Infectious Disease Flashcards
Bacterial CSF finding
- Opening pressure
- Leukocyte count
- Leukocyte differential
- Glucose
- Protein
- Gram stain
- Culture
- Opening pressure- 200-500 mm H2O
- Leukocyte count- 1000-5000/μL
- Leukocyte differential- Neutrophils
- Glucose- <40 mg/dL
- Protein- 100-500 mg/dL
- Gram stain- Positive in 60%-90%
- Culture- Positive in 70%-85%
Viral CSF finding
- Opening pressure
- Leukocyte count
- Leukocyte differential
- Glucose
- Protein
- Gram stain
- Culture
- Opening pressure- ≤250 mm H2O
- Leukocyte count- 50-1000/μ
- Leukocyte predominance- Lymphocytes
- Glucose- >45 mg/dL
- Protein- <200 mg/dL
- Grams stain- Negative
- Culture- Negative
Most common causes of bacterial meningitis
Streptococcus pneumoniae and Neisseria meningitidis
Tx for Immunocompetent host with community acquired bacterial meningitis
IV ceftriaxone or cefotaxime plus IV vancomycin
Tx meningitis in Patient >50 years or those with altered cell mediated immunity
IV ampicillin (Listeria coverage) plus IV ceftriaxone or cefotaxime plus IV vancomycin
Tx meningitis in Allergies to β-lactams
IV moxifloxacin instead of cephalosporin
IV trimethoprim-sulfamethoxazole instead of ampicillin
Hospital-acquired bacterial meningitis treatment
IV vancomycin plus either IV ceftazidime, cefepime, or meropenem
Neurosurgical procedures meningitis tx
IV vancomycin plus either IV ceftazidime, cefepime, or meropenem
when to give dexamethasone in meningitis
In patients with suspected or confirmed pneumococcal meningitis- 15 minutes before administration of antimicrobial agents and continued for 4 days.
viral meningitis tx
symptomatic and supportive. Empiric antimicrobial agents may be initiated in viral meningitis
until bacterial meningitis is excluded.
Brain abscess causes
ENT source, from penetrating trauma, or after neurosurgery
Testing for brain abscess
MRI is more sensitive than CT
tx for brain abscess
Empiric antimicrobial treatment should be based on the suspected source and Gram stain results. A narrowed regimen is based
on culture results and is continued for 4 to 8 weeks.
when should you drain brain abscess
Abscesses >2.5 cm should be excised or drained stereotactically.
should you do lp in suspected brain abscess
NO, because increased pressure and herniation risk
Herpes simplex encephalopathy test findings
CSF
CT and EEG
CSF testing shows lymphocytic pleocytosis and, when necrosis is extensive, erythrocytes.
Temporal lobe abnormalities on imaging and periodic lateralizing epileptiform discharges on EEG suggest HSE.
Bloodwork for HSE
HSV PCR of the CSF allows rapid diagnosis of HSE
- do not test csf culture or serologic tests for HSV
TX for HSE
High-dose IV acyclovir should be started within 24 hours of symptom onset and continued for 14 to 21 days.
season for West Nile
the summer and early fall
severe west nile symptoms
acute asymmetric flaccid paralysis and may progress to respiratory failure.
DX for west nile
Diagnosis is established by detecting serum and CSF IgM antibody to WNV. (never a viral culture)
west nile tx
Treatment is limited to supportive care. Monitor patients with significant muscle weakness for respiratory failure in an intensive
care setting
testing for autoimmune encephalitis
Anti-NMDA receptor antibody
what is associated with autoimmune encephalitis
ovarian teratoma
tx of autoimmune encephalitis
Treatment includes removal of the teratoma, when present, and immunosuppression with glucocorticoids, rituximab, cyclophosphamide, or IV immune globulin
Erysipelas character
affects the superficial skin layers, including the upper dermis and dermal lymphatics. It classically involves the malar
region. The key clinical finding is a sharply raised border and orange-peel texture. It is usually caused by streptococcal infection.
if Honey-colored, crusted pustules.. think
Impetigo caused by β-hemolytic Streptococcus or Staphylococcus
if Sepsis, cellulitis, and hemorrhagic bullae after exposure to
saltwater fish or shellfish in patients with cirrhosis or chronic
illnesses such as diabetes mellitus, rheumatoid arthritis, or CKD.. think
Vibrio vulnificus infection
if Skin ulcer with necrotic center in a patient with neutropenia think
Ecthyma gangrenosum from Pseudomonas or other bacterial infections
if Chronic nodular infection of distal extremities with exposure to fish tanks or marine environments.. think
Mycobacterium marinum
Chronic nodular infection of distal extremities with exposure to plants/soiL
Sporotrichosis and Nocardia
Sepsis following a dog bite in a patient with asplenia
Capnocytophaga canimorsus
Swelling and erythema with pain out of proportion to physical examination findings
Necrotizing (deep) soft tissue infection (surgical emergency)
Acute, tender, well-delineated, purulent lesions
Abscess caused by S. aureus
Follicle-centered pustules in the beard and pubic areas, axillae, and thighs
S. aureus folliculitis
Follicle-centered erythematous papules and pustules on the trunk, axillae, and buttocks 1-4 days after hot tub or whirlpool exposure
Pseudomonas folliculitis
Symmetric, pink-to-brown patches with thin scale in intertriginous areas (axillae, groin, inframammary)
Erythrasma caused by Corynebacterium minutissimum.
