Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Med > Infectious Disases > Flashcards

Infectious Disases Flashcards

1
Q

Preventive measures for contact infectious

A

Contact precaution

Barrier precaution

Safe needle/sharp practices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Example of droplet borne infections

A

Influenza

Mumps

N.meningitidis

Bordetella pertussis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Prevention of droplet borne diseases

A

Contact/droplet precaution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Droplet borne range

A

Up to 2 meters

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Airborne infections examples

A

TB
VZV
measles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Preventive measures for airborne diseases

A

Airborne precaution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Preventive measures for food/water borne infections

A

Vaccination where available

Clean food/water supply

Contact precautions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Preventive measures for zoonotic infections

A

Prophylactic meds

Vaccination

Protective clothing

Repellents

Mosquito nets

Tick inspection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Preventive measures for vertical infections

A

Prenatal screening

Prophylactic treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Definition of nosocomial infections

A

Acquired more than 48 h after admission

Or

Within 30 days from discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

RFs for nosocomial infection

A

Prolonged hospital stay

AB use

Hemodialysis

Intensive care

Colonization with a resistant organism

Immunodeficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Common nosocomial infectious agents

A

MRSA

VRE

C.difficile

Extended spectrum B-lactamase producing E.Coli, K.Pneumoniae

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Inv for nosocomial MRSA

A

Admission screening culture from nares and peri-anal region (to identify colonization)

Culture of infected sites

CXR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Mx of MRSA nosocomial infection

A

Contact precaution

Vancomycin
Linezolid
Daptomycin

Decolonization:
2% chlorhexidine wash
+doxy/TMP-SMX/refampin x7d
+mupirocin bid to nares x7d

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Inv for vancomycin resistant enterococcus

A

Rectal/perirectal swab Or Stool culture For colonization

Culture of infected site

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of nosocomial VRE

A

Contact precautions

Ampicillin

Linezolid

Tigecycline

Daptomycice

No effective decolonization method

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

C. Difficile inv

A

Stool PCR for toxin A and B genes

Stool immunoassay for toxins A and B (less sensitive than PCR)

AXR

Sigmoidoscopy (avoid if known colonic dilatation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Mx of nosocomial C. Difficile

A

Contact precautions

Stop culprit AB

IV fluid

Mild-mod: metronidazole, PO, x 10-14 d

Severe: vancomycin, PO, x 10-14 d

Toxic megacolon: metronidazole IV + Vancomycin PO + general surgery consult

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Most common culprit ABs for C.difficile

A

Q

Cephalosporins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

ESBL producing E.Coli, K. Pneumoniae inv

A

Blood/sputum/urine/aspirated fluid culture

Imaging at infected site: CXR, CT, U/S

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Mx of ESBL producing

A

Carbapenems

Non-betalactams

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

The most common organisms in community-acquired pneumonia

A 
Typical
S. Pneumoniae
M.catarrhalis
HI
S.aureus
GAS

Atypical:
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila

Viral:
Influenza virus
Adenovirus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

