Infectious 1 Flashcards
What to do next if the patient tests positive for HIV?
Start ART irrespective of CD4 count Determine CD4 count Determine viral load Determine drug resistance Prophylaxis based on CD4 Vaccination
Prophylaxis based on CD4 and other indications?
Primary prophylaxis
Cd4<200, Oropharengisl candidiasis, history of PCP-Dailey Cotri for PCP
<100(and positive serology for Toxo)–Daily Cotri for Toxo
<150 and live in an endemic area:Itraconazole for HC
Vancyclovir/acyclovir–For recurrent herpes
VarIG or IVIG administer within 4 days of exposure: For patients with close contact with shingle/Cp and no previous infection history and negative serology
Azithromycin for MAC and fluconazole for fungal infection not recommended more
Vaccine?
Varicella zoster-for patients with negative serology and have no shingles/chickenpox
Pneumococcal
Influenza
HAV and HBV
Alternative for COTRI?
For PCP:Dapsone,atovaquone and Pentamidine
For Toxo:Dapsone + Pyramitamine +lukoverine or Atovaqone +- pyramitamine + lukoverine
Lyme disease?
Transmitted by Ixodus thick bite
&-14 dy incubation
Caused by borrelia bergdoferi
Symptoms based on the stage
Common in the northeastern United States.
Stage 1—early localized: erythema migrans
(typical “bulls-eye” configuration B is
pathognomonic but not always present),
flu-like symptoms.
Stage 2—early disseminated: secondary lesions,
carditis, AV block, facial nerve (Bell) palsy,
migratory myalgias/transient arthritis.
Stage 3—late disseminated: encephalopathy,
chronic arthritis, peripheral neuropathy.
CSF:Lymphocytic predominancy
Managment?
Localized(EM)–Doxycyclin, amoxicillin for pregnants and azithromycin if patient allergic for both
Disseminated(Stage 2 &3)–IV ceftriaxone
Rhino cerebral mucormycosis CM?
caused by rhizopus specious(Irregular, broad, non septate hyphae branching at wide angles)
acute/progressive
Purulent nasal discharge, Fever, sinus pain,headache, and nasal congestion
Necrotic innovation of palate, orbit, and brain
Rhinocerebral, frontal lobe abscess; cavernous sinus thrombosis and cranial nerve involvement
Diagnosis and treatment?
Sinus endoscopy with biopsy and culture
Liposomal amphoteracine B
Surgical debridement
Treat underlying cause(hyperglycemia)
Risk for RCM?
DM(ketoacidosis)
Hematologic malignancy
Solid-organ or stem cell transplant
Prevention for meningiococcus?
Droplet precaution
Chemophrophlaxix(rifampin, ciprofloxacin, ceftriaxone, minocycline, and spiramycin)
Risk for PCP?
AIDS(<200 CD4) and Chronic Immunosuppressive therapy
This patient should receive COTRI prophylaxis
Clinical manifestation?
Indolent(AIDS) and respiratory failure(IST)
Fever, Dry cough, Hypoxia, and dyspnea
Increase LDH
Diffiuse bilateral reticulonodular infilitrate on CXR
Diagnosis?
Induced sputum or bronchoalveolar lavage
Managment?
Cotri(Po for mild and moderate and IV for sever) +/- Corticosteroid
AIDS: ART initiation within 2 weeks (after hypoxia improve)
Steroid and PCP?
Cotri lyse bacteria and worsen inflammation--worsen pulmonary function Indication saturation < 92% Spo2 < 70 mmg PA-Pa gradient more than 35
What test to do inpatient with IE with S.Bovis?
Colonoscopy(especialy type I S.B)
Diagnosis of early Disseminated and late disseminated LD?
Serology
Bacillary angiomatosis RF?
Bartonella hanselae/quintana Cat scratch, Body/hair lice bitee, or homelessness Sever IC(<100 CD4)
CM?
