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1
Q

Nocardia

A

gram positive, partially acid-fast, filamentous, branching rods

systemic sxs, lung nodules, brain abscess (seizures), skin findings

tx - bactrim

  • add carbapenem when brain is involved
  • 6-12 mo

can be confused for TB

  • TB - acid fast rods that DONT gram stain
  • isoniazid, rifampin, ethambutol

Actinomyces - another gram pos filamentous rod

  • anaerobic
  • sulfur granules
  • cervicofacial infections
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2
Q

clinda

A

anaerobes and gram pos

pulmonary abscesses due to aspiration pneumonia

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3
Q

histoplasmosis

A

disseminated histoplasmosis - CD4 count < 100
- midwest and central US, soil (bat or bird droppings, cavingf), dose related, immunocompromised

sxs - systemic

  • pulm - cough, dyspnea,
  • mucocutaneous lesions
  • reticuloendothelial - LAD, HSM

labs - pancytopenia (due to bone marrow infiltration), transaminitis, elevated LDH and ferritin
- CXR - reticulonodular or interstitial infiltrate (because lungs are the portal of entry), bilateral hilar LAD, granulomas with budding yeasts

get - urine Histoplasma antigen, serology, culture (4-6 wks)

tx

  • most cases resolve spontaneously
  • ampho B for 1-2 wks
  • itraconazole for 1 yr thereafter
  • AND consider all pts who develop this for antiretroviral therapy
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4
Q

hep C

A

chronic hep C - asx or non-specific sxs

  • elevated tranaminases - but normal in 1/3 of pts
  • 20% progress to cirrhosis
  • HCC

extrahepatic manifestation - mixed cryoglobulinemia syndrome, membranoproliferative GN, porphyria cutanea tarda (recurrent blistering with trauma or sun exposure, blisters will scar), lichen planus

porphyria cutanea tarda - STRONGLY linked to HCV

  • dx supported by plasma and urine porphyrins
  • tx with serial phlebotomy or hydroxychloroquine
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5
Q

A1AT

A

emphysema, chronic hepatitis, cirrhosis, and panniculitis

panniculitis - painful, erythematous nodules and plaques on thighs or buttocks

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6
Q

S pneumo

A

most common cause of community acquired bacterial meningitis

  • headache, fever, nuchal rigidity, AMS
  • LP - high opening pressure (>350), neutrophilic leukocytosis (>1000)
  • tx = cephalosporin (3), vanc, dexamethasone
    • -> add amp for pts >50 or immunocompromised due to increased risk of Listeria

can have concurrent pneumococcal PNA

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7
Q

meningitis

A

S pneumo - 70%
N menin - 12%
others - H flu, listeria

N menin - esp in adolescents

  • meningitis + myalgias, petechial/purpuric rash
  • complications - DIC, adrenal hemorrhage, shock
  • tx - ceftriaxone and vanc, glucocorticoids are NOT helpful
  • mortality >15% even with appropriate tx
  • ppx for contacts - rifampin, cipro, ceftriaxone

IV cef and vanc = empiric tx for bacterial meningitis

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8
Q

HIV

A

BRAIN

cryptococcal meningitis - subacute
- increased ICP sxs, elevated opening pressure on spinal tap

GI

odynophagia and dysphagia

  • esophagitis, most pts will also have oral thrush - Candida, fluconazole, EGD if no improvement
  • severe sxs –> EGD –> HSV, CMV
    - -> white plaques - Candida - fluconazole
    - -> linera ulcers - CMV (intranuclear and intracytoplasmic inclusions) - ganciclovir
    - -> vesicles - HSV (ballooning degeneration, eosinophilic intranuclear inclusions) - acyclovir
    - -> aphthous ulcers (non-infectious) - treat symptomatically, prednisone

LUNGS

MAC - occurs CD4 < 50, all pts with this level of CD4 count should receive azithro ppx