The most common organisms in nosocomial pneumonia

A

Enteric GNB

Pseudomonas

S. Aureus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Aspiration

A

Oral anerobes

Enteric GNB

S. Aureus

Gastric contents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
The most common organisms in pneumonia in ImmComp pts
P. Jiroveci Fungi Nocardia CMV HSV TB
26
The most common organisms in pneumonia in alcoholic pt
Klebsiella Enteric GNB S. Aureus Oral anaerobes TB
27
As of klebsiella
Alcoholic Aspiration Abscess
28
Red currant jelly sputum
Klebsiella
29
Most common location for aspiration pneumonia
Right middle or lower lobes
30
Inv for pneumonia
Pulse oximetry, ABG CBC, diff, Electrolytes Urea, Cr, U/A Troponin/CK, LFT Sputum Gram stain/C&S Blood C&S Serology/viral detection Pleural fluid C&S CXR, CT Bronchoscopy, washing
31
Indication of pleural effusion assessment in pneumonia
If effusion > 5cm
32
Indication of bronchoscopy and washing in pneumonia
Severely ill pt refractory to Tx ImmComp
33
Tx of pneumonia
ABC O2 IV fluid Salbutamol Determining the need for hospitalization, and AB
34
CURB 65 score for pneumonia admission
Confusion: 1 Urea/BUN: > 7/20 : 1 RR > 30: 1 BP > 90/60 : 1 Age > 65 : 1 If 2: hospitalize If 4: ICU
35
AB for CAP outpatient No comorbidity No AB within last 3 mo
Macrolide Or Doxy
36
``` AB for CAP Outpatient With comorbidity Or AB within last 3 mo ```
Respiratory Q (moxi, gemi, levo) Or B-lactam (cefotax, ceftria, ampi-bactam)+ Macrolide
37
AB for CAP Inpatient Ward
Respiratory Q
38
AB for CAP Inpatient ICU
B-lactam + macrolide Or B-lactam+ Q
39
Tx of HAP No increased likelihood if MRSA No hogh risk of mortality
``` Piperacillin-tazobactam Or Cefepime Or Levo Or Imipenem Or Meropenem ```
40
Tx of HAP With increased likelihood of MRSA Not at high risk of mortality
``` Piperacillin-tazobactam Or Cefepime Or Ceftazidime Or Levo Or Cipro Or Imipenem Or Meropenem Or Aztreonam ``` PLUS Vancomycin Or Linezolid
41
If HAP with high risk of mortality Or Recipient of IV AB within last 3 mo
``` Two of (avoid 2 Beta) Piperacillin-tazobactam Or Cefepime Or Ceftazidime Or Levo Or Cipro Or Imipenem Or Meropenem Or Aztreonam Or amika/genta/tubra ``` PLUS MRSA: vanco Or linezolid Or MSSA: piperacillin-tazobactam, cefepime, levo, imipenem, meropenem
42
Tx of VAP
Double anti pseudomonas/gram negative coverage + MRSA coverage ``` Piperacillin-tazobactam Or Cefepime Or Ceftazidime Or Imipenem Or Meropenem Or Aztreonam ``` ``` PLUS Cipro Or Levo Or Amika/genta/tubra Or Polymyxin (colistin or polymyxin B) ``` PLUS Vanco Or Linezolid
43
High risk of mortality in pneumonia:
Need for ventilatory support Septic shock
44
Indications for S. Aureus coverage in pneumonia
IV AB Tx within 3 mo Prevalence of MRSA > 20% or unknown
45
Summary of HAP/VAP Tx
If HAP: 1 anti gram negative/pseudomonas If HAP + Risk of MRSA: 1 anti-pseudomonas/gram neg + 1 anti-MRSA If HAP + High risk for mortality: 2 anti pseudo/gram negative + 1 anti-MRSA/MSSA (depending on risk) If VAP: 2 anti-pseudomonas/gram negative + 1 anti-MRSA
46
Pneumonia prevention
Influenza A and B vaccine: Annually, for all ages 6 mo and higher PPSV (pneumovax): All > 65 2-65 yr: if high risk of invasive pneumococcal disease (asplenia, Immdef...) PCV (prevnar): All < 5 yr 5-17 yr: if high risk for invasive pneumococcal disease and who have not received prevnar before. CDC: adults at high risk for invasive pneumococcal disease
47
Seasonal influenza is the result of:
= epidemic New subtypes due to antigenic drift (point mutations)
48
Pandemic influenza is the result of
``` Antigenic shift (Mixing of two different viral strains from different hosts= new strain) ``` Only with type A
49
Transmission of influenza
Droplet | Possible airborne
50
Influenza incubation period
1-4 d
51
Influenza course
7-10 d
52
Dx if influenza
Clinical Gold: RT-PCR of nasopharyngeal swab Rapid Ag detection: DFA Serology: rarely
53
Tx of influenza
Supportive If severe/ high-risk of complication: Zanamivir (Tx and Px against flu A and B) Oseltamivir (Tx and Px against flu A and B) If Tx within 48 h: decreased duration and severity Tx beyond 48 h: in ImSup and critically ill pts
54
RF of cellulitis with G-, fungi
Water exposure | ImComp
55
RF for cellulitis
``` Trauma Surgery PVD Lymphedema DM Cracked skin Tinea pedis ```
56
Inv for cellulitis
CBC, diff Blood C&S if febrile Skin swab if open wound with pus
57
Tx of cellulitis
Cephalexin G- coverage if RFs present IV cefazolin if: Extensive erythema Systemic symptoms Consider MRSA coverage Limb rest and elevation
58
Necrotizing fasciitis types
Type I: Polymicrobial Type II: Monomicrobial with GAS >>S. Aureus
59
Inv for necrotizing fasciitis
DO NOT WAIT FOR RESULTS BEDORE STARTING Tx Clinical/surgical Dx Blood/tissue C&S Serum CK Plain Xray Surgical exploration
60
Tx of necrotizing fasciitis
IV Fluids Emergency debridement IV AB: Meropenem OR piperacillin/tazobactam + clindamycin IV + vancomycin (if MRSA considered) If Type I: piperacillin/tazobactam + clinda IV If Type II: cefazolin (or cloxacillin) + clinda If Confirmed GAS: penicillin G + clinda AND: evaluate for streptococcal TSS (IVIg)
61
Diarrhea definition
3 or more loose/liquid stool/d Or > 200 g/d for >2/d Acute: >2 d but < 14 d
62
Purpose of evaluation of acute diarrhea
Identifying characteristics of the illness or patient that warrants further investigation Assessing volume status for appropriate method of rehydration
63
Tx of diarrhea
Mainstay: Hydration: oral, IV if oral insufficient ``` Antidiarrheal agents (loperamide, bismuth): Contraindications: Fever Bloody stool C. Difficile ``` AB: rarely indicated
64
Risks of AB in diarrhea
No effect for viral (most common cause) Eradication of normal flora, predisposing to C. Difficile Prolongs shedding of Salmonella and other bacteria HUS if EHEC
65
Indications for investigations in acute diarrhea
Fever Blood in stool Severe abdominal pain +/- peritoneal signs Profuse diarrhea with signs of hypovolemia Hospitalized or recent use of antibiotics Age 65 or higher with comorbidities Immunocompromised Diarrhea more than 7 days duration Exposure to suspicious foods or untreated water Sexual contacts: MSM
66
Investigations for acute diarrheazg
Stool for leukocyte Stool C&S for: Salmonella, Shigella, Campylobacter Special tests: If blood in stool: Stool C&S for EHEC Stool for shiga toxin If recent AB/hospitalization/>65+comorbidities/ImSup: Stool for C. Difficile toxins A and B If diarrhea >7d, exposure to untreated water, HIV, MSM: Stool O&P for giardia/cryptospordium/E.histolytica
67
If there are no indications for further investigation in acute diarrhea what’s next step
Rehydration Anti-diarrheal agents
68
Indications for antimicrobial therapy for acute diarrhea
``` Absolute indications: S. Typhi Shigella C. Difficile Cryptospordium E. Histolytica ImmComp pts ``` ``` Relative indications: V.cholerae Non-typhoid salmonella Campylobacter Yersinia Giardia ETEC (Based on severity of illness) ```
69
B. Cereus types
``` Type A: Emetic, no fever, no pain, no blood Rice dishes. Preformed exotoxin Inc: 1-6 h Dur: <12 h ``` ``` Type B: Diarrhea, no other Sx Meat, veg, dried beans, cereal. 2° endotoxin Inc: 8-16 h Dur: <24 ```
70
Campylobacter jejuni
Most common bacterial cause of diarrhea in Canada Uncooked meat Especially poultry Inc: 2-10d Fever, diarrhea, bloody stool, abdominal pain, N/V Dur: < 1wk AB: Macrolide Quinolone If: >1wk, bloody, ImComp
71
C. Difficile
Can be present in colon in small numbers +/-Fever, pain, bloody diarrhea Tx: Stop culprit AB
72
C. Perfringens
Meat, poultry Inc: 8-12 h Diarrhea, fever, abdominal pain Dur < 24 h Heat resistant spores 2° enterotoxin Enteroinvasive
73
EIEC
Food/water Inc: 1-3 d Fever, bloody stool, diarrhea, abd pain Dur: 7-10d
74
ETEC
Food/water, travel Inc: 1-3 d Diarrhea, abd pain Dur: 3 d If mod-severe: Q Azithro Heat liable and heat stable toxins
75
EHEC
Hamburger Raw milk Drinking/recreational water Inc: 3-8 d Diarrhea, blood, pain, N/V Dur: 5-10 NO AB, NO ANTIDIARRHEA (increase HUS) Shiga toxin Monitor renal function
76
