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1
Q

What is disseminated gonococcal infection?

A

Presentation: purulent monoarthritis OR triad of tenosynovitis, dermatitis (vescicopustular rash), migratory polyarthralgia (wrists, ankles, fingers, knees); fever
Rash rarely involves the face
Dx: N. gonorrhea in urine, cervical, or urethral sample; Nucleic acid amplification testing; blood cultures are frequently negative
Tx: ceftriaxone IV and azithro PO

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2
Q

What is the treatment of choice in pregnant pts w/ Lyme Disease?

A

Amoxicilin PO is OTC in pregnat and lactating women as well as children age <8y.

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3
Q

What is Lemierre Syndromne (LS)?

A

Caused by oropharyngeal infection, usually phayrgnitis or tonsillitis that leads to local invasion of lateral pharyngeal wall and infection of the neurovascular bundle, esp the internal jugular vein
Thrombosis of vein allows dissemination of septic embolic to distal sites
Fusobacterium necrophorum is the most frequent bacterial cause of LS
Presentation: prolonged duration of sore throat, high fever, rigors, dysphagia, neck pain/swelling along SCM; complications - seeding of lungs after JV infected (nodules on CXR); septic pulmonary emboli
Tx: IV abx, possible surgery (eg I D, vein excision) in pts with no response to abx

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4
Q

What is chronic hep c infection?

A

Dx is a 2-step process: requires both a positive serologic test for the HCV antibody and a confirmatory molecular test for the presence of circulating HCV RNA
Tx with direct-acting antiviral agents (ledipasvir-sofosuvir) should be considered

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5
Q

What is cervical lymphadenitits?

A

Acute, unilateral cervical lymphadenitis in children is usually caused by bacterial infection.
Most common pathogen is s. aureus.

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6
Q

Pain in viral sinusitis

A

Exacerbated by leaning forward.

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7
Q

Cathether-related bloodstream infection.

A

Central venous catheters are the most common cause of nosocomial bloodstream infections b/c they created a direct pathway for colonozed skin organisms to asses circulatory system.
Coag-negative staph and s. aureus cause majority of infections; however, candida species are isolated in approx. 10% of cases.
Positive blood culture for candida should never be considered a contaminant.

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8
Q

VZV vaccine.

A

Given at ages 1 and 4 years old.

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9
Q

What is progressive multifocal leukoencephalopathy?

A

Due to reactivation of JC virus.

Spreads to the CNS and lyses oligodendrocytes, causing white matter demyelination.

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10
Q

HIV Toxoplasmosis.

A

Imaging typically reveals multiple ring-enhancing lesions w/ edema.

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11
Q

What is cryptococcal meningitis?

A

Presentation: fever, malaise, headaches.
Imaging: ring-enhancing lesions on MRI are atypical.

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12
Q

Imaging findings in HIV dementia?

A

MRI: Diffuse increase in intensity in the white matter.

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13
Q

Yellow fever vaccine.

A

Live attenuated
Contraindications: allergery to vaccine components (eggs), AIDS (CD4<200), certain immunodeficiencies (including those assoc. w/ thymus disorder), recent stem cell transplantation, immunosuppressive therapy (eg TNF antagonists, high dose systemic corticosteroids)

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14
Q

Malaria PPX.

A

Choloroquine resistance is common.
Preferred. Atovaquone-proguanil, doxycycline, or mefloquine
Mefloquine: tx should begin >=2w prior to travel, continued during the stay, and discontinued 4 weeks after returning

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15
Q

HIV + HSV ppx.

A

Acyclovir or valacyclovir can be used to prevent HSV recurrences.
It is used for pts w/ severe or frequent recurrences (secondary ppx) regardless of CD4 counts.

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16
Q

What is porphyria cutanea tarda?

A

Fragile, photosensitive skin that develops vesicles and bullae w/ trauma or sun exposure
Healed lesions typically scar and can form hypo- and hyperpigmented area
HCV is strongly assoc. with PCT and all pts with PCT should be screened.
Dx: increased plasma and urine porphyrins
Tx: serial phlebotomy or hydroxychloroquine along w/ management of underlying causes (HCV).
Looks like a mangled hand.