Vascular cutanous lesion (papular ,pruritic, prple, pedanculated) Systemic symptoms(fever, fatigue, and night sweet) Organ involvement(liver, bone and CNS)
Diagnosis and managment?
Biopsy:Microscopy/histopathology
Doxycycline/azithromycin
ART for HIV
Clinical manifestation of influenza?
abrupt onset of symptom
Peak Jan-Feb
mild UR symptoms
High fever (possibly predominate), headache, and myalgia
Variable but often unremarkable PE finding(mild pharyngeal erythema w/o exudate)
Managment?
For the healthy patient: treat symptomatically and not require diagnostic modality
For patients present within 48 hours of symptoms and have the risk for influenza complication: Give antiviral (e.g oseltamivir)
Who are at risk of developing complication?
Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis) Endocrine disorders (such as diabetes mellitus) Heart disease (such as congenital heart disease, congestive heart failure, and coronary artery disease) Kidney diseases.
Streptococcal pharyngitis?
Variable onset of symptom
Predominant pharyngeal symptom
variable possible fever/myalgia
Pharyngeal erythema, tonsilar hypertrophy, and exudate, tender cervical LN
Viral URTI?
slow, stepwise, migratory or evolving
Rhinorrhea, coryza, sneezing, and mild pharengitis
Nasal edema, mild pharyngeal erythema or normal
Mild systemic system
Managment of neutropenic fever?
Blood and urine culture
empiric broad-spectrum antibiotic with antipseudomonal coverage(e.g cefepime, meropenem, and piperacillin -Tezobactem)
Empiric antifungal with patient > 4 days of fever after antibiotic initiation
Neutropenia?
ANC<1500
Sever:ANC <500
ANC<1000:high risk for infection
Kaposi sarcoma?
Vivacious papular lesions predominantly affect the face, oral mucosa, perineum, and lower extremity
Lymphedema can present(due to cytokine and Vessel obstruction)
Can involve GI and other organs
Caused by HHV8
The presence of other OI increase the risk of devt and exacerbation
Is due to vascular proliferation
Diagnosis?
If atypical lesion or presence of systemic symptoms biopsy: To rule out BA
Managment?
HART
Surgery and chemotherapy in sever case
Clinical presentation of Chronic HCV infection
Asymptomatic
Nonspesific symptome(joint pain,fatigu,nusea,anorexia,myalgia and wight loss)
Increase transaminase(normal in 33%)
Progression to cirrhosis in 33%:HCC
Extrahepatic symptom?
Mixed cryoglobulinemia(palpable purpura, arthralgia, Glomerulonephritis, and Low Complement
Membroprolifrative disease
Porphyria cutaneous tarda(present with Bulle/vesicle on trauma/sun exposed are and all patients with PCT need to be screened for HCV)
Lichen planus(pruritic papular/vesicular lesion in dorsal forarm,butock and knee)
Trichinillosis epidimology and life cycle?
Caused by round worm trichinella
Ingestion of undercooked meat(MC: pork)
South America, Asia, and central Europe
Gastric acid releases larvae within 1 week of ingestion-Invade SI and develop to worm–worm release larvae and invade striated muscle and encyst
Clinical presentation?
Intestinal stage(1 week)
Abdominal pain, vomiting, diarrhea, and nausea
Muscle stage(4 weeks)
Fever and splinter hemorrhage
Myositis(increase CK);pain,tenderness & swelling
Periorbital edema, conjunctival/retinal hemorrhage
Eosinophilia
The disease can involve heart, lung & CNS
Sporotricosis caracter and risk?
Sporotrix shrunki (dimorphic fungi)
Decaying plant matter/soil
Gardners and landscapers
Clinical menifestasion?
subacute/chronic
skin papule: papule can ulcerated, non-prulent and odorless discharge
Proximal extension using lymphatic drainage
LDP, deeper spread, and systemic symptoms are rare
(Absence of this helps to differentiate from cat scratch disease and filariasis)
Diagnosis and managment?