Salmonella Typhi/paratyphi
Fecal-oral Food, water, travel Inc: 10-14 d Diarrhea, fever, blood, pain, N/V Dur: <5-7 d Tx: Ceftriaxone, cipro, azithro Rose spot, fever, abd pain precede diarrhea in S. Typhi
77
Non-typhoid salmonella
Egg, poultry, meat, milk Inc: 12-72 h Diarrhea, fever, blood, pain, N/V Dur: 3-7 d Tx: Q: If severe, extremes of age, joint prostheses, valvular heart disease, severe atherosclerosis, cancer, uremia
78
Shigella
Fecal-oral Food/water Inc: 1-4 d Diarrhea, fever, blood, pain, N/V Dur:< 1wk Tx: Q
79
S. Aureus
Unrefrigerated meat/dairy products (custard, pudding, potato salad, mayo) Inc: 2-4 h Diarrheal, pain, N/V Dur: 1-2 d Heat-stable preformed exotoxin Tx: none
80
Vibrio cholerae
Food/water, shellfish Diarrhea Inc: 1-3 d Dur: 3-7 d Tx: Q, tetra
81
Yersinia
Food, milk Incu: 5 d Diarrhea, fever, pain, N/V, blood Dur: up to 3 wk If severe: Q Mainly children Mesenteric adenitis, terminal ileitis mimicking appendicitis
82
Cryptospordium
Fecal-oral Inc: 7 d Diarrhea, fever, N/V Dur: 1-20 d Tx: Paromomycin + nitazoxanide Immune reconstitution if ImSup
83
Entamoeba histolytica
Fecal-oral Inc: 2-4 wk Diarrhea, fever, blood, N/V Tx: Metro + iodoquinol/paromomycin If asymptomatic cyst passage: Iodoquinol/paromomycin
84
Giardia
Food/water, fecal-oral Inc: 1-4 w Diarrhea, pain, N/V Tx: Metro, nitazoxanide Asymptomatic carrier: none ``` Daycare children Untreated water MSM ImDef May need duodenal Bx ```
85
Diarrhea causing Guillain-Barré
Campylo
86
Dysentery agent mimicking appendicitis
Yesinia
87
Diarrheal agent causing liver abscess
E. Histolytica
88
E. Histolytica sigmoidoscopy
Flat ulcers with yellow exudates
89
Beaver fever
Giardia
90
Diarrhea in pts with decreased IgA
Giardia
91
Norovirus (norwalk)
Fecal-oral Inc: 24h Diarrhea, pain, N/V Dur: 24 h
92
Rotavirus
Fecal-oral Inc: 2-4 d Diarrhea, fever, N/V Dur: 3-8 d All children infected by 3 yr of age Oral vaccine: at 2-4 mo
93
Most common traveller diarrhea agent in southeast Asia
Campylo
94
Tx of traveller diarrhea
Rehydration: Sealed beverages Oral rehydration solution if severe (1 package in 1 litre boiled/treated water) Loperamide, bismuth AB if mod-sev: cipro, azithro, rifaximin
95
Prevention from traveller diarrhea
``` Proper hygiene practices: Avoid unhygienic food/beverage Avoid raw fruits, vegetables without peel Avoid raw/undercooked meat/seafood Avoid untreated water ``` Bismuth Vaccine
96
Antidiarrheal agent, causing stool be mistaken for melena
Bismuth
97
Dukorel
Oral vaccine against: V. Cholerae ETEC Indications: Short-term travellers, >2yr, who are high-risk (chronic illness): CRF, CHF, DM1, IBD ImSup Hx of repeat traveller diarrhea Increased risk of acquiring traveller diarrhea: Hypochlorhydria, young children > 2yr Cholera endemic area Vaccine against S. Typhi available
98
Septic arthritis RFs
N. Gonorrhea: Previously 75% of cases in young sexually active adults S. Aureus: All ages. Most non-gono cases GAS, GBS G- : Neonates, elderly, IV drug, ImComp S. Pneumoniae: Children Kingella kingae: Children <4 yr HIB: Unvaccinated children Salmonella: SCA Coagulase - staph: Prosthetic joints
99
RFs for gonococcal septic arthritis
<40 Multiple partners Unprotected intercourse MSM
100
Rf for non-gono arthritis
Most affected children: No R Bacteremia Prosthetic joint Recent joint surgery Underlying joint disease ImmComp Loss of skin integrity Age > 80
101
Gonococcal arthritis forms
Bacteremic form: Fever, malaise, chills Migratory polyarthralgias, tenosynovitis next to inflammed joint, pustular dermatitis Septic arthritis form: Local symptoms in involved joint.
102
Most common involved joins in non-gonococcal arthritis
Most often large, Wt-bearing joints Wrists
103
RFs for polyarticular septic arthritis
RA GBS Endocarditis
104
Inv for septic arthritis
Gono: Blood C&S Endocervical/urethral/rectal/oropharyngeal testing Non-gono: Blood C&S For all: Arthrocentesis: CBC, diff, Gram, Crystals Xray
105
Joint fluid in infectious arthritis
Opaque WBC > 15000 PMN > 90% Positive culture
106
Positive culture in gono septic arthritis
<50%
107
Empiric treatment for septic arthritis in adults
Ceftriaxone + vancomycin Daily joint aspirations until sterile culture Physiotherapy
108
Empiric treatment for septic arthritis in children
Cefazolin or cloxacillin IV, unless MRSA considered Daily joint aspirations until sterile culture Physiotherapy
109
If culture result is gono in septic arthritis, AB modification?
Change to Ceftriaxone + azithro Responds well after 24-48 h
110
Duration of AB therapy in septic arthritis
Staph: 4 wk Strep: 2-3 wk GNB: 4 wk
111
Indications for surgical joint drainage in septic arthritis
Persistent positive culture on repeat arthrocentesis Hip joint involvement Prosthetic joint involvement
112
Diabetic foot ulcer infection organisms
Mild cases: S. Aureus Strep Mod-sev cases: Polymicrobial (aerobe, GNB, anaerobe) Mild: no bone/joint involvement Mod: bone/joint Sev: systemic toxicity
113
When to consider infection in a diabetic ulcer?
Positive probe to bone Ulcer > 30 d Recurrent ulcers Trauma PVD Prior amputation Loss of protective sensation Renal disease Hx of walking barefoot
114
Dx of infected ulcer in diabetic foot
2 or more of cardinal signs of infection Or Presence of pus
115
Inv for diabetic ulcer
Curettage specimen from ulcer base Aspirate from an abscess Bone Bx Blood C&S if fever Xray or MRI to assess osteomyelitis
116
Negative initial Xray in diabetic foot ulcer. Next step?
Repeat 2-4 wk later If high suspicion: MRI
117
Tx of diabetic foot ulcer
Early surgical debridement Revascularization Amputation Eliminate/reduce pressure Local wound care AB: Mild: cephalexin, clinda PO Moderate: Clinda + cipro/moxi/cftriaxone/ertapenem IV +/- MRSA Severe: Piperacillin/tazobactam or meropenem +/- vanco for MRSA
118
Clinical/paraclinical finding in favor of associated osteomyelitis in diabetic foot ulcer
Visualization of bone Ulcer area > 2cm (and erythema > 2cm) Probe-to-bone Clinical judgment ESR > 70 Plain radiographs findings MRI findings
119
high-risk RFs for endocarditis
Prosthetic cardiac valve Previous IE Congenital heart disease (unrepaired, repaired within six months, repaired with defects) Cardiac transplant with valve disease
120
Moderate-risk RFs for infective endocarsitis
Other congenital cardiac defects Acquired valvular dysfunction Hypertrophic CMP
121
Low/no-risk RFs for Infective endocarditis
Secundum ASD or Surgically repaired ASD < VSD, PDA, MV prolapse, IHD, Previous CABG
122
Non-cardiac RFs for infective endocarditis
IVDU indwelling venous cath Hemodialysis Poor dentition DM HIV
123
Frequency of valve involvement in IE
MV>>AV>TV>PV In IVDU: TV in 50%
124
IE etiology in native valve
Strep viridans> S. Aureus Entrococcus
125
IE etiology in IVDU
S. Aureus>>> Strep Enterococcus If using tap water to dilute drug: pseudomonas Saliva: oral flora Toilet water: GI flora
126
IE etiology in prosthetic valve
<2 mo surgery: S.aureus> S. epid ``` > 2mo: Strep S. Aureus S. Epi Enterococ ```
127
IE etiology in association with underlying cirrhosis
S. Bovis (gallolyticus)
128
IE etiology in association with underlying GI malignancy
S. Bovis
129
Culture negative IE etiologies
HACEK Hemophilus parainfluenza Aggregatibacter Cardiobacterium Eikenella Kingella Coxiella Bartonella Tropheryma whipplei Fungi Mycobacteria
130
Clubbing in IE
In subacute type
131
Immune complex lesions of IE
Osler Roth GN Arthritis
132
Embolic/vascular lesions of IE
``` Petechia over legs Splinter hemorrhage Janeway FND H/A Splenomegaly (subacute) Microscopic hematuria Flank pain Active sediment ```
133
Major Duke criteria for IE
``` 1. Positive Blood culture Typical MO+ 2 separate B/Cs Or persistently positive B/C (>12h apart) Or all 3 B/Cs positive Or majority of > 3 B/Cs positive Or single Coxiella positive Or antiphase IgG titer > 1/800 ``` 2. Evidence of endocardial involvement Echo: mass, abscess, new partial dehiscence Or new valvular regurgitation
134
Minor Duke criteria for IE
Predisposing condition Fever 38 Vascular phenomena Immunologic phenomena Positive B/C not meeting criteria