Erythrasma will fluoresce to a coral red color with a Wood lamp
Empiric treatment for β-hemolytic streptococci and MSSA Tx
Dicloxacillin, cephalexin, clindamycin (all oral); IV antibiotics for unsuccessful outpatient treatment or patients with signs of toxicity
Purulent cellulitis, mild to moderate severity Empiric treatment for MRSA tx
Clindamycin, trimethoprim-sulfamethoxazole, doxycycline
Purulent cellulitis with extensive disease or signs
of systemic toxicity tx
Vancomycin (IV) or linezolid (oral or IV), daptomycin, telavancin, ceftaroline
Impetigo tx
Extensive disease, treat as nonpurulent cellulitis; limited disease, mupirocin (topical)
Erysipelas tx
With systemic symptoms, ceftriaxone (parenteral); if mild/asymptomatic, penicillin or amoxicillin (oral)
Folliculitis (staphylococcal and pseudomonal) tx
Spontaneous resolution is typical. Topical mupirocin or clindamycin lotion can be used
Human bite (Clenched fist injury) tx
Ampicillin-sulbactam (IV)
Animal bites tx
Ampicillin-sulbactam (IV) or amoxicillin-clavulanate (oral)
Neutropenia infection tx
Vancomycin and cefepime
Necrotizing fasciitis, compartment syndrome,
myonecrosis on imaging, purple bullae, or
sloughing of skin tx
Imipenem, clindamycin, vancomycin, and prompt debridement
Erythrasma Tx
Topical erythromycin, clarithromycin, or clindamycin
Mild (nonpurulent) DM foot infection tx
Single oral antibiotic, such as cephalexin, dicloxacillin, amoxicillin-clavulanate, or clindamycin
Mild (purulent and at risk for MRSA) DM foot infection tx
Clindamycin, doxycycline, or trimethoprim-sulfamethoxazole
Moderate DM foot infection tx
Two-drug therapy, such as trimethoprim-sulfamethoxazole plus amoxicillin-clavulanate or
clindamycin plus ciprofloxacin, levofloxacin, or moxifloxacin
Severe DM Foot infection tx
β-lactam/β-lactamase inhibitor (e.g., ampicillin-sulbactam), a carbapenem (e.g., imipenem cilastin), and a fluoroquinolone (e.g., moxifloxacin) and surgical debridement
PNA cause Aspiration
Gram-negative enteric pathogens, oral anaerobes
PNA w/ Cough >2 weeks with whoop or posttussive vomiting
Bordetella pertussis
Lung cavity infiltrates
Community-associated MRSA, oral anaerobes, endemic fungal pathogens, Mycobacterium tuberculosis, nontuberculous mycobacteria
pna associated with etoh
S. pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter species, M. tuberculosis
pna associated with smoking/copd
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella species, S. pneumoniae, Moraxella catarrhalis, C. pneumoniae
PNA in HIV (early)
S. pneumoniae, H. influenzae, M. tuberculosis
PNA in southwest usa
Coccidioides species, Hantavirus
pna in Travel or residence in Southeast and East Asia
Burkholderia pseudomallei (melioidosis)
Exposure to bat or bird droppings
Histoplasma capsulatum
Exposure to birds
Chlamydophila psittaci
Exposure to rabbits
Francisella tularensis
Exposure to farm animals or parturient cat
Coxiella burnetii
Exposure to rodent excreta
Hantavirus
prophylaxis for lyme
antibiotic prophylaxis with doxycycline only when the attached tick isidentified as an adult or nymphal deer tick, attachment is estimated at 36 hours or longer, prophylaxis is begun within 72 hours
of tick removal, the tick bite occurred in an endemic area
lyme endemic areas
northeast, mid-Atlantic, and Midwest United
States.
Lyme treatment if Within 30 days of exposure: erythema migrans, fever, fatigue, headache, arthralgia, myalgia
Treat without serologic confirmation`
Lyme tx if Weeks to months after exposure: multiple erythema migrans lesions, heart conduction block, cranial neuropathy, radiculoneuropathy, lymphocytic meningitis, acute attacks of monoarticular or oligoarticular arthritis
Treat if ELISA is positive Obtain Western blot if ELISA is
indeterminate
Lyme if Months to years after exposure: attacks of monoarticular or oligoarticular arthritis and/or chronic monoarthritis or oligoarthritis, peripheral neuropathy, or encephalomyelitis
Treat if ELISA is positive Obtain Western blot if ELISA is
indeterminate
early lime tx
begin doxycycline (10-21 days, preferred), amoxicillin, or cefuroxime for 14 to 21 days without laboratory confirmation of Borrelia burgdorferi
Manage late carditis or neurologic disease with
h IV penicillin or IV ceftriaxone for 28 days, and manage arthritis and facial nerve palsy with
doxycycline
bebisiosis tick and endemic area
black-legged deer tick) malaria-like illness endemic to the northeast coast of the United States
signs of beibisiosis
myalgia, headache, and fatigue. Severe hemolytic anemia, jaundice, kidney failure, and death
testing for beibisiosis
A Wright- or Giemsa-stained
peripheral blood smear will show intraerythrocytic parasites in
ring, or more rarely, tetrad formations (Maltese cross shape).