  • fever, cough, diarrhea
  • splenomegaly, elevated alk phos

PCP - CD4 < 200

  • indolent (HIV), acute respiratory failure (immunocompromised)
  • fever, dry cough, decreased PaO2
  • elevated LDH, diffuse reticular infiltrates
  • sputum culture and BAL to id org
  • tx - bactrim and added prednisone if PaO2 is low
  • ppx - bactrim (pentamidine if pt cant tolerate bactrim) and HAART
    - -> organ tx pts have to also be prophylaxed - will be d/c 6-12 mo after transplant

SCREENING
- one time screen - age 15-65 regardless of sxs (and younger/older if at risk), tx for TB or other STD
- annual - IVDA, MSM, sex worker, partner habits, homeless/incarcerated
- additional screening - pregnancy, occupational exposure, new STD sxs, (suggested prior to any new sexual relationship)

post-exposure ppx - <0.5% risk after needlestick
- high risk contact - exposure of mucocutaneous surfaces to blood or bloody secretions or pt has risk factors for HIV
- low risk contact - exposure to secretions other secretions
- immediate HIV testing and f/u serology at 6 wks, 3 mo, and 6 mo
- urgent start 3 drug regimen for 1 mo - two NRTIs (tenofovir, emtricitabine) + other agent (raltegravir)

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9
Q

pyelonephritis

A

tx for 7-14d

uncomplicated

  • healthy, not pregnant, E coli
  • tx - oral FQ, bactrim
  • IV abx if vomiting, elderly, or septic

complicated - DM, obstruction, renal failure, immunosuppression, hospital-acquired

  • increased risk of abx failure
  • tx - IV FQ, AG, extended-spectrum b-lactam
  • after 48hrs of sx improvement - most pts can be switched to culture-guided oral abx
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10
Q

diabetic infections

A

FOOT
additional RFs - poor glycemic control, neuropathy, PAD

suspect deeper infection in pts with long-standing wound s (1-2 wks), systemic sxs, and ulcer > 2cm, elevated ESR

  • polymicrobial infection that has spread by contiguous spread
  • tx empirically - pip-tazo + vanc

MUCORMYCOSIS = fungus, hyphae

  • risk factors - DM (DKA), heme malignancy, solid organ/stem cell transplant
  • necrotic invasion of palate, orbit, and brain
  • dx - sinus endoscopy with bx and culture
  • tx - surgical debridement and ampho B
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11
Q

rabies

A

px - motor weakness, paresthesia, encephalitis –> coma and death

post-exposure ppx - spread by mammals

  • high risk wild animal (bat, raccoon, skunk, fox, coyote) - start PEP if animal is rabies pos or if animal is unavailalbe
  • low risk wild animal - nothing
  • pet - quarantine and observe animal for 10d, no PEP if animal is healthy, start PEP if animal is not available
  • livestock or unknown wild animal - contact public health dept
  • summary - DONT treat unnecessarily (if you can figure out if the animal has rabies, do that first
    - -> why? - because rabies incubation lasts several mo, PEP effective at any point during that time
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12
Q

HBV and serology

A

SEROLOGY:
acute
- window - anti-core IgM (window because it is the period where HBsAg has disappeared but HBsAb has not yet appeared)
- recovery - antibodies (IgG core, anti-HBs, anti-HBe)

chronic HBV carrier - pos HBsAg and IgG anti-core

  • infected during perinatal period - 100% progression to chronic HBV
  • kids age 1-5 - 30-50% will progress to chronic infection
  • adults - only 5% progress to chronic infection

acute flare of chronic - will have DNA

vaccination - only anti-HBs

immune due to natural HBV infection - pos anti-HBs and IgG anti-HBc

HBe antigen is an indicator of infectivity

HBsAg present during active infection - early phase, chronic HBV carrier

SCREENING: blood transfusions before 1990s
- HBV transmitted by blood, boners, babies
(-HCV - blood)

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13
Q

disseminated gonococcal infection

A

monoarthritis and/or triad: tenosynovitis, dermatitis (pustules, papules), polyarthralgias (smaller joints, wrists, ankles)

dx - blood cultures (may be NEG, gonorrhea is very slow growing), synovial fluid ana lysis, NAAT of joint aspirate and urethra…

tx - IV ceftriaxone –> oral cefixime when clinically improved
- empiric azithro or doxy for concomitant chlamydial

