsible for causing human malaria
Plasmodium falciparum, Plasmodium vivax, Plasmodiumovale, Plasmodium malariae, Plasmodium knowlesi
202
clinical manifestations of malaria
cyclic or irregular fevers
| anemia, h/a, nausea, chills, lethargy, abdo pain, upper resp complaints
203
what is the difference between P. falciparum aand other malari
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
what is the gold standard for diagnosis of malaria
light microscopic examination of thick and thin blood films
205
treatment of malaria
in chloroquine-resistant regions: doxycycline or clindamycin, proguanil-atovaquone
for complicated falciparum infection: IV quinine or quinidine used
206
side effects of rapid infusion of quinine
profound hypoglycaemia, hyponatremia and coma vigil (neuroimpairment due to high rates of parasite destruction)
207
malaria treatment to prevent recrudescent disease in ovale, vivax
primaquine
208
who is primaquine contraindicated in
G6PD deficiency
209
what are the clinical manifestations of babesiosis
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
what organism causes babesiosis
Babesia microti, gibsoni, and divergens
| malaria-like illness due to protozoan similar in structure and life cycle to plasmodia
211
what areas of travel are at risk for babesiosis
NE US, NW US, Europe
| endemic to Long Island, Cape Cod, Block Island
212
how to diagnosis babesiosis
multiple thick and thin smears
213
treatment of babesiosis
atovaquone plus azithromycin or for severe illness quinine plus clindamycin
214
how is babesiosis transmitted
deer tick Ixodes dammini
215
parasitic illnesses that cause significant fever
```
malaria
babesiosis
schistosomiasis
leishmaniasis
toxoplasmosis
amebic liver abscess
African and American trypanosomiasis
fascioliasis
```
216
what is katayama fever
initial phase of schistosomiasis
spiking fevers, diaphoresis, wheezing and cough - eosinophilia common
exposure to fresh water in endemic areas
217
what is fascioliasis
liver fluke Fasciola hepatica - sheep/cattle exposure- metacercariae ingested in watercress
within 6 weeks, its get RUQ pain, fever, eosinophilia
218
what is American trypanosomiasis (Chagas disease)
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
what is leishmaniasis
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
how does Entamoeba histolytic present
amebic liver abscess
| high fevers, RUQ pain, elevated WBC count
221
what parasitic infections are neurotrophic and cause neurologic symptoms
malaria
cysticercosis
echinococcosis
trypanosomiasis
222
examples of anthelmintic drugs
thiabendazole
mebendazole
albendazole
ivermectin
223
examples of trematodicide drugs
praziquantel use for flukes/schistosomes
224
example of antiprotozoal drugs
metronidazole
tinidazole
niridazole
225
example of antimalarial drug
chloroquine
mefloquine
proguanil-atovaquone
doxycycline
226
what bug causes cysticercosis and where do you get it
Taenia sodium - tropical areas - undercooked pork contains larval cysts
227
parasitemias that present with anemia
malaria
whipworm and hookworm
tapeworm
228
parasxitemias that present with peripheral edema
filarial infection or parasite-induced malnutrition and hypoproteinemia
elephantiasis or filariasis - Wuchereria bancrofti or Brugia malayi
229
parasites that present with derm symptoms
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
parasites that present with visual symtpoms
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
parasites that present with pulmonary symptoms
```
P. falciparum
E. histolytica
Pneumocystis penumonia
Strongyloides
W. bancrofti, B.malayi
E. granulosus - pulmonary hydatid cyst disease
```
232
parasites with CV symptoms
Chagas' disease- Trypanosoma cruzi - in reduviid bug - usually bites near eye and forms chagoma - can lead to CHF
233
parasites that cause diarrha
```
Cryptosporidium pavum
Cyclospora cayetanensis
Entamoeba histolytica
Balantidium coli
Giardia lamblia
S. stercoralis
Capillaria philipinensis
T. trichura
Schistosome
```
234
which micro-organisms cause infective endocarditis
```
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
what are HACEK organisms
```
Haemophilus spp.