Consider PCR for Babesia DNA in cases of low parasitemia
Babesiosis tx
monitor asymptomatic patients for 3 months. use Atovaquone plus azithromycin is the treatment of choice for patients with persistent parasitemia after 3 months and for mild-to-moderate symptomatic disease
erlichiosis and anaplasmosis pathogen, tick and demographic
Ehrlichia chaffeensis (transmitted by the lone star tick and most prevalent in south central and southeastern United States) and Anaplasma phagocytophilum (transmitted by the Ixodes tick) are rickettsia-like organisms that infect leukocytes
anaplasmosis and erlichosis signs and symptoms
The clinical syndromes of HME and HGA are very similar:
• fever, headache, and myalgia
• multiorgan failure (AKI, ARDS, meningoencephalitis)
• fever of unknown origin (symptoms can persist for months)
• elevated aminotransferases with normal alkaline phosphatase and bilirubin levels
• leukopenia and thrombocytopenia
• presence of morulae (clumps of organisms in the cytoplasm of the appropriate leukocyte)
testing and tx of erlichosis and anaplasmosis
Whole blood PCR and Doxy(IV or Oral)`
RMSF epidemiology
a tick-borne rickettsial infection most prevalent in the southeastern and south central states.
spring and summer months
RMSF rash
r rash starting on the ankles and
wrists and often affecting the palms and soles of the feet; lesions spread centripetally and become petechial.
Diagosiing RMSF
Thrombocytopenia and elevated aminotransferase levels are characteristic. Immunohistochemistry or PCR of a skin biopsy
tx of RMSF
Select doxycycline. In patients who are pregnant, choose chloramphenicol
when to screen or treat asymptomatic bacturia
pregnant or are about to undergo an invasive urologic procedure
when to obtain a urine culture
- suspected pyelonephritis
- complicated UTI
- recurrent UTI
- suspicion of an unusual or antimicrobial-resistant microorganism or a patient who is pregnant
best treatment for uncomplicated cystitis
- 3 days of oral trimethoprim-sulfamethoxazole
- 5 days of oral nitrofurantoin
- single 3-g oral dose of fosfomycin
best tx patient at high risk for complicated UTI
obtain a urine culture and initiate empiric treatment for 7 to 14 days with a
fluoroquinolon
best tx for pregnant patient with complicated uti
choose 7 days of empiric therapy with amoxicillin-clavulanate, nitrofurantoin,
cefpodoxime, or cefixime. Obtain a urine culture after treatment.
r recurrent uncomplicated UTIs tx
- postcoital antibiotic prophylaxis, particularly if UTIs are temporally associated with coitus
- continuous antibiotic prophylaxis
- self-initiated therapy for frequent recurrent episodes
when bactrim is contraindicated?
sulfa allergy or s taken in the preceding 3 months
Tx duration for pyelo
Treat uncomplicated infection for 5 to 7 days and complicated infection for 14 days.
tx of pyelo in long term care facilities
Patients admitted from a long-term care facility should also receive empiric coverage for vancomycin-resistant Enterococcus
and fluoroquinolone-resistant gram-negative rods.
when to obtain extra imaging for pyelo
Obtain ultrasonography or CT for persistent fever or continuing symptoms after 72 hours of antibiotics to evaluate for complications of pyelonephritis (e.g., perinephric abscess).
CT and MRI should be considered in patients with persistent or relapsing pyelonephritis despite a negative ultrasound.
tx for latent tb
: For patients without HIV, select daily isoniazid for 6 months or
daily rifampin for 4 months. In patients with HIV, select daily isoniazid for 9 months
tx for active tb
the core first-line agents are isoniazid, rifampin, pyrazinamide,
and ethambutol. These agents are administered for 8 weeks as part of the initiation phase, and then isoniazid and rifampin are continued for either 4 or 7
months as part of the continuation phase.
criteria that patient is no longer infectious from TB
- adequate TB treatment >2 weeks
- improvement of symptoms
- three consecutive negative sputum smears
what to check for patients on pyrazinamide or ethambutol
uric acid levels or visual acuity and
color vision testing are recommended, respectively
two presentations of MAC
- middle-aged to older adult male smokers with underlying lung disease who clinically and radiographically resemble patients with TB.
- healthy white women presenting as right middle lobe or left lingular lobe lung infection. These women often have scoliosis, pectus excavatum, or MVP suggesting an underlying connective tissue defect.
when does disseminated mac occur
HIV who have CD4 cell counts less than 50/μL who are not receiving MAC prophylaxis
tx for mac
usually consists of clarithromycin or azithromycin with ethambutol and either rifampin or rifabutin.
