Fever - Tyler Flashcards
abnormal presence of bacteria in blood
bacteremia
what are the most common source of bacteremia?
- skin and soft tissue infections
- central venous catherters and other IV devices
- bone and joint infections
- pneumonia
- endocarditis
what are the clinical manifestations of bacteremia?
- fever
- fatigue, malaise
- N/V
- loss of appetite
- dehydration
- myalgias, arthralgias
- leukocytosis and left shift
what is the definition of early sepsis?
an inflammatory response to bacteremia
what is a SOFA score?
organ dysfunction score, but lengthy and time-consuming
score based on:
- resp rarate >22/min
- altered mentation
- systolic bp <100
- arterial hypotension (<90/70)
- temp >36 C
- HR >90bpm
- tachypnea, resp rate >20/min
clinical manifestation of sepsis
- warm, flushed skin
- as sepsis progresses to shock, skin may become cool d/t redirection of blood to organs
- decreased cap refil, cyanosis, or mottling
- altered mental status, obtundation, restlessness
- ileus or absent bowel sounds
end-organ manifestations
- leukocytosis >12k, or leukopenia
- normal WBC with greater than 10% immature forms
- hyperglycemia w/out diabetes
- plasma C-reactive protein 2 std above normal
- arterial hypoxemia
- acute oliguria
- creatinine increase
lab eval in sepsis
- coagulation abnormalities
- thrombocytopenia
- hyperbilirubinemia
- hyperlactatemia** -> elevated serum lactate can be manifestation of organ hypoperfusion
sepsis
most common bacterial infection?
staph, strep
most common viral infections?
- influenza
- HIV
- CMV
most common fungal infections?
coccidiomycosis, histoplasmosis
what does mycobacterium cause?
Tb
what do the plasmodium species cause?
malaria
skin or soft tissue infection:
- breaks in skin integrity (erysipelas, folliculitis, cellulitis, trauma)
- IV catheters
- cardiac devices
- orthopedic hardware
staph infections
systemic infections (30%):
- bone or joint pain (back pain -> vertebral osteomyelitis, discitis or abscess) or septic arthritis
- protracted fever/sweats
- abd pain (LUQ -> splenic infarction)
- CVA tenderness -> pyelonephritis, renal infarct, psoas abscess
- HA -> meningitis, septic emboli
staph
common in immunocompromised host
- wounds have localize erythema with induration and purulent drainage (abscess formation)
- gam stain of pus shows gram-POS cocci in clusters
MRSA
what should s.aureus bacteremia ALWAYS focus on?
endocarditis, osteomyelitis, deep-seated systemic infections (epidural abscess)
superficial skin infection
- usually with well-defined borders
- minimal lymphangitis
erysipelas
deeper skin infection involving the dermis and subQ fat
- more propensity for lymphangitis, edema, swelling
- looks warm/swollen
cellulitis
painful, warm, indurated, erythematous, non-localized
- may be accompanied by lymphangitis
- distinguishing strep v staph can be difficult (staph may have more purulence)
erysipelas and cellulitis
commonly implicated in diabetic foot infections
- infection ay complicate surgical incisions
- joint infections are unusual, but when they do occur, usually associated with bacteremia or instrumentation (aspiration, injection, arthroscopy)
- osteomyelitis d/t MRSA may be assoc with fixation device or prosthesis, hematogenous infection in children, or non-healing foot ulcers in diabetics
MRSA
what is the most common cause of tonsillopharyngitis?
strep pyogenes
what is the most common manifestations of neonatal disease?
bacteremia without a focus, sepsis, pneumonia, or meningitis
what are the three most common manifestations of streptococcal bacteremia in pregnant women?
- uTI
- chorioamnionitis
- postpartum endometriosis
what are the most common manifestations of streptococcal bacteremia in non-pregnant adults?
- bacteremia without a focus
- sepsis, soft tissue infections, endocarditis
most common cause of bacterial pharyngitis in children and adolescents
strep pyogenes (group A strep)
what are common sx of group A strep pharyngitis?
- scarlatiniform rash
- palatal petechiae
- tonsilar enlargement
- vomiting
- tender cervical LN’s
what organism causes:
- productive cough
- hemoptysis
- fatigue
- weight loss
- fever
- night sweats
mycobacterium tuberculosis
primary infection of which organism:
- occurs with inhalation of airborne droplets containing viable tubercle bacili and subsequent lymphagitic and hematogenous spread before immunity develops
Tb
- up to 1/3 of cases are from primary infection acquired by person-person transmission
occurs when bacili are contained within granulomata
- non-transmissible while latent, but may become active disease if the infected person’s immune function becomes impaired
latent Tb (LTBI)
may occur if the individual’s immune system becomes weak and no longer is able to contain the latent bacteria
- the bacteria then becomes active; they overwhelm the immune process and active infection ocurs
reactivation of Tb
what are risk factors for reactivation of Tb?