Culture aspirate
3-6 month of oral intraconazol
Epidemiology of disseminated histoplasmosis?
Midweast and the central US
Soil contaminated by bird and bat dropping
Increase dose exposure or IC
symptoms?
Fever, chills, weight loss and cachexia Cough and dyspnea Papules and nodules Hepatosplenomegaly Lymphadenopathy
Diagnosis?
Pancytopnia Transaminase elevation High LDH CXR(intersticial or reticulonudular infiltratin with hilar LDP) Urine/Serum Ag(sensetive/rapid) serology culture(2-4 week)
Managment?
Mild/maintainace(intraconazol)
Moderate and severe (amphotericin B)-1-2 weeks then maintenance > 1-year itraconazole
ART within 2 week
Cause of esophagitis in HIV patients?
Candidiasis(oral trush present concomitanteley)
HSV(Orolabial lesion present concomitanteley)
CMG(if no above lesion present)
Odynophagia sever/predominate in viral case
Dysphagia predominate in candidiasis
Endoscopy?
Candidiasis(white plaqu)
HSV(Ulcerative round lesion)
CMV(distal ulcerative lesion
Bright red, friable exophytic mass in HIV patient with the systemic symptom?
Bacilary angiomatosis
Oral erythromycin is a treatment choice
Clinical manifestation of cryptococcal meningoencephalitis?
Subacute presentation
Symptom(Headache,Fever,Neck stiffness &AMS)
LP:(elevated P,Low glucose,Low Wbc elevation(<50/ul),and elevated protein
Managment?
2-week Amphoteracine B + Flucytosine Fluconazole maintenance (8 weeks) and consolidation for >1 year. Intrathecal AmpB for refractory case
Differentiation of cause of conjunctivitis?
different Clinical sign
Eye involvement?
V: U/B
B: U/B
A: B
Eye” stuck shut”?
In all 3 case
Discharge?
V: Watery, scanty, and string
B: Prulent, thick
A: Watery, scanty, and string
Discharge reaper with wiping?
V: No
B: Yes
A: No
sensation?
V: Burning, gritty
B: Continous discharge sensation
A: Itchy
Conjectural appearance?
V: diffuse injection, follicular: bumpy
B: diffuse injection,non follicular
C: diffuse injection, follicular: bumpy, conjunctival edema(bumpy)
Prenormal symptoms?
V: may have URTI symptom
B: No
A: No
MCC cause of bacterial conjunctivitis in adults?
S.Aures
HZ(shingle) pathogenesis?
VZ virus reactivation in sensory ganglia
Clinical manifestation?
predorm:pain,iching and tingling
rash: vesicular rash in dermatomal distributuion
Postherpetic neuralgia:Pain > 4 month from start of rash
Managment?
Acyclovir, valacyclovir and famciclovir
When to give PEP( Vaccine and immunoglobulin) for rabies exposure?
Must breach the skin
Bite by a high-risk wild animal(raccoon, bat..) and animal unavailable for the exam(euthanasia and brain biopsy)
If bitten by a domestic animal and become symptomatic within 10 day of followup
Domestic animal unavailable for follow=up
what about low-risk animals?
mouth, rabites,chumpek, and squirrel
No PEEP
Blastomycosis?
Fever, productive cough, weight loss, and NS
Skin ulceration and lytic bone lesion in a ribs(specific)
Common in Mississippi and Ohio(Wisconsin)
INH liver toxicity managment?
If AT >10x .Immidiateley discontinu
If AT <100.Contniu tx and follow up
Managment of patient exposed to HBV infected and transmitting individual?
If vaccinate and known AB response: may only need a booster vaccine
If not vaccinated: Vaccine + immunoglobulin
Vaccine within 12 hr
Immunoglobulins within 24 hr
Nocardia microbiology?