Aggregatibacter actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodes
Kingella kingae
```
236
symptoms associated with infective endocarditis
intermittent fever
malaise
```
weakness
myalgia
back pain
dyspnea
CP
cough
headaches
anorexia
```
"classic" triad: fever, anemia, heart murmur
237
what diagnosis to think about stroke like symptoms and fever
endocarditis with septic emboli causing stroke like symptoms
238
physical exam findings in endocarditis
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
what are the major clinical criteria in Duke criteria
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
what are the minor clinical criteria in Duke criteria
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
how does duke criteria classify definite endocarditsi
2 major
1 major + 3 minor
5 minor
242
how does duke criteria classify possible endocarditis
1 major and 1-2 minor
| 3 minor
243
how does duke criteria classify rejected endocarditis
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
empiric abx for endocarditis in the ED
ceftriaxone 2g + 15mg/kg vancomycin
245
which endocarditis patients are appropriate for outpatient mgmt
HD stable, compliant, and capable of managing technical aspects of IV therpay
246
conditions requiring surgical therapy for infective endocarditis
```
infective endocarditis with acute heart failure
fungal endocarditis
periannular extension of infection
recurrent emboli
large mobile vegetations
persistent bacteremia
```
247
which conditions are high risk for bacterial endocarditis and should have prophylaxis prior to certain procedures
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
jones criteria for diagnosis of acute rheumatic fever
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
what valve is most commonly affected in rheumatic fever
mitral - causing MR
250
treatment of acute rheumatic fever
penicillin 250mg kids or 500mg adults B-TID x 10 days
| asa for arthritis
251
when should you culture an asbcess
complicated purulent infections, like surgical wound infections and abscesses in immunocompromised patientss
252
when to get blood cultures in skin infections
deep tissue infection or systemic infection likely ie. septic shock, necrotizing infections, immunocompromised, multifocal infections suggesting ghemoatogenous seeding and infections complicating lymphedema
253
likely bacterial cause and 1st line therapy for uncomplicated cutaneous abscess
CA-MRSA, others
| I/D without abx.
254
likely bacterial cause and 1st line therapy for non purulent bacterial skin infections
various strep, staph aureus
| keflex or clindamycin
255
likely bacterial cause and 1st line therapy for purulent cellulitis and wound infections
CA-MRSA, others
| keflex + septra or clinda monotherpay
256
likely bacterial cause and 1st line therapy for diabetic foot infection
mixed gram-positive, gram negative and anaerobes
| amox-clav + septra - avoid abx for uninfected ulcers
257
likely bacterial cause and 1st line therapy for any cat bite or infected dog bite
Pasteurella multiocida, others
| amox-clav
258
likely bacterial cause and 1st line therapy for human bite
oral anaerobes, orhters
| amox-clav
259
likely bacterial cause and 1st line therapy for erythema migrans
```
Borrelia burgdoferi (lyme)
doxycycline
```
260
likely bacterial cause and 1st line therapy for puncture wound through sole of shoe
Pseudomonas aeruginosa
| cipro
261
likely bacterial cause and 1st line therapy for buccal cellulitis
H. flu type b
| ceftriaxone or amp-sulbactam
262
likely bacterial cause and 1st line therapy for balanitis
Candidia albicans or group A strep
| fluconazole plus pen/amox; consider diabetes
263
likely bacterial cause and 1st line therapy for skin infection after liposuction
Peptostreptococcus (anaerobe), group A strep
| amp-clav +/- septra
264
likely bacterial cause and 1st line therapy after skin infection with saltwater exposure
Vibrio vulnificus
| doxycycline
265
likely bacterial cause and 1st line therapy for skin infection after freshwater exposure
Aeromonas species
| cipro
266
likely bacterial cause and 1st line therapy for skin infection if pt is butcher, clam handler or veterinarian
Erysipelothrix rhusiopathiae
| amoxicillin
267
likely bacterial cause and 1st line therapy for skin infection with black necrotic eschar with raised border and severe surrounding edema
```
Bacillus anthracis (anthrax)
cipro
```
268
risk factor for Vibrio vulnificus infection
patients with liver disease/ cirrhosis
269
what is inducible resistance and when does it occur
CA-MRSA can be become resistant to clindamycin in single course of torment - about 2%
270
abx effective against MRSA