- gastrectomy
- silicosis
- diabetes mellitus
- HIV
- immunosuppressive drugs
what is the most common sx of Tb?
cough
- blood-streaked sputum is common, frank hemoptysis is rare
- post-tussive apical rales are classic PE finding
what are the slowly progressive sx of Tb?
malaise, anorexia, weight loss, fever, night sweats
- pts appear chronically ill
onset of fever, chills, malaise, cough, arthralgia, myalgia
- 3 subtypes (types A and B produce identical sx)
- GI sx may occur, particularly among children with type B
influenza
- leukocytosis may be a marker of secondary complications
pandemics usually due to which type of influeza?
A with major antigenic shift
transmitted through sexual contact, parenteral exposure to infected blood, or perinatal exposure
- sx: sweats, diarrhea, weight loss, wasting
- neurologic sx: dementia, aseptic meningitis, neuropathy
HIV
- opportunistic infections d/t diminished cellular immunity
- aggressive cancers, esp NHL
these conditions are highly suggestive of what infection?
- hairy leukoplakia of the tongue
- disseminated kaposi sarcoma (HHV-8)
- cutaneous bacillary angiomatosis
- generalized lyphadenopathy
HIV
- multiple, or recurrent bacterial infections
- pneumocystic jirovecii pneumonia
- kaposi sarcoma
- lymphoma
- CMV infection
- histoplasmosis
- coccidiomycosis
- cryptococcosis
- extrapulmonary
- mycobacterium Tb or ANY site
AIDS-defining illnesses
most infections are asymptomatic
- seroprevalence increases with: age, lower socioecon status, hx of STI, employment in daycare center)
- similar to infectious mononucleosis, but not usually pharyngeal sx
CMV
- not all pts with infections dvlp disease!
virus isolation or detection of viral proteins (Ags) or nucleic acid in any body fluid or tissue specimen regardless of sx
CMV infection
- evidence of CMV infection with attributable sx
- may manifest as either a viral syndrome (fever, malaise, leukopenia, neutropenia, atypical lymphocytosis, thrombocytopenia) or as a tissue-invasive disease
CMV disease
- jaundice, heptasplenomegaly, thrombocytopenia, purpura, microcephaly, periventricular CNS calcifications, mental retardation, motor disability
- hearing loss in >50% of infants who have sx at birth
- most are asymptomatic, but neurologic deficits may ensue later in life (hearing loss, mental retardation)
CMV inclusion disease due to perinatal infection
- infection acquired thru breast feeding or blood products typically shows a benign clinical course
mono-like syndrome with negetive heterophil Abs
- cutaneous rash is common
- mono-like syndrome can occur post-splenectomy, often years later
- fever, malaise, myalgia/arthraligia, splenomegaly, atypical lymphocytes, abnl liver function tests
- leokopenia is followed by leukocytosis
CMV infection in immunocompetent person
when is CMV retinitis usually seen?
- neovascular and proliferative retinal lesions
advanced AIDS
when is GI and hepatobiliary CMV, with esophagitis, small bowel inflam, colitis, cholangiopathy seen?
AIDS or with high-dose chemo
when is pneumonitis seen in CMV?
transplant recipients (2-6 months after) and AIDS
what are the complications of mucosal gastrointestinal damage?
- mucosal GI damage
- encephalitis
- severe hepatitis
- thrombocytopenia
- guillain-Barre synd
- pericarditis
- myocarditis
exposure to bird/bat droppings; common along river valleys
- most pts asymptomatic, resp illness mc problem
- common in AIDS or immunosuppressed
- influenza-like illness, lasts 1-4 days
- more severe illness presents as atypical pneunomia (fever, cough, mild central chest pain 5-15 days)
histoplasmosis
what cultures/tests are helpful in dx of disseminated histoplasmosis dz?
- blood, bone marrow cultures
- urine polysaccharide Ag
when is progressive disseminated histoplasmosis usually seen?
pts with underlying HIV (with CD4 counts <100)
when is chronic progressive pulmonary histoplasmosis seen?
older patients with chronic obstructive pulmonary disease
what are the complications of progressive histoplasmosis?