135
Inv for IE
B/C: 3 sets, each containing one aerobic, one anaerobic sample Collected from different sites >1 h apart Repeat B/C: After 48-72 h of appropriate AB At least x 2 ``` CBC, diff ESR RF BUN/Cr U/A, urine C&S ECG Echo: TEE if TTE not adequate/prosthetic valve/complicated IE ```
136
Dx of IE using Duke criteria
``` Definite Dx: 2 major Or 1 major + 3 minor Or 5 minor ``` Possible: 1 major + 1 minor Or 3 minor
137
Tx of infective endocarditis
Wait for confirmation, Treat empirically if pt is unstable (AFTER OBTAINING CULTURES)
138
1st line empiric AB for native valve IE
Vanco + Genta/ceftriaxone
139
1st line empiric AB for prosthetic valve IE
``` Vanco + Genta + Cefepime + Rifampin ```
140
IE prophylaxis indications
``` High risk individuals: Prosthetic valve Previous IE Cardiac transplantation valvuloparhy Congenital heart disease... ``` Procedures: Dental (bleeding) Invasive respiratory tract procedures (incision, Bx) Procedures on infected skin Procedures on infected musculoskeletal tissue
141
AB for IE Px
Dental/respiratory: Amoxi, single dose, 30-60 min prior Skin/soft tissue: Cephalexin, single dose, 30-60 min prior Clinda if penicillin-allergic in both
142
Indications for surgical treatment of IE
Refractory CHF (MOST COMMON) Abscess Fungal Valve perforation Unstable prosthesis 2 or more major emboli AB failure Mycotic aneurysm Staph on prosthesis valve
143
Adverse prognostic factors for IE
CHF Prosthetic valve infection Abscess Embolization Persistent bacteremia Altered mental status
144
Highest mortality rates in IE
Prosthetic valve> Non-IVDU S.aureus> IVDU S. Aureus or Strep
145
Common organisms in meningitis 0-4 wk
GBS E. Coli Listeria Klebsiella
146
Common organisms in meningitis 1-3 mo
``` GBS E. Coli S. Pneumoniae N. Meningitidis HI ```
147
Common organisms in meningitis > 3 mo
S. Pneumoniae N. Meningitidis Listeria if > 50 and comorbidities
148
Petechial rash location in meningococcal meningitis
Trunk | Lower extremities
149
Inv for meningitis
CBC, diff, Lytes Blood C&S ``` CSF: Opening pressure Cell count, diff Protein Glucose Gram, C&S ``` Imaging: CT, MRI, EEG, if FND
150
Further investigations for meningitis
``` If viral etiology suspected: WNV serology (summer, early fall) ``` PCR for: HSV, VZV, enteroviruses, if infant < 6m, parechoviruses AFB, fungal C&S, cryptococcal Ag, if: ImmComp, subacute, travel Hx, TB exposure
151
CSF WBC count in bacterial meningitis
500-10,000
152
CSF WBC in viral meningitis
10-500
153
Tx of bacterial meningitis
DO NOT DELAY AB FOR CT OR LP <28 d: Cefotaxime + ampicillin 1-3 mo: Cefotaxime + vancomycin >3 mo: Ceftriaxone + vancomycin + IV ampicillin if RFs for listeria Dexa IV within 20 min prior to or with 1st dose of AB Continue dexa if proven pneumococcal meningitis Dexa not recommended for neonates
154
RFs for listeria
>50 yr ImComp Alcoholism
155
Prevention of meningitis with vaccination
Immunization: Children: Vaccination: HIB, S. Pneumoniae (conjugate: Prevnar or Synflorix), N. Meningitisdis Adults: Vaccine: N. Meningitidis (if outbreak, epidemics, travel). S. Pneumoniae (Pneumovax, polysaccharide) if high risk
156
Post-exposure meningitis Px for HIB
For close contacts if: They live with an inadequately immunized (<4y) Or They live with an ImComp child (<18yr) “Rifampin”
157
Post-exposure meningitis Px for N. Meningitidis
Close or household contacts Cipro Rifampin Ceftriaxone Also meningococcal vaccine for post-exposure Px and outbreak control
158
Highest mortality rate among meningitis etiologies
Pneumococcal
159
Poor prognostic factors for meningitis
Extremes of age Delay in Dx/Tx Stupor/coma Seizures FND Septic shock at presentation
160
Indication for pneumococcal polysaccharide vaccine (pneumovax)
>65 yr Can also give conjugate vaccine (polysaccharide 8 wk later than conjugate)
161
Indications for giving both polysaccharide and conjugate pneumococcal vaccines
Chronic cardiovascular/respiratory/hepatic/renal disorder. Asplenia. SCA. ImmSup Polysaccharide 8 wks later than conjugate
162
Imdications for meningococcal vaccine
Healthy young adults Asplenia Travelers to high risk areas Military Lab personnel Complement/ factor D, properdin deficiency Eculizumab
163
Auto-Ab mediated encephalitis in adults is associated with
Malignancy
164
HSV encephalitis site
Medial temporal, inferior frontal lobes
165
HSV encephalitis pathologic process
``` Acute Necrotizing Hemorrhagic Lymphocytes Plasma cells ``` HSV1 >>HSV 2
166
Encephalitis associated with influenza and respiratory viruses
Acute | Necrotizing
167
HSV encephalitis symptoms
Acute onset FND: hemoparesis, ataxia, aphasia, seizures Temporal lobe involvement: behavioral disturbances Rapidly progressive Sequela: memory and behavioral disturbances
168
Inv for encephalitis
CSF (including PCR for HSV, VZV, EBV, enterovirus, parechovirus, M.pneumonia...) Serology: EBV, WNV, rabies, bartonella Imaging: CT, MRI, EEG Brain Bx
169
EEG in HSV encephalitis
Early focal slowing Periodic discharge
170
Tx of encephalitis
Supportive Monitor vital signs Empirical IV acyclovir until HSV R/O
171
Pathophysiology of tetanus
Toxin travels back axons to CNS In CNS it irreversibly binds presynaptic neurons Inhibits release of inhibitory NTs (GABA) Effect: disinhibition of spinal motor reflexes Tetanus, autonomic hyperactivity
172
Tetanus Sx
Initial: trismus Sustained contraction of skeletal muscle Periodic painful spasm (triggered by sensory stimuli) Paralysis descends to neck, abd (large muscle groups) Apnea, respiratory failure, pharyngeal tonic contraction Autonomic hyperactivity: Diaphoresis, tachycardia, HTN, fever
173
Inv for tetanus
Clinical Dx ( Hx of wound/ non-immunization is not always present) CK Culture wound
174
Tx of tetanus
Stop toxin production: Wound debridement IV metro/penicillin G Neutralize toxin: TIg ``` Supportive therapy: Intubation Spasmolytic medications (benzodiazepines) Quite environment Cooling blanket ``` Autonomic dysfunction: a-, B-blocker MgSO4
175
Prevention of tetanus
Vaccinate pt on diagnosis INFECTION DOES NOT PRODUCE IMMUNITY Tetanus toxoid vaccination
176
Rabies transmission
Breaching of skin by teeth Direct contact of skin/mucous membranes with saliva/neural tissue
177
Pathogenesis of rabies
Bite VIRUS travels via axon to CNS Virus multiplies rapidly in brain Then spreads to other organs
178
Rabies Sx
Development of symptoms is concurrent with virus excretion in saliva Animal can transmit rabies as soon as it shows signs of disease Inc: 1-3 mo Prodrome: < 1wk Influenza-like Pain, paresthesia, pruritus at wound sign Acute neurologic syndrome: Encephalitic: Hyperactivity, fluctuating LOC, hydrophobia, aerophobia, hypersalvation, fever, seizures. Painful laryngeal spasm on gust of air or drinking water Paralytic: Quadriplegia, loss of anal sphincter tone, fever Coma: Complete flaccid paralysis, respiratory and cardiovascular failure Death
179
Inv for rabies
Purpose: Limit contact of pt with others Identify others exposed to the infectious source Anti-mortem: DIF/PCR on saliva/skin Bx/serum/CSF Post-mortem: DIF on nerve tossue (Negri bodies)
180
Tx of rabies
Post-exposure prophylaxis: Wound care: promptly with soap and running water HRIG: into wound site. Any remaining volume administered IM in site distant from vaccination Vaccine: 4 shots (inactivated virus) If Sx manifested, only supportive Tx
181
Prevention of rabies
Vaccination for: Lab staff working with rabies Veterinarians Animal/wildlife control workers Long-term travelers to endemic areas
182
Post exposure rabies prophylaxis in fully vaccinated pt
No need for HRIG 2 shots of HDCV instead of 4
183
SIRS definition
2 of: T<36 or >38 PR>90 RR>20 Or PCO2<32 WBC <4000 or > 12000 or > 10% band
184
Sepsis definition
SIRS + proven/provable infection
185
Severe sepsis
Sepsis + | Signs of EOD or hypoperfusion
186
Septic shock
Severe sepsis + Hypotension despite adequate fluid (<90 sBP)
187
Inv for SIRS/sepsis
``` CBC, diff Lytes BUN, Cr Liver enzymes ABG, lactate INR, PTT, FDP Blood C&S x 2 U/A, C&S Culture of any wounds/lines CXR ```
188
