What do you do if an patient is Dx with AIDS and: Cocci (not meningitis) PCP Toxo CMV retinitis and neurologic disease

Cocci: initiate within 2 weeks (except in meningitis) PCP: Initiate within 2 weeks of dx (preferably when stable on PCP regimen; Zolopa et al 2009 19440326) Toxo: Initiate within 2 weeks of dx (preferably when stable on toxo regimen; Zolopa et al 2009, IDSA guideline) CMV: Evidence Unclear – but recommended to start ART within 2 weeks after initiating therapy for CMV (IDSA guideline)

High Yield Flashcards by Akira Shishido

Treatment for Trichinella

Albendazole/Mebendazole

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What are notable misses of Amphotericin?

candida lusitanae

candida auris

aspergillus terreus

scedosporium (vori)

Fusarium (+/-)

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What does vori miss?

Mucor

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When does CAP turn into HAP?

48 hours

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vanco IgA bullous dermatosis

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Traveller returns from Thailand with fever, myalgias and headache. He returned 3 weeks ago before onset of symptoms.

What is in play?

Malaria (up to 40 day incubation)

Typhoid (5-21 day incubation)

Shorter incubations:

Dengue up to 14

Zika up to 14

Chikungunya up to 14

Rickettsial/Salmonella/JEV/Yellow fever all shorter

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Difference between FMF and TRAPS?

Rash in TRAPS - rare in FMF

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When do you start ART?

In general, start immediately or next clinic visit. Reasonable to delay if concern for active comorbid condition/OI.

Even with most OI’s star w/in 2 weeks. Zolopa et al 2009. early ART arm resulted in lower AIDS progression and mortality with no increase in AE’s compared to alter arm.

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Patient is Dx with AIDS AND ACTIVE PULMONARY TB. How do you approach?

Start anti TB therapy (RIPE)

if CD4 < 50, start ART w/in 2 weeks (severe IRIS is a risk, however benefits of AIDS progression/mortality with early ART outweigh that risk)
if CD4 > 50, start ART within 8 weeks

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Patient is Dx with AIDS AND CNS TB. How to approach?

Delay ART x 4-8 weeks of TB therapy. IRIS can manifest as paradoxical worsening and cause increase cerebral edema. Also give steroids.

Torok et al 2011 https://www.nejm.org/doi/10.1056/NEJMoa040573

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Patient is Dx with AIDS AND CRYPTO MENINGITIS. How to approach?

Ampho + Flucytosine (fluconazole)
Initiate ART 2-10 weeks after antifungal therapy is initiated (IDSA Guideline).
Benefits of immune recovery vs risk of IRIS. Trials show improved survival in delayed ART in crypto meningitis patients. Studies are in resource-limited countries – unclear if same applies to resource-rich. 20415574 24963568 23362285
NO STEROIDS (it’s like sugar for fungus)

https://www.nejm.org/doi/full/10.1056/nejmoa1312884

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What do you do if an patient is Dx with AIDS and:

Cocci (not meningitis)
PCP
Toxo
CMV retinitis and neurologic disease

Cocci: initiate within 2 weeks (except in meningitis)
PCP: Initiate within 2 weeks of dx (preferably when stable on PCP regimen; Zolopa et al 2009 19440326)
Toxo: Initiate within 2 weeks of dx (preferably when stable on toxo regimen; Zolopa et al 2009, IDSA guideline)
CMV: Evidence Unclear – but recommended to start ART within 2 weeks after initiating therapy for CMV (IDSA guideline)

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How to approach HIV and pregnancy?

Initiate ART ASAP (if not suppressed by 28 weeks, much higer rates of transmission)

Bictegravir and TAF not currently preferred in pregnancy (limited clinical data)

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Preferred NRTI backbones in pregnancy?

TDF-FTC

abacavir-lamivudine

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Preferred integrase and protease inhibitors in pregnancy?

dolutegravir (prev assoc w/NT defects, but subsequent data does not suggest) and raltegravir

Darunavir/Riton or Atazanavir/Riton

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treatment for RMSF in pregnancy?

chloramphenicol

(aplastic anemia)

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How do you approach TB in pregnancy:

Latent

Active

Latent: avoid until 3 months post partum (not worth it unless AIDS or exposure to known active pulmonary TB- Rif regimens preferred)
Active: treat with INH + rif + ethambutol x 2 months, then INH/Rif x 7 months (plus pyridoxine)
*pyrazinamide is recommended by WHO but not CDC due to lack of safety data
*avoid aminoglycosides, quinolones

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A patient from TX presents with 6 plaques over his body on which he has no feeling. What is this and what is the treatment?

Does he need to be isolated?