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14
Q

infective endocarditis

A

Duke criteria - need 2 major or 1 major + 3 minor
major:
- pos blood culture - s viridans, s aureus, enterococcus
- echo showing a valvular vegetation
minor criteria: IVDA, temp, embolic, etc.

most common sx- fever and murmur
- IF r-sided disease (tricuspid valve involvement, IVDA) - will not have HF or murmur as it is a low pressure system

vascular sxs
- systemic septic embolic (esp to lung, can be cavitary in nature, sx will be pleuritic CP and dyspnea), mycotic aneurysm, Janeway lesions (non-tender)

immunologic phenomena

  • Osler nodes (painful, fingertips and toes)
  • Roth spots - hemorrhagic lesions in retina
  • pos RF
  • immune complex mediated GN - hematuria, red cell casts

get blood cultures and echo

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15
Q

Parvo B19

A

malar rash + flu-like sxs

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16
Q

syphilis

A

primary - painless chancre + mild inguinal LAD

secondary
- diffuse maculopapular lesions, LAD

tertiary - CV, gummas

latent - axs

tx - penicillin (first-line), doxy is alternate (desensitization is costly, time consuming, and not worth it when there is another alternative)

  • same treatment regardless of stage of dz - increase doses/duration depending on dose
  • RPR (non-treponemal titers) at time of tx –> repeat titers at 6-12 mo after tx initiation
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17
Q

TB

A

px

  • fever, hemoptysis, weight loss
  • disseminated - miliary TB
  • reactivation dz - apical infiltrates

who to treat by PPD/IFN quantiferon
>5mm - HIGH RISK, HIV pos, recent contacts of known TB, CXR findings, organ transplant recipients and other immunosuppressed pts
>10 mm - immigrated 5 yrs ago, IVDA, residents/employees of high-risk setting, mycobacteria lab personnel, high risk for Tb reactivation (DM, prolonged corticosteroid, leukemia, ESRD, chronic malabsorption syndromes), kids < 4yo
>15mm healthy
- treat with isoniazid + pyridoxine
- pts with HIV and CD4 <200 may have false negative PPDs - retest these pts after starting HAART

TREATMENTS
latent - isoniazid - mild-severe hepatitis
- 10-20% of pts experience mild, subclinical hepatic injury, self-limited, continue INH
- risk of developing severe hepatotox is 2.6% for those who drink alcohol daily, have liver dz, or are 50+
- pyridoxine (B6) is added to prevent isoniazid-induced peripheral neuropathy (stocking-glove) - isoniazid binds pyridoxine and results in its renal excretion (most pts have sufficient stores but pts with malnourishment, pregnancy, or certain comorbid illness can develop deficiency)
- isoniazid tox - p. neuropathy, hepatotox, sideroblastic anemia

active
- RIPE for 2 mo

BCG vaccine - given in countries with high incidence, to prevent miliary disease and TB meningitis

18
Q

hepatic cysts/lesions

A

hydatid cyst - Echinoccus, dogs

  • unilocular (typically single) cystic lesions (in any organ, lung, muscle, bone)
  • eggshell calcification
  • surgical resection + albendazole
  • risk of anaphylactic shock if contents of cyst spill

amebic liver abscess -will also have systemic sxs

  • 1) intestinal amebiasis
  • 2) fever, RUQ pain in 1-2 weeks

pyogenic liver abscess - generally follow surgery, GI infection, acute appendicitis
- extreme pain, high fevers, leukocytosis

simple hepatic cysts - congenital, mass lesion/obstructive sxs

19
Q

cysticercosis

A

Taenia

cysts in brain or msucle

20
Q

Legionella

A

Legionella - gram negative rod that stains poorly because it is intracellular

contaminated water - in hospital, travel (cruise, hotel)

px - high fever ~39, bradycardia (relative to high fever), GI upset and delayed pulm sxs
- can have hepatic dysfuntion and hematuria & proteinuria

dx - hyponatremia, lobar infiltrate, sputum stain will show PMNs (few-no orgs)