Partially acid-fast
Filamentous G+ rode
Aerobic
epidemiology?
Endemic in soil
Contracted by inhalation and skin injury
IC and elderly affected
Clinical fetcher?
Pnumonia:similar to TB
CNS: Brain abscess
Skin: abscesses on your hands, chest, or rear end.
Managment?
Antibiotic susceptibility assessment for all case
TMP-SMX(6-12)month–to prevent a recurrence
Add Ab like amikacine in sever case
Approch odynophagia and dysphagia in HIV patient?
If oral thrush:Fluconazole –if not respond endoscopy
No thrush?Endoscopy
CMV?
Gancyclovir
Aphthous ulcer?
Symptomatic therapy
Common 3 skin infection type?
Erysipelas
Cellulitis(prulent)
Cellulitis(non prulent)
Erysipelas?
Streptococcus pyogenic(GAS) Superficial dermis and lymphatics(E.ear involvement suggestive (lake deep dermis) Raised sharply demarcated edge Rapid spread and onset Fever in early course
Cellulitis(prulent)?
Streptococcus pyogenic and MRSSA Deep dermis and sucutanous fat Flat edge with poor demarcation Indolent(develop or days) Fever occurs latterly
Cellulitis(non prulent)?
MSSA and MRSA Purulent drainage Folliculitis;Hair follicle infection Furuncle:Folliculitis + dermis involvment--abcess Carbuncle: Multiple furuncle
Erysipilase managment?
No SS: oral amoxicillin
If SS: Ceftriaxone, cephazolin
extensive rash, Systemic toxicity, and comorbidity: culture
Treat if there skin breach
Biopsy finding in HSV and CMV?
HSV: Multinucleated giant cell
CMV: Intranuclear/cytoplasmic eosinophilic inclusion and balloning degeneration
Cause of urethritis in men?
N.G
C.T
M.G
Tricomonas(Rare)
Diagnosis?
NAAT: Diagnose all
N.G: Gram stain(G-ve rod)
C.T: Culture negative and gram stain negative
Managment?
C:T: Azithromycin or doxycycline/add ceftriaxone if gonococcus not ruled out or suspected
Meningitis empiric managment?
Age 2-50—Vancomycine + ceftriaxon/cefotaxin(3rd GC)
Age >50-Vancomycine + ceftriaxon/cefotaxin +Ampicilin
IC:Vancomycine + Cefepime(4th GC) + ampicilin
Nurosurgery/trauma(PS):Vancomycine + Cefepime
Dexametazone:D/C if S.P ruled out
Alternative for cefempime–Ceftazidime or meropinem
Alternative for Ampiciline– TMP-SMX
jarisch-herxheimer reaction?
Occur 6-48 hr after initiation of Ab to spirochete (syphilis, leptospirosis, and Lyme disease) infection
Acute onset fever, chills, and myalgia
Rash progression in case of 2ndary syphilis
Managment?
suportive(fluid and NSAID)
resolve within 48 HR
A complication of influenza?
inpatient with risk to develop complications
Pneumonia(bilateral diffuse reticular opacity)-may be a secondary bacterial infection
Muscle: Myositis and rhabdomyolysis
Cardiac: Myocarditis and pericarditis
CNS: encephalitis and TM
Oseltamivir is indicated
Infective endocarditis symptoms?
Systemic: Fever, Wt loss, myalgia, Arthralgia & malaise
Cardiac: Valvular insuficiency and HF
Vascular phenomena
immunologic phenomena
Vascular phenomena?
systemic emboli
mycotic aneurysm
Janeway lesion: macular, erythematous, and non-painful on palm and sole
immunologic phenomena?
Osler nodule: painful, violaceous nodule in fingertip/toes
Roth spot: Edematous and hemorrhagic lesion in retina
Glomerulonephritis
Positive RF
HCV diagnosis?
First, do AB
Confirm with PCR
Asses genotype and liver fibrosis