Multibacillary or Lepromatous Leprosy

Dapson, rifampicin and clofazimine x 2 years

No - all guidelines suggest against isolation (although appears to be transmitted through respiratory droplets)

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Patient starts treatment for lepromatous leprosy and develops multiple erosions and ulcers with serrated edges. What is this?

How would you treat?

Necrotic Vasculitis or “Lucio’s Phenomenon”

Hemorrhagic/Necrotic vasculitis resulting from treatment of lepromatous leprosy

treat with steroids and supportive care. Consider plasmapharesis and severe cases.

Also consider:

Type 1: Reversal Reaction (worsening of nodules/plaques treated with steroids)

Type 2: Erythema Nodosum Leprosum (similar except develop fevers/fatigue - treated with steroids and thalidomide)

*both can also develop neuritis

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What is the post exposure ppx rabies shot series in a patient previously unvaccinated?

0 , 3, 7, and 14

https://www.cdc.gov/rabies/medical_care/vaccine.html

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what is the infectious differential for eosinophilic meningitis (5)?

What are the associations and treatment?

Angiostrongylus - Asia, Hawaii, rats, snails/slugs - supportive care

Baylisascaris - US, racoons - albendazole

Gnathostoma - wide-spread, fish, pigs, snakes - no proven rx (albendazole)

Cryptococcus - HIV - Ampho+fluc

Coccidioides - West- fluc

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which steroid is not metabolized by CYP?

beclometasone

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When do you start ART in a patient diagnosed with MAC and AIDS?

ART should be started as soon as possible after the diagnosis of MAC disease

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What are the indications for Valve Surgery in IE?

STRONG INDICATIONS

HF
Pulm HTN
Fungi/highly resistant orgs
INVASION (abscess, sinus, heartblock, etc)

Less Strong Indications

emboli
vege > 10mm

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Patient with neisseria meningitis started on treatment - when to DC airborne precautions?

24 hours on treatment

Who gets Post Exposure Ppx for neisseria meningitis? When should it be initiated? What regimen?

* “Close Contacts” in general 8 hours of exposure within 3 feet * Healthcare workers (unless direct exposure to respiratory secretions) usually do not need to be treated * Ideally within 1 hour - but up to 14 days (Beyond 14 days not recommended) * Rifampin, Cipro or ceftriaxone (2 days or single dose ceftriaxone)

Patient with ICD and + BCx for Staph aureus. When can device be re-implanted?

Negative blood cultures x 72 hours

When might you consider NOT removing an ICD with a positive blood culture?

GNR (e coli) with negative TEE and no suspicion of pocket infection

what bacteria have intrinsic resistance to polymyxins?

MAPPS Morganella “and” providencia proteus Serratia

# Chroni N155H, Y143C, T66I

Integrase mutations

Preferred treatment for NDM infection?

Avy-Caz + Aztreonam or, cefiderocol Aztreonam is resistant to NDM, but susceptible to other BL's - therefore give Avy-Caz so the avibactam protects the aztreonam.

commercially available beta lactamase inhibitor for NDM?

Doesn't exist…

what mutation causes dapto resistance in staph aureus?

mprF - changes charge of cell membrane disrupting dapto binding

treatment for cat scratch fever?

azithromycin | (also doxy for severe disease)

streptococcus iniae

fish-borne GPC causes cellulitis, bacteremia, endocarditis Tilapia!

Patient on TB therapy ![]()

Rifabutin! can cause uveitis w/eye pain, vision changes and hypopyon. Ethambutol causes optic neuritis - which presents as difficulties with color discrimination and painless visual blurring

50M with kidney transplant p/w swollen fingers/hands

voriconazole periostitis (patient was being treated for disseminated fungal infection) elevated fluoride levels alk phos worsened by CNI's (tacro) must stop vori

management of chronic active hep B in pregnant patient?

Tenofovir with start of 3rd trimester, then Hep immune prophaylxis (HBIG and Vaccination) at birth

Dx and Rx of relapse Brucella?

Dx: rise in Ab titer 1:160 after rx of streptomycin/doxy x 6weeks Rx: rifampin/doxy

PAS-positive granules in foamy macrophages of the lamina propria

whipples disease Rx: doxy+hydroxychloroquine x 1 year

What cells serve as a reservoir for HHV8? CMV?

HHV8 - B lymphocytes CMV - lung, salivary glands and immune-privileged tissues

Treatment for Primary VZV in adult? Give VZIG?