  • urine legionella antigen
  • tx - FQ (or macrolides)
21
Q

augmentin

A

sinusitis, otitis media, human bite wounds
- note on human bites - debridement is often necessary, wounds left to heal by secondary intention

bugs - H flu and Moraxella

22
Q

pneumonia

A

S pneumo

flu

  • URI/LRI
  • adults at high risk for flu complications (namely post-bacterial PNA or PNA due to direct viral injury) - 65+, pregnant, chronic illness, immunosuppression, morbid obesity, NA, nursing home residents
  • for influenza PNA - will see bilateral, diffuse interstitial infiltrates, give supp O2 and osteltamivir
  • post-viral bac PNA - S pneumo, S aureus, less commonly Pseudomonas

Mycoplasma pneumonia

  • respiratory droplets, close quarters, fall or winter
  • indolent, persistent dry cough, pharyngitis, macular/vesicular rash
  • dx - normal WBC, hemolytic anemia (subclinical), interstitial infiltrate, pleural effusion
  • tx - macrolide

Treatments:

  • CAP - ceftriaxone + azithro
  • HAP - vanc + pip-tazo
23
Q

C diff colitis

A

consider even in a pt with unexplained leukocytosis (and no diarrhea)

abx implicated - clinda, FQs, penicillins, and cephalosporins

  • PPIs change colonic microbiome - increases risk of C diff proliferation (note the spores are acid resistant)
  • C diff carriage is 8-15% and extensive proliferation is required to reach exotoxin levels that are pathogenic

get stool studies (PCR for toxin) - high sensitivity and specificity

  • pt with negative studies may require sigmoidoscopy or colonoscopy with bx
  • bacterial toxins –> apoptosis of colonic cells, loss of tight junctions

tx with oral metro or vanc

mild-mod = WBC < 15K, Cr < 1.5x baseline
- metro

severe = WBC > 15K, Cr > 1.5x baseline, serum albumin <3 g/dl

  • oral vanc - if pt has an ileus –> add IV metro and switch to rectal vanc
  • if pt develops WBC > 20K, lactate >2.2, toxic megacolon, or severe ileus –> subtotal colectomy or diverting loop ileostomy with colonic lavage

fidaxomicin can also be used

note: IV vanc is not excreted into the colon (that is why it is not used)

24
Q

neutropenic fever

A

neutropenia

  • abs is <1500
  • severe is <500

pts who are on chemo

  • disruption of skin and mucosal barrier –> mucositis and bacterial translocation, usually by gram negative orgs like pseudomonas
  • tx - pip-tazo (or cefepime, mero)

add an antifungal if pt has not responded to abx in 4-7d

25
Q

Moraxella catarrhalis

A

otitis media (kids)

26
Q

Guillain Barre

A

1) paresthesias of toes and fingertips

2) ascending motor weakness

27
Q

hep A

A

fecal-oral, international travelers

fever, N&V, abd pain –> jaundice, pruritis

tender hepatomegaly and transaminitis in the 1000s

dx - anti-HAV IgM

tx - supportive, most pts COMPLETELY recover in 3-6 wks
- post-exposure ppx - HAV vaccine or HAV Ig for close contacts

28
Q

schistosomiasis

A

Asia and Africa

fever, urticaria, angioedema, dry cough, eosinophilia

portal vein occlusion can occur due to chronic hepatosplenic schistosomiasis

29
Q

yeasts in the US

A

blasto - great lakes, Mississippi

  • disseminated disease may occur even in immunocompetent pts - hematogenous spread
  • PNA, osteomyelitis, prostatitis, epididymo-orchitis
  • skin - wart-like lesions, violaceous nodules, skin ulcers

dx - culture, microscopy, and antigen testing

tx

  • mild pulmonary dz - dont have to treat
  • mild-mod pulm dz, mild disseminated - oral itraconazole
  • severe pulmonary disease, severe disseminated disease, immunocompromised - IV ampho B