Tx of sepsis
``` ABC Intubation O2 Fluids +/- NE, ICU IV AB IV hydrocortisone (if shock unresponsive to fluid and vasopressors) ```
189
Leprosy transmission
Nasal secretion | Skin lesions
190
Leprosy Sx
1.Intact cell-mediated immunity: Paucibacillary. 5 lesions or less skin lesions: Well defined, dry, hypoesthetic, hypopigmented Early nerve involvement: Enlarged nerve, neuropathic pain 2.Weak cell-mediated immunity: Multibacillary. 6 or more lesions. Symmetrical, leonine facies, Late and insidious nerve involvement: Sensory loss at the face and extremities 3.Borderline form
191
Inv for leprosy
Skin Bx Slit skin smear for AFB staining PCR Granuloma, lepra cells
192
Tx of leprosy
Single skin lesion: ROM (rifampin, ofloxacin, minocycline) Paucibasillary: Dapson daily Rifampin monthly x 6 mo ``` Multibacillary: Dapsone daily Rifampin monthly x 12 mo Clofazimine monthly x 12 mo Clofazimine low dose daily ```
193
Leprosy treatment reactions
ENL Reversal reaction Tx: Mild: NSAID Sev: pred ENL: thalidomide
194
Drug med causing hyperpigmentation
Clofazimine
195
Primary reservoir for lyme disease
Rodents (mice)
196
Hosts for lyme transmitting ticks
White-tailed deer
197
Time and area of lyme infection
May-august Low brush near wooded areas Requires > 36 h tick attachment
198
Lyme Sx
Stage 1: 7-14 d post-bite Malaise, fatigue, H/A, myalgias, erythema migrans Stage 2: (early disseminated) Weeks CNS: aseptic meningitis, CN palsies (VII)peripheral neuritis Cardiac: transient block, myocarditis Stage 3: (late persistent) Months to years May not have early stages MSK: chronic monoarticular or oligoarticular arthritis. Acrodermatitis chronicum atrophicans. Neurologic: encephalopathy, meningitis, neuropathy
199
Inv for lyme
Serology
200
Prevention of lyme
Protective clothing, Insect repellent Inspection for ticks Doxy: within 72 h of removal of an engorged tick, in hyperendemic (tick infection rate > 20%) areas, pts >8 yr who are not pregnant or lactating
201
Tx of lyme
Stage 1: doxy/amoxicillin/cefuroxime Stage 2-3: ceftruaxone
202
Superantigens in TSS
Staphylococcal: TSST-1 Streptococcal: SPEA, SPEB, SPEC
203
RFs for staphylococcal TSS
Tampon Nasal packing Wound infection
204
RFs for streptococcal TSS
Minor trauma Surgical procedure Preceding viral illness (chickenpox) Use of NSAID
205
Tx of TSS
Fluid Remove source Staph: MSSA: Clinda + cloxa x 10-14 d MRSA: clinda + vanco x 10-14 d Strep: Penicillin IV + clinda + IVIg
206
Cat scratch disease transmission
Cat bite Cat scratch B. Hensella
207
Cat scratch Sx
Skin lesions 3-10 d post-inoculation Fever Regional tender LAP ``` In some pts, organisms disseminate: FUO HSM retinitis Encephalopathy ``` Usually self-limited
208
Inv for cat scratch disease
Serology PCR LN Bx
209
Tx of cat scratch disease
Mild-mod disease in immunocompetent pt: Azithromycin 5 d Disseminated disease: Rifampin + Doxy/azithro Aspiration of painful suppurative lymph nodes
210
Organism of RMSF
Rickettsia rickettsii Obligate intracellular GN Reservoir: rodents, dogs
211
Pathophysiology of RMSF
Inflammation of endothelial lining of small blood vessels Small hemorrhages, and thrombi Widespread vasculitis
212
Sx of RMSF
Summer Following tick bite Flu-like prodrome Macular rash on day 2-4 of fever: Begins on wrists and ankles Spreads centrally (arms, legs, trunk, palms, soles) 10% spotless H/A, CNS changes, death if delayed Tx
213
Inv for RMSF
Skin Bx | Serology
214
Tx of RMSF
Doxy 5-7 d (3 days after defervescence)
215
West nile virus epidemiology
All US | Much of southern Canada
216
WNV transmission
Mosquitoes (feeding on birds) Transplacental Blood products Organ transplantation
217
WNV Sx
Mostly asymptomatic Symptomatic: Mostly mild: H/A, backache, myalgia, anorexia, maculopapular non-pruritic rash on back, chest, arms Severe complications: encephalitis, meningoencephalitis, acute flaccid paralysis (esp in those > 60)
218
Inv for WNV
IgM in serum/CSF IgM lasts for > 6mo (so may not indicate current infection) CSF/tissue/blood/fluids PCR CSF: elevated lymphocytes and proteins
219
False positive WNV serology
Yellow fever vaccine Japanese encephalitis vaccine Dengue fever infection St. Louis virus infection
222
Tx and prevention of WNV
Treatment: supportive Prevention: repellent (DEET), drain stagnant water, community mosquito control programs
223
Syphilis Sx
1. Primary 2. Secondary 3. Latent 4. Tertiary
224
Primary syphilis
3-90 d post infection Chancre Regional LAP Lasts 3-6 wk 25% progress to 2°
225
Secondary syphilis
2-8 wk following chancre Maculopapular, non priritic rash Generalized LAP Low grade fever Malaise H/A Aseptic meningitis Ocular/otic syphilis Chondyloma lata
226
Latent syphilis
Asymptomatic Following untreated primary or secondary syphilis <1y : early latent >1y : late latent Unknown duration : late latent
227
Tertiary syphilis
1-30 y post infection Gummatous syphilis Aortic aneurysm, AI Neurosyphilis: dementia, personality changes, argyll-robertson, tabes dorsalis
228
Congenital syphilis
Abortion Stillbirth Malformations Developmental delay Deafness Most newborns asymptomatic Early infancy: rhinitis, LAP, HSM, psudoparalysis, rash Late-onset (>2y): saddle nose, saber shin, glutton joints, Hutchinson’s teeth, mulberry molars, rhagades, CN VIII deafness, interstitial keratitis, juvenile paresis.
229
Tx of syphilis
1°, 2°, early latent: Benzathine penicillin G 2.4 mU IM x 1 Late latent, 3°: Benzathine penicillin G 2.4 mU IM x 3 Allergic: Doxy, 100 bid, 14 d Neurosyphilis: Aqueous penicillin G 18-24 mU/d x 14 d Congenital: Penicillin G IV x 10 d
230
False positive VDRL/RPR
``` Mononucleosis Hepatitis Drugs/substance abuse Rheumatoid fever Lupus Leprosy ```
231
Jarisch-Herxheimer reaction
In 2° and 3° syphilis treated with penicillin Lysis of organism Release of pyrogens: fever, chills, myalgia, flu-like Lasting up to 24 h
232
TB RFs
Travel/ birth in a country with high TB prevalence Aboriginal Crowded living condition Low SES Homeless IVDU Personal/occupational contact ImmCom/ImmSup (HIV, extremes of age) Silicosis CRF + dialysis Malig + chemo Substance abuse (smoking, alcohol, drug)
233
What’s the most common thing that happens to TB when it enters the body?
``` Latent TB (95%): Asymptomatic infection contained by host immune defenses ```
234
Primary TB Sx
Usually asymptomatic Can be progressive in children/ImComp
235
Secondary TB infection/reactivation Sx
Constitutional symptoms ``` Site dependent symptoms: 1- pulmonary TB: Chronic productive cough +/- hemoptysis CXR: consolidation, cavitation, LAP Non-resolving pneumonia ``` 2- miliary TB Widely disseminated: lung, abd organs, marrow, CNS CXR: 2-4 mm millet seed-like lesions 3-extrapulmonary Lymphadenitis, pleurisy, pericarditis, hepatitis, peritonitis, meningitis, osteomyelitis (pott’s vertebral disease), adrenal, renal, ovarian
236
Inv for TB
Screen: PPD IGRA (fewer false positive, since detecting Ag not present in BCG or other mycobacteria): Preferable in Hx of BCG vaccination or pt who may not return for reading the test If pulmonary: Three sputum specimens: 1h apart. AFB smear and culture BAL CXR
237
> 5mm PPD is positive if:
ImmComp Close contact with active TB
238
>10 mm PPD is considered positive in:
All
239
If positive PPD, what’s next step?
CXR
240
False negative PPD
Poor technique Anergy ImmSup Infection < 10 wk or remotely
241
False positive PPD
BCG after 12 mo in a low-risk individual Non-TB-MB
242
Booster effect in PPD
Initially false negative test Boost to true positive by testing procedure itself (happens in remote infection or BCG)
243
TB CXR
Primary: middle/lower lobe Secondary: apical Nodular/alveolar infiltrate Cavitation Pleural effusion (unilateral, exudative) LAP. Hilar, mediastinal (esp children) Tuberculoma (semicalcified, well-defined, solitary nodule, 0.5-4 cm) Miliary TB Evidence of past disease( calcified hilar/mediastinal nodes, calcified pulmonary focus, pleural thickening and calcification, apical scarring)
244
Inv for syphilis
Screening: VDRL, RPR (non-treponemal) CMIA, CLIA, EIA (treponemal) ``` Confirmatory tests: TPPA FTA-ABS MHA-TP TPI Dark field with silver stain ``` LP Long bone Xray (congenital)