- fever, weight loss, prostration
- dyspnea, cough
- ulcers of the oropharyx
- hepatosplenomegaly
- GI involvement may mimic IBD
- CNS invastion in 5-10% of individuals
what are the complications of disseminated histoplasmosis?
- occurs mainly in immunocompromised pts**
- fever and multiple organ system involvement
- may simulate septic shock
influenza-like illness with malaise, fever, backache, headache, and cough
- might see meningitis, arthralgia, bone lesions, skin/soft tissue abscess
- infection results from inhalation of molds that grow in SW US
coccidioidomycosis
incubation period 10-30 days
- 40% have respiratory sx
- nasopharyngitis with fever and chills
- common (unrecognized) cause of community-acquired pneumonia
- arthralgia with perarticular swelling of knees and ankles
- erythema nodosum can dvlp 2-20 days after sx onset
- persistent pulmonary lesions in 5%
primary coccicioidomycosis
can involve any organ
- productive cough
- enlarged mediastinal LNs
- lung abscesses, empyema
- meningitis in 30-50%, may result in chronic basilar meningitis
- lymphadenitis
- HIV-infected pts more often show miliary infiltrates, lymphadenopathy, meningitis, but skin lesions are uncommon
disseminated coccidioidomycosis
intermittent attacks of chills, fever, sweating
- HA, myalgia, vomiting, splenomegaly, anemia, thrombocytopenia
- intra-ethrythocytic parasites identified in thick or thin blood smears
plasmodium species-malaria
- anopheline mosquitoes!
what 4 plasmodium species responsible for human malaria?
- p. vivax
- p. malariae
- p. ovale
- p. falciparum
which plasmodium species is responsible for nearly all severe disease?
falciparum
which plasmodium species rarely causes severe disease?
vivax
- ovale and malariae generally do not cause severe illness either
begins with prodrome of HA, fatigue, followed by fever
- fevers may become irregular without tx
- 48 hr cycles for vivax and ovale
- 72 hr cycles for malariae
acute malaria
- anemia
- jaundice
- splenomegaly
- mild hepatomegaly
- hypotension
- seizure
PE findings malaria
bone pain, often in the spine, ribs, or proximal long bones
- monoclonal Ig in serum or urine
- clonal plasma cells in bone marrow or tissue bx
- organ damage d/t plasma cells (bones, kidneys)
- characterized by infiltration of bone marrow, bone destruction, and paraprotein elaboration
- lytic bone lesions
- soft tissue masses
multiple myeloma
- ** Waldenstrom’s macroglobulinemia is similar, but will NOT have lytic bone lesions**
what leads to kidney failure in MM?
light chain components of Ig accumulate
- may also be deposited in tissues as amyloid, worsening kidney failure and causing systemic symptoms
myeloma pts are especially prone to infections with what?
- occurs most commonly in adults >65
encapsulated orgs
- strep pneumo, h. influenzae
HHV-8 infection, most common HIV-related malignancy
- red, purple or dark plaques/nodules on cutaneous or mucosal surfaces
kaposi sarcoma
sarcoma that can present with SOA, cough, hemoptysis, or chest pain
- may be asymptmatic, appearing only on CXR
pulmonary kaposi sarcoma
sarcoma that can develop in pts with HIV infection, high CD4 counts, low viral loads
- potential for clinically aggressive diease
chronic kaposi sarcoma
what is the ddx for kaposi sarcoma?
melanoma
occurs mainly in young women
- rash over areas exposed to sunlight (malar rash)
- joint sx in 90% of pts often earliest sx
- anemia, leukopenia, thrombocytopenia
- glomerulonephritis, CNS disease, antiphospholipid Abs are major sources of disease morbidity
- fever, malaise, weight loss, alopecia
- Raynaud phenomenon in 20% of pts
SLE
what are the serologic findings of SLE?
- ANA 100%
- anti-dsDNA Abs 67%
- low serum complement levels
what are the ocular findings of SLE?
- blurring of vision
- conjunctivitis
- cotton-wool spots of retina
what are the cardiac findings of SLE?
- pericardium is affected
- heart failure
- cardiac arrhythmias
what are the pulmonary findings of SLE?
- pleurisy
- pleural effusion
- bronchopneumonia
- pneumonitis
- restrictive lung dz
dryness of eyes and mouth (sicca)
- chronic enlargement of parotid glands
- xerostomia causes dysphagia
- Rh factor and antinuclear Abs common
- increased incidence of lymphoma
- can occur in isolation “primary” or in association with another rheumatic dz
- pancreatitis, pleuritis, obstructive airways
- neuropsychiatric dysfunction
- rental tubular acidosis (type 1, distal)
sjogrens