coccidioidomycosis - SW and cali
- unilateral infiltrate, ispilateral hilar LAD
- spherules with endospores

histo - midwest, Mississippi, ohio
- asx mild pulmonary infection

30
Q

Sporotrichosis

A

rose bushes - pustular ulcerated lesions

- localized to wound and associated lymphatic channels

31
Q

HSV encephalitis

A

fever, AMS, seizures, coma

exam

  • clinical signs of meningeal irritation are absent in pts with pure encephalitis
  • focal neuro deficits (hemiparesis, CN palsies), hyperreflexia

labs/imaging

  • CSF studies (increased RBC count), dx by viral DNA on PCR
  • MRI - temporal lobe abnormalities
  • tx - IV acyclovir
32
Q

Lyme disease

A

early localized - erythema migrans (pathognomonic, no need for lab confirmation), myalgais/arthralgias, fatigue, headache
- serology NOT recommended - many will be seronegative

early disseminated

  • bells palsy, meningtis, carditis (AV block), migratory arthralgias
  • get serology

late - mo-yr

  • arthritis, encephalitis, peripheral neuropathy
  • get serology

tx - oral doxy (or amox)

33
Q

diarrhea

A

B cereus - preformed toxin, rice

S aureus - vomiting (diarrhea is not typical), rapid onset (toxin is preformed)

C diff - abx

C perfringens - unrefrigerated food

Salmonella

Vibrio vulnificus - raw or undercooked shelfish

E coli, Shigella, Campy - BLOODY

  • E coli - afebrile, watery –> bloody (if it is the Shiga-toxin producing strain, can look for Shiga toxin in stool), associated with undercooked beef, supportive tx (abx may INcrease the risk of HUS)
  • Shigella - bloody diarrhea, fever, and bacteremia
  • Campy - blood diarrhea, kids, raw/undercooked meats

rotavirus - gastroenteritis and vomiting
- kids

34
Q

FQs

A

levo

cipro - gram neg (and some gram pos, NOT strep)
- GI and GU infections

35
Q

trichinellosis

A

undercooked pork in Mexico, China–> gastric acid releases larva that invade SI and develop into worms –> worms release larvae that migrates and forms cysts in striated muscle

intestinal stage (1 week) - abd pain and GI upset

muscle stage (4 weeks) - myositis, fever, subungual splinter hemorrhage, periorbital edema, eosinophilia, elevated CK

36
Q

Ascariasis

A

nonproductive cough, eosinophilia

worms can obstruct small bowel or bile ducts

37
Q

Dengue fever

A

fever, headache, retro-orbital pain, myalgias

hemorrhagic fever - hemorrhage in skin or nose

38
Q

typhoid fever

A

progressive manner: fever –> abd pain, salmon-colored rash –> HSM and abd perf/bleeding

39
Q

STDs

A

urethritis in men

  • gonorrhea - will see gram neg diplococci on gram stain
  • Chlamydia - negative gram stain, culture negative
  • tx - azithro or doxy + ceftriaxone for gonorrhea coverage
40
Q

organ transplant

A

vaccines for pneumococci and hep B before transplant

inactivated IM flu vax annually (live vaccines are contraindicated after solid-organ transplant)

bactrim to ppx against PCP- can be d/ced in 6-12 mo

41
Q

osteomyelitis

A

fever, back pain, focal spinal tenderness
- can also have increased muscle spasm in the area and decreased ROM of back

orgs - S aureus (50% of spinal cases)

dx - blood cultures, ESR/CRP, plain films

  • WBC count may be normal (sometimes fever is not present either)
  • get MRI if xrays are nl but ESR and CRP are elevated
  • CT-guided needle aspiration/bx to confirm dx

note - alarm features for back pain
- fever, recent infection, focal tenderness, hx of cancer

42
Q

ear infection

A

malignant (necrotizing) otitis externa - Pseudomonas, affects immunocompromised

  • ….granulation tissue, elevated ESR
  • consequences - osteomyelitis of skull base or TMJ (pain exacerbated by chewing)
  • anti-pseudomonal abx - IV cipro

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