```
vancomycin
septra
clindamycin
doxycycline
linezolid
daptomycin
tigecycline
telavancin
```
271
adjunctive measure to treat cellulitis
compression, elevation of extremity
| NSAIDs
272
when do abscesses need abx after I/D
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
cause of impetigo
most S.aureus
| some strep pyogenes
274
tx impetigo
nonbullous -topical mupirocin
| extensive dz. or bullous- clinda or keflex+septra
275
mgmt of Bartholin cyst abscess
I/D, place Word catheter, test for GC/chlaydia
276
tx hot tub folliculutis
antihistamines, cipro
277
what causes hot tub folliculitis
Pseudomonas
278
treatment of folliculitis
hot compresses, mupirocin
279
AIDS-associated folliclutls - fungal or eosinophilic
isotretinoin topical or systemic antifungal
280
tx of fungal folliculitis
topical anitfungal
281
what is the distribution of hidradenitis supparativa
apocrine gland bearing skin - perineum, breasts, inner thighs, axilla
282
clinical manifestations of skin infection associated with necrotizing infection
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
risk factors /inciting events for necrotizing skin/soft tissue infections
diabetes, vascular insufficiency, immunosuppression
| inciting events: pentrating trauma, recent surgery, varicella infection, injection drug use, burns and childbirth
284
what are the two types of necrotizing fasciitis
Type I - polymicrobial with aerobes and anaerobes
| Type II- single organism, usually GAS
285
tretment of suspected nec fasc
clindamycin, piptazo, Vanco
| refer to surg ASAP
286
how to differentiate staphylococcal scalded skin syndrome from staphylococcal toxic shock syndrome
mucosa spared in SSSS,
287
components in MEDS (mortality in ED sepsis) score
```
terminal illness (death within 30 days)
tachypnea/hypoxia
septic shock
platelet < 150
bands >5%
age > 65
pneumonia
NH resident
AMS
```
288
DDX for sepsis
```
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
hows does lactate correlate with mortality in sepsis
0-2.5 - 5% mortality
2.5-4 - 9% mortality
> 4 - 28% mortality
290
blood cultures in endocarditis ?
3 from 3 separate sites, 1 hour apart if possible
| pt doesn't have to be febrile, always bactermeic in IE
291
recommendedventilation in ARDS
plateau pressures below 35
| TV 6ml/kg
292
dose of dobutamine infusion
5-15ug/kg/min
293
dose of dopamine infusion
2-20ug/kg/min
294
dose of epinephrine as vasopressor infusion
5-20ug/kg/min
295
dose of NE as infusion
5-20ug/kg/min
296
dose of phenylephrine infusion
2-20ug/kg/min
297
how does NE work
mixed alpha and beta agonist, minimal B2 activity
| increases CO and SVR
298
how does dopamine work
precursor of epi and NE, acts on alpha, B1 and dopamine
| side effects: persistent tachycardia, decreased PaO2, increased PA occlusion pressure
299
how does phenylephrine work
pure alpha1 agonist, increases SVR
can cause reflex bradycardia/suppress CO
may be useful when significant tachycardia limits use of another agent
300
how does epi work
mixed alpha and beta agonist
also associated with increased O2 consumption, increased splanchnic lactate concentrations, decreased splanchnic blood flow
301
how does vasopressin work
naturally occurring peptide in hypothalamus - initially early surge followed by profound drop in sepsis, which is the though behind using it
302
how does dobutamine work
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
initial abx management in patient with sepsis unknown source - immunocompetent
ceftazidime + aminoglycoside or fluroquinolone
piptazo + aminogylcoside or fluoroquinolone
carbapenem + amino glycoside or fluoroquinolone
304
initial abx management in patient with sepsis unknown source - suspected anaerobic infection
add metronidazole or clindamycin to piptazo + aminogylcoside or fluoroquinolone
305
initial abx management in patient with sepsis unknown source - MRSA
add vancomycin to piptazo + aminogylcoside or fluoroquinolone
306
initial abx management in patient with sepsis unknown source - splenectomy
ceftriaxone
307
initial abx management in patient with sepsis unknown source - HIV infection
ticarcillin-clavulanature + tobramycin
308
initial abx management in patient with sepsis - source pneumonia - immunocompetent
ceftriaxone + azithro or levo
309
initial abx management in patient with sepsis- source pneumonia - Legionella suspected
azithromycin or fluoroquinolone
310
initial abx management in patient with sepsis- source abdominal infection - immunocompetent
ampicillin + amino glycoside + metronidazole
311
initial abx management in patient with sepsis- source -MDRO suspected
ticarcilin-clavulanate or carbapenem or piptazo+aminoglyocside
312