245
Indications for LP in syphilis
``` Seropositive and Sx of neurosyphilis Or Treatment failure Or Other tertiary Sx Or HIV and late latent Or Congenital ```
246
Prevention of TB
Primary prevention: Airborne isolation BCG vaccine: Infants in high-incidence communities if no evidence of HIV/ImDef Secondary prevention: INH-sensitive: INH + B6 x 9 mo INH-resistant: rifampin x 4mo
247
Secondary prevention from TB in pregnancy
Defer, unless mother is high-risk
248
Tx of active TB
``` Pulmonary: Initiation phase: INH + rifampin + pyrazinamide + ethambutol + B6 x 2 mo Continuation phase: INH + rifampin + B6 x 4 mo ``` Extrapulmonary: Same regimen 12 mo Tx if bone/joint/CNS/miliary-disseminated + CS if meningitis/pericarditis
249
BCG can prevent?
Miliary TB and Meningeal TB in children
250
MDR TB is resistant to
INH and rifampin Suspect if: Previous Tx for TB Exposure to known MDR Immigration from a high-risk area
251
XDR TB is resistant to
INH + rifampin + Q + 1 or more of injectables, 2nd lines
252
Most new cases of HIV in Canada is among
MSMs
253
HIV transmission probability based on receiver site
``` Contaminated blood product > Intrapartum/breast milk > Placental > Rectal (via semen) > Sharp/Needlestick > Female genital tract (via semen) > Male genital tract ```
254
Acute retroviral syndrome Sx
2 to 6 weeks post exposure Lasting 10 to 15 days Fever, pharyngitis, LAP, rash, arthralgias, H/A, myalgia, G.I. symptoms, oral ulcers, weight loss. Aseptic meningitis High level of plasma virion High risk of transmission HIV RNA/p24 in CSF
255
Asymptomatic/latent phase
HIV replicates in CD4 in LNs Normal CD4 counts (500-1100) CD4 drops 60-100/y
256
Definition of AIDS
HIV + and one of: Opportunistic infections (PCP, esophageal candidiasis, CMV, MAC, TB, toxo) Malignancy (kaposi, invasive cervical cancer) Wasting syndrome Or CD4 < 200 (or < 15%)
257
Clinical manifestations of HIV Associated with CD4 count <500
Often asymptomatic Constitutional Sx Mucocutaneous lesions: SD, HSV, VZV, OHL (EBV), Candidiasis (oral, esophageal, vaginal), KS Recurrent bacterial infections TB Lymphoma
258
Clinical manifestations of HIV Associated with CD4 count <200
PCP KS Oral thrush Local/disseminated fungal infections: Cryptococcus Coccidioides Histoplasma
259
Clinical manifestations of HIV Associated with CD4 count <100
PML (JC virus) CNS toxoplasmosis
260
Clinical manifestations of HIV Associated with CD4 count <50
CMV: retinitis, colitis, cholangiopathy, CNS MAC Bacillary angiomatosis Primary CNS lymphoma
261
Inv for HIV
Anti-HIV-Ab: Detectable in all after up to 3 mo (3 mo window period) Screening test: ELISA Anti-HIV Or Combination p24 Ag/HIV-Ab (p24 may be positive during window period) ``` Confirmatory test: Western blot (Ab against at least 2 HIV protein bands: p24, gp41, gp120/160) ```
262
Mx of HIV positive pts
F/U q 3-6 mo Routine CD4 count Routine HIV-RNA level (important indicator of ART effect) Baseline HIV resistance testing HLA-B*5701 genetic test (abacavir hypersensitivity) CCR5 tropism testing (if Tx with CCR5 antagonist considered) Baseline PPD Baseline serologies (hepatitis A,B,C, syphilis, toxo, CMV, VZV) Routine biochemistry and hematology, CXR, U/A Annual FBS and lipid profile (ART side effect)
263
Education for HIV pt
Regular F/U on CD4 count/viral load Strict adherence to ART Safe sex and needle practice Barrier protection during sex (to prevent HIV superinfection) Importance of disclosing HIV status to partners (risk of criminal prosecution of non disclosure) Connect to relevant community groups and resources
264
Dx of HIV in infants born to HIV + mothers
Detection of HIV RNA | Maternal Ab positive up to 18 mo
265
Health care maintenance in HIV pt
Assessment of psychosocial concerns Referral to psychiatry or social worker if needed ``` Vaccines: Influenza/y 23-valent pneumococcal/ q 5 yr HBV HIV ``` Annual PAP smear and STI Mx of comorbid conditions, provision of general primary care
266
Indication of PCP Px in HIV
CD4 < 200 Hx of oral candiduasis
267
Prophylactic regimen for PCP
TMP-SMX 1 SS or DS OD
268
Indication of toxo Px in HIV
CD4 < 100 and IgG to toxo
269
Prophylaxis regimen for toxo in HIV
TMP-SMX DS OD
270
Indication of TB Px in HIV
PPD > 5mm Or Contact with case of active TB
271
Indication of MAC Px in HIV
CD4 < 50
272
Prophylaxis regimen for MAC
Azithromycin 1200 mg q 1 wk
273
When to discontinue 1° and 2° Px against opportunistic infections?
If CD4 > threshold for > 6mo while on ART
274
Anti-retroviral pre-exposure Px for HIV prevention in high risk individulals
Daily oral tenofovir +/- emtricitabine
275
Targets for ART Tx
All HIV + pts | May defer treatment on the basis of clinical and psychosocial factors
276
Goal of ART
Viral load < 40 copies/ml (undetectable) Viral load should decrease 10 fold within 4-8 wk Viral load should be undetectable within 6 mo Restore immunological function NO INTERMITTENT ART OR DRUG HOLIDAYS
277
How much does ART reduce risk of HIV transmission to partner?
96%
278
ART recommendation for Tx of naïve pts
2 NRTI + 1 INSTI/PI
279
Tx failure definition in HIV
Viral load persistently > 200/ml
280
Symptoms of lactic acidosis
Abdominal pain N/V Fatigue Muscle weakness
281
Lipodystrophy by ART
Lypohypertrophy: PI Lipoatrophy: NRTI (AZT, d4T)
282
Prevention of HIV infection
Education, harm reduction: Safer sex practice: condom, barrier fir oral sex Avoid sharing needles if IVDU Prevention of vertical infection: ART should be initiated prior to pregnancy or as early as possible during pregnancy Blood/body precautions for healthcare workers. Post exposure Px Pre-exposure Px (oral, topical) ART (96% decrease in partner transmission) Screening of blood/organ donation
283
Post-exposure Px for HIV
2-3 drug regimen Started immediately (within 72 h) Continue for 4 wk
284
Nominal/name-based HIV testing
Person ordering the test knows the identity of pt Test ordered using the name of the pt Person ordering the test, legally obliged to notify public health if positive test Test result recorded in the health care record
285
Non-nominal/Non-identifying HIV testing
Test ordered using a code or initials of pt All others similar to nominal
286
Anonymous HIV testing
Available at specialized clinics Person ordering the HIV test does not know the identity of the person being tested HIV test carried out using a unique non-identifying code that only the person being tested for HIV knows Results not recorded on the healthcare record of person Patient identification and notification of public health required to gain access to ART
287
HIV pre-and post test counseling
Required since a diagnosis of HIV is overwhelming and associated with stigma and discrimination Should be connected with local support services Goals: Assessing risk Making informed decision to be tested Education to protect themselves and others Where to go for more information and support
288
Subcutaneous fungus
Sporothrix schenckii
289
Transmission of sporothrix schenckii
Rose thorn, splinter
290
Sx of sporotricosis
Nodule/ulcer at inoculation site | Nodular lymphangitis
291
Tx of sporotricosis
Itraconazole IV amphitricin B if severe/disseminated
292
Endemic mycoses transmission
Inhalation of spores, inoculation injury Dimorphic: Mould in cold Yeast in warm Three major ones: Histoplasmosis Blastomycosis Coccidioidomycosis
293
Transmission of histoplasmosis
Chicken coops Bird roosts Bat caves Ontario, Quebec
294
Sx of histoplasmosis
Mostly asymptomatic ``` Primary pulmonary: Fever Cough Chest pain H/A Myalgia Anorexia CXR(acute): pulmonary infiltrate +/- hilar LAP CXR(chronic): infiltrate, cavitation ``` ``` Disseminated disease: In ImComp Bone marrow (pancytopenia) GI tract (ulcer) Lymphadenitis Skin, liver, adrenal, CNS ```
295
Inv for histoplasmosis
Fungal culture Fungal stain Ag detection (urine, serum) Serology
296
Blastomycosis Sx