Immunocompetent Valtrex Immunosuppressed IV Acyclovir \*VZIG is given only for PPX (susceptible persons with immunocompromise: HIV, malignanc,y pregnancy, steroids) \< 96 hours

what cephalosporin does aztreonam cross react with?

ceftazadime

Post Exposure Prophylaxis for Meningitis in Prego's and Children

Ceftriaxone

3 factors linked with decreased transmission of HIV from mother 2 baby

1. Short interval between ROM and delivery 2. VL \< 1000 3. cesarian section

In NVE, when do you add gent to PCN for Strep Viridans?

PCN MIC \> 0.12

Difference between lesions from KS and Bacillary Angiomatosis?

Bacillary Angiomatosis lesions are painful and bleed easily

what is the treatment for Corynebacterium diphtheriae

* [Diphtheria antitoxin](http://www.cdc.gov/diphtheria/dat.html) (obtain from CDC, +1 770-488-7100) + [Erythromycin](https://webedition.sanfordguide.com/resolveuid/b758035793d94dcea21ecb87f0d33919) 40 mg/kg/d (maximum dose 500 mg four times a day) IV or po (as tolerated) in 3-4 divided doses x 14 days * Document with 2 neg cx * Close contacts should get vax booster and PCN G or erythromycin 7-10 days

first line pangenotypic treatment for Hep c NO cirrhosis w/compensated cirrhosis?

glecapravir/pibrentasvir x 8 or sofosbovir/velpatasvir x 12 same except genotype 3

bamboorat

*Talaromyces marneffei*

beavers

giardia

elephants

Ppx for RF?

RF with NO carditis/residual disease: 5 years or 21yo (whichever longer) RF with carditis but NO residual disease: 10 years or 21yo (whichever longer) RF with carditis AND residual disease: 40/lifelong

abacavir NOT to be used when HIV RNA \> 100 UNLESS?

combined with dolutegravir

Hep B non responder exposed - PPx? Hep B unknown Status exposed - PPx?

HBIG x 2 1 month apart HBIG and initiate accelerated vaccine

bullous lesions and sepsis in cirrhotic patient Rx?

Vibrio Vulnificus! ceftriaxion/ceftax + cipro/doxy

What are the recommendations for PPX against rheumatic fever?

monthly benzathine PCN, or daily PO Pen VK no Carditis -5 years since most recent episode or 21 y/o, whichever is longer Carditis but no valvular damage -10 years since most recent episode or into adult which, whichever is longer Carditis with residual heart disease -until age 40 or 10 years after last ARF, whichever is longer

Infliximab \> adalimumab \> etanercept increases risk of:

TB reactivation (TNF)

abatacept increases risk of:

severe infections in general (CD28 binding, inhibiting T cell stimulation)

alemtuzumab (campath) increases risk of:

PJP, herpes, CMV

natalizumab increases risk of:

PML/JC virus (blocks VCAM1 inhibiting leukocyte migration)

rituximab increases risk of:

hep B, PJP, JC virus

fulminant hepatitis in pregnant woman with no foodborne exposures

HSV (hep E if exposure/travel)

how long is VZIG good for?

3 weeks - if a new exposure, check serology, administer VZIG if negative \*VZIG offers no additional benefit if Ab+

what is first line antibiotic for tetatnus infection?

metronidazole

first line therapy for mild cutaneous leish?

topical paramomycin (aminoglycoside)

visceral leish species?

L. donovani, L infantum chgasi

what are the sizes from small to big of AF intestinl parasites? where does microsporidium fit in?

crypto (5), cyclo (10), cysto/iso (20-30) microsporidium is ~1 but not acid fast

what survives in swimming pools even with chlorine?

cryptosporidium

What is a better test for recent strep infection? ASO or DNAse Abs?

DNAse Ab - while both are increased in pharyngitis, only dnase is elevated after SSTI

Gent trough and peak?

\<1 4-10

What are the most and least hepatotoxic RIPE Drugs?

INH \> PZA \> RIF \>\>\>EMB (which is not really hepatotoxic)

Feared complication of typhoid?

terminal ileum perforation

What is Sens/Spec PPV/NPV?

[https://www.frontiersin.org/files/Articles/308890/fpubh-05-00307-HTML/image\_m/fpubh-05-00307-g001.jpg](https://www.frontiersin.org/files/Articles/308890/fpubh-05-00307-HTML/image_m/fpubh-05-00307-g001.jpg) Sensitivity=[a/(a+c)]×100 Specificity=[d/(b+d)]×100 Positive predictive value(PPV)=[a/(a+b)]×100 Negative predictive value(NPV)=[d/(c+d)]×100.

peripartum HIV management

mother VL \> 1000 → c-section at 38 weeks mother VL \< 1000 ok for SVD High Risk Birth: combination ART PPX (AZT,3TC,raltegravir) for baby Low Risk Birth: Zidovudine PPX for baby