initial abx management in patient with sepsis- source abdominal infection - urinary tract source
fluoroquinolone or ceftriaxone or ampicillin + aminogylcoside
313
initial abx management in patient with sepsis- source nonnecrotizing fasciits
cefazolin or nafcillin
314
initial abx management in patient with sepsis- source skin MRSA possible
vancomycin
315
initial abx management in patient with sepsis- source necrotizing fasciitis
piptazo + aminoglycoside + clinda
or ticarcillin-clav
or carbapenem
316
initial abx management in patient with sepsis- source IV catheter infection (remove cath) - outpatient acquired
ceftriaxone
317
initial abx management in patient with sepsis- source IV catheter infection (remove cath) - MRSA suspected
ceftriaxone + vancomycin
318
initial abx management in patient with sepsis- source IV catheter infection (remove cath) - fungal infection
amphotericin B
319
initial abx management in patient with sepsis- source CSF - immunocompetent
ceftriaxone + vanco
320
initial abx management in patient with sepsis- source CSF - older adult or immunocompromised
ceftriaxone + vancomycin + ampicillin
321
initial abx management in patient with sepsis- IVDU - MRSA not suspected
nafcillin + aminoglycoside
322
initial abx management in patient with sepsis- IVDU - MRSA suspected
vancomycin +aminoglycoside
323
antibiotics that cover pseudomonas
* 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
what are the serious bacterial infections in paediatric fever referring to
UTI, bacteremia, meningitis, osteomyelitis, bacterial gastro, bacterial pneumonia, cellulitis, and septic arthritis
325
causes of fever in 0-28 day old
bacterial: GBS, E.coli, Listeria, Chlamydia trachomatis, Neissseira gonorrhea, Strep pneumo
viral: HSV, varicella, enteroviruses, RSV, influenza
other: bundling, environmental
326
cause of fever in 1-3 month old
bacterial: H. flu, Strep pneumo, Neisseria meningitis, E.coli
viral: varicella, enteroviruses, RSV, influenza
other: environmental
327
cause of fever in 3-36months
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
cause of fever in 3 years to adulthood
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
what workup is needed after UTI is diagnosed in infant
ultrasound to look for hydronephrosis or renal/perirenal abscesses
VCUG only needed if abnormal US
330
what peds groups are high risk for UTI
febrile girls under 24 months
uncircumcised boys under 12 months
circumcised boys under 6 months
331
contraindications for lumbar puncture in peds
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
how to differentiate children with bacterial vs. aseptic meningitis
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
when to get CXR in febrile child
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
RSV with other SBI - what workup needed
in kids UTI risk 7% still with RSV positive - so get urine/culture
335
amount of fluids to give kid with signs of shock (poor perfusion, hypotension, altered)
20cc/kg bolus of crystalloid, repeat up to 60cc/kg in 60 mins then think about pressors
336
when to consider neonatal HSV
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
non infectious causes of septic appearing neonate
acute salt wasting crisis in CAH, undiagnosed ductal dependent CHD
338
workup required for infant 0-28 days with fever
CBC, blood cultures, UA + culture, and lumbar puncture
CXR, stool prn
339
treatment of neonate 0-28 days with fever
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
treatment of infant 29-90 days old with fever
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
what is Rochester criteria
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
what workup needed according to Rochester criteria
minimum: CBC, cath UA and urine culture, then
blood culture if WBC abnormal
CXR if respiratory symptoms
LP if WBC abnormal
343
what are the disposition options for infant 29-90 days old with fever
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
what workup needed for Boston criteria
CBC, blood culture, LP, urine + culture, +/- CXR, ABX prior to D/C
345
what workup needed for Philadelphia critera
CBC, blood culture, urine+ culture, LP, CXR, no ABX prior o DC`
346
what work up needed for kids3 month - 3 years with fever
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
what is rate of epilepsy after febrile seizure
gen pop epilepsy - 0.5-1%
| after febrile seizure - 1-2%
348
what is rate of recurrence after febrile seizure
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
what classifies a simple febrile seizure
brief < 15 mins
non focal
single occurrenceli
350
what kids need LP after febrile seizure