which mycobacteria infections are associated with soft tissue esp after trauma, surgery or tattoo
Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae
when does aspergilloma occur
preexisting pulmonary cavities or cysts, or in areas of devitalized lung
aspergilloma symptoms
cough, hemoptysis, dyspnea, weight loss, fever, and chest pain
at risk for aspergillus infection
Neutropenic patients and organ transplant recipients
gold standard diagnostic test for Aspergillus infection
deep body specimen; galactomann in right clinical setting or to ensure resolution
tx for aspergilloma
surgical resection
tx of invasive aspergilosis
variconizole
allergic bronchopulmonary aspergillosis tx
oral glucocorticoids
tx for Patients with aspergilloma who are asymptomatic and have stable x-rays
no tx required
tx for cadedemia
caspafungin, micafungin
preventative tx against cadidemia
Fluconizole
do you treat resp cadidemia
no likely contaminant
do you tx asymptomatic candiduria
no unless yrological procedure or neutropenic
most common form of meningitis in aids
crypto
which HIV pt usually are susceptible to crypto
Most patients have a CD4 cell count of less than
100/μL
dx of crypto
cryptococcal antigen in the CSF or culture of Cryptococcus neoformans in the
CSF. The opening CSF pressure is typically elevated.
tx for crypto meningitis
amphotericin B plus flucytosine for induction treatment of meningitis followed by fluconazole maintenance therap
blasto demographic and symptoms
1. Midwestern, southeastern, and south central United States (Mississippi, Missouri, and Ohio river valleys) 2. onset 4-6w and Consider in patients with primary skin lesion or concurrent pulmonary and skin or bone findings
coccido demographic and symptoms
- Southern Arizona, south central California, southwestern New Mexico, west Texas
- Consider in patients with pulmonary symptoms and
erythema nodosum or erythema multiforme
histo demographic and symptoms
- Midwestern states in the Ohio and
Mississippi River valley regions - Consider in patients with complex pulmonary disease
(nodular, cavitary, lymphadenopathy)
sporotrichosis demographic and symptoms
- gardeners
- A papule appears days to weeks later at the inoculation site.
Similar lesions then occur along lymphatic channels
proximal to the inoculation site.
tx for chlamydial infection
azithro or doxy
signs of disseminated gonnorhea
sparse peripheral necrotic pustules
• monoarthritis or oligoarthritis (knees, hips, and wrists)
• tendon sheath inflammation
Besides NAAT to test for gonorrhea what should you also get for arthritis and for disseminated disease
1 Joint aspiration
2. Blood culture
Tx for gonorrhea epipdidmitis
ceftriaxone and azithromycin or doxycycline for 10 days
tx for disseminated gonorrhea
Treat disseminated gonococcal infection with
a 7- to 14-day course of ceftriaxone.
outpatient tx for pid
a single parenteral dose of ceftriaxone plus doxycycline with or without metronidazole for 14 days.
when to admit for pid
no clinical improvement after 48 to 72 hours of antibiotic treatment
• inability to tolerate oral antibiotics
• severe illness with nausea, vomiting, or high fever
• suspected pelvic abscess
• pregnancy
inpatient treatment for pid
Inpatients are treated with parenteral cefoxitin or cefotetan and doxycycline
if patient is non-responsive to abx inpatient what is the next best step
nonresponsive to antibiotics in 48
to 72 hours, choose ultrasonography for evaluation of possible tubo-ovarian abscess.
how to diagnose secondary syphilis
• fever and any type of rash (except vesicles), often with palmar or plantar involvement
• nontender generalized lymphadenopathy
• headache, cranial nerve abnormalities, altered mental status, or stiff neck
• mucous patches (a slightly elevated oval erosive lesion with surrounding inflammation) and condylomata lata lesions
(grey to white, raised, wart-like lesions on moist intertriginous surfaces)
latent syphilis is..
involves the presence of serologic evidence of infection in the absence of clinical signs. Latent syphilis
is divided into early latent (infection ≤1 year in duration) or late-latent (infection >1 year
Late syphilis classified as
meningitis and subarachnoid arteritis (a cause of stroke in a young patient)
• aortitis
• general paresis and tabes dorsalis
• gumma in any organ
VDRL and RPR titers syphilis
primary
secondary
tertiary
- often negative in primary infection
- positive in high titers in secondary syphilis
- lower titers are seen in latent and tertiary infection
how should you confirm syphilis
fluorescent treponemal antibody absorption test
(FTA-ABS) or Treponema pallidum particle agglutination (TPPA) assay
which test in syphils will remain +
e FTA-ABS and microhemagglutination assay for T. pallidum (MHA-TP) antibodies will remain positive indefinitely
csf in neurosyphilis
- CSF lymphocytes >5/μL
- elevated CSF protein
- positive CSF VDRL test
Herpes (HSV type 1 or 2) rash character
Multiple 1- to 2-mm tender vesicles or erosions and tender lymphadenopathy
Syphilis (T. pallidum) rash character
Single 0.5- to 1.0-cm painless indurated ulcers and nontender bilateral inguinal lymphadenopathy
Chancroid (Haemophilus ducreyi) rash character
Ragged, purulent, painful ulcers with tender lymphadenopathy`
Lymphogranuloma venereum (Chlamydia trachomatis) rash character
Single 0.2- to 1.0-cm ulcer, sometimes painful, with tender unilateral lymphadenopathy,
which may suppurate
Fixed drug eruptions (NSAIDs,
phenobarbital, antibiotics) rash character
Single or multiple blisters or erosions, 1-3 cm, frequently on the glans penis
Treat primary or secondary or early latent syphilis with
one dose of IM benzathine penicillin
treat late latent or asymptomatic syphilis of unknown
duration
3 weekly doses of benzathine penicillin
Treat late (tertiary) nonneurosyphilis
three weekly doses of IM benzathine penicillin.
Treat neurosyphilis with
continuous penicillin G infusion
(or every 4 hours) for 10 to 14 days.
Failure of treatment of syphilis or reaquisition is determined by
Failure of nontreponemal serologic test results to decrease
fourfold in the 6 to 12 months after treatment
how to tx prego patient with penicillin allergy for syphilis
desensitized and treated with penicillin.
what is e Jarisch-Herxheimer reaction
acute febrile illness occurring within 24 hours of treatment for any stage of
syphilis and is not an allergic reaction to penicillin
where does herpes stay latent in the body
a latent state in nerve cell bodies in ganglion neurons
most diagnostic sensitive modality for testing herpes
PCR testing of clinical specimens obtained from ulcers and mucocutaneous sites
what does a positive HSV-2 antibody test indicate
indicates only previous infection and is not a useful diagnostic test.
tx for oral or genital hsv
first and recurrent
first episode acyclovir, famciclovir, or valacyclovir 7-10 days recurrent 3-5 days
Treat primary herpes keratoconjunctivitis
topical trifluorothymidine, vidarabine, or acyclovir. Ophthalmology referral is
mandatory.
treatment for bells palsy
glucocorticoids may be beneficial. The role of antiviral therapy is unclear
genital warts vaccine
The HPV4 and HPV9 vaccines are approved for both sexes and protect against HPV types that cause genital warts and cervical
cancer.
which hpv resp for genital warts
6 and 11
most commonly isolated pathogen causing hematogenous osteomyelitis and what about other causes of osteo
1 s aureus
2 polymicrobial
pathogen of osteo caused by cat or dog bit
pasturella multicoda
pathogen of osteo caused by foot puncture wound
psuedomonas, puncture through sole of foot
what predisposes sickle cell patients to oseto
bone infarcts or bone marrow thrombosis
pathogen of osteo in sickle cell patients
s aureus or salmonella (capsule)
diagnostic imagining for osteo
mri or bone scan if contraindicated
what is definitive study for osteomyelitis
bone biopsy
do you need to get bone biopsy if osteo is negative
no
do you start abx before bone biopsy in stable osteo
no get bone biopsy first
most common pathogen in vertebral osteo
s. aureus or coagulase negative staph
next step if imaging mri shows vertebral osteo but bcx negative
ct percutaneous biopsy
empiric tx of osteo
Vancomycin or daptomycin plus ceftriaxone, ceftazidime, cefepime, or a fluoroquinolone are appropriate choices.
tx for osteo with implanted device that cannot be removed
a prolonged course (3-6months) of fluoroquinolone and rifampin
definition of FUO
a temperature >38.3 °C (100.9 °F) for at least 3 weeks that remains undiagnosed after 2 outpatient visits or 3 days of inpatient evaluation
drugs that can cause fever
anticonvulsants (phenytoin, carbamaz- epine), antibiotics (β-lactams, sulfonamides, nitrofurantoin), and allopurinol.
iga deficiency may present with
recurrent sinopulmonary infections, giardiasis, and have an increased risk for autoimmune disorders, including RA and SLE.
what do you need to be cautious of if patient has iga deficiency
high risk for transfusion reactions because of the development of anti- IgA antibodies.
what is CVID
most common symptomatic primary immunodeficiency and is characterized by low levels of one or more immu- noglobulin classes or subclasses
diagnose cvid
Measure serum IgM, IgA, IgG (all low), and IgG subclasses (variably low), and measure the ability to mount an antibody response to tetanus toxoid (protein) and pneumococcal polysaccharide vaccine (polysaccharide) antigens.
treatment for CVID
Choose IV immune globulin as first-line therapy for CVID. Most patients with selective IgA therapy do not require treatment.
why is standard immunuglobulin therapy contraindicated in isolated iga deficiency
these patients may have IgG or IgE antibodies directed against the transfused IgA.
what infection are pts at risk for with complement deficiency
neisseria (terminal deficiency test CH50 assay)
treatment for patient with compliment deficiency
atients with complement deficiency respond to standard antibiotics. Patients should maintain currency of vaccinations, especially meningococcal, pneumococcal, and Haemophilus b conjugate vaccine.
symptoms of small pox
- fever>38.5°C (101.3°F), fatigue, and headache and backaches
- rash beginning 2 to 3days after onset of fever
- rash first appearing on buccal or pharyngeal mucosa, then the face and proximal arms and legs, and then spreading to the chest and distal extremities, including the palms and soles
- rash in the same stage at any one time, in any one location of the body (all papules, all vesicles, all pustules, or all crusts)
chickenpox symptoms
- generally mild prodrome of fever and constitutional symptoms in children and adolescents, occurring simultaneously with rash
- rash beginning on the trunk, then spreading to the face and extremities
- rash in different stages(mix of papules,vesicles,pustules, and crusts) at any one time
How long are patient still contagious with small pox
untilall scabs and crusts are shed
tx of small pox
supportive maybe tecovirmat
exposure to small pox treatment
post- exposure vaccination with vaccinia within 7 days of exposure and targeting close contacts of patients with smallpox (“ring vaccination”) is recommended.
risk factors for anthrax
• travel to the Middle East, Africa , South America ,or Asia
• exposure to wool, hides, or animal hair from endemic
countries
• bioterrorism
diagonses for enlarging, pain- less ulcer with black eschar surrounded by edema or large gram-positive bacilli on Gram stain
cutaneous anthrax
inhalation anthrax
dyspnea, fever, chest pain, and a wid- ened mediastinum on chest x-ray or CT scan.
post exposure prophylaxis for anthrax
postexposure vaccination and ciprofloxacin for 60 days or Raxibacumab
tx for cutaneous anthrax vs inhalation anthrax
cutaneous: oral cipro
inhalation anthrax: IV Cipro and 2 other abx, Raxibacumab can be used to neutralize toxin
how is yersinia pestis transmitted
by fleas
bubonic plague vs septicemic plague vs pneumonic plague
- Bubonic plague follows primary cutaneous exposure and is characterized by buboes (infected, swollen lymph nodes).
- Septicemic plague is characterized by DIC and multiorgan system failure.
- Pneumonic plague most often arises secondarily through hematogenous spread from a bubo or direct inhalation.
how do patient’s with pneumonic plague present
en high fever, pleuritic chest discomfort, a productive cough, and hemoptysis. The chest x-ray is nonspecific.
yersinia pestis gram stain
Sputum Gram stain (and possibly blood smear) may identify the classic bipolar gram-negative
staining or “safety pin” shape.
tx of plague
gent or streptomycin
Francisella tularensis gram stain
gram-negative coccobacillus
Diagnose tularemia
A high index of clinical suspicion is necessary for diagnosis. Routine laboratory tests are nonspecific. Diagnosis is confirmed 2
or more weeks after infection with presence of IgM and IgG antibodies to Francisella tularensis.
tx for tularemia
mild -oral cipro
severe- IV gent or streptomycin
MOA of Clostridium botulinum
neurotoxin inhibits acetylcholine release at ganglia and neuromuscular junctions, causing bulbar
palsy and symmetric flaccid paralysis beginning 12 to 72 hours after exposure
5 Ds of botulism
- Diplopia
- Dysphonia
- Dysarthria
- Dysphagia
- Descending paralysis (starting with facial muscles)
tx of botulism
respiratory support and trivalent (tequine serum antitoxin should be administered as early as
possible to prevent progression; it cannot reverse existing paralysis.
Malaria clinical clues
Paroxysmal fever (every 48 or 72 hours, depending on the species and may be continuous with Plasmodium falciparum), intraerythrocytic parasites, thrombocytopenia
Dengue fever clinical clues
Acute onset of fever with chills, biphasic fever pattern (“saddleback”),
frontal headache, lumbosacral pain, extensor surface petechiae
Chikungunya fever clinical clues
Fever (abrupt onset up to 40 °C [104 °F] with rigors with recrudescent
episodes), rash, and small joint polyarthritis
Zika virus clinical clues
Nonspecific symptoms of fever, rash, joint pain, and/or conjunctivitis
(asymptomatic in up to 80% of persons)
Typhoid fever clinical clues
Prolonged fever, pulse-temperature dissociation, diarrhea or constipation,
faint salmon-colored macules on the abdomen and trunk (“rose spots”)
Novel coronaviruses (severe acute respiratory syndrome clinical clues
Flu-like syndrome prodrome, diarrhea, dry cough with progressive
dyspnea, lymphopenia, thrombocytopenia, elevated lactate dehydrogenase
Hemorrhagic fever viruses (Ebola, Marburg, and Lassa) clinical flu
Fever, malaise, myalgia, vomiting, diarrhea, coagulation disorders, and
bleeding
Rabies clinical clues
Paresthesias or pain at wound site, fever, nausea and vomiting, hydrophobia, delirium, agitation
zika virus effect on pregnancy
flavivirus that causes microcephaly and other congenital malformations
how long after being in a zika endemic place should you wait to conceive
3 mo for men
8 weeks for women
zika testing
initial 2 weeks reverse transcriptase pcr after that igM
how long is incubation period for malaria
1 w to 3 months
diagnosis for malaria by
thick and thin peripheral blood smears
which malaria have >2% parasitemia
Parasitemia levels >2% are most consistent with P. falciparum or Plasmodium knowlesi
tx for malaria
use chloriquine in areas that flaciproum is not prevelant otherwise use atovaquone-proguanil, mefloquine, and quinine-based regimens
symptoms of leptospirosis
fever, rigors, myalgias, and headache. Kidney failure, uveitis, respiratory failure, myocarditis, and rhabdomyolysis can occur.
A key physical sign is conjunctival suffusion, infrequently found in
other infectious diseases.
diagnosis and tx of leptospirosis
serological screening
Tx: Most cases are self-limited, but doxycycline and penicillin may
be helpful in severe disease or shortening the duration of mild
disease.
bacteria and tx Watery diarrhea, bloating, flatulence, weight loss HIV patients have more severe illness with wasting
cyclospora
tx bactrim
parasite and tx Watery diarrhea, bloating, flatulence, weight loss HIV patients have more severe illness with wasting
cyclospora
tx bactrim
parasite and tx
Watery diarrhea, abdominal
cramping, steatorrhea, weight loss
Prolonged infection with IgA
deficiency
Giardia
Metronidazole × 5-10 days
virus and tx
Watery, noninflammatory
diarrhea; vomiting in >50% of
cases; highly transmissible;
frequent cause of outbreaks
norovirus
tx supportive
bacteria and tx
Bloody stools (>25% of cases), fever, vomiting (>50% of cases) Severe infection with sepsis in patients with hepatic dysfunction or alcoholism
Vibrio cholerae
fluroquinolones
bacteria and tx
Fever, diarrhea, RLQ pain (mimics
appendicitis), pharyngitis
Postinfectious reactive arthritis
yersenia
tx Fluoroquinolone; trimethoprimsulfamethoxazole
bacteria and tx
Nonbloody, watery stools after traveling
Enterotoxigenic E. coli
(travelers’ diarrhea)
tx Fluoroquinolone, azithromycin, or
rifaximin
bacteria and tx
Bloody stools in >80% of cases;
fever often absent; may be
associated with HUS
STEC including
Escherichia coli
O157:H7
Tx None (antibiotic treatment of STEC may increase the risk of HUS)
bacteria and tx
Fever, chills, diarrhea; bacteremia in 10%-25% of cases and may result in endothelial infection, including aortitis, arteritis, mycotic aneurysm; osteomyelitis in sickle cell disease
Salmonella
(nontyphoidal)
Do not treat mild disease; this may lead to prolonged shedding of bacteria in stool If significant comorbid illness or severe illness, treat with fluoroquinolone
bacteria and tx
Dysentery
Day-care center or nursing home
workers
Rare cause of HUS or reactive arthritis
Shigella
Usually self-limited
Fluoroquinolone; azithromycin for
severe symptoms or positive stool
cultures to reduce transmission
bacteria and tx
Fevers, chills, bloody diarrhea,
abdominal pain
Postinfectious IBD, reactive
arthritis, Guillain-Barré
Campylobacter
tx
Azithromycin or erythromycin
what infections are patient post transplant susceptible to in first 30 days
same as those
that develop postoperatively in patients who have undergone non–transplant-related surgery
neutropenia patient can be susceptible to
what are patient’s post transplant susceptible to after the first 30 days
CMV esp in a CMV negative patient and CMV positive donor
what is CMV infection posttransplant associated with
- an increased risk for renal graft failure
- GI perforations and significant bleeding
- CMV-related pneumonia and respiratory failure
- EBV, polyomavirus BK, polyomavirus JC, and hepatitis B and C reactivation
Polyomavirus JC infection can progress to
progressive multifocal leukoencephalopathy
what infection is almost always found in posttransplantation lymphoproliferative disease
EBV
Kidney transplant patients with polyomavirus BK infection may develop
nephropathy, organ rejection, or ureteral strictures.
HSCT recipients with BK infection may develop
hemorrhagic cystitis.
Transplant ppx
ppx during Neutropenia
Pneumocystis and Toxoplasma prophylaxis.
CMV ppx solid vs hsct
neutropenia should include antifungal such as voriconazole.
PCP/Toxo- Bactrim
CMV solid valganciclovir
HSCT acycovir to avoid myelosupression
what can cmv ppx in transplant patient also lower the occurance of
a lower incidence of polyomavirus BK and EBV
reactivation.
tx for transplant cmv
immunosuppressive therapy may need to be reduced. IV ganciclovir,
oral valganciclovir, oral foscarnet, and IV cidofovir are used for treatment
The only known effective treatment for polyomavirus
JC infection is to
reverse immunosuppressive therapy
HAP VS VAP
HAP is defined as pneumonia that occurs ≥48 hours after admission. VAP, a subset of HAP, is defined as occurring >48 hours
after endotracheal intubation.
how to reduce vap
- following daily weaning protocols for timely extubation
- keeping the head of the bed elevated >30 degrees
- avoiding nasal intubation and nasogastric tubes
- using chlorhexidine mouth rinse and subglottic suction catheters
catheter related infections when should you remove line
- tunnel or pocket infection
- sepsis
- metastatic infection (septic thrombosis, endocarditis, or osteomyelitis)
- Staphylococcus aureus or Pseudomonas infection
- fungemia
is routine dressing changes beneficial in preventing line infection
no actually increases risk
tx for line infection
MSSA is treated with either nafcillin (or oxacillin) or cefazolin
• MRSA is treated with vancomycin or daptomycin
For septic or neutropenic patients cover for psuedomonas.
duration of tx in line infections
IV catheter-related S. aureus bacteremia that clears within 72 hours without evidence of endocarditis or metastatic infection
may be treated with 10 to 14 days of parenteral antibiotics.
Persistent S. aureus bacteremia >72 hours after the start of appropriate antimicrobial therapy suggests a complicated infection. Evaluate with echocardiography, preferably transesophageal. Treat complicated S. aureus bacteremia for 4 to 6 weeks.
HIV testing protocol
• a fourth-generation combination immunoassay that includes an EIA for HIV antibody (HIV-1 and HIV-2) and HIV p24
antigen
• if combination immunoassay is positive, obtain immunoassay to differentiate HIV-1 from HIV-2
• detection of either HIV-1 or HIV-2 antibody confirms the diagnosis
• if differentiation immunoassay is inconclusive for either HIV-1 or HIV-2, obtain NAAT
• a positive NAAT in the setting of a negative antibody test indicates acute HIV infection
*if patient has postive saliva test still needs to go through algorhythm
what diseases should warrent HIV testing
- severe or treatment-refractory HSV infection
- oral thrush or esophageal candidiasis
- Pneumocystis jirovecii pneumonitis
- cryptococcal meningitis
- disseminated mycobacterial infection
- CMV retinitis or GI disease
- toxoplasmosis
- severe seborrheic dermatitis, or new or severe psoriasis
- recurrent herpes zoster infections
what is the best indicator for predicting long term prognosis in HIV and what is the best indicator to determine risk of opportunisitic infection
viral load
CD4
tx for iris
continue art, tx underlying infections, steroids and nsaids can assist
HIV ppx for CD4<200
Pneumocystis -> bactrim
HIV ppx for CD4< 100
Toxoplasmosis -> Trimethoprim-sulfamethoxazole
HIV ppx for CD4 <50
MAC -> azithro
can you give MMR and varicella to HIV patients
only if CD4>200
when can you discontinue ppx for hiv opp infections
when cd4 count >200 and undetectable viral load for 3 mo
how do you diagnose pjp
An elevated LDH level may be present in HIV-infected patients with P. jirovecii pneumonia. The diagnosis is established by immunofluorescent monoclonal antibody stain or silver stain examination of induced sputum or a bronchoscopic sample show- ing characteristic cysts.
The most common cause of a pneumothorax in a patient with AIDS is
PJP
tx for PJP
oral trimethoprim-sulfamethoxazole for mild to moderate pneumonia
• IV trimethoprim-sulfamethoxazole for moderate to severe pneumonia
• glucocorticoids within 72 hours for A-a ≥35 mm Hg or arterial P o2 <70 mm Hg
• IV pentamidine or IV clindamycin plus oral primaquine for patients with sulfa allergy
signs of toxo
- encephalitis, chorioretinitis, or pneumonitis in immunocompromised patients
- any focal neurologic syndrome, acute or subacute
- mononucleosis-like syndrome
Lymphoma (primary CNS, B-cell lymphoma)
Often a solitary lesion is located in the periventricular or periependymal area or in the corpus callosum
Neither clinical nor neuroradiologic findings reliably distinguish lymphoma from toxoplasmosis
Brain biopsy is diagnostic
imaging findings in toxo
Typical findings on imaging include multiple ring-enhancing lesions.
Progressive multifocal leukoencephalopathy
Dementia is often the presenting symptom
CD4 cell counts are usually <50/μL and
PCR of CSF can show JC virus
Brain biopsy is diagnostic
Cryptococcus neoformans
Headache, fever, and altered mental status are present CD4 cell counts are usually <100/μL
CSF culture for Cryptococcus or cryptococcal antigen tests on CSF and serum are diagnostic;
elevated CSF opening pressure is characteristic
MTB in the brain characteristics
Basilar meningitis with cranial nerve abnormalities Culture and PCR of CSF are diagnostic
CMV encephalitis
Diffuse encephalitis and fever are characteristic CD4 cell counts are <50/μL; CSF PCR is positive, and brain biopsy is diagnostic
neurosyphilis
Atypical and accelerated neurosyphilis is seen in HIV infection
Lymphocytic pleocytosis and elevated CSF protein Positive serum RPR or VDRL test, FTA-ABS, and MHA-TP; positive CSF VDRL
toxo tx
sulfadiazine, pyrimethamine, and folic acid in patients with multiple ring-enhancing lesions, positive T. gondii serologic test results (IgG), and immune suppression (CD4 cell count <200/μL). Treat patients with persistent immunosuppression indefinitely. Biopsy lesions that fail to respond to 2 weeks of empiric therapy.
what do you do in setting of institutional outbreak of flu
vaccinate staff members and residents not already immunized and give chemoprophylaxis with zanamivir or oseltamivir for at least 2 weeks following immunization.
most common complication of the flu
super imposed bacterial pna
what should you test for in a young patient who gets shingles
HIV
how does shingles occur
latent VZV within sensory ganglia, especially in adults >60 years or in immunosuppressed patients.
what is postherpetic neuralgia
neuropathic pain lasting more than 1 month after resolution of the vesicular rash.
what is ramsey hunt syndrome
vesicular rash in external ear associated with ipsilateral peripheral facial palsy and altered taste
shingles vaccination guideline
recombinant zoster vaccine for all adults ≥50 years, including those who have previously had herpes zoster infection or have been vaccinated with the live attenuated vaccine.
whos should get post exposure ppx for shingles
postexposure varicella vaccination is appropriate in immunocompetent persons, and varicella-zoster immune globulin should be used in immunocompromised adults and in pregnant women.
tx for shingles
Antiviral therapy (acyclovir, valacyclovir, and famciclovir) speeds recovery and decreases the severity and duration of neuropathic pain if begun within 72 hours of VZV rash onset.
Intravenous acyclovir should be used for immunosuppressed or hospitalized patients and those with neurologic involvement.
cancer association with ebv
B-cell lymphoma, T-cell lymphoma, Hodgkin lymphoma, and nasopharyngeal carcinoma. Another EBV manifestation is oral hairy leukoplakia