Asymptomatic Primary: Acute/chronic pneumonia Fever, cough, chest pain, chills, night sweats, Wt loss. CXR (acute): lobar/segmental pneumonia CXR (chronic): lobar, fibronodular interstitial disease Disseminated: Verrucous skin lesions, ulcers, SQ nodules, Bones (osteomyelitis, osteolytic lesions) GU (prostatitis, epididymitis)
297
Inv for blastomycosis
Smear and culture (sputum) Direct exam of clinical specimens: Broad-based budding yeast BBBB: Broad based budding blastomycosis
298
Coccidioides
Valley fever: Subacute fever, chills, cough, chest pain, sore throat, fatigue, Lasts weeks to months Hypersensitivity with arthralgia, EN ``` Disseminated: Skin ulcers Synovitis Lytic bone lesions Meningitis ``` Opportunistic in HIV
299
Inv for coccidioides
Sputum culture Direct exam of clinical specimen
300
Epidemiology of blastomycosis
Northern ontario Along the great lakes
301
Tx of endemic mycoses
``` Mild-mod: Oral azole (itra) ``` Sev: IV ampho B if systemic
302
Sx of PCP
Fever Non-productive cough Progressive dyspnea
303
Inv for PCP
Sputum/BAL/endotracheal aspirate to demonstrate organism CXR: Bilateral Diffuse opacities Normal in 20-30 % CT: Cysts NEVER PLEURAL EFFUSION
304
Tx of PCP
``` O2, keep O2 sat > 90% AB: TMP/SMX Dapsone + TMP Clinda + primaquine Pentamidine Atovaquone ``` CS if: pO2 < 70 A-a gradient > 35
305
PCP Px
HIV with CD4 < 200 Non HIV immunocompromised
306
Cryptococcus transmission
Airborne: From Soil contaminated with pigeon droppings (C. Neoformans) Eucalptus, Douglas fir (C. Gatti) Neoformans: ImmComp pts Gatti: healthy hosts
307
Sx of cryptococcus
Asymptomatic Pulmonary: Pneumonitis, asymptomatic, self-limited Productive cough, chest tightness, fever ``` Disseminated: Esp in HIV + CNS: meningitis Skin: molluscum-like Bone, LN, BM, soft tissue, eyes ```
308
Leading cause of meningitis in HIV pts
Cryptococcus
309
Inv for cryptococcus
Serum Ag | CSF: India-ink stain, Ag, culture
310
Tx of cryptococcus
In HIV with severe pulmonary form or meningitis: ``` Amphotricin B (+ flucytosine) x 2 wk + fluconazole x at least 8 wk + fluconazole at lower dose for prolonged maintenance ```
311
C. Gatti epidemio
Vancouver
312
RFs of candidiasis
ImComp: DM CS ICU pt: CV-line Broad-spectrum AB TPN Obesity
313
Tx of candidiasis
Thrush: Nystatin for mild Fluconazole for severe Vulvovaginal: Topical imidazole, nystatin Oral fluconazole if recurrent Cutaneous infection: Topical imidazole Opportunistic infection in HIV, systemic infection: Fluconazole Echinocandin Chronic mucocutaneous: Azoles
314
Aflatoxin is produced by
Aspergillus
315
Aflatoxin found in
Nuts Grains Rice
316
Allergic bronchopulmonary aspergillosis
IgE-mediated Asthma-type reaction Dyspnea, high fever, transient pulmonary infiltrates More frequently in pts with asthma and allergies
317
Aspergilloma
Ball of hyphae in pre-existing cavity Asymptomatic Massive hemoptysis CXR: round opacity surrounded by thin lucent rim of air in upper lobes (air-crescent sign)
318
Invasive aspergillosis
In prolonged persistent neutropenia Or Transplantation ``` Sx: Pneumonia (most common): Fever, cough, dyspnea, cavitation, CXR: Local/diffuse infiltrate Pulmonary infarction Nodule with surrounding ground glass (halo sign) ``` May disseminate to brain, skin...
319
Sx of mycotoxicosis by aflatoxin
Liver hemorrhage, necrosis, hepatocellular carcinoma
320
Tx of aspergillosis
Ampho B Voriconazole Aspergilloma: surgical resection ABPA: CS +/- itra
321
E. Histolytica transmission
Fecal-oral
322
Sx of E.histolytica
1. asymptomatic carrier 2. Abd pain, cramping, colitis, dysentery, low grade fever 3. Liver abscess (hematogenous): RUQ pain, Wt loss, fever, hepatomegaly
323
Inv for E. Histolytica
Serology Fecal/serum Ag Stool exam Colon Bx
324
Tx of E. Histolytica
Metro + iodoquinol/paromomycin ``` Liver abscess: AB Aspiration if: Risk of rupture Poor response to Tx Diagnostic uncertainty ``` Asymptomatic cyst shedding: Iodoquinol/paromomycin
325
Prevention od E. Histolytica
Good personal hygiene Purification of water supply: Boiling, filtration CHLORINATION NOT EFFECTIVE
326
Infective form of E. Histolytica
Cyst (not trophozoite)
327
Giardia transmission
Fecal-oral | Cyst ingestion
328
Sx of giardiasis
Asymptomatic Mild watery diarrhea Malabsorption syndrome Nausea, malaise, abd cramps, bloating, flatulence, fatigue, wt loss, steatorrhea NO HEMATOCHEZIA, NO MUCOUS IN STOOL
329
Inv for giardia
Multiple stool samples (daily x 3d) Stool Ag Small bowel aspirate, Bx
330
Tx of giardia
Metronidazole, nitazoxide
331
Prevention of giardia
Good personal hygiene and sanitation Water purification (iodine better than chloriniation) Outbreak investigation
332
Transmission of TV
STD
333
TV Sx
Often asymptomatic. Occasionally urethritis/prostatitis in males Vaginitis in female: Discharge, pruritus, dysuria, dyspareunia
334
Inv for TV
Wet mount Ag detection Culture Males: urine PCR
335
Tx of TV
Metro for pt and partners
336
Cryptospordium transmission
Fecal-oral Water contaminated by humans and cows
337
Sx of cryptospordium
Asymptomatic Self-limited watery diarrhea Chronic, severe, non-bloody diarrhea N/V, anorexia Wt loss, death in ImComp
338
Inv for cryptospordium
Modified acid-fast stain of stool or tissue S/E Stool Ag
339
Tx of cryptospordiosis
Supportive If HIV: ART, increase CD4 to > 100 If failure: Nitazoxanide
340
cryptospordium Px
Water filtration Personal hygiene
341
Malaria transmission
Anopheles bite Vertical(rare) Blood transfusion
342
Sx of malaria
Flu-like prodrome Paroxysms of high spiking fever and shaking chills Abd pain, myalgia, H/A, cough, diarrhea Hepatomegaly, thrombocytopenia
343
In which type of malaria are there relapsing attacks after several months?
Oval and vivax Due to reactivation of dormant liver hypnozoites
344
Most common malaria
Falciparum
345
Most lethal malaria
Falciparum
346
Complications of falciparum
CNS involvement (seizures, coma) Severe anemia Acute kidney injury ARDS Death
347
Inv for malaria
Blood smear q 12-24 h (x3) Thick smear Thin smear Rapid Ag
348
Tx of malaria
Vivax, Oval: Chloroquine + primaquine (to eradicate liver forms) Chloroquine resistance vivax: Atovaquone/proguanil + primaquine Or Quinine and doxy + primaquine P. Malariae: chloroquine P. Knowlesi: chloroquine ``` P. Falciparum: Artesunate + doxy/clinda/atovaquone-proguanil Or Quinine + doxy/clinda Or Atovaquone/proguanil ```
349
Malaria prevention
Covering exposed skin Bed nets Insect repellents Meds: Atovaquone-proguanil Doxycycline
350
Trypanosoma cruzi transmission
Reduviid: Kissing bug (stool rubbed into bite site by host) Placental Organ donation Blood transfusion Ingestion of contaminated food
351
Trypanosoma cruzi Sx
Acute: Asymptomatic Local swelling (Roman’s sign) Fever, LAP, HSM, cardiomegaly Chronic indeterminate phase: Asymptomatic Increasing Ab level in blood ``` Chronic determinate phase (30-40% of individuals): 10-25 y after infection: Dilated CMP Esophagomegaly Megacolon ```
352
Inv for Chagas
Thick and thin blood smears: Wet prep, Giemsa Serology PCR
353
Tx of Chagas
Acute: Nifurtimox Benznidazole Indeterminate phase: Treat as above for age <50 Chronic determinate: Symptomatic, surgery Antiparasitic Tx
354
Prevention of chagas
Insect control Bed nets
355
Toxo transmission
Exposure to cat feces Ingestion of undercooked meat Vertical Organ transplantation Gardening without gloves (cat feces) Whole blood transfusion
356
Sx of congenital toxo
Result of: acute primary infection of mother during pregnancy ``` Stillbirth Chorioretinitis Blindness Seizures Severe developmental delay Microcephaly ``` Or asymptomatic in infancy with adolescence/adulthood: Chorioretinitis
357
Sx of acquired toxo
Asymptomatic Mononucleosis-like syndrome Remains latent for life, unless reactivation due to ImSup
358
Toxo Sx in ImSup pts
Encephalitis Focal CNS lesions: Single/multiple ring-enhancing lesions H/A, FND LAP, HSM, pneumonitis Chorioretinitis
359
Inv for toxo
Serology CSF: Wright-Giemsa stain, Ag, PCR Bx CT if ImComp Ophthalmologic examination
360
Toxo serology in AIDS
might be false negative
361
Toxo Tx
None ``` If pregnant: Spiramycin Or pyrimethamine + sulfadiazine (+ folinic acid) Avoid undercooked meat Refrain from emptying cat litter boxes ``` If HIV: Pyrimethamine + sulfadiazine If eye disease, meningitis: CS