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
differential diagnosis for fever + petechiae
```
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
what tests to order for kid with fever + petechiae
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
what abx are used in sickle cell kids
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
what bug often causes infection in Sickle cell kids
Salmonella - osteomyelitis, gastroenteritis
355
what workup needed for Sickel cell kids with fever
CBC, reticulocyte count, ESR, blood culture,
356
acute HIV infection clinical manifestatiosn
fever, pharyngitis, LAD 2-6 weeks after transmission
neuro: cases of GBS, encephalitis, and mono neuritis have occurred
357
AIDS defining conditions
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
what abx prophylaxis regimens are usedin HIV
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
common clinical presenation of Toxoplasma encephalitis in HIV pt
fever, h/a, AMS, focal neuro findings, seizure, evolves during days to weeks
360
imaging/diagnostic test findings in Toxoplasma encephalitis in HIV
```
ring enhancing CNS lesions
frequent edema nd mass effect
toxoplasma antibodies (reflects past exposure)
CD4 often <100cells/uL
PCR detection of Toxoplasma gondii
```
361
common clinical presentation of primary CNS lymphoma (PCNSL) in HIV pt
confusion, lethargy, memory loss, hemiparesis, aphasia, seizure, fever, night sweats, weight loss, evolves during months
362
imaging/diagnostic test findings in primary CNS lymphoma
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
common clinical presentation of progressive multifocal leukoencephalopathy
progressive focal neuro deficits (during months), hemiparesis, visual field defects, ataxia, aphasia, cognitive impairment
364
imaging/diagnostic test findings in PML
multifocal areas of demyelination primarily involving white matter
less frequent mass effect or ring-enhancing
PCR assay for DNA of JC virus
365
common clinical presentation of HIV encephalopathy
memory and psychomotor speed impairment, depressive symptoms, movement disorders
366
imaging/diagnostic test findings in HIV encephalopathy
multiple hyperintesine signals in T2-weighted images
| often symmetric, not well demarcated
367
common clinical presentation in CMV encephalitis
delirium, confusion, focal neuro abnormalities
368
imaging/diagnostic tests in CMV encephalitis
MRI shows multifocal scattered micro nodules and ventriculoencephalitis
CD4 < 50 cells/uL
369
common clinical presentation of brain abscess
focal neuro deficit, h/a, bacteremia or craniofacial infection
370
imaging and diagnostic tests in brain abscess
often concomitant evidence of disseminated infection
| focal ring-enhancing lesion
371
common clinical manifestation of tuberculoma
focal neuro deficit, h/a, tuberculous infection
372
imaging/diagnostic tests in tuberculoma
single or multiple mass lesions
| can be manifested as focal lesion or meningeal infection
373
dermatologic and mucocutaneous manifestations of WHO Stage 4 HIV disease
```
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
what renal manifestations of HIV occur
HIVAN -HIV associated nephropathy - FSGS
| vs. HIV immune complex kidney disease
375
DDX of respiratory infections in HIV patients by CD4 counts
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
clinical manifestations/diagnostic labs of bacterial pneumonia in HIV
acute onset, <1 week, cough, purulent sputum ,fevers, chills, rigors
elevated WBC, CXR- focal consolidation, CD4 variable
377
treatment of bacterial pneumonia in HIV
abx against Strep pneumo and H. flu, also cover atypical pathogens
ie. ceftriaxone, azitho.
378
clinical manifestations/diagnostic labs in PCP
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
treatment of PCP
septra x 21 days, if PaO2 < 70 on r/a, or A-a gradient > 35, give prednisone, taper over 21 days
380
clinical manifestations/diagnostic labs in TB in HIV pt
gradual onset > 2 weeks, cough, fever, night sweats, weight loss, LAD
CXR- alveolar pattern +/- cavitation, military pattern, nodules, adenopathy, effusions
CD4 variable
381
clinical manifestations/diagnostic labs of Kaposi's sarcoma
gradual onset >2-4 weeks, cough, dyspnea, fever
CXR- bilateral perihilar nodules, opacities, effusions, adenopathy
CD4 <200
382
treatment of Kaposi's sarcoma
cryotherapy, radiation therapy
infrared coagulation
sclerosing agents, intralesional vinblastine
systemic chemo
383
treatment of esophageal candidiasis
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
cutaneous findings highly suggestive of HIV disease
```
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
```
