ID Emergencies 2

Question 1

Toxic Shock Syndrome
1. TSS results from the absorption of what?

2. Historically was usually seen in who?
3. Increasing number of cases now seen from what? 2

Answer 1

1. toxin from localized Staph aureus colonization or infection
2. females following tampon use
3. wound or sinus infections

Question 2

TSS
Signs and symptoms
1. Short Prodrome consisting of? 5

2. Develops into? 4
3. What does the rash look like?
4. rash fades how quickly?
5. desquamation of hands and feet occurs in what time?

Answer 2

1. • fever,
   • myalgias,
   • vomiting,
   • diarrhea,
   • pharyngitis
2. • Rapidly develop fulminate shock
   • SBP 102.2
   • with multiple organ failure
3. A diffuse, blanching, macular erythema appears with signs of pan-mucosal inflammation
4. in 2-3 days;
5. all 5-12 days after rash disappears

Question 3

Toxic Shock Syndrome
Labs are non-specific, but represent multiple organ system involvement:
1. Bone marrow tox? 2
2. Renal tox?
3. Liver tox?
4. UA?
5. Muscle damage?
6. Leaking capillaries will cause? 2

7. Blood cultures will show?
8. Cultures of the source (vagina, wound, or sinus) will grow what?

Answer 3

1. • Leukocytosis and
   • thrombocytopenia (bone-marrow toxicity)
2. • Elevated BUN and Creatinine (Renal toxicity)
3. • Elevated LFTS and
   • Bili (Liver toxicity)
4. Sterile pyuria
5. Elevated CPK (muscle damage)
6. • Decrease serum albumin and
   • total protein due to leaking caps
7. Blood cultures will be NEGATIVE as this is TOXIN induced
8. grow S. aureus

Question 4

TSS tx?

Answer 4

Maximum supportive care and treat to prevent additional toxin production (TSS is a NATIONALLY REPORTABLE Disease)

Question 5

Arthropod borne diseases

3

Answer 5

1. Rocky Mountain Spotted Fever
2. Lyme Disease
3. Malaria

Question 6

Rocky Mountain Spotted Fever

1. What is it?
2. Occurs in what areas of the country mostly? 3
3. 80% of patients have a positive hx of?
4. Most cases occur during what season?
5. Incubation period of?
6. Presentaion? 4

Answer 6

1. Acute febrile tick-borne illness caused by Rickettsia rickettsi
2. Occurs in all states and most common in
   - South Atlantic region,
   - South Central region and
   - Oklahoma
3. 80% of patients have a positive history of tick bite
4. Most cases occur during warm months when ticks are most active
5. Incubation period of ~ 1 week
6. • Sudden onset fever, chills,
   • malaise,
   • myalgias,
   • severe frontal headache

Question 7

Rocky Mountain Spotted Fever

1. Which day will the rash appear?
2. What does it look like?
3. Where does it appear?
4. Over the next 24-48 hours rash cahnges how?
5. Spreads in what pattern?
6. Diffuse edema due to? 4
7. dx?
8. Tx?

Answer 7

1. On the 2nd – 5th day of illness rash appears
2. Pink, macular 1-4mm in diameter
3. appears on the palms of hands, soles of feet, hands, feet wrists and ankles
4. Over next 24-48 hours, rash becomes petechial, purpuric, and even gangrenous
5. Spreads centripetally to involve the rest of the body
6. Diffuse edema due to
   - capillary leakage,
   - hypotension,
   - splenomegaly
   - delirium
7. There is NO definitive laboratory test for RMSF in the acute stage; all labs may be NORMAL; You must make the diagnosis clinically
8. Treatment is early TCN or Doxy (In Children use Chloramphenicol)

Question 8

Lyme Disease

1. What is it?
2. Transmission?
3. Highest prevalence where?

Answer 8

1. A chronic disease caused by a spirochete Borrelia burgdorferi
2. Transmission is by several species of ticks
3. Highest prevalence in NE and Midwest

Question 9

Describe Stage I Lyme disease? 2

Answer 9

Stage I

1. Rash = erythema migrans: gradually expanding area of redness with central clearing from bite site
2. May be accompanied by fever, chills, malaise, reginal adenopathy

Question 10

Describe Stage II Lyme disease? 3

Answer 10

Stage II

1. Days to weeks after infection
2. Multisystem involvement (heart, liver, neuropathy, muscular)
3. Fatigue and lethargy may persist for months

Question 11

Describe Stage III Lyme disease? 3

Answer 11

Stage III
Lingers for months to years with 
-arthritis, 
-neuropathy, 
-acroderamtitis chronica 
atrophicans

Question 12

Lyme Disease

1. Only laboratory “proof” of disease is what?
2. The best approach to treatment?
3. Abx?

Answer 12

1. a rising titer seen in paired sera
2. The best approach is to treat empirically while awaiting labs
3. Tetracycline 500mg QID X 30 days at minimum

Question 13

1. Malaria is what?

2. Symtpoms occur when after exposure?

Answer 13

1. Parasitic infection secondary to Plasmodium falciparum (90% of cases), plasmodium vivax or plasmodium knowlesi
2. Symptoms occur 12-35 days after exposure (mosquito bite) and can wax and wane due to the parasite load

Question 14

Malaria
1. Uncomplicated cases, symptoms: ?

2. Fevers may be predictable and occur at regular intervals (described as what?)
3. Blood work will show? 3
4. Diagnosis is clinical and based on the parasite dx with what? 3

Answer 14

1. fever, malaise, myalgias, arthralgias, headache
2. “cyclical fever”
3. • Anemia,
   • elevated WBC,
   • low platelets
4. 0Giemsa stained visualization of parasites in peripheral blood smear,
   -antigen or antibody tests,
   -molecular techniques for extracting parasite genetic material

Question 15

Malaria:

1. Complicated cases, symptoms? 11

Answer 15

1. Fever,
2. anemia,
3. splenomegaly,
4. altered consciousness,
5. seizures,
6. ARDS,
7. circulatory collapse,
8. metabolic acidosis,
9. renal failure, liver failure,
10. coagulopathy, DIC, severe anemia, intravascular hemolysis,
11. hypoglycemia

Question 16

Malaria:
Symptoms can progress rapidly and can be fatal

PE? 6

Answer 16

1. pallor,
2. petechiae,
3. jaundice,
4. hepatomegaly,
5. splenomegaly,
6. splenic rupture

Question 17

Malaria:

Consult CDC when treating as treatment may depend on what?

Answer 17

the region in which the infection was aquired

Question 18

Bioterroism

What are we worried about? 3

Answer 18

1. Botulism
2. Smallpox
3. Anthrax

Question 19

Botulism:

1. What is it?
2. Usually transmitted how? But can be used as a weapon when?

Answer 19

1. Rare but potentially life threatening neuroparalytic syndrome secondary to infection with Clostridium botulinum
2. Usually ingested through the GI tract but can be aerosolized and released as an act of bioterrorism

Question 20

Botulism

1. Ubiquitous: meaning?
2. What kind of bacteria is it?
3. 5 forms of botulism exist: they are?

Answer 20

1. Spores in soil and marine sediment worldwide
2. Gram positive, rod-shaped, spore forming obligate anaerobic bacteria
3. • foodborne,
   • infant,
   • wound,
   • adult enteric and
   • inhalation

Question 21

Botulism

1. Classically described as the acute onset of what?
   - with associated what?
2. Other key features in the clinical presentation? 4

Answer 21

1. bilateral cranial neuropathies
   - associated with symmetric descending weakness
2. Other key features in the clinical presentation:
   - Absence of fever,
   - pt remains responsive,
   - normal or slow heart rate and normal BP,
   - no sensory deficits with the exception of blurred vision

Question 22

Botulism Testing
1. Infants: evaluate what?

2. Foodborne: dx?
3. Wound dx?
4. Adult enteric dx?

Answer 22

1. Infants
   Negative in the serum, evaluate stool for spores and toxin (takes time)
2. Foodborne
   Serum analysis for toxin
3. Wound
   Culture of wound should be +, likely negative serum assays
4. Adult enteric
   Evaluate stool for spores and toxin

Question 23

Botulism:

Treatment
1. Any signs, symptoms or history suspicious for botulism should be hospitalized immediately and monitored for signs of what?

2. 2 botulism-a antitoxin therapies: What are these?
3. Antibiotics are only helpful in what?
   - Use which ones? 2

Answer 23

1. respiratory failure
2. • Equine serum heptavalen botulism antitoxin (> 1 year in age
   • Botulism immune globin for infants (less than 1 year)
3. wound botulism
   - PCN G and Metronidazole

Question 24

What is the only disease known to be eradicated?

Why is this possible?

Answer 24

Smallpox

Possible because smallpox is viral disease only infecting humans

Done with worldwide cooperation, vaccination, and isolation

Question 25

Smallpox Epidemiology 1. ______ transmission from person to person 2. Anyone ______ has no immunity (110 million in United States alone) 3. Vaccine before or within _________ of exposure > 99% effective 4. Spreads most readily during what season?

Answer 25

1. Droplet 2. less than 26 3. 2-3 days 4. cool, dry winter

Question 26

Smallpox virology 1. Agent? 2. Orthopoxviruses? 2 3. Mullucipoxvirus? 1 4, Nonhuman orthopoxviruses? 4

Answer 26

1. Variola (family poxviridae) 2. Variola, varicella (chickenpox) 3. : Mulluscum contagiosum virus 4. - Monkeypox, - cowpox, - canarypox, - rabbitpox, etc.

Question 27

Smallpox: Epidemiology 1. Reservoir? 2. Transmission? 3 3. Transmission does not occur until what? 4. Maximum infectiousness which days? 5. Increased infectiousness if pt is what? 2

Answer 27

1. Humans Transmission 2. - Contact, - droplet - airborne 3. the onset rash 4. days 7-10 of rash 5. - patient coughing or - has a hemorrhagic form of smallpox

Question 28

Smallpox 1. Incubation period? 2. Clinical features? 4

Answer 28

1. 12 days (7-17 days) 2. - Non-specific prodrome (2-4 days) of fever, mylagias - Rash most prominent on face and extremities (including palms and soles) in contrast to truncal distribution of varicella - Rash scabs over in 1-2 weeks - Variola rash has a synchronous onset (in contrast to the rash of varicella which arises in crops

Question 29

Smallpox: Diagnosis 1. Appearance of ____? 2. Hemorrhagic smallpox may be mistaken for what? 2 3. Culture of what? 4. Should be obtained how? Alert lab

Answer 29

1. rash 2. - meningococcemia or - severe acute leukemia 3. lesions 4. by immunized person; place specimen in vacutainer tube, tape juncture of stopper and tube, place in second durable, watertight container

Question 30

Smallpox: Signs, Symptoms and Disease Course 1. Day 0? 2. Day 12-14? 3. Day 14-16? 4. Day 16-18? 5. Day 22-26? 6. Day 28-30? 10% will develop malignant disease and progress how?

Answer 30

1. (Day 0) Exposure 2. (Day 12-14) Fever, malaise, non-productive cough, headache, backache, joint pain 3. (Day 14-16) Papular rash on face and extremities 4. (Day 16-18) Papular rash with vesicular and pustular lesions 5. (Day 22-26) Crusted lesions 6. (Day 28-30) Resolving 10% will develop malignant disease and die 5-7 days after incubation

Question 31

Smallpox Control 5

Answer 31

1. Clothing/fomites: Decontaminate 2. Prophylaxis 3. Pre-exposure: Vaccine 4. Post-exposure: Vaccine (within 4 days) or vaccine plus VIG (>4 days); potential role for cidofovir (antiviral agent) 5. Isolation: Contact plus airborne

Question 32

Variola 7 vs. Varicella 7

Answer 32

1. Variola (smallpox) - Rash starts face - Lesions same stage - Deep lesions - Often palms/soles - Centrifugal rash - Back > Abdomen - Multiloculated vesicles 2. Varicella (chickenpox) - Rash starts trunk - Lesions in crops - Superficial lesions - Never palms/soles - Centripetal rash - Back = Abdomen - Uniloculated vesicles

Question 33

Smallpox diagnostic testing Rule-out other vesiculating dz When in doubt?

Answer 33

Quarantine/Isolate

Question 34

Smallpox treatment | 3

Answer 34

1. Supportive 2. Must isolate and immunize contacts 3. Cidofovir treatment may help Mortality is age dependent and ranges from 30-95%

Question 35

Anthrax: The Basics 1. Caused by the what? 2. Human infection typically acquired through contact with what? 3 3. Three clinical forms?

Answer 35

2. spore-forming bacterium, Bacillus anthracis 2. - anthrax-infected animals - or animal products or - atypically through intentional exposure 3. - Cutaneous - Inhalational - Gastrointestinal

Question 36

Cutaneous Anthrax: Clinical Course 1. Begins as a what, progresses through a vesicular stage to a what? 2. What else may occur on the skin? 3 3. Form most commonly encountered in which cases? 4. Incubation period: ? 5. Case-fatality: Without antibiotic treatment—? With antibiotic treatment—?

Answer 36

1. papule, depressed black necrotic ulcer (eschar) 2. - Edema, - redness, and/or - necrosis without ulceration 3. naturally occurring 4. 1–12 days 5. - 20% - 1%

Question 37

Differential Diagnosis of Cutaneous Anthrax 5 How painful is this?

Answer 37

1. Spider bite 2. Ecthyma gangrenosum 3. Ulceroglandular tularemia Plague 4. Staphylococcal or streptococcal cellulitis 5. Herpes simplex virus Cutaneous Anthrax is PAINLESS

Question 38

Diagnostic Testing: Cutaneous Anthrax | 5

Answer 38

1. Gram stain, . polymerase chain reaction (PCR), or 3. culture of vesicular fluid, exudate, or eschar 4. Blood culture if systemic symptoms present 5. Biopsy for immunohistochemistry, especially if person taking antimicrobials

Question 39

When do vesicles develop in cutaneous anthrax?

Answer 39

Vesicle development | Day 2

Question 40

Inhalational (Pulmonary) Anthrax 1. A brief prodrome resembling a “viral-like” illness, characterized by ? 4 2. Followed by? 3 3. What happens in 50% of pts?

Answer 40

1. - myalgia, - fatigue, - fever, - with or without respiratory symptoms, 2. followed by - hypoxia - dyspnea, - often with radiographic evidence of mediastinal widening. 3. Meningitis in 50% of patients

Question 41

Differential Diagnosis of Inhalational (Pulmonary) Anthrax | 9

Answer 41

1. Mycoplasmal pneumonia 2. Legionnaires’ disease 3. Psittacosis 4. Tularemia 5. Q fever 6. Viral pneumonia 7. Histoplasmosis (fibrous mediastinitis) 8. Coccidioidomycosis 9. Malignancy

Question 42

What on Chest X-Ray in Inhalational Anthrax? | 2

Answer 42

1. Mediastinal Widening and | 2. Pleural Effusion

Question 43

What will be Seen on Chest CT in Inhalational Anthrax? 2

Answer 43

1. Mediastinal and | 2. Hilar Adenopathy

Question 44

Gastrointestinal Anthrax 1. Abdominal distress, usually accompanied by what? 2 2. followed by? 2 3. Gastrointestinal illness sometimes seen as what? 3 4. Develops after ingestion of what? 5. Incubation period? 6. Case-fatality?

Answer 44

1. - bloody vomiting or - diarrhea, 2. followed by - fever - signs of septicemia 3. - oropharyngeal ulcerations - with cervical adenopathy and - fever 4. contaminated, poorly cooked meat 5. 1–7 days 6. 25–60% (role of early antibiotic treatment is undefined)

Question 45

Differential Diagnosis of Gastrointestinal Anthrax | 5

Answer 45

1. Acute appendicitis 2. Ruptured viscus 3. Diverticulitis 4. Diseases that cause acute cervical lymphadenitis or acute gastritis 5. Dysentery

Question 46

Anthrax Treatment protocol for cases associated with Bioterroist Events 1. Adults? 2 2. Duration? 3. Children? 2 4. Duration?

Answer 46

1. Adults - Cipro 500mg BID or - Doxycycline 100 mg BID 2. 60 days 3. Children -Cipro* 10-15 mg/kg BID or -Doxycycline: > 8 yrs and > 45 kg: 100 mg BID