362
Toxo Px
Hand hygiene Cook meat thoroughly
363
Pinworm transmission
Fecal oral : self-inoculation | Fomite: person to person
364
Pinworm Dx
Sticky tape test x 5-7 times
365
Pinworm Tx
Mebendazole Albendazole Pregnancy: pyrantel Tx all family members ``` Prevention: Change underwear Bathe in the morning Pajamas to bed Wash hands Trim fingernails ```
366
Onchocerca vulvulus
Blackfly bite River blindness Ivermectin + doxy
367
Wuchereria bancrofti
Mosquito bite LAP, Lymphedema Elephantiasis Tx: diethylcarbamazine + doxy
368
Trichuris trichiura
Ingestion of eggs in soil Diarrhea (mucous, blood) Rectal prolapse Abd pain Stunted growth Tx: mebendazole, albendazole
369
Strogyloides stercoralis
Fecal contamination of soil: Walking barefoot, via unbroken skin Autoinfection through GI mucosa or perianal skin Adult worm in small intestine
370
Pulmonary migration of larva
Loffler SS Ascaris
371
Larva currens
Itchy rash due to SS
372
Tx of SS
Ivermectin | Albendazole
373
SS hyperinfection
Massive autoinfection in immunocompromised host The most common RF: Immunoablarive therapy including CS
374
Taenia solium transmission
Cestode Undercooked pork: Taeniasis: mild abdominal symptoms Human feces: Cysticercosis: mass lesion in CNS, eye, skin, seizure
375
Tx of taenia solium
Taeniasis: Praziquantel Cysticercosis: CS + albendazole Anti-epileptic if seizures
376
Taenia saginata
Cestode Undercooked beef Mild GI symptoms Tx praziquantel
377
Diphyllobutrium latum
Cestode North America Europe Asia Raw fish B12 deficiency Tx: praziquantel
378
Echinococcus granulosus
Cestode Dog feces Mass effect of cysts Anaphylaxis during surgical release Tx: Albendazole +/- praziquantel Surgery + peri-op albendazole Percutaneous aspiration + peri-op albendazoke
379
Clonorchis sinensis
Asia Raw fish Bile duct inflammation/cholangiocarcinoma Tx: praziquantel
380
Schistosoma transmission
Penetration of unbroken skin by the larvae in fresh water Adult worms in terminal venules, passing eggs into urine/stool
381
Schistosomiasis symptoms
Most asymptomatic Swimmers’ itch (cercarial dermatitis) Acute schistosomiasis: Hypersensitivity to migrating parasite (4-8 wk later): Fever, hives, H/A, Wt loss, cough, abd pain, chronic diarrhea, eosinophilia Chronic: S. Mansoni, S. Japonicum: Worms in mesentric veins, eggs in portal tract of liver, and bowel. Intestinal polyps, portal/pulmonary HTN, splenomegaly, hepatomegaly ``` S. Hematobium: Worms in vesical plexus, eggs in distal ureter and bladder. Granulomas and fibrosis Hematuria Obstructive uropathy SCC if bladder ```
382
Neurologic complications of schistosomiasis
Cerebral Cerebellar Transverse myelitis Increased ICP FND Seizures
383
Pulmonary complications of schistosomiasis
Pulmonary HTN Corpulmonale Granulomatous pulmonary endarteritis
384
Inv for schistosomiasis
Serology CBC S/E (eggs in mansoni, japonicum) Liver U/S: fibrosis Rectal Bx Bladder Bx Hematobium: eggs in urine and occasionally feces Kidney/bladder U/S
385
schistosomiasis Tx
Praziquantel If acute: add CS If neurologic complications: add CS
386
schistosomiasis Px
Proper disposal of human fecal waste Molluscicide Avoidance of infested fresh water
387
Prevention of vector-borne diseases
Long sleeves Long pants Permethrin repellents to cloths, belongings, bed nets DEET repellents for skin
388
Prevention of food/water borne diseases
Avoid raw meat/seafood Avoid uncooked vegetables Avoid milk/dairy products Drink only bottled beverages, Chlorinated water, Boiled water
389
Prevention of recreation-related infections
Caution when swimming in schistosomiasis endemic regions, fresh water rafting/kayaking, beaches that may contain human/animal waste products, near storm drains, after heavy rainfalls
390
Med prophylaxis for malaria
Chloroquine Mefloquine Atovaquone + proguanil Doxy
391
Med for traveler diarrhea Px
Bismuth
392
Vaccinations for travelers
Std vaccines up to date: Hep B, MMR, teranus/diphteria, varicella, pertussis, polio, influenza ``` Travel vaccines: Hep A, B Japanese encephalitis Typhoid fever Yellow fever Rabies ETEC Cholera ```
393
Prevention of STD, blood borne diseases
Safe sex practices Avoidance of percutaneous injury (razor, tattoo, piercing)
394
Fever in traveler, | Incubation < 21 d, consider:
Malaria Thyphoid fever Dengue fever Chikunguny Rickettsioses R/O: Hepatitis TB
395
Traveler fever | Incubation > 21 d
Malaria TB Typhoid ``` R/O: Dengue Chikungunya Traveler diarrhea Rickettsiosis ```
396
Inv for fever in returned traveler
``` CBC, diff Liver enzymes BUN, Cr Lytes Thick/thin blood smear x 3 Blood C/S U/A, C/S if dysuria Stool: C/S, O/P CXR IgM for dengue ```
397
Dengue fever transmission
Mosquito Urban Day biting SE Asia Caribbean
398
Dengue fever incubation
3d- 2wk
399
Dengue fever Sx
``` Sudden onset headache H/A Retro-orbital pain Myalgia Arthralgia Leukopenia Thrombocytopenia Hemorrhagic manifestations ```
400
Dx of dengue fever
Serology. IgM
401
Tx of dengue fever
Acetaminophen AVOID NSAIDS (BLEEDING)
402
Typhoid geography
Mostly indian subcontinent
403
Pathogens of enteric fever (typhoid)
Salmonella typhi/paratyphi
404
Incubation period of Typhoid fever
3-60 d
405
Typhoid fever Sx
``` Sustained fever 39-40° Abd pain H/A Loss of appetite Cough Constipation! ```
406
Dx of enteric fever
Stool/blood/urine sample positive for salmonella typhi/paratyphi
407
Tx of enteric fever
Quinolone Ceftriaxone Macrolide
408
Tick typhus geography/agent
India, south Aftica, mediterranean Rickettsia Inc: 1-2 wk
409
Tick typhus Sx
``` Fever H/A Fatigue Muscle aches Eschar at site of tick bite Thrombocytopenia Elevated liver enzyme ```
410
Dx of tick typhus
Serology | Eschar
411
Tx of tick typhus
Doxycycline
412
Mononucleosis pathogens and incubation period
EBV/CMV Inc: 30-50 d Tx: acetaminophen, NSAIDs, fluids
413
Zika Sx
Flu-like Inc: 3-12 d Dx: RT-PCR, serology
414
Zika Tx
Rest Fluid Analgesics/antipyretics (avoid NSAIDs until dengue R/O)
415
Zika geography
Africa SE Asia S. America
416
Plague vector
Flea
417
Inv for FUO
``` CBC, diff Lytes BUN, Cr Ca profile Liver enzymes ESR, CRP Muscle enzymes RF, ANA SPEP Blood smear Stool C/S, O/P ``` Cultures: blood x2, urine, sputum, stool, other fluids Serology: HIV, monospot, CMV Imaging: CXR, abd imaging
418
If no Dx for FUO after all workups,
Consider empiric therapy vs watchful waiting Good prognosis
419
Infections associated with asplenia
``` HIB S. Pneumoniae N. Meningitidis Salmonella Babesiosis Malaria Capnocytophaga canimorsus ```
420
Neutrophil dysfunction makes vulnerable to
``` Catalase-producing organisms: Staph Serratia Nocardia Aspergillus ```
421
Febrile neutropenia definition
``` Fever 38 or higher for more than 1 h And: ANC <0.5 Or ANC <1 but trending down to 0.5 ```
422
Nutritional deficiencies causing neutropenia
B12, folate
423
Most common etiology of infection in febrile neutropenia
GP
424
Inv for febrile neutropenia
PEx, including perianal region DO NOT PERFORM DRE ``` Blood C/S x2 Urine C/S Culture all indwelling caths Sputum C/S Nasopharyngeal swab ``` CBC, diff BUN, Cr Lytes AST/ALT, total Bil
425
Most common infections in febrile neutropenia
Mucositis Line infection
426
Indications for G-CSF or GM-CSF before chemo
Febrile neutropenia in previous chemo cycle Or Risk of febrile neutropenia > 20 Effect: decreased hospitalization (no effect on mortality)
427
Prophylactic vaccination given before organ transplant
All: DTaP, pneumococcal, influenza, hepatitis A and B If low titer/poor documentation: MMR, polio, varicella (booster 4-8 wk later)
428
Immune reconstruction syndrome worse with
Lower pre-treatment CD4 count Quick increase in CD4 count
429
Settings in which immune reconstruction syndrome happens
``` ART in HIV Solid organ transplant recipients Post-partum Neutropenic pts Anti-TNF therapy ```
430
Tx of IRS
Mild-mod Sx: Continue HAART in HIV Life-threatening or potentially irriversible Sx: D/C Tx underlying infection (sometimes prior to HAART) CS/NSAIDs

Med (25 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions