Infections

Question 1

Patient presents with cough for 2 weeks (no sputum), a little difficulty breathing, and some complains of pain in the chest. No fever. Upon auscultation, you hear rhonchi. CBC shows slightly elevated WBC count.

Answer 1

Acute bronchitis

Question 2

It’s fall and a patient comes in with a sudden onset of a cough, sore throat, nasal congestion, fever, headache, and myalgia that began abruptly 2 days ago. The patient appears flushed. You notice swollen lymph glands in the neck and swollen part of pharynx between epiglottis and soft palate.

Answer 2

Influenza

Question 3

Tx for acute bronchitis

Answer 3

Symptomatic.

1. NSAIDS, acetaminophen, bed rest
2. Don’t use cough suppressants, beta 2 agonists (unless airway obstruction), or mucolytics
3. Treat rhinorrhea symptoms if follows URI

Question 4

Tx for Influenza

Answer 4

Supportive care- bed rest-self limiting so should resolve within a week, analgesics (no aspirin under 18), cough suppressants

2. Antiviral therapy for very severe cases, initiated within 2 days- Zanamivir or oseltamivir
3. Abx only for secondary bacterial infections

Question 5

Common causes of Acute Bronchitis

Answer 5

Virus- Influenza A and B, parainfluenza. Bacteria infection uncommon- Mycoplasma pna, chlamydophilia pna, and bordatella pertussis

Question 6

Common causes of Influenza

Answer 6

Influenza A and B. VERY contagious. Ptns are infectious 24-48 hrs before illness onset and 2 days after symptom onset.

Question 7

Diagnostic evaluation of Influenza

Answer 7

CBC may show leukopenia or leukocytosis. Rapid detection assay has poor sensitivity. Can do nucleic acid PCR.

Question 8

Most serious complications of influenza

Answer 8

Reye’s disease and primary influenza pneumonia

Question 9

What symptoms could Reye syndrome cause

Answer 9

Hepatic failure and encephalopathy.

Question 10

Prevention of influenza

Answer 10

Vaccine! 3 types available: Live attenuated vaccine, intradermal inactivated vaccine, intramuscular inactivated vaccine. Chemoprophylaxis in high risk patients with oseltamivir or zanamivir prescriptions

Question 11

Cause of CAP

Answer 11

Usually bacterial- S. pneumoniae most common, then H. Influenza. Viral- Influenza, RSV, adenovirus, etc. In pediatric population less than 5, viral infection more common

Question 12

How can you differentiate bacterial vs. viral CAP?

Answer 12

Bacterial CAP is more common. Patient will appear ill and more toxic. In viral, patient usually less toxic. Auscultation findings more diffuse and bilateral. Typically will have preceding URI sx.

Question 13

Patient presents with acute onset of fever, sweats, chills, dyspnea, productive cough with blood, chest discomfort, pleurisy, fatigue, anorexia, headache, and abdominal pain. In the PE, you note an elevated heart rate and increased respiratory rate. Arterial oxygen desaturation as well. Upon auscultation, there is slight wheezing and crackles. Bronchophony, egophony, and whispered pectiriloquy are positive. Decreased, bronchial breath sounds. Decreased? tactile fremitus, and dullness to percussion.

Answer 13

Community Acquired PNA

Question 14

Diagnostic evaluation of CAP

Answer 14

CXR or CT scan. CBC, acute phase reactants, serum electrolytes, blood and sputum cultures, pleural fluid cultures, nasopharyngeal swabs. Procalcitonin (viral vs. bacterial), Ag testing for different organisms, TB skin testing, serum and urine testing for histoplasmosis. HIV testing in high risk ptnts. Arterial blood gases in hypoxemic ptnts.

Question 15

Tx of CAP for outpatient adult

Answer 15

Macrolide or doxycycline. For high risk patients, respiratory FQ OR macrolide with beta lactam

Question 16

Tx of CAP for inpatient (Non-ICU) adult

Answer 16

Respiratory FQ OR macrolide with beta lactam

Question 17

Tx of CAP for inpatient (ICU) adult

Answer 17

Respiratory FQ plus azithromycin plus beta lactam (anti-strep/anti-pneumococcal)

Question 18

Tx for outpatient child

Answer 18

Amoxicillin

Question 19

Tx for inpatient child

Answer 19

3rd generation cephalosporin

Question 20

Tx for CAP

Answer 20

Supportive care, empiric therapy until culture comes back, smoking cessation

Question 21

How to decide whether CAP should be treated inpatient or outpatient?

Answer 21

Clinical prediction tools assess severity of illness, ability to maintain oral intake, compliancy of patient, living situation, functional status/cognitive impairment using PSI (Pneumonia Severity Index) or CURB-65

Question 22

Recovery of CAP

Answer 22

Cough may persist for weeks to months, follow up CXR if persistent or recurrent PNA

Question 23

Causes of fungal PNA

Answer 23

Cryptococcus, Histoplasmosis, Coccidioides, Blastomyces

Question 24

Type of pneumonia with wide range of manifestations- can be asymptomatic, flu-like, or present as severe pulmonary infection with associated respiratory failure.

Answer 24

Fungal pneumonia

Question 25

Diagnosis of fungal PNA

Answer 25

clinical presentation, radiographic imagine (CXR), fungal cultures, body fluid or tissue analysis

Question 26

What causes atypical pneumonia?

Answer 26

Atypical bacteria- legionella, mycoplasma, or chlamydophilia spp.

Question 27

Tx for Mycoplasma pneumonia

Answer 27

Macrolides, fluoroquinolones, and/or tetracyclines

Question 28

Tx for Legionella pneumonia

Answer 28

Macrolides or floroquinolones

Question 29

Tx for Chlamydophilia pneumonia

Answer 29

Doxycycline

Question 30

Incubation period for Influenza

Answer 30

1-4 days

Question 31

Patient with Influenza. They just got it yesterday morning. When can they go back to school, and when will they feel better?

Answer 31

Influenza is contagious for 24-48 hours before symptom onset, and 2 days after. So if they just started to get symptoms yesterday, can probably return to school tomorrow, but do a day after tomorrow just to be safe. Symptoms resolve within a week.

Question 32

Patient with influenza comes back into office after 5 days with fever that has gotten worse. You do a CBC, and find that elevated levels of Leukocytosis. What do you suspect?

Answer 32

Secondary bacterial infection- complications include acute sinusitis, otitis media, purulent bronchitis, and pneumonia

Question 33

What is the most deadly infectious disease in the U.S.?

Answer 33

Pneumonia

Question 34

Patient comes in that had URI last week. They now have CAP. Auscultory findings are more diffuse and bilateral. Bacterial or viral?

Answer 34

Viral. Bacterial is usually more toxic with moderate to severe respiratory distress.

Question 35

What can cause CAP in children?

Answer 35

measles, varicella, HSV

Question 36

Evidence of infiltrate on CXR in patient with fever, cough, dyspnea, sweats, chills, chest discomfort.

Answer 36

CAP.

Question 37

Is F/U necessary with CAP patient after resolution of symptoms?

Answer 37

Yes, follow up after 6-8 weeks, especially in patients >50 years of age and smokers to document resolution of pneumonia and exclude malignancy

Question 38

Your patient with pneumonia wants to know the complications associated. What do you tell them?

Answer 38

The following are more common to occur as a result of bacterial pneumonia: pleural effusion and empyeme, necrotizing pneumonia, lung abscess, pneumatocele, hyponatremia

Question 39

Fungus commonly seem to cause pneumonia found in the south (Texas, mexico, central and south america)

Answer 39

Coccidioides spp.

Question 40

What pneumonia causing fungus is found in soil throughout the world. vs. in moist soil?

Answer 40

Blastomyces- moist soil, cryptococcus- soil throughout the world

Question 41

Pneumonia causing fungus most likely caused by someone that lives near the mississippi river?

Answer 41

Histoplasmosis

Question 42

Tx for fungal pneumonia

Answer 42

Resolves on its own or treat with antifungals

Question 43

What atypical bacteria would you most commonly see in patient under 40?

Answer 43

Mycoplasma

Question 44

Your 60 year old patient has pneumonia. She just came back from a trip to India where she lived in a village and may have had uncontaminated water. What caused her pneumonia most likely?

Answer 44

Legionella- spread through contaminated water

Question 45

What is chlamydophilia pneumonia associated with?

Answer 45

Pharyngitis and hoarseness.

Question 46

Leading cause of death in hospitals due to infection

Answer 46

Nosocomial pneumonia

Question 47

Contrast CAP with nosocomial pneumonia

Answer 47

caused by different infections, have different abx susceptibility patterns (higher incidences of drug resistance with nosocomial), and more likely to get more severe infection with nosocomial because systems are already compromised

Question 48

Nosocomial pneumonia cause

Answer 48

S. aureus, Psuedomonas

Question 49

Tx for nosocomial pneumonia

Answer 49

Start of with broad spectrum combination abx followed by de-escalation of therapy once culture results are available.

Question 50

What kind of tx would you give for HIV-related pneumonia?

Answer 50

MicrobiCIDAL therapy start asap

Question 51

Reactivation of virus is common in which pneumonia?

Answer 51

HIV-related. Includes Cytomegella virus, strongyloidiasi

Question 52

How are bacterial HIV-related pneumonias different from general population?

Answer 52

They are more often preceded by viral URI

Question 53

Patient presents with dyspnea, cough, and fever. Bilateral, diffuse interstitial infiltrates. What is the diagnosis if you know the cause is a fungal infection.

Answer 53

HIV-related pneumonia, caused by pneumocystis jirovecii. = most common opportunistic infection in patients with HIV.

Question 54

How is fungal pneumonia in HIV-related patient diagnosed?

Answer 54

Isolation of the organism in respiratory secretions, can't grow in lab.

Question 55

Tx for HIV-pneumocystis pneumonia

Answer 55

Supportive therapy, TMP-SMX, and prednisone. Bactrim can be administered as prophylaxis in selected patients if prone to getting pneumonia.

Question 56

What symptoms would you expect to find in a child with HIV-pneumocystis pneumonia?

Answer 56

Non-specific and insiduous

Question 57

Tx you would prescribe to newborn with high chance of developing HIV pneumonia

Answer 57

bactrum Prophylaxis after 4-6 weeks of life even if CDR count is more than 200 and continued for 1 year of life

Question 58

Normal CD4 count

Answer 58

500-1000

Question 59

HIV-related fungal infections

Answer 59

pneumocystis jirovecci and aspergillus species

Question 60

What is the most consistent feature of PNA?

Answer 60

Tachypnea

Question 61

Ages of live attenuated vaccine

Answer 61

2-49

Question 62

Age of inactivated intradermal vaccine

Answer 62

18-64

Question 63

When are adults and children suspected of HIV pneumocystis jirovecii

Answer 63

Adults- CD4 counts greater than 200. Infants can get it below or event about 200

Question 64

Alternative test to diagnose latent TB, (if have receieved BCG vaccine) besides TB skin test

Answer 64

Interferon gamma release assay- don't use to diagnose active TB

Question 65

Side effects of ioniazid in tx of TB?

Answer 65

hepatitis and peripheral neuropathy- treat with pyridoxine supplementation

Question 66

What part of TB does reactivation or progressive primary TB affect?

Answer 66

Apices