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17
Q

Vertebral osteomyelitis

A

RF: IV drug user, sickle cell anemia, IC
S. aureus is most common pathogen
Presentation: chronic (>6w) and insidious w/ minimal sxs; back pain unrelieved by rest, fever present in less than 50%, tenderness to gentle percussion over involved spinous processes,
Labs: elevated or normal WBC, elevated platelets due to inflammation/stress, ESR >100
Dx: MRI
Tx: long-term IV abx w/ or w/o surgery

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18
Q

Immunizations.

A

Medically stable premature infants should receive routine immunizations on the same schedule as full-term infants, based on their chronological age (age since birth).

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19
Q

Dtap vaccine.

A

Seizure, triggered by fever or pertussis vaccine component, is rare and is typically short and self-limited.
Uncomplicated seizure following vaccine administration is NOT a contraindication to future vaccination.
Contraindications: anaphylaxis devloping following Dtap vaccine component; unstable neurological disorders (infantile spasms, uncontrolled epilepsy); encephalopathy (coma, decreased level of consciousness, prolonged seizures) w/in 1w of dtap vaccine administration (for the combination vaccine) and as a result the toxoids should be administered w/o pertussis

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20
Q

Infective endocarditis.

A

Normocytic anemia, elevated ESR
Minimum of 3 blood cultures should be obtained from separate venipuncture sites over a specified period prior to initiating antibiotic therapy.
TTE or TEE is recommended afater blood cultures are drawn.
Major criteria: blood culture + for typical microorganism, echo showing valvular vegetation

R-sided: consider in pts w/ hx of IVDU
Empiric treatment to native valve: vanc for MRSA, streptococci, and enterococci coverage

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21
Q

HIV + tx for Pneumocystis pneumonia

A

TMP-SMX is DOC for tx of PCP regardless of pneumonia severitiy.
Adjunctive corticosteroids decrease mortality in severe cases.
Indications for steroid use: PaO2 <70 or an A-a gradient >35 on room air.

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22
Q

Febrile neutropenia.

A

Neutropenia ( absolute neutrophil count <1500, severe <500)
Chemo leads to disruption of skin and mucosal barrier of mouth and GI tract resulting in mucositis and subsequent translocation of bacteria into bloodstream
GN organisms (p. aeruginosa) are most frequently identified
Dx: blood and urine cultures
Tx: IV broad spectrum abx that is anti-pseuodomonal, pip tazo, cefepime, meropenem for GN and GP

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23
Q

HIV + vaccines

A

All pts with CD4 <200 should NOT receive live attenuated vaccinations (MMRV, zoster).
Those with CD4 >200 are immunocompetent enough to clear attentuated infection and should receive MMRV if titers are low.
All pts w/HIV should receive the inactivated vaccines (influenza, Dtap) recommended for the general pop as well as those recommended specifically for ppl w/ HIV (pneumococcal, hep B).

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24
Q

Aspiration pneumonia

A

In pts w/ fever and a cough productive of foul-smelling sputum after instrumentation of the upper airway or esophagus, an anaerobic lung infection should be suspected.
Common abx for anaerobic coverage: metronidazole w/ amoxicillin, amox-clavulanate, and clindamycin

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25
Q

Amp + gent

A

Good synergism against gram negative aerobes
But many anaerobes produce beta-lactamases; consequently using amp w/o beta lactamase inhibitor (sulbactam) is not ideal for anaerobic coverage
Amp, gent, metro sometimes used for abdominal infections

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26
Q

PCP

A

RF: pts taking chronic glucocorticoids (esp in combo w/ other immunosuppressant meds)
Elevated LDH
XR: bilateral, diffuse intersitial infiltrates

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27
Q

Foodborne botulism

A

From improperly canned foods, cured fish

Tx: passive immunity through administration of horse-derived antitoxin

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28
Q

HSV genital ulcer

A

multiple, painful ulcers, tender inguinal LAD
sterile pyruia (wbc but no bacterial on u/a) due to urethral and vulvar inflammation and passage of urine over the open lesion
acute urinary retention due to either reluctance to urinate or from a lumbosacral neuropathy that can complicat the infection
Dx: viral culture or PCR testing

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29
Q

H. ducreyi genital ulcer

A

Causes chancroid which causes multiple painful ulcers, tender inguinal LAD
Ulcers have a gray/yellow exudate and friable base, and LN undergo suppuration (eg pus)
Dx: bacterial culture; gram stain with gn rods

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30
Q

Postop fever

A

Temp >100.4F
Common following major surgery
Generally mediated by the release of pyretic cytokines (IL 1, 6, TNFalpha) in response to tissue trauma, blood cell lysis, or bacterial endotoxins/exotoxins
Immediate postop fever occur w/in hours of operation
Most cases are caused by tissue damage during procedure; fever, leukocytosis generally last <3d and are managed symptomatically and observed.

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31
Q

Ecythma grangrenosum

A

A rapidly progressive cutaneous disorder seen most commonly in IC pt w/ p. aeruginosa bacterima/sepsis.
P aeruginosa is the most common opportunistic bacterial infection
Lesions begin as painless red macules, quickly progress to pustules/bullae, and then form “punched out” gangrenous ulcers.
Pts are usually febrile and ill
Blood cx and empiric IV abx are required

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32
Q

What is intermittent catheterization?

A

Periodic insertion and removal (q4-6h) of a clean urinary catheter; can be performed by the patient
Initial trx for neurogenic bladder
Reduces risk of catheter-assoc. UTI

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33
Q

Tuberculin skin test

A

Used to identify pt w/ latent TB infection and a high risk of reactivation TB.
In the US, induration size of less than or equal to 15mm is considered NEGATIVE in healthy patients w/ a low likelihood of TB infection

34
Q

What is clostridium septicum?

A

A gram-positive spore forming colonic bacterium
Risk of bacteriemia and invasive infection (gas gangrene, tissue necrosis) is significantly increased in pt w/ colonic malignancy
About 30% of pts w/ c septicum bacteremia have colon cancer; therefore, colonoscopy is required for those w/ no hx of the tumor
Bacteremia w/ group D strep, particularly strep bovis, is also strongly assoc. w/ colon cancer and should prompt screening colonoscopy

35
Q

What is scarlet fever?

A

Fever, sore throat, ha precede the rash which spreads across trunk, groin, and axillae.
Exanthem has “sandpaper” texture and is most pronounced in the skin folds.
Circumoral pallor.
As the illness resolves, desquamation of the rash results in peeling of the hands and feet.

36
Q

Mycoplasma pneumonia

A

Incessant dry cough, nonexudative pharyngitis
Macular/vesicular rash
XR: interstitial infiltrates, w/ or w/o small, serous pleural effusion
Tx: azithromycin

37
Q

Moraxella catarrhalis

A

Primarily causes otitis media (in children) and COPD exacerbations.
It is an uncommon cause of pneumonia in healthy adults.

38
Q

Strep pneumo

A

Causes lobar infiltrate on CXR.

39
Q

Neonatal conjunctivitis

A

Chemical: <24h Tx: eye lubricant
Gonococcal 2-5 dy. Tx: 3rd gen cephalosporin
Chlamydial conjunctivitis presenta at 5-14d w/ mild eye swelling, chemosis, watery or mucopurulent discharge.
Affected infants should receive ORAL macrolide tx (azithro) b/c topical tx are not effective.

Topical erythromycin ointment is administered to all neonates as ppx against gonococcal conjunctivitis but does not effectively prevent or treat chlamydial disease.

40
Q

Ampicillin/sulbactam

A

Braod spectrum penicillin-beta lactamase inhibitor combo.

DOES NOT cover Pseudomonas

41
Q

Aminoglycosides

A

Cause sensorineural (rather than conductive) hearing loss.

42
Q

Infectious mononucleosis

A

TENDER Adenopathy commonly located in posterior cervical region, but may be generalized (axillary, inguinal).
Tonsillitis/pharyngitis +/- exudates
Some pts develop autoimmune hemolytic anemia and thrombocytopenia due to cross reactivity of EBV induced antibodies against red blood cells and platelets - IgM cold agglutinin antibodies cause complement-mediated destruction of RBCs, can occur 2-3w after onset of sxs leading to jaundice, elevated bilirubin, and increased retic count
Acute airway obstruction is a rare but potentially fatal complication - dysphagia, respiratory distress
Tx: corticosteroids to decrease airway edema.
Viral so abx are not beneficial or indicated

43
Q

Acute HIV infection

A

Fever, malaise, generalized LAD that is NONTENDER
NO tonsillar exudates
+ Rash, diarrhea

44
Q

Rubella

A

Fever then cephalocaudal rash, starts on the face
LAD: suboccipital, posterior auricular, posterior cervical
Forchheimer spots: petechiae or erythematous papules on the soft palate

Adolescents: + arthralgias and/or arthritis, rash spares the palms and soles

45
Q

What is adult still disease?

A

Uncommon inflammatory disorder
Presentation: recurrent high fevers, arthritis/arthralgias, salmon colored macular or maculopapular rash
ESR may be elevated
No active urine sediment, painful fingertips, and pulm sxs

46
Q

Measles.

A

Tx is supportive.
However, vit A reduces morbidity and mortality rates in children w/ severe measles and should be administered to hospitalized patients.

47
Q

Vitamin E deficiency

A

Hemolytic anemia and neurologic abnormalities such as ataxia.

48
Q

Hepatitis A vaccine

A

Hep A vaccine became part of routine childhood vaccinations in 2006.

49
Q

HIV infection + infants

A

FTT, lymphadenopathy, opportunistic infection (Pneumocystis pneumonia, severe thrus)
Loss of CD4+ cells is suggestive of HIV
PCR reaction testing confirms diagnosis

50
Q

Congenital toxoplasmosis

A

Presentation: diffuse intracerebral calcification and ventriculomegaly (macrocephaly, hydrocephalus)
Maternal acquisiton of toxoplasmosis most commonly due to ingestion of cat feces directly (exposure to kitty litter), indirectly (via contaminated soil or prduce) or raw or undercooked meat
Tx: pyrimethamine, sulfadiazine, and folate for 1y

51
Q

Zika

A

Acquired by mother via mosquito bite or sexual transmission.
Microcephaly.

52
Q

Congenital CMV

A

Saliva is the most common source. CMV is shed in body fluids (eg saliva, urine, breast milk) and is most commonly transmitted to the mother by exposure to salive.
Infant: Presents w/ periventricular calcifications
Microcephaly - Head circumference is low or normal

53
Q

Trimethroprim-sulfamethoxazole + UTIs in pregnancy

A

Safe during the 2nd trimester.
Contraindicated during the 1st trimester due to interference w/ folic acid metabolism and should be avoided during the 3rd trimester due to increased risk of neonatal kernicterus.

54
Q

Secondary bacterial pneumonia

A

Most common influenza complication and should be suspected when fever and pulm sxs worsen after initial improvement.
Most cases occur in pt >65y, but community acquired MRSA has predilection for young pts w/ recent influenza.
S. aureus causes rapidly progressive, necrotizing pneumonia w/ high fever, productive cough (often w/ hemoptysis), leukopenia, and multilobar cavitary infiltrates.

S. pneumonia is most common cause of influenza-related bacteria pneumonia, but is RARE in young individuals and less likely to cause cavitary lung lesions.

55
Q

What is ehrlichiosis?

A

Should be suspected in a patient from an endemic region w/ hx of tick bite, febrile illness w/ systemic symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases.
Rash is uncommon
Tx: doxycycline

56
Q

HIV + pneumonia

A

Pts w/ HIV are at increased risk for community acquired pneumonia with CD4 <200.
S. pneumo causes majoritiyi of cases likely due to incrased rates of colonization and impaired immunity against encapsulated bacteria.
Fever, pleuritic pain, dyspnea, productive cough, “rusty sputum”
Dx: lobar, interstitial, or cavitary infiltrate on CXR
Pneumococcal vaccine is recommended for all pt

57
Q

HIV + pneumonia due to s. aureus

A

Pt w/ HIV have higher rates of s. aureus cap, which usually manifests as rapidly progressive necrotizing pneumonia
However, s. pneumo is far more common

58
Q

Epiglottitis

A

Most commonly caused by H. influenzae type b.
Due to widespread vaccination against Hib, the incidence of epiglottitis has diminished. However, the proportion of epiglottis caused by other pathogens: other strains of H. influenzae, streptococcous species (s. pneumo, s. pyogenes), and s. aureus has increased.
Tx: ceftriaxone (to target H influenza and strep species) and vancomycin (to target s aureus including methicillin resistant strains)

59
Q

Parvo virus + pregnancy

A

Most adults w/ parvovirus B19 infection are asymptomatic
W/ increasing severe fetal anemia, fetal heart tries to compensate for hypoxemia by increasing CO. But can’t and high output heart failure develops leading to ascites, generalized skin edema (subsequent peeling).
Pleueral or pericardial effusions, placental edema

60
Q

TB + INH therapy

A

Approx. 10-20% of pts on isoniazid will develop mild aminotransferase elevation <100 w/in first few weeks of treatment.
This hepatic injury is typically self-limited and will resolve w/o intervention.

61
Q

Brain abscess

A

In children, frequently presents w/ headache, fever, focal neurologic deficits, and seizure.
Cyanotic heart disease, Tetralogy of Fallot) is a risk factor for brain abscess due to hematogenous spread of bacteria (bacteria bypass pulmonary circulation, where they are typically filtered and removed by phagoctyosis, and spread to the brain)

Hypocalcemia is common in DiGeorge resulting from underdeveloped parathyroid glands (tetany and seizures). However, it would not cause fever and unilateral weakness for several days.

62
Q

Sickle cell disease

A

Causes functional asplenia due to recurrent splenic infarction.
Pt are at risk of infection w/ encapsulated organisms (S. pneumo, H. influ, N. meng) and should receive vaccination and PCN ppx until 5yo.
Despite vaccination, S. pneumo (usually from non vaccine serotypes) remains MOST COMMON cause of sepsis in pt w/ SCD.

63
Q

Salmonella + s. aureus

A

2 most common causes of osteomyelitis in pt w/ SCD.

Neither organism is a common cause of sepsis.

64
Q

Organisms in acute sinusitis

A

Nontypeable H. influ, s. pneumo, and moraxella catarrhalis are the most common bacterial causes of acute bacterial rhinosinusitis, which commonly presents w/ >=10d of persistent nasal discharge and cough.
Since advent of 13 valent pneumococcal vaccine, s pneumo infection has become less prevalent.

65
Q

Pertussis ppx

A

Treatment during catarrhal stage w/ macrolide may help shorten the course of illness.
Ppx is recommended for all close contacts of infected individual despite vaccination status as immunity wanes over time.
Macrolides are preferred for ppx.
In additon to ppx, household contacts not fully immunized should receive pertussis vaccination according to recommended immunization schedule.
Older than/= 1mo: macrolide
Less than 1mo: azithro for 5d as erythromycin use in neonates is assoc. w/ pylori stenosis and no data on clarithromycin use

66
Q

Syphilis

A 
After exposure (3-60d), pts develop a single papule that turns into a shallow, painless, nonexudative ulcer w/ indurated edges = chancre
Bilateral inguinal lympadenopathy 
Repeat nontreponemal serology should be done in 2-4 weeks to establish baseline titers; 4-fold titer decrease at 6-12m confirms adequate treatment
Tx: single dose of IM benzathine PCN G is TOC for early syphilis. 
Pts w/ severe PCN allergy should receive doxycycline.
67
Q

Granuloma inguinale (donovanosis)

A

Caused by Klebsiella granulomatis
Presentation: formation of extensive, progressive, and painless genital ulcers; no lymphadenopathy
Rare in the US; more common in India, Guyana, and New Guinea

68
Q

What is chikungunya fever?

A

Most likely in pts returning from trip to Caribbean
A mosquito borne viral illness that typically presents w/ flulike illness, symmetric polyarthralgias (almost always present), macular or maculopapular rash on the limbs and trunk, peripheral edema, and cervical lympadenopathy.
Lymphopenia, thrombocytopenia
Tx: supportive

69
Q

Organ transplant ppx

A

Risk for opportunitistic infection w/ pneumocystis pneumonia* and cytomegalovirus
PCP sxs: pulm (resp failure, cough, SOB),
NO GI or hepatic issues
Dx: cannot be cultured, dx requires examination of respiratory samples using microscopy w/ specialized stains - induced sputum is least invasive way to do this; if this does not yield a dx, bronchoscopy w/ bronchoalveolar lavage is required
PPX for PCP: TMP-SMX

Pts who under renal transplantations are at risk for CMV reactivation w/ viremia and/or end organ disease; GI manifestations are common (abdominal bain, vomiting, bloody diarrhea, and endoscopic evidence of multiple large shallow ulcers); dx: biopsy
CMV sxs: pulm (SOB, cough), GI (abd pain, diarrhea, hematochezia), pancytopenia, mild hepatitis, interstitial infiltrates on CXR
-DX: PCR,
Tx: discontinue antimetabolite immunosuppression (mycophenolate) and initiate antiviral therapy (IV ganciclovir)
PPX for CMV: ganciclovir or valganciclovir
-also effective against listeria, toxo

Live vaccines are contraindicated in pts after solid organ transplant

70
Q

Cryptosporidiosis (cryptosporidium parvum)

A

Intracellular protozoan transmitted via ingestion of contaminated water (drinking, swimming)
Most common cause of prolonged, profuse, water diarrhea among travelers
NO LUNG INVOLVEMENT
Healthy adults typically have spontaneous resolution of symptoms w/in 10-14d
However, patients who are immunocompromised (eg AIDS) are at risk for severe, chronic disease
HIV pts: chronic, profuse, watery diarrhea in pt w/ CD4 counts <180, does not typically cause sxs of colitis
DX: Microscopy w/o specialized stains

71
Q

Molluscum contagiosum

A

Skin infection caused by poxvirus; spread through skin-to-skin contact or via contaminated fomites w/ subsequent autoinoculation to additional sites
Characterized by firm, flesh-colored, dome-shaped, umbilicated papules.
Pt w/ impaired cellular immunity (eg HIV disease) are at risk for more severe, widespread disease.

72
Q

Tuberculosis

A

Substance abuse is most common behavioral risk factor
Pts w/ HIV have a higher risk of reactivitation TB (up to 10%/year).
Pts typically present w/ subacute or chronic symptoms (fever, fatigue, cough, wt loss, night sweats)
XR: upper lobe cavitary lesion is common

73
Q

EBV reactivation

A

Typically assoc. w/ malignancies (eg nasopharyngeal carcinoma, non-HL).

74
Q

Graft versus host disease

A

Typically seen in pts who have undergone allogeneic stem cell transplantation.

75
Q

STD/STI testing

A

Individuals w/ a history of high risk sexual intercourse (unprotected or MSM) should be screened for HIV and hep B infection.
Individuals who use injection drugs, have a high-risk needlestick exposure, or received blood transfusion before 1992 should be screened for hep C.

76
Q

HIV + CMV

A

Any pt w/ HIV who has BLOODY diarrhea and CD4 count <50 should have a colonoscopy w/ biopsy to look for CMV colitis.
CMV colitis characterized by frequent, small volume, BLOODY stools and abdominal pain.
Any pt w/ HIV who has active CMV disease requires ocular exam to r/o concurrent retinitis.

77
Q

HIV + M. avium complex

A

Infection can cause chronic diarrhea and wt loss

However, diarrhea is typically WATERY not bloody

78
Q

Varicella vaccine

A

The varicella-zoster virus vaccine is recommended for all children at ages 1 and 4 to prevent primary varicella infection.
The live-attenuated virus can cause a varicella like maculopapular rash that is mild but contagious. Therefore, pts who develo rash after vaccine should avoid contact w/ high-risk inviduals who are susceptible to varicella (eg pregnant women, people receiving chemo) until rash has completely crusted over.

79
Q

Wild type varicella

A

> 100 lesions in successive crops over several days

Highly contagious

80
Q

Fluoroquinolones

A

eg Levofloxacin
Increase collagen degradation and are assoc. w/ adverse effects, including achilles tendon rupture, retinal detachment, and aortic aneursym rupture.
When possible, fluoroquinolone use should be avoided in pts w/ a known aortic aneursym or substantial risk factors for aortic aneurysm.

81
Q

Pharyngitis in children

A

Viral: cough, rhinohrrea, conjunctivitis, oral ulcers
-symptomatic treatment

Bacterial: exudate, edema, palatal petechiae

  • Rapid strep antigen testing is quick.
  • Negative RSAT results in children must be confirmed w/ throat culture; if positive tx w/ PCN or amox for GAS
82
Q

Pharyngitis in adults

A

Adults who meet all Centor criteria can receive empiric antibiotic tx w/o testing.
Centor criteria are not reliable in pre-adolescents and are not recommended for use in